XY Chromosome in a Female With Secondary Amenorrhea

XY Chromosome in a Female With Secondary Amenorrhea Dania Al-Jaroudi, M.D Capsule A 17-year-old girl presented to our gynecology clinic with secondary amenorrhea. She had been diagnosed with ALL at the age of 5 years, she received chemotherapy and radiotherapy over the following years. Her chromosomal analysis showed a karyotype of 46, XY. Introduction Primary ovarian insufficiency is a disorder that is emotionally traumatic and bears lifelong consequences on fertility, bone and cardiovascular health (1,2), making it more challenging is its occurrence in adolescents. Previously the term premature menopause had been used and found to be incorrect; as about 50 % of women have intermittent ovarian function and may ovulate and conceive after this diagnosis (1,2,3). The diagnosis is made when women younger than 40 years, have four or more months of amenorrhea and two serum FSH levels taken one month apart in the menopausal range (2). Causes of primary ovarian insufficiency in adolescents include chromosomal abnormalities, premutation in the FMR1 gene for fragile X, or iatrogenic from chemotherapy or radiation therapy (1). Infiltrative, infectious processes and pelvic surgery are less common causes (1). Autoimmune disease is another cause, as around 4% of women will have adrenal or ovarian antibodies. Still the etiology remains unknown in many cases (3). Although advances in oncology treatments have improved survival of childhood cancer, this came at the expense of ovarian function, increasing the risk of ovarian insufficiency and infertility (4). Morse et. al showed in a prospective observational study of ovarian function during cancer treatment of females aged 0 to 18 years that ovarian insufficiency occurred in chemotherapy treated prepubertal and pubertal patients regardless of menarche, age, diagnosis or chemotherapy given (5). Furthermore, females receiving radiotherapy below the diaphragm and/or stem cell transplant (SCT) had no recovery in their ovarian function followed for one and a half years from the end of their treatment (5). Clinicians need to be sensitive in delivering the diagnosis of primary ovarian insufficiency to their patients (6). This diagnosis can be emotionally traumatic and emotional needs of the patient need to be addressed as should further support be available (6). Adequate information regarding the diagnosis should be given as according to Groff AA et al (6); most patients feel that inadequate information decreased their sense of control (6). Case Report Our patient is a17-year old single girl who presented to our clinic with secondary amenorrhea. She had been diagnosed with acute lymphocytic leukemia (ALL) in 2002 at 5 years of age. Therapy began with hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). She relapsed in 2007 and 2012 and was treated with methotrexate (MTX), dexamethasone (DEXA), vincristine, and L-asparagine. She then had total body radiation in 2012. In July 2012, patient was referred to King AbdulAziz medical city at 15 years of age with pancytopenia, she was again given hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). After remission she was given busulfan/cyclophosphamide then she had stem cell transplant (SCT) from her full HLA matched sibling. Patient had menarche at 11 years, after which she had regular menstruations for 4 years before she developed secondary amenorrhea. Progesterone challenge test was done with no response. Hormonal profile showed hypergonadotropic hypogonadism, normal thyroid function test and prolactin levels. Pelvic ultrasound showed normal, but small sized uterus and ovaries. Chromosomal analysis showed 46, XY, this confused her primary physician was unsure about the best plan of management. On further review of her previous investigations, her chromosomal analysis one-year back had been a normal female genotype. So with the stem cell transplant (SCT) from her HLA matched sibling her genotype and her whole cell line had changed. With the impression of premature ovarian insufficiency as her primary diagnosis, patient was started on cyclical hormonal therapy; estradiol valerate 2 mg, norgestrel 500 mcg (progyluton ®, Bayer Health, Germany) for 6 months. On follow up after 2 months, she didn’t start progyluton because she thought she needs to start 5th day of cycle; proper counseling was done and patient was seen 2 months afterwards on hormonal therapy, calcium and vitamin D with withdrawal bleeds. Objective: To report a case of primary ovarian insufficiency in 17 year old, single girl, who had ALL and was treated with chemo and radiotherapy, followed by bone marrow transplant. Design: Case report. Setting: King Abdulaziz Medical City Patient(s): A patient diagnosed with primary ovarian insufficiency, after receiving chemo and radiotherapy for ALL. She later received bone marrow transplant from her HLA matched brother. Intervention(s): Hormone replacement therapy. Main Outcome Measure(s): After ruling out other causes, counseling and emotional support where given to the patient. She was then started on hormonal replacement therapy, calcium and vitamin D. Result(s): Patient started hormonal therapy and was followed in the clinic. Conclusion(s): This case describes a primary ovarian insufficiency in a girl post chemo and radiotherapy; it also describes a change in cell line following bone marrow transplant from her HLA matched brother. Key Words: Secondary amenorrhea, primary ovarian insufficiency, Hormonal replacement therapy, stem cell transplant. Acknowledgments: We would like to express our thanks to Dr. Hanan Dahlawi for providing care to the patient. Discussion: Conditioning with chemotherapy and radiotherapy prior to stem cell transplant (SCT) particularly with cyclophosphamide and total body irradiation will inevitably lead to primary ovarian insufficiency and infertility (7). The risk of primary ovarian insufficiency when patients receive busulfan and cyclophosphamide is about 100%, similar to what our patient has received (7). We report this case as this patient’s karyotype changed to a male karyotype following stem cell transplant (SCT) from her full HLA matched sibling. This led to a diagnostic confusion at first, and was later understood after her karyotype one year earlier was reviewed and genetist was consulted. There was no similar cases reported in the literature, although numerous cases where reported on primary ovarian insufficiency in adolescents, and successful pregnancy thereafter. Therefore, we recommend to educate physician on changes occurring after stem cell transplant. Unfortunately, this patient was not offered fertility preservation options prior to her treatment; this again is another area of awareness that needs to be raised in physicians. Nonetheless, this patient was offered counseling and hormonal therapy after she was referred to our out patient clinics. The aim of hormonal therapy in adolescents with primary ovarian insufficiency includes the relief of hypoestrogenic symptoms in addition to bone support, cardiovascular, and sexual health (8). Adolescents may need higher doses of estrogen than menopausal women to ensure adequate replacement and optimal bone health (8).

The Arctic National Wildlife Refuge (ANWR) in Alaska

The world is filled with many natural wonders, and one of these marvels is the Arctic National Wildlife Refuge (ANWR) in Alaska. Its 19. 6 million acres comprise some of the last truly undisturbed wilderness, and the area has even been called the crown jewel of America's refuge system. This refuge is composed of a far-reaching stretch of tundra covered with marshes and lagoons and intertwined with rivers spectacularly positioned among the foothills of the snowcapped Brooks Mountain Range and the sparkling waters of the Beaufort Sea, presenting an awe-inspiring spectacle (Defenders of Wildlife, 2001a). It was because of this beauty that ANWR was set-aside as government land. Originally, the North Slope of Alaska was only used for military purposes, and the public was not allowed on any of its 48. 8 million acres during World War II. But in 1952-1953, some government scientists decided that this area of Alaska should become a conservation area. So, Fred Seaton, the Secretary of the Interior, made 8. 9 million acres of the North Slope into the â€Å"Arctic National Wildlife Range† to protect it. A lot of oil was found throughout the North Slope in the following years, so many wanted to drill for oil in the Arctic National Wildlife Range. In the Alaska National Interest Lands Conservation Act (ANILCA – 1980), most of the Range plus more of the North Slope was designated as Wilderness and called the Arctic National Wildlife Refuge. However, Section 1002 of ANILCA decided the part of the Range not considered Wilderness should be part of ANWR, although it must be researched before it was decided whether or not it should be designated as Wilderness or used for oil development. This disputed section is called the 1002 Area (Alaska Wilderness League 2003a; Ecological Society of America, 2002; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b). Studies conducted in the 1002 Area showed that oil and gas development would cause great harm to its wildlife (U. S. Fish and Wildlife Service, 2000b). Unfortunately, the oil companies do not seem to see the beauty of this wild area, only the possible profit in it. The oil industry would still like to drill in the 1002 Area (the Coastal Plain), an area of 1. 5 million acres between the Arctic Ocean and the Brooks Range (Alaska Wilderness League 2003a; Ecological Society of America, 2002; Gibbs, 2001; Sierra Club, 2001). However, the Coastal Plain is vital to the continued existence of many organisms and is full of life during the short spring and summer months, giving it the nickname â€Å"America's Serengeti† (Alaska Wilderness League 2003a; Alaska Wilderness League 2003b; Defenders of Wildlife, 2001b). The Porcupine River caribou herd of about 130,000 goes to the Coastal Plain on an annual basis to bear and nurse their young before migrating to warmer climates (Alaska Wilderness League 2003b; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b; Roth, 1995). Polar bears use it as their most vital denning area on land (Alaska Wilderness League 2003b; Roth, 1995). Musk oxen, grizzly bears, wolves, wolverines, foxes, golden eagles, and snowy owls assemble there to stalk their prey and build their dens. Dall sheep, whales, moose, 36 fish species, and eight other marine mammals thrive in the region, too. About 300,000 snow geese also stop there in the fall to eat after coming from their nesting grounds in Canada (Alaska Wilderness League 2003a; U. S. Fish &Wildlife Service, 2002). Another 135 species of birds use the land to breed, nest, raise their young, feed, or rest before they migrate to areas throughout the United States and beyond (Alaska Wilderness League 2003b; Babbitt, 1995). The 1002 Area is home to a variety of wildlife. So, drilling should not occur in the 1002 Area because it would be detrimental to the animals living there. Oil development could hurt the wildlife in many ways. The emissions from aircrafts, scents of workers, and the noise of vehicles and other engines could displace the animals (Gibbs, 2001). Roads and pipelines would also displace the wildlife because their normal routes would be blocked (Alaska Wilderness League, 2003b). Drilling would cause great harm to the animals that rely on the Coastal Plain of ANWR. Additionally, the 135 species of birds that nest and feed in the 1002 Area would be affected. Many of the birds would lose critical habitat, causing population declines for already small populations. Also, the oil fields would attract predators, further lowering their numbers (Audubon, 2002). Other studies around the other Alaskan oil fields have shown tundra swans to nest over 650 feet from the roads (Gibbs, 2001). Many of the other migratory birds are also sensitive to disturbances, and oil production in ANWR would interrupt migration patterns that have been occurring for many years (Alaska Wilderness League 2003b). The migratory species would carry the effects with them throughout the world (UNEP, 2001). Caribou are also sensitive to disturbances. Caribou with young stay at least 2. 5 miles away from roads (Gibbs, 2001). So, the caribou would be pushed into the foothills of the Brooks Range, an area with more predators (Ecological Society of America, 2002). A computer model estimated that calf survival would be reduced about 14 percent by oil production in ANWR (Gibbs, 2001). And, the U. S. Fish and Wildlife Service believes that lowering the calf survival by only five percent would cause the Porcupine caribou herd to suffer population declines (Alaska Wilderness League 2003b). The musk oxen's population would also drop, too. They live on the Coastal Plain year-round (Montgomery, 2003). They need to conserve their energy and move very little to live on the Coastal Plain in the winter because there is little to eat, and it is very cold. The musk oxen would be forced off of the 1002 Area by drilling, and the Department of the Interior thinks this would lower their population 25 to 50 percent (Alaska Wilderness League 2003). The polar bears need the Coastal Plain to continue their current population numbers as well. It is needed for pregnant polar bears to nest upon and raise their cubs. The cubs need to be protected in their dens for three months. Any sort of disturbance would cause them to leave their dens early, which would harm their newborn cubs (Alaska Wilderness League 2003b). Bowhead whales also migrate past the Coastal Plain. They are needed by the Kaktoviks (the people indigenous to the North Slope) for food and cultural activities. However, the oil development occurring presently has already displaced them 9 to 15 miles from any noise (Montgomery, 2003). So, the Kaktoviks need areas without drilling to continue their subsistence way of life. Furthermore, all of the aquatic animals (including bowhead whales and polar bears) would be greatly harmed by an oil spill. Development in the waters is not significant as of yet, but if more development occurs on land, then more development may occur offshore. Many animals are very vulnerable to the effects of an oil spill, so more development should not occur (Montgomery, 2003). In addition to harming wildlife, oil development would harm the physical environment as well. The drilling west of the refuge (near Prudhoe Bay) has already done considerable damage. It has turned 400 square miles of undisturbed wilderness into 1500 miles of roads and pipelines, 1400 wells, three airports, 17 sewage treatment plants, and hundreds of large waste pits. The drilling has discharged into the environment more that 43,000 tons of nitrogen oxides each year, contributing to smog and acid rain production, and 100,000 metric tons of methane that leads to global warming. There have been about 1,600 spills containing 1. 2 million gallons of oil, diesel fuel, acid, drilling fluid, and many other harmful substances between 1994 and 1999 (Indigenous Environmental Network, 2001). There is about one spill each day (Alaska Wilderness League 2003c). All of this could occur in ANWR if the oil companies get what they want. And, you would think that there must be a gold mine of oil under the 1002 Area if they would sacrifice such an important area of land. However, the U. S. Geological Survey predicts there is only enough oil beneath the Coastal Plain to sustain the energy needs of America for six months (Alaska Wilderness League 2003a; Alaska Wilderness League 2003c). The Department of the Interior has estimated that â€Å"there is only a one-in-five chance of finding any economically recoverable oil in the refuge† (Roth, 1995). It is not worth ruining a pristine wilderness supporting many animals for very little oil that may not even be â€Å"economically recoverable. † Not only is there little oil under the Coastal Plain, it is also found in only small accumulations rather than one large oil field (like Prudhoe Bay). So, there would have to be more development areas, increasing the effect on the wildlife and environment (Ecological Society of America, 2002). Overall, the drilling would cause a lot of damage. A pristine wilderness would be turned into a noisy, polluted, developed area. Millions of species of animals would be harmed. They would no longer be able to use the Coastal Plain to feed, mate, nest, and hunt. They would be forced onto marginal lands, and their numbers would be negatively affected (Alaska Wilderness League 2003b; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b). And, the drilling could cause many environmental problems, including global warming, smog, and acid rain (Indigenous Environmental Network, 2001). Plus, the drilling would not even solve the energy problems in the U. S. So, drilling in ANWR should be prevented!

Analysis Of The Outsiders - 769 Words

Robert Frost wrote this poem to express how he feels about polotics.The peom can relate to S.E. Hintons The Outsiders by showing that things will get better it just takes time. The poem is a short narritive peom that tells a story. The story that Robert Frost is trying to tell us is that things might not be the best at the time but it will come to and end. The title of the poem is four words. Four words that show you that it will all eventually come to an end. By it all coming to an end things might just get better. Things getting better will repeat the process when a decision is made. Nothig Gold Can Stay can mean many things, one of those thing is that we all may die when things get rough. Another way to think of it is if times are†¦show more content†¦It would seem as if they were facing the pain instead of us. In reality we are using the plants to better explain our attitude towards the subject. The mood of this poem is kind of deathly and gloomy. Frost demonstarates that things are coming to an end and they wont stay long. The tone of this poem is that, nothign will stay as long as you want it too so enjoy it while you can. The theme of Robert Frosts poem, being that nothign really lasts forever, so cherish it, is understood by most readers. The rhythm of the poem could seem like a journal entry where they are realizing something bad happening in their life, analyzing it, and making that realization come to life by using this to express their feelings. the rhyming of the poem fits it well because it is a repeating pattern where it repeats itsself for two then changes. It goes well because when you read it you want to slow down at the end to get the feel that nothing gold can stay. The poem shows a couple of signals of stress through out the poem. It shows distress, discomfort, and realization by the author showing something may have happened in his life. Im not sure if Frost was planning on readrs but the imagery I had while reading this peom was a beautiful flower dying and not coming back. Frost may have envisioned for readers to have the same concept but thatsShow MoreRelatedAnalysis Of The Outsider 1397 Words   |  6 PagesCamus uses pathetic fallacy to describe the importance of the physical world in the novel The Outsider, through his character Meursault. Camus uses the elements to exhibit the importance of an individual s physical needs, and how they shape their personality. Meursault is a character that requires his physical needs to be met before he is able to make logical decisions for himself. When he follows through with his decisions, society views them as immoral creating Meursault as a villain in the eyesRead MoreAnalysis Of The Outsiders708 Words   |  3 Pagesencountered in the past will help me succeed in the future.† In my own words this quote addresses that hardships creep around every corner and if you face them determinedly you will end up stronger in the future. This quote relates to the novel The Outsiders by informing people that tough moments in life are hard to overcome. Just like Ponyboy has to learn to overcome the death of his best friend, Johnny. The main theme that S.E. Hinton tries to convey through the novel is: hardships lurk wherever youRead MoreThe Outsiders Analysis1215 Words   |  5 PagesFracis Ford Coppola’s â€Å"The Outsiders† (1983) is an adaptation of the novel of the same name by E.Hinton published in 1967. There are many theories that can be found throughout the movie, victim precipitation theory, differential association theory, strain theory and labeling theory are the most prevalent. The story takes place in Tulsa, Oklahoma and revolves around the story of a 14 year old Greaser named Ponyboy Curtis. The town is split into two conflicting adolescent groups, the Greasers and theRead MoreThe Outsiders Analysis712 Words   |  3 PagesA 1 950’s, commonly known novel, ‘The Outsiders’ written by S.E Hinton is based on two rival gangs; the Socs and the Greasers who, throughout the novel understand the importance of belonging. The main concept explored of belonging shows that most young people in society need to feel the urge of belonging for a reason. Through this, Hinton has focused on the Greasers needing to feel a sense of belonging more than the Socials. 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He readily admits that he is smart at school, but sometimesRead MoreAnalysis Of The Book The Outsiders 2098 Words   |  9 Pages Analysis of Disenfranchisement in The Outsiders by S.E. Hinton Survival instincts allow individuals to persevere during times of hardship and struggle. Unfortunately, many families in America are struggling lower-middle class or live in poverty. It’s nice to think a person can easily go from being dirt poor to filthy rich, but it doesn’t usually work that way. The Outsiders by S. E. Hinton depicts the hardships and struggles experienced by two rival gangs, â€Å"The Greasers† from the lower middleRead MoreLiterary Analysis : The Outsiders 2595 Words   |  11 PagesGina Cabano Eng-150 Whetstine Literary Analysis 05/04/15 Inside The Outsiders The Outsiders, a coming-of-age novel, written by S.E. Hinton who was a teenager at the time of writing is firmly based upon groups of teenagers divided amongst their social classes. The novel takes on the rival battles of the Socials and the Greasers. Susan Eloise Hinton as known as, S.E. Hinton was born July 22, 1950 in Tulsa, Oklahoma. She had grown up as a voluntary tom boy in love with horses. Susan could not writeRead MoreLiterary Analysis Of The Outsiders1429 Words   |  6 Pagesthere are some popular novels that attempt to imitate this, such as the coveted The Fault in Our Stars or Divergent. These selections, while widespread in the hands of young adult readers today, will not stand the test of time in the way that The Outsiders has, written by S. E. Hinton in 1967, has. This novel, both produced by and intended for teenagers, instead is a better candidate of realistic young adult fiction. Other selections, from Hinton’s era and from today, do not radiate the same relatable

The Declaration of Independence And A Great Britain - Free Essay Example

Sample details Pages: 2 Words: 645 Downloads: 6 Date added: 2019/04/26 Category History Essay Level High school Tags: Declaration of Independence Essay Did you like this example? The Declaration of Independence which was adopted by the Second Continental Congress on July 4, 1776, can be thought as the birth of the United States. Since Thirteen Colonies not only revealed their main purpose about American Revolutionary War but also they proclaimed their independence. The process leading up to The Declaration of Independence did not emerge overnight. Many years and various events led to colonist fight for their independence. Political interference of Britain, economic laws and the impact of ?Common Sense ? on the society affected the development of The Declaration of Independence. One cause which affecteds emergence of The Declaration of the Independence was political interferences of Great Britain. Because first American colonies were established mostly by people who migrated from Britain. The number of colonies increased and they progressed in time, nonetheless, they were still governed by England. The British government let the colonists govern themselves with little interference until the 1760s. The 1760s could be thought as a turning point because mother country gained vast territory from France after the Seven Years War.However, London officials had no experience managing the territory as vast as it acquired from France. That is why England increaseds interferences in order to maintains control over colonies with strict precautions and various laws. Colonist began to worry about these laws and they felt as these laws threatened their right to govern themselves. The more political interferences caused more conflicts between England and the colonists. Consequently, these conflicts created the idea of separation from mother country step by step. The second cause was economic laws. After the Seven Years War Great Britain wideneds borders in the New World. Nevertheless, during the war, Britain sent troops in order to help American colonies to fight in the war. When the war ended, England needed money to pay its war debt s. That is why The British Parliament decided to tax the American colonies to help pay for the cost of war. They passed a number of laws such as the Sugar Act and the Stamp Act. While the British Parliament believed that they had the right to tax colonies because they supported them during the war, many colonists felt that they had not to pay these taxes.Because these laws were passed by the British Parliament, not by their colonial governments. Moreover, they had no representative on British Parliament to defend their rights. Colonists protests created the motto No Taxation Without Representation.. Trade restriction laws and taxes developed the process of The Declaration of Independence. The third cause was the impact of ?Common Sense ? on society. Common Sense was a pamphlet which was written by Thomas Paine in the plain and persuasive language in order to be understood by every people in the society. Thomas Paine wrote it in order to encourage the people in the colonies ab out separation from England. In his pamphlet, not only criticized the British Government but also he explained the disadvantages of being connected with England. He emphasized the importance of independence and he explained why it was the wrong regard as Great Britain as Mother Country. Although there were opposite ideas in the society about separation, the pamphlet was adopted by the colonists and united them against England in a little while. Common Sense improved the need for independence. To sum up, multiple causes led to the birth of the United States. Britain started to getting involve American colonies after the Seven Years War. Because they had different politic and economic ideology, caused various problems between Great Britain and the colonists. Most of the colonists rejected taxes without representation. ?Common Sense emphasized on these differences and protests that is why united the colonists under the common purpose. On July 4, 1776, Declaration of Independence proclaimed and it underlined their aim during the American War of Independence. The independence process took time and developed step by step. Don’t waste time! Our writers will create an original "The Declaration of Independence And A Great Britain" essay for you Create order

The Effects Of Birth Control And Abortion - 2816 Words

On March 2, 1873, the Comstock Act was passed which â€Å"forbade the sending through the mails of any drug or medicine or any article whatever for the prevention of conception† (Case Western University, 2010). Although this act did not focus on fertility, it remained as a statute for birth control. Birth control and abortion were both considered obscenities (Case Western University, 2010). The Comstock Laws declared family planning and contraception illegal and obscene (Planned Parenthood Federation of America, 2014). In 1916 Margaret Sanger, her sister, and a friend, opened the first Birth Control Clinic in Brooklyn, New York (Planned Parenthood Federation of America, 2014). According to the Planned Parenthood Federation of America (2014), Margaret Sanger â€Å"witnessed the sickness, misery, and death that result from unwanted pregnancy and illegal abortion†. Her mother was one of those women who had endured eighteen pregnancies, raised eleven children, and passed away at the age of 40 (Planned Parenthood Federation of America, 2014). It was already a difficult era for women. During this time, women did not have many rights. They were not allowed to vote, sign contracts, have bank accounts, or divorce abusive husbands (Planned Parenthood Federation of America, 2014). The clinic provided contraceptive advice to poor, immigrant women, until police raided it and the three women were convicted of disseminating birth control information (Planned Parenthood Federation of America, 2014).Show Mor eRelatedBirth Control And Abortion Should Not Be Used Widely1440 Words   |  6 Pages Birth Control and Abortion Should Not be Used Widely Submitted by: Yuhuan Yu Submitted to: Daniela Greco-Giancola Class: Act Writing Date: August 11, 2014 Word Count: 1281 The world population is 7.046 billion and there are 8.260 million new babies are born every year (Worldometers n.d.), because of this global over population problem, some countries’ government allowed birth control pill and medicine or artificial abortion can be used to control the population. Now, due to different reasonRead MoreAbortion And Birth Control : Pro Choice And Pro Life Essay1281 Words   |  6 Pages Different Arguments for Different Ends Shana Meyer December 7, 2016 â€Æ' Different Arguments for Different Ends Abortion and birth control have long served as very heated, very debated topics, especially in the equal rights movement. Groups on both sides of the dispute have made strong arguments either in support of or against a woman’s right to use birth control and/or seek an abortion. Interestingly, many of the arguments share very similar foundational thoughts but are used to suggest very differentRead MoreBirth Control Of Infant Control1192 Words   |  5 PagesBirth control pills is one of the biggest debate in our society, there’s many people against and also people that support the case. Birth Control consist in : â€Å"any of various preparations that usually contain a combination of a progestogen (as norethindrone) and an estrogen (as ethinyl estradiol) but sometimes only a progestogen, are taken orally especially on a daily basis, and act as contraceptives typically preventing ovulation by suppressing secretion of gonadotropins† (Dictionary).There areRead MoreP ros And Cons Of Birth Control1442 Words   |  6 PagesEven though birth control issues remain as a controversial topic from the early 18th century to now, the debate between Margaret Sanger and Winter Russel on the pros and cons of providing information about birth control strategies for the public was a foundation stone for today’s family planning policies and regulation of transmission of venereal disease in the United States of America. It is important to note that although in 1920 information about birth control strategies were banned from reachingRead MoreAbortion942 Words   |  4 PagesAbortion Thou shall not murder is one of the Ten Commandments from the Bible. Is a mothers right to choose considered murder? Several states in our country still allow the capital punishment for criminals who have committed heinous crimes. We, as a nation however, have moved on to the innocent and the unborn. It seems that our culture in todays time is strictly based on convenience. So why shouldnt terminating pregnancies be the same as committing murder? First of all, I would like to provideRead MoreAbortion Should Be Restricted1707 Words   |  7 PagesThe number of abortions today is almost 1.5 million a year, which is about 30% of all pregnancies (McConnell). Too many women are getting abortions as a means of birth control. The Supreme Court needs to restrict abortions to women who have been raped, been victims of incest, if the child will die at a young age, or if the womans health is in danger. By reading this paper, the reader will gain an understanding of why abortions need to be restricted. Although abortions are necessary they need toRead MorePro Choice Vs Pro Life1482 Words   |  6 PagesMost people don’t know that there has been approximately 57,762,169 abortions since the decision was made in Roe vs. Wade in 1973 (Life News). Some people look at this number and are appalled. But others see this and think of all the people who used abortion as a means to a second chance. Abortion has long been a controversial to pic in the U.S. but lots of people are choosing sides without really knowing all the facts. Abortion can be seen from many different sides but most know these sides as pro-choiceRead MoreArgumentative Essay On Abortion1175 Words   |  5 PagesAbortion in America is a controversial issue in which both sides have valid arguments. But, the arguments can be refuted. Abortion is the ending of pregnancy and expulsion of the embryo or fetus, generally before the embryo or fetus is capable of surviving on its own. Abortion should be illegal for a number of reasons. To begin with, some may argue that a fetus is not a person but, just a â€Å" †¦ little more than a bundle of cells †¦Ã¢â‚¬ (Littlefield). Abortion normally is performed around the eighth weekRead MorePersuasive Essay On Abortion1575 Words   |  7 PagesBrenneman said she was a 21-year-old junior at Harvard when her birth control failed and she had an abortion. ‘It allowed me to choose when to become a mother,’ she said. ‘As a mother now, I know I was correct at 21†¦ I didn’t have a college degree†¦ I didn’t have an income. I didn’t have a marriage. I didn’t have anything a child needs. And I didn’t want it† (Liptak, 2016). Brenneman, among the 24% of women who will undergo an abortion during their lifetime by the age of 45, chose the best decisionRead MoreThe Right to Live832 Words   |  3 PagesAccording to the National Right to Life, nearly 4,000 abortions are performed daily. When you think abo ut it, that’s a great deal of unborn children that are just â€Å"discarded† or erased, like a sheet of paper containing an awful mistake. An abortion, by definition, is the termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of a human embryo or fetus (spontaneously or by induced expulsion). Abortions have been performed for centuries, and surprisingly, are

Johnson Johnson Case Free Essays

The corporate strategy that Johnson Johnson pursue is to encourage autonomy in each division and cultivate entrepreneurial culture throughout the organization. It has heavily relied on acquisitions to grow over the years to expand the company into a board range of businesses in the healthcare industry. As Johnson Johnson has grew into a complex enterprise, granted near-total autonomy has fostered each division to develop and expand its best-seller products and to be responsible for their promised achievement. We will write a custom essay sample on Johnson Johnson Case or any similar topic only for you Order Now This independence attributes most to the company’s success. It also provides the firm with the ability to respond quickly to emerging opportunities. Each division has the freedom to develop its own strategy, and to work with its own resources. However, this decentralization brings up the company’s overhead costs. Merger and acquisition has also brought up quality control problems that some of its products have been recalled. Johnson Johnson has evolved to have top-notch products and strong skills in all three basic divisions: drugs, devices, and diagnostics, that few companies can compete for. To increase collaboration between these divisions will attract new business opportunities, and the firm will benefit from his convergence by allowing different units work together. Weldon has pushed all of its units to work together to deal with different health problems and to work on new opportunities. As a leader, Weldon understands the importance of entrepreneurial spirit in the company. So he takes steps and cautions to foster collaboration among disparate operations. He set up groups that draw people from different division to work together on specific health problems, and each of the groups will be reported every six months on potential strategies and projects. He is also pushing for more internal growth that to accelerate top-and bottom-line growth. Weldon encourage employees to share database across the various business units to further improve innovation. To create a sustainable competitive advantage, Johnson Johnson has to have valuable resources. By acquiring different segment of healthcare industry, they have the ability to develop new products that requires different segments of healthcare industry. Encouraging synergy will improve its efficiency and effectiveness in solving difficult health problem and neutralize threats, because few companies have such large resources as Johnson Johnson does. Since few firms could actually be able to attain the idea of synergy, the resource that Johnson Johnson has is rare. Besides that, Johnson Johnson has to make sure their resource is difficult to imitate and difficult to substitute. Apparently, for competitors who own as large resources as Johnson Johnson does will be able to perform same synergy; however, if Johnson Johnson come up with some unique idea and products on curing one of the difficult health problems and get patent on it, it will be then difficult for competitors to imitate. In order to be hard to substitute, Johnson Johnson has to make sure their products have distinctive effectiveness that it would be hard to achieve without their products. From balance sheet, Johnson Johnson’s liquidity, as measured by current assets compared to current liabilities, increased over the year. We might be tempted to conclude that its balance sheet has grown â€Å"stronger† currently. But its net income per sale has dropped dramatically. This might be caused by a string of product recalls and consumers are lost confidence in their products after recalls. Quality issues have risen since converging of two divisions, which directly affect Johnson Johnson’s reputation. Investors are starting to question Johnson Johnson’s management. Its financial picture looks even worsen now. Synergy to fix the manufacturing problems that had caused the recalls are taking longer than expected, and some brands might not return to shelves until 2013. Current situation that Johnson Johnson though may not put the company in a struggle condition, Consumers are losing faith in its products. Also, recent legal losses for Johnson Johnson related to its antipsychotic drugs and the announcement to remove out some ingredients that have been proved harmful to personal health have made its overall picture worsen. From its 2nd quarter 2012 conference calls, they mentioned that their current main goal is to restore reliable supply and to regain trust from consumers. Consumers have lost some degree of confidence in Johnson Johnson because of the recalls. But they have also mentioned in the conference calls that its pharmaceutical team achieved success in new products launching and their Synthes acquisition successfully closed in the 2nd quarter. Although they are still dealing with the negative impact of the How to cite Johnson Johnson Case, Essay examples

Critical Appraisal of the Evidence

Question: Discuss about the Critical Appraisal of the Evidence. Answer Introduction: Stroke is sudden onset of neurological deficit that results in weakness or paralysis on one side of the body. Stroke is the major health concern in Singapore and also is the largest cause of long-term physical disability. The most common problem found in stroke patients is the motor function problems in upper limb. In the case of sub acute stroke, the patient suffers from diminished motor functions; the body also displays weakness on any one side. This weakness of the body on one side is called as hemiplegia. Hemiplegic arm is the condition, where the patient cant move their arm after stroke. The most common form of providing movement to such arm is the passive range movement (LanninAda, 2011 ). Spasticity and contractures in the upper limb may affect the patients in their daily activities. These problems often start to develop within 6 to 8 weeks post stroke. (Andria, van de port Meijer, 2013).The exact cause of contractures is undetermined; however some article said that contracture may result from neurological condition example like stroke and Traumatic brain injury. (Beaty Murphy,2013).After a stroke, spasticity is a common problem in paretic limb that often leads to severe and permanent deformity.(Sheehan, winzer, Mercay Mudie,2006).When our group members discussed we also found that in Singapore each hospital are using different kinds ofsplints.However wanted to know if splinting was more effective in reducing contractures comparing to positioning. Therefore, the topic was chosen due to interest.Through evidence based practice by comparing hand splinting and hand position, to find which method is more effective in preventing contractures. The selected clinical questi on is important to be reviewed, because these are the two most common methods that are used in various clinical setting to treat contractures in stroke patients. So decided to choose randomized control trial design. In this design participants are assigned to treatment conditions at random that is they have an equal probability of being assigned to any group. Critical Appraisal Tool for RCTs The article used for the critical appraisal is Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial. Was true randomization used for assignment of participants to treatment groups? The study is the single blind pilot randomized control trial. Yes, the participants was randomly assigned two different groups using opaque, sealed envelopes containing leaflets with either a capital A(experimental group) or a capital B (control group). The participants included in the study, were all the stroke patients, who had to go through the inclusion criteria. The participants, who had been going through the good recovery of the arm, were excluded from the study. The treatment groups used in the study were selected on the basis of the inclusion criteria. The researcher included only those subjects, who had first time stroke defined according to WHO, the participant must have the medial cerebral artery stroke which has been established by means of computerized tomography/magnetic resonance imaging (CT/MRI), The participant should not have any premorbid impairment in the affected arm, should not have severe pain in the arm and should not have used antispasticity drugs, no pain reducing medicine except paracetamol has been used, no planned date of discharge, and must provide the written consent. The methodology used in the study seems to be appropriate for obtaining the desired outcomes. Having a control group verifies the study to be Randomized control trial. Was allocation to groups concealed? Yes, an independent person carried out the randomization procedure by allocating the groups using opaque, sealed envelopes containing leaflets with either a capital A( experimental group) or a capital B( control group).Therefore, no biasness. Were treatment groups similar at the baseline? Yes, the participants in the treatment group were similar. All the subjects in both the groups were randomized after the initial selection criteria. All the participants with subacute stroke were selected for the study and patients with severe stroke or other cognitive problems were excluded. The subjects with fair to good recovery of the arm were excluded from the study to avoid any kind of biases. The patients with same stage of the disease and similar co-existing condition were selected. Means of passive range motion were equally compared. Were participants blind to treatment assignment? No, the participants were not blinded to the treatment assignment. The written consent was taken from the participants. The positioning procedure was carried out for 5 weeks. The subjects in the experiment group were asked to participate in the procedure for another 5 weeks for the purpose of follow-ups. Thus, the subjects were not blinded. Were those delivering treatment blind to treatment assignment? No, positioning was carried out by the nursing staff under supervision of trained research physical therapists who instructed how the positioning procedure should be carried out. Were outcome assessors blind to treatment assignment? Yes, Blinding was achieved by reminding the participants before every measurement that they should not reveal allocation to the observers. Were treatments groups treated identically other than the intervention of interest? Yes, all the subject in the treatment groups received conventional rehabilitation treatment, as prescribed by the primary physician of the subject. The subjects in the experimental group were additionally asked to carry out the positioning posture for the five weeks, twice a day for half an hour. Controlled group didnt receive additional positioning procedure or therapies. Was follow-up complete, and if not, were strategies to address incomplete follow-up utilized? Yes, follow up of each subject in experimental group and control group were done through every stage of the trial. Follow up was done from the initial screening by the rehabilitation physician till the outcome measurements. If the subjects were excluded from the study for one reason or the other, the reasons were also specifically mentioned separately in the study. Were participants analyzed in the groups to which they were randomized? Yes, the participants were analyzed in the groups to which they were randomized. The flow of the subjects, through every stage is presented through a chart. Means (standard deviations) of content of treatment sessions and time spent in the positioning procedure at five weeks, were analyzed in both the groups separately. Were the outcomes measured in the same way for the treatment group? Yes, the outcomes of the treatment groups were measured in the same way. The mean passive range of all the motions were included and represented in the form of table that was measured through hydrogoniometer. The resistances to passive range movements were measured through Ashworth Scale. Resistence to passive stretch in both the groups was measured through Fugl-Meyer Assessment. Barthel Index scores for used for finding ADL-independence in the subjects of both the groups. Were the Outcomes measured in the reliable way? Yes, the outcomes measured in the study are done in the reliable way, as the same measurement scales were used to measure the outcomes in treatment groups. The study also measured outcomes in reliable way, because the results are clearly stated through comparable charts and also primary and secondary outcomes are clearly mentioned. The positioning procedures were carried out in the presence of the trained physiotherapists and also the measurement scales used in the study are reliable. Was appropriate statistical analysis was used? Yes, all the statistical analysis has been done by carrying out the SPSS for Windows (version 10.0.5). For this purpose the level of significance was set as P/0.05. p value is the widely used statistical hypothesis. The assumptions of the statistical test were respected Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? Yes, the trial design is appropriate, as the study involves the random procedure of assigning the subjects in the experiment and control groups. The main strength of the study is that it used the reliable way of statistical analysis and measurement of the treatment group outcomes. The major limitations of the study are that the study is underpowered, because the sample size is very small. Another limitation was the positioning procedure was carried out in front of various nurses and four physiotherapists, who have the training of carrying out positioning procedures, but there was a lack of individual assessors, which could have increased the rigour of the methodology. The key findings from the paper are that positioning of the hemiplegic arm has small beneficial effect on shoulder abduction in passive range of motion (Prabhu, Swaminathan, Harvey, 2013). The positioning procedures slowed down the development of the shoulder abduction contractures. However, no major difference was found in control group and experiment group. The gap in the knowledge is seen, as effect of positioning procedure on the motor recovery performance, spasticity and independence in ADLs is still unclear (Skalsky, McDonald, 2012). Discussion The suitability of the evidences in the clinical setting and implications for the change in practice is evaluated by the use of F.A.M.E. Scale. F Feasibility; specifically: The cost effectiveness of the study is that it conducted for the limited period of time to collect the samples. The practice used by the researcher is available and considered as the most reliable practice for preventing contractures in stroke patients. The professionals involved in the study have sufficient experience and skills. The trained physiotherapists are asked to carry out the positioning procedures, which signify the feasibility of the study. A Appropriateness; specifically: The practice and procedure used by the study can be considered as culturally safe. The procedure can be considered as transferable to majority of population, as the study was representative of the target population (stroke patients eligible for rehabilitation services). Thus, study is transferable to such settings. However, the study is not easily acceptable to variety of circumstances, as it had particular inclusion criteria since only subacute stroke patients were include and patients with severe stroke were excluded from the study. M Meaningfulness; specifically: The meaningfulness of the study is associated with positive outcomes. The study did not mention any kind of negative outcomes. However, the positive outcomes were limited with small slow down in the development of the shoulder abduction contractures. No other positive result was found. E Effectiveness; specifically: The beneficial effect of the contracture preventing positioning procedure was very small and no major differences were found in experiment and control groups. However, the practice is safe, as contracture prevention positioning is often supported by various studies (Prabhu, Swaminathan, Harvey, 2013). However, this study adds some value to the clinical practice by providing the evidences about the problems (Sanford, 2009). The change in practice can be brought by understanding the problems in the available evidences. The study adds value by explaining the effectiveness of the positioning procedure (Lannin et al, 2007). The current clinical practice continues to use splints for benefitting the people, who have suffered stroke. But, it is important to address that no current research supports or validates the use of splints (Thibaut et al, 2013). . However, contracture prevention positioning is often supported by various studies. What I consider important for change in practice is that passive stretching has found to be beneficial in improving the range of motion. It is also associated with slowing the development of the contractures. Thus, it can be said that positioning procedure is important in preventing contractures (Dewey, Richard, Parry, 2011). The barriers that may hinder the implication of the EBP are the lack of authority to change patient care procedures, insufficient time to apply new practice and difficulty in completely understanding the statistical analysis. These barriers can be overcome by bringing changes on the individual and institutional level. Barriers can be removed by collecting more related evidences, considering clients value, clinical judgment, clinical decision making and system resources. There is also a need for further research with the qualitative analysis. This kind of trial can help in closing the gap. Conclusion The main aim of the paper is to provide the critical appraisal of the selected study through JBI RAPid cghzyshecklist. The critical appraisal of the study by LD de Jong et al (2006) is done. This study is based on finding the effectiveness of the contracture preventing positioning hemiplegic arm in subacute stroke patients. The scope of the study and number of participants is very limited or under powered. The study was carried out on limited numbers of subjects in experimental and control groups. The design of the study is single blind pilot randomized control trial. The evidences provided by the study are very limited, as it excludes number of stroke patients on the basis of inclusion criteria. However, the study is important as it informs about the positioning of the affected limb for preventing contractures. The further and future research requires concentrating on more number of participants. The major problem found in stroke patients is pain. Future research requires developing the study to manage pain in the patients, by preventing contractures. Motor function recovery is the major goal of stroke rehabilitation centers. Motor recovery cannot be achieved without using different clinical treatments. The paper provided the discussion on the basis of substantial research from the reliable resources. References Basaran, A., Emre, U., Ikbal Karadavut, K., Balbaloglu, O., Bulmus, N. (2012). Hand splinting for poststroke spasticity: a randomized controlled trial.Topics in stroke rehabilitation,19(4), 329-337. Borisova, Y., Bohannon, R. W. (2009). Positioning to prevent or reduce shoulder range of motion impairments after stroke: a meta-analysis.Clinical rehabilitation,23(8), 681-686. Bovend'Eerdt, T. J., Newman, M., Barker, K., Dawes, H., Minelli, C., Wade, D. T. (2008). The effects of stretching in spasticity: a systematic review.Archives of physical medicine and rehabilitation,89(7), 1395-1406. Dewey, W. S., Richard, R. L., Parry, I. S. (2011). Positioning, splinting, and contracture management.Physical medicine and rehabilitation clinics of North America,22(2), 229-247. Fergusson, D., Hutton, B., Drodge, A. (2007). The epidemiology of major joint contractures: a systematic review of the literature.Clinical orthopaedics and related research,456, 22-29. Greg Pitts, D., Peganoff OBrien, S. (2008). Splinting the hand to enhance motor control and brain plasticity.Topics in stroke rehabilitation,15(5), 456-467. Katalinic, O. M., Harvey, L. A., Herbert, R. D. (2011). Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review.Physical therapy,91(1), 11. Katalinic, O. M., Harvey, L. A., Herbert, R. D., Moseley, A. M., Lannin, N. A., Schurr, K. (2010). Stretch for the treatment and prevention of contractures.The Cochrane Library. Lannin, N. A., Cusick, A., McCluskey, A., Herbert, R. D. (2007). Effects of splinting on wrist contracture after stroke.Stroke,38(1), 111-116. Lannin, N. A., Ada, L. (2011). Neurorehabilitation splinting: theory and principles of clinical use.NeuroRehabilitation,28(1), 21-28. Marco, E., Duarte, E., Vila, J., Tejero, M., Guillen, A., Boza, R., ... Espadaler, J. M. (2007). Is botulinum toxin type A effective in the treatment of spastic shoulder pain in patients after stroke? A double-blind randomized clinical trial.Journal of rehabilitation medicine,39(6), 440-447. Prabhu, R. K., Swaminathan, N., Harvey, L. A. (2013). Passive movements for the treatment and prevention of contractures.The Cochrane Library. Sanford, D. (2009). Effectiveness of Wrist and Hand Splinting for Increasing Recovery of Individuals Post-Stroke. Skalsky, A. J., McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases.Physical medicine and rehabilitation clinics of North America,23(3), 675-687. Thibaut, A., Chatelle, C., Ziegler, E., Bruno, M. A., Laureys, S., Gosseries, O. (2013). Spasticity after stroke: physiology, assessment and treatment.Brain Injury,27(10), 1093-1105.