Effect of Adrenaline on Cardiac Arrests Survival

Effect of Adrenaline on Cardiac Arrests Survival Effect of Adrenaline on Survival in Out-of-Hospital Cardiac Arrests: A Randomized Double-Blind Placebo-Controlled Trial Hem Patel The study shepherded by Jacobs et al juxtaposed the effect of adrenaline on survival in out-of-hospital cardiac arrests with a randomized double-blind placebo controlled trial. This study was the first of its kind to address the knowledge deficit of two majors goals: survival of the patient to a hospital discharge and return of spontaneous circulation (ROSC). Cardiac arrest occurring out of hospital is a significant public health issue causing fatality rates upwards of 90%, although improving in the recent decades.1 Thus, the researchers analytically examined the relationship between the uses of adrenaline in such patients through a randomized control led trial (RCT) in the region of Western Australia (WA), under government contract with St John Ambulance Western Australia (SJA-WA). Being on top of the studies’ hierarchy, RCT studies like this one, quite evidently fortified the experiment’s internal validity. The creation of comparable groups in the study allowed the control of confounding variables enhancing the internal validity. An investigationRandomized controlled trials, such aslike RCTthis one, decreases the sampling bias by decreasing the likelihood of chance results occurring, thus enhancing the internal validity of the study. which was evident in the Jacob study. Logistic regression modeling further augmented this investigation The investigation was further augmented by logistic regression modeling which was undertakenin order to control for the effect of potential confounders1 (i.e. the patients’ initial cardiac rhythm, age and ambulance response time). on the relationship between study drug and patient outcome.1 Although, as a result of a small sample size, often the case with RCTs, and specific geographical demographics, limited external validity was a given. Low external validity was evident in this study as only one major hospital in the region of WA took part in it. The other hospitals requested did not participate due to rejection from their hospital ethics board.This was evident in this study as four of the five hospitals requested to participate felt the ethicality of the study superseded their own ethical board, negatively. Hence, the total number of patients being able to participate in this study had quite drastically decreased, in turn hampering the power of the study. However, two very crucial experimental qualities in high precision and internal validity were upheld consistently throughout the experiment, in spite of the very limited external validity. All out-of-hospital cardiac arrests attended by SJA-WA paramedics between 11 August 2006 and 30th November 2009 were screened into the experiment for entry into the trialwere entered into the trial.1.1 Patients suffering a cardiac arrest from any cause, aged 18 years or older with resuscitation commenced by paramedics were eligible for entry as well; indicating a moderately strict eligibility and inclusion criteria. Patients were excluded based on having no resuscitation commenced, were of an age less than 18 years, and eligible patients’ personal declination. n and randomization number of patient lost/As noticed, the external validity along with confounding bias of the study decreased due to the increased criterion required for a patient to take part in the trial. It may look as if few categories were used to determine the eligibility of the patient, though many factors such as patient age, male gender, bystander witnessed, response interval, and the study drug were accounted for through univariate analysis. The only confounding variable, which was accounted for, stated by the study is the factor of initial shockable rhythm (when a particular type of cardiac rhythm is treatable using a defibrillation) – one that is not very significant (p-Value of 0.24) in changing the efficacy of adrenaline in out-of-hospital cardiac arrests. Being able to eliminate thisese potential confounding variables and biases, internal validity increased showing that the lack of a causal relationship between effect of adrenaline and cardiac arrests was less likely to be an upshot of an uncontrolled confounding variable, rather than one accounted for. In regards to a This studyRCT study, has a sample size of 534 patients, one that is of a moderate size in comparison to other RCT studies., out of whichOut of 534 patients, 272 were randomly assigned to the group being treated with adrenaline and 262 to that of the placebo group.1.1 As eEach of the patients had an completely equal chance to be presented with either of the treatments, and this randomization of the participants controlled for a potentiality of a sampling bias – a chance yet again enhancing the internal validity. Additionally, although very diminutive confounding bias was associated with this study, the potential of selection bias was still present as the study took place only in Western Australia. it was unable to exclude the potential for selection bias as the participation in the study by the SJA-WA paramedics was voluntary, only 40% of eligible patients were recruited. However, trial patients were well matched on baseline characteristics (age p-value of 0.69, location of arrest p-value of 0.25, volume of trial drug versus placebo drug administered p-value of 0.28).1 , Henceforth, no reason to suggest that paramedics who participated in the trial were more likely to selectively enroll patients into the trial.1 . Furthermore, to reduce the possibility of confounding bias, all paramedics in WA underwent the same type of training familiarizing them of this trial protocol; even if they were not participating in the actual experiment. This further enhanced the internal validity of the study. As mentioned above, as resuscitation commenced by paramedics, the patients were eligible for entry, where if they were administered adrenaline it would be at a rate of 1mL every 3 minutes, with no other drugs entering through tracheal administration. Prior to the commencement of each trial to be presented with an equal chance of the level of treatment for each of these patients specific training of the pharmacology of adrenaline, familiarization with the trial protocol, further practice in intravenous cannulation and cardiac simulation exercises along with testing was undertaken to ensure the prerequisite resuscitation competency standard had been achieved. This training was provided to all of the paramedics in the WA area regardless of their intention to participate in the study; being able to decline confounding bias from the patient-care givers’ aspect, enhancing the internal validity.Analyzed above in this critical appraisal are many aspects of the study that allow for a s tudy it to be very well received by majority of the readers, although there were a couple of limitations. Firstly, the researchers were unable to achieve full patient recruitment as planned (4103 patients who had cardiac arrests attended by an ambulance). This study was designed as a multicenter trial involving a five-ambulance service. , Ddespite having ethical approval from the Human Research Ethics Committee of the University of WA, four out of five hospitals opted out.otherwise. Thus, giving this gave the study a moderate sample size, increasing the chance of making a type two error and ; essentially decreasing both the internal validity and the power of the study. The failure to achieve an adequate sample size left the trial underpowered (power of 40%) to detect significant effects on survival to hospital discharge.1 The second limitation to the study was the ability for it to continue, as the study experimental drugs had gone past their expiry date and no additional funding wa s available. Granted,ing the patient as well as researcher blinding was well preserved in this study such that, the researchers can consider the likelihood of these factors being differentially distributed between the two study arms (placebo vs. adrenaline) to be small.1 The researchers claim that there is a significant (3.4 times) increase in the likelihood of achieving ROSC pre-hospital if the patients were administered adrenaline versus the placebo (23.5% versus 6.4%; OR 3.4; 95% CI 2.0-5.6; p-value 1).1 They base this conclusion on the oOdds ratio (OR), which were used to quantify the odds of achieving ROSC pre-hospital depending on the administration of the placebo or the adrenaline. how strongly the presence of the outcome was associated with the presence of the administered adrenaline versus the placebo saline solution2. After adjustment for confounders (age, sex, initial rhythm shockable, ambulance response interval and study drug) using the logistic regression model, there was little change in the effect of adrenaline on ROSC (OR. 3.5; 95% CI 2.1-6.0).1 The degree of precision that a study maintains is defined by a confidence interval. The experimenters claim that they are 95% confident that the odds ratio of being ROSC pre-hospital with the administration of adrenaline is between 2.1 and 6.0 indicates a moderately definite statement (explained further). However, there was insignificant evidence (OR 2.2; 95% CI 0.7 – 6.3; p-value 0.15) of the patient administered with adrenaline versus placebo to survive until hospital discharge. Because 1.0 is included in the confidence interval, the researchers acknowledge it as not statistically significant. However, from a clinical standpoint, 3.5 times greater chances of the patient achieving ROSC are significant and one should definitely consider applying such a method, if in the position to do so. Results indicated the OR for ROSC achieved pre-hospital patients at 3.4 (95% confidence interval [CI] 2.0-5.6; P saline placebo. The outcomes dictate an approximate 16% greater advantage of a chieving ROSC pre-hospital with the administration of adrenaline than having the placebo. Statistical significance is generally considered at 20%, but in aspects dealing with topic as such, upwards of 5% could statistically mean more to the medical community; allowing to save more lives.3 At an OR of 2.2 (95% confidence interval [CI] 0.7 – 6.3; P = 0.15) indicates no difference between the two testing groups with the p-value greater than that of the alpha value of 0.05. Results are further negatively supported by the CI including the value of 1, demonstrating statistical insignificance; decreasing the study’s precision in this aspect of the outcome, although balanced by the significance in the previous outcome. The findings of this study are equivocal to several other clinical trials designed the to assess the efficacy of adrenaline in cardiac arrest. The most dominant feature about this study is that it is the first ever-randomized placebo-controlled clinical trial of adrenaline in cardiac arrest, while others all have been non-randomized trials. Similar results were replicated through the Rresearch conducted by Olasveengen et al. also His study reported a doubling in the proportion of patients achieving ROSC with an OR of 1.99 (95% confidence interval [CI] 1.48-2.67), and achieving similar non-significant increasing results in the proportion surviving to hospital discharge4..4 Although, Jacob’s study, although further expanded on the generality of the efficacy of drug to locations of arrests, ambulance response interval, cardiac arrest witnessed (bystander and paramedic) and airway management; bringing greater appreciation to this study..1 Three sources of Mill’s Canons were evidently utilized to support the causality. The strength of association was statistically significant, as noted by the greater effect of adrenaline in ROSC being achieved pre-hospital transportation. An increase dosage of adrenaline would directly increase ROSC, and possibly an increase number of patients survive to hospital discharge.1, 5Adrenaline stimulates ÃŽ ²-adrenergic receptors which stimulate the increase of blood flow indicates the final Mill’s Canon in biological plausibility. Thus, it can be noticed that a causal relationship can be agreed upon adrenaline and increased ROSC being achieved pre-hospital. Jacobs points out the importance of his study’s contribution to clinical research on adrenaline usage during cardiac arrests, and at the same provides suggestions to further research avenues. To be able to determine the optimal dose or timing of adrenaline administered during cardiac arrest are the two main areas of further research. In my opinion, the study was done welldone, extremely well, providing sufficient evidence for a relationship between the adrenaline and an increase ROSC in 18 and above out-of-hospital cardiac arrests. With the elimination of a majority of the biases, through the use ofwith logistical regression and creating comparable groups (placebo versus adrenaline), internal validity and the precision of the study was enhanced. .The findings of this study are clinically important in that it established efficacy for the continuous use of adrenaline in cardiac arrest as currently recommended.5 With a study related to such a topic, the sample size should adequa tely be increased to allow for a greater power and external validity in the study; allowing a generalization to a greater portion of the public. References Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effects of adrenaline on survival in out-of-hospital cardiac arrest: a randomized double-blind placebo-controlled trial.resuscitation2011; 82: 1138-1143. Szumilas, M. Explaining odds ratios.National Center for Biotechnology Information2010; 19(3): 227-229. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938757/ (accessed 28 October 2014). Pocock, SJ. Clinical trials with multiple outcomes: a statistical perspective on their design, analysis, and interpretation.Elsevier1997; 97. Olasveengen TM, Sunde K, Brunborg C, Thowsen K, Steen PA, Wik I. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.JAMA2009; 302: 2222-2229. Vandycke C, Martens P. High dose versus standard dose epinephrine in cardiac arrest a meta-analysis.Resuscitation2000; 45: 161-166

Essay --

Postpartum depression affects 8-15% of mothers within a few days or weeks after giving birth. Some mothers experience a mild form of this disorder, while others experience a more rare and intense version. This intensified postpartum depression is known as postpartum psychosis. According to the Journal of the American Academy of Psychiatry and Law, Nau, McNiel, and Binder (2012) express â€Å"Postpartum psychosis occurs in 1-2 of 1,000 births and frequently requires hospitalization to stabilize symptoms.† These symptoms include: Hallucinations, restlessness, disturbed sleep, insomnia, drastic mood or behavior change, delusional thinking, thoughts of suicide or death, and extreme depression. In The Journal of Women's Health, Sit, Rothschild, and Wisner described postpartum psychosis as â€Å"an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery†. Approximately 72%-88% of mothers who experience postpartum ps ychosis (PP) have bipolar illness, schizo-affective disorder or a family history of either which is why PP is classified as a psychotic disorder by the APAA. Many women who are affected by postpartum psychosis are too afraid or embarrassed to come forward and claim the disorder. This is dangerous for both mother and child(ren) as the disorder has a 5% suicide rate and a 4% infanticide rate. Even if there is no physical harm done to the child there may be emotional harm. The behaviors that are exhibited by the mother to the child may â€Å"interfere with the children's emerging cognitive skills...†(Sohr-Preston & Scaramella, 2006). It has been theorized both before and after birth the mothers' health, physical and emotional, may affect the child's cognitive skills later in li... ...omeone do this to their child?†. There have been many similar cases where the mother was found not guilty, so why was Yates found guilty? The answer may come from the website Andrea Yates: Ill or Evil? â€Å"In America, there are no clear standards in court for dealing with mentally ill mothers—not even in the same city.† This is a sad, but true statement. People tend to use their own morals and experiences as how they perceive things. Of course what Andrea Yates did was wrong, but she was also seriously ill. Postpartum psychosis is an extremely scary and dangerous disorder. PP is treatable, however there are no guidelines for treatment at this time. Most patients have been treated using a combination of pharmaceuticals and psychotherapy. Even though treatment options are still being evaluated, the sooner any treatment starts the better off mother and child are.

Characterization of Tom in “The Great Gatsby” Essay

In the first three chapters of The Great Gatsby by F.Scott Fitzgerald, he characterized Tom Buchanan as violently aggressive in order to show the kind of man that had turned out from the Ivy League school and have contributed to two different social classes. For example, in the first chapter of the book, Nick introduces us couple of characters as well as Tom Buchanan and he says the following â€Å"Now he was a sturdy straw-haired man of thirty with a rather hard mouth and a supercilious manner. Two shining arrogant eyes had established dominance over his face and gave him the appearance of always leaning aggressively forward† (pg.7). We are told that Tom has a hard mouth and arrogant eyes. He is said to be always leaning forward aggressively, making up for the unmanly clothes he’s wearing at the time and very muscular with a â€Å"cruel† body. Nick describes Tom looking aggressive just by his looks without any further detail of how he acted aggressively. As a graduate from a prestigious school, Tom would be expected to be more characterized as a good, pleasant character when describing an educated man, however Tom was the opposite and Fitzgerald does this to show that the characteristic of a man does not depend on the school they had attended and graduated from. Furthermore, in chapter 2 it is proven that Tom is violent â€Å"Sometime toward midnight Tom Buchanan and Mrs. Wilson stood face to face, discussing in impassioned voices weather Mrs. Wilson had any right to mention Daisy’s name†¦I’ll say it whenever I want to! Daisy! Dai- Making a short deft movement, Tom Buchanan broke her nose with his open hand† (pg.37). At their little gathering party, Tom there breaks his lover, Myrtles, nose just because Myrtle had not stopped chanting Daisy’s name even if she had been warned by Tom before. Tom expresses his aggressiveness when he becomes violent when Myrtle does not stop. Fitzgerald is showing that not all man graduating from Ivy League school such as (Yale, Oxford, and Princeton) are all well-mannered, with a good characteristic as one would think.

The crop protection industry Essay Example

The crop protection industry Essay Example The crop protection industry Essay The crop protection industry Essay The AHP firm Cynamid was purchased by German based company BASF in 2000. This purchase results in a reduction of the competitive ability of AHP and increases the threat posed by BASF. Previously Monsanto had entered agreements with Cynamid in which they were able to sell glyphosphate for use in the herbicide created by Cynamid called Extreme. This increase in the products ability to provide protection is an example of Cynamids focus strategy, providing particular customers with their specific needs. BASF is a major power in the pharmaceutical organisation with many branches into different areas of research. While this draws on its resources it also provides substantial revenue for RD which is essential in the biotechnology industry. More recently BASF claims to be aiming to remain the worlds leading chemical company. (Dorothe Myer 2005) They intend to do this by helping customers and providing sustainable development. While farmers who purchase technologies may want to produce the best yields they also want their customers to be happy with their products. For this reason the strategy BASF is adopting is appropriate for achieving future profits. Monsanto focuses its business on agricultural crop growers. It exceeds in this industry and has obtained a large amount of revenue due to its creation of the Roundup herbicide. Novartis is not completely concerned with crop protection but concentrates on health products. It does not focus solely on crop protection and I dont believe they pose the most significant threat to the market share of Monsanto. BASFs firm Cynamid has developed products that directly impact Monsantos market share. The organisation accumulates large revenues each year and through this revenue can spend more on RD then less successful companies. These revenues are spent over a number a more substantial area as BASF is involved in more industries then crop protection. I dont believe that they are the most significant threat to Monsanto as they have just acquired Cynamid and are not as established as some other organisations in the crop protection industry. DuPonts firm Pioneer focuses on crop protection and in the past has developed useful and profitable products using Monsantos glyphosphate ingredient. Although it has proved competitive it has used Monsantos technology to its advantage and has increased profits partly due to Monsantos patent conclusion. Pioneer is still a threat but I do not believe it is as much a threat as the established Syngenta organisation. Syngenta is another competitor of Monsanto that focuses solely on crop protection. It is a greater threat to Monsanto as it has worldwide operations with high revenues and continually innovative products. Syngenta had sales in 2004 equal to approximately US$7. 3 billion. (Syngenta 2005) It has also been granted recent court ruling that allow it to enter markets and compete with Monsanto. (Corey Gillam 2004) Syngenta is also responsible for releasing a new combination product called LOMAX which provides season long control of broadleaf weeds and grasses. (Syngenta2005) I believe Syngenta has the resources to create innovative products and threaten any thoughts of a monopoly by Monsanto. It is a well established organization with the revenue and technology to expand in the crop protection industry.

Free Essays on Aunt Julia And The Scripwriter

1. Point of view Characterization Imagery Magical realism 2. Pablo Enrique Manuel Hernandez was on his way to the biggest game of his life. He was once the most famous and best basketball player around. But then the tragedy happened. Today, he was a man who had reached the prime of his life, his fifties, and in his person-broad forehead, aquiline nose, a penetrating gaze, and the very sole of rectitude and goodness. However today Pablo was not going to play in the game today, but to coach it. 3. The narrators of this novel are Mario Vargas Llosa, Marito, and Pedro Camacho. Each one of these narrators is there for a different purpose. Pedro serves the purpose of writing magical realism and adding comedy to the work. And since this work is semi-autobiographical Mario Vargas Llosa is in a way talking through Marito. Marito brings a sense of reality to the story. 4. Sgt. Lituma is a minor character that appears repeatedly throughout the even chapters. The one thing that seams constant throughout the even chapters is that Lituma remains a character with high moral standards. This is important to the book, because in the even chapters he is just about the only one who has any morals. 5. Big Pablito is a minor character found throughout the odd chapters. He is important to the novel from a social standpoint. He was pretty much a nobody lackey at the radio station throughout the novel. At the end of the book though, you come to find out he has become a very successful man. 6. The unique structure in this novel is very noticeable. Every other chapter was about something totally different. They are connected because as Pedro is going insane in the chapters narrated by Marito, the characters in Pedro’s serials were getting increasingly getting mixed up. 7. This novel exhibits several different traits of Latin American culture. The novel shows that it might be a cultural norm fo... Free Essays on Aunt Julia And The Scripwriter Free Essays on Aunt Julia And The Scripwriter 1. Point of view Characterization Imagery Magical realism 2. Pablo Enrique Manuel Hernandez was on his way to the biggest game of his life. He was once the most famous and best basketball player around. But then the tragedy happened. Today, he was a man who had reached the prime of his life, his fifties, and in his person-broad forehead, aquiline nose, a penetrating gaze, and the very sole of rectitude and goodness. However today Pablo was not going to play in the game today, but to coach it. 3. The narrators of this novel are Mario Vargas Llosa, Marito, and Pedro Camacho. Each one of these narrators is there for a different purpose. Pedro serves the purpose of writing magical realism and adding comedy to the work. And since this work is semi-autobiographical Mario Vargas Llosa is in a way talking through Marito. Marito brings a sense of reality to the story. 4. Sgt. Lituma is a minor character that appears repeatedly throughout the even chapters. The one thing that seams constant throughout the even chapters is that Lituma remains a character with high moral standards. This is important to the book, because in the even chapters he is just about the only one who has any morals. 5. Big Pablito is a minor character found throughout the odd chapters. He is important to the novel from a social standpoint. He was pretty much a nobody lackey at the radio station throughout the novel. At the end of the book though, you come to find out he has become a very successful man. 6. The unique structure in this novel is very noticeable. Every other chapter was about something totally different. They are connected because as Pedro is going insane in the chapters narrated by Marito, the characters in Pedro’s serials were getting increasingly getting mixed up. 7. This novel exhibits several different traits of Latin American culture. The novel shows that it might be a cultural norm fo...

BMW Luxury Cars

BMW Luxury Cars The core customer value for BMW luxury cars are prestige and hi-tech performance in their endeavors. Having full understanding of the specific needs of their target group, BMW has largely considered the psychographic factors of its customers.Advertising We will write a custom essay sample on BMW Luxury Cars specifically for you for only $16.05 $11/page Learn More As it has been revealed, BMW targets active individuals who have achieved success at their early age, desiring prestigious and super-performing luxury cars like themselves. Notably, the customers of BMW are technology oriented and very active in their life-time, as they pursue success in their ventures. In this regard, the brand seeks to establish strong relationship with its customers by providing them with the driving experience they desire in their life-time. As it has been revealed, the luxury cars having the BMW brand name are in three series including MBW 3, MBW 5 and MBW 7. These three series of the MBW brand are the ultimate core aspects for maintenance of customer loyalty to the BMW luxury cars. More specifically, the MBW 3 series provides its users with extra-ordinary performance as it is made to facilitate self actualization among the customer target base. Precisely, BMW 3 series seeks to establish trust and loyalty with its customers by offering splendid personalized experiences with the product. After the users of BMW 3 advance into more experience with BMW luxury cars, they move further to acquire BMW 5, which is more expensive, but maintaining the outstanding performance of BMW luxury cars . On the other hand, BMW 7 series is meant for the already established customer base for BMW luxury cars as it propels higher the user-oriented experience with the BMW products through its advanced features to facilitate prestige and higher performance than 3 series. It is important to note that, 7 series is much more expensive that 3 series since it is mainly meant for compan y’s loyal customers who have had prior experience with the former series. Following the currently competitive global markets, the development of products to achieve competitive advantage forms a real of success among brands marketers. Since the customers’ needs of BMW products are based outstanding performance, more innovations of the existing products need to be done to come up with more superior luxury cars capable of competing with potential competitors like Mercedes Benz among others. More so, powerful advertisements based on psychographic factors of the customers’ needs to be made. For instance, creation of short films showing the uniqueness of BMW products on the context of other competitors may be quite appealing. Since visual advertisements are more accurate and highly effective, the films will be able to attract target customers’ attention largely. As a result, success and efficiency in marketing BMW products will be realized.Advertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Further, a variety of channels in marketing the BMW luxury cars would be more appropriate to reach wider customers base. Since the target customers for BMW are always busy and very active, the use of precise and direct advertisements over the internet would be quite effective so that the customers don’t waste time interpreting information of the advertisement. It can also be recommended that, the product promotion uses the internet to collect information about the needs of their customers with respect to the specific aspects of the luxury cars which need to be improved. By having enough data about the accurate needs of the target customers, it would be easier for the company to modify the cars to intersect with the specific needs of the customers.

Select a form of global business and explain where you might go. Also Essay

Select a form of global business and explain where you might go. Also say how you might find the best business climate - Essay Example Branches will be opened in every continent across the globe to ensure that the business satisfies all customer food requirements. The management of these hotels will be under the leadership of fully qualified professionals who have prior experience in running similar businesses. I intend to find the best business climate by considering the micro and macro conditions that might affect the business. In considering the micro environment, I will consider the availability of my suppliers of raw materials and other supplies (Mathis and Jacks 56). I will also consider the presence of my target market, the accessibility to the hotels and the competitors in an area. The macro conditions to be considered include the factors influencing the operations of the business, but are beyond our control. This will involve the evaluation of demographic, normal, fiscal, political and the technological environments (Mathis and Jacks 76). I will consider the legal restrictions that certain countries impose on the type of business to ensure the operations of the business run smoothly. I will also consider issues such as security since the business will depend on it to maintain our customers. The best business climate is the one that will adequately satisfy the above conditions henc e ensure effective competition and success of my hotel