Electrical Bone Growth Stimulator Devices

Electrical Bone Growth Stimulator Devices Nonunion and delayed fractures are prevalent in the United States, accounting for a significant health care cost (Simon Simon, 2008). Bone is able to remodel and adapt to applied loads and electromechanical stimuli (Smeltzer, Bare, Hinkle, Cheever, 2009). One method of repairing these types of fractures is with an electric bone growth stimulator, which has been used for over 25 years. There are three types of electric bone growth stimulators, all of which provide an electric current to the bone that causes the bone cells to grow and proliferate. Treatment with bone growth stimulators shortens the recovery time, however cannot be used for large gaps in the bone (Simon Simon, 2008). Clinical Significance Every year in the United States 7.9 million fractures occur (Goldstein, Sprague, Petrisor, 2010). Approximately 600,000 fractures do not heal properly. Fractures that do not heal properly are usually delayed or nonunion fractures. These fractures require treatment or surgical intervention to heal properly and cost the United States $3 to 6 billion health care dollars each year (Simon Simon, 2008). A delayed union is a fracture that heals very slowly and does not heal within a normal amount of time. Although many factors affect how long it takes for a bone to heal such as which bone is broken and the severity of the fracture, the typical healing time is about three to four months. A delayed union can be caused by several factors including, poor blood supply, not casting the bone properly, and infection (Parker, 2010). Sometimes delayed union fractures can heal on their own without intervention or treatment. A nonunion is a fracture that does not heal within twice the expected healing time, generally six to nine months after the injury. Fibrocartilage also forms between the two pieces of broken bone (Mora, Pedrotti, Galli, 2006). Figure 1 shows a nonunion fracture of the tibia, the fracture is circled in red and you can see some of the fibrocartilage that formed between the two pieces of bone. Several factors that can cause nonunion are poor blood supply, not casting the bone p roperly, infection, and loss of bone or soft tissue (Parker, 2010). A nonunion fracture will not heal on its own and requires some form of intervention. Some of the options for treating nonunion are internal and external fixation devices, bone grafts, bone substitutes, biologics like platelet extracts and bone morphogenic proteins, and biophysical stimulation including ultrasound and electrical stimulation (Simon Simon, 2008). Since the repair of delayed and nonunion fractures requires intervention and treatment, the clinical problem is how to provide an intervention that allows the patient to recover from the injury in the shortest possible amount of time with the fewest complications and the least cost (Simon Simon, 2008). The ideal treatment is to repair the fracture without surgery and hospitalization (Goldstein, Sprague, Petrisor, 2010). Therefore, electrical bone growth stimulators are frequently used to treat delayed and nonunion fractures. Research has shown that electrical stimulation is a prevalent treatment that is utilized to speed up the process of healing in delayed and nonunion fractures. In the United States, electrical bone growth stimulators have treated approximately 400,000 delayed and nonunion fractures (Goldstein, Sprague, Petrisor, 2010). Electrical bone growth stimulators, shown in Figure 2, are therapeutic devices that are used to produce and apply electric fields to bone, similar to the electric fields that occur naturally inside the body but as a result of the injury are either not being produced fast enough or are not being produced at all (Goldstein, Sprague, Petrisor, 2010). Electrical bone growth stimulators have been shown to be 88% effective for treating delayed and nonunion fractures (Nolte, van der Krans, Patka, Janssen, Ryaby, Albers, 2001). The typical treatment time with an electrical bone growth stimulator is between three and six months (Simon Simon, 2008). Biology and Physiology Humans have 206 bones in their body (Smeltzer, Bare, Hinkle, Cheever, 2009). Bone can adapt and remodel as a result of an applied force, an injury or a stimulus. Bone is made up of three types of cells, osteoblasts, osteocytes, and osteoclasts, which are involved in bone formation and remodeling. Osteoblasts are cells that form bone (Smeltzer, Bare, Hinkle, Cheever, 2009). Osteocytes are formed from osteoblasts and are responsible for maintaining bone, whereas, osteoclasts are cells that absorb bone. These cells play an important role in fracture healing (Smeltzer, Bare, Hinkle, Cheever, 2009). The process of healing a fracture, shown in Figure 3, has four major steps. The first step occurs within hours following the injury and lasts for about a week. During this step, the injury causes increased blood flow and bleeding, causing a hematoma to form. This results in inflammation and swelling (Smeltzer, Bare, Hinkle, Cheever, 2009). The next step begins when fibroblasts reach the injury site then release collagen fibers and form a soft fibrocartilaginous callus between and around the two pieces of bone. The third step begins around week 4, when osteoblasts enter the callus, multiply and begin to form bone. This forms a harder bony callus that eventually turns into bone. The final stage is remodeling which starts around week 17 and continues until the bone is completely healed. During the remodeling stage, the callus is completely turned into bone by the osteoblasts, and the osteoclasts absorb the extra bone that was produced and not needed (Chiras, 2008). Market Trends The market for electrical bone growth stimulators has grown to over $500 million dollars in the last 25 years, and by 2012 the market is expected to rise to $690.1 million (Schenberger, 2007). The consumers of electrical bone growth stimulators are hospitals, orthopedic surgeons and patients with a delayed or nonunion bone fracture. Electrical bone growth stimulators have been used to treat 400,000 fractures (Simon Simon, 2008). These devices can be both invasive and noninvasive. The typical cost for a noninvasive electrical bone growth stimulator is between $3000 and $7000 and can increase to $20,000 for an invasive stimulator that requires two surgeries (Morone Feuer, 2003). Insurance will cover the cost of the device as long as the patient meets certain criteria, for example the gap between the bones must be less than 1 centimeter (CIGNA , 2010). This cost is much less than the approximately $27,000 cost for surgery and hospitalization after a procedure such as internal fixation (Hughes Anglen, 2010). Seven companies have received FDA approval (U.S. Food and Drug Administration, 2010) and the five companies that have electric bone growth stimulators on the market are Orthofix, Biomet, DJ Orthopedics (acquired the company Orthologic), Smith and Nephew and DePuy Spine (medcompare, 2010). The only company that has received FDA approval (U.S. Food and Drug Administration, 2010) and that has invasive electric bone growth stimulators on the market is Biomet (medcompare, 2010). Some of the noninvasive stimulators are shown in Figure 4 and two of the invasive stimulators from Biomet are shown in Figure 5. Bioelectric Principles Bone that goes through effective growth or repair holds an electronegative potential compared to that of resting bone (Glazer Glazer, 2001). In bone where a break or fracture has occurred with nonunion or delayed union, it has been found helpful to introduce electric stimuli to the area undergoing complications. The introduction of an electrical current allows the process of bone regeneration to reinitiate. The electrically charged particles within the current act as the missing catalyst for the necessary chemical reactions to stimulate the desired biological response of bone repair at the site of nonunion. Pulsed electrical stimulation can cause changes in the intracellular level of cyclic adenosine monophosphate (cAMP) and thus triggers DNA synthesis within cells (Somjen, Fischler, Binderman, 1984). The electrical current excites the Na+/K+ pump of mesenchymal osteoblasts, which causes them to differentiate into osteoblasts that produce a woven matrix of bone (Shapiro, 2008).The electronegative current (DNA synthesis) applied at the surface of the fracture site or at the surface of the skin initiates endochondral bone formation the synthesis of cartilage, closely followed by bone formation (Shapiro, 2008). Bone naturally generates an electrical field because of Wolffs Law and piezoelectric properties, which is what the electric bone growth stimulators are also based off of. Wolffs law states that bone changes its external shape and internal (cancellous) architecture in response to stresses acting on it (Hunt, 2008). Piezoelectricity (Figure 6) is the stress-generated potentials in bone in which the side of the bone under mechanical compression [becomes] electronegative and the side under tension [becomes] electropositive (Kim, Won-Ki, Sung Jac, 1984). The mineral matrix in bone is piezoelectric because of the applied force to the skeletal system from tension (resting bone), and it changes its charge when the bone is under mechanical compression (bone repair/hematoma). The electric field produces electric potentials that cause the bone cells to grow and proliferate (Kim, Won-Ki, Sung Jac, 1984). Electrical stimulation creates an increased regulation of osteoinductive growth factors as well as enhancing osteoblastic activity, and decreasing osteoclastic activity through electrochemical reactions. This all leads to the desired reactions of increased bone formation and repair. The electrical stimulation increases the transmembrane calcium translocation, which activates calmodulin, a calcium binding protein involved in inflammation (Hematoma). Electric stimuli also brings about the upregulation of BMP-2, BMP-6, BMP-7, and the BMP receptor ALK-2, which are all bone morphogenic proteins needed to promote bone regeneration (Gan, Fredericks, Glazer, 2004). At the cathode of the Electric Bone Growth Stimulator, when the electric impulse is applied, three things happen: 1) the local oxygen concentration decreases, causing an increase in the biological process of bone growth, 2) the pH level increases, resulting in a decrease of osteoclastic function, and 3) the release of hydrogen pe roxide causing macrophages to release VEGF, which stimulates the growth of blood vessels in the area of injury. These growth factors enter the tissue matrix and trigger proliferation and differentiation which causes bone to form, thus increasing the healing rate of delayed union or nonunion (Gan, Fredericks, Glazer, 2004). History Device History The history of Bone Electric Growth Stimulators dates back to the late 1780s when the biologist, Luigi Galvani used electricity on a biological system. Galvani discovered that a frog could generate muscle spasms throughout its body when an electrical charge was applied to its spinal cord. Alessandro Volta, a colleague of Galvanis, was able to reproduce these (SilcoTek, 2010). The first documentation of electrical stimulation being used to heal fractures was in 1841 by Dr. Hartshorne, when he reported that a patient with a tibial nonunion was treated with electricity. In 1850, the scientist R. W. Lente was the first to report successful use of Galvanic currents used to treat patients with nonunion. In 1892, the German scientist Wolff was the first to describe how bone formed in response to stress; this description became known as Wolffs Law (Glazer Glazer, 2001). The significant gains of healing with electrical stimulation in the 17 1800s ends with Wolffs phenomenon description of bone formation. The modern theories that the Electric Bone Growth Stimulators are based off of are from the work that Iwao Yasuda and his colleagues found in the 1950s. In 1938 Yasuda started researching electrical stimulation of square wave to organic substance at Kyoto Prefectural University of Medicine (Crenshaw, 1977). In 1953, Yasuda et al discovered that bone in compression was electronegative, and bone in tension was electropositive (Glazer Glazer, 2001). From 1962 to 1964, the scientists Friedenberg and Brighton furthered Yasudas research and discovered that bone that is growing or repairing itself shows and electronegative potential, while bone that is not has an electropositive potential. This discovery has encouraged others to research electrical stimuli in relation bone regeneration (Glazer Glazer, 2001). In 1975, Dr. McElhannon published a report stating the technology used to treat fractures in humans with electrical stimulation is not yet advanced enough to promote bone regeneration, but shows promise in animals (Meadows, 2008). Two years later, Dr. Paterson et al performed an experimental model on delayed union fractures of the tibia in adult dogs. The model showed an accelerated healing time where Osteogenesis was normal, and no other abnormalities were found (Meadows, 2008). In 1978, the FDA approved the use of external bone growth stimulators (Haverbush, 2005). In 1983, Dr. Hanaoka performed a study observing the effects of pulsed micro-electrical currents on internal remodeling in long tubular bone and bone healing (Meadows, 2008). A group of 14 dogs had electrodes inserted into the femora with pulsed micro-electrical currents applied to the right femora for four weeks. The dogs were split into groups and each group had different electrical currents (Hz) applied. The results s howed that bone healing in all cases was promoted (Meadows, 2008). Dr. Ahl et al, in 1984, used a semi invasive technique for bone healing on 23 patients with nonunion. Ten of those had solid bone regeneration, and the other 13 did not fully unite these were later determined to have been breaks that were too far apart (Meadows, 2008). In 1985, Dr. Kondo performed a study on the femur of dogs. The bones in the experimental group observed proliferation of osteoblasts on the third day, which transitioned into bone remodeling and a shortened healing time by the end of the third week (Meadows, 2008). In 1995, Dr. Zamora-Navas et al performed a study on 22 patients with nonunion, with a gap of 0.5 or more, using capacitively-coupled electrical signal for a treatment time of about 26 weeks. In the end, over 70% of the 22 had solid bone union if the gap was 1 cm or smaller (Meadows, 2008). In 1996, the FDA approved the use of Electrical Bone Growth Stimulators, both invasive and noninvasiv e. Patent History On May 31, 1977, Dr. Levys bone generating device was approved. The stimulator produced electrical pulses applied to the bone, as opposed to direct current potential, to make the bone grow faster and stronger (Levy, 1977). The device is invasive, and is made of materials that will not poison or react with the surrounding tissue or bone (Levy, 1977). On November 15, 1983, Hirshorn et al had their patent approved on their implantable bone growth stimulator that uses a direct current output, and constantly transmits pulsed electromagnetic energy to the injury site. The output of energy(rate) is directly proportional to the set current. To make sure that the device is not affected by the pulsing of the transmission, a coil was placed inside the device to deliver a constant current. The device is enclosed in a titanium case, and has a longer shelf life due to an electrical switch that was placed inside the device (Hirshorn, Swift, Evans, 1983). On My 19, 1987, Dr. Campbells patent was approved. His stimulator was circuit adapted, and relied on the tissue (bone) to act as the load to make the circuit work. The storage device controlled the oscillator circuit, which in turn controlled the charge of the current that was issued from the battery and applied directly to the bone at the fracture site (Campbell, 1987). On May 9, 1995, Kronbergs stimulator was approved. This device was a non-invasive device that used low alternating currents applied to the patients skin. This particular device is battery powered and was found to generate the electrical characteristics found in bones naturally that generate normal bone growth (Kronberg, 1995). On June 16, 1998, Dr. Ericksons electric bone stimulator was approved. His stimulator came with a hand-held device which transmitted, and received, signals to the implanted stimulator (Erickson, Tepper, Thacker, Varrichio, Pilla, 1995). On August 2, 2007, Dr. Nyezs invasive stimulator was approved. The device is controlled by an external remote that sends a wireless signal to the stimulator. The current is circuitry controlled. It was made to be coupled with a hip prosthesis to help with healing and proper function, but can be used to stimulate healthy bone growth in areas of injury (Nyez, 2007). Device Theory In 1953, surgeon Iwao Yasuda first demonstrated that callus could be created by applying electric fields to bone (Figure 8). His experiment consisted of wrapping wire around a rabbitt femur and sending a small (1 uA) current to the anode, away from the bone. After three weeks of continuous current, Yasuda observed that a callus-typically generated during fracture repair- was beginning to form in the direction of the current (Liboff, 2006). There are three types of electric bone growth stimulators. They are categorized based on invasiveness and type of current. Table 1 gives a brief description of the different devices. Note that there are only two types listed, invasive and noninvasive (Liboff, 2006). Semi-Invasive Treatment Semi-invasive systems are semi-implantable: partially internal and partially external. The device provides a constant direct current supplied by an external power supply. The electrodes, on the other hand, are percutaneous and pass through the skin (Electrical Bone Growth Stimulators). These systems, however, are not currently in production, and consequently are not refered to by other scholars and have no relevant data (Clinical Policy Bulletin: Bone Growth Stimulators, 2010). Invasive Treatment The invasive treatment option, also known as direct current (DC) stimulation, is fully implanted and utilizes constant direct current. The device requires two surgies: one to implant the device, and one to remove the device. The anode is placed in the soft tissue, and the cathodes are connected to a power supply (typically a lithium battery) [cain] and placed at the fusion site. At the fracture site, the electrodes can be arranged in two ways (Figure 9). They can be placed on each side of the fracture as to bridge the defect; or, the electrode can be placed directly in the defect (Liboff, 2006). The although the current setting depends upon the fracture, it is typically set at 20 uA for up to six months (Lyle E. Cain, 2002). Noninvasive Treatments There are both electric and electromagnetic noninvasive EBGS devices. They are completely external and do not require surgery. Electric Option The electric noninvasive EBGS device works through capacitive coupling (CC). The CC device uses a 60 kHz alternating sinusoidal signal to produce a current. Two electrodes are placed on the skin, one on each side of the fracture (Figure 10) (Gan, Fredericks, Glazer, 2004). The power supply (typically a 9-V battery) is worn on the hip, and operated twenty four hours a day. Treatment generally applies 5-10 mA at the skin, and 15-20 uA at the fracture site. Device maintainence relies on the patient and includes changing the battery daily. Electromagnetic Options Pulsed Magnetic Field The pulsed magnetic field device (PMF or PEMF) follows Faradays law that Any change in the magnetic environment of a coil of wire will cause a voltage (emf) to be induced in the coil (Faradays Law). It applies a sawtooth (nonsinusoidal) voltage to two parallel external coils, one above the fusion site, and one below (see figure #). The applied voltage creates a current through the coils that generates a single, magnetic field through the defect. Because the field is constantly changing, an induced voltage is created, which appears as pulses (Liboff, 2006). The coils can be worn on the skin, or over a cast (if applicable) (Lyle E. Cain, 2002). The device includes an external battery pack and may be operated up to ten hours a day (Lyle E. Cain, 2002), but treatment is typically only three hours daily (Liboff, 2006). Ion Cyclotron Resonance The ion cyclotron resonance (ICR) device is similar to the PFM device in that it also uses an external coil system. ICR devices, however, apply a different theory than PMF devices. It was shown in 1985 that the results embodied in the so-called calcium efflux effect were in close agreement with the predictions based on the resonance characteristics of certain biological ions subject to the Lorentz force (Liboff, 2006). The device combines both dc and ac magnetic fields to achieve resonant condition. The theory is that ions in resonance are more likely to stimulate the gating mechanism for ion channel transport, and tuning to these ions can increase growth (Liboff, 2006). The device (Figure 11) also uses an external battery pack, and the unit should only be operated thirty minutes per day (Lyle E. Cain, 2002). Regulatory Standards The FDA recognizes the noninvasive bone growth stimulator and the invasive bone growth stimulator under the Title 21-Food and Drugs, of the Code of Federal Regulations (CFR) (Product Classification, 2010). Both are Class III devices, so they must abide by general controls and receive premarket approval. Class III devices support or sustain human life, that are of substantial importance in preventing impairment of human health, or that present a potential, unreasonable risk of illness or injury. Premarket approval (PMA) is the FDA process of scientific and regulatory review to evaluate the safety and effectiveness of Class III medical devices. A PMA application must be submitted and reviewed before marketing the products because they are considered high-risk medical devices (Device Classification, 2010). Device Review Advantages Previous treatments for nonunions included rigid fixation, bone grafts, and amputation. The electric bone growth stimulator has several advantages over these more tradition treatments. The treatment is less severe than bone grafting and the hospital stay after the invasive treatment is typically only three to four days, as opposed to ten days of recovery after grafts. Also, the average completion time for a successful union is only four months, compared to six to eight for bone grafts (Anbuselvan, Krishnamurthy, Madhumathi, Manonmani, Aravindan, Babu, 1995). Moreover, the EBGS is less traumatic than amputation and allows for the retention of limbs. In regards to the devices, the invasive option is advantageous because it provides constant uniform current and does not require an active patient role. After surgery, the device is self operated and maintained. Also, the invasive option bypasses tissue resulting in less resistance and better treatment results. The CC device is small, light, and easy to use (Lyle E. Cain, 2002). Disadvantages The main disadvantage of the EBGS is that union may be unsuccessful if the fracture gap is too large, typically over one centimeter. Also, before an EBGS is used, it must be determined that the bone is not healing properly on its own. Lastly, these devices have not yet been proven successful for treatment of nonunions in locations other than long bones or spine (Clinical Policy Bulletin: Bone Growth Stimulators, 2010). In regards to the devices, the invasive option has a higher hospital cost and patient morbidity due to the surgeries necessary for device implantation and removal. The CC device requires patient compliance. The patient must monitor, operate, and maintain the device, which includes changing the battery daily. Also, there may be skin irritation from the electrodes. Also, the PEMF and ICR devices are often larger and heavy than other external devices, which may create difficulties for patients (Clinical Policy Bulletin: Bone Growth Stimulators, 2010). Product Comparison Biomet is the only company that produces invasive electric bone growth stimulators. Their products include the OsteoGen Bone Growth Stimulator, the OsteoGen Dual Lead Bone Growth Stimulator for use with bone graft surgery, and the OsteoGen-M Bone Growth Stimulator, which utilizes a mesh cathode. Biomet also produces the following external, noninvasive EBGS devices: EBI Bone Healing System and the OrthoPak 2 Bone Growth Stimulator. The EBI Bone Healing System is more convenient because the actual device is worn like a sports band or brace that wraps around the limb, where as the OrthoPak 2 is a larger device with dermal electrodes that must be carried along with the battery pack. On the plus side, the OrthoPak 2 allows for easier placement of hard-to-reach fracture sites (Biomet, 2010). DJO sells the CMF OL1000 Bone Growth Stimulator. It follows a similar concept as the EBI Bone Healing System, except this device is not fully closed, giving it the ability of being worn over a cast if necessary (Products, 2009). Literature Review We assigned the designated sections of the report to each team member to research individually. We attended a research session with librarian Christine Drew to better understand WPIs academic databases and resources. Key terms used in our research included the following: electric bone growth stimulator, bone growth stimulator, bone growth devices, fracture healing, delayed union fracture, non union fracture, Faradays Law, Wolffs Law, piezoelectricity, bone repair, bone cells, electric bone growth device regulations, cost of bone growth stimulation, FDA class III devices, premarket approval, bone growth device history, Luigi Galvani, electric bone growth studies, companies that sell electric bone growth stimulators, Biomet, Exogen, modern electric growth theory, and bone growth stimulator patent. We searched several databases and reliable search engines including the following: Google Books, Google Scholar, Gale PowerSearch, EBSCOhost, ScienceDirect, PubMed, and Wiley Interscience.

Henry Ford Biography :: essays research papers

Henry Ford Born July 30, 1863 in Dearborn, Michigan, Henry Ford was the first child of William and Mary Ford. As a young man he became an excellent self-taught mechanic and machinist. At age 16 he left the farm and went to nearby Detroit, a city that was becoming an industrial giant. There he worked as an apprentice at a machine shop, while months later he would begin work with steam engines at the Detroit Dry Dock Co., where he first saw the internal combustion engine, the kind of engine he would later use to make his automobiles. When he was 28 Ford took a job with Thomas Edison's Detroit Illuminating Company, where he became chief engineer. In his spare time he began to build his first car, the Quadricycle. It resembled two bicycles positioned side by side with bicycle-like wheels, a bicycle seat, and a barely visible engine frame. Some said it bore a resemblance to a baby carriage with a two-cylinder engine. In June 1896, Ford took an historic ride in his first automobile that was observed by many curious Detroit on-lookers. The Quadricycle broke down in a humiliating scene. By 1899 Ford created a more proper looking motorcar with the help of wealthy businessman William Murphy. It had high wheels, a padded double bench, brass lamps, mud guards, and a "racy" look. In the same year Ford founded the Detroit Automobile Company. Within 3 years Ford had built an improved, more reliable Quadricycle, using a four-cylinder, 36 horsepower-racing engine. In 1901 his car beat what was then the world's fastest automobile in a race before a crowd of eight thousand people in Grosse Pointe, Michigan. The publicity he received for this victory allowed Ford to finance a practical laboratory for refining his auto ideas. In 1903 Ford launched his own car company, The Ford Motor Car Company, and by January 1904 he had sold 658 vehicles. By 1908 he built the famous Model T, a car that was affordable to the middle class. The automobile was no longer the toy of the rich. Ford was able to make a reliable and inexpensive automobile primarily because of his introduction of the innovative moving assembly line into the process of industrial manufacturing. The assembly line is a system for carrying an item that is being manufactured past a series of stationary workers who each assemble a particular portion of the finished product.

Essay --

Jonathan Swift was a famous author who combined humor and politics to create many prominent works. He was born in Dublin, Ireland on November 30, 1667. Swift was born prematurely and with Menierà ©Ã¢â‚¬â„¢s Disease, a condition in the inner ear that causes nausea and hearing problems. Because his birth mother couldn’t provide for him, she gave him over to a relative named Godwin Swift. As a child, Jonathan Swift went to Kilkenny Grammar School, which was the best school in Ireland. During elementary and middle school, Jonathan was friends with William Congreve, a future poet and playwright. At the age of fourteen, Swift entered Trinity College in Dublin. Because he didn’t have financial support, he had to drop out after four years, but he still received a bachelor’s degree. After college, Swift moved to his mother’s home in Leicester, England, and it was there where he received his first job. He became Secretary to a retired diplomat, Sir William Temple, staying with him at his home in Moor Park. This was an important event for Swift where he gained some power as a politician. He only obtained this job because he had many family connections, and his relatives had good reputations. At his job at Moor Park, he met Esther â€Å"Stella† Johnson who was 8 years old at the time. They had a long-lasting friendship, and he became a tutor, mentor, and a great friend to her. Soon, Jonathan Swift sought a new occupation, and in 1694, he worked for an Anglican priest. After he worked with the church for about a year, Swift returned to Moor Park and had his old job back. When Sir William Temple grew old, Jonathan Swift was instructed to publish William’s work after his death. Soon, Sir William passed away, and he left Swift  £100 and his unpublished books th... ...s. Gulliver is able to sail to Japan, and from there, he travels back to England. On his fourth and final journey, Gulliver becomes a victim of mutiny and lands in a mysterious land populated by Houyhnhnms, rational-thinking horses who rule the Yahoos, savage humanlike creatures. He becomes great friends with the Houyhnhnms, but when they realize that he physically resembles a Yahoo, they banish him from the island. Jonathan Swift was an Irish satirist, essayist, poet, and cleric who turned political writing into something more riveting and humorous. Although his works were aimed towards the political audience, his writings impacted everyone in Europe in many ways. His combination of genres created a new theme that was admired by many groups of people. Though his work may not be remembered forever, he will remain a distinguished author in all of his reader’s hearts.

The Fulcrum and the Lever Essay -- essays research papers fc

I turn the key and unlock the deadbolt. It’s been a long day’s work. I have been working three jobs for weeks now. I come through the door of my tiny one-bedroom house and stare at the desk, piled high with debris: old junk mail, magazines, and a few bills. I keep thinking maybe on my day off I’ll clean this mess up, balance my check book and pay my bills. â€Å"But what’s the use?† I think to myself, â€Å"I have $210 left on my credit card, that’ll get me through another week.† Independence is what I wanted and that’s what I got. I have a car, a house, furniture, stocked cupboards, and plenty of I-can-do-what-I-want free will. I was working a lot, and sure was doling out a lot of dough, yet I felt atrophy kicking in. When I was dying to leave my parents house, I didn’t think that it would be like this. Going and doing whatever I wanted all the time was not something I did. Life cost money and the reality was kicking me in the stomach every time I walked in my front door and looked at my desk. â€Å"Where is that Consumers bill? How much money is left in my checking account? Do I even have any in my savings?† These thoughts break-danced in my head often. In a day where I see more commercials advertising credit cards, debt consolidation, and home mortgage lenders, one might find it hard to believe that debt can actually be a problem. Seeing those poor saps dance in a conga line screaming, â€Å"Freedom!† makes it that much harder to notice. With three maxed-out credit cards, and other debt in the thousands of dollars, I was one of those people screaming, â€Å"Save me!†   Ã‚  Ã‚  Ã‚  Ã‚  My life could go nowhere while I was struggling to make payments on three credit cards that I hadn’t even used in two years. One of my frustrations stemmed from the fact that all of this money was going to the credit card companies for things that I don’t even remember buying. With my student loan in deferment, I had only to worry about everything else. Working three jobs was not my cup of tea. The â€Å"American Dream† was killing me.   Ã‚  Ã‚  Ã‚  Ã‚  A lot of Americans are drowning in debt, with predators just waiting to add to the pile. Dave Ramsey, New York Times best selling author and financial advisor, says: Debt is dumb. Most normal people are just plain broke because they are in debt up to their eyeballs with no hope of help. If you're in debt then you're a slave, i... ...y Book. Holbrook, MA: Adams Media Corporation. 1999. Sylla, Richard. â€Å"American History Information About National Debt.† The Reader's Companion to American History. Houghton Mifflin Company. 20 May 2005. . Ramsey, Dave. The Total Money Makeover: A Proven Plan for Financial Fitness. Nashville, TN: Thomas Nelson, Inc., 2003. -----. More Than Enough: The Ten Keys to Changing Your Financial Destiny. New York, NY: Penguin Books. 1999. â€Å"The Debt To the Penny.† Bureau of the Public Debt: United States Department of the Treasury. 20 May 2005. . Waggoner, Darren. â€Å"Going Broke?: Younger Americans have a serious debt problem.   Ã‚  Ã‚  Ã‚  Ã‚  Not surprisingly, lenders and consumer advocates propose different remedies   Ã‚  Ã‚  Ã‚  Ã‚  for the credit crunch.† Collections & Credit Risk. 10.5 (2005): 21. Infotrac:   Ã‚  Ã‚  Ã‚  Ã‚  General Reference Center Gold. Online. 31 May 2005. Webster, Noah. Noah Webster's First Edition of an American Dictionary of the English Language. San Francisco, CA: Foundation for American Christian Education, 1995; Reprint edition 1 June 1967. Yaqub, Reshma Memom. â€Å"Swipe at Your Own Risk.† Parents. July 2005. 49-53.

Vulnerable Population In The Workplace

One has chosen to focus on the substance abuse patients as the vulnerable population for the project. Frequently one has identified and seen stigmatization, prejudgments, and poor care given to this population in the workplace. Many patients are discharged each day with no plan of care, no education on resources and no instructions for follow up care. The outcomes and possibilities for the patient’s recovery have shown to be slim by the frequent return of the patient in the emergency room.The patients return within hours of discharge from the ER and seem to be in the same condition as when they left. One has created an action plan and a teaching brochure for health care providers to help facilitate a better system and care process for this population. The first step of overcoming this issue is to start from the base of it, which are the providers and their beliefs. The focus will be on educating the health care providers to stop stigmatization, develop self-awareness, and lear n to be culturally competent and to be the best advocate for the patient.In the emergency room there are frequent patients via ambulance, walk-in’s, which are intoxicated and requesting, detox. Typically when the patient arrives he or she are intoxicated, wheatear it is drugs or alcohol. The patient is registered and triaged. Depending on their condition or level of intoxication, they are either immediately brought in or are placed on a stretcher and wait to be evaluated by a physician. Because of the large population of substance abusers in New York City, these patients tend to have a stigma attached to them.The stigma is the patients will not follow up with his or her detox programs, they will return to the ER with-in hours of discharge, they are seeking food and shelter for the night, and they are not serious in their treatment to recover. Therefore, many of the providers and nurses in the ER tend not to take the patient or his or her care seriously. They often wait to see if the patient will walk out and leave after a few hours of warmth and food. If the patient is in the waiting area and waiting to come in, many charge nurses will continue to skip over the patient to bring in others.If the patient is in the department the providers tend not to pick-up their charts in assumption the patient will just leave to continue his or her addiction. One has created a teaching brochure to help identify three concepts, which may lead and assist in caring for the substance abuse patient. The concepts will help providers to be empathetic, trustworthy, and intelligent to the patient’s backgrounds and beliefs. The brochure speaks of the concepts and reasons it will aid in the patient success in recovery.If these patients are seen as a lost cause and providers do not listen or rectify the problem the population of the substance abuser will grow and increase the death rate and increase dangers to others as well. Substance abuse does not only endanger the patie nt but the people around him or her. For example, a person who is drinking and driving can hit a pedestrian walking and cause fatal danger to that person. One has learned through lessons in this class how to identify a vulnerable population, how self-awareness cultural competence, and advocacy can help treat these patients and provide the best care needed to have the best outcome.The first step as a provider is to have self –awareness. It is only possible for one to relate to others when they know whom one is and what one will or will not accept from others (Jack, Kristen, Smith, & Anne, 2007,para. 1). In the treatment of others it is important for the provider to be aware of their own personal beliefs and identity. To truly understand what one believes in is to have self –awareness. â€Å"Being self-aware enables us to identify our strengths and also those areas that can be developed.If we do not know our good and bad points then we are less likely to be able to help others (Burnard 1992). Nurses can use the self to therapeutic effect when working with patients, for example, when empathizing or advocating (Jack, et al 2007,para. 2). Cultural competence is also important for the health care team to incorporate in accurate care for substance abuse patients. Cultural competence is not only about ethnic background, religion, race, or spirituality. It is also about the environment in which one lives.â€Å" The layers of culturally competent practice do not solely address race and ethnicity. A comprehensive culturally competent practice encompasses issues related to language, migration and acculturation, family history, religious practices, as well as social trust and community attachment† (Mallow & Cameron-Kelly, 2006, para. 11). The staff needs to learn the importance of empathy and pre-judgmental thoughts toward the culture of the substance abuse patient. They live and survive in a different environment. To provide care for them is to under stand and keep biased opinions out of the treatment.Providers should analyze and try to learn of their culture and struggles they see and handle each day. The third concept implemented in this learning tool would be advocacy. Nurses and doctors are essentially the patient’s voice. Patients relay on the health care provider to help them and guide them through care and also to represent them in the hospital or within the community. The nurse and physician are the main identifiers of the recurring problem. The providers can help to implement new policies or create outpatient programs to keep the patient on a positive track.Identifying the flaws and implementing new systems can help the patient have a better health outcome. â€Å"The knowledge and expertise of a nurse regarding the care and concerns of a patient are vast. Overlay that knowledge and expertise with a sense of community, and the nurse advocate is born. Whether teaching proper car-seat installation to parents, advoc ating for primary seatbelt laws at the state house, or testifying at a congressional committee hearing, each nurse should be aware of the importance of political advocacy.Health care is in an evolving state, and nursing is at the table; every nurse should be aware and supportive of this advocacy† (Philips, 2012, para. 10). In conclusion one believes substance abuse patients would benefit greatly and outcome goal would improve if he or she were cared for and handled by a provider who was empathetic and knowledgeable to his or her cultural needs, ethnic background, and beliefs, whether they were spiritual or not. Each person or patient is unique and should receive treatment in a way, which suits him or her uniquely.In order for a provider to do so, they should be knowledgeable to self-awareness, cultural competence, and advocacy. Knowing oneself, possessing knowledge of others and motivation to be a trustworthy advocate will help the substance abuse patient feel support and allo w him or her to recognize the provider as a trustworthy person. Building trust and creating a stable health climate with the patient will paint a road to recovery for the substance abuse patient. Vulnerable Population in the Workplace Nursing profession is a career with a vast field of different practices with different roles to choose from. This variety makes the nursing field a vulnerable profession for mistakes if not tackled with adequate educational and clinical training. Although there are different specialties for a nurse to choose from to continue their career, it is still necessary for every nurse to have even a little amount of knowledge, or background, of the different scopes of practice of the other specialties of nursing. If this can’t be achieved as an individual, teamwork is necessary by sharing the knowledge you have especially in the workplace.Having that knowledge about vulnerable population is an essential tool to be able to work with patients properly. Sharing that knowledge to your workplace is important in order for them to be able to work competently, especially in the field that I work with where we handle different kinds of patients. In this paper, we will see how the knowledge abou t the vulnerable population is essential in the workplace, which consists of topics essential to this subject such as the Vulnerable Population: Vulnerable People, Cultural Competence and Resilience, and Social Justice in Nursing.Vulnerable Population: Vulnerable PeopleUnderstanding the definition of being vulnerable is the first step to be able to work competently with this population. According to the American Journal of Managed Care, members of this â€Å"vulnerable population† are those who are at risk for certain health problems. (AJMC, 2006) As the term elaborates, vulnerability is the susceptibility of any group or individual for risks of problems. Home health nurses meet lots of vulnerable patients especially those who have chronic diseases, disabled, and the elderly.Understanding  what their at risk for are essential in order for nurses to plan for prevention interventions. Examples of vulnerable population that home health nurses meet frequently are those who are disabled, have chronic illness, and the elderly. They are also on the top of the list that are high risk for falls, pressure ulcers, pneumonia, DVT, depression, and the list goes on and on. It is important for home health nurses to understand these risks for this vulnerable population to be able to generate prevention interventions.Cultural Competence and ResilienceCultural Competence and Resilience is an important quality that should always be carried by a professional nurse. According to Poole, cultural competence is practiced by nurses not only because it is politically appropriate, but it is also an inner sense that being culturally competent is an essential attitude to be able to build that therapeutic relationship with the patient, which promotes better healing environment. (Poole, 1998)Resilience is the ability of an individual to bounce back from change or difficulty as defined by the Merriam-Webster Online Dictionary (2010). With these two combined, home health nurses can b e able to deal with patients with different cultures competently without any difficulty adapting from the great changes that they may experience from different types of patients.Social Justice in NursingSocial Justice is known as the ability to provide fair treatment regardless of age, ethnicity, race, economic status, disability, and gender as defined by the American Association of Colleges of Nursing (2008). When this attitude is applied to nursing, it makes a nurse aware that everyone is equal, and therefore should be treated equal. In home health nursing, this equality is sometimes not seen because of the inability of the patient to pay for the right services that is appropriate to his/her condition.But this is not an excuse for a nurse to neglect the other appropriate care that can be done independently. To show care more than to show how vulnerable they are because of socioeconomic status is more important than having that full coverage of treatment they can get but is not rec eiving that genuine care that they need for therapeutic relationship and healing. This attitude is important because ever since the nursing profession started, nurses became an advocate to their patients to protect their rights and to  encourage them to exercise that power of their rights.These three important topics are important to understand more deeply in order for the nurse to be able to provide care more effectively especially to those who are included in the vulnerable population. More importantly, knowledge with these topics should be shared to my workplace to expand the knowledge on caring with the vulnerable, especially for home health nurses who most of the time take care of the elderly, disabled, chronically ill, minorities, and the socioeconomically unfortunate.

Unity day

The little short tear on the site titled Stile Post or the telephone game made a little impact on how I view our world today. They start finish off the film with Miriam the little girl essentially picking on Paul, the only colorize kid In the class, by motto that Paul never washes, and passing it to the succeeding(prenominal) person. That person then passes that little sec of information to the next kid, who passes It to the next kid, and so on. So this group of children could of Just unploughed the rehearsal that Paul never washes press release around until It was whispered into Palls ear.One kid In the circle changes the rumor from Paul never washes to Miriam Is In love with Paul. This film shows that plucking on other races and bullying can be halt at a new-fangled age, one kid from that class stopped the ugly secret and made a funnier one to sort of get game at the little girl. Rumors can be spread so easily In our society and people can say a stop to It by ever-cha nging the rumor to better the person the rumor Is ab come forth. The film Crutch was amazing, I loved any second of this film, how Bill Shannon or cantor that has been dealt some bad cards in invigoration has overcame his medical problems.He has a system of transportation on a skateboard, chip dances, and gets around super easily, all succession having bilateral hip deformity. Just by listening to him speak in the film, I can tell he loves his life, and energy really brings him down. It is just a huge motivational story for everyone, no depicted object how bad you believe you think your life is, always remember there is someone out there that has it worst than you and is enjoying every second of their life. So never out yourself down do exactly as Bill said in the film Take what is thrown at you in the best way that you can, and evolve your skills in that manner.

Strategic Management and Personal Media Players

orchard apple tree, Inc. in 2010 Assignment Questions 1. What argon the chief elements of Apples general hawkish scheme? How advantageously do the pieces fit in concert? Is the strategy evolving? 2. What argon the befall out elements of Apples strategy in computers, ain media players, and smartphones? Have its strategies in its core blood linees yielded mastery? Explain. 3. What does a rivalrous authorisation assessment reveal near Apples computer business, as compargond to the leaders in the personalised computer sedulousness? Use the methodology in disconcert 4. to support your answer. Does it appear that the companionships competitive associations in personal media players and smartphones or bullockyer or weaker than its position in computers? 4. Does it put to work good strategic sense for Apple to be a contention in the computer, personal media player, smartphone, and tablet computer industries? ar the value chain activities that Apple performs in computers , personal media players, tablet computers and smartphones very similar and compatible or be there very important disaccordences from intersection to product?Which of the four products linescomputers, tablet computers, personal media players, or smartphonesdo you think is most important to Apples future growth and advantageousness? wherefore? 5. What is your assessment of Apple Computers pecuniary outcome the past three years? (Use the monetary ratios in Table 4. 1 on pages 94-96 of the school text as a result in doing your pecuniary analysis. ) 6. What recommendations would you make to allow Apple to strengthen its position in its most important markets? What steps should it deliberate to ensure that the iPad becomes a succeeder in the food market and a major contributor to the high societys overall performance?Googles Strategy in 2010* Assignment Questions 1. Discuss competition in the pursuit labor. Which of the five competitive forces seem strongest? weakest? Wh at is your assessment of overall industry attractiveness? 2. How is the search industry ever-changing? What forces seem most give c bely to bring about major change to the industry within the near three to five years? 3. What are the key factors that define success in the industry? What are the key competencies, capabilities, and alternatives of productive search engine companies? 4. draw Googles customer value roposition and profit traffic pattern linked to its business model. What strategies has Google relied upon to build competitive expediency in the industry? 5. Have Googles business model and strategy proven to be successful? Should investors be impressed with the companys financial performance? How does the companys financial performance compare to that of Microsoft and Yahoo? Please conduct a financial analysis to support your positionyou whitethorn wish to use the financial ratios presented in the Table 4. 1 of the text as a guide in doing your financial analysis of the company. . What are the companys key resources and competitive capabilities? What competitive liabilities and resource weaknesses does it buzz off? What opportunities exist? What threats to its continued success are present? 7. What recommendations would you make to Googles top- caution team to protract its competitive advantage in the search industry? How should it best capitalize on its strategic initiatives in mobile phones, cloud computing, emerging markets, and other ventures? southwestward Airlines in 2010 Culture, Values, and Operating Practices Assignment Questions . Is there anything that you find particularly impressive about southwesterly Airlines? 2. What grade would you give southwestward management for the job it has through with(p) in crafting the companys strategy? What is it that you give care or dislike about the strategy? Does southwestern have a winning strategy? 3. What are the key policies, procedures, operating practices, and core values key sou thwesterlys efforts to implement and execute its cheap/no frills strategy? 4. What are the key elements of Southwests stopping point? Is Southwest a strong culture company? Why or why not?What problems do you foresee that Gary Kelly has in sustaining the culture now that Herb Kelleher, the companys ghostly leader, has departed? 5. What grade would you give Southwest management for the job it has done in implementing and executing the companys strategy? Which of Southwests strategy execution approaches and operating practices do you believe have been most crucial in accounting for the success that Southwest has enjoyed in executing its strategy? argon the any policies, procedures, and operating approaches at Southwest that you pass up of or that are not working well? 6.What weaknesses or problems do you see at Southwest Airlines as of mid-2010? 7. Does the AirTran acquisition make good strategic sense for Southwest? 8. What strategic issues and problems do Gary Kelly and Southwes t executives need to address as they proceed to penny-pinching the deal with the AirTran acquisition and contemplate how best to fuse AirTrans operations and AirTrans employees into Southwest? 9. What recommendations would you make to Gary Kelly and Southwest executives as the company heads into 2011? Competition in Energy Drinks, Sports Drinks and Vitamin-Enhanced Beverages Assignment Questions 1.What are the strategically pertinent components of the global and U. S. beverage industry macro-environment? How do the frugal characteristics of the alternative beverage segment of the industry differ from that of other beverage categories? Explain. 2. What is competition like in the alternative beverage industry? Which of the five competitive forces is strongest? Which is weakest? What competitive forces seem to have the greatest effect on industry attractiveness and the potential profitability of new entrants? 3. How is the market for energy drinks, sports drinks and vitamin-enhance d beverages changing?What are the underlying drivers of change and how might those forces individually or collectively make the industry more or less attractive? 4. What does your strategic group map of the energy drink, sports drink, and vitamin-enhanced beverage industry look like? Which strategic groups do you think are in the best positions? The worst positions? 5. What key factors determine the success of alternative beverage producers? 6. What recommendations would you make to Coca-Cola to improve its battle in the global alternative beverage industry? to PepsiCo? to Red Bull GmbH?