Ocean carrier Essay

The purpose of this report is to evaluate whether Ocean Carriers Inc. should immediately commission a new capesize carrier that would cost $39 million, and would be completed two years hence, in order to finalize a lease of the ship for a three-year period with a potential charterer in very good faith. The contrasting tax regulations between the two countries where the company locates its office, and the different cost-benefit circumstances under different length of time in service are considered in the analysis. Taking all available information into consideration, we highly recommend that the company should purchase the new capesize carrier, have it registered under the Hong Kong office, and put it on a scheme for a 25-year service. Industry Prospects Capesize carriers are mainly used to carry iron ore and coal worldwide. The daily hire rates are therefore determined by the total exports of iron ore and coal, the distance between the exporting countries and the destinations, and the fleet size of capesizes in service. According to the market trends, in the next few years, Australian production in iron ore is expected to be strong and Indian iron ore exports are expected to take off. However, imports of iron ore and coal are expected to be stagnant in next two years. Therefore, total exports of iron ore and coal will be flat in the coming two years, and will rise remarkably in the following few years. Besides, as East Asia countries absorb the largest portion of the iron ore imports, the joining of India to the iron ore exporting won’t significantly increase travel distance because Australia is almost the same distance away by water. Moreover, in 2001 and 2002, 63 and 33 new capesize vessels would be delivered adding up to about 17% of total capesizes currently in service. Consequently, in the first two years, the supply of capesizes would be greater than the demand, the daily hire rates are expected to decrease. But in the mid-to-long run, the daily hire rates are expected to increase continuously. Revenues and Costs – Intuitions Before going into the numbers, we want to discuss some intuitions of this project that support the decision of purchasing the capesize. First, the increasing mid-to-long run daily hire rates will provide basis for promising future cash flows. Secondly, although the daily hire rate for the first two years are expected to be low, the charterer had already offered a rate higher than expected to compensate the company. Thirdly, a great portion of the expenditures come from the preparation for special surveys which should be renewed every five years if the ship needs to stay in the business. The high escalation of costs between the second and third surveys, and the fourth and fifth surveys, indicates that maximum net present value of the project would be achieved when the carrier serves for either 15 years or 25 years. Free Cash Flows In this part, we will discuss the detailed numbers. Some assumptions are made based on the economic outlook and company characteristics when calculating free cash flows. We assume that inflation rate is 3% per annual, and that operation cost would increase 1% above inflation rate per annual. We assume that discount rate is 9%, and will discuss the impact of a rate change later. Provided that the scrape value is estimated to be $5 million at the end of the fifteenth year, we estimate that the value would decrease to $4 million due to more wear in the steel. Please refer to Exhibits 1 to 4 for the calculations of estimated free cash flows and NPVs. We can see that if the company chooses to purchase the capesize, have it registered in Hong Kong instead of USA, and runs it for 25 years, the NPV will be the highest compared to other alternatives. Besides, the Hong Kong option (have the vessel registered in Hong Kong) dominates the USA option (have the vessel registered in USA) because no tax is required in Hong Kong in these operations. Also, the 25-year option dominates the 15-year option because, even if the scrap value is reduced to zero after 25 years, the NPVs for options that keep the capesize for 25 years are still higher than for 15 years. Sensitivity Analysis In the above calculations for the NPVs, we assume discount rate to be 9%. If the discount rate is higher, the NPVs for the projects will be reduced because the benefits from recording depreciation and tax deferring will increase. For example, we found that the USA-25-year option will produce a positive NPV if the discount rate is lowered to 6.67%. However, even if the discount rate is as low as 0.1%, the HK option still dominates the US option, and the 25-year option still dominates the 15-year option. Conclusion To sum up, if Ocean Carriers Inc. purchase a $39 million capesize carrier immediately, register it in Hong Kong, sign the three-year contract with the charterer, and keep the vessel in business for 25 years, based on estimations, it would acquire the largest possible NPV of $3.89 million on the project.

Patients Rights Essay

The legal interests of persons who submit to medical treatment. For many years, common medical practice meant that physicians made decisions for their patients. This paternalistic view has gradually been supplanted by one promoting patient autonomy, whereby patients and doctors share the decision-making responsibility. Consequently doctor-patient relationships are very different now than they were just a few decades ago. However, conflicts still abound as the medical community and those it serves struggle to define their respective roles. Consent Consent, particularly informed consent, is the cornerstone of patients’ rights. Consent is based on the inviolability of one’s person. It means that doctors do not have the right to touch or treat a patient without that patient’s approval because the patient is the one who must live with the consequences and deal with any dis-comfort caused by treatment. A doctor can be held liable for committing a Battery if the doctor touches the patient without first obtaining the patient’s consent. The shift in doctor-patient relationships seems inevitable in hindsight. In one early consent case, a doctor told a woman he would only be repairing some cervical and rectal tears; instead he performed a hysterectomy. In another case, a patient permitted her doctors to examine her under anesthesia but insisted that they not operate; the doctors removed a fibroid tumor during the procedure. In yet another case, a doctor assured a man that a proposed operation was simple and essentially without risk; the patient’s left hand was paralyzed as a result of the surgery. Consent must be voluntary, competent, and informed. Voluntary means that, when the patient gives consent, he or she is free from extreme duress and is not intoxicated or under the influence of medication and that the doctor has not coerced the patient into giving consent. The law presumes that an adult is competent, but competency may be an issue in numerous instances. Competence is typically only challenged when a patient disagrees with a doctor’s recommended treatment or refuses treatment altogether. If an individual understands the information presented regarding treatment, she or he is competent to consent to or refuse treatment. Consent can be given verbally, in writing, or by one’s actions. For example, a person has consented to a vaccination if she stands in line with others who are receiving vaccinations, observes the procedure, and then presents her arm to a healthcare provider. Consent is inferred in cases of emergency or unanticipated circumstances. For example, if unforeseen serious or life-threatening circumstances develop during surgery for which consent has been given, consent is inferred to allow doctors to take immediate further action to prevent serious injury or death. Consent is also inferred when an adult or child is found unconscious, or when an emergency otherwise necessitates immediate treatment to prevent serious harm or death. Consent is not valid if the patient does not understand its meaning or if a patient has been misled. Children typically may not give consent; instead a parent or guardian must consent to medical treatment. Competency issues may arise with mentally ill individuals or those who have diminished mental capacity due to retardation or other problems. However, the fact that someone suffers from a mental illness or diminished mental capacity does not mean that the individual is incomp etent. Depending on the type and severity of the disability, the patient may still have the ability to understand a proposed course of treatment. For example, in recent years most jurisdictions have recognized the right of hospitalized mental patients to refuse medication under certain circumstances. Numerous courts have ruled that a mental patient may have the right to refuse antipsychotic drugs, which can produce disturbing side effects. If a patient is incompetent, technically only a legally appointed guardian can make treatment decisions. Commonly, however, physicians defer to family members on an informal basis, thereby avoiding a lengthy and expensive competency hearing. Consent by a family member demonstrates that the doctor consulted someone who knows the patient well and is likely to be concerned about the patient’s well-being. This will probably be sufficient to dissuade a patient from suing for failure to obtain consent should the patient recover. Legal, moral, and ethical questions arise in competency cases involving medical procedures not primarily for the patient’s benefit. These cases typically arise in the context of organ donation from one sibling to another. Many of these cases are approved in the lower courts; the decisions frequently turn on an e xamination of the relationship between the donor and recipient. If the donor and recipient have a relationship that the donor is aware of, actively participates in, and benefits from, courts generally conclude that the benefits of continuing the relationship outweigh the risks and discomforts  of the procedure. For example, one court granted permission for a kidney transplant from a developmentally disabled patient into his brother because the developmentally disabled boy was very dependent on the brother. In another case, a court approved a seven-year-old girl’s donation of a kidney to her identical twin sister after experts and family testified to the close bond between the two. Conversely, a mother successfully fought to prevent testing of her three-and-a-half-year-old twins for a possible bone marrow transplant for a half brother because the children had only met the boy twice and were unaware that he was their brother. Married or emancipated minors, including those in the Armed Services, are capable of giving their own consent. Emancipated means that the minor is self-supporting and lives independently of parents and parental control. In addition, under a theory known as the mature minor doctrine, certain minors may consent to treatment without first obtaining parental consent. If the minor is capable of understanding the nature, extent, and consequences of medical treatment, he or she may consent to medical care. Such situations typically involve older minors and treatments for the benefit of the minor (i.e., not organ transplant donors or blood donors) and usually involve relatively low-risk procedures. In recent years, however, some minors have sought the right to make life- or-death decisions. In 1989, a state court first recognized that a minor could make such a grave decision. A 17-year-old leukemia patient refused life-saving blood transfusions based on a deeply held, family-shared religious conviction. A psychologist testified that the girl had the maturity of a 22-year-old. Ironically, the young woman won her right to refuse treatment but was alive and healthy when the case was finally decided. She had been transfused before the slow judicial process needed to decide such a difficult question led to a ruling in her favor. Some state statutes specifically provide that minors may give consent in certain highly charged situations, such as cases of venereal disease, pregnancy, and drug or alcohol abuse. A minor may also overrule parental consent in certain situations. In one case, a mother gave consent for an Abortion for her 16-year-old unemancipated daughter, but the girl disagreed. A court upheld the daughter’s right to withhold consent. Courts often reach divergent outcomes when deciding whether to interfere with a parent’s refusal to consent to a non-life-threatening procedure. One court refused to override a  father’s denial of consent for surgery to repair his son’s harelip and cleft palate. But a different court permitted an operation on a boy suffering from a severe facial deformity even though his mother objected on religious grounds to the accompanying blood transfusion. In another case, a child was ordered to undergo medical treatments after the parents unsuccessfully treated the child’s severe burns with herbal remedies. Courts rarely hesitate to step in where a child’s life is in danger. To deny a child a beneficial, life-sustaining treatment constitutes child neglect, and states have a duty to protect children from neglect. One case involved a mother who testified that she did not believe that her child was HIV positive, despite medical evidence to the contrary. The co urt ordered treatment, including AZT, for the child. Many other cases involve parents who want to treat a serious illness with nontraditional methods or whose religious beliefs forbid blood transfusions. Cases involving religious beliefs raise difficult questions under the First Amendment’s Free Excise of Religion Clause, Common Law, statutory rights of a parent in raising a child, and the state’s traditional interest in protecting those unable to protect themselves. When a child’s life is in danger and parental consent is withheld, a hospital seeks a court-appointed guardian for the child. The guardian, often a hospital administrator, then consents to the treatment on behalf of the child. In an emergency case, a judge may make a decision over the telephone. In some cases, doctors may choose to act without judicial permission if time constraints do not allow enough time to reach a judge by telephone. In 1982, a six-day-old infant with Down’s syndrome died after a court approved a parental decision to withhold life-saving surgery. The child had a condition that made eating impossible. The baby was medicated but given no nourishment. The public furor over the Baby Doe case eventually helped spur the department of health and human services to create regulations delineating when treatment may be withheld from a disabled infant. Treatment may be withheld if an infant is chronically and irreversibly comatose, if such treatment would merel y prolong dying or would otherwise be futile in terms of survival of the infant, or if such treatment would be virtually futile in terms of survival and the treatment would be inhumane under these circumstances. Although courts overrule parental refusal to allow treatment in many instances, far less common are cases where a court overrides an otherwise competent adult’s denial of consent. The cases where courts have compelled treatment of an adult usually fall into two categories: when the patient was so physically weak that the court ruled that the patient could not reflect and make a choice to consent or refuse; or when the patient had minor children, even though the patient was fully competent to refuse consent. The possible civil or criminal liability of a hospital might also factor into a decision. A court typically will not order a terminally ill patient to undergo treatments to prolong life. Informed Consent Simply consenting to treatment is not enough. A patient must give informed consent. In essence, informed consent means that before a doctor can treat or touch a patient, the patient must be given some basic information about what the doctor proposes to do. Informed consent has been called the most important legal doctrine in patients’ rights. State laws and court decisions vary regarding informed consent, but the trend is clearly toward more disclosure rather than less. Informed consent is required not only in life-or-death situations but also in clinic and outpatient settings as well. A healthcare provider must first present information regarding risks, alternatives, and success rates. The information must be presented in language the patient can understand and typically should include the following: * A description of the recommended treatment or procedure; * A description of the risks and benefits—particularly exploring the risk of serious bodily disability or death; * A description of alternative treatments and the risks and benefits of alternatives; * The probable results if no treatment is undertaken; * The probability of success and a definition of what the doctor means by success; * Length and challenges of recuperation; and  * Any other information generally provided to patients in this situation by other qualified physicians. Only material risks must be disclosed. A material risk is one that might cause a reasonable patient to decide not to undergo a recommended treatment. The magnitude of the risk also factors into the definition of a material risk. For example, one would expect that a one in 10,000 risk of death would always be disclosed, but not a one in 10,000 risk of a two-hour headache. Plastic surgery and vasectomies illustrate two  areas where the probability of success and the meaning of success should be explicitly delineated. For example, a man successfully sued his doctor after the doctor assured him that a vasectomy would be 100 percent effective as Birth Control; the man’s wife later became pregnant. Because the only purpose for having the procedure wa s complete sterilization, a careful explanation of probability of success was essential. Occasionally, informed consent is not required. In an emergency situation where immediate treatment is needed to preserve a patient’s health or life, a physician may be justified in failing to provide full and complete information to a patient. Moreover, where the risks are minor and well known to the average person, such as in drawing blood, a physician may dispense with full disclosure. In addition, some patients explicitly ask not to be informed of specific risks. In this situation, a doctor must only ascertain that the patient understands that there are unspecified risks of death and serious bodily disabilities; the doctor might ask the patient to sign a waiver of informed consent. Finally, informed consent may be bypassed in rare cases in which a physician has objective evidence that informing a patient would render the patient unable to make a rational decision. Under these circumstances, a physician must disclose the information to another person designated by the patie nt. Informed consent is rarely legally required to be in writing, but this does provide evidence that consent was in fact obtained. The more specific the consent, the less likely it will be construed against a doctor or a hospital in court. Conversely, blanket consent forms cover almost everything a doctor or hospital might do to a patient without mentioning anything specific and are easily construed against a doctor or hospital. However, blanket forms are frequently used upon admission to a hospital to provide proof of consent to noninvasive routine hospital procedures such as taking blood pressure. A consent form may not contain a clause waiving a patient’s right to sue, unless state law provides for binding Arbitration upon mutual agreement. Moreover, consent can be predicated upon a certain surgeon doing a surgery. It can also be withdrawn at any time, subject to practical limitations. Right to Treatment In an emergency situation, a patient has a right to treatment, regardless of ability to pay. If a situation is likely to cause death, serious injury, or  disability if not attended to promptly, it is an emergency. Cardiac arrest, heavy bleeding, profound shock, severe head injuries, and acute psychotic states are some examples of emergencies. Less obvious situations can also be emergencies: broken bones, fever, and cuts requiring stitches may also require immediate treatment. Both public and private hospitals have a duty to administer medical care to a person experiencing an emergency. If a hospital has emergency facilities, it is legally required to provide appropriate treatment to a person experiencing an emergency. If the hospital is unable to provide emergency services, it must provide a referral for appropriate treatment. Hospitals cannot refuse to treat prospective patients on the basis of race, religion, or national origin, or refuse to treat someone with HIV or AIDS. In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 U.S.C.A.  § 1395dd), which established criteria for emergency services and criteria for safe transfer of patients between hospitals. This statute was designed to prevent â€Å"patient dumping,† that is, transferring undesirable patients to another facility. The law applies to all hospitals receiving federal funds, such as Medicare (almost all do). The law requires hospitals to provide a screening exam to determine if an emergency condition exists, provide stabilizing treatment to any emergency patient or to any woman in active labor before transfer, and continue treatment until a patient can be discharged or transferred without harm. It also delineates strict guidelines for the transfer of a patient who cannot be stabilized. A hospital that negligently or knowingly and willfully violates any of these provisions can be terminated or suspended from Medicare. The physician, the hospital, or both can also be penalized up to $50,000 for each knowing violation of the law. One of the first cases brought under EMTALA involved a doctor who transferred a woman in active labor to a hospital 170 miles away. The woman delivered a healthy baby during the trip, but the doctor was fined $20,000 for the improper transfer of the woman. In addition to federal laws such as EMTALA, states may also impose by regulation or statute a duty on hospitals to administer emergency care. There is no universal right to be admitted to a hospital in a nonemergency situation. In nonemergency cases, admission rights depend largely on the specific hospital, but basing admission on ability to pay is severely limited by statutes, regulations, and judi cial decisions. For  example, most hospitals obtained financial assistance from the federal government for construction; these hospitals are required to provide a reasonable volume of services to persons unable to pay. The amount of services to be provided is set by regulation, and the obligation continues for 20 years after construction is completed. Patients must be advised of the hospital’s obligation under the law, or the hospital may be foreclosed from suing to collect on the bill. In addition, many states prohibit hospitals from denying admission based solely on inability to pay; some courts have made similar rulings against public hospitals based on hospital charters and public policy reasons. Hospitals are also prohibited from requiring a deposit from a Medicare or Medicaid patient. Once a patient has been duly admitted to a hospital, she or he has a right to leave at any time, or the hospital could be liable for False Imprisonment. This is so even if the patient has not paid the bill or if the patient wants to leave against all medical advice. In rare cases, such as contagious disease cases, public health authorities may have state statutory or regulatory authority to quarantine a patient. In addition, state laws governing involuntary commitment of the mentally ill may be used to prevent a person of unsound mind from leaving the hospital if a qualified psychiatrist determines that the person is a danger to himself or herself or to the lives of others. A doc tor familiar with a patient’s condition determines when a patient is ready for discharge and signs a written order to that effect. If the patient disagrees with a decision to discharge, she or he has the right to demand a consultation with a different physician before the order is carried out. The decision to discharge must be based solely on the patient’s medical condition and not on nonpayment of medical bills. In the mid-1990s, concern over maternity patients being discharged just a few hours after giving birth prompted legislation at both the state and federal levels. In September 1996, President bill clinton signed a law ensuring a 48-hour hospital stay for a woman who gives birth vaginally and a 96-hour stay for a woman who has a caesarean section, unless the patient and the doctor agree to an earlier discharge. A number of state legislatures have passed similar laws as well. With the rise of Managed Care and Health Maintenance Organizations (HMOs), patients faced new issues involving the right to treatment. HMOs may deny authorization for expensive or experimental treatments, or for treatments  p rovided outside the network of approved physicians. HMOs contend that they must control costs and make decisions that benefit the largest number of members. In response, state legislatures have enacted HMO regulations that seek to give patients a process for appealing the denial of benefits. The HMOs have opposed these measures and have vigorously defended their denial of benefits in court. In Moran v. Rush Prudential HMO, Inc., 536 U.S. 355, 122 S.Ct. 2151, 153 L.Ed.2d 375 (2002), the Supreme Court in a 5–4 decision upheld an Illinois law that required HMOs to provide independent review of disputes between the primary care physician and the HMO. The law mandated that the HMO must pay for services deemed medically necessary by the independent reviewer. Most importantly, the court ruled that the federal Employee Retirement Income Security Act (ERISA) did not preempt the Illinois law. ERISA is an extremely complex and technical set of provisions that seek to protect employee benefit programs. The decision was significant because it empowered other states to enact similar laws that give patients more rights in obtaining treatment Med ical Experimentation Medical progress and medical experimentation have always gone hand in hand, but patients’ rights have sometimes been ignored in the process. Sometimes patients are completely unaware of the experimentation. Experimentation has also taken place in settings in which individuals may have extreme difficulty asserting their rights, such as in prisons, mental institutions, the military, and residences for the mentally disabled. Legitimate experimentation requires informed consent that may be withdrawn at any time. Some of the more notorious and shameful instances of human experimentation in the United States in the twentieth century include a 1963 study in which terminally ill hospital patients were injected with live cancer cells to test their immune response; the Tuskegee Syphilis Study, begun before World War II and continuing for 40 years, in which effective treatment was withheld from poor black males suffering from syphilis so that medical personnel could study the natural cou rse of the disease; and a study where developmentally disabled children were deliberately infected with hepatitis to test potential vaccines. Failure to obtain informed consent can arise even when consent has ostensibly been obtained. The California Supreme Court ruled in 1990 that a physician must disclose preexisting research and  potential economic interests that may affect the doctor’s medical judgment (Moore v. Regents of the University of California, 51 Cal. 3d 120, 793 P. 2d 479). The case involved excision of a patient’s cells pursuant to surgery and other procedures to which the patient had consented. The surgery itself was not experimental; the experimentation took place after the surgery and other procedures. The cells were used in medical research that proved lucrative to the doctor and medical center. Patients in teaching hospitals are frequently asked to participate in research. Participants do not surrender legal rights simply by agreeing to cooperate and validly obtained consent cannot protect a researcher from Negligence. In hospitals, human experimentation is typically monitored by an institutional review board (IRB). Federal regulation requires IRBs in all hospitals receiving fed eral funding. These boards review proposed research before patients are asked to participate and approve written consent forms. IRBs are meant to ensure that risks are minimized, the risks are reasonable in relation to anticipated benefits, the selection of subjects is equitable, and informed consent is obtained and properly documented. Federal regulations denominate specific items that must be covered when obtaining informed consent in experimental cases. IRB approval never obligates a patient to participate in research. Advance Medical Directives Every state has enacted advance medical directive legislation, but the laws vary widely. Advance medical directives are documents that are made at a time when a person has full decision-making capabilities and are used to direct medical care in the future when this capacity is lost. Many statutes are narrowly drawn and specify that they apply only to illnesses when death is imminent rather than illnesses requiring long-term life support, such as in end-stage lung, heart, or kidney failure; multiple sclerosis; paraplegia; and persistent vegetative state. Patients sometimes use living wills to direct future medical care. Most commonly, living wills specify steps a patient does not want taken in cases of life-threatening or debilitating illness, but they may also be used to specify that a patient wants aggressive resuscitation measures used. Studies have shown that living wills often are not honored, despite the fact that federal law requires all hospitals, nursing homes, and other Medi care and Medicaid providers to ask  patients on admission whether they have executed an advance directive. Some of the reasons living wills are not honored are medical personnel’s fear of liability, the patient’s failure to communicate his or her wishes, or misunderstanding or mismanagement by hospital personnel. Another way individuals attempt to direct medical care is through a durable Power of Attorney. A durable power of attorney, or proxy decision maker, is a written document wherein a person (the principal) designates another person to perform certain acts or make certain decisions on the principal’s behalf. It is called durable because the power continues to be effective even after the principal becomes incompetent or it may only take effect after the principal becomes incompetent. As with a Living Will, such a document has little power to compel a doctor to follow a patient’s desires, but in the very least it serves as valuable evidence of a person’s wishes if the matter is brought into court. A durable power of attorney may be used by itself or in conjunction with a living will. When advance medical directives function as intended and are honored by physicians, they free family members from making extremely difficult decisions. They may also protect physicians. Standard medical care typically requires that a doctor provide maximum care. In essence, a livin g will can change the standard of care upon which a physician will be judged and may protect a physician from legal or professional repercussions for withholding or withdrawing care. Right to Die A number of cases have addressed the right to refuse life-sustaining medical treatment. Broadly speaking, under certain circumstances a person may have a right to refuse life-sustaining medical treatment or to have life-sustaining treatment withdrawn. On the one side in these cases is the patient’s interest in autonomy, privacy, and bodily integrity. This side must be balanced against the state’s traditional interests in the preservation of life, prevention of suicide, protection of dependents, and the protection of the integrity of the medical profession. In in re quinlan, 355 A.2d 647 (1976), the New Jersey Supreme Court permitted withdrawal of life-support measures for a woman in a persistent vegetative state, although her condition was stable and her life expectancy stretched years into the future. Many of the emotional issues the country struggles with in the early 2000s were either a direct result of or were influenced by this case,  including living wills and o ther advance medical directives, the right to refuse unwanted treatment, and physician-assisted suicide. The first U.S. Supreme Court decision addressing the difficult question regarding the removal of life support was Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224 (1990). Cruzan involved a young woman rendered permanently comatose after a car accident. Her parents petitioned to have her feeding tube removed. The Supreme Court ruled that the evidence needed to be clear and convincing that the young woman had explicitly authorized the termination of treatment prior to becoming incompetent. The Court ruled that the evidence had not been clear and convincing, but upon remand to the state court the family presented new testimony that was deemed clear and convincing. The young woman died 12 days after her feeding tube was removed. The Supreme Court decided two right-todie cases in 1997, Quill v. Vacco, 521 U.S. 793, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997), and Washington v. Glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 138 L.Ed.2d 772 (1997). I n Glucksberg, the appellate courts in New York and Washington had struck down laws banning physician-assisted suicide as violations of Equal Protection and due process, respectively. The Supreme Court reversed both decisions, finding no constitutional right to assisted suicide, thus upholding states’ power to ban the practice. Though both cases were considered together, Glucksberg was the key right-to-die decision. Dr. Harold Glucksberg and three other physicians sought a Declaratory Judgment that the state of Washington’s law prohibiting assisted suicide was unconstitutional as applied to terminally ill, mentally competent adults. The Supreme Court voted unanimously to sustain the Washington law, though five of the nine justices filed concurring opinions in Quill and Glucksberg. Chief Justice william rehnquist, writing for the Court, based much of his analysis on historical and legal traditions. The fact that most western democracies make it a crime to assist a suicide was backed up by over 700 years of Anglo-American common-law tradition that has punished or disapproved of suicide or assisting suicide. This â€Å"deeply rooted†opposition to assisted suicides had been reaffirmed by the Washington legislature in 1975 when the current prohibition had been enacted and again in 1979 when it pass ed a Natural Death Act. This law declared that the refusal or withdrawal of treatment did not constitute suicide, but it explicitly stated that the act did not authorize Euthanasia. The doctors had argued that the law violated the Substantive Due Process component of the Fourteenth Amendment. Unlike procedural due process which focuses on whether the right steps have been taken in a legal matter, substantive due process looks to fundamental rights that are implicit in the amendment. For the Court to recognize a fundamental liberty, the liberty must be deeply rooted in U.S. history and it must be carefully described. The Court rejected this argument because U.S. history has not recognized a â€Å"right to die† and therefore it is not a fundamental right. Employing the Rational Basis Test of constitutional review, the Court concluded that the law was â€Å"rationally related to legitimate government interests† and thus passed constitutional muster. Privacy and Confidentiality Confidentiality between a doctor and patient means that a doctor has the express or implied duty not to disclose information received from the patient to anyone not directly involved with the patient’s care. Confidentiality is important so that healthcare providers have knowledge of all facts, regardless of how personal or embarrassing, that might have a bearing on a patient’s health. Patients must feel that it is safe to communicate such information freely. Although this theory drives doctor-patient confidentiality, the reality is that many people have routine and legitimate access to a patient’s records. A hospital patient might have several doctors, nurses, and support personnel on every shift, and a patient might also see a therapist, nutritionist, or pharmacologist, to name a few. The law requires some confidential information to be reported to authorities. For example, birth and death certificates must be filed; Child Abuse cases must be reported; and infectious, contagious, or communicable diseases must be reported. In addition, confidential information may also be disclosed pursuant to a judicial proceeding or to notify a person to whom a patient may pose a danger. In spite of the numerous exceptions to the contrary, patients legitimately demand and expect confidentiality in many areas of their treatment. Generally speaking, patients must be asked to consent before being photographed or having others unrelated to the case (including medical students) observe a medical procedure; they have the right to refuse to see anyone not connected to a hospital; they have the  right to have a person of the patient’s own sex present during a physical examination conducted by a member of the opposite sex; they have the right to refuse to see persons connected with the hospital who are not directly involved in the patient’s care and treatment (including social workers and chaplains); and they have the right to be protected from having details of their condition made public. A patient owns the information contained in medical records, but the owner of the paper on which they are written is usually considered the actual owner of the records. The patient’s legal interest in the records generally means that the patient has a right to see the records and is entitled to a complete copy of them. The patient’s rights are subject to reasonable limitations such as requiring inspection and copying to be done on the doctor’s premises during working hours. Federal Patients’ Bill of Rights Dissatisfaction with an expanding corporate healthcare industry dominated by profit margins has spawned numerous reform ideas. One idea that has gained a foothold is a patients’ federal Bill of Rights. In 1997, President Bill Clinton appointed an Advisory Commission on Consumer Protection and Quality in the Health Care Industry. The commission was directed to propose a â€Å"consumer bill of rights.† The 34-member commission developed a bill of rights that identified eight key areas: information disclosure, choice of providers and plans, access to emergency service, participation in treatment decisions, respect and nondiscrimination, confidentiality of health information, complaints and appeals, and consumer responsibilities. The proposed rights include: the right to receive accurate, easily understood information in order to make informed health care decisions; the right to a choice of healthcare providers that is sufficient to ensure access to appropriate high-quality health care; the right to access emergency healthcare services; the right and responsibility to fully participate in all decisions related to their health care; the right to considerate, respectful care from all members of the healthcare system at all times and under all circumstances; the right to communicate with healthcare providers in confidence and to have the confidentiality of their individually identifiable healthcare information protected; the right to a fair and efficient process for resolving differences with their health plans,  healthcare providers, and the institutions that serve them; and the responsibility of consumers to do their part in protecting their health. This bill of rights has been debated in Congress and there are bipartisan areas of agreement, but, as of 2003, no final action has taken on enacting a set of rights into federal law.

Culture and the Collective Consciousness: Nelly Richard and Crítica Cultural Essay

French born but Chilean based, Nelly Richard is an influential figure within contemporary Latin American cultural studies, though she has often taken issue with the use of this term to describe her work. A leading proponent of psychoanalytical and feminist understandings of the social, Richard, editor of the Revista de Crà ­tica Cultural between 1990 and 2008, is an innovative thinker responsible for creating a way of approaching cultural analysis which has been dubbed crà ­tica cultural. Her conceptual framework privileges theoretical insights gleaned from structuralism, which in French includes what is commonly referred to in the Anglo academy as post structuralism. Our discussion of her work focuses on her vision of the role of the social sciences in Latin America today. Richard questions the conceptual underpinning of these disciplines and argues for a more thoroughly contextualised understanding of the relationship between knowledge production and power. Richard, Nelly. â€Å"The Social Sciences: Front Lines and Points of Retreat†. In The Insubordination of Signs: Political Change, Cultural Transformation and Poetics of the Crisis. London: Duke University Press, 2004. Beasley-Murray, Jon. â€Å"Reflections in a Neoliberal Store Window: Nelly Richard and the Chilean Avant-garde†. Art Journal 64 (3): 126–129. PDF Pino-Ojeda, Walescka. â€Å"Critica cultural y marginalidad: Una lectura al trabajo de Nelly Richard†. Revista de Crà ­tica Literaria Latinoamericana, Aà ±o 25, No. 49 (1999), pp. 249-263. PDF Del Sarto, Ana â€Å"Cultural Critique in Latin America or Latin-American Cultural Studies?† Journal of Latin American Cultural Studies: Travesia, Volume 9, Issue 3, 2000. PDF

Respirtory case study Essay Example | Topics and Well Written Essays - 1250 words

Respirtory case study - Essay Example It can also be due to the allergic rthinitis, as well as the rhinitis that occurs following an environmental irritant. The patient’s condition might be indicating that he or she has influenza infection. Part 2 In order to reach at a conclusion concerning the patient’s condition, certain questions are essential in helping eliminate some of the range of suspected diagnosis (Bass, 2004). Following the initial physical examinations, the patient was said to have a prolonged coughing that is persistent with chest pressure radiating to the back. This implies that in order to be sure that the patient’s case is not as a result of acute cough or common cold, such questions as how often do you sneeze or at what frequency do you sneeze, do you feel any sort of obstruction in your nose do you feel any irritation in your throat, have you been experiencing a postnasal drip lately, shall be of use. The rationale behind these questioning is that, in case, the patient presents sig ns of irritation and lacrimation in her/his throat, nasal obstruction, signs of sneezing, signs of postnasal drip, with a normal chest, and possibly rhinorrhea, then common cold or acute cough shall be responsible for the patient’s conditions. On the contrary, if the patient fails to show this signs, then common acute cough may be ruled out of the possible causes of the patient’s condition. ... The rationale behind asking this question is based upon the idea that the patient is a smoker and thus prone to noxious particles from tobacco smoking that can end up triggering an abnormal inflammation response in the patient’s lungs. In ascertaining if the patient’s condition suggest anything that he/she is influencer affected, the essential questions shall be do you feel feverish or chilly, has your sore throat lasted for more than 3 days, do you experience frontal or retro-orbital headache and how severe is it, do you have any burning sensations, or pain upon motion, do you feel weak or fatigued when performing normal activities, do you experience shortness of breath and pains in your chest. A range of questions set above are meant to help rule out influencer as the possible cause of the patient’s condition. Part 3 lungs shall be the vital system that I would checked by performing lung functioning tests. The rationale behind checking the lungs is that at admi ssion, the patient was said to be a smoker, and had cough accompanied by chest pressure radiating to the back. This implies that smoke particles must be the causal agent for patient P’s condition. Part 4 Diagnostic tests The Recommended treatment plan for each of the Differential Diagnoses Diagnosis of the exacerbation of the chronic obstructive pulmonary disease needs lung function tests Diagnosis of acute cold require laboratory tests. b. Therapeutic regimens Acute cold due to common cold can be treated with dexbrompheniramine plus naproxen and pseudoephedrine. Ipratropium for relieving rhinorrhea and sneezing along with zink Lozenges. Antibiotics for treating bacterial infections due to bacterial sinusitis. In treating the exacerbation of the

Analysis of Jack Sheltons Im Just a Bill Assignment

Analysis of Jack Sheltons Im Just a Bill - Assignment Example There needs to be a strong majority on certain bills before the bills can go to the White House to be signed by the president, and become law. There needs to be a majority in both houses before the bill can go to the White House to be signed into law by the president. â€Å"I’m Just a Bill† did not inform viewers of the time it would take for a bill to go from a thought to a bill, to become a law. Sometimes, Congress votes on a bill because of its urgency. Some bills are less important to national security and the safety of Americans. â€Å"I’m Just a Bill† did not inform viewers it could take less than 30 days for a bill to pass through Congress. Sometimes, like with the United States of America Patriot Act Congress put all other bills on hold, and passed the United States of America Patriot Act within 30 days of September 11, 2001. â€Å"I’m Just a Bill† says it takes months, and years for Congress to debate over a bill. Congress has a rule that all bills introduced during one session of Congress need to be voted on before the end of that session. Congress does not allow bills to sit around from session to session. If someone watches â€Å"I’m Just a Bill† this person is led on to think that it takes more than several months for a bill to go from a thought, to a bill and to law. If someone watches â€Å"I’m Just a Bill† this person may think it could take years for a bill to be discussed in Congress. Question Number Two When Saunders, Abramowitz, and Williamson discussed the level of sophistication as it pertains to the study of voters from 1996 the data in the table appears to prove the hypothesis by Saunders, Abramowitz, and Williamson. However, Saunders, Abramowitz, and Williamson received the data for the table using data from the voting machines. The data in the table; therefore would be inconclusive. Every district has a socioeconomic status. The voting machines can count mixed ticket s; therefore the data reflects the number of mixed tickets was cast in the 1996 election. However, some sophisticated voters may live in underprivileged areas such as an urban area.  

Duties of an Intergovernmental Public Manager Essay

Duties of an Intergovernmental Public Manager - Essay Example DSS had a budget of $770 million for 2007, over 3,300 employees most of whom are social workers (2,600-plus) and some 580 in administrative work, and is under the Office of Children, Youth, and Family Services (annual budget: $1.6 billion) under the Health & Human Services budget item which, at over $12 billion annually, is the Commonwealth's single biggest expenditure. Considering that the DSS has the largest departmental budget in Massachusetts (accounting for 6%) makes it easier to understand the important role of Mr. Kelley as the Department's Audit Manager, especially when the general public is clamoring for greater fiscal accountability (Kelley, 2007). Mr. Kelley is a Certified Public Accountant (CPA) who has steadily gone up the ranks of the DSS bureaucracy. When he was still in college, he was thinking of working at one of the established accounting firms but decided to work instead with the government because he felt that this was where he would find the best work-life balance. Coming from a long line of public servants, Mr. Kelley found it easier to decide to become one. It was a decision he never regretted. When asked whether education or experience played the most important role in his success, he claimed that one without the other would not have been enough, since auditing/accounting is a highly-technical profession that combined intellectual and mathematical skills with a dash of detective work. Without education, the highest position one could get would have been that of a bookkeeping clerk. Experience played an important role because although education could get you started, one needed to learn from experience to survive and thrive. He learned the most from his mistakes, of which there were several. What helped him most, however, was a mentor, a senior bureaucrat now retired but who trained him on the intricacies of the bureaucracy. The DSS is one of the most important human services offices in the Commonwealth and their mandate of taking care of the most helpless citizens - children who are abandoned or abused by those who are supposed to care for them - puts Mr. Kelley's work in the proper context. He talked about his sacred duty to ensure that all federal and state funds channeled to the department find their beneficiaries in the most efficient and effective manner. He passionately believes that how a society takes care of its most helpless members is a measure of the society's values and quality. The fact that the DSS gets one of the biggest shares of the budget exposes the office to a lot of politics, which goes on not only within DSS or the Commonwealth structure competing for funds, but also with other private charities in and out of Massachusetts. This is something he has learned to manage quite well, but that he sees as something that comes with the territory. Contrary to common perceptions, government offices are highly dynamic and change quite more rapidly as top officials can be changed every two years. Thus, policies change and, with these changes, so do management styles and points of focus. One of the most remarkable change efforts within the organization started taking place in 1989 and is still ongoing, which is the implementation of Chapter 647, a Commonwealth Act designed to improve the internal controls within all State agencies. The law aimed at improving the

Research Designs Assignment Example | Topics and Well Written Essays - 250 words

Research Designs - Assignment Example This helps us to verify that the effects seen are actually due to the said Independent variable and not other factors. A true experimental design has all these components; and thus offers the most reliable data and analysis (Kerlinger, 1986). An example of a true experimental study would be when a new medicine is being tested, and different dosages are given to different groups to test it’s efficacy. A control group in not given the medicine, but a placebo instead. The dosage levels are varied as per to opinion of the professional researcher; and the sample chosen is such that it represents the larger population from which it comes. On the other hand, a cross-sectional design and a quasi-experimental design would not allow for manipulation of the independent variable or for the presence of a control group given the nature of the Independent variables under study (Frankfort-Nachmias & Nachmias, 2008). An example of a cross-sectional study would be a study that tried to verify the type of music preferred across different age groups. Although the experimenter can choose the range of each group; there is no ‘control group’ for this study. On the other hand, a quasi-expeimental design would be one where the efficacy of different treatment options for an illness are compared (Frankfort-Nachmias & Nachmias, 2008). The researcher cannot assign treatment options and has to collect data from participants who choose the said options. There can be a control group only if there are people who choose to abstain from treatment. The least strong type of study is one that uses a pre-experimental design (Frankfort-Nachmias & Nachmias, 2008), which only allows for comparison or observation. A typical pre-experimental design is when a group is tested for knowledge before and after a training procedure and then the two scores are compared for difference. The strength of the research design

Supply Relationships in Procurement Management Essay

Supply Relationships in Procurement Management - Essay Example In practical contexts, sourcing products from external suppliers do not lack in technical hitches, particularly hitches related to supplier performance. According to Maxwell (2005), a procuring firm expects suppliers to demonstrate high levels of production and delivery competencies. Unfortunately, maintenance of the required level of competences by suppliers may be restricted by internal factors like high costs of production, and external factors like intense industry competition. Subsequently, suppliers may deliver goods and services that are below the required standards. In this context, the significance of supplier relationship management in procurement processes cannot be overemphasized. Within practical commercial settings, outsourcing goods and services from external suppliers are indispensable. Currently, most firms in Europe and the United States are sourcing products from external suppliers in Asian nations like China and India. Apparently, suppliers in these Asian nations deliver goods and services at relatively low prices. Therefore, companies rely heavily on such suppliers. Since external suppliers are essential players in today’s business, it becomes necessary to create and maintain a healthy relationship between enterprises and their suppliers. According to Lydia (2010), supplier relationship management, commonly abbreviated as SRM, is a managerial discipline meant to optimize the efficiency of processes used in acquiring products from suppliers. Undeniably, supply chains are becoming increasingly complex. In most cases, external suppliers may sub-contract certain production processes to third parties. In addition, such third parties may assemble goo ds from products and services delivered by other parties. Therefore, elongation of supply chains necessitates the sustainable development of supplier policies.  In conclusion, it is undeniable that success of procurement exercises relies upon efficiencies within the component of supplier relationship management. Presently, and even in future, outsourcing is and will be a necessary part of the business.  

The Causes of the Development of Antimicrobial Resistance Essay

The Causes of the Development of Antimicrobial Resistance - Essay Example The former class includes antibiotics like the ÃŽ ² lactams (penicillin, penicillin derived antibiotics, carbapenems, cephalosporins, vancomycin) and most aminoglycosides especially against Gram-negative organisms but not against Gram-positive and anaerobic micro-organisms. The other class of antibiotics, the microbiostatic, include antibiotics that prevent the micro-organisms from multiplying by interfering with their protein production, DNA replication, and other metabolic pathways. Tetracycline, sulphonamides, trimethoprim and most microbicidal antibiotics at low concentration are few examples of the microbistatic group. The first antibiotic to be discovered was penicillin derived from the Penicillium mold. It was discovered by Alexander Fleming in 1928. Later on, the development of synthetic penicillin broadened the spectrum of activity and at the same time enhanced the efficacy of these drugs. However, with the emergence of resistant bacterial strains, the usefulness of penicillins have been limited in the recent years. Methicillin is a narrow spectrum ÃŽ ² lactam antibiotic which was developed in 1959 by Beechman in order to treat penicillin-resistant Gram-positive organisms like Staphylococcus aureus.  In the 1960s and 1970s, it proved so efficient against Staphylococcus aureus that it was extensively used and even sprayed in the wards of hospitals to control Staphylococcal infection in newborn. ( Elek SD, Fleming PC. A new technique for the control of hospital cross infection. Lancet 1960;ii:569–72). Methicillin-resistant isolates though present were not notably troublesome because of the emergence and prevalence of microbial resistance especially MRSA( methicillin-resistant Staphylococcus aureus) in hospitals. The major antibiotic-resistant pathogen associated with nosocomial infection.

Unique Messages of The Cruci-Fiction Project and The Three Crosses Essay - 3

Unique Messages of The Cruci-Fiction Project and The Three Crosses - Essay Example The two artworks send messages to the audiences. In the Rembrandt artwork, the government crucifies the criminals. Similarly, the Gome-Pena and Roberto Sifuentes artwork show the collaborators’ crucifixion is meant to protest the strict immigration and discrimination policies of the United States and the Los Angeles police department. The two artists, Chicano Guillermo Gome-Pena and Roberto Sifuentes, collaborated to produce a popular project, The Cruci-fiction Project, during 1994 (Dutta 210). The Golden Gate Bridge democratic artwork shows their disgust over the procedural hindrances of the Immigration and Naturalization Services (INS). There are differences between the two artworks. The Gome-Pena and Roberto Sifuentes artwork show the authors were not really crucified. The collaborators were only acting. No one was hurt by the crucifixion. On the other hand, the Rembrandt van Rijn artwork shows Jesus Christ and the two thieves were nailed to the cross. The three individuals died. Further, the art form used differs. In the Rembrandt, a masterpiece is done using the print or etching venue. The venue involves the use of metal plates. On the other hand, the Gome-Pena and Roberto Sifuentes artwork use real human beings. The collaborators are actors. They play the three-hour crucifixion to dramatize their protests. During April 1994 event, the collaborators’ costumes represented the undocumented bandits trying to enter the United States. Further, Roberto depicted the gang members who were trying to enter the United States. The April 1994 event questions why prevailing United States sentiments blame the immigrants for the United States’ rising criminal activities.  

Management strategic-------Carry out a strategic analysis of the UK Assignment

Management strategic-------Carry out a strategic analysis of the UK grocery market using appropriate strategic management models - Assignment Example All these analyses have been carried out from the point of view of Tesco. However, references to UK general grocery market have been made times and again when required. The report concludes with the key takeaways from this detailed strategic analysis. 2. Overview of UK Grocery Market Retailing is one of the main contributors to UK economy with over 12% share. This sector acts as a bridge between production and consumption and is also a great generator of employment. In addition to the organized sector, there are a large number of unorganized players who are self-employed. UK grocery market has witnessed changes across both horizontal and vertical dimensions in the past few years. Horizontally, food retailers have ventured into other retail segments such as consumer goods, clothes, services and so on. Vertically, there has been a shift of power in the supply chain from the manufacturers to large organized retailers. This had a huge impact on the dynamics of the industry (Institute of Retail Studies 2003). 3. Internal Analysis of Tesco Tesco is primarily a food retailer with more than 2500 stores across the globe, a majority of which are in UK. The company has lately ventured into other business segments such as financial services, insurance, electrical appliances, telecommunications and insurance (Data Monitor 2004). SWOT analysis can be effectively used to carry out an internal assessment of Tesco. 3.1. Strengths One of Tesco’s biggest strengths is its continuously increasing market share. As of July, 2011, its market share is above 30% (Institute of Grocery Distribution). Tesco has almost doubled its market share in the past 7-8 years speaking high volumes of its growth. This growth has been enabled because of the continuous geographical expansion and opening of new stores. In addition, Tesco has strategically focused on non-food segment of the business and now it contributes very significantly to its revenues. Tesco has realized the importance of web i n its marketing. It has one of the biggest online supermarkets in the world. Tesco has a great brand image among its customers. It is known for high quality goods, innovative measures and efficient processes. Tesco’s lead over other players in UK market is huge. This has been made possible due to economies of scale it has gained over the years. 3.2. Weaknesses Tesco’s success story has largely been possible due to the UK market. However, it is susceptible to risk in case of change in government regulations. Tesco has a largely untapped market in emerging economies such as China and India. In addition, Tesco has been very aggressive in its expansion strategy and acquisitions. This has meant taking a large amount of debt affecting its balance sheets. Such a capital structure would work till the going gets good but may backfire in tough times. 3.3. Opportunities Tesco has opportunities from two perspectives. One is the geographical expansion in emerging markets as discuss ed above. The second opportunity is to make efficient use of its scale and venture into new business segments. The margins in the food industry are declining and it is profitable to consider new avenues. Tesco has already started working on the same with new segments such as skincare (Data Monitor 2004). In this way, it would also be able to realize economies of scope. 3.4. Threats UK grocery market has witnessed a lot of price wars. This has especially occurred due to entry of

Conan Doyle Essay Example for Free

Conan Doyle Essay The final villain we are introduced to is Irene Adler. She is introduced during The Scandal in Bohemia and is a very unusual villain compared to the others. Conan Doyle presents her differently mainly because she is a woman. However Doyle was writing a head of his time as during his era women were looked upon as inferior to men yet she is the only villain to successfully outwit Holmes. She is also the only villain of the three who never uses aggression. She relies entirely on cunning and intelligence and manages to outwit Holmes very skilfully. She also completely changes Holmes opinion. Holmes originally believes her to be no different to any other villain. However by the end of the story she has gained his respect and In his eyes she eclipses and predominates the whole of her sex. This shows Holmes lack of respect for women and how he sees himself as superior. This is clear because he considers outwitting him an extremely impressive thing meaning he thinks himself better than other people. But Adler changes this. With her cunning she is able to defeat Holmes at his own game. And at the same time as being so good at what she does she hides it from everyday people with her appearance which makes her seem innocent. She was a lovely woman, with a face a man might die for. From that last bit a face a man might die for we can interpret it to mean she is very good at manipulating people. And we know that although she is beautiful she is ruthless. She has the face of the most beautiful of women, and the mind of the most resolute of men As well as showing her two different images of how she can be very clever and ruthless but also alluring this shows the contrast of men and women at the time. Showing how men were considered to be more resolute and cunning. We also know that her skills are enough to impress anyone even royalty. This is clear when the king says What a queen she would have made. On the other hand the king feels this from the beginning but Holmes is always unwilling to deem anyone to be equal to or greater than him does not change how he feels until the end. Holmes himself is quite different throughout the stories. In the speckled band he is a true hero. Not caring about personal gain working for the love of his art rather than the acquirement of wealth showing dedication to his work. And how he feels the feeling he gets from solving the mysteries is a better reward than any amount of money. However even here we see some of his darker side as he was able to see deeply into the manifest wickedness of the human heart. This suggests he has perhaps been there himself and is able to understand wickedness so well that there could be a side to him which is quite different to the hero presented to us. However no matter how dark he may seem sometimes, there is no denying his brilliance as a detective. His faculties of deduction and of logical synthesis mean he is always one step ahead. We also know that he is very observant and notices the smallest things. I observe the second half of a return ticket in the palm of your glove. You must have started early and yet you had a good drive in a dog cart along heavy roads. This shows he notices and observes everything and works things out that no one else could. However in the Copper Beaches he has become less of the helpful hero who would help anyone and anything. He considers himself better than others. His friend Watson was repelled by the egotism. Showing a completely different side of Holmes. He is egotistical and believes the rest of the world to be beneath him. The public, the great unobservant public, who could hardly tell a weaver by his tooth or a compositor by his thumb. This shows that he believes himself to be better than anyone else and that the public are ignorant. Overall I think all the villains posses similar qualities but with key noticeable differences. They are all cunning and intelligence with Roylott being the only physically villainous one. And Adler being the only one successful in outwitting Holmes. Conan Doyle was writing ahead of his time by show Adler as equal to Holmes as women were looked upon as weaker at the time. As for Holmes himself we see he is not perhaps the true hero who can do no wrong he would appear in the Speckled Band. And even venturing in the worlds of drugs, which gives him darker apparel and make him more of an anti-hero.

Interventions and preventative management related to skeletal traction

Interventions and preventative management related to skeletal traction List nursing interventions and preventative management related to skeletal traction. As what we had discussed, traction is the application of pulling force to a part of the body. There are two types of traction, the skin traction and the skeletal traction. In skeletal traction, the traction is directly applied to the bone by the use of metal pin or wire. To maintain an effective traction, the nurse must check the traction apparatus. Make sure that the ropes are positioned properly in the pulley track, ropes are not ragged, the weights hang freely and the knots in the rope are tied securely and make sure that the skeletal traction equipment are tight. Check the pins to be sure they are secure and tight, and insert the small finger or the index finger between the vest and the patients skin to be sure the vest if comfortable and not too tight. The nurse must also maintain the position of the patient. Inspect the patients proper body alignment every 2 hours. Avoid foot drop, inward rotation and outward rotation. The foot of the patient may be supported in a neutral position. Monitor neurovascular status of the patient at least every 4 hours. The patient must report to the nurse if there are any changes in his sensation or movement. The immobilized patient is risk for DVT. So, encourage the patient to do active flexion and extension of the extremities and isometric contraction of the calf. Also, anti-embolism stockings, anti-coagulant therapy may also be used to prevent thrombus formation. Instruct the patient to exercise to maintain strength and tone of his muscle. Also, this will help in patients rehabilitation. Pin at the insertion site may be risk for infection or the development of osteomyelitis. Pin care should be performed 1 or 2 times a day. Clean the site with chlorhexidine solution or water and saline. The nurse must inspect the pin every 8 hours for infection. When pins are stable for 48- 72 hours, weekly pin site care is suggested. The nurse must prevent skin breakdown by inspecting the elbows and heels for pressure ulcers. A trapeze can be used to help the patient move about in the bed without the use of elbows and heels. The nurse must keep the bed dry and free from crumbs and wrinkle for patient who is unable to change positions. Discuss a component of cast care for the pediatric client or adult client. Identify manifestations of compartment syndrome. General cast care includes avoid getting cast wet, especially padding under cast-cause skin breakdown as plaster casts become soft. Moisture weakens plaster and damp padding next to the skin can cause irritation. Advise the patients that do not cover a leg cast with plastic or rubber boots, as this causes condensation and wetting of the cast. Also, avoid weight bearing or stress on plastic cast for 24 hours. Report to the physician if the cast cracks or breaks, instructs the patient not to fix it himself. To clean the cast, remove surface soil with slightly damp cloth, rub soiled areas with household scouring powder, and wife off residual moisture. For pediatric patient there are some additional cast cares. The child is usually more troubled by immobilization than the adult. A special attempt should be made to ensure that his activities are as normal as possible and that full use is made of his unaffected joints and muscles. The younger child may not be able to understand why the cast is necessary. He may attempt to remove it. Allow the child to work through his question and feelings via play like giving her a doll with a cast. Children may be frightened by the removal of the cast. They often think of cast as part of their body and may be helped by analogies of having fingers nails or hair cut. Age- appropriate explanations and demonstrations should be provided. Parents should be instructed in care following cast removal. Daily soaking of the area may be necessary to remove desquamated skin and secretions. Oil or lotion may provide comfort to the child. Exercise should be done as prescribed to increase strength and function. Manifestations of compartment syndrome: In acute compartment syndrome: The classic sign is pain in the injury site. Stretching the muscles increases the pain. There will be tingling or burning sensation in the skin. The muscle will feel tight. The late sign of compartment syndrome is paralysis indicating permanent tissue damage. In chronic compartment syndrome: There is pain and cramping during exercise. The pain usually subsides when the activity stops. Numbness Difficulty moving the foot Visible muscle bulging Compare the nursing needs of a total hip replacement patient with those of a total knee replacement patient. In patient who had undergone hip replacement, nursing intervention focuses on preventing dislocation of hip prosthesis. The nurse must instruct the patient to position his leg in abduction because this may prevent dislocation of the prosthesis. A wedge pillow is usually placed between the legs to remain the legs abducted. Also, the hip of the patient should never be flexed for more than 90 degrees. When the patient sits, advice him than his hips should be higher that his knees. The patients affected leg should not be elevated and the knee may be flexed. Emphasize to the patient that he should maintain his legs in abducted position, to avoid internal and external rotation, hyperextension and acute flexion. Due to invasive procedure, there will be fluid and blood being accumulated. The nurse must remember that drainage is still normal if 200-500 ml of fluid were drained for the first 24 hours and after 48 hours it usually decreases to 30 ml or less. Report to the physician if the volum e of the drainage is greater than expected. Risk for deep vein thrombosis is common after the hip replacement because of immobility. Anti-embolic stockings, anti-thrombolytic medication can be used as preventive measures. Advise the patient to report any signs of calf pain, swelling and tenderness because it may indicate DVT. One of the serious complications after hip replacement is infection; it may occur within 3 months after surgery and associated with hematomas. Use of aseptic technique for dressing changes should be observed and implemented to avoid introducing organisms. Severe infections may require surgical debridement or removal of the prosthesis. In patient who had undergone knee replacement, nursing intervention should focus on mobilizing the patient. While in hip replacement the patients legs should be abducted, in knee replacement the patient is encourage to do active flexion of the foot every hour when the patient is awake. Like in hip replacement, knee replacement is also risk for deep vein thrombosis. Active range of motion, anti- embolic stocking and anti-coagulant can be used to prevent DVT. Also, knee replacement is an invasive procedure and its fluid had accumulated in the joint. Drainage of this replacement may ranges from 200-400 ml during the first 24 hours and less than 35 ml by 48 hours. If extensive bleeding happens, an autotransfusion drainage system may be used during postoperatively. Change in the characteristics and amount of drainage is promptly reported to the physician. Encourage the patient to use a continuous passive motion device with physical therapy to improve patients knee mobility, decreased hosp ital stay and minimize the intake of analgesic agents. The nurse must assist the patient to get out of the bed on the second postoperative day and start ambulating as tolerated. Discuss methods to avoid dislocation after hip replacement surgery. Dislocation of the hip is a serious complication of surgery that causes pain and necessitates reoperation to correct the dislocation. The desirable positions such as abduction neutral rotation and flexion of less than 90 degrees must be emphasized during the patient teaching. Instruct the patient to keep the knees apart at all times by putting a pillow between the legs to keeps hip in abduction and in neutral position to prevent dislocation. The patient should never cross his/ her legs while sitting. Avoid bending forward while sitting in a chair. The patient should not flex the hip to put on clothing such as pants, stockings or socks. Use a high-seated chair and a raised toilet seat. You are caring for a patient who has had skeletal traction placed to treat a fractures femur. Discuss nursing interventions and assessment techniques related to this type of treatment. Fracture of the femur usually is treated with some form of traction to prevent deformities and soft- tissue damage. Skeletal traction is used to align the fracture in the preparation for the future reduction. Traction restricts patients mobility and independence; therefore the nurse must assess and monitor the patients anxiety level and psychological responses to traction. Since the patient requires assistance with self-care activities, the nurse must help the patient to eat, bathe, dress and toilet. Assess the patient and the traction set-up to determine the best method for changing the bed linen. Eliminate any factors that reduce the traction pull or alter its direction. Ropes and pulleys should be in straight alignment and the ropes should be unobstructed. The nurse must inspect the body part that is placed in traction and its neurovascular status to determine if there is sign of inflammation. Because the patient is confined to bed, the nurse must implement measures to prevent complications of immobility and inactivity. One of the complications in patient to skeletal traction is atelectasis and pneumonia due to immobility. To assess respiratory status, the nurse auscultates the patients lungs every 4-8 hours. Teach the patient deep exercises to fully expand the lungs and to clear out secretions. Constipation is also a complication due to decreased peristalsis, a high fiber diet and fluids may help stimulate gastric motility. Urinary infection is also a common complication because of incomplete emptying the bladder due to the uncomfortable effects of voiding into a bed pan. The nurse must encourage the patient to drink large quantities of water and to void every 3-4 hours. DVT is also a serious complications, nurse must assist the patient in foot and ankle exercise. Also, drinking a lot of fluids makes the patients hydrated and prevents homoconcentration which can contribute to stasis. A patient is being discharged with an external fixator for a fractured humerus. Discuss home care instructions for this patient. These are the instructions that the nurse must teach to the patient before discharge: Patient must inspect each pin site for signs of infection and loosening of pins. Watch for pain, soft tissue swelling and drainage and consult a physician when it occurs. Cleanse around each pin daily, using aseptic technique to prevent contamination of bacteria leading to infection. Do not touch wound with your bare hands. Clean fixator daily to keep it free of dust and contamination. Do not tamper with clamps or nuts because it can alter compression and misalign fracture. Encourage the patient to follow rehabilitation regimen because it is helpful in teaching the patient to use ambulatory aid safely, adjust to weight- bearing limits and altered gait patterns. Identify various types of traction and the principles of effective traction. The first type of traction is the running traction, it is a form of traction in which the pull is exerted in one plane; it may be either skin or skeletal traction and Bucks extension traction is an example of running skin traction. The other type of traction is balanced suspension traction, which uses additional weights to counterbalance the traction force and floats the extremity in the traction apparatus. The line of pull on the extremity remains fairly constant despite changes in the patients position. According to our discussion, to achieve an effective traction, countertraction, a force acting to the opposite direction, is applied. The patient body weight and positioning in bed supply the counterforce; Traction must be continuous to reduce and immobilize fracture; Skeletal traction is never interrupted; weight are not removed unless intermittent traction is prescribed; any factor that reduces pull must be eliminated; ropes must be unobstructed and weight must hang freely and knots or the foot plate must not touch the foot of the bed. Discuss the use of Bucks traction, its uses and the involved nursing considerations. Bucks traction is skin traction to the lower leg. It is used to immobilize fractures of the proximal femur before surgical fixation. It can be use for hip and knee contracture, preoperative and postoperative positioning and immobilization of hip fractures, muscle spasm, joint rest. Nursing management: Ensure skin integrity by avoiding pressure on heel, dorsum of foot, fibular head, or malleolus. Maintain countertraction by elevating foot of the bed or keeping head of bed flat. Encourage independence with use of trapeze. Do not put a pillow under the affected limb. Observe skin by removing traction, with someone holding the leg in alignment with manual traction, at least once every shift. A maximum of 10 lb of traction should be used. Discuss the nursing care for a patient undergoing orthopedic surgery. Preoperative nursing care: In relieving the pain of the patient, elevation of the edematous extremities promotes venous return and reduces discomfort. Also, the use of ice relieves swelling and reduces discomfort by diminishing nerve stimulation. The physician may order analgesic to control the acute pain of the musculoskeletal injury. The nurse must also maintain adequate neurovascular function by assessing color, temperature, capillary refill, sensation and motion of the extremities. For the nurse to promote health to the patient, th nurse should assist the patient in performing activities that promote health during the perioperative period. The nurse also assesses nutritional status and hydration. The goal of the nurse in the preoperative period is to focus on helping the client to experienced reduced pain; continue to be active, mobile and injury free; and practice measures to reduce the potential for postoperative wound infection. Postoperative nursing care: The nurse assesses the patients level of pain since pain is common after orthopedic surgery. the use of repositioning, relaxation, distraction and guided imagery may help in reducing the patients pain. The physician must order patient- controlled analgesia and epidural analgesia to relieve the pain. In maintaining an adequate neurovascular function, the nurse must instruct the patient to perform muscle- setting, ankle, and calf-pumping exercise hourly while awake to enhance circulation. Encourage the patient to increase intake of foods that is rich in protein and vitamins because it is essential for wound healing. Positioning the patient at least every 2 hours can minimize pressure ulcer and skin break down. The patient may use assistive device for postoperative mobility. There are potential complications that may arise after the surgery. The goal of the nurse is to the patient is to exhibit absence of complication. The patient is risk having pneumonia and atelectasis, the nurse must instruct the patient to deeply breath and cough every 2 hours to expand the lungs and mobilize secretions; encourage the use of incentive spirometry to increase respiratory effort; turning the patient at least every 2 hours to prevent pooling of secretions and auscultate lung sounds every 4 hours to note for breath sounds. The patient is also risk for infection. When changing the dressing of the patient and performing pin care, the nurse must use aseptic principle to reduce microorganisms that may go into the wound and incision; keep the wound drainage system below the level of incision to prevent backflow of the drainage; and administer prescribe antibiotics to control the infection. The patient is also risk for deep vein thrombosis. The nurse encourage the patient to us e ankle and calf- pumping exercises, anti embolism stockings. To avoid constipation, the nurse encourages the patient to increase fluid intake to 2000 ml/ day unless contraindicated to prevent fecal impaction. Sources: Brunner, Suddarths et al. (2008). Medical- Surgical Nursing 12th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins Mahler, Salmond et al. (2005). Orthopaedic Nursing. Philadelphia, Pennsylvania: W.B Saunders Company Timby and Smith (2003). Introductory Medical- Surgical Nursing 8th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins Web Assignment 1. Find a research article addressing health teaching needs for the patient with a cast. Explain your findings in a one-page paper. The nurse must instruct their patient to rest and keep the affected extremity elevated on a one or two pillow as much as possible during the first 24 hours. The use of crutches may be suggested for your patients with a leg cast or a sling for patients with an arm cast for use during the first 24-48 hours. Remind your patient that the cast must be dry at all times. Advise them that water or any liquids will cause the plaster to weaken and it may lead to skin irritation. While bathing, instruct your patient to cover the cast with a plastic bag, tape the opening shut, and hang the cast outside the tub. Even when covered with plastic, you should not place the cast in water or allow water to run over the area. If the cast becomes wet, your patient can dry it with a hair dryer on the cool setting. Do not use the warm or hot setting because this can burn the skin. Your patient can also use a vacuum cleaner with a hose attachment to pull air through the cast and speed drying. To decrease swelling and pain in the first 24-48 hours, your patient should place crushed ice in a plastic bag, covered with a pillow case or towel, on the cast over the injury every 15 minutes per hour while awake. Do not apply ice directly to the skin. Dents or compression of the cast can cause pressure or irritation to the skin beneath the dressing, which may develop sores or ulcers. The nurse must teach the patient to reposition his body every two hours during the first 24 hours to allow even drying of the cast and every two hours when awake thereafter to avoid developing pressure sores on the skin. Do not place anything inside the cast, even for itchy areas. Sticking items inside the cast can injure the skin and lead to infection. Using a hair dryer on the cool setting may help soothe itching. The cast should be inspected regularly. If it develops cracks or soft spots, the physician should be notified. The patient should never attempt to remove the cast. The physician will remove the cast at the appropriate time with a special saw that cuts through the casting material but will not damage skin. Advise the patient that a serious complication can occur after cast application which is known as compartment syndrome. Instruct your patients to call the physician at once if any of the following signs or symptoms appear such as increased pain combined with the feeling that the cast is too tight, numbness and tingling in the hand or foot, burning and stinging sensations, excessive swelling in the part of the limb below the cast and inability to actively move the toes or fingers Advise your patient to seek for medical help if there are sores areas or a foul odor from the cast, cracks or breaks in the cast, or the cast feels too tight, if there is swelling that causes pain, if the patients fingers or toes are blue or cold or the cast becomes soaking wet and does not dry with a hair dryer or vacuum. Source: http://www.uptodate.com/contents/patient-information-cast-and-splint-care

Socio-economic Factors and Postnatal Depression Relationship

Socio-economic Factors and Postnatal Depression Relationship (a) Objectives of the project and any related information The aim of his project is to study the relationship of socio-economic factors with postnatal depression in Spanish mothers. This will be done both at individual and area–based level. The main hypothesis of the research is that unemployed mothers, with low education and low income have higher risk of developing postpartum depression. Besides a geographical comparison among four different areas within the Spanish cities of Barcelona, Bilbao, Madrid and Seville will be done. An area-based deprivation index will be used for testing the complementary second hypothesis of the study which is that the communities more deprived have higher prevalence of postpartum depression than the less deprived ones. (b) Work which has led up to the project Postpartum depression is one the most common disorders suffered from mothers within the first 12 months after childbirth. Several studies places its average prevalence around 10-15% (24) and needs to be considered as a public health problem that can affect, besides to the mother and to her environment, to the emotional development and well-being of the children. Postpartum depressions also needs to be differenced from the baby-blues and the puerperal psychosis, a more severe type of depression. The baby blues is mainly caused for the hormonal alterations and, although might have the same impact on the mood as a depression, the symptoms normally disappear within two weeks after giving birth without any treatment. The puerperal psychosis affects on average to a 0.1 – 0.2 % (24) of mothers and hospitalisation is usually required. The postpartum depression and can last several weeks or months and, if not treated, can lead to a chronic recurrent depression. The most common symptoms of the postpartum depression are sadness, emptiness, exhaustion, low energy, feeling incapable of taking care of the baby, guiltiness. The signs are similar to any other depression disorder, but with a special focus on the life changes and relationship with the new born. Regarding the causes of the there are many research that have studied the predictors or risk factors for developing a postpartum depression, and based on two existing literature reviews on the topic (22) (24) the main predictors of postpartum depression could be categorised as follows: Physical and biological factors: poor physical health, negative body image and bodyweight. Psychological factors: antenatal depression, previous psychiatric illness and childcare stress. Social factors: low education level, low income, unemployment and social support. This study will focus on the social factors and within them, the ones related to the socioeconomic status: education level, income and employment. They can lead to unequal rates in postpartum depression that, as socially determined, could be avoidable. In the past the relationship of socioeconomic status and depression has been underlined in many studies worldwide (10) (18) (22) but in the particular case of Spain no research that take into account these factors and their impact in postnatal depression prevalence have been found. Spain is one of the European countries that is suffering the most consequences of the global recession that begun in 2007. The economic crisis is having dramatic impact in the labour market, public sector and therefore in population lives. The socioeconomic status is related with higher psychiatric morbidity, but in an economic crisis context, because of the additional uncertainty about the future, the mental health of the population tends to get worse. There are already studies taking place in Spain that are founding increases in mental health problems since 2007, especially in families that are experiencing unemployment (17). The current unemployment rate in Spain is 23.2% raising until 24.3% in case of women versus 22.2% in men and up to 50.7% in population younger than 25 years old (14). But these rates are not equally geographically distributed. There are Spanish regions that because of their past productive framework are suffering bigger economic struggles. As said above no studies that relate postnatal depression and socioeconomic factors in Spain are known, that is why this research will test the association between socioeconomic status and postnatal depression at the individual level and then will compare with Spanish areas with unequal deprivation indexes. On top of this there are studies that encourage to use both the area deprivation index and individual socioeconomic status, as these two measures make independent contributions to the health outcome (28). Although the results of this study will not be able to be compared with past records on postpartum depression this could be a starting point for further studies of the impact of the crisis on the mothers’ mental health and about its geographical disparities. (c) Study design and methods to be used in investigating this problem and potential limitations Design A longitudinal cohort study will be conducted for this research. Because of the nature of the outcome this is the most appropriate type. The onset of the postpartum depression is within 12 months after birth, and the longer periods of evaluation will predict higher prevalence (24). A single point of collection of data would minimise therefore the results. Study population and sample Pregnant women that are 18 years old or older and who are registered in the Spanish maternity services and live in Barcelona, Bilbao, Madrid or Seville will be invited to participate in the study The exclusion criteria will be individuals with psychiatric illness in the previous year. The sample size was calculated based on equivalent measures found in existing literature regarding the socioeconomic individual exposures (income, employment status and education) (LITERATURE) and in an area-based deprivation index and their association either with postnatal depression or similar outcomes. The desired power of the sample (90%), the potential non-responders and the loss over the course of the follow up was also considered in the calculations. The area-based deprivation index that will be used in this study was created in 2001 in Spain (8) in order to identify the socioeconomic conditions of the measured areas. The information needed for feeding the index is available in the National Census Institute (INE) and could be updated with the data of 2014. This index allows to identify the more disadvantaged areas within a city. Although it was associated in its origin with rates of mortality, it was created with the aim of studying wider range of social inequalities in health in Spain. This area-based deprivation index is created from the following socioeconomic indicators: manual workers, unemployment, temporary workers, total low education, and youth low education. The geographical units for the composition of the index are the census tracts of the cities of Barcelona, Bilbao, Madrid and Seville. (2.358 in Madrid, 1.491 in Barcelona, 510 in Seville y 288 in Bilbao). The index will be divided in 4 quartiles from the more deprived to less deprived measure. In each city one census tract for each quartile will be selected. The sample will be selected through multi-stage cluster sampling. The census tract will be the primary sample unit. Then sample of individuals will be selected from a primary care centres where pregnant women living in each one of the tract are registered. Four primary centres in each city will be selected. SAMPLE SIZE   THE POPULATION BETTER DEFINED Data collection Spain has a universal health system, everyone has the right and free access to it. When a women becomes pregnant it is registered and monitored by her assigned general practitioner, gynaecologist and paediatric medical doctors, during and after her pregnancy, in the primary care centre of her neighbourhood. Every pregnant women in the centres selected will be invited to participate in the study, with the exclusion criteria of women who had any psychiatric disorder in the previous year. They will be informed about the study in their first visit to their GP and appointments for filling in the questionnaires during their next visit and during pregnancy will be planned. 3 questionnaires will be used during the 4 interviews scheduled. During pregnancy: Baseline questionnaire with socio-demographic questions, employment status and type, income, education, marital status, number of children and address of residence. Three months after delivery: Social support questionnaire and the Edinburgh Postnatal Depression Scale questionnaire Six months and twelve months after delivery: Edinburgh Postnatal Depression Scale questionnaire All the questionnaire will be self-reported. The Edinburgh Postnatal Depression Scale is a 10 items questionnaire used to screen postpartum depression. The validated Spanish version will be used (9) The social support questionnaire is the Spanish abbreviated version (6 items versus 19) of the MOS Social Support Survey (23). Statistical analysis The main outcome of the study is postpartum depression defined as a categorical variables derived from the results of the Edinburgh Postnatal Depression Scale. The cut-off point of the validated Spanish version for a positive outcome is 11. Cases will be considered when women report positive outcome the 3 times of follow-up against women who reported zero, once or twice (non cases). Main exposures are level of income, education, and employment status (socioeconomic status measures), and area-based deprivation. Other covariates selected for the baseline and social support questionnaires will be included as possible confounders or effect modifiers. The sample characteristics will be describe through univariate and bivariate statistics. Multivariable logistic regression will be used for testing the association between main exposures and outcomes adjusted for the others covariates. Initially each main exposure will be modelled individually with the outcome, only age-adjusted. Secondly each exposure it will be adjusted by other covariates, then by covariates and other socioeconomic status exposures and the area-based deprivation. Finally the model will be fully adjusted with all exposures and covariates together. The statistical software STATA will be used. Other Potential limitations As in all the longitudinal studies there is the risk of loss during the follow–up. This is already considered in the calculation of the sample size. The self-reported questionnaires could lead to the common limitations of these types of tools: response bias, the restrictive nature of the scale-based questionnaires, understanding, lack of introspective ability etc. The social support questionnaire is a reduced version because this study wants to focus in the socioeconomic risk factors of postpartum depression. It was included because social support is considered also an important predictor of postpartum depression. More extensive version could be included in future studies. Also, further analysis that include structured interviews to measure the outcome could be performed. However the positive results of this questionnaires for finding significant associations it is validated by multiple previous studies (CITATION). Study organisation The principal applicant is the main coordinator of the study, has extensive experience in social epidemiology and is specialised in socioeconomic determinants on health. It is also a lecturer in statistic in for medical science and will be responsible of the data analysis. The co-applicant is a UCL member of the social epidemiology department and a visiting lecturer of the Basque Public University (UPV) in Spain. It will be responsible of the coordination and communication with the Spanish team. The local co-applicant was a member of the research group who developed the area-based deprivation index used on this study and a professor on social epidemiology in the UPV. It will coordinate the Spanish team who will conduct the field work. The research assistants will conduct the field work and the logistics and communications with the primary care centres. One research assistant will be recruited in each city. (d) Timetable using Gantt chart or similar diagram (e) Ethical issues All participants will be informed and will need to sign a written consent prior to any analysis of the data. All the data will be anonymous and treated confidentially following the current Spanish and UK laws of Protection of Data. Ethical approval will be submitted to the UCL and the UPV. I am still a bit confused with sample calculation: For example in the paper below, that is measuring social support and PPD as a binary outcome.Which effect should I focused in? If I calculate the sample size from it, would I alsoneed to use in my study the same questionnaire they are using in this paper and same follow up time? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390689/ ANNE here is the useful info that I found in the paper (copied and pasted direct from paper) à ¢Ã¢â€š ¬Ã¢â‚¬ ¹Incidence of depression was calculated in women who were not depressed at baseline based on proportions of new cases at follow-up in that sample. 55 of the 386 without antenatal depression had depression at follow-up, indicating case incidence of 13.9%. table 1 unadjusted association between education/income and incidence of depression (ie new events). So suggests OR=0.49 (low versus high ie high > low OR=2) and even steeper for income But these are unadjusted so after adjusted the measure of effect would probably be attenuated ie smaller. If there is no better data, then you could use this, for examplelow educ vs high educsampsi0.174 0.093, p(0.9) but see if you would have power to look at low > middle education etc. For income as above using numbers from table 1 And for the sample calculation of area based deprivation and PPD, I could use papers of association between income inequality and PPD? OR What about this one? http://www.ncbi.nlm.nih.gov/pubmed/24392759 The undjusted results are: low-SES community 26.2% (104/397) had depression, compared with 14.8% (24/162) high-SES community If I do calculation in STATA sampsi 0.26 0.14, p(0.8) My sample size would be for each group N1= 190 N2= 190 But when I use my are based deprivation index I might use different percentiles to categorise lower and higher deprived areas (four at least) What would be the sample size in this case for each percentile? ANNE if you use quartiles for deprivation, then you would need to consider not just low > high, but as for education low > middle, then middle > high, and high > higher. If incidence is 26% in highest deprivation and14% in lowest, then if you think the association is linear, then you can estimate inicidence in intermediate groups e.g. 26, 22, 18, 14%. So you need to choose the sample size for these e.g. sampsi 0.26 0.22, p(0.9) etc. After all these sample size calculations, choose the largest. Then in your proposal just report that you based sample size on the sample size per group needed to find the smallest difference between SE groups. remember if your sample size calculation says 3200 per group, and you have 4 groups, then your sample size with be 32004. You will also need to include extra in the sample because there will be non-responders eg 40%. Also maybe 20% loss over the course of your follow up. For example, if number per group is 3200, and 4 groups possible, and 60% response and 20% loss during follow-up,then you will need (3200 x 4) / (0.6 x 0.2). You also asked if you need to use the same measures as the paper uses if you use if for sample size calculation. As long as you state thatyour measures are comparableit is okay. Q10 REFERENCES