Abuse Institutional Abuse Essay

Unit 204 – Principles of safeguarding and protection in health and social care The numbers in the bracket after each question relate to the assessment criteria in the standards UNIT 4222-205 1. Define the following types of abuse: (1.1.1) see more:reports into serious failures to protect individuals from abuse †¢ Sexual abuse Sexual abuse is the forcing of undesired sexual behaviour by one person upon another †¢ Emotional/psychological abuse Emotional/psychological abuse may involve threats or actions to cause mental or physical harm; humiliation; voilation †¢ Financial abuse Financial abuse is the illegal or unauthorised use of a person’s money, property, pension book or other valuables. †¢ Institutional abuse Institutional abuse involves failure of an organisation to provide appropriate and professional individual services to vulnerable people. It can be seen or detected in processes, attitudes and behaviour that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, stereotyping and rigid systems. †¢ Self neglect Self-neglect is a behavioural condition in which an individual neglects to attend to their basic needs, such as personal hygiene, feeding, clothing, or medical conditions they might have. †¢ Neglect by others Neglect is a passive form of abuse in which the wrongdoer is responsible to provide care, for someone, who is unable to care for oneself, but fails to provide adequate care to meet their needs. Neglect may include failing to provide sufficient supervision, nourishment, medical care or other needs. 2. Identify the signs and/or symptoms associated with each type of abuse (1.1.2) 3. Describe factors that may contribute to an individual being more vulnerable to abuse (1.1.3) 4. Explain the actions to take if there are suspicions that an individual is being abused (2.2.1) 5. Explain the actions to take if an individual alleges that they are being abused (2.2.2) 6. Identify ways to ensure that evidence of abuse is preserved (2.2.3) 7. Identify national policies and local systems that relate to safeguarding and protection from abuse (3.3.1) 8. Explain the roles of different agencies in safeguarding and protecting individuals from abuse (3.3.2) 9. Identify reports into serious failures to protect individuals from abuse (3.3.3) 10. Identify sources of information and advice about own role in safeguarding and protecting individuals from abuse (3.3.4) 11. Explain how the likelihood of abuse may be reduced by: (4.4.1) a. person-centred values b. active participation c. promoting choice and rights 12. Explain the importance of an accessible complaints procedure for reducing the likelihood of abuse (4.4.2) 13. Describe unsafe practices that may affect the wellbeing of individuals (5.5.1) 14. Explain the actions to take if unsafe practices have been identified (5.5.2) 15. Describe the action to take if suspected abuse or unsafe practices have been reported but nothing has been done in response (5.5.3)

Marijuana Legalization Outline

The Legalization of Marijuana Thesis Statement: The legalization of marijuana in the United States would create a drastic change by forming a more productive society through all of the positive uses of cannabis, physically, economically, and socially. I. Examination of the plant A. The other common names—hemp, cannabis, bud, and weed B. Society’s views on the plant are very stereotypical 1. Known as harmful, deathly, and hazardous 2. It is said that one’s attitude can be alarming and harmful to others C. Marijuana can be consumed in baked goods, vaporized, or even brewed 1. Brownies can be cooked with marijuana . Tea or coffee can be brewed with the plant D. THC is the main chemical 1. The amount can be regulated 2. It determines the strength of the high E. Marijuana has been proved to help and cure many diseases and health problems 1. Glaucoma, epilepsy, arthritis, chronic pain, and depression can be cured and prevented with the use of marijuana 2. Marijuana can even help one with aids II. Past legality in the United States A. At one point in time, it was 100% legal 1. It was one of the largest agricultural crops in the world 2. The first law to exist in the U. S. was a law demanding the U. S. armers to grow hemp B. In 1920, cannabis, hemp, and marijuana became illegal 1. It remained illegal until World War II 2. In 1948, all forms of marijuana were illegal again and still remains to be illegal. III. The United States’ debt and taxation A. As of February of 2013, the national debt was $16,797,828,899,087. B. The death rates are more common for other abused substances 1. 50,000 people each year die from alcohol poisoning. 2. More than 400,000 deaths are attributed to tobacco smoking. 3. There are zero deaths related to the use of cannabis. C. The amount of Americans who smoke is substantial . 25 million Americans smoke marijuana in the past year. 2. More than 14 million people smoke regularly. D. Enforcing marijuana prohibition costs taxpayers an estimated $10 billion annually. 1. More than 750,000 individuals are arrested per year 2. The amount of money taxpayers pay to equip the state and federal prison facilities is substantial and would decrease with the legalization of marijuana IV. Regulations in stores vs. on the streets A. Cigarettes and alcohol are monitored 1. One must be 18 to purchase any tobacco product 2. One must be 21 to purchase an alcoholic beverage B.Marijuana is sold on the streets to anyone who wishes to purchase it 1. The legalization could help prevent the smoking of underage teens 2. Crime rates would decrease, as well as drug cartels V. Dangers A. Studies of the harm to the body caused by marijuana 1. It shows no sign of brain cell damage 2. Not one case of lung cancer has been found caused solely by marijuana B. Overdose will not occur if one smoked too much 1. One would have to smoke 750 joints in about 20 minutes 2. One wouldn’t die from smoking marijuana where the death would be caused from carbon monoxide poisoning VI.California A. Decriminalized Marijuana 1. California was the first state to decriminalize it 2. The crime percentage dropped by 24% VII. Legalization in Colorado and Washington A. Illegal to anyone under the age of 21 1. An adult can legally possess up to 1oz of dried marijuana, 16oz of marijuana solids (edibles), and 72oz of cannabis infused liquids 2. Minors are still arrested and/or charged and will face sentencing B. Public consumption would remain a violation in both states, but a civil, not criminal, one 1. Crime rates have decreased 2. Debt has decreased

Cardiovascular Diseases

Cardiovascular disease Introduction Heart disease is No. 1 killer disease worldwide. It causes 12 million deaths annually. Thanks to the rising health awareness and government programmes this number significantly reduce during last 30 years. Coronary heart disease and cardiovascular disease Cardiovascular diseases are diseases of the heart (cardiac muscle ) or blood vessels (vasculature).Cardiovascular disease (CVD) means all the diseases of the heart and circulation (blood vessels disease) including coronary heart disease (angina and heart attack) and stroke, as well as coronary and periphery blood vessels disease (problems with circulation). Diseases from this group are the biggest killer in Europe and USA, but developing and non-develop countries too. The final and most tragic consequence of different types of heart disease is heart attack with tragic consequences. Heart diseases are caused by atherosclerosis, a disease of arterial blood vessels resulted from atheroma i. . plaques accumulated (forming; sticking) on artery walls which makes the blood vessels nonelastic and narrowed and leads to decreased blood flow. For the atherosclerosis doctors very often use alternative name chronic cardiovascular disease. The opposite group acute heart disease made group of diseases which are dangerous for patients lives. Acute heart diseases include conditions or illnesses which usually have a rapid onset of symptoms and may resolve within days with or without treatment.A condition or illness that is sudden or severe. On the other hand a condition or illness that arises slowly over days or weeks and may or may not resolve with treatment made a group of chronic heart disease. Both of them are caused by atheroma and the most known are next: a) Acute heart disease Heart attack is caused by lack of O2 in heart muscle cells. Very often it is caused by rupture of â€Å"hard plaques† patches which result in blood clots and partially or completely block blood flow and ca use a heart attack.When a fiber cap becomes thin, these â€Å"hard plaques† can suddenly rupture, spilling their contents, resulting in blood clots that partially or completely block blood flow and cause a heart attack http://www. authorstream. com/Presentation/nitin-35423-heart-diseases-science-technology-ppt-powerpoint/ Cholesterol glossary. http://www. mybwmc. org/library/28/000225 Stroke Stroke is death of brain cells caused by obstructed blood flow to parts of the brain. Since the level of LDL cholesterol is main cause of narrowed of blood vessels, it is necessary control it. If not treated properly, high LDL cholesterol can cause a stroke.Cholesterol glossary. http://www. mybwmc. org/library/28/000225 b) Coronary heart disease Heart disease (coronary heart disease), When the plaque build up in th conorary arteries heart does not get sufficient blood, the condition is called coronary artery disease or coronary heart disease. Atherosclerosis is a disease of arterial blood vessels in which plaques form on artery walls. This is a consequence of different substances circulating in the bloodstream (inflammatory cells, proteins, cholesterol and calcium) sticking inside the vessel walls. Plaque patches influence on narrowing blood flow in the artery. ttp://www. bodybuilding. com/fun/gastelu5. htm Peripheral artery disease (reduced blood flow in the limbs, usually the legs Coronary plaque Coronary plaque is a term which use in practice as a synonym for atheroma or atherosclerosis. Patches of atheroma are formed from substances that circulate in the bloodstream. They consist of lipid, or fat, cores covered by collagen fiber caps which are sticking to the inside of the vessel walls. Over time plaque or patch of atheroma increases making an artery narrower and the blood flow through the artery is reducing.We can see the changes in blood vessels caused by plaque in the Figure 1. Figure 1 Artery with the patches of atheroma – plaque Preventing Cardiovasc ular Diseases. Patient. co. uk. emis < www. patient. co. uk/health/Preventing-Cardiovascular-Diseases. htm> (March 13, 2013) http://medicineworld. org/blogs/heart/blog/permalinks/Jan-2006/coronary-plaque-detection-by-molecular-imaging. html> (March 13, 2013) Mature plaques typically consist of two main components: soft, lipid-rich atheromatous â€Å"gruel† and hard, collagen-rich sclerotic tissue.Lipid-rich and soft plaques are more dangerous than collagen-rich and hard plaques because they are more unstable and rupture-prone and highly thrombogenic after disruption. Researchers have found that many people who have heart attacks do not have arteries narrowed by plaque. Many heart attacks are now known to be caused by soft or vulnerable plaques, located on an inflamed part of an artery. This plaque can burst, leading to the formation of a blood clot that can cause a heart attack. The 2009 issue of â€Å"The American Journal Pathology† edited explanation of those relatio ns discovered by Olga Ovchinnikova and er colleagues. They found that inflammation results in the formation of soft (vulnerable) plaque which is filled with different cell types that promote blood clotting. This leads to a reduction of mature collagen, resulting in thinner caps that are more likely to rupture, even in the cases when total level of plaque isn’t extremely high. The authors advocate different viewpoints about relations between the plaque level and structure, i. e. its influence on heart attack. The first group claims that described types of blockages cause only about 30 percent of heart attacks.On the other hand, some sources state that more than two-thirds of acute coronary events result from rupture of coronary plaques. However problems that plaque creates are extremely dangerous for people’s life and it is very important to prevent and monitor its appearance and changes. Graphs of vulnerable plaque and rupture of plaque which causes a heart attack is p resented below. Figure 2 Vulnerable atherosclerotic plaques. Vulnerable atherosclerotic plaques. A. Atherosclerosis in a chronic disease that leads to plaque rupture and vascular occlusion. B.Cross-section of a lethal coronary plaque rupture. Adapted from Heistad D. Unstable coronary-artery plaques. N Engl J Med. 2003. Atherosclerosis Modeling In-vitro. http://www. remedi. uzh. ch/research/disease. html Figure 3 Plaque Rupture and Heart attack http://hon. nucleusinc. com/generateexhibit. php? ID=30468&A=1027 Factors influencing plaque growth and stability Based on everything mentioned above and medical experience the conclusion about relations between heart attack and other cardiovascular disease and the level of plaque increasing are found.The higher the level of plaque the higher risk of heart disease will be. The level of plaque will increase as the result of high level of cholesterol, type LDL, so called â€Å"bad cholesterol† in blood. When the level of LDL is normal, bl ood can pass in and out of the blood vessels without problems, but if it significantly increase particles of the blood will accumulate and sooner or later provoke trigger (cause) heart attack. Other very important factors influencing plaque level increasing are high blood pressure and cigarette smoking.Both factors accelerate the plaque formation changing (damaging) artery walls and even more, helping cholesterol forming. Medical experience proved that plaque composition and vulnerability (hard or soft plaque) is more responsible for the conversion of a stable disease to a life-threatening condition than the plaque size. Except the plaque vulnerability the risk of plaque disruption is are consequence of rupture triggers (extrinsic forces). Soft plaque – lipid-rich one is more dangerous because of its instability and higher probability for rupture.Even (IAKO) Although â€Å"hard plaque† that one having higher level of calcium influence on the blood vessels walls and the ir â€Å"hardness† experience show that heart attacks are mostly caused by soft plaque disruption. Figure 4 Plaque rupture and its consequences in the form of heart diseases http://www. nature. com/nrg/journal/v7/n3/fig_tab/nrg1805_F2. html Risk factors of coronary heart disease Risk factors influencing cardiovascular disease we can group based on their stability into the three groups: a) Modifiable risk factorsIn this group hypertension is the most dangerous risk factor for heart attacks, but even more for stroke. It is forming as the result of abnormal blood lipid levels which means high total cholesterol, high levels of triglycerides and high levels of low-density lipoprotein or low levels of high-density lipoprotein (HDL). Smoking, physical inactivity, Type 2 diabetes, and a diet full with saturated fats are risk factors strongly influencing the heart disease. All of them are treatable and patients (individuals) belonging into the different types of risk customersâ€℠¢ groups should avoid practice them. b) Non-modifiable risk factorsThe factors from this group mostly are constant, like the case in gender or family history. Others are changing when time is passing, like age and lifestyle and personal habits. Older people have more chance to get heart attack and the man, especially those having â€Å"bad medical history†. Ration between man and woman are changing when women past the menopause. After that the level of risk is similar as the men’s one. As I’ve presented there is direct correlation between cardiovascular disease and condition and health of blood vessels, more precisely of developing atheroma, means level and structure of plaque in vessels.On the other development of plaque and its level is directly influenced by level of cholesterol and some other elements which are connected with individual person and his/her life and genetic predispositions. As with the other diseases everybody has some risk of developing ather oma, but some risk factors increase the risk level for several categories. Those risk factors include: fn 12 †¢Fixed risk factors – factors that person cannot change: oA strong family history which means close relatives who developed heart disease or a stroke before they were 55 (for males) or 65 (for female). Severe baldness in men at the top of the head. oAn early menopause in women. oAge. Older people have more risk to develop atheroma. oEthnic group. Medical data show that people from different ethnic group have different risk for heart diseases. †¢Treatable or partly treatable risk factors include different health problems caused basically by the same causes as the: oHypertension (high blood pressure). oHigh cholesterol blood level. oHigh triglyceride (fat) blood level. oDiabetes. oKidney diseases causing diminished kidney function. All factors from this group have to be controlled and monitor.Any kind of their complication probably will trigger more serious pr oblems such as heart attack or stroke. †¢Lifestyle risk factors that can be prevented or changed. Actually these factors PRETHODE precede to those belonging to the second group. Except the genetic factors way of life and daily habits are the more responsible for different kind of heart diseases. Those factors are: oSmoking (Smoking cigarette increase blood pressure, decrease HDL; damages arteries and blood cells and increases heart attacks. Passive smoking is also a risk factor for cardiovascular disease ) oLack of physical activity. Obesity (People who are overweight (10-30% more than their normal body weight) have 2 to 6 times the risk of developing heart disease. ) oAn unhealthy diet and eating too much salt. oExcess alcohol. Looking on those three groups one can easily conclude that people with â€Å"bad predisposition† having high fixed risk factors have to think about their lifestyle risk factors even more, in order to try to decrease the second group of factors (t reatable or partly treatable risk factors). On the other hand some of risks are more dangerous than the others; for example smoking increases risk for heart disease more than obesity.And of course combination of two or more risk factors increases significantly the level of risks; older man (or woman) who smokes, without physical activity and with bad eating habits has more chance to get some of previously explained disease than the one who have â€Å"just one of bad habits†. The more risk factors someone has the greater is the likelihood that he/she will develop cardiovascular disease, unless taking action to modify his/her risk factors and working to prevent them compromising his/her heart health.That doesn’t mean that people with â€Å"good genes† can be irresponsible and ZANEMARITI risk factors from other groups. With or without genetic predisposition modern life significantly increases a risk of heart disease for everybody. Hormones impact on lipids and othe r risk factors Different numbers of man and women died from heart attack initiated a lot of research about hormones' influence on the risk factor and heart disease development. Number of men died from the heart attack outnumbered the number of women in pre-menopause period, but in the post-menopause data show completely opposite situation.A percentage of women in post-menopause having heart disease and dying from heart attack increase dramatically and now outnumbered the men. The main reasons for those changes are connected to the level of hormones and their influence on level and structure of cholesterol and consequently on risk factors and heart disease. As mentioned before total cholesterol actually is made of two different types of cholesterol: LDL – low density lipoprotein (LDL), so called bad cholesterol and high density lipoprotein (HDL).High levels of LDL cholesterol lead to atherosclerosis increasing the risk of heart attack and ischemic stroke. HDL cholesterol redu ces the risk of cardiovascular disease as it carries cholesterol away from the blood stream. http://www. walgreens. com/marketing/library/careguides/careguide. jsp? docid=000225=28=High%20Cholesterol Estrogen, a female hormone, raises HDL cholesterol levels, partially explaining the lower risk of cardiovascular disease seen in premenopausal women.But after menopause (natural or surgical) when a level of estrogen significantly decreases total cholesterol rises, low density lipoprotein (LDL) cholesterol rises, and high density lipoprotein (HDL) cholesterol does not change or decreases slightly. This is the reason why negative hormones’ effect after menopause increasing more than proportionally. Some authors argue that even influence of estrogen on LDL and HDL level is proved it is yet unclear whether increase in risk is caused, at least partially, by increased level of androgen (the other of hormones belong to steroid as estrogen too), which is characteristics of menopause too. This sexual dimorphism means a lower incidence in atherosclerotic diseases in premenopausal women, which subsequently rises in postmenopausal women to eventually equal that of men. These observations point towards estrogen and progesterone playing a lifetime protective role against CAD in women. As exogenous estrogen and estrogen plus progesterone preparations produce significant reductions in low-density lipoprotein (LDL) cholesterol levels and significant increases in high-density lipoprotein (HDL) cholesterol, this should in theory lower the risk of CAD.UKLOPITI U ONO GORE Among estrogen's positive effects on the heart are: †¢Reducing the LDL (â€Å"bad†) cholesterol in the blood. †¢Increasing the HDL (â€Å"good†) cholesterol in the blood. †¢Helping to keep blood vessels open. †¢Lowering blood pressure at night. †¢Reducing blood viscosity (how sticky the blood is), a property that may cause blood clots which could result in a heart attack o r stroke. Estrogen's effects on clotting are complicated, however, since there also is an increased risk for thromboembolism (a blood clot that blocks a vessel) in women taking estrogen. Possibly enhancing fibrinolysis, which is the body's natural process for breaking down blood clots. Read more: http://ehealthmd. com/content/what-are-benefits-hrt#ixzz2NbWR3MxY http://ehealthmd. com/content/what-are-benefits-hrt#axzz2NbW1GJJN Nutrition guidelines As presented before three different groups of risk factor exist. Some of them people can change but the other are fixed, non-changeable because they caused by genetic heritage ( ) influences. Controllable factors are connected to the lifestyle of person.Lifestyle changes can prevent or slow the development of coronary plaque and heart disease. In order to prevent a disease development one have to keep track of his/her blood pressure and cholesterol levels. Choosing a heart-healthy diet is vital in controlling weight, which helps keep blood pressure and cholesterol levels down. Foods high in cholesterol and saturated fat should be avoided, and quitting smoking is imperative. Regular exercise and an increased overall activity level contribute to heart health and help reduce stress.The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. e. 150 mins/week minimum). Currently practiced measures to prevent cardiovascular disease include: †¢A low-fat, high-fiber diet including whole grains and plenty of fresh fruit and vegetables (at least five portions a d ay)[29][30] †¢Tobacco cessation and avoidance of second-hand smoke;[29] †¢Limit alcohol consumption to the recommended daily limits;[29] consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30%[31][32] However excessive alcohol intake increases the risk of cardiovascular disease. [33] †¢Lower blood pressures, if elevated, through the use of antihypertensive medications[citation needed]; †¢Decrease body fat (BMI) if overweight or obese;[34] Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week;[29] †¢Decrease psychosocial stress. [35] Stress however plays a relatively minor role in hypertension. [36] Specific relaxation therapies are not supported by the evidence. [37] Routine counselling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended. [38] http://www. news-medical. net/health/What-i s-Cardiovascular-Disease. aspx http://www. barnesandnoble. om/w/prevent-halt-and-reverse-heart-disease-joseph-piscatella/1100260037 Primary and secondary prevention of heart disease It is necessary start with prevention from heart disease as early as possible. Changes in the number of people killed by heart attack in developed countries show that prevention and awareness about this group of disease help to http://circ. ahajournals. org/content/123/20/2274/F2. expansion. html health plans must continue to drive cardiovascular care further along the continuum toward primary prevention of cardiovascular disease (CVD).CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such and event. Ideally, health lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, CVD care can be moved from the inpatient setting to the outpatient setting. Sidney C. Smith Jr, MD. Focus on Cardiovascular Dise ase; A Word About the Quality of Care in Cardiovascular Disease. Director, Center for Cardiovascular Science and Medicine University of North Carolina at Chapel Hill. http://www. qualityprofiles. rg/leadership_series/cardiovascular_disease/cardiovascular_introduction. asp Key priorities for implementation Primary prevention of CVD †¢For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk †¢People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records †¢Risk equations should be used to assess CVD risk People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: opresen ts individualised risk and benefit scenarios opresents the absolute risk of events numerically ouses appropriate diagrams and text (See www. npci. org. uk) †¢Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible.Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) thyroid-stimulating hormone (TSH) if dyslipidaemia is present †¢Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes or people in high-risk ethnic groups) †¢Treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg.If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. Secondary prevention of CVD †¢For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated.Assessment sho uld include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) othyroid-stimulating hormone (TSH) if dyslipidaemia is present. Statin therapy is recommended for adults with clinical evidence of CVD †¢People with acute coronary syndrome should be treated with a higher intensity statin. Any decision to offer a higher intensity statin should take into account the patient’s informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment †¢Treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvasta tin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin ay be chosen †¢In people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment http://www. eguidelines. co. uk/eguidelinesmain/guidelines/summaries/cardiovascular/nice_lipid_modification. phpHow to lower the risk of cardiovascular disease The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All peop le, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. . 150 mins/week minimum). Cessation of smoking The aim of this measure is complete cessation of smoking and avoidance of second-hand smoke. Patient and their families need to stop smoking. Those who are unable to quit may need professional help in form of counselling, behavioral therapy and even pharmacological therapy. Nicotine replacement therapy (NRT) is the first line choice of medication. Nutrition The aim of this measure is to ensure a healthy diet. Total diet should have no more than 8% (of total energy intake) of saturated + trans fatty acids.All patients are advised to take approximately 1g Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) and more than 2g Alpha Linolenic Acid (ALA) daily. Diet should have vegetables, fruits and legumes, g rain-based foods, moderate amounts of lean meats, poultry, fish and reduced fat dairy products. EPA and DHA can be obtained from oily fish and marine n-3 (fish oil) capsule supplements. Alcohol consumption All patients should be advised to lower alcohol consumption. Men should drink no more than 2 standard drinks per day and women no more than 1 standard drink per day. Physical activityThe aim of this measure is to raise physical activity and exercise to the recommended goal of at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week (i. e. 150 mins/week minimum). Maintaining a healthy body weight The aim should be to achieve a waist measure of less than or equal to 94 cm in men and less than or equal to 80 cm in women. The body mass index (BMI) should be maintained at 18. 5–24. 9 kg/m2 Lowering blood cholesterol The aim of therapy should be to maintain blood cholesterol at: †¢Low density lipoprotein (LDL) at – less than 2. mmol/L †¢HDL – more than 1. 0 mmol/L †¢Triglyceride (TG) less than 1. 5 mmol/L The blood cholesterol can be maintained with the use of pharmacotherapy. Statins are commonly used lipid lowering drugs. Those with diabetes and atherosclerosis need stringent blood cholesterol control as well. Other lipid lowering drugs include fibrates like gemfibrosil, clofibrates etc, Ezetimiber and niacin. Lowering blood pressure High blood pressure is one of the important risk factors for cardiovascular disease. Those with coronary heart disease, diabetes, kidney disease or stroke need tight blood pressure control.The aim should be a blood pressure of less than 130/80 mm of Hg. Diabetes and blood sugar control Those diagnosed with diabetes need stringent blood sugar control to prevent cardiovascular damage. HbA1c levels should be maintained at less than 7%. Other drugs to lower risk of cardiovascular disease Other drugs used to lower risk of cardiovascular diseases include: †¢ Antiplatelet agents – this includes Aspirin and Clopidogrel. These drugs when given to patients with risk of heart attacks may prevent such attacks and events. †¢ACE inhibitors like Enalapril, Captopril, Lsinopril and Cardiovascular Diseases Cardiovascular disease Introduction Heart disease is No. 1 killer disease worldwide. It causes 12 million deaths annually. Thanks to the rising health awareness and government programmes this number significantly reduce during last 30 years. Coronary heart disease and cardiovascular disease Cardiovascular diseases are diseases of the heart (cardiac muscle ) or blood vessels (vasculature).Cardiovascular disease (CVD) means all the diseases of the heart and circulation (blood vessels disease) including coronary heart disease (angina and heart attack) and stroke, as well as coronary and periphery blood vessels disease (problems with circulation). Diseases from this group are the biggest killer in Europe and USA, but developing and non-develop countries too. The final and most tragic consequence of different types of heart disease is heart attack with tragic consequences. Heart diseases are caused by atherosclerosis, a disease of arterial blood vessels resulted from atheroma i. . plaques accumulated (forming; sticking) on artery walls which makes the blood vessels nonelastic and narrowed and leads to decreased blood flow. For the atherosclerosis doctors very often use alternative name chronic cardiovascular disease. The opposite group acute heart disease made group of diseases which are dangerous for patients lives. Acute heart diseases include conditions or illnesses which usually have a rapid onset of symptoms and may resolve within days with or without treatment.A condition or illness that is sudden or severe. On the other hand a condition or illness that arises slowly over days or weeks and may or may not resolve with treatment made a group of chronic heart disease. Both of them are caused by atheroma and the most known are next: a) Acute heart disease Heart attack is caused by lack of O2 in heart muscle cells. Very often it is caused by rupture of â€Å"hard plaques† patches which result in blood clots and partially or completely block blood flow and ca use a heart attack.When a fiber cap becomes thin, these â€Å"hard plaques† can suddenly rupture, spilling their contents, resulting in blood clots that partially or completely block blood flow and cause a heart attack http://www. authorstream. com/Presentation/nitin-35423-heart-diseases-science-technology-ppt-powerpoint/ Cholesterol glossary. http://www. mybwmc. org/library/28/000225 Stroke Stroke is death of brain cells caused by obstructed blood flow to parts of the brain. Since the level of LDL cholesterol is main cause of narrowed of blood vessels, it is necessary control it. If not treated properly, high LDL cholesterol can cause a stroke.Cholesterol glossary. http://www. mybwmc. org/library/28/000225 b) Coronary heart disease Heart disease (coronary heart disease), When the plaque build up in th conorary arteries heart does not get sufficient blood, the condition is called coronary artery disease or coronary heart disease. Atherosclerosis is a disease of arterial blood vessels in which plaques form on artery walls. This is a consequence of different substances circulating in the bloodstream (inflammatory cells, proteins, cholesterol and calcium) sticking inside the vessel walls. Plaque patches influence on narrowing blood flow in the artery. ttp://www. bodybuilding. com/fun/gastelu5. htm Peripheral artery disease (reduced blood flow in the limbs, usually the legs Coronary plaque Coronary plaque is a term which use in practice as a synonym for atheroma or atherosclerosis. Patches of atheroma are formed from substances that circulate in the bloodstream. They consist of lipid, or fat, cores covered by collagen fiber caps which are sticking to the inside of the vessel walls. Over time plaque or patch of atheroma increases making an artery narrower and the blood flow through the artery is reducing.We can see the changes in blood vessels caused by plaque in the Figure 1. Figure 1 Artery with the patches of atheroma – plaque Preventing Cardiovasc ular Diseases. Patient. co. uk. emis < www. patient. co. uk/health/Preventing-Cardiovascular-Diseases. htm> (March 13, 2013) http://medicineworld. org/blogs/heart/blog/permalinks/Jan-2006/coronary-plaque-detection-by-molecular-imaging. html> (March 13, 2013) Mature plaques typically consist of two main components: soft, lipid-rich atheromatous â€Å"gruel† and hard, collagen-rich sclerotic tissue.Lipid-rich and soft plaques are more dangerous than collagen-rich and hard plaques because they are more unstable and rupture-prone and highly thrombogenic after disruption. Researchers have found that many people who have heart attacks do not have arteries narrowed by plaque. Many heart attacks are now known to be caused by soft or vulnerable plaques, located on an inflamed part of an artery. This plaque can burst, leading to the formation of a blood clot that can cause a heart attack. The 2009 issue of â€Å"The American Journal Pathology† edited explanation of those relatio ns discovered by Olga Ovchinnikova and er colleagues. They found that inflammation results in the formation of soft (vulnerable) plaque which is filled with different cell types that promote blood clotting. This leads to a reduction of mature collagen, resulting in thinner caps that are more likely to rupture, even in the cases when total level of plaque isn’t extremely high. The authors advocate different viewpoints about relations between the plaque level and structure, i. e. its influence on heart attack. The first group claims that described types of blockages cause only about 30 percent of heart attacks.On the other hand, some sources state that more than two-thirds of acute coronary events result from rupture of coronary plaques. However problems that plaque creates are extremely dangerous for people’s life and it is very important to prevent and monitor its appearance and changes. Graphs of vulnerable plaque and rupture of plaque which causes a heart attack is p resented below. Figure 2 Vulnerable atherosclerotic plaques. Vulnerable atherosclerotic plaques. A. Atherosclerosis in a chronic disease that leads to plaque rupture and vascular occlusion. B.Cross-section of a lethal coronary plaque rupture. Adapted from Heistad D. Unstable coronary-artery plaques. N Engl J Med. 2003. Atherosclerosis Modeling In-vitro. http://www. remedi. uzh. ch/research/disease. html Figure 3 Plaque Rupture and Heart attack http://hon. nucleusinc. com/generateexhibit. php? ID=30468&A=1027 Factors influencing plaque growth and stability Based on everything mentioned above and medical experience the conclusion about relations between heart attack and other cardiovascular disease and the level of plaque increasing are found.The higher the level of plaque the higher risk of heart disease will be. The level of plaque will increase as the result of high level of cholesterol, type LDL, so called â€Å"bad cholesterol† in blood. When the level of LDL is normal, bl ood can pass in and out of the blood vessels without problems, but if it significantly increase particles of the blood will accumulate and sooner or later provoke trigger (cause) heart attack. Other very important factors influencing plaque level increasing are high blood pressure and cigarette smoking.Both factors accelerate the plaque formation changing (damaging) artery walls and even more, helping cholesterol forming. Medical experience proved that plaque composition and vulnerability (hard or soft plaque) is more responsible for the conversion of a stable disease to a life-threatening condition than the plaque size. Except the plaque vulnerability the risk of plaque disruption is are consequence of rupture triggers (extrinsic forces). Soft plaque – lipid-rich one is more dangerous because of its instability and higher probability for rupture.Even (IAKO) Although â€Å"hard plaque† that one having higher level of calcium influence on the blood vessels walls and the ir â€Å"hardness† experience show that heart attacks are mostly caused by soft plaque disruption. Figure 4 Plaque rupture and its consequences in the form of heart diseases http://www. nature. com/nrg/journal/v7/n3/fig_tab/nrg1805_F2. html Risk factors of coronary heart disease Risk factors influencing cardiovascular disease we can group based on their stability into the three groups: a) Modifiable risk factorsIn this group hypertension is the most dangerous risk factor for heart attacks, but even more for stroke. It is forming as the result of abnormal blood lipid levels which means high total cholesterol, high levels of triglycerides and high levels of low-density lipoprotein or low levels of high-density lipoprotein (HDL). Smoking, physical inactivity, Type 2 diabetes, and a diet full with saturated fats are risk factors strongly influencing the heart disease. All of them are treatable and patients (individuals) belonging into the different types of risk customersâ€℠¢ groups should avoid practice them. b) Non-modifiable risk factorsThe factors from this group mostly are constant, like the case in gender or family history. Others are changing when time is passing, like age and lifestyle and personal habits. Older people have more chance to get heart attack and the man, especially those having â€Å"bad medical history†. Ration between man and woman are changing when women past the menopause. After that the level of risk is similar as the men’s one. As I’ve presented there is direct correlation between cardiovascular disease and condition and health of blood vessels, more precisely of developing atheroma, means level and structure of plaque in vessels.On the other development of plaque and its level is directly influenced by level of cholesterol and some other elements which are connected with individual person and his/her life and genetic predispositions. As with the other diseases everybody has some risk of developing ather oma, but some risk factors increase the risk level for several categories. Those risk factors include: fn 12 †¢Fixed risk factors – factors that person cannot change: oA strong family history which means close relatives who developed heart disease or a stroke before they were 55 (for males) or 65 (for female). Severe baldness in men at the top of the head. oAn early menopause in women. oAge. Older people have more risk to develop atheroma. oEthnic group. Medical data show that people from different ethnic group have different risk for heart diseases. †¢Treatable or partly treatable risk factors include different health problems caused basically by the same causes as the: oHypertension (high blood pressure). oHigh cholesterol blood level. oHigh triglyceride (fat) blood level. oDiabetes. oKidney diseases causing diminished kidney function. All factors from this group have to be controlled and monitor.Any kind of their complication probably will trigger more serious pr oblems such as heart attack or stroke. †¢Lifestyle risk factors that can be prevented or changed. Actually these factors PRETHODE precede to those belonging to the second group. Except the genetic factors way of life and daily habits are the more responsible for different kind of heart diseases. Those factors are: oSmoking (Smoking cigarette increase blood pressure, decrease HDL; damages arteries and blood cells and increases heart attacks. Passive smoking is also a risk factor for cardiovascular disease ) oLack of physical activity. Obesity (People who are overweight (10-30% more than their normal body weight) have 2 to 6 times the risk of developing heart disease. ) oAn unhealthy diet and eating too much salt. oExcess alcohol. Looking on those three groups one can easily conclude that people with â€Å"bad predisposition† having high fixed risk factors have to think about their lifestyle risk factors even more, in order to try to decrease the second group of factors (t reatable or partly treatable risk factors). On the other hand some of risks are more dangerous than the others; for example smoking increases risk for heart disease more than obesity.And of course combination of two or more risk factors increases significantly the level of risks; older man (or woman) who smokes, without physical activity and with bad eating habits has more chance to get some of previously explained disease than the one who have â€Å"just one of bad habits†. The more risk factors someone has the greater is the likelihood that he/she will develop cardiovascular disease, unless taking action to modify his/her risk factors and working to prevent them compromising his/her heart health.That doesn’t mean that people with â€Å"good genes† can be irresponsible and ZANEMARITI risk factors from other groups. With or without genetic predisposition modern life significantly increases a risk of heart disease for everybody. Hormones impact on lipids and othe r risk factors Different numbers of man and women died from heart attack initiated a lot of research about hormones' influence on the risk factor and heart disease development. Number of men died from the heart attack outnumbered the number of women in pre-menopause period, but in the post-menopause data show completely opposite situation.A percentage of women in post-menopause having heart disease and dying from heart attack increase dramatically and now outnumbered the men. The main reasons for those changes are connected to the level of hormones and their influence on level and structure of cholesterol and consequently on risk factors and heart disease. As mentioned before total cholesterol actually is made of two different types of cholesterol: LDL – low density lipoprotein (LDL), so called bad cholesterol and high density lipoprotein (HDL).High levels of LDL cholesterol lead to atherosclerosis increasing the risk of heart attack and ischemic stroke. HDL cholesterol redu ces the risk of cardiovascular disease as it carries cholesterol away from the blood stream. http://www. walgreens. com/marketing/library/careguides/careguide. jsp? docid=000225=28=High%20Cholesterol Estrogen, a female hormone, raises HDL cholesterol levels, partially explaining the lower risk of cardiovascular disease seen in premenopausal women.But after menopause (natural or surgical) when a level of estrogen significantly decreases total cholesterol rises, low density lipoprotein (LDL) cholesterol rises, and high density lipoprotein (HDL) cholesterol does not change or decreases slightly. This is the reason why negative hormones’ effect after menopause increasing more than proportionally. Some authors argue that even influence of estrogen on LDL and HDL level is proved it is yet unclear whether increase in risk is caused, at least partially, by increased level of androgen (the other of hormones belong to steroid as estrogen too), which is characteristics of menopause too. This sexual dimorphism means a lower incidence in atherosclerotic diseases in premenopausal women, which subsequently rises in postmenopausal women to eventually equal that of men. These observations point towards estrogen and progesterone playing a lifetime protective role against CAD in women. As exogenous estrogen and estrogen plus progesterone preparations produce significant reductions in low-density lipoprotein (LDL) cholesterol levels and significant increases in high-density lipoprotein (HDL) cholesterol, this should in theory lower the risk of CAD.UKLOPITI U ONO GORE Among estrogen's positive effects on the heart are: †¢Reducing the LDL (â€Å"bad†) cholesterol in the blood. †¢Increasing the HDL (â€Å"good†) cholesterol in the blood. †¢Helping to keep blood vessels open. †¢Lowering blood pressure at night. †¢Reducing blood viscosity (how sticky the blood is), a property that may cause blood clots which could result in a heart attack o r stroke. Estrogen's effects on clotting are complicated, however, since there also is an increased risk for thromboembolism (a blood clot that blocks a vessel) in women taking estrogen. Possibly enhancing fibrinolysis, which is the body's natural process for breaking down blood clots. Read more: http://ehealthmd. com/content/what-are-benefits-hrt#ixzz2NbWR3MxY http://ehealthmd. com/content/what-are-benefits-hrt#axzz2NbW1GJJN Nutrition guidelines As presented before three different groups of risk factor exist. Some of them people can change but the other are fixed, non-changeable because they caused by genetic heritage ( ) influences. Controllable factors are connected to the lifestyle of person.Lifestyle changes can prevent or slow the development of coronary plaque and heart disease. In order to prevent a disease development one have to keep track of his/her blood pressure and cholesterol levels. Choosing a heart-healthy diet is vital in controlling weight, which helps keep blood pressure and cholesterol levels down. Foods high in cholesterol and saturated fat should be avoided, and quitting smoking is imperative. Regular exercise and an increased overall activity level contribute to heart health and help reduce stress.The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. e. 150 mins/week minimum). Currently practiced measures to prevent cardiovascular disease include: †¢A low-fat, high-fiber diet including whole grains and plenty of fresh fruit and vegetables (at least five portions a d ay)[29][30] †¢Tobacco cessation and avoidance of second-hand smoke;[29] †¢Limit alcohol consumption to the recommended daily limits;[29] consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30%[31][32] However excessive alcohol intake increases the risk of cardiovascular disease. [33] †¢Lower blood pressures, if elevated, through the use of antihypertensive medications[citation needed]; †¢Decrease body fat (BMI) if overweight or obese;[34] Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week;[29] †¢Decrease psychosocial stress. [35] Stress however plays a relatively minor role in hypertension. [36] Specific relaxation therapies are not supported by the evidence. [37] Routine counselling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended. [38] http://www. news-medical. net/health/What-i s-Cardiovascular-Disease. aspx http://www. barnesandnoble. om/w/prevent-halt-and-reverse-heart-disease-joseph-piscatella/1100260037 Primary and secondary prevention of heart disease It is necessary start with prevention from heart disease as early as possible. Changes in the number of people killed by heart attack in developed countries show that prevention and awareness about this group of disease help to http://circ. ahajournals. org/content/123/20/2274/F2. expansion. html health plans must continue to drive cardiovascular care further along the continuum toward primary prevention of cardiovascular disease (CVD).CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such and event. Ideally, health lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, CVD care can be moved from the inpatient setting to the outpatient setting. Sidney C. Smith Jr, MD. Focus on Cardiovascular Dise ase; A Word About the Quality of Care in Cardiovascular Disease. Director, Center for Cardiovascular Science and Medicine University of North Carolina at Chapel Hill. http://www. qualityprofiles. rg/leadership_series/cardiovascular_disease/cardiovascular_introduction. asp Key priorities for implementation Primary prevention of CVD †¢For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk †¢People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records †¢Risk equations should be used to assess CVD risk People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: opresen ts individualised risk and benefit scenarios opresents the absolute risk of events numerically ouses appropriate diagrams and text (See www. npci. org. uk) †¢Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible.Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) thyroid-stimulating hormone (TSH) if dyslipidaemia is present †¢Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes or people in high-risk ethnic groups) †¢Treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg.If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. Secondary prevention of CVD †¢For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated.Assessment sho uld include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) othyroid-stimulating hormone (TSH) if dyslipidaemia is present. Statin therapy is recommended for adults with clinical evidence of CVD †¢People with acute coronary syndrome should be treated with a higher intensity statin. Any decision to offer a higher intensity statin should take into account the patient’s informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment †¢Treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvasta tin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin ay be chosen †¢In people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment http://www. eguidelines. co. uk/eguidelinesmain/guidelines/summaries/cardiovascular/nice_lipid_modification. phpHow to lower the risk of cardiovascular disease The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All peop le, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. . 150 mins/week minimum). Cessation of smoking The aim of this measure is complete cessation of smoking and avoidance of second-hand smoke. Patient and their families need to stop smoking. Those who are unable to quit may need professional help in form of counselling, behavioral therapy and even pharmacological therapy. Nicotine replacement therapy (NRT) is the first line choice of medication. Nutrition The aim of this measure is to ensure a healthy diet. Total diet should have no more than 8% (of total energy intake) of saturated + trans fatty acids.All patients are advised to take approximately 1g Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) and more than 2g Alpha Linolenic Acid (ALA) daily. Diet should have vegetables, fruits and legumes, g rain-based foods, moderate amounts of lean meats, poultry, fish and reduced fat dairy products. EPA and DHA can be obtained from oily fish and marine n-3 (fish oil) capsule supplements. Alcohol consumption All patients should be advised to lower alcohol consumption. Men should drink no more than 2 standard drinks per day and women no more than 1 standard drink per day. Physical activityThe aim of this measure is to raise physical activity and exercise to the recommended goal of at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week (i. e. 150 mins/week minimum). Maintaining a healthy body weight The aim should be to achieve a waist measure of less than or equal to 94 cm in men and less than or equal to 80 cm in women. The body mass index (BMI) should be maintained at 18. 5–24. 9 kg/m2 Lowering blood cholesterol The aim of therapy should be to maintain blood cholesterol at: †¢Low density lipoprotein (LDL) at – less than 2. mmol/L †¢HDL – more than 1. 0 mmol/L †¢Triglyceride (TG) less than 1. 5 mmol/L The blood cholesterol can be maintained with the use of pharmacotherapy. Statins are commonly used lipid lowering drugs. Those with diabetes and atherosclerosis need stringent blood cholesterol control as well. Other lipid lowering drugs include fibrates like gemfibrosil, clofibrates etc, Ezetimiber and niacin. Lowering blood pressure High blood pressure is one of the important risk factors for cardiovascular disease. Those with coronary heart disease, diabetes, kidney disease or stroke need tight blood pressure control.The aim should be a blood pressure of less than 130/80 mm of Hg. Diabetes and blood sugar control Those diagnosed with diabetes need stringent blood sugar control to prevent cardiovascular damage. HbA1c levels should be maintained at less than 7%. Other drugs to lower risk of cardiovascular disease Other drugs used to lower risk of cardiovascular diseases include: †¢ Antiplatelet agents – this includes Aspirin and Clopidogrel. These drugs when given to patients with risk of heart attacks may prevent such attacks and events. †¢ACE inhibitors like Enalapril, Captopril, Lsinopril and

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Chemistry - mechanism and synthesis - Essay Example Next, FGI agents are used to convert the methyl group to a nitrile one and the final product – scheme 1, product 2 – is formed. This lithium salt is undergoes acid hydrolysis to form the pentane-2-diol, the hydrate of the ketone, and this, in the absence of the organolithium any excess of which is destroyed by the addition of water, readily decomposes to form the ketone (Taylor, p. 95, 2002). The reagent acts as a source for , that acts as a nucleophile and replaces the leaving group in the halide. This forms the ketone. The organocopper is not strong enough to attack the ketone and the reaction stops here (Taylor, p. 103, 2002). Note to the above diagram: Grignard reagents usually react with carboxylic acid derivatives to form ketones as intermediate substances but ketones cannot be prepared in this manner because they react further with more Grignard reagents to form alcohols. Usually, to prepare ketones, a less reactive organocopper reagent that reacts with the carboxylic derivative but not with the ketone is used (Taylor, p. 84, 2002). In this case, is a nitrile with a functional group that has similar polarisation characteristics to the carbonyl group. Thus, it can undergo addition reaction with the Grignard reagent and form a magnesium salt of an imine. It is notable that the salt has no leaving group and is also negatively charged and does not react further with the Grignard reagent. Thus, it is treated with aqueous acid and the excess Grignard reagent is destroyed and the salt is now converted to the imine – pentane-2-imine. The imine is unstable in the aqueous acidic conditions and readily hydrolyses to the ketone (Taylor, p. 85-86, 2002). This is the least stable radical as the relevant carbocation is flanked on either sides by other carbocations while only one side is somewhat stabilised by the alkyl electron-releasing group (Taylor, p. 126, 2002). (Part b): The technical

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Chapter 7 - Literature review Example Utilizing theoretical and experimental methods, a uniform mathematical model was arrived at that could be applied to small parts of the overall drive cycle to predict fuel consumption without any need for physical testing. The primary objectives of this study were to determine engine speed and engine torque. In addition to the primary objectives, a number of different input and output parameters need to be determined to ensure that the engine is operating within safe limits and optimally. Secondary parameters that required determination and control during testing included (but were not limited to): Measurement of the parameters listed above was done using automated means in order to enhance accuracy (Gitano-Briggs, 2008, p.40). Moreover, this allowed real time monitoring of equipment to perform adjustments online. The primary aim of this research was to examine the fuel consumption of passenger vehicles based on a standardized driving cycle. In addition, this research aimed to explore the development of a mathematical model that could be used to predict the fuel consumption of passenger vehicles. The current research was able to meet its objectives in large part. Laboratory and real life driving provided significant findings on fuel consumption of passenger vehicles. A mathematical model was developed based on the NEDC driving cycle that was validated for most testing regimes in the driving cycle. However, the current mathematical model has certain limitations in the NEDC driving cycle and is also limited for other standard driving cycles. The current research provides a mathematical model for validating fuel consumption over the NEDC driving cycle under urban and extra urban driving conditions. Additionally, laboratory testing of engines was carried out in order to determine operating parameters. Laboratory testing was done through a generator type dynamometer based on engine torque testing. The mathematical

Healthcare services Essay Example | Topics and Well Written Essays - 2000 words

Healthcare services - Essay Example One manifestation of these policies is the appointment of Patient Information Strategy Project Manager (PISPM) at the North Devon Primary Care Trust (PCT). North Devon PCT developed a strategy to involve the public and provide multiple services to enhance the understanding of patient needs within the PCT. They also aim to improve the knowledge based from the patients and general publics' opinion. PISPM post's performances have strengths and weaknesses but they also play an important role in leading this strategy. By improving North Devon Information Strategy, value will be added in developing a greater public involvement in North Devon PCT. Patient & Public Involvement Definition Patient & Public involvement and other allied terms are used to covey a variety of meanings. Public involvement refers to the involvement of individual patients, together with health professionals, in making decisions about their own health care (Florin & Dixon 2004). According to the Department of Health, patient and public involvement is not just about structures, it is a cultural change. It is about empowering patients and the public to have a role in health care society. ... Through these practices, the way to address the needs of the growing number of people with chronic conditions will now be appropriate and effective. Hennessy (2002) pointed out that involving individual encourages and empowers them. The sense of ownership improves health outcomes and patient experiences. On the other hand, the Trusts will also benefit from this involvement. It will provide a more responsive service, which meets the local needs. Involvement in NHS activities encourages staff to consider alternative ways of meeting the care needs and look at providing services from a different perspective which is that of the patients' perspective. Florin & Dixon (2004) indicated that involving the public may help ensure health policy decisions better reflect the values of the community. It will make services more responsive to the individuals and communities who uses them and that more responsive services will lead to improved health. Patient & Public Involvement Policies Policies to encourage public involvement in the NHS are not new. Previous governments have used various policies in an attempt to encourage democratic and informal decisions in the NHS. A review of policies from 1948 to 1997 showed that public involvement in the NHS decreased over this period (Harrison, Milewa and Dowswell 2002). In contrast, Klein & New (1996) reviewed the period from 1990 and concluded that there had been a moderate increase in democracy in the NHS. Since the Labor government came to power in 1997, a new raft of policies has been introduced with the stated aim of increased public or patient involvement. The NHS Plan, published in July 2000, aimed to give the

Teaching with Tech by Vicky Hallett Essay Example | Topics and Well Written Essays - 1000 words

Teaching with Tech by Vicky Hallett - Essay Example According to Hallett, numerous academic institutions in the United States (US), particularly in the tertiary level, strive to employ the latest technological innovations in the classroom setting. For instance, colleges and universities including the John Hopkins University, Massachusetts Institute of Technology among others encourage the use of gadgets like camera phones, Wi-Fi laptops, course websites and other classroom technologies. The application of these new techniques has substantially revolutionized the learning process. In her article, Hallett asserts that the introduction of each new tool in the classroom brings about opportunities to further enhance the education process and results in the development of new learning models. Indicative of the significant contribution of technology to education, the term "e-learning" was coined. This refers to the use of multi-media technology to support learning and teaching. There are numerous instances that illustrate how technology has improved teaching and learning. For example, utilization of e-learning tools such as web-based courses and podcast lectures has made learning and teaching more flexible. Given these tools, students may easily access lectures of modules anytime, even outside the campus, through the internet. These tools enable students to conveniently review lecture notes or recorded lecture provided online if they misses any important point or find a particular lesson difficult. With these features, the education process is improved such that students are able to learn at their own pace ("Laying the foundation for the Future of Digital Learning," 2004). Similarly, technology has rendered support to teachers by providing additional avenues for learning. By using technology, teachers are able to create a relatively more interactive learning environment. Hallett cites the John Hopkins University as an example. In its biology class, all students are provided with thin blue devices which resemble remote controls. These devices make it possible for the professor to track students' participation. As the teacher flashes a question and corresponding choices on the monitor, students use their devices for pointing their answers on the screen. Similar to "Who Wants to be a Millionaire" their responses are then tabulated to gauge their comprehension of the subject matter presented. Aside from the use of Microsoft Powerpoint, Macromedia and other computer programs for presentation, Hallett also mentions the use of gaming concept in teaching. As more and more students become obsessed with Xbox and Playstation, teachers attempt to use these technological tools to promote interactive learning. Games like "The Sims" and "Civilization" have become part of some teachers' lesson plan. These make lessons more fun and sustain students' attention span. In response, software companies have also released new games which are in line with a specific course.An example of this is "Making History" created by Muzzy Lane Software. This video game allows students to play the role of World War II leaders and use critical thinking as well as teamwork to triumph by coming up with sound political and military judgments.

The killing of US citizen Anwar al Awlaki in Yemen Research Paper

The killing of US citizen Anwar al Awlaki in Yemen - Research Paper Example President Obama sought to justify the killing by stating that Anwar and his Al-Qaeda affiliates guided a failed trial or attempt to bomb an airplane in December 2009 during Christmas celebrations. Further, the president stated that Anwar also directed a failed trial to bomb an American cargo aircraft in 2010 (CBSNEWS.Com, 2012). The killing of Anwar al-Alwaki by a missile assault elicited a heated debate on the U.S justification of using lethal force against American citizens. For the first time since the end of American civil war, the U.S government had conducted an intentional and deliberate killing or murder of an American resident or citizen as a wartime foe and in absence of trial. The American government tried to keep the matter a secret but the choice to hunt and murder Anwar became an issue of public debate and scrutiny. Some American wondered the limitation of the powers of the president if he can order the killing of Americans abroad based on secret intelligence. It is significant to note that the killings of Anwar in Yemen brought in new information about the intelligence, military and legal challenges that the U.S government faced. This is because it shows the risks or perils of war, depending on missile strike from drone rarely recognized by the U.S citizens and intricate justifications written for only a selected few officials to read (The New Times, 2013). It is believed that Anwar al-Alwaki and Samir Khan who killed in the drone strike were al-Qaeda operational leader in Yemen. The two were U.S citizens who had never been accused by the American government nor indicted with any crime. The secrecy behind such drone strikes emerged as major issue because of the legal and ethical issues involved in the killings (Wilson Center, 2012). Information from the U.S department of Justice asserted that the drone missile

Barnabas Medical Centre Essay Example | Topics and Well Written Essays - 1750 words - 14

Barnabas Medical Centre - Essay Example 2. The power boundary between Dr. Tony, the Associate Chief Medical Officer, and the departmental managers could jeopardize this process, especially if Dr. Tony opted not to cede power to them to come up with a solution to the problem facing BMC. Â  There could also be a conflict between the departmental managers as they sought to establish how each department influences the other. This was overcome through Dr. Tony’s effective relationship and communications management. Â  3. In this case, leaders encompass all that offered support and facilitation in the process. Dr. Tony exhibited emotional intelligence as a leader, self-motivating and motivating other members of staff towards the realization of the intended goal and showing social awareness. He shared authority and collaborate knowledge. Departmental managers exhibited their active leadership by engaging in the problem-solving process at BMC. Â  4. The factors that made the collaborative effort successful included Dr. Tony’s effective collaborative leadership and his effective management of communications and relationships. His knowledge of BMC’s ED situation and knowledge and skills on healthcare operations also made the collaborative effort successful. Â  1. The leader-followers boundary posed a challenge as the followers (medical staff) could resist the change by their leader, Dr. Till, in adopting the proposed changes. There was also a challenge between the organization and the government, such that, whereas the hospital management seeks to provide the best services to Willow Springs residents, the government cuts the needed financial aid. Â  2. Dr. Till is a leader in this case, having ceded his power to the medical staff to allow them to come with effective solutions for Willow Springs residents. He served as a servant leader by supporting and facilitating the workload with the medical staff.

Performance Management in International Human Resource Management Essay

Performance Management in International Human Resource Management - Essay Example e to employees that the company is committed to the wellbeing of its employees, and in developing a management that will provide assistance for both the company and its employees. Further, employees are likely to perceive HR practises as effective with the use of communication through information sharing, communicating with supervisors,  promotes employee’s understanding of the purposes and expectations (Edgar & Geare, 2005). Previous studies have stated that HRM practise predicts employee attitudes (Edgar & Geare, 2005). Specifically, when these practises are implemented properly with motivating factor, proper leadership, and communicated well to the employees, the organisation could produce a gratifying attitude from the employees (Edgar & Geare, 2005). In addition, implementing an effective HRM practises could affect the output of the employees in accordance with firm performance. Employees could become more productive and more committed to the organisation (Huselid, 1995; Delaney & Huselid, 1996).  Ã‚  Ã‚  Ã‚   HRM practise is an important topic in the field of human resource since it increases the level of motivation, working habits, skills, and abilities of employees (Delaney & Huselid, 1996). With good implementation of various HRM practises, organisations could retain talented employees. These could also serve as a communication tool between the employer and the employee since it sends messages that the employee could use to make sense and define the essence of their work (Bowen & Ostroff, 2004). In addition, the existence of HRM practises has positive effects since it delivers a message to employees that the company is devoted to the welfare of the employees, and in developing management that will benefit both the company and its employees. Further, employees are likely to perceive the HRM practises as effective with the use of communication through information sharing, communicating with supervisors,  promotes employee’s understanding of the purposes and

A Comedy in Two Acts Essay Example for Free

A Comedy in Two Acts Essay A naive yet charming sixteen year old going out on her first date. She is the youngest of three sisters and was raised mainly by her traditional mother. She often finds herself caught between her mothers’ traditional views and her older sisters’ modernity and aggressiveness. She admires her sister Georgia the most for her individuality and sense of freedom. (Definition of Feminine – Gentle (easily handled) by Bernessa Wilson, co-worker; Timid (shy) by Pam Magel, co-worker; Weak (soft) by John Nowicki, co-worker. ) MARTHA – The matron of the house and mother of Olivia, Georgia, and Julia. Her petite frame belies a strong and rugged personality. She is around forty years old and although she shows signs of age and weathering, she wears it with grace and a quiet self-assurance. Her husband passed away early and she has had to raise her daughters by herself on meager savings and odd jobs. Julia is her favorite daughter. (Definition of Feminine – Corsets by Craig Jensen, co-worker; Modest (not bold) by Johannes Laun, boss) TYRA – A close friend of Olivia. She is in her early thirties and although her occupation is not clear to us, it seems evident that she is some kind of model or works in television. She has fashionably short hair and a very slim and long legged body. She has a beguiling charm about her and is not shy to use it on men in order to have her way. She views being feminine as an asset and uses it to her advantage. (Definition of Feminine – Cleavage by Dave Atkins, co-worker; High heels by Matt Tuttle, co-worker; Beauty by Danya Slozerek, co-worker) OLIVIA – The eldest of the three daughters and the most accomplished. She is in her early thirties and works as a senior executive in a bank. She is slim and pretty but has an air of manly seriousness about her and this makes her even sexier. She is the archetypal modern independent woman and views femininity as a liability in her predominantly masculine world. She has learned how to be taken seriously without losing her sense of femininity. (Definition of Feminine Elie Tahari’s shoes designed to let a woman’s true beauty shine through. Made in fine fabrics and leathers, Tahari shoes feature clean lines and tasteful embellishments. His designs are smart, sexy, and feminine) GEORGIA– The middle child in the family and somewhat boyish. She is similarly pretty like her two sisters but is less self-conscious about herself. With strong traces of Audrey Hepburn, she embodies Ralph Lauren’s vision of a modern denim version of the traditional Gregory Peplum Jacket – modern, practical and rugged yet somewhat delicate and fanciful at the same time. (Definition of Feminine: Ralph Lauren describes the Gregory Peplum Jacket as an inspiration, which lends a modern edge to the structured stretch denim jacket, defined by its shape, a feminine flared peplum and puffed sleeves. ) BEN – Julia’s date for the night. A shy and awkward sixteen year-old. ACT ONE: Before us is a modest two-story house. It is around 6pm in the afternoon and the sun is just about to set. The ground floor of the house is divided into a sparsely decorated living room to the right and a dining room and kitchen to the left, separated by a swinging door. The front door opens to the right side of the living room while the back door opens to the left of the kitchen. The living room holds a practical yet smart looking leather couch big enough to seat four and matching wooden chairs around a low glass coffee table with a few magazines. A stairway behind the couch leads upstairs to a woman’s peach-walled bedroom. In the living room, Olivia is seated casually on the couch browsing through a copy of Vogue. She is dressed in a blazer and a skirt and looks as if she has just come home from the office. Georgia is looking through some bills and writing down some notes on a notebook. She is wearing a slim fitted denim Peplum jacket and purple pajama pants. In the kitchen, Martha is quietly preparing food in a plain dress and apron. Upstairs Julia (in a red dress) is seated in front of an ornate ivory colored powder table with a large oval shaped mirror. She is sitting unnaturally straight with her chin up to the mirror looking in mild anxiety as Tyra (dressed in a white tank top and tight dark jeans) puts make up on her. TYRA: There†¦ that’s it! You’re all set baby girl. JULIA: (stands up and twirls around looking at herself in the mirror) TYRA: Damn I wish my ass still looked that good! JULIA: (blushes in embarrassment) What? Don’t you think it’s too much? Maybe I should†¦ TYRA: (interrupts quickly) I’m just kidding dear, you look great and that’s how you’re supposed to look. Besides boys love older looking women. And I know that for a fact (winking at Julia). JULIA: (tentatively) Umm†¦ maybe I should just wear my jeans and pink sweater. I don’t think we’re going anywhere that fancy anyway. TYRA: Hell no! (defiantly) If that boy’s worth anything he’d better be taking you somewhere where they at least serve some Cabernet. And if he’s not planning to well baby we’re sure as hell going to make him. JULIA: (exasperated) But I’m not even allowed to drink! GEORGIA: (calls from downstairs) Hey Julia come on lets see you! JULIA: (calls back) Coming! TYRA: All right, go on now (heading towards the door) Julia goes down the stairs followed by Tyra. Both Georgia and Olivia look up from their business and look admiringly at Julia. Julia walks down the stairs gingerly in new strappy heels and in a slightly skimpy maroon dress. She looks beautiful but awkward as if her clothes are itching her. GEORGIA: (in admiration) Oh Julia! You just look absolutely lovely. OLIVIA: Wow nice work Tyra. Yeah Jules you look fantastic. You’re going to break some hearts tonight. JULIA: (unsure) Do you really think so? Don’t you think it’s a bit too much? Aunt Tyra picked out this dress from some Italian woman’s shop. I think it’s supposed to be for adults. TYRA: Darling please, I’m too young to be your aunt. And I bet there are going to be girls younger than you trying to dress like Paris Hilton with skirts ten times shorter than that. You have to show those boys what you got. MARTHA: (Enters from the kitchen carrying a teapot. She looks at Julia in both shock and awe. ) Julia?! Oh my! Where on earth did you get that dress? Cover your chest young lady! OLIVIA: (guffawing in disbelief) Oh please mother! It’s called cleavage and it seems to be the most highly prized commodity a woman can posses these days. GEORGIA: (in a calm soothing voice) It’s alright mother that’s a very conservative dress by today’s standards. Besides I’m sure Julia here has the best reputation as a lady (smiles warmly at Julia). JULIA: (stuttering) Y†¦yes mother I promise to be at my utmost behavior tonight. MARTHA: (loudly to Georgia) I don’t care what today’s standards are. If I followed today’s standards I’d be dressed in a bikini mowing the lawn. I know what’s right and proper for a lady and that dress does not look proper to me. (turns her attention to Julia and addresses her patiently) Oh my sweet innocent child, I just don’t want boys to get the wrong idea about you Julia, you’re such a sweet sweet girl and I don’t want you turning into a†¦(stops herself as she glances involuntarily at Tyra and Olivia). OLIVIA: (completing her mothers sentence)†¦into a successful empowered woman? (says defiantly) The days of housewives are over mother. These days either a woman fends for herself or she gets stuck with three kids in a tiny one bedroom apartment while her husband elopes with some nineteen year old intern. MARTHA: (looks as if about to shout but then collects herself and says resignedly to Julia who looks at her pleadingly with puppy eyes) Well dear†¦ at least just put a jacket on won’t you? So you don’t catch a cold? TYRA: (enjoying the tirade) Oh don’t worry I took care of that too. She won’t be catching any colds tonight. I already showed her how to put on a jacket. (gives Julia a sly wink) JULIA: (looking puzzled) †¦a jacket? MARTHA: (looks threateningly at Tyra and starts to open her mouth) OLIVIA: (gives Tyra a look of warning) GEORGIA: (stands abruptly) Come mother! I’ll help you dinner. MARTHA: (takes a deep breath) No it’s alright it’s already done, let’s just all sit down and have some tea. TYRA: (smiling apologetically) Let’s! Anyways, so Julia why don’t you tell us a little about this boy toy of yours. What car does he drive? I for one would never go out with a guy who drives anything less than a BMW. MARTHA: (surprised) Driving?! Oh I’m sure he’s too young to drive. And where will you be going anyway? JULIA: Well his dad usually drops him at school everyday so I don’t think he drives yet. But I think we’ll just be walking tonight mother, we’re only going to the plaza down the block for a burger. TYRA: The plaza? For a burger? Baby with you looking like that it ought to be a damn expensive burger. Well the least he can do is bring us home some of apple pie and chocolates. And if he gives you anything less than half a dozen roses†¦ MARTHA: (interrupts Tyra) Well if he does bring a car I don’t want you to spending any time in there you here me? You just finish your dinner and you order him to take you back home you understand? GEORGIA: (laughing) Mother please! Let the young lady enjoy a night out. JULIA: (in eager agreement to Martha) Yes mother, I promise I won’t even hold his hand, we’re only friends that’s all. Besides Ben is a nice boy, all the teachers like him MARTHA: Oh I know all those tricks the boys use these days, they haven’t changed since your father. Sure he may have gotten me at first but I won in the end. OLIVIA: Mother please can we have one day of not mentioning dad? MARTHA: (ignoring Olivia) But men†¦boys these days, you just don’t know what to think of them†¦ OLIVIA: I’ll tell you what to think of them sis, they are absolutely useless. All they’re good for is making babies. All I need is a decent good-looking guy to get me pregnant and I can live peacefully. The doorbell rings and all the women stop and look at the door, then look at each other questioningly. JULIA: (nervously) That must be him! MARTHA: Alright girls behave yourselves. Julia, go upstairs and put on a jacket. JULIA: (looks at Georgia for help) GEORGIA: Just go put a jacket on honey, you can take it off later if it gets warm. JULIA: Ok mother. ACT TWO The setting is in an old-fashioned diner where a few other young people are having burgers and fries. BEN: Boy you sure have one weird family†¦that’s a really nice dress. You look really uh†¦grown up. JULIA: Thanks Ben, my aunt Tyra got it for me. BEN: Well your aunt sure knows how to dress up. JULIA: I know, you sure couldn’t seem to keep you eyes off her. BEN: uhh†¦well (blushes) JULIA: I’m just kidding Ben, (brushes her hand against his hot cheek) BEN: (becomes flustered) JULIA: (enjoying the moment) So have you ever kissed a girl before? BEN: um†¦well (becomes even redder) JULIA: (coyly) Would you like to? BEN: (looks at Julia in disbelief) uhhh†¦ JULIA: But first you have to promise me something Ben. BEN: (quickly) Sure, I mean anything. JULIA: Promise you’ll take me to the movies next week? And we can have dinner in a nice restaurant. Somewhere with ca-ver-nay. (trying to say Cabernet). BEN: (tentatively) Yeah, yeah sure. JULIA: (excitedly) Great! And you can bring me a dozen roses for me to put in my room when you pick me up in a car. BEN: Uh†¦ a car? Yeah sure. JULIA: (suddenly) Oh! And Ben! BEN: (starting to get scared) yes? JULIA: The car that your dad drives†¦ BEN: uh-huh JULIA: It’s a BMW right? Curtain Falls The End

Free

Free Will and Schopenhauer Essay Free will is considered as having the ability to choose a course of action solely based on one’s character. Immanuel Kant argues that humans have free will and act accordingly, while Arthur Shopenhauer suggests that humans are delusional and desire to have free will, yet they are lead by laws of nature and motives only. Perceiving ourselves as acting with free will is just to satisfy the metaphysical requirement on being responsible for ones action. Free will is a phenomenon that does not exist; what is perceived to be free will is causes that we act upon and motives that drive us to do so. Every single action needs a cause to act upon. .Kant connects free will with morality and implies that morality lies within reason. He does not really explain free will but only refutes objections against it by stating that we are free by knowing we have duties. His argument suggests that even though we have morals we can always act immorally, by having the ability to act otherwise we have free will. Shopenhauer’s water example proves otherwise. â€Å"This is exactly as if water spoke to itself: â€Å"I can make high waves (yes in the sea during a storm), I can rush down hill (yes! in the river bed), I can plunge down foaming and gushing (yes! In the waterfall), I can rise freely as a stream of water in the air (yes! In the fountain) I can, finally, boil away and disappear (yes! At a certain temperature); but I am voluntarily remaining quiet and clear in the reflecting pond. † This example is deterministic and proves that in order for the water to do all those things, it needs a cause to act upon. Just as a man must have a cause that pushes him forward in order to act accordingly. The man needs a motive that will act as a cause. The causal determinism proposes that all future events are necessitated by past and present events combined by laws of nature. It is not a man’s free will that makes him act morally, but rather, it is the motives that make him act in any particular way. Kant would argue that acting morally has absolute worth because by acting morally, we engage in a higher order of existence. Schopenhauer gives the example of a man who gets out from work and evaluates his options which he thinks he can freely choose from. That man decides to go home to his wife. He thinks he made this choice freely but actually it is because the motive of going home was greater than the other options. If Schopenhauer was to challenge him to say ‘that was expected of you being the boring man that you are’, and he went to the theater with him instead, this would still not mean he has free will. It only means that his motives have changed because there is a different cause. Schopenhauer’s comment causes him to act defying manner. If this man had a more passive character, he might have still gone home to his wife. Causes would have affected him in different ways and he would have had different motives. Being responsible of our actions is demanded from us by the society; when we act accordingly it is because the society’s expectations cause us to act responsibly. Kant argues that as rational beings, we should consciously and freely choose the responsible thing to do because it is the laws we choose to obey that make us free. Schopenhauer would argue that the only reason we obey rules and act responsibly is because our motives drive us to that direction. If our motives were to conflict with the rules, we would stop being responsible. If men actually had free will that leads them to act responsibly, we would not be able to explain murder, theft or any illegal action that harms the society. When the murderer, the thief or the criminal perform their actions, it is because their motives are conflicting with the rules society set. Humans are subject to law of nature, without a cause, there is no effect; therefore we have no free will. According to Kant, one should act as if the maxim of one’s action were to become, a universal law of nature through one’s will. By stating that, Kant is actually making the law of nature subject to human free will, putting the effect before the cause. Schopenhauer presents an argument which explains why man are subject to law of nature: â€Å"For man, like all objects of experience, is a phenomenon in time and space, and since the law of causality holds for all such a priori and consequently without exception, he too must be a subject to it. † This suggests that we are experiencing the same causalities as every other being does, yet we are blind to see what is obvious. There are too many causes that affect men, which is why we get delusional while recognizing the causes. Both Kant and Schopenhauer use the billiard balls example to illustrate the relation between cause and effect. Kant states that we are not like billiard balls because we have the ability to make our own choices as rational beings. Whereas Schopenhauer suggests that we are like the more complex version of the billiard balls: we will only move if we are hit. We differ from billiard balls not because we have reason, but because we are so constantly hit that we stop perceiving the causes. Every single component in life cause our motives to shape in certain ways which is why it is so hard to recognize the causes we act upon. All our actions can be reduced to motives we have in order to satisfy our ultimate purpose: to live and to create life. Eventually we are ranned by simple motives such as maintaining our successive continuity of existence, reproduction or protection. Even a man who is about to commit suicide will pull his hand away if he accidentally touches a hot iron. His reflex will send faster signals to his brain before he can even acknowledge it. He would have no free will over that action; it would purely be him obeying the law of nature without even thinking about it. As subjects to law of nature, the decisions we make in our daily lives are mostly caused by the motives to find the best mate possible to create the best off spring. We do not necessarily recognize it, but even the most trivial choices we make, like the desire to drive a fancy car over a cheaper one, is not an act of free will. By doing so, just like a peacock showing his feathers, we are unconsciously lead by motives that push us into a certain direction which will make us more desirable as a mate. We want to be accepted by the society for the same reasons, being a part of a community provides a protection and opportunity to reproduce. The reason why a rich man would help the poor, or join a country club is not because he has free will that makes him morally responsible, or that he enjoys playing golf, but it is because that will make him more respected and better accepted by the society which he wants to belong. Our reflexes, hormones, neurons, our DNA and the causes that act on us condition the decisions we make. We choose to believe that we have free will because it makes us feel as if we have control on our life. As the biologist Lynn Margulis defines â€Å"Life is the strange fruit of individuals evolved by symbiosis. Swimming, conjugating, bargaining and dominating, bacteria living in intimate associations during the Proterozoic gave rise to myriad chimeras, mixed beings, of which we represent a tiny fraction of an expanding progeny. Through corporeal mergers disparate beings invented meiotic sex, programmed death, and complex multicellularity. Life is an extension of being into the next generation, the next species. † Nothing makes us any different than the bacteria, other than being more complex, that solely acted on their instincts. The only difference is the equation that determines our actions have many variables, whereas it was much fewer in prokaryotes. If we are able to understand that the simplest forms of life were acting upon the basic motives and no free will, we should be able to perceive that our actions are not different. The chemical distribution of our DNA will cause us to have an essence, which will determine our motives and actions under different circumstances. As the being gets more complex, the cause and effect relation will be harder to observe but still, there will not be free will.