Postoperative Nausea and Vomiting: Causes and Treatments

Postoperative Nausea and Vomiting: Causes and Treatments Postoperative nausea and vomiting is the nausea and vomiting symptoms which occurred after a surgery, medicines intake or anaesthesia usage. Around 18 to 30 of surgical patients have PONV and the nausea and vomiting symptoms are usually self-limiting in most cases.1 Uncomplicated PONV usually resolve within 24 hours after an operation whereas intractable PONV involve various triggering factors and resist to medical treatment, making it harder to treat. Studies revealed that most patients dislike chronic PONV more than postoperative pain as it is a more distressing illness and it may lead to several serious clinical consequences if left untreated. In the case of repeated vomiting, PONV patients might suffer from dehydration and have a higher chance of developing hiatal hernia, a condition where the upper part of stomach protrudes into the thorax through the opening of diaphragm. Other than that, patients might also experience anorexia, gastrointestinal discomfort, headache, weakness, dizziness and nausea while not vomiting. Chronic vomiting can also cause complications like dental damage and sore throats due to exposure of oesophageal lining and mouth cavity to the low pH gastric acid. Moreover, PONV may induce serious problems like pulmonary aspiration, electrolyte abnormalities, wound dehiscence, increased pain and oesophageal rupture.4,5 Despite causing patients discomfort, patients also have to pay more for the delayed hospital discharge. Each incidence of vomiting has increased postanaesthetic care unit (PACU) stay duration by 20mins. Therefore, to reduce the unanticipated hospital admission and the financial burden broug ht by PONV, there is a need to understand the disease pathophysiology so that precise and mechanism-based treatment strategies can be developed to tackle the emesis problem. The vomiting centre and the chemoreceptor trigger zone (CTZ) are the two main parts of the brain controlling the vomiting action. The vomiting centre is located within the medulla oblongata and the emesis action is initiated via the stimulation of five primary afferent pathways. They are the chemoreceptor trigger zone, vagal mucosal pathway of the gastrointestinal system, neuronal pathways from the vestibular apparatus system, inputs from the periphery glossopharyngeal nerve and reflex afferent pathways from  cerebral cortex C2,3 and midbrain afferents. Next, efferent nerve impulses are sent to various place of the body such as the pharynx, larynx, diaphragm, intercostals muscles and gut to initiate the vomiting reflex. During the ejection phase of the vomiting reflex, the diaphragm and abdominal muscles  simultaneously contract and the elevated intra-abdominal pressure leads to the throw up and expulsion of gastric contents. A variety of receptors are participated in the emesis action. They are the histaminergic(H1), dopaminergic(D2), serotonergic(5-HT3), muscarinic and neurokinin-1 receptors. Consequently, pharmacological agents which target on these receptors can be utilized to treat PONV. However, the British National Formulary (BNF) had advised that antiemetic agents should only be used once the causative factor for nausea and vomiting was identified. This is because the use of antiemetic is sometimes dangerous and inappropriate in clinical cases like diabetic ketoacidosis, digoxin or antiepileptic overdose.6 Hence, the aetiology and possible causative factors of PONV should be investigated to guide the planning of the pharmaceutical management steps and the antiemetic selection for treating PONV. There are patient-specific factors, surgical factors and anaesthetic risk factors which contribute to PONV prevalence. Patients who aged 6 to 16 year old, female, non-smoker, obese or have a history of motion sickness or PONV are proven to be the high-risk patient group. Moreover, patients who have chemotherapy, migraine and gastroparesis problems are also susceptible to PONV. Other causative factors include elevated intracranial pressure, metabolic abnormalities, gastroduodenal ulcers, dehydration and infections of the gastroesophageal lining. As for the surgical factors, PONV is related to the premedication side-effect, prolong fasting, conditions of gastric inflation during mask ventilation, use of long-acting opioids, nitrous oxide, volatile anaesthetics and high dose neostigmine in surgery. In addition, frequent head movement of patient and early intake of food after surgery can also potentiate the nausea problem.1 Some types of operations have higher chance of developing PONV, they are the gynaecological surgery, ear, nose and throat operation, intra-abdominal and squint correction surgery. Furthermore, the surgical duration is also an important contributor which predisposes patients to a higher risk of PONV. Every 30 minutes extension in surgical time can increase risk of PONV by 60% as patient is taking in more anaesthetics into the body. Hence, healthcare team should control and minimize the surgery duration such that risk of getting PONV is reduced. Although it is not relevant to discuss anaesthetic techniques in this case scenario, it is important to note that regional anaesthesia should be preferred over general anaesthesia during surgical process. According to SOGC guideline, there is an 11-fold increase in the PONV risk when using general anaesthesia rather than regional anaesthesia. Apart from that, volatile anaesthesia, long-acting opioid and neostigmine should also avoid in surgery as these agents predispose patient to PONV. If the use of general anaesthesia is unavoidable in a surgery, propofol can be a suitable induction agent because it induces less PONV incidence. A thorough assessment should be carried out to serve as a rationale for the management plan of PONV. The past medical history, frequency and nature of the vomiting episode, blood electrolyte test and physical examination can be evaluated to identify the severity of disease condition and the aetiology of PONV. Subsequently, the appropriate pharmacological agents which target on the responsible pathway of emesis can be given. Many antiemetic preparations are available in the market and patients can choose between formulations of solution, buccal tablets, rectal suppository and subcutaneous (SC), intravenous (IV) or intramuscular (IM) injections when oral route is not feasible.6 As no single agent provides complete control in emesis, most hospital has adopted a multimodal approach and a combination strategy where different antiemetics which target on different receptors are utilized in the treatment of PONV.1 Combination therapy becomes the preferable way to treat PONV and the generally used combination is 5-HT3 receptor antagonists with droperidol or dexamethasone. Granisetron and ondansetron are examples of 5-HT3 or serotonin receptor antagonists. They exert their effects in the chemoreceptor trigger zone and at vagal afferents of the gastrointestinal tract. Previous studies showed that no single agent performed exceptionally well than the others of same class as all 5-HT3 antagonists illustrated similar safety and efficacy profile. Yet, a recent meta-analysis which includes 85 randomized controlled, double-blind studies with 15,269 patients involvement had established that the antiemetic effect of granisetron is significantly superior to ondansetron and dolasetron. Ondansetron was also found to be more cost effective than granisetron. 1-2mg of granisetron or 4-8mg of ondansetron can be delivered in intravascular route at the end of surgery for PONV treatment. Long-acting serotonin antagonist with higher binding affinity to 5-HT3 receptors, palonosetron, is also available in the market with a long half-life of about 40 hours. Patients receivin g these agents might experience headache, constipation and dizziness problems. Droperidol is a butyrophenone which acts competitively on central dopaminergic receptors in the chemoreceptor trigger zone (CTZ). It is applied in 0.625-1.25mg IV route at the end of surgery. A systematic review of 24 randomized studies was carried out by Schaub and team, they concluded that droperidol decreases PONV incidence regardless of the dose given to patients. However, this drug is only used as a third-line antiemetic for intractable PONV when other alternative treatments failed because droperidol can lead to adverse effects associated with QT prolongation and torsades de points, sedation, anxiety, hypotension and extrapyramidal symptoms. Due to its possibility in causing fatal arrhythmia, electrocardiographic monitoring is compulsory each time upon its usage. Nonetheless, a double-blinded randomized clinical study which included 120 patients stated that there was insufficient evidence to prove the QTc prolongation effect induced by droperidol after surgery. Dexamethasone is classified under corticosteroids and often delivered in a 4 to 5mg one-off dose via IV or IM route.19 The exact mechanism of action is unknown but it is related to the peripheral inhibition of prostaglandin synthesis and its ability to reduce 5-HT turnover in the CNS. Although dexamethasone is not licensed for the indication of PONV, this drug is as effective as other conventional antiemetic drugs like droperidol and serotonin antagonists. A single blinded, randomized-controlled interventional study had illustrated that the administration of dexamethasone is useful for the reduction of PONV episodes (30% in contrast to 70% of the placebo group).20 Moreover, Ormel et al. illustrated that the addition of dexamethasone to droperidol and ondansetron showed a profound amplification in the efficacy profile of these triple agents combination. It stands as a good alternative for PONV treatment due to the advantage of cost-effectiveness issue and its characteristic of long ac tion duration. As dexamethasone can increase plasma glucose level, it is not recommended for diabetic patient. Furthermore, unfavorable side-effect like postoperative euphoria, impaired wound healing, irritability and adrenal suppression can happen in patient taking long-term corticosteroids. Metoclopramide is a gastroprokinetic agent which acts on the D2 receptors of the gastrointestinal tract. It can accelerate the gastric emptying rate of gastroparesis and GI obstruction patients.2,6 Despite blocking the D2 receptors, it also has antagonist action on 5-HT3 receptors in the CTZ and vomiting centre when delivered in high doses. 5 to 20mg dose of metoclopramide in subcutaneous, oral or IV route is commonly taken by patient before meal and before bed.6 This medicine is commonly administered as combination therapy because there is conflicting evidence stating that metoclopramide alone is ineffective for PONV and it should not be use unless the causative factor for PONV is gastric stasis. Yet, a recent meta-analysis has proved that 10mg IV metoclopramide does well in preventing nausea and vomiting problems after the general anaesthesia surgery. As with the phenothiazines discussed below, both drugs have limited use in practice due to the adverse reactions like extrapyramidal effects and dystonia disorder particularly in pediatric and young adults population. Phenothiazines is an example of strong dopamine antagonist which also act on medullary CTZ. Promethazine, prochlorperazine and perphenazine belong to this group and take part in the prophylaxis and treatment of PONV.24 Prochlorperazine is often administered as a 12.5mg deep intramuscular injection or in a 3 to 6mg dose buccal preparation 12 hourly after the surgery. These agents show superior efficacy in treating opioid-induced PONV. However, high-dose metoclopramide and phenothiazines are now less likely used in clinical practice because of their significant side effects like acute dystonic reactions, sedation, dizziness and extrapyramidal symptoms.9,25 A systematic analysis consisting of 19 non-randomized and randomized clinical trials had demonstrated that most studies supported the effectiveness of promethazine in reducing PONV occurrence when compared to placebo and that combination therapy is always preferable and more effective than promethazine alone. Cyclizine is an antihistamine drugs which block the H1 sympathetic pathway in the vomiting centre. The antimuscarinic and antihistamine properties of cyclizine render it to become an antiemetic drug in PONV treatment. A randomised double-blinded study which involved the participations of 960 women had shown that patients who received cyclizine monotherapy showed a slightly greater antiemetic effect than granisetron alone (PONV incidence of 24% with cyclizine compare to 23% in granisetron group).26 Cyclizine can be given orally, intramuscularly or intravenously, with common antimuscarinic side-effects like sedation and dry mouth. Severe heart failure patient should avoid taking this medicine because it leads to detrimental haemodynamic effect.6 The acidic pH of cyclizine at 3.2 also causes pain and irritancy to body upon injection.10 As a result, patients usually have 50mg of cyclizine IV injection every 8 hours after proper dilution. A lower dose of 25mg in oral, IM or IV preparation s can also be applied in elderly patient. Scopolamine has anticholinergic property which inhibits the muscarinic as well as the histaminergic receptors in the vestibular apparatus and the nucleus of the tractus solitarus.3,9 Patients who undergo middle ear surgery or use opioids as postoperative anaesthetics are recommended to take scopolamine for their profound efficacy in reducing PONV.3 Scopolamine requires 2 to 4 hours for onset of duration. Hence, a fast-acting antiemetic or a loading bolus dose is needed in urgent case. It is available in transdermal form as a 1.5mg patch which can be placed behind the ear. This slow-release formulation can have sustained effect up to 72 hours. Apfel C et al. had reported that transdermal scopolamine had significantly reduced the risk of PONV when compared to the placebo group although it has the main side-effects of dry mouth, sedation and visual disturbances.28 Furthermore, a comparative study between the combination use of ondansetron plus scopolamine patch and ondansetron alone als o proved that the earlier group significantly decrease the nausea and vomiting incidence after surgery. Other than a mechanism-based approach, less conventional therapeutic agents can also be used to treat intractable PONV cases. An antidepressant with a novel indication, mirtazapine, is able to ease the nausea and vomiting symptoms because it can antagonize 5-HT3 receptors. A small scale randomized trial which compared the therapeutic outcome of mirtazapine and ondansetron had showed that patients using mirtazapine were less anxious and had fewer PONV episodes than the ondansetron group. Next, olanzapine which is recognized as an atypical antipsychotic drug also proved to have potential in treating PONV. It can inhibit several receptors such as the dopamine, acetylcholine, histamine and 5-HT3 receptors. Ibrahim M et al. had conducted a randomized controlled study which involved 82 surgical patients. The result proved the efficacy and safety profile of olanzapine against PONV especially during the late postoperative stage. Other than medications approach, non-pharmacological interventi ons also show potential therapeutic efficacy in PONV management. Acupuncture, acustimulation or acupressure serves as a good alternative or adjuvant therapy for PONV patients as it shows good tolerability and safety profile. The P6 point (Neiguan) which located at 5cm near to the ventral wrist is the target site of these alternative approaches. Transcutaneous electrical stimulation delivered to the P6 point of the pericardium meridian has been proved to be an efficient way in preventing emesis. Patients only complain of light side-effects like needle fainting, allergy, needle site pain, anxiety or lethargy problems when using this method. In order to solve the labour intensive and time-consuming issues of traditional Chinese acupuncture, the acupressure and acustimulation wristband are introduced in the market (Sea-Band and ReliefBand). Sea-Band applies steady, continuous pressure on the P6 point whereas ReliefBand is a watch-like device which conducts low current to P6 point via electrodes in contact with the skin. Based on the well-established efficacy profile and good evidence-base literature support, healthcare professionals can involve more acupuncture interventions in treatment practice as part of the multimodal approach. In this case, the intractable emesis symptoms experienced by the old woman might indicate the failure of prophylaxis treatment or the need to start a primary antiemetic treatment. Before the initiation of a rescue treatment, a bedside examination and a patient interview should be done to find out whether the PONV symptom is associated to issues such as morphine analgesia, surgical pain management, infection, intestinal obstruction, hypotension, hypoxia, blood in the pharynx, anxiety or removal and insertion of nasogastric tube. 5-HT3 antagonist is the recommended drug for patients who previously do not receive a prophylaxis treatment. Patient can start with a low dose regimen such as ondansetron 1 mg, dolasetron 12.5 mg and granisetron 0.1 mg. If drugs for prophylaxis had been given but fail, patients can then try other class of antiemetics to tackle more diverse receptor pathways. For instance, Habib et al. had found that the failure of prophylactic ondansetron or droperidol can be replaced with rescue agents like promethazine (12.5-25 mg IV), prochloperazine (12.5mg IM) or cyclizine (25-50mg IV or IM) to achieve a better outcome. This is because consensus guideline support that the repeat use of 5-HT3 antagonist within the initial 6 hours postoperative period provides no extra recovery response. If patient use dexamethasone as prevention agent, small dose 5-HT3 antagonist (25% of prophylactic dose) can then be given as a rescue approach. A study also concluded that the cost-effectiven ess of ondansetron in low dose treatment group was higher than that in the high dose prophylatic group. Moreover, in the case of the aggressive treatment failure, such as those who had taken 5-HT3 antagonist, droperidol and dexamethasone altogether but failed, repeat dosing of same prophylactic regimen except dexamethasone can only be considered 6 hours after the surgery though the optimal dosage and timing for readministration still remain unknown. Transdermal scopolamine can also be prescribed for outpatients as it is a more convenient preparation than the parenteral drugs. Prolong use of opioids for pain control after surgery should also be minimized as side-effects like nausea and vomiting are correlated to the prescribed dose. Alternative analgesics like NSAIDS can be used to substitute the causative opioids. In persisting case, pharmacist can review the prescription and anaesthetic charts to ensure adequate maintenance of analgesia, antiemetic and oxygen supply. Dose escalation under safety and therapeutic dosage range can also be worked on. However, pharmacist should be cautious on polypharmacy problem as it may aggravate nausea and vomiting in susceptible patient. Non-oral drug preparations can be considered over oral route to avoid burdening of patient with excessive pills at one time. If necessary, the acupuncture treatment can also be applied to attempt a multimodal approach. Pharmacist should also concern about the possible dehydration risk that might be encountered by chronic PONV patients. For this reason, the blood pressure, hydration and perfusion level of patients have to be checked on a regular basis. Patients should be told to report of symptoms like dry or sticky mouth, sunken eyes, reduced urination or dark yellow urine. If constipation or diarrhea happens, intravenous fluid replacement therapy, osmotic or stimulant laxative can be given to solve the issues. For the dietary measures, patients should avoid oily or spicy food which might aggravate the nausea. Small, frequent meal is preferable over big heavy meal as light meal reduce the possibility of gastric discomfort. Patients should be advised to not move around too often to avoid triggering the vomiting centre. Furthermore, in post-discharged nausea and vomiting (PDNV) case, the antiemetic efficacy profiles are different from PONVs as they have dissimilar underlying cause. Droperidol should be avoided as it is ineffective in treating PDNV.2 If the patient still not responsive to all these approaches, specialist intervention should be initiated to treat intractable nausea and vomiting symptoms. Serious causative factors like surgical complication might be suspected and further investigations are required to treat this disease. In a nutshell, the optimization management of PONV disease requires the participation of the multimodal approach. Patients should be treated accordingly after the accurate disease assessment and further modifications of treatment approaches like (dose-adjustment, introduction of new agents or alternative approaches) can be done to control patients nausea and vomiting symptoms. Lifestyle modification and non-pharmacological interventions also play an important part in treating PONV. Proper patient education about symptoms management should be delivered and follow-up session can be arranged to assess patients rehabilitation progress. Apart from that, reassurance and full supportive care from healthcare teams also play an important role in reducing patient distress and anxiety level.

Essay --

The events of Hara-kiri can be contextualized within a span of time that saw both the end of decades of war, and the unification of Japan. The unification of Japan ushered in a new line of Shoguns, Shoguns with the momentous task of designing a social and legal system that would prevent the usurpation of power by the many fringe yet powerful daimyo. Believing in the Machiavellian idea that â€Å"fear is simply a means to an end, and that end is security for the prince,† the Tokagawa Shoguns implemented a series of policies in which petty crimes were met with harsh punishments. To any astute observer, such a legal system is sure to breed hypocrisy. Indeed, it was during this time that the bushido code’s emphasis on honor dwindled. To most samurai during this time, the bushido code’s high standards of honor were unobtainable2, making disobedience common and sometimes unavoidable. But to acknowledge disobedience meant certain death, and was thus unheard of. It was i n this unjust milieu that the events of Hara-kiri unfolded. Both Motome and the retainers of the Iyi were honorable samurai motivated by an inextinguishable desire to protect the ones they love; however, the unjust policies of the Shogun made this desire incompatible with the high standards of the bushido code, driving both parties to reluctantly defy the code. The use of the armor in the first scene establishes that the Iyi are honorable samurai, and shows their desire for the public to perceive them as such. The scene begins with a close up of the helmet. The camera is held at eye level, allowing the viewer to look directly into the eyes. The camera then switches to a position below the midline, close to the feet and points upwards at the helmet, the view of a person on hi... ...triguing to consider Motome’s state of mind when as he commits seppuku. Did he die hating the Iyi for allowing him to commit seppuku? Or did he ultimately realize the foolishness of his actions and that the Iyi had no other alternative? The latter is most likely true. In the moments before his death, we see Motome with his head down. He is relaxed and calm, his irrationality gone. He realizes that the Iyi’s decision to allow him to go through with his seppuku was not born out of greed or hate, but out of love, a love for the members of the clan and a desire to protect them from the possible repercussions of dishonor. He then breaks the clam, takes his sword, but he does not fight like Tsugumo does. He thrusts the sword into his stomach, performing seppuku for the retainers of the Iyi and their wives and children, ensuring none of them will ever be in his situation.

Black Boy :: Essays Papers

Black Boy3 Most young people have a dream of what they want to become. Maybe it doesn’t have to be a dream, but some kind of goal that they reach for. In the book, Black Boy, Richard, the main character, also had a dream, even though he lived in the South with strong white discrimination, pressure and a bad relationship with his relatives. As a student right now, I have dreams that I want to achieve in the future, even though I really don’t know how to achieve those dreams. Usually, when people are young, they have dreams of what they want to become. Those dreams may be being a firefighter, baseball player, teacher, pilot and so many other great jobs. When I was a child, I really wanted to become a pilot. The reason that I wanted to become a pilot when I was a child is that my father is a pilot. Richard had a dream to become a writer. However, Richard Wright’s main dream and reasons that made him have his dream are really different from mine. Richard was discriminated against by the whites, and was not treated fairly by his relatives. This terrible environment, which Richard lived through his young age, led him to seek freedom in nature. Even though he dreamed to become a writer, he had no leeway to think about dreams like that or mine. At first, he was just hungry for a better life and environment. Richard’s dream was to go up North for a better life and environment because he was tired of the discrimination and the racial distin ction between whites and blacks. Richard and I are similar in some ways. I really don’t know how to get a job or anything. It is the same as Richard for not knowing the reality of being in the North and becoming a writer. He just imagined himself working all over the place where he could find jobs as one step to reach his dream. I study here in Keio and I believe that it is a step and part of a process to be an adequate person, to gain enough knowledge to have a job in the future. My dream right now is to have a job that would let me work in a foreign country.

Incorporating Nonverbal Communication into Dietetics and Nutrition Essa

1.1 Introduction This research paper makes recommendations for incorporating nonverbal communication into Dietetics and Nutrition. 1.2 Limitations This report is limited to paralinguistics, gestures, clothing and adornment within nonverbal communication in the field of Dietetics and Nutrition. 1.3 Scope This report aims to highlight the importance of paralinguistics, gestures, clothing and adornment in the setting of Dietetics and Nutrition. Peer reviewed articles and theoretical evidence provided to address how we change individual’s perceptions of professionals by using nonverbal behaviours therefore effecting client health outcomes. Advice and strategies for improving client /professional relationships are included. 1.4 Methodology To complete this report, data was collected over a 5 week period using resources from the Internet and Library of the University. Theoretical evidence was also taken from the Communication Theory textbook. The data was collected and analysed from numerous authors of peer reviewed articles that discussed in varying degrees the many aspects of nonverbal communication. 2.0 Outline of nonverbal communication and link to Dietetics and Nutrition Non-verbal communication plays an integrative role for successful client/professional relationships in the field of Dietetics and Nutrition. Non-verbal communication effects the way we a person perceives our level of empathy, trust, competence, therefore can effect the success of client outcomes. Clothing and adornment, paralinguistics and gestures are aspects of non-verbal communication that are used in conversing consciously or subconsciously, conveying a message to another about themselves and their purpose. Problems can occur... ... p. 504). Koster, FRT. (2005). The power of communication. Modifying behaviour: effectively influencing nutrition patters of patients. European Journal of Clinical Nutrition, 17-22, . Koster, FRT.,Verheijden, MW., & Baartmans, JA. (2005). The power of communication. Modifying behaviour: effectively influencing nutrition patterns of patients. European Journal of Clinical Nutrition, 17-22. Mishra, B. (2009). Role of Paralanguage in Effective English Communication. The Icfai University Journal of Soft Skills, 29-36, NSControl. Nair, B.R., Attia, J., Mears, S. & Hitchcock, K. (2002) Evidence-based physicians’ dressing: a crossover trial. M.J.A. 177, 681–682. (as cited in Cant, 2009, p. 504). Rane, D.B.. (2010). Effective Body Language for Organizational Success. The IUP Journal of Soft Skills, 17-26, . Incorporating Nonverbal Communication into Dietetics and Nutrition Essa 1.1 Introduction This research paper makes recommendations for incorporating nonverbal communication into Dietetics and Nutrition. 1.2 Limitations This report is limited to paralinguistics, gestures, clothing and adornment within nonverbal communication in the field of Dietetics and Nutrition. 1.3 Scope This report aims to highlight the importance of paralinguistics, gestures, clothing and adornment in the setting of Dietetics and Nutrition. Peer reviewed articles and theoretical evidence provided to address how we change individual’s perceptions of professionals by using nonverbal behaviours therefore effecting client health outcomes. Advice and strategies for improving client /professional relationships are included. 1.4 Methodology To complete this report, data was collected over a 5 week period using resources from the Internet and Library of the University. Theoretical evidence was also taken from the Communication Theory textbook. The data was collected and analysed from numerous authors of peer reviewed articles that discussed in varying degrees the many aspects of nonverbal communication. 2.0 Outline of nonverbal communication and link to Dietetics and Nutrition Non-verbal communication plays an integrative role for successful client/professional relationships in the field of Dietetics and Nutrition. Non-verbal communication effects the way we a person perceives our level of empathy, trust, competence, therefore can effect the success of client outcomes. Clothing and adornment, paralinguistics and gestures are aspects of non-verbal communication that are used in conversing consciously or subconsciously, conveying a message to another about themselves and their purpose. Problems can occur... ... p. 504). Koster, FRT. (2005). The power of communication. Modifying behaviour: effectively influencing nutrition patters of patients. European Journal of Clinical Nutrition, 17-22, . Koster, FRT.,Verheijden, MW., & Baartmans, JA. (2005). The power of communication. Modifying behaviour: effectively influencing nutrition patterns of patients. European Journal of Clinical Nutrition, 17-22. Mishra, B. (2009). Role of Paralanguage in Effective English Communication. The Icfai University Journal of Soft Skills, 29-36, NSControl. Nair, B.R., Attia, J., Mears, S. & Hitchcock, K. (2002) Evidence-based physicians’ dressing: a crossover trial. M.J.A. 177, 681–682. (as cited in Cant, 2009, p. 504). Rane, D.B.. (2010). Effective Body Language for Organizational Success. The IUP Journal of Soft Skills, 17-26, .

Abuse? :: essays research papers

Abuse   Ã‚  Ã‚  Ã‚  Ã‚  According to a May 2001 article in Parents magazine 67% of the American population condones spanking as a regular form of discipline. Also, 67% say they would oppose a law prohibiting spanking at home and says that only 17% would support it. According to advice columnist and family psychologist John Rosemond, â€Å"Many parents are becoming frustrated with the very weak forms of discipline du jour advocated by ‘psychologically correct’ experts. He also says â€Å"More than 90% of children raised in the 1950’s and early ’60s were spanked and we don’t go around hitting people when we don’t get our way.†   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚   While I was visiting a friend recently, she told me about her most recent visit to the doctor with her two-year-old daughter. She told me that she was trying to get her daughter ready to leave after the appointment was over and her daughter would not quit playing with the toys which were in the doctor’s office. After several minutes of struggling with her daughter to get her coat on, her daughter turned to her, said â€Å"no, mom† and then her daughter proceeded to slap her across the face. My friend put her daughter over her knee and gave her a quick swat and told her that she was not to treat her mother like that. After seeing this, a nurse came over to my friend and told her that if they ever see her hit her daughter again they would call the Department of Children and Family Services.   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  This situation is not all that unfamiliar to me these days. I hear of parents in similar situations almost every day and sometimes I actually see it with my own eyes. For instance, I was in Wal-Mart a few weeks ago and witnessed a woman tell a father that she was going to report him for child abuse because he grabbed his son’s arm and yelled at him for taking off and running through the store. Apparently the father had turned to look at something on the shelf and when he turned back around his son was gone and the father was paged over the store intercom to come and retrieve his son from across the store. In my opinion, that child was lucky that his father hadn’t given him a spanking right in the middle of the store. When I was a child my father would have given me a real whopper of a spanking for pulling a stunt like that in a store.

Acct553 Homework Es

1. (TCO A) A taxpayer may litigate a tax dispute without first paying the tax in the:  (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  U. S. District Court. U. S. Tax Court. U. S. Court of Federal Claims. All of the above | 2. (TCO F) A business bad debt is deductible for tax purposes as a(n):  (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  ordinary business deduction. short-term capital loss. long-term capital loss. miscellaneous itemized deduction. | 3. (TCO I) Under the cash method of tax accounting, tax deductions are generally taken when:  (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  payment is made. the liability arises. there is net income to absorb the expense.None of the above | 4. (TCO A) Which of the following constitutes tax evasion? (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Arranging your affairs to keep your tax liability as low as possible under the tax law   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Failing to disclose a tax liability from a completed transaction   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Trying to maximize profits Trying to minimize your tax liability. | 5. (TCO C) Which of the following items is subject to federal income tax? (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Interest on U. S. Treasury bonds Gambling winnings Interest on loans made in the ordinary course of business   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  All of the above | 6. (TCO B) Sam owes Bob $8,000.Bob cancels (forgives) the debt. The cancellation is not a gift, but Sam is insolvent. Which of the following statements is correct concerning the impact of this transaction? (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Both Bob and Sam recognize $8,000 of taxable income. Bob recognizes $8,000 of taxable income. Sam recognizes $8,000 of taxable income. Neither Bob nor Sam has any taxable income from this transaction. | 7. (TCO I) David, a cash basis taxpayer, owns two rental properties. Based on the following information, compute the amount that he must include in his 2012 gross rental income.Property #1, security deposit on one-year lease received 2/1/12 All of deposit returned at lease end: $1,000 Property #1, payment received 2/1/12 for last month of lease(1/13): $900 Property #1, rental income received in 2012 2/12-12/12: $8,000   Property #2, rental income received in 2012 1/12-12/12: $9,600 Property #2, security deposit received 1/1/12 to be used for last month's rent: $800 Property #2, rent 1/13 received 12/28/12: $800  (Points : 5)|   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  $21,100 $19,300 $18,500 $20,100 | 8. (TCO F) Section 197's intangible assets, such as patents and trademarks, are amortized for tax purposes over:   (Points : 5)| years. 15 years. 10 years. 20 years. | 9. (TCO E) Explain the constructive receipt doctrine. (Points : 17)  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  | 10. (TCO G) Answer the following questions concerning tax laws. a. What roles do the U. S. Constitution and U. S. Congress play in creating the tax law? b. What does the common body of tax law (CBOTL) consist of? Br iefly explain how a tax bill becomes a tax law. c. What role does the Internal Revenue Service play in interpreting, and providing guidance on, the tax law? What types of tax law guidance are published by the IRS? (Points : 18)  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  |

Views of Christianity and Islam Towards Trade

Christianity and Islam are two of the most practiced religions in the world, and have been for centuries. These two faiths are both monotheistic, which means they worship one God, or Allah. Started over 2000 years ago, Christianity is based on the teachings and life of Jesus Christ and was spread throughout the Roman Empire. The religion of Islam began early in 600 C. E. by the prophet Muhammad, and he spread the word of Allah. These religions spread quickly in Europe and the Middle East. As they progressed, new trading routes came about in these areas.Overtime, Christianity and Islam developed opinions about the trading and businesses activity and the people who pursued it. According to the religion’s holy books, the Bible and Qur’an, their views on trade were different at first. Christians believed that people should not trade; for it was not the pursuit of man. Muslims were much more tolerant of trade, as long as merchants were honest in their bargaining. By 1000 C. E, both the religions’ attitudes towards trade had changed completely. Christian scholars began to teach that honest trade was acceptable, while Muslim scholars saw the danger that trade brought to a man’s soul.By the 15th century, attitudes towards trade had even more drastic change once again. Christianity espoused that trade was encouraged and worthy, while Muslims believed merchants were corrupt. When the two religions first began, Christianity and Islam differed at first on their views concerning trade. As stated in the Christian Bible, it is almost impossible for a rich man to enter the kingdom of God (document 1). For Christians, at first they had to live a humble life without making any profits.Its said that it was easier for a camel to go through the eye of a needle, than for a rich man to enter into the kingdom of God. As for Muslims this differed because in the Qur’an, men were allowed to trade as long as they were honest; said in document 2. â€Å"I f the two parties speak the truth and make it manifest, their transaction shall be blessed, and if they conceal and tell and lie, the blessing of their transaction shall be obliterated. † This means that if two people trade fairly amongst each other without cheating, then nothing is wrong according to the Islam beliefs.If one of the men are cheated, then their business will be wiped out. The point of document 1 was that Jesus was a poor man, therefore his followers lived up to being poor as well. When Christianity started, Christians believed that in order to go to heaven, they must live a poor and humble life, like Jesus did. The same logic applies for Muslims in document 2, who’s founder Muhammed was a wealthy merchant. In document two, the author is supporting merchants and saying that they will be accepted by Allah as long as they are truthful.Muslims strongly believed that it was okay to be a wealthy merchant as long you are honest, like Muhammed. Therefore, the tw o religions were at first different because Christianity had negative views toward trade while Islam was for it; and they were alike because the reason for their views both traced back to their founders. In documents four and five, the view points of Christians and Muslims toward trade began to change. Christians, who were at first against trade and becoming wealthy from it, now say that it is okay to trade as long as you are honest.Stated in document four, â€Å"No man should sell a thing to another man for more than its worth. † This is saying that for men to do business with one another, they must not sell things for more than they are worth, or in other words scam each other. While Christian scholars are becoming more lenient towards trade than they were when the religion started, Islamic scholars are becoming more strict. Muslims now believe that selling things for a profit, even if it is honest, is inevitably affecting the soul. â€Å"These qualities lead to a decrease and weakening in virtue and manliness,† (document five).The Islam look on trade now sees that the methods that trade employs are tricks aimed at making a profit by securing the difference between buying and selling prices. The two religions, however, are still somewhat similar because they both believe that trading for large profits can eventually lead to corruption of the soul. Views of trade by Christians and Muslims yet continued to change even further in documents six and seven. It seems in document six as if Christians were being encouraged to trade as long as it involved God.Religious paintings of Our Lady were being asked for, therefore Christians now want people to trade. Also in document six it is stated that, â€Å"You know God has granted you to acquire great riches in this world, may He be praised. † It is now expected for Christian merchants to trade and use God while doing so. Overtime you can see the change on the views of trade, because at first Christi ans did not want anyone making a large profit. As for Muslims, merchants are loosing money from trading. In document seven, Sakaoglu Nasuh is an example of how over time the commerce activity has affected his ethical customs. The aforementioned has now acted contrary to the old custom. † This is because he is buying all the cotton yarn and selling them for higher prices. Hence, not giving the other merchants a fair opportunity to buy and sell the cotton as well. This is going against what the Islam religion believed, which is business activities are acceptable as long as you are not taking advantage of others. The Islamic Court probably said this is document seven because they wanted to please the people and let them know that merchants must obey.The two religions continue to differ in these documents because Christians are now persuading people to trade, while Islam trading is becoming monopolized. However, Christianity and Islam are still alike in which they both use religio n as an example. The attitudes of Christianity and Islam towards trade and merchants differed. When the two religions first began, they had opposite views from each other. Christians saw trade and wealth as being far from God and it was not approved. Muslims, on the other hand, tolerated trade as long as the two parties were honest and no one was taken advantage of.Later on, these views changed when Christians became more lenient and also accepted honest trade. Muslims then saw trade as inevitably affecting the soul when merchants became corrupt by outbidding other merchants. However, we would need additional documents such as documents from the common people in order to asses the consequences of the merchant activities. We do not know how the Christians’ or Muslims’ commoners viewed the trading business, therefore, we cannot fully understand all aspects of the religions towards it.