Techniques for Donor Nephrectomy Analysis

Techniques for Donor Nephrectomy Analysis Laparoscopic donor nephrectomy versus robotic assisted laparoscopic donor nephrectomy: A prospective randomised comparative study Introduction: Donor nephrectomy is unique surgery which is done on person who is not a patient and come forward for purely altruistic reasons. So the margin of error in donor nephrectomy is nil and hence the stress in donor surgeon is quite high. At the same time all attempts should be done to minimize the donor morbidity to minimum. With the same intension in 1995, Ratner reported first laparoscopic living donor nephrectomy (LDN) (1) and later gradually the laparoscopic approach has become almost the standard of care for living donor nephrectomy. Randomised controlled trials (RCT) comparing the laparoscopic vs. open donor nephrectomy suggested that laparoscopic approach was associated lesser postoperative analgesic requirement and lesser hospital stay and faster returned to work compared to open approach without affecting immediate graft outcome although there was significantly increased warm ischemia time and total operative time with LDN group (2,3). So LDN was associated with dec rease in the disincentives associated with voluntary donor nephrectomy. Further course of time saw further refinement in the techniques of LDN and towards further reducing the morbidity associated with donor nephrectomy. These modifications were introduction of laparo- endoscopic single site surgery(LESS) (4), retroperitoneoscopic donor nephrectomy, robotic assisted laparoscopic donor nephrectomy (RDN) (5) and transvaginal laparoscopic donor nephrectomy (6). In 2002 Horgan first reported the RDN. The goal of this study was to compare the outcomes of LDN and RDN. Materials and methods: The study was started after approval from institutional review board. Study enrollment time was from March 2014 to February 2015.Primary end point was the postoperative visual analogue pain scores of the donors. Secondary end points were donor’s postoperative analgesic requirement, haemoglobin drop, hospital stay ,lost arterial and venous length, total operative time(TOT) , retrieval time (RT) , warm ischemia time ( WIT),. Recipient related secondary end points were graft function at serial follow up. Surgeon difficulty scores for different steps of surgery were also analyzed. Total of 45 donors were to be enrolled into the study with enrollment ratio of 1:2 for Robotic: Laparoscopy arm for establishing mean pain score difference of 1 with standard deviation of 1 to reject the null hypothesis that the robotic and laparoscopic pain score means are equal with probability (Power) of 0.871 and the type 1 error ( ÃŽ ±) of 0.05.The sample size was calculated w ith power and sample size program version 3.0.7. After written informed valid consent for inclusion in study, 45 live related voluntary kidney donor who were completely evaluated and planned for right (N=27) or left donor nephrectomy (N=18) were randomised into robotic (Da Vinci Si TM-Intuitive surgical ® ) or laparoscopic approach for donor nephrectomy with chit method.(Figure 1). Exclusion criteria were patient unwilling for inclusion in study, preemptive transplantation, body mass index (BMI)> 35kg/ square meter, multiple renal artery or veins on donor side or epsilateral adrenal adenoma. Parameters noted in all donors preoperatively were, age, gender, comorbidities, previous surgeries GFR (Cockroft-Gault), serum creatinine BMI, length of renal artery and vein ( up to level of bifurcation) on CT angiogram. RDN was done by two surgeons with expertise in robotic surgery.LDN was done by multiple surgeons (including both the surgeons performing RDN) with expertise in LDN. Bed side surgeons in RDN were the same surgeons who were performing LDN. The operative room team in both the group was same. In Right LDN, access was achieved from three 12 mm ports for camera and working and two 5 mm ports for lifting ureterogonadal packet and liver retraction. In 9 cases additional 12 mm port was placed from Pfanensteil retrieval wound for insertion of vascular stapler. In Left LDN, two 12 mm ports for camera and working and two 5 mm ports for working and lifting ureterogonadal packet were used. Three left LDN could be managed without port for lifting of ureterogonadal packet. In Left RDN, three 8mm robotic working ports and two 12mm ports ,one for robotic camera and another was for bed side surgeon working port were used. In Right RDN in addition to above ports one more 12 mm port in Pfanensteil retrieval wound for stapler insertion was used in 7 cases and one 5 mm port for liver retraction was used in all cases. The steps for the surgery were similar in LDN as well as RDN. The difficulty scores (visual analogue score 0-10; 0 being easiest and 10 being most difficult ) of donor surgeon were noted on for bowel reflection, lifting up the ureterogonadal packet, hilar dissection, upper pole dissection, clipping the ureterogonadal packet, clipping renal artery and vein, cutting renal artery and vein and retrieval of graft in laparoscopy group. The console surgeon difficulty scores were noted for bowel reflection, lifting up the ureterogonadal packet, hilar dissection, and upper pole dissection, cutting renal artery and vein in robotic cases. Bed side surgeon difficulty scores were noted for tasks done by him like clipping ureterogonadal packet, clipping of renal artery and vein and retrieval in robotic cases. A 5-7cm Pfanensteil incision is placed and deepened to the level of parital peritoneum for graft retrieval. In 2 right RDN kidney was flipped for getting longer renal artery stump. Mannitol was given intravenous before cutting ureterogonadal packets. After cutting the ureter brisk urine output was observed from cut ureter before clipping of hilar vessles. After cutting renal vein, graft was freed of lateral attachments and kept free in peritoneal cavity. After incising this parital peritoneum in Pfanensteil incision, graft is retrieved in longitudinal axis by hand introduced into peritoneum by donor surgeon in LDN and patient side surgeon in RDN. During retrieval undocking of fourth arm of robot was necessary in most of the cases with RDN. Intraoperatively noted parameters in robotic as well as laparoscopic cases were number of ports, retrieval time, warm ischemia time total operative time, length of artery and vein (Up to level of bifurcation) on bench, intraoperative complications. Retrieval time was considered from clipping of artery up to the retrieval from donor. Warm ischemia time was considered from clipping of artery up to reperfusion of kidney with perfusion fluid till the time when efflux from renal vein is clear. Docking time was noted in robotic cases. Post operative visual analogue pain scores (VAS) were noted in donor at 6 hours, 24 hours and 48 hours. Donors were discharged when they were allowed full oral diet, passed motions, ambulant and comfortable. Other donor parameters noted postoperatively were analgesic requirement in milligrams of tramadol, complication grades by Clavien –Dindo complication scale, hospital stay, haemoglobin drop, and serum creatinine at 1 month follow up. Recipient parameters noted were e GFR (Cockcroft-Gault) at 7 days, 1month, 3 month, 6 months and 9 months, graft complications, graft loss. Statistical analysis was done with Statistical package for social sciences (SPSS) version 15.0. Analysis was done for comparing RDN vs. LDN. Subgroup analysis was done to compare Right RDN vs. Right LDN and Left RDN vs. Left LDN. The Chi-square test and Student’s t-test was used for categorical and continuous variables respectively. Results: The demographic parameters in donors are as shown in table 1.Demographic parameters in right and left subgroup are shown in table 2 and 3 respectively. Both the RDN and LDN groups as well as right and left donor subgroups were similar in age, gender, BMI, preoperative renal function, previous surgeries and comorbidities and preoperative artery and vein lengths. All 15 RDN were completed without conversion to LDN or open donor nephrectomy. All 30 LDN were completed without conversion to open donor nephrectomy. There were no intraoperative complications in any of RDN or LDN. In all the RND and LDN the ureter was cut at pelvic brim level. All the recipients (N=45) in both the groups had good urine output on table after vascular anastomosis. 2 surgeons (one on console and one on patient side) were necessary in RDN compared to single donor surgeon in LDN. The difficulty score on VAS scale 0-10 for donor surgeon in LDN and console surgeon and patient side surgeon in RND is shown in table 4 for right side and table 5 for left side. The VAS score of patient side surgeon in RDN was higher in graft retrieval compared to donor surgeon in LDN in both right and left subgroup. In right subgroup, the VAS scores of RDN surgeons were less than LDN surgeon except in step of upper pole dissection and adrenal sparing which have comparable VAS scores. In left subgroup, the VAS scores of RDN surgeon and LDN surgeon are similar other than step of renal artery and vein cutting which was easier in RDN group. The analysis of intraoperative and postoperative parameters as well as recipient and graft outcomes is shown in table 6.The subgroup analysis in right and left group is shown in table 7 and 8 respectively. Donor VAS pain score at 6 hours, 24 hours and 48 hours, analgesic requirement, hospital stay was less in RDN group compared to LDN group. There was no significant difference in donor haemoglobin drop, donor complications, donor serum creatinine at 1 month, recipient eGFR at 7 days, 1month, 3 months, 6 months and 9 months or graft complications between RDN and LDN group. More ports were necessary in RDN in either of the subgroups. The total operative time was not significantly different in RDN and LDN group as well as in right and left subgroup. However the retrieval time was higher in RDN group overall as well as in both right and left subgroup. The warm ischemia time is higher in RDN group overall as well as in left subgroup. However it is not significantly different in right subgroup. There was no difference in lost length of vein during clipping in RND or LDN in both subgroups. However in right RDN longer artery length could be preserved compared to right LDN. This was not found in left subgroup. Discussion: More important than introduction of any new technology is safety associated with the technique. This is more so in transplant as there are outcomes in two persons are at stake. As found in our study the RDN is safe technique. It is associated with similar immediate and early postoperative outcomes in donors as well as corresponding recipient’s graft function. Previous literature also suggest that RDN is safe(5,8,9). Study comparing robotic versus laparoscopy suggest that robotic approach is associated with less pain than laparoscopic approach (10). The possible reason for less pain in robotic surgery is robotic arms which are pivoted around port site are moved at fixed remote centre. So there is less leverage around the port site and lesser pressure at port sites which leads to lesser trauma to abdominal wall tissues around the port. Our study suggested that RDN is associated with lesser pain score and lesser analgesic requirement compared to LDN. This also transforms into earlier recovery and discharge from the hospital. Although the voluntary kidney donors donate with altruistic approach, any donor will prefer approach which further reduces the morbidity associated with donor surgery. It is for this reason that live donor nephrectomy rates increase after advent of LDN compared to open donor nephrectomy (11, 12).RDN may further reduce morbidity associated with donor nephrectomy. Most of the transplant centres prefer left sided graft kidney over right in view of small right vein length and need for retrocaval dissection or flipping of kidney on right side to achieve good graft artery length (13, 14) which may be technically more challenging.Studies also propose that the robotic approach with its 3 Dimentional vision,7 degrees of freedom,higher magnification and enhanced dexterity compared to standard laparoscopic approach facilitate the renal hilar dissection(15). In our study we found that the VAS of donor surgeon for right hilar dissection was lesser in RDN than LDN. Right kidney was flipped in two RDN. The preserved renal artery length was more in right RDN than right LDN. The technical ease was felt in right RDN compared to right LDN in all steps other than upper pole dissection and retrieval. However it is worth noting that this technical ease did not reach level of significance in any steps of left RDN vs. LDN except cutting of renal artery and vein. Th e lost artery or vein length was not different in left RDN and LDN. This suggest that robotic approach may provide some technical advantage compared to laparoscopic on right side but not so significantly on left side.At the time of writing this manuscript and during the conduct of this study instruments like robotic vascular stapler are not available. Availability of such instruments will further reduce the role of patient side surgeon and may influence the technical ease of this surgery. It may also reduce the steep learning curve associated with LDN(9). The total operative time was not different in RDN vs. LDN. However the warm ischemia time was significantly more in Left RDN group than LDN (p=0.01, power of test for this parameter=87.8%) which is definitely a matter of concern. The retrieval time was more in RDN in both subgroups. The difference in WIT did not reach level of significance on right side.Possible cause for this increased WIT and RT is need to undock the fourth arm during retrieval. This is also a cause for increased patient side surgeon VAS during retrieval in RDN. The increase in WIT does not correlate with recipient graft function in limited range of time (16,17).In our study as well the recipient graft related complications or e GFR was not different between RDN and LDN group at 7 days,1 month ,3 month,6 month,9 month follow up . We acknowledge the limitation of our study that although it is well powered for its primary end point of post operative visual analogue pain scores of donor, it is less powered for few of the secondary end points. The longest recipient graft follow up is 1 year in our study and we don’t have any longer follow up. Last but not least ,our study does not focus on the economic aspects of comparison between RDN and LDN.The RDN increased the cost of surgery for donor nephrectomy(18).It remains to be determined if the benefits of RDN in reducing donor morbidity and technical ease associated with it out weight the cost implications associated with it. Conclusion: RDN is safe procedure and is associated with better postoperative pain scores, analgesic requirement as well as lesser hospital stay compared to LDN. Robotic approach in right donor nephrectomy is associated with more technical ease to console surgeon compared to laparoscopic donor surgeon in most of the steps of surgery and facilitates preservation of longer length of right renal artery. However there is no significant technical ease associated with left RDN compared to left LDN. Left RDN is associated with longer WIT than LDN however this does not reflect adversely into early graft function from 7 days up to 9 months.

Lord of The Rings/Kite Runner Compare and Contrast Essay

What objects do you associate innocence with? Marriage, virginity, a childhood toy? When we think of dominance we think of war; we think of negativity. When the phrase ‘parental influence’ comes to mind, we go to our mothers tucking us into bed and watching the game with our fathers—at least that is what us lucky ones think of. Not everyone is lucky enough to have that innocence stored forever, violent free lives, and a mother and father by our side.The Kite Runner and Lord of the Flies have many similarities, particularly when comparing themes such as loss of innocence, power and dominance, and paternal influences and the ways in which they are depicted through symbolism and irony. From the beginning of The Kite Runner Hoseinni showed innocence through Amir’s passion and longing for kites, but not any kite; Amir longed for the winning kite in the annual kite flying tournament. Kites were constantly present during Amir’s childhood. They were his good ness and his purity; the goodness and purity of Afghanistan at that time.Amir’s innocence was stolen by him when he was twelve-years-old by the neighborhood bully, Assef. Amir longed for the winning kite, but at the expense of his friend, Hassan: â€Å"But there were two things amid the garbage that I couldn’t stop looking at: One was the blue kite resting against the wall,† (75). Amir witnessed the rape of Hassan, and after he took his trophy kite home and hung it up on the wall it mocked him, reminding him of his cowardice, and the purity and the innocence that were taken from him. When Amir returned to Kabul as an adult there were no kites.Afghanistan had been run over by the Taliban and everything had been destroyed, just like the innocence that was taken by Amir and the goodness and that was stolen from him. In The Kite Runner, Amir wanted the winning kite. After witnessing the rape of Hassan—witnessing his beloved friend sacrifice himself for the fi rst place kite and seeing Kabul in ruin with the kites gone and the tournaments ended, he craves the innocence and goodness of his past. In Lord of the Flies, Golding used symbols very similarly to Hoseinni’s use of the kite as a symbol of innocence.Instead of an object or toy, Golding used Simon to show purity. Simon, the quiet and kind hearted boy, was murdered savagely by his peers. Simon had been the good and the innocent on the island; unlike the other boys he knew that the evil was inside of the others, though he himself had been too good for the evil. Simon was taken away from the boys but not by outsiders, like the Taliban; the boys themselves took Simon away, unlike The Kite Runner where Assef and the Taliban took the innocence away from Amir. â€Å"There were no words, and no movements but the tearing of teeth and claws† (153).The boys turned into savages and took Simon away from themselves. Unlike The Kite Runner, Simon and innocence were not wanted and were easily thrown away. As goodness was being murdered, the boys turned into monsters. Not once did they think of what was being depleted. Another theme shared by the two novels is the idea of power and dominance. In The Kite Runner, Hoseinni showed this through the bully Assef, who later became a Taliban official. Not only did Hoseinni use Assef and the Taliban as symbols of power, but he enforced them through irony.One example of dramatic irony in The Kite Runner took place when Baba was talking to Amir as a child. Baba said to him, â€Å"’God help us all if Afghanistan ever falls into their hands! ’† (17). Baba was referring to the Taliban and how he hoped they would never come into power, though consequently, the Taliban later dominate Afghanistan. Baba pleads to God for help if the Taliban run over, he pleads to a God that he doesn’t necessarily believe in, and ironically, the Taliban justify all of their actions with the word of God. Likewise, Golding used Jack and his hunters to illustrate power and dominance in Lord of the Flies.In order to assert their dominance Jack and his hunters murdered the pig in an ostentatious manner thinking that being flashy and strong will bring respect. Not only did Jack allege his power through conspicuous hunting acts, but he also imposed power with his violent mannerisms towards Ralph, Piggy, and the others. Jack is not the only power figure in this story. In turn, the British official that appeared to rescue the boys has a stature of power along with the British army. Golding expressed his love of irony with the British soldier on the island as well.The boys had been creating their own war on the island, and they were, in a way, mimicking the war that had been happening on a world-wide scale. Golding did not stop here, as the British soldier then observed the boys savagery, he reprimanded them for not being more proper and British. â€Å"’I should have thought that a pack of British boy s—you’re all British, aren’t you? —would have been able to put up a better show than that—‘† (202). How ironic, that despite the soldier’s talk of being proper and â€Å"English,† he too was being a savage. He too, was in the middle of a war.Not only do The Kite Runner and Lord of the Flies share themes of innocence and power, but they both partake in the lack of positive parental influence. In The Kite Runner, Amir envied the father-son relationship that Hassan and his believed-to-be-father, Ali, shared. Like his stolen innocence, Amir yearned for his father’s approval, for these were the things he could not have. â€Å"He’d close the door, leave me to wonder why it was always grown-ups’ time with him† (5). Here, Hoseinni clearly illustrates that as growing up, and even as an adult, Amir never received the love and the affection that he so craved from his father.At every turn he would find a cl osed door; Baba would see Amir as a calamity. The one person who gave Amir positive parental influence was his father’s friend and business partner, Rahim Kahn. Amir did not take this influence to heart; his longing for approval from Baba and a mother he did not have created a hole that Rahim Kahn could not fill. With a deceased mother and apathetic father, Amir had a deep hunger for a father figure to such a degree that the lack of a parental influence caused self destruction and mental instability. In contrast to The Kite Runner, the boys in Lord of the Flies did not care for paternal influences as Amir did.In fact, they rejoiced because there were no adults on the island to keep them in check; â€Å"’Aren’t there any grownups at all? ’ ‘I don’t think so. ’ The fair boy said this solemnly; but then delight of a realized ambition overcame him’† (8). From the start, Amir wanted the parental influences that he grew up with out; the boys on the island were more than happy to be rid of them. The consequences of the lack of parental influence did not make an appearance right away, but contrary to what the boys believed, not having a parental figure did have its repercussions.One can take Roger, in consideration. At first he could not bring himself to throw stones at the smaller, younger boys. The memories of civilization and punishments still had their hold on him, but as the story progresses, Roger finds himself becoming less and less humane; much like Assef, in The Kite Runner, who as a child, subconsciously knew he could be punished for his bullying, but as he grew older and as the influence of his parents lessened, he was able to use his wrath however he pleased.The lack of parental influence in Lord of the Flies through the immature, adolescent behavior of the boys and lack of adults residing on the island leads to destruction and chaos, similar in ways to that of Amir’s, but far more externa lly dramatic. Indeed, Golding and Hoseinni share many tastes when it comes to writing, and that becomes quite apparent when one looks at the themes of the two novels. Through the loss of innocence, power and dominance, and the lack of those positive parental influences Golding and Hoseinni manage to paint the picture of a life different than the life of the average American youth.Amir kept his innocence in a kite. In his homeland. The boys on the island never knew that their innocence lay within one small boy. They didn’t have a father to look up to, a mother to run to, and neither did Amir. Now, innocence is mocked. Parental figures are pushed away, but most don’t know what it is like to lose that innocence. To not have a mother or father there in times of need. Where is your innocence stored? Where do you find the comfort and protection that are craved through a mother’s love and a father’s adoring pride?

The Moai Statues of Easter Island Rapa Nui Essay - 982 Words

W4A1 Question 1: a. Why do you believe each culture undertook the creation of your selected monumental work of architecture and sculpture despite the difficulties of accomplishing them? What can we assume about a work of art without such knowledge? The moai statues of Easter Island, also known as Rapa Nui, are some of the most mysterious structures ever seen (Cothren Stokstad, 2011, p.873). Easter Island is one of the most remote islands in the world. It is 2,300 miles from the coast of South America and 1,200 miles from Pitcairn Island. The moai sit majestically on the coast and face inward. Each statue is different, some have hats and some have earrings. The moai may have been tributes to their chieftains, or to their ancestors.†¦show more content†¦Without this valuable information, we can never really know what the purpose of the moai was. We can only assume what we know from other cultures, when no knowledge of a culture is known. In other culture, monuments were built for a number of reasons, including religious, governmental, or personal motives, such as the Taj Mahal (Cothren Stokstad, 2011, p.771). Nan Madol is located on the island of Pohnpei in Micronesia. It was built between the thirteenth and seventeenth centuries. On top of a coral reef built from black basaltic rock, it is a series of artificial islets. This complex was the ceremonial and political seat of the Saudeleur Dynasty (Beardsley, 1998). It also enclosed the royal tomb. The city was built to house the supreme rulers and all food, water and resources had to be brought from the mainland. All resources were brought to the city by commoners and slaves on the mainland. After the Saudelaur were defeated, the structure was abandoned because of the lack of food and water. Like the Forbidden City, it was a structure built to house the rulers and their court (Cothren Stokstad, 2011, p.799). 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Leonardo Da Vinci And The Renaissance - 1071 Words

Roughly between the times of the 14th and 17th centuries a cultural movement called the Renaissance existed. The Renaissance housed some of the greatest intellects, such as Leonardo da Vinci, and a radically different way of thinking emerged. Humanism developed largely and rapidly among this time, and was greatly influenced by a man named Desiderius Erasmus (1466-1536). Erasmus, a Dutchman, originally lived among monasteries where he developed many opposing views during his years of service. In the midst of the Renaissance, around the 16th century, the Reformation movement began to splinter the faiths of Europe. Some say that Erasmus bridged the ideals of the Renaissance and Reformation movements. Among his many contributions to the humanist drive, he wrote many colloquies originally intended for teaching Latin to school children, which doubled as underlying preaching of Erasmus’s ideals. A collection of a variety of these stories entitled the â€Å"Ten Colloquies† writ ten by Erasmus shows specific examples of the tethering of Renaissance to the Reformation largely on the theme of ad fontes. One of Erasmus known standards was the importance of going back to the sources. During the Renaissance, born in Florence, this was very common thought, as it was a period of admiration of early Greek and Roman culture, intellect, and art. This began to pave some of the ways of many reformers mainly as they begin to question the practices of the Catholic Church. Many began to question whereShow MoreRelatedThe Renaissance Painting : Leonardo Da Vinci And Leonardo Da Vinci971 Words   |  4 Pagesstated in her book â€Å"The Annotated Mona Lisa† (32). During the Renaissance period, artists discovered new techniques, that gave paintings and sculptures more character. 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This philosophy or intellectual movement initiated the Renaissance. During the middle ages, elements of daily life were strictly structured around the church and religion. However, toward the beginning of the 14th century, the power of the Church began to significantly decline. This was sparked by the Bubonic plague. The plague was viewed as a punishment fromRead MoreLeonardo Da Vinci And The Renaissance Era1572 Words   |  7 Pagesmasterpieces are created to represent the time of its creation. During the Renaissance Era, the humanist and classical values of art flourished. One of the great masters of the Renaissance known as Leonardo Da Vinci, dominated the period of the High Renaissance. The values of the Renaissance exist in the works of Leonardo Da Vinci portrayed through his paintings of Mona Lisa, The Last Supper, and Salvator Mundi. The Renaissance Era was a period in Europe that lasted between the 14th century and 17thRead MoreLeonardo Da Vinci : A Renaissance Man1112 Words   |  5 PagesLeonardo da Vinci was a painter, sculptor, architect, inventor, and military engineer which is the perfect example of a â€Å"Renaissance man.† With a curious mind, da Vinci studied the laws of science and nature, which greatly informed his work. His ideas and body of work have influenced countless artists and made da Vinci a great influence of the Italian Renaissance. Leonardo da Vinci was born on April 15, 1452, near the village of Vinci about 25 miles west of Florence. He was the illegitimate sonRead MoreLeonardo Da Vinci And The Renaissance Period1455 Words   |  6 PagesLeonardo Da Vinci once said,† the painter who draws merely by practice and by eye, without any reason, is like a mirror which copies everything placed in front of it without being conscious of their existence.† Who would have thought that this rural boy would become one of the world’s greatest mind and artist? Leonardo Da Vinci was born on April 14, 1452 in the town of Vinci near Florence Italy. He lived during the fifteenth century, a period when the people of Europe were becoming interested inRead MoreLeonardo Da Vinci : The Renaissance Man963 Words   |  4 Pagesthan Leonardo da Vinci. Da Vinci was not only a painter, but also a sculptor, architect, engineer, musician, inventor and scientist. There are not many that were gifted in multiple aspects like him. His actions alone coined him the name The Renaissance Man. On April 15, 1452, Leonardo da Vinci was born out of wedlock in a farmhouse on the outside the village of Anchiano. He was the son of a Florentine notary named Ser Piero and a young peasant girl by the name of Caterina. When da Vinci turned

Gun Control and Mental Illness - 790 Words

The question of Gun control is in the news. The subject comes up with each election along with the latest tragedy statistics. Both sides of the debate throw explicit words towards the other, it all turns into an argument and there seems to never be any agreement. It s very disparaging to me to see the innocent lives of children taken and for a defense gun owners hide behind what amounts to a 400 year old scrap of paper which is neither relevant to modern day problems or understood the same way by any two people reading from it. It really goes to show the poor quality of the generation of people we are in. An example would be, they play the same Christmas songs from 300 years ago and half of them have never seen a sleigh bell or ate a†¦show more content†¦One of the scariest of these is schizophrenia. Once a person has been diagnosed doctors place the patient on medications to alleviate the symptoms and send them home, with no other special supervision. Only if and when, th e patient complains of adverse side effects to medications or family members have them committed for evaluation do doctors put the patient through a monitoring process of seventy two hours, and prescribe other medications along with their own set of side effects, to alleviate the side effects of the main medications. This can go on for years as there is no cure for the disease! It s all what becomes a vicious cycle of ups and downs done in plain view of the public but known only to those close to the person in need of help. Some patients get tired of the medications and simply stop taking it and far too often it leads to a tragedy. Sadly those close to the person in need are only contacted for information after the tragedy takes place. We hear them tell the news reporters how â€Å"shocked† they are, and how they â€Å"didn t see it coming because so and so was always so friendly† and â€Å"how they kept to themselves bothering no one†. It truly is a sad time to live in, and things will only get worse because everything has been left â€Å"as is† for far too long. Nobody has an easy answer or the patience to come up with a workable solution so the whole mess will continue as it has now for so long. The government will give the people what itShow MoreRelatedGun Control Versus Mental Illness Essay2085 Words   |  9 PagesThe Debate over Gun Control versus Mental Illness Jeffrey Glass COM/220 July 14, 2013 Erin Fagan The Debate over Gun Control versus Mental Illness The debate over gun control is not a new argument, neither is the existence of mental illness. There have been those who support and those who oppose gun control for many years. What has recently re-ignited the debate is an increase in mass shootings over the past few decades; one in particular is the Newtown, Connecticut, massacre. 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The Importance of Career Planning in Industry Free Essays

the importance of Career Planning in industry. Career planning involves efforts on the part of the organizations to provide avenues for growth to its employees. Certainly this growth should be accompanied by development. We will write a custom essay sample on The Importance of Career Planning in Industry or any similar topic only for you Order Now The other side of the coin is the role of employees in career planning. It involves effort on the part of employees to clearly think through and decided areas in which they would like to make a career for themselves. When employees have assessed their career needs and have become aware of organizational career opportunities, the problem is one of alignment. The crucial role has to be played by HRD in ensuring this alignment to build up morale in the organization. A systematic choice of development techniques like training, special assignment, counseling and rotational assignments should be made to ensure this alignment. Employees are often uncertain as to the type of work that would suit them best. There are a number of evaluation instruments available to determine basic aptitudes. Human Resource Development Managers should be able to guide employees by administering these instruments on them. Employees should also find out whether they are loners or socially active. These exercises with some assistance from HRD Managers should help in career need assessment. At certain stage the upward mobility stops for many employees. This is inescapable in view of pyramid organizations structure. This phenomenon is called plateauing. It takes place around the age f 40. Some suggested measures to deal with such employees are: ? Mentors should be assigned measures to deal with such employees. Depending on the maturity of such mentors, good results can be achieved in assuaging the hurt feelings of plateaued employees ? Additional career ladders could be established to retain some valuable resource. Giving them importance by assigning them to some important task force or committee. ? Assisting them to choose a new career. Some organizations assist their plateau executives to start their own business. Career path models developed by a large public sector undertaking: This organization has developed career paths models for the major discipline †¢ Sales †¢ Technical services †¢ Operations †¢ Engineering †¢ Aviation †¢ LPG †¢ Finance †¢ Personnel Career path models have not been drawn for the disciplines like materials, public relations, training, etc. areer path models have been evolved to provide direction to career progression of officers. It forms the basis for placement, transfer, rotation etc. so that the officers are prepared for higher responsibilities progressively and the experience they gain becomes cumulative rather than respective. The most distinguishing feature of these career path model are the stress on jib rotation and testing the incumbent in a different environment to enhance his coping capability before giving him a higher position in the hierarchy. How to cite The Importance of Career Planning in Industry, Papers

Hourly Rounding free essay sample

A change that a nurse manager could implement that would help improve patient care is hourly rounding. In order to implement this change successfully, the nurse manager needs to clearly communicate the expectations, and then follow up with good monitoring. When the nurse manager sees the staff meeting the expectations the staff should be acknowledged rewarded/recognized and celebrated. On the other side, if the staff is not meeting the expectations they should be reminded, coached, and counseled. Sticking to the communicated expectations can have powerful results when the nurse manager diligently and consistently puts the plan into practice. Justification to Improve Patient Care and Perspective Theories to Support the Change As a manager an area of change that could improve patient care is hourly rounding. Hourly rounding involves rounding on patients every one to two hours and practicing a series of 8 specific behaviors. There are seven recognized reasons patients use their call bells. We will write a custom essay sample on Hourly Rounding or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page These seven reasons include bathroom/bedpan assistance (15%), IV/Pump alarm (15%), pain medication (10%), needed a nurse or CNA (9%), position assistance (4%), accidental hits of the call light (13%), miscellaneous reasons (13%). Studies show by using the hourly rounding on patients the percent can decrease by bathroom 40%, pain 35%, positioning 29%, Iv/pump alarms 40%, and miscellaneous 39% (Studer Group, 2010). Hourly rounding is more than just â€Å"checking in† every hour. Once this practice becomes part of the nurse’s workflow, the organization will begin to see decreases in lost charges, incidental overtime, med errors, and an increase in nursing and patient satisfaction. Strategies and Internal and External Need for this Change: The first step to implementing this change is to gather baseline data on falls, hospital acquired decubiti and call light statistics. Falls and decubiti information may be acquired from the quality department, for call lights stats have the unit clerk keep a log on all call light activity for two weeks. This process will allow you to demonstrate the positive outcomes from hourly rounding. Next, explain the rounding process to the nursing staff. Making sure to connect â€Å"why† this is being done and â€Å"why† it matters. Ask nurses how often they are in a patient’s room and then reinforce the difference between â€Å"checking† on a patient and performing the eight behaviors associated with hourly rounding. Some nurses may state that they are in the patient’s rooms often. However, the nurse manager will still receive complaints from patients about not seeing their nurses. Nurses are in some patient’s rooms often, while not being in others rooms at all. Hourly rounding will help to ensure that every patient sees their nurse hourly. Assess the Steps in Hourly Rounding As the hourly rounding is being implemented it is important to recognize and reward the nurses who are consistently performing the hourly rounding behaviors. The eight behaviors are (Studer Group, 2010): 1. Use opening key words to decrease anxiety 2. Perform scheduled tasks 3. Address the â€Å"3 p’s† – pain, potty and position 4. Assess additional comfort needs 5. Conduct environmental assessment 6. Ask â€Å"Is there anything else I can do for you? I have time. † 7. Tell each patient when you will be back 8. Document the process in a rounding log posted in the patients room These behaviors help to create a specific desired outcome. Thank your nurses for incorporating this best practice into their daily routines. Ask the nurses what the positives have been, and are there any barriers that the nurse manager needs to address. The Three Stages to Implementing Hourly Rounds There are three stages to implement changes. They are unfreezing, moving and refreezing (Grohar-Murray Langan, 2011). Unfreezing is the breaking of the old practices and habits. In order to be successful in this stage, the nurse needs time to process the information along with positive motivation as to why this change is needed. The next stage is moving. This step requires reeducation with exactly what is expected during this change, and the tools that will be needed. As the nurse manager, you will need to reinforce how this change will increase patient care and safety. The last stage is refreezing. This stage shows consistent evidence that the change is stable, integrated, and internalized by the staff. The nurse manager  will need to continue to monitor the effectiveness of the change. This can be done by having the unit clerk continue to log the call bells, doing their own rounding on the patients, and evaluating the feedback from the nurses and patients Skills for the Change Agent The skills needed for a change agent are experience, success, respect, and leadership skills, and management competencies (Grohar-Murray Langan, 2011). A change agent is any one who has a positive attitude, communicates the goals of the organization and is willing to get involved to help facilitate these goals. Strategies to Improve Responses to Change Strategies that could be used to improve responses to change could be to continue to educate the nurse on the importance of the change. Another strategy may be to educate the staff on how the change will help to improve patient care and will also give them more time. Make sure to have conversations about what the expectations will be in regards to the extra time the nurses will have. Also, allow them to suggest their ideas, and concerns about the extra time. It is important to identify to each individual nurse how they are doing in the change process. The nurse manager should discuss the positive areas that they are achieving and where they could still improve. This communication will allow the nurse to know where he/she stands in their performance. It also gives the nurse manager a way to document each nurse’s response to the change and identifies which ones need further education and /or reinforcement of the change. Evaluation of the Change of Hourly Rounding Once hourly rounding has been implemented you will need to evaluate the success of the implementation. This can be done through clinical quality, patient satisfaction, and efficiency. The nurse manager should think about where to display the number of days without a fall and without a hospital acquired decubiti, what questions on the patient satisfaction survey will be watched closely to evaluate the success, and when to re-measure the number of call lights to ensure the achievement of the decrease. Once this information has been identified and collected, the nurse manager can present it to the staff. This should be done so that the information resonates to the employee’s. An example could be to show a math equation of how many call lights the unit started with, minus the amount of call lights there are now. Then make this information meaningful by showing how much time was saved and by saving time, how many nurses can now have a 30-minute lunch break! Conclusion Hourly rounds get results. When staff members start seeing the results, they will naturally strive to become even more efficient and effective. Once the staff sees how much happier and healthier their patients are because of hourly rounds, this will increase their enthusiasm. Hopefully, this will make the staff more willing to give other changes a chance, and their organization will keep getting better and better because of these changes.