The Hunters: Moonsong Chapter Twenty-Eight

â€Å"Of course Bonnie's upset,† Alaric said. â€Å"This is her first real boyfriend. But the three of you have been through a lot together. She'l come back to you, and she'l listen to you, once she gets a chance to cool down.† His voice was deep and loving, and Meredith squeezed her eyes shut and held the phone more tightly to her ear, picturing his grad-student apartment with the cozy brown couch and the milk-crate bookshelves. She had never wished so hard that she was there. â€Å"What if something happens to her, though?† Meredith said. â€Å"I can't wait around for Bonnie to get over being mad at me if she's in danger.† Alaric made a thinking noise into the phone, and Meredith could picture his forehead scrunching in that cute way it did when he was analyzing a problem from different angles. â€Å"Well,† he said at last, â€Å"Bonnie's been spending a lot of time with Zander, right? A lot of time alone? And she's been fine thus far. I think we can conclude that, even if Zander is the one behind the attacks on campus, he's not planning to hurt Bonnie.† â€Å"I think your reasoning is sort of specious there,† Meredith said, feeling oddly comforted by his words nevertheless. Alaric gave a smal huff of surprised laughter. â€Å"Don't cal my bluff,† he said. â€Å"I have a reputation for being logical.† Meredith heard the creak of Alaric's desk chair on the other end of the line and imagined him leaning back, phone tucked into his shoulder, hands behind his head. â€Å"I'm so sorry about Samantha,† he said, voice sobering. Meredith nestled farther into her bed, pressing her face against the pil ow. â€Å"I can't talk about it yet,† she said, closing her eyes. â€Å"I just have to figure out who kil ed her.† â€Å"I don't know if this is going to be useful,† Alaric said, â€Å"but I've been doing some research on the history of Dalcrest.† â€Å"Like the ghosts and weird mysteries around campus Elena's professor was talking about in class?† â€Å"Well, there's even more to the history of the col ege than he told them about,† Alaric said. Meredith could hear him shuffling papers, probably flicking through the pages of one of his research notebooks. â€Å"Dalcrest appears to be something of a paranormal hotspot. There have been incidents that sound like vampire and werewolf attacks throughout its history, and this isn't the first time there's been a string of mysterious disappearances on campus.† â€Å"Real y?† Meredith sat up. â€Å"How can the col ege stay open if people disappear al the time?† â€Å"It's not al the time,† Alaric replied. â€Å"The last major wave of disappearances was during the Second World War. There was a lot of population mobility at the time, and, although the missing students left worried friends and family behind, the police assumed that the young men who disappeared had run off to enlist and the young women to marry soldiers or to work in munitions factories. The fact that the students never turned up again seems to have been disregarded, and the cases weren't viewed as related.† â€Å"Super work on the police department's part,† Meredith said acidly. â€Å"There's a lot of weird behavior on campus, too,† Alaric said. â€Å"Sororities in the seventies practicing black magic, that kind of thing.† â€Å"Any of those sororities stil around?† Meredith asked. â€Å"Not those specific ones,† Alaric said, â€Å"but it's something to keep in mind. There might be something about the campus that makes people more likely to experiment with the supernatural.† â€Å"And what is that?† Meredith asked, flopping down on her back again. â€Å"What's your theory, Professor?† â€Å"Well, it's not my theory,† Alaric said, â€Å"but I found someone online who suggested that Dalcrest may be somewhere with a huge concentration of crossing ley lines, the same way that Fel ‘s Church is. This whole part of Virginia has a lot of supernatural power, but some parts even more than others.† Meredith frowned. Ley lines, the strong lines of Power running beneath the surface of the earth, shone like beacons to the supernatural world. â€Å"And some people theorize that, where there are ley lines, the barriers between our world and the Dark Dimensions are thinner,† Alaric continued. Wincing, Meredith remembered the creatures she, Bonnie, and Elena had faced in the Dark Dimension. If they were able to cross over, to come to Dalcrest as the kitsune had come to Fel ‘s Church, everyone was in danger. â€Å"We don't have any proof of that, though,† Alaric said reassuringly, hurrying to fil up the silence between them. â€Å"Al we know is that Dalcrest has a history of supernatural activity. We don't even know for sure if that's what we're facing now.† An image of Samantha's blank dead eyes fil ed Meredith's mind. There had been a smear of blood across her cheek below her right eye. The murder scene had been so gruesome, and Samantha had been kil ed so horrifical y. Meredith believed in her heart of hearts that Alaric's theories must be correct: there was no way Samantha had been murdered by a human being.

Prison Nursing Essay

I had been a nurse for 1 yr, and only worked in long term care. I craved a change in my career that was exciting, yet challenging; I decided to become a correctional nurse. I had no idea what was in store for me when I applied for a position with UTMB . I spoke with family and friends who thought I was crazy for wanting to work in such a hostile environment. Needless to say, I didn’t listen and followed my own instinct. When I was hired, I had not taken a tour of the facility; day one was the first time I walked into a prison. As I walked in the gate house, I was saying to myself â€Å"this isn’t so bad! I kept telling myself those same words the whole time I was taking my shoes off , letting my hair down to be searched, and getting frisked while checking for contraband. After the most violating pat down I had ever received was over, my heart began to pound. â€Å"What am I getting myself into? † Once in the infirmary I was given a brief description of job duties. By now my heart was in my throat, but I kept up the brave front . I learned that I would be working in our clinic with convicts that required inpatient medical care. My role was to provide nursing care only. A few things I had to take into consideration; they were convicts. They could be quite manipulative and they tried to test me every time I turned around. They asked questions about my personal life and they asked for favors. They would also ask me to bring in things from the â€Å"real world† or deliver items or letters. This behavior could be grounds for termination so any and every time I was asked to do any of the things I listed or anytime an inmate tried to get to personal it had to be reported. The inmate would then have to face disciplinary action. It was very hard to remember all the dos and don’ts while maintaing professionalism, as well as maintain safety and sanity. In the Texas prison system the inmates endure grueling conditions. In the winter its freezing cold, old boilers are all they have to keep warm. In the summer its smoldering hot, old noisy fans are all they have to keep cool. Being tender hearted as I am, I couldn’t help but feel sorry for them. I was raised to see the good in every body. I was also raised to believe in an eye for an eye. It was really hard to provide unbiased care when I knew I was dealing with a child molester or a rapist. I know we were trained to put all our emotions aside, but in reality my emotions would sometimes get the best of me. I only worked as a correctional nurse for a yr. I enjoyed working with other members of the medical staff as well as correctional officers. I actually enjoyed working with the inmates, providing medical care. I have had my share of inmates cursing and yelling at me and have witnessed situations I will never forget. I learned very quickly to be thick-skinned. I learned to be tough in order to do the job and survive. I still reminisce about the adrenalin rush I would get every time and emergency would arise. I’m glad I made the choice to work at the Wynne Unit it was definitely a life changing experience.

Criminal Minds Essay

Essay is â€Å"Criminal Minds† it is a Police Procedural† about a team of profilers in the FBI’s Behavioral Analysis Units (Criminal Minds 2014). The team’s job is to establish a profile of the suspect. The suspect is always a criminal who committed unusual crime. This program is chosen because it clearly displays social deviance. The suspects in this Police Programs are not ordinary criminals. They usually suffer from a mental or personality disorder that makes the incapable of remorse. The criminals were serial killer, child rapist, cult murderers and cold blooded murders. The FBI team often meets together and study the evidence in the crime scene. The evidence may include the manner of killing, the motive, the weapons use and the strategy to conceal the crime helps the FBI establish a personality profile of the suspect or criminal. The criminals in these programs are social deviant and the where labeled by the police organization as deviant based on the crimes they committed. The FBI behavioral analysis unit who work hand in hand with the police, labels the suspects as not the everyday criminal. The criminals were extremely dangerous and usually suffering from behavioral disorders or mental illness. They are not normal criminals who committed their crimes because of survival or to earn money. These criminals usually commit their crimes due to passion, for fun or for some superstitious belief. The FBI unit labels these criminals as the most deviant of all criminals; they are extremely dangerous and will continue to commit their crimes until they are caught. It is therefore necessary for the FBI unit to build a personality profile of the criminal in order to known which is the next victim and where will be the next crime. The FBI team is the one doing the labeling for the deviance. The crimes committed by the criminals and the criminals themselves could be considered as primary deviance (Siegel, 2008). The crimes are murders; homicide, robbery and rape are all primary deviance. The criminal is pursued, arrested killed or sent to jail by the FBI team. This is the penalty of the criminal. They are treated and penalized like any ordinary criminal but the FBI team labels them as extre mely dangerous criminal. This is secondary labeling. Because they are labeled as extremely dangerous, they become top priority of the organization. The FBI may sometimes employ questionable practices just to capture these extremely dangerous criminals. They may sometimes hack the email of the suspect just to know what is in his mind. Another instance of  secondary labeling is when cult members commit a crime and then when another crime is committed, they were being blamed for the crime simply because they are cult members. Some individuals in this program are not actually criminals and do not actually commit a crime. Such as in the episode where Satanist are considered suspect for the crime they did not commit. However, the FBI have encountered murders and homicide committed by cult members. Hence, when a murder was committed and style of the murder is similar to a cult, the FBI agents quickly concluded that the Satanists were involved. There are no cults in the community but there are Satanists who meet together in discos and private gatherings. The NBI team felt that the Satanists were responsible for the crime simply because they are Satanists. This is secondary deviance. According to Sociologists, secondary deviation is what causes individuals to become hardened criminals. Stigma could also be found in this episode. Satanists in the film were considered deviants even though the leader of the Satanists claimed that they were only misunderstood, He has a valid justification but because the society considered Satan as the king of Evil, his believers were considered evil and deviant. The four functions of Emile Durkheim are also portrayed in the series. In the Season three- episode 12, entitled â€Å"3rd Life.† A teenager was found murdered and her friend went missing and believed to be abducted. The task of the FBI agents was to create a profile of the killer and finds him before he kills the other teen. According to Durkheim, Deviance serves four functions. The first is Affirming Cultural Values and Norms (Thompson, 2012). Murder and abduction that takes place in the episode go against the cultural values of norms of the American society. The murder is also against moral standard of the US society. It is wrong to murder this is the moral standards. Durkheim third function of deviance is promoting social unity. The crime allowed all community members to participate in the hunt for the killer and kidnapper. Everybody is willing to give information regarding the events related to the murder. People do not approve crime. When crime rate is high they group together and pressure the government to do something about the crime. Some participate in solving crimes and cooperate with the government by standing as witness or providing information to help solve the crime. Uniting the community is the third function of deviancy. Community may also group together to stigmatize people  who are considered not following the norms. The people in the TV series agreed that Satanists are bad. Both the policemen and the FBI agents stigmatized the Satanists. The fourth function of deviancy according to Durkheim is it encourages social change. The social change in the TV series as brought about by the crimes is implied. FBI procedure are revised whenever they encounter a very difficult to find criminal. References: Criminal Minds (2014) Per. Mandy Patikin, Thomas Gibson & Lola Glaudini. USA. ABC studios Siegel, L. (2008) Criminology. Theories, Practice and Typologies. NJ: Prentice Hall. Thompson. W. 92012) Society in Focus: an Introduction to Sociology. NY Allyn and Beacon

Client Centric Aproach for Brokerage Business Essay

Client Centric Aproach for Brokerage Business - Essay Example For business such as brokerage firm, it becomes more important that they should evolve and embarrass client centric approach because by building long term relationships, the firms can achieve the necessary breadth and focus on its customers to achieve strategic superiority but also gain necessary competitive advantage over their competition. It is therefore very critical that the firms involved in business which requires different and potentially sensitive relationships with the clients, a client centric approach would be a viable and effective alternative to achieve the strategic objectives. However, such approach require a collaborative approach since engaging with the client from the initial stages of registering as a client to the process of conducting business through the brokerage firm requires a very focused strategy to develop effective relationships with the clients. This paper would attempt to understand and analyze how the client centric approach would allow a brokerage firm to gain client assets/share of wallet. The focus of this paper will be two fold. First it would discuss what the client centric approach is and secondly its application on the brokerage business will be studied. A brokerage firm acts as an intermediary between the buyer and the seller, typically in a stock market. Due to peculiar nature of the stock exchange functioning, there is a greater need for the financial intermediaries who play the role of a link between the buyers and the sellers so that the exchange against some consideration can take place. A discount broker is a person who carries out the business of buying and selling at much reduced commissions and fees etc. The purpose of the stock broker therefore is to address that segment of the market which could not otherwise afford the usual high rates of the brokerage firms which provide similar services. In doing so, firm tend to attract bulk of the small investors especially who due to lack of capital. The focus of such investors therefore always remains on reducing the transaction costs so that they can maximize their profits. Firms offering such services therefore tend to be generalized in nature as they offer services which are hardly differentiated therefore such firms need to develop their specialties based on pricing as well as non-pricing factors. Since such types of firms are offering discount services therefore they are already leading in that area however, non-pricing factors include the use of different and innovate means of attracting and maintain customers. Being client centric is one such mean through which such type of firms attempt to attract clients. In order to assess the client centric approach being adopted by discount broker firm, we must also understand as to how the discount firms perform their jobs. Discount firms do not offer advice to their clients and simply sell out whatever you have therefore this reduces their spreads and offer services which are discounted. It is also argued that the discount brokers are used by the experienced investors who can do their own research and only

Reflection Paper Essay Example | Topics and Well Written Essays - 750 words - 2

Reflection Paper - Essay Example Hence, a student can be able to achieve success in some aspects of their life while at school. For example, there are students who will excel in sports, socialization, and other different aspects of development while failing to pose excellent grades in class. In effect, qualifying such students as failures and branding them as such is not appropriate. To me, I think I have been an overall good student this far. However, the adjective ‘good’ is relative since there have been incidences whereby I think I have not done my best to be a good student. In effect, this reflection paper analyses my student life and the adjustments that I can make to turn my failures into successes while make the successes only better to help me achieve a lot in future. Assignments and school projects form the foundation of a student’s life in school. In this case, the assignments and projects ensure that a student is graded and their progress determined depending on the grades they obtaine d. In effect, a student who fails many of their assignments is branded a failure once they fail to post good grades in their examinations while those who posted impressive grades become successful. For me, I value the challenge posed by assignments and projects since they have been important in ensuring that I posted good grades. In this case, I have been able to hand in my assignments and projects on time. However, I am not happy with the approach that I was taking towards completing these assignments. In this case, I used to work on my assignments a few days, or even hours, before the submission deadline. In effect, I do not think that the level of hard work and research I was putting on these assignments helped me produce and realize my full potential. I feel that the grades were not a reflection of the best that I could have done, which effectively means that the grades are far from what I should have achieved. On the other hand, group projects have been influential since I have been able to interact with diverse people and gain self-confidence. However, we did not conduct our group’s projects in an approach that brought the best out of every member. In this case, I feel that I was not a good a student since I did not speak to my colleagues about this issue. Rather, I chose to remain silent instead of asking my group members to change the way we engaged each other since we were not achieving our full potential. Maintaining silence was not reflective of the behavior that a good student should have observed and I regret this approach. In effect, I want to ensure that I adjusted the approach that we used to conduct our group activities so that I can achieve success as a student in the United States. I realized that I relied more on fellow students than I relied on my instructors. In line with this, relying on my fellow students was beneficial since I gained insights that helped me during my studies. However, I think that I should have engaged my instru ctors more than my fellow students in order to obtain informative insights due to the experience that instructors have in comparison to students. I want to adjust this aspect in order to become a successful student in the United States. Overall, I am a good student although there are some aspects of a good student that I have to accomplish. In this regard, I realize that I have not engaged in extra-curricular activities throughout the course of my

Wal-Marts sustainability strategy Essay Example | Topics and Well Written Essays - 2750 words

Wal-Marts sustainability strategy - Essay Example From that time the company has attained massive expansion and is currently operating under different brand names. It is one of the most successful groups with operations in 27 countries, has more than 10,000 stores with different departments and employs over 2 million people. (Wal-Mart, 2012, p.3). The aim was to improve the lives of the people by saving their money while making profit through reduced expenses and improved management. They operate as supercenters, food and drug store, restaurants, general merchandise stores, warehouse clubs, small markets, discount stores human and cash and carry stores. Its strategic management has been based on five principles: resource development, reduced expenses, online shopping services, satisfied customers and social and environmental responsibility (Sullivan, 2010, p. 156).These have led to the rapid growth in revenue, customer base and workforce. Like any other large international companies, there need to develop a proper management strateg y to ensure the business fulfills its mission.This paper will critically analyses the challenges facing Walwart international and gives its recommendation on how to overcome these challenges with keen consideration of seafood supply chains. Challenges of Wal-Mart’s supply chain Employees The company employs over two million employees across the world and has been accused of violating their rights. According to Marshall (2012, p.3), their employees went on strike in Los Angeles after several months of trying to reach out to the company’s executives with success. Prior to this strike, there was also demonstration in other regions, with the employees complaining of low wages, healthy risk and poor treatment while at work. There has been case of firing of workers that are actively involved in their trade union OUR Wal-Mart (Marshall, 2012, p. 4). OUR Wal-Mart has filed several cases on unfair treatment of the workers Such as termination, warnings or reduced working hours. Most complain seem to be a strategy by the executives to reduce the cost of labor and eventually reducing the operational cost. The reduction in expenses is supposed to increase in sales and revenue. Staff reduction can hinder proper management of day to day activities in the stores as well as in factories. Each outlet has different management and this has worsened the situation, some stores lack proper safety facilities, do not give employment contract to their employees, and poor sanitation. Poor working conditions can affect the quality of their products especially food and this pose greater health risk to the consumers. Thestrikes, demonstrations and poor working conditions, not only have negative impacts on the employees but also create a negative image of the company thus affecting business. Competition Like any other company in profit making business, Wal-Mart faces stiff competitions from other large stores, small stores and international companies and sometimes has been for ces to close down their stores. This has forces them to change their mode of marketing as well as their mode of doing business. Being an international company poses greater challenges because of different ways of doing businesses in these countries and also different cultural back grounds of their customers. Sea food store in China almost closed down due to the way chines prefer to choose their sea food, they were forced to display them while uncovered and this led to high sales. According to Ellickson at el (2012. P 750) Wal-Mart has changed the pricing strategy of supermarkets to reduce completion. Its entrance in the market led to closed down of other business but this is just one sided opinion since it has also faced competition. Their low price strategy has worked well for

Medical Marijuana Essay Example | Topics and Well Written Essays - 750 words

Medical Marijuana - Essay Example No scientific study has been done to support this. Cigarette smokers are said to be heavier addicts than the marijuana users. Sufficient medical research has been carried out it has proven that marijuana can be used for various medical purposes. It is known to relieve nausea and several types of pain. On the hand, medics still believe that better alternatives still exist than using marijuana. Such medicines contain chemicals with the capability to relieve similar pains and symptoms. They therefore, know that such medicines are better compared to the â€Å"dangerous† marijuana (Haerens 2013). Marijuana under medical supervision has been proven to relieve pain and stress among the ill. Other officials still believe on the fact that smoked marijuana damages internal body organs and systems. It initiates cancer related illnesses. Little evidence supports that smoked marijuana poses risks to human health. Beliefs on the marijuana-cancer relationship are misplaced. Smoked marijuana however, damages and infects most of the respiratory organs (Gieringer& Cartel 2008). Different physicians have come up with different arguments concerning marijuana use. Although most of the civilian population believes in healing powers of marijuana, physicians partly agree on that. They support themselves on this by lack of positive consistent results on marijuana. They therefore, term it as dangerous. It is known to cause damage to the brain, hearts, immune system and the lungs. It is scientifically proven to contain cancer related causing compounds. Marijuana further compromises the ability to learn by interfering with the memory. Based on such grounds, some government officials have maintained their say that it is dangerous and illegal. Cigarettes of tobacco cause a lot of damage to the bronchial mucosa. Samples of such twenty tobacco cigarettes pose the same health threat as four cigarettes of marijuana. This appears to be quite dangerous than

For admission Essay Example | Topics and Well Written Essays - 250 words

For admission - Essay Example It was both a difficult and interesting transition in my life; on one hand was the shock of environmental and cultural change whereas on the other my quest for academic excellence. I went through a period of depression being away from home and in an environment where English is the sole language of communication but stood strong. I was not going to give up on my academic goals. I therefore developed friendships with fellow students and teachers who offered tremendous assistance with my English skills and now drastically improved. The challenges have taught me to be strong and now I am applying for my postgraduate studies. I am more confident than ever before to enjoy the postgraduate academic experience considering that I am now used to international cultures, my English language skills are impressive and have learnt a lot from interacting with people of different cultures. I will be using any opportunity both in and out of class to learn and interact so as to grow not only academically but also

Globalisation Essay Example | Topics and Well Written Essays - 2000 words - 2

Globalisation - Essay Example The Cold War was characterised by the two-block system, the East and the West, or the opposition between the United States and the Soviet Union, with their supporter countries. And when this was dissolved, with the collapse of the Berlin Wall known as the Iron Curtain, the world seemed dominated with a one-bloc system with a single marketplace. (Eriksen 2007, p. 4) Meaning and concept Globalisation refers to economic consolidation through liberalisation of policies leading to an open economy (Van Der Bly 2005, p. 875). An important characteristic is the interconnectedness of people and openness of nation states. This is enhanced by technology and the Internet, with emails and websites becoming so popular, and everyone can connect and communicate with anyone in any part of the world for as long as there is a computer and an Internet connection. Mobile technology also has become popular and impacted on business and human transactions. Technology and the Internet are referred to as â₠¬Ëœa world of signs’, ‘the age of digitisation’, or the global village where nation states have fewer roles (Bairoch 2000). Some other important aspects include internationalisation, protectionism, liberalisation, and improved competitiveness in world commerce. Mooney and Evans (2007, p. 11) indicated that the beginning of globalisation was the ‘rise of capitalism’. But the question of chronology of globalisation has never been agreed upon by authors. Our primary aim here is to define first what globalisation is and to have a full understanding of its meanings, concept and features. Globalisation encompasses many subjects or disciplines. There are scholars in various fields that can be called globalisation scholars, such as those pursuing interesting studies in culture, sociology, economics, international studies, politics, language and the arts, and much more. Globalization is covered in many subjects and it is one of the much researched fields in m an’s pursuit for knowledge (Ampuja 2012, p. 17). This is one of the main features of globalisation – its being cross-disciplinary, which allows it to borrow terms and concepts from those discipline’s own lexicon. (Mooney & Evans 2007, p. ix) Scholte (2005) asserts that globalisation is closely linked to the concept of internalisation, which means the word ‘global’ is a word that describes cross-border interactions or transactions between nation states, and globalisation pertains to an increasing international relations and interdependence of countries. Another important word that we can add to the meaning is liberalisation. This word pertains to a process where there are no restrictions or hindrances during economic transactions between countries. Economists also call it ‘international economic integration’. Liberalisation refers to removal of trade regulations and barriers, foreign-exchange laws and other related laws, and even visa re strictions (Sander cited in Scholte 2005, p. 31). Scholte (2005) adds the word ‘universalisation’ to the concept of globalisation. He theorised that when Oliver Reiser and Blodwen Davies first introduce the word ‘globalize’ in the 1940s, they meant it was about ‘universalising’ or a unity of cultures, or the global village. Thus, Scholte defined globalisation as the way of distributing objects or products and experiences or services to people in many parts of the world. Globalisation can be

The Influence of Essentialst Attitudes Portrayed in the Modern Day Sitcom on the Views and Beliefs of Modern Society Essay Example for Free

The Influence of Essentialst Attitudes Portrayed in the Modern Day Sitcom on the Views and Beliefs of Modern Society Essay The Influence of Essentialst Attitudes Portrayed in the Modern Day Sitcom on the Views and Beliefs of Modern Society. Throughout its long history, the sitcom has been commonly understood to define the cultural norms of modern society through such comedy techniques as satire and irony. Like modern society, certain characteristics of the sitcom have evolved over time, while others have remained consistent. The evolution of the sitcom coincides with the generational shift in attitudes of society towards certain beliefs and values. So, it would seem that there must be some sort of correlation between the evolution of the sitcom and that of society, as if one is the cause of the other. * * While this can be safely said about the effect of society in shaping the structure of the sitcom, whether the modern sitcom has a significant effect on the views and beliefs of society is debatable. This essay will demonstration that, although the modern version of this genre contains essentialist themes and characters, it does not promote essentialism and therefore does not negatively influence society. From the fifties to the eighties, sitcoms have adhered to a rigid structure involving a live studio audience and certain unchanging characteristics that would define the genre. They also conveyed a very apparent moral code. In the 90’s, Seinfeld’s seemingly non-existent moral code would see it labeled by some as â€Å"apolitical or nihilisticâ€Å" (Gencarella 2005,390). However, even if these aspersions were true, it would not necessarily follow that the audience would agree with these moral values and thus accept them as normal behavior. In any case, Gencarella (2005) argues that, although the four main characters do show an extent of self-interest, their moral behavior does not reflect the teachings of the show. Issues of race, gender and politics are still addressed but are presented in a different way than they were ten to forty years ago. * The ingredients of a successful sit-com consistently involve strong, sometimes iconic characters, which often represent stereotypes. Recent sitcoms have challenged and broadened the idea of traditional stereotypes. For example, Gencarella (2005,394) argues that the four main characters of Seinfeld represent four distinct political stereotypes: the individualist, the hierarchical, the egalitarian, and the fatalist. The way these political stereotypes interact with each other and their community have no doubt contributed to the comicality and thus the success of the show. * Unlike the 2005 sit-com The Office (American version), Seinfeld does not consistently display essentialist traits in its characters. It conveys essentialist themes through satirical situations involving essentialism. This is none more evident than the following example (â€Å"The Yada Yada†), which Gencarella (2005,398) also uses to describe the egalitarian nature of Kramer: * Jerry: Those people can be so touchy. * Kramer:â€Å"Those people. † Listen to yourself. * Jerry: What? * Kramer: You think that dentists are so different from me and you? * They come to this country just like everybody else in search of a dream! * Jerry: Kramer, he’s just a dentist. * Kramer:Yeah, and you’re an anti-dentite! * Jerry: I am not an anti-dentite! * Kramer:You’re a rabid anti-dentite! Oh, it starts with a few jokes and some slurs – â€Å"Hey denty! † Next thing you know you’re saying they should have their own schools! * Jerry: They do have their own schools! Jerry Seinfeld is clearly representing an essentialist point of view towards dentists. The absurdity of the situation, however, entails that this essentialist view is not being endorsed; rather it is being exposed in a ludicrous fashion. It shows the absurdity of prejudice and racism. This draws comparisons, as Detweiler (2012,730) explains, to Randy Newman’s defense of his controversial song Short People. The song criticises short people in an essentialist manner, describing them as having small voices and little beady eyes. Randy Newman explains, â€Å"that by choosing an object of prejudice so absurd, he might expose the absurdity of all prejudice†¦Ã¢â‚¬  * In the case of The Office (American version), Michael Scott is blatantly and shockingly racist, sexist and prejudice. The perception that the audience recognizes this view as essentialist, which is the basis of its humor, reinforces the idea that the text does not endorse this kind of behavior. As Detweiler (2012,730) describes, this is further broadcast by the occasional ironic facial expressions, to camera, of Michaels Scott’s colleague, Jim Halpert. Through the clever use of irony it sets an example of how not to act. * Due to the satirical and ironic nature of the sit-com, the question of whether the inclusion of stereotypes and essentialist views warrant a critique as a conclusively essentialist text depends solely on the audience’s interpretation of the text. The writer’s intention here is irrelevant.

Case Study Of Unstable Angina

Case Study Of Unstable Angina The patient in context is a 61 year old male, Mr. X, admitted to hospital in the late evening for a case of unstable angina. Presenting complaints include left-sided chest pain which was less severe than that of his previous admission and localized pain during rest. Absent symptoms are profuse sweating as well as nausea and vomiting, orthopnea and paroxysmal nocturnal dypsnoea, cough and fever. Patients past medical history includes diabetes mellitus and hypertension diagnosed 6 years ago, ischaemic heart disease (IHD) since 3 years ago, for which the last hospital admission was 11 months ago. In the previous admission for IHD, Mr. X also suffered from pneumonia and ventricular failure, his electrocardiogram (ECG) indicated right bundle branch block, his serum troponin I levels were 0.3 ng/mL (normal levels 0-0.1 ng/mL), and his creatinine levels were 5.0 mg/dL (normal for males 0.2-0.6 mg/dL). Mr. X is also afflicted with chronic kidney disease, for which his baseline creatinine dur ing his last admission was 208 ÃŽÂ ¼mol//L. Mr. X has retired from the military and is living with his wife, who monitors his medications and compliance. He used to be a chronic smoker but has stopped smoking 15 years ago. His previous medication history is as below: Drug and Form Strength Frequency Furosemide tabs 40 mg BD Omeprazole tabs 20 mg PRN Amlodipine tabs 10 mg OD Simvastatin tabs 20 mg ON Perindopril tabs 4 mg OD Table 1: Table showing past medications of Mr. X. Mr. X takes no non-prescription medications and has no known drug allergies. On examination he appears to be alert and comfortable on his nasal cannula for delivery of oxygen 3L/min. His blood pressure is 134/81 mmHg, pulse rate is 76 bpm, body temperature 37oC, SpO2 of 99%, abdomen feels soft and non-tender, and no pedal oedema was observed. A blood glucose strip test reveals that Mr. Xs glucose levels were 10.3 mmol/L. Emergency ECG shows right bundle branch block and no ischaemic changes. The tentative diagnosis was unstable angina and further tests were scheduled, including a full blood count (FBC), renal profile (RP), liver function test (LFT), troponin and creatinine (CKMB) investigations, as well as a urine full examination and microscopy (UFEME). The immediate plan was to give Mr. X subcutaneous enoxaparin 60 mg stat and twice daily thereafter, aspirin 75 mg tablets once daily, lovastatin 20 mg tablets once daily, sublingual glyceryl trinitrate when required, and to continue the 3L/min oxygen cannula. Clinical Progress Day 1 Morning Patient was well, free from chest pain, tolerating orally and suffering from no nausea or vomiting. He had minimal shortness of breath (SOB). Troponin I levels were at 0.15 ng/mL and ECG showed no acute or evolving changes. Fasting plasma glucose was at 4.8 mmol/L (within normal range). Secondary dehydration was observed using the skin pinch test, so patient was started on intravenous normal saline drip (3 x 500 mL bag per 24 hours). Patient was found to be anaemic due to pre-existing chronic renal failure. Evening Patient reported mild chest pain and SOB. His troponin I levels were 0.15 ng/mL and other vitals were normal. His creatinine levels were 423 ÃŽÂ ¼mol/L. Day 2 Patient felt comfortable and his vitals were normal. His creatinine levels decreased to 345 ÃŽÂ ¼mol/L. Day 3 Patients condition was well, no chest pain was reported but he was still experiencing some SOB in the morning, which subsided in the afternoon. Patient was put on continuous peritoneal dialysis in the late morning. Patients vitals were normal, and he was taken off enoxaparin in the evening. Day 4 Patient complained of chest pain in the morning, with minimal SOB. His vitals were normal. Subcutaneous enoxaparin 60 mg was given and the IV saline was continued. Lab Findings Urine Biochemical Analysis (Day 1) Investigation values Normal values Protein ++100 mg/dL Glucose negative negative Blood negative Leucocytes +-10 WBC/ÃŽÂ ¼L Ketone negative negative Bile negative negative Urobillinogen normal Specific gravity 1.025 1.003 1.040 pH 5.5 4.6 8.0 Nitrite negative negative Table 2: Results of urine biochemical analysis on Day 1 Lipid Panel Fasting Serum Lipid Plasma total cholesterol / mmol/L 4.5 Desirable Borderline 5.17-6.19 High risk >6.20 Plasma triglyceride / mmol/L 1.27 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 1.7-5.64 High risk >5.65 Plasma LDL-cholesterol / mmol/L 2.91 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 3.36-4.12 High risk >4.13 Plasma HDL-cholesterol / mmol/L 1.01 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable >1.03 High risk Total cholesterol / HDL-cholesterol 4.5 Desirable Borderline 3.8-5.8 High risk >5.9 Table 3: Results of lipid panel (fasting serum lipid levels). Renal Profile Electrolytes Measured levels on Day 1-1.14am Measured levels on Day 1-12.54am Measured levels on Day 2-10.47am Normal range Urea / mmol/L 22.8 22.4 21.1 2.8-7.2 Sodium / mmol/L 129 128 129 136-146 Potassium / mmol/L 5.3 4.8 4.7 3.5-5.1 Chloride / mmol/L 98 94 101 98-107 Creatinine / ÃŽÂ ¼mol/L 423 398 345 58-96 Table 4: Renal profile of Mr. X showing levels of electrolytes and creatinine. Plasma troponin I 0.15 ng/mL Liver Function Test Measured level Normal range Plasma total protein 81 g/L 66-83 g/L Plasma albumin 34 g/L 35-52 g/L Plasma globulin 47g/L 25-44 g/L A/G ratio 0.7 0.9-1.8 Plasma alkaline phosphatase 119 u/L 30-120 u/L Plasma aspartate transaminase 19 u/L Plasma alanine transaminase 43 u/L à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Plasma total bilirubin 6 ÃŽÂ ¼mol/L 5-21 ÃŽÂ ¼mol/L ESR 47mm/hour à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ 0-20 mm/hour Table 5: Results of liver function test showing protein and liver enzyme levels in plasma. Full Blood Count (FBC) (Beckman Coulter) Cell type Measured level Normal range WBC 9.9109/L 4-10109/L RBC 3.341012/L 3.8-4.81012/L Haemoglobin 95g/L 120-150g/L Haematocrit 0.273L/L 0.36-0.46L/L Mean cell volume 81.8fl. 83-101fl. Mean cell haemoglobin 28.4pg. 27-32pg MCH concentration 347g/L 315-345g/L Platelets 353109/L 150-400109/L RDW 19.4% Neutrophils 3.3 2-7 x109/L Lymphocytes 1.74 1-3 x109/L Monocytes 0.55 0.2-1.0 x109/L Eosinophils 0.21 0.02-0.5 x109/L Basophils 0.03 0.02-0.1 x109/L Table 6: Full blood count of Mr. X. Vital Stats Chart Date Time Blood Pressure/ mmHg Temperature / oC Pulse Rate/ bpm SpO2/ % Blood Glucose levels/ mmol/L Day 0 11.05 pm 140/80 37 91 100 13.9 11.30 pm 137/84 37 80 100 Day 1 8.30 am 130/80 37 70 4.8 (fasting) 3.55 pm 130/70 37 90 10.30 pm 108/64 37 81 Day 2 8.20 am 119/69 37 78 4.50 pm 130/90 37 82 9.6 9.45 pm 140/90 37 80 6.7 Day 3 8.50 am 114/77 37 72 98 6.6 Table 7: Records of vital stats of Mr. X from Day 0 3. Disease Overview Pharmacological Basis of Drug Therapy Acute coronary syndrome (ACS) is a broad term used to classify a continuum of symptoms and events stemming from acute ischaemic episodes affecting the cardiac muscle.1 This includes unstable angina, non-ST segment elevation myocardial infarction (NTEMI), and ST segment elevation infarction. It is usually characterised by chest pain which increases in its severity at rest or with physical exertion. The ischaemic events usually arise from the development of unstable atheromatous plaques,2 which explains the fact that stable angina (due to a stable coronary atheromatous plaque) is not included under this umbrella term. Rupture, ulceration or fissures of the atherosclerotic plaque often leads to formation of a thrombus, causing occlusion of coronary arteries and inadequate blood flow and, subsequently, inadequate supply of oxygen and nutrients to the cardiac muscle. This can be precipitated by acute stress factors on the sclerotic cap usually consisting of fibrous material, which is caus ed by local blood flow disturbances or vasospasms3. Unstable angina usually occurs without cardiac muscle damage while myocardial infarction (MI) may occur with or without myocardium damage. The thrombus formed in unstable angina is labile and obstruction is transient, and not a full-on occlusion as would occur in MI.4 Unstable angina occurs at rest and is almost indistinguishable from a non-ST segment elevated myocardial infarction except in the severity of cardiac muscle ischaemia. Theoretical definitions of unstable angina would include changes in usual patterns of stable angina after a stable pain-free period, or severe acute anginal pain causing almost total incapacity5, though it is difficult to define it exactly as the term is often used by medical professionals to describe a range of different conditions intermediate between stable angina and MI. The primary clinical symptoms of unstable angina are: sudden occurrence of chest pain that persists for more than 20 minutes which may be felt in other areas such as the jaw, arm, shoulder, neck or back; without cause (as opposed to stable angina which stems from physical exercise); shortness of breath, rapid pulse rate, and sometimes a rapid drop in blood pressure. Patients suffering from an ACS have a high risk of MI and possible even death; immediate hospitalization is often required1 and treatment is of a more urgent nature compared to that of stable angina. It has been suggested by the National Health Service (NHS) Hospital Episode Statistics in 1998 that 1000 out of every million per population is affected with unstable angina, or 10 acute hospital admissions per week.6 On a more recent note, NHS has reported in 2009 that angina affects between 10-15% of women and 10-20% of men aged 65 and above in England.7 Due to the close relationship between unstable angina and coronary events, it is worth noting that the highest averaged rates of cardiovascular events were observed in Glasgow and Belfast (UK), North Karelia and Kuopio (Finland), Newcastle (Australia), and Warsaw (Poland).8 Diagnosis of an unstable angina episode, or any ACS in that matter, is based on several aspects9. Physical symptoms include anginal pain at rest that lasts for 20 minutes or more; new onset angina severely limiting ability of physical activity; or changes in existing angina intensity, frequency or length of attack. One or more of these symptoms are an urgent indication that the patient is suffering from an ACS attack. Upon admission to hospital, ECG and blood tests should be performed to confirm the type of ACS in order to initiate treatment. In unstable angina, the ST segment is not elevated and levels of cardiac enzymes are normal (especially troponin T and I). If the onset of symptoms is unclear as to indicate ACS, a measurement of serum troponin concentration should be carried out 12 hours from presentation to establish the diagnosis.10 Treatment of unstable angina and NSTEMI are similar in terms of pharmacological management; indeed they are at presentation indistinguishable exc ept in terms of the severity and extent of cardiac muscle ischaemia, in which the ischaemia is less severe in unstable angina and less troponin T and I are released into the bloodstream. Antiplatelet agents. Aspirin and clopidogrel are the immediate emergency drugs used in the ambulance, both being antiplatelet drugs. Aspirin is an irreversible inhibitor of arachidonate cyclooxygenase (COX) enzyme, in which covalent acetylation of the serine moiety in a hydrophobic channel in the enzyme11 reduces synthesis of thromboxane A2 in platelets and prostaglandins in the endothelium. This prevents platelet aggregation and further enlargement of the thrombus formed in the coronary artery. Clopidogrel is an inhibitor of the ADP-dependent activation of the GPIIb/IIIa receptor and prevents the formation of fibrinogen bridges between glycoprotein IIb/IIIa receptors on the surfaces of platelets11, subsequently preventing platelet activation. Glycoprotein IIB/IIIA receptor antagonists, eg, abxicimab, have the advantage of inhibiting all pathways in the platelet activation process by inhibiting the glycoprotein IIB/IIIA receptor. Anticoagulants. Unfractionated heparin is an activator of antithrombin III, which inhibits the action of thrombin and serine proteases. The heparin also binds to thrombin; the combined effect of this and the heparin-antithrombin complex formed inhibits thrombin, which decreases the conversion of fibrinogen to fibrin and reduces platelet aggregation. In contrast, low molecular weight heparins (LMWH) have molecular sizes that are too small to bind to thrombin but still bind to antithrombin III, which inactivates all serine proteases including Factors XIIa, IXa, and Xa11, preventing the coagulation process. Direct thrombin inhibitors such as hirudin and bivalirudin inhibit thrombin reversibly. These agents can bind to free and bound thrombin, thus have the ability to prevent and dissolve preformed clots. Synthetic pentasaccharides (fondaparinux) is a selective indirect inhibitor of Factor Xa. It binds to antithrombin III reversibly, catalyzing the inactivation of Factor Xa12 and inhibit ing the coagulation cascade. Beta blockers. All beta blockers bind to beta-adrenoceptors, competitively antagonizing the action of catecholamines. These drugs block the beta-1 adrenoceptors at the heart, achieving a decreased heart rate and force of cardiac contractions, as well as lowering blood pressure. Atenolol is relatively specific for cardiac beta-1 adrenoceptors and exerts fewer side effects associated with beta-2 adrenoceptor blockade, for example bronchospasm in asthmatics. Nitrates. Organic nitrates mimic the actions of endogenous nitric oxide to relax vascular smooth muscle by increasing the synthesis of cGMP, leading to the dephosphorylation of myosin light chains.11 Vasodilatation of coronary arteries causes increased coronary blood flow and coupled with its effects of decreasing arterial pressure and also cardiac output, the myocardial oxygen consumption is largely reduced. Statins. Also termed HMG-CoA reductase inhibitors, these medicines inhibit the rate-limiting enzyme in the synthesis of cholesterol, in which this enzyme converts HMG-CoA to mevalonic acid. ACE inhibitors are diuretics acting on the rennin-angiotensin system which inhibit the angiotensin-converting enzyme (ACE) and block the production of angiotensin II from angiotensin I. This reduces vascular resistance, increases tissue perfusion, and reduces cardiac afterload. Angiotensin II receptor inhibitors also act on the same system as the ACE inhibitors, except that they block the angiotensin II receptors directly instead of inhibiting their formation. The outcome is the same as above. Evidence for Treatment of the Condition Antiplatelet Agents The SIGN guidelines advocate that aspirin and clopidogrel be given to patients with ECG ischaemic changes or increased levels of cardiac markers; and aspirin is advocated for all patients suffering from ACS. A meta-analysis of 287 randomised trials proves the protective effect of aspirin on patients with unstable angina, halving the rate of cardiovascular events, including death, non-fatal MI and strokes, or also termed the first primary outcome; while in those with an acute MI, it reduces the rate of coronary events by almost a third13. Long-term use of aspirin for these patients was also shown to be a beneficial antiplatelet therapy. According to the same study, reduction of serious vascular events by clopidogrel was 10% compared to aspirin. The combined use of clopidogrel and aspirin as compared with a placebo and aspirin showed significantly higher success rates in reducing occurrences of first primary outcomes (9.3% compared to 11.4%, P On the flipside, although short term studies have shown that antiplatelet medications are effective for patients with renal failure in the prevention of serious vascular events13, the risks of bleeding is increased by renal disease15, posing a possible contraindication for antiplatelets to Mr. X. A clinical study found that treatment for NSTEMI ACS in patients with chronic renal disease (mild to moderate stages) was less aggressive than those with normal renal function, despite the risk that these patients with renal disease would experience greater adverse outcomes from insufficient treatment for ACS compared to the other patient group16. However the available information on adverse effects of antiplatelets on patients with varying degrees of renal disease is limited and it would appear that this would result in the reluctance of medical professionals in using this class of drugs for patients with chronic renal disease as well as ACS. It can be inferred that Mr. X would gain the maximum benefits if his medications were changed to aspirin 300 mg and clopidogrel 300 mg stat and aspirin 75 mg and clopidogrel 75 mg thereafter, in which the patient should be closely monitored for signs of bleeding. Heparins LMWHs A 2003 review of 7 studies involving 11,092 patients with non-ST elevation ACS found that low molecular weight heparins (LMWH) were more effective than unfractionated heparins in reducing MI events, requirement for revascularization procedures, and thrombocytopenia17. No difference in the mortality, recurrent angina, major and minor bleeds were observed in the two types of drugs. A meta-analysis of 12 randomised trials with 17,157 patients involved found that patients who have had a non-ST elevation ACS who were put on aspirin experienced no significant difference in benefits in efficacy (preventing MI or death) or safety (major and minor bleeding complications) when they were put on unfractionated heparin or LMWH17, implicating no difference in the thrombolytic effect in both classes of drugs. These results are partially similar to those of the first review. Another meta-analysis of 2 phase-3 trials comparing enoxaparin and unfractionated heparin, on the other hand, showed a signifi cant (20%) difference in reducing death or severe cardiac ischaemic events18. From an economic point of view, authors of yet another meta-analysis on the subject stated that the cost of LMWH is 3-5 times higher than unfractionated heparin19. From these data it can be concluded that LMWHs does indeed have additional positive treatment outcomes compared to unfractionated heparins22; it does not show significantly decreased side effects (bleeding). Enoxaparin has, though, an increased bleeding effect on patients with renal disease as reported by an investigation of 106 patients, in which total bleeding complications occurred in 22% of normal patients and 51% of patients with impaired renal function (p It is still the drug of choice for patients present with non-ST elevated ACS, and this is applicable to Mr. X with unstable angina. Beta-Blockers Beta-blockers were not prescribed for Mr. X. The SIGN guidelines states that beta-blockers should be the drug of choice for first line treatment of anginal pain in patients with non-ST elevated ACS. A meta-analysis of 5 trials consisting of 4700 patients in all showed a 13% reduction in anginal pain with the use of beta blockers (initially IV then oral for a week) in patients with non-ST elevated, MI-characterised chest pain23. It was stated in the clinical progress Mr. X had chest pain on Day 1 and 4, thus the addition of a beta blocker to his medications would be useful in alleviating his pain. Despite the popular belief that beta-blockers are contraindicated in patients with diabetes mellitus, it is possible to treat these patients using beta-blockers as long as good glycaemic control is achieved and the patient is monitored regularly24. This would further support its use in Mr. X; furthermore, several studies have shown that diabetic patients derive a significant benefit from the use of beta-blockers after an MI, in which diabetic patients had a significantly lower mortality 1 year post-discharge25, total mortality after 3 years, and deaths from cardiac events26. A multicentre randomized trial, the HINT trial, on patients with unstable angina found that metoprolol, a relatively cardioselective beta blocker, reduced occurrence of myocardial ischaemia or progress to MI within 48 hours, indicating that metoprolol has a short term beneficial effect on patients not already taking beta blockers prior to the unstable angina episode27. It has been suggested that beta-blockers be the first line treatment for unstable angina and if patients remain unstable, a calcium channel blocker should be added28. Statins The beneficial effects of statins in reducing mortality and cardiovascular events have been proven by a meta-analysis of large, randomized controlled trials (n=90,056) where coronary artery disease was present or absent29. The positive results were also proven spanning a large range of serum cholesterol levels. Investigations comparing the use of intensive versus moderate doses of statins in the early stages and post-ACS showed positive results: a meta-analysis of 4 large trials (n=27,548) shows a 16% reduction in cardiovascular deaths or MI, as well as a 16% reduction in cardiovascular deaths or coronary events30. This view is shared by another meta-analysis of the same subject of 13 randomised controlled trials which found a decrease in mortality and coronary events after 4 months of treatment31. These data support the use of statins by Mr. X. Nitrates Nitrates have been widely used in relieving pain from unstable angina, despite its lack of clinical evidence in supporting its role in improving survival and reducing the rate of MI and cardiovascular events32. ISIS-433 and GISSI-334 reports no significant difference of the use of glyceryl trinitrate post-MI in reducing the overall mortality; however this may be explained by the fact that more than 50% of patients in the controlled group are also on other forms of nitrate therapy, such as intravenous glyceryl trinitrate. Despite this, nitrates will still be of use for reducing the pain in post-MI patients and those with unstable angina. The BNF advises against the use of nitrates in patients with serious anaemia (Hb Glycaemic control Mr. Xs plasma glucose levels were elevated on the day he was admitted to hospital (13.9 mmol/L). Diabetes mellitus has been proven to be a strong independent risk marker for coronary heart disease: patients with poorly controlled diabetes at hospital admission have a worse outlook on prognosis and future development of cardiovascular events35. The DIGAMI investigation reports that the use of intensive insulin therapy increased long-term prognosis (P=0.011) of patients presenting with hyperglycemia (>11mmol/L) at admission compared with those on standard antidiabetic therapy36. These data support the use of insulin to control the blood glucose levels of Mr. X which were highly increased upon admission. This is also supported by the SIGN guidelines which advocate immediate control of blood glucose is carried out for MI patients with glucose levels of more than 11.0 mmol/L for at least 24 hours. ACE Inhibitors The SIGN guidelines recommend that patients with unstable angina should be given ACE inhibitors as long-term therapy. In patients at high risk of cardiovascular events, ACE inhibitors (ramipril was investigated in a report37) have been proven to reduce overall mortality, MI, and stroke, particularly in patients with diabetes mellitus. Perindopril was found to reduce cardiovascular risk (relative risk reduction =20%, P=0.0003) in a population with stable coronary heart disease in absence of heart failure38 in a double-blinded, randomized multicentre trial involving 13,655 patients. A meta-analysis of the 2 above trials and a third one (PEACE) showed a reduction in overall mortality, cardiovascular death, non-fatal myocardial infarction, stroke, heart failure, and coronary artery bypass surgery by ACE inhibitors39. This demonstrates the benefits of ACE inhibitors in patients with atherosclerosis: as patients who had an ACS event would have a higher rate of cardiovascular events, the po sitive outcomes of ACE inhibitors can perhaps be extrapolated to this population in order to decrease coronary events and improve prognosis. However, the BNF advises caution and close clinical monitoring if ACE inhibitors are to be used in patients with hyponatremia ( Oxygen therapy On admission, Mr. Xs SpO2 was 99% and remained high throughout his stay in the hospital. The use of oxygen therapy is significantly beneficial only in hypoxic patients (with SpO2 Anaemia and Unstable Angina Anaemia can disturb the balance between myocardial oxygen supply and demand: a decrease in the number of red blood cells can lead to a reduction in the supply of oxygen to the myocardium. Thus correction of the causative factor would be sensible in the treatment of unstable angina for the patient in context. Mr. X was given a combination of ferrous fumarate, vitamin B complex, and folic acid for treatment of his anaemia. From the data in Table 6, it can be seen that Mr. X has low haemoglobin concentrations (95 g/L) and a low mean cell volume (81.8 fl.). To confirm that Mr. X is indeed suffering from iron-deficiency anaemia (as suggested by his treatment medication), three parameters must be established namely the plasma iron, the plasma ferritin, and total iron binding capacity. However, as very few conditions can cause abnormalities in the mean cell volume, and a decreased value is due to iron-deficiency anaemia or thalassemia42, it is safe to assume that Mr. Xs anaemic condition is due to an insufficiency of iron. Iron supplements are given to correct the iron status of the patient, in which the ferrous form given orally is found to be cheap, safe and effective in the majority of patients with iron-deficiency anaemia2. Vitamin B complex and folic acid are only indicated in patients with the respective deficiencies2; there is little evidence that they would be of any significant benefit in patients with iron-deficiency anaemia. Summary Based on the evidence given, Mr. Xs aspirin dose should be changed to 300 mg stat and 75 mg thereafter, and clopidogrel should be added into his medication profile in the same doses. These changes ensure that Mr. X is obtaining sufficient antiplatelet effects from his medications to prevent another attack of unstable angina or even a myocardial infarction. Present drugs that were given for his condition that are suitable and supported by evidences include enoxaparin, lovastatin, insulin, and GTN: these can be safely continued without problems. A beta-blocker (metoprolol tablets) may be given additionally in doses of 50-100 mg as evidences described above have shown that they can be safely used in diabetic patients contrary to popular belief; an ACE inhibitor (perindopril as previously used by Mr. X) may be initiated coupled with regular electrolyte

The Lynmouth Floods

The Lynmouth Floods Case Study: Lynmouth Lynmouth is a village in Devon, England, on the north edge of Exmoor. The village is on the converging point of the West Lyn and East Lyn rivers, in a gorge 700 feet (210 m) below Lynton, to which it is connected by the Lynton and Lynmouth Cliff Railway. The two villages are governed at local level by Lynton and Lynmouth Town Council. Lynmouth is rural area with not much corporate activity going on. It is in the coastal part of the United Kingdom Island, which makes it a large tourist attraction spot. People usually come to Lynmouth for Tourism and the activities they do are mainly horseback riding, fishing and boat rides. Flood in 1952 On the 15th and 16th of August 1952, a storm of tropical started over in south-west England, precipitating 229 millimetres (9.0 in) of rain within 24 hours on a coastal area, Exmoor. It is thought that a cold front started a thunderstorm, and the storm worsened. An immediate surface run-off occurred and it caused a flash flood. Large amounts of floodwaters moved down the northern part, converging upon the village of Lynmouth; in particular, in the upper West Lyn valley, a dam was formed by fallen trees. This caused potential energy to form and after a while the water broke through the dam sending a huge wave of water and fragments down that river. Overnight, over 100 buildings were destroyed or seriously damaged along with 28 of the 31 bridges, and 38 cars were washed out to sea. In total, 34 people died, with a further 420 made homeless. Overall the rainstorm lasted about fourteen hours and 300 million gallons of rain precipitated. Cause of the Flood The small but steep sided drainage basin in which Lynmouth was situated increased the risk of flooding in the area. The steep sides encouraged greater surface runoff and combined with the small drainage basin size meant any water could reach the river fairly quickly. This was made worse by the high drainage density of the area due to the impermeable rocks of the area around Exmoor which formed the source of the river; again increasing the amount of surface runoff following rainfall. Prior to August 15th 1952 Lynmouth had received above average rainfall for 12 out of the first 14 days of the month meaning the soils were already saturated and the river levels high. On August 15th a heavy thunderstorm resulted in 200mm falling in 14 hours, one of the three heaviest rainfalls recorded in the UK. This heavy rain combined with the saturated ground and rapid surface runoff resulted in a huge volume of water flowing down the river. As Lynmouth is situated at the confluence of the East and We st Lyn rivers the volume of water was increased further at this point and the was far beyond the capacity of the river channel causing the river to burst its banks. This resulted in devastating floods as the West Lyn which had been diverted during the construction of parts of Lynmouth retook its natural course, flowing straight through the village. Prevention Following the Lynmouth flood disaster, flood management plans were put in place to try and ensure such a disaster could not happen again by managing any excess rain water so that the River could handle it in the in the future. A number of flood management strategies were put in place: The mouth of the East Lyn was widened to increase capacity and allow water to quickly pass into the Bristol Channel The West Lyn was straightened to increase channel efficiency straightening the channel reduces friction and increases velocity, enabling water to travel through the channel as quickly as possible making it more efficient in coping with flood waters; The West Lyn was not redirected, instead being allowed to follow its natural course Floodplain zoning was used to identify areas around the river most at risk from flooding. Building restrictions were then put in place with areas close to the river which are most prone to flooding being left as open spaces such as car parks. Bridges were made wider and taller to allow flood water to tr avel quickly beneath them and to reduce the likelihood of debris becoming trapped and acting like a dam as had happened in 1952;Embankments were built by the river to increase channel capacity and reduce the likelihood of flooding; More trees were planted upstream in the source area to try and reduce initial surface runoff through interception and the soaking up of water. Tree roots also help to improve infiltration by opening up the soil and slowing down the rate at which water reaches the ground;

Stopping By Woods On A Snowy Evening :: essays research papers

The circumstances surrounding the composition of Robert Frost's poem "Stopping by Woods on a Snowy Evening" explain his use of "The darkest evening of the year" (L.8) which is closely related it to the greater theme of perseverance in the face of hardship. Frost wrote this poem, in November(Frost Chronology) 1923; on the same late night he finished his book New Hampshire (Jackson sec. 1). Being "a little excited from getting over-tired"(qtd. in Jackson sec. 3), he decided to venture out into the wilderness, probably to calm down. Frost hitched his horse to a sleigh and left on his journey to eventually find the "Woods" in this poem. Being in an "autointoxicated"(qtd. in Jackson sec. 3) state, Frost was mesmerized by the scene of the woods beside the frozen lake. He eventually broke out of his trance, possibly with the aid of his horse, by thoughts of prior commitments. The former statement is shown in the text by: "He gives his harness bells a shake To ask if there is some mistake"(L.L. 9-10) and the latter by: "But I have promises to keep And miles to go before I sleep"(L.L. 13-14). According to Frost, upon his return home, "Stopping by Woods on a Snowy Evening" "was wri tten in a few minutes without any strain"(qtd. in Jackson sec. 1). Therefore, Frost wrote this poem about himself and his journey. Literally, "The darkest evening of the year"(L.8), refers to the winter equinox on December 21st. But, if thought of symbolically, this line could be the culmination of difficult work, by the author, to finish his book New Hampshire. Furthermore the equinox aspect of "The darkest evening of the year"(L.13) symbolizes the transition, from the writing of a new book to its realization. Therefore, the meaning "The darkest evening of the year"(L.8) is dual even if the poem was not written in December 21st. In and of itself, the poem is an extended metaphor for perseverance. The reader only realizes this after having finished reading the poem because the information about the narrator's prior commitments and fatigue is provided at the end. In retrospect, the first stanza can be analyzed as the narrator's difficult journey. The middle and last parts of the text, like the woods, can be seen as the temptation, as is evident in the lines "The woods are lovely dark and deep"(L. 13). But the narrator overcomes his temptation shown by: "But I have promises to keep, And miles to go before I sleep†¦"(L.

Gaelic League :: Essays Papers

Gaelic League What are the Irish known for? Most people would automatically think of some trivial fact about something like the potato famine, others the stereotypical views of the Irish drinking habits, and undoubtedly good old Irish American pubs would definitely come to mind. Although these are definitely interesting parts of the Irish history there are many other aspects to this unique heritage that truly capture the spirit of the Irish tradition. The Gaelic League was started with the founding of the Gaelic Athletic Association. This group founded in 1884 in attempts to promote and maintain Irish sports, helped to spawn the idea of Irish nationalism which eventually personified itself into organizations such as the Gaelic League. The Gaelic League was founded in 1893 by Douglas Hyde and Ed MacNeil to spread the Irish language (Hachey and McCaffery 14). Formed in Barnesmore where language classes were held in the national school; the support of both Catholics and Protestants made it poss ible to branch off to other areas (O’Connor 37). After the devastation of the potato famine and the implications of the home rule; both the Gaelic League and its predecessor the Gaelic Athletic Association had the common goal of bringing forth Irish nationalism in a country that desperately needed national pride. This movement for national pride had some success, but not before the failure that preceded it. There are a few reasons that this move, for national pride, produced failure one was the reputation of the Irish and another was the pressure of politics put on the different associations. The Irish language was considered to be a peasant’s language (O’Connor 87). Because of this the people of country that were poor and not educated in the language did not think it was worth spending money to learn. Tthe people in the country that had the money to learn the language normally did not want to learn the language for the mere fact it was considered to be a peasants language. Another reason for some of the failure that this movement attained is due to the political pressure created because of the nature of the movement itself. The two founders of the Gaelic League Hyde and McNeil never wanted the movement to become political (Gavin 56). However, this was inevitable. The mo vement caused a split in the people, those who were educated in the language and those who were not educated in the language (Hopkins 129).

Fineprint Company Case

Case Overview FinePrint Company (FPC) owner and manager John Johnson is weighing a proposal from a local Virginia businessman by the name of Ernest Bradley and his small business â€Å"SmallPrint Shop† (SPS). FPC employs one sales representative and one printing-press operator, but it also relies on temporary labor to help with the fluctuations in volume. At current it is running at full capacity: 150,000 brochures a month. SPS is known for its basic printing services; however it is capable of more elaborate work.Recently it lost its largest client and is now sitting with idle capacity on its specialty press, which it bought mainly to serve their orders. It is hoping to do some elaborate work cheap for â€Å"FinePrint Company. † Because SPS would like to simply keep the press running, Bradley proposed a deal with FPC to print a maximum of 30,000 brochures at $8 per 100 brochures. John Johnson felt that SmallPrint was a good company that did dependable quality work. The proposal sounded like a good deal to him but he was unsure of the price comparisons.Issues The Fineprint Company faced two major internal issues. First is the fact that it is operating its production facility at near capacity. This leaves little room for new jobs and threatens to increase the fixed cost associated with the capacity. Second, FPC is relying heavily on temporary labor to meet volume changes in production. With the use of temporary workers comes the burden of fluctuating labor costs through wage changes and constant training. FPC also has external issues of SmallPrint affecting it in a positive way.When SPS lost its largest customer, it opened up opportunity for FinePrint to use its idle capacity. SPS’s limited exposure as an elaborate printing house and its willingness to work for cheap allows FPC the upper hand in negotiations on price of possible venture. Relationship Between Issues FPC’s consistent operation at near capacity increases its need to use t emporary labor. SmallPrint lost of a major customer and its lack of reputation as an elaborate print house caused it to have idle capacity.That idle capacity increased its need to make a discounted outsource deal with FinePrint. Relationships to Aim of the Company FinePrint Company’s use of temporary labor and consistent operation near capacity along with SmallPrint Shop’s idle capacity and willingness to deal cheap, has FPC considering an outsourcing deal with SPS to help free up production capacity and reduce need for temporary labor. Resulting in a possible reduction of manufacturing cost for FinePrint and ultimately a higher profit. Problem StatementWhile operating at near capacity and relying on temporary labor to meet the changing demand, FinePrint must pay close attention to cost and capability to expand. A proposal from a SmallPrint gives an opportunity to lower production costs and free up capacity for new orders, through outsourcing. Owner, John Johnson must review the offer carefully to decide if he will save or spend more outsourcing his current work to his rival, Ernest Bradley. Objectives John Johnson objective is to find a way to maintain or lower cost associated with production and free up manufacturing capacity.In conjunction with this he would like to maintain or increase his profits. He does this by considering the changes in cost of outsourcing 30,000 units of current production. Alternatives We found that Fineprint had four alternatives when deciding on this offer. Johnsons’ first option is to keep the situation as is. He would decline SmallPrint Shop’s offer to outsource 30,000 brochures per month for $8/100 brochures. Second, is to accept the deal offered by Ernest Bradley and lose $600 per month.Doing so to help out during troubled times. Third, Johnson can negotiate the price to be $6/100 brochures rather than $8/100 brochures in an effort to help out but still break-even. Lastly, they can buy out SmallPrint and use its capacity and workforce to cut cost on labor and open up to new jobs. Action Plan Since FinePrint Company is looking to keep its manufacturing costs low, it is in their best interest to decline the offer and adhere to their current production of 150,000 units 100% in-house.We made our decision based on the relevant cost involved, which includes direct material, direct labor and manufacturing overhead. We ignored the fixed costs, totaled at $12,000 a month, because they will not reduce with a partial outsource order. Currently, FPC’s total variable cost are $10,500 for 150,000 units, $7 per 100 brochures and only $6 being relevant cost. The $1 difference is attributed to variable sales cost, which FPC would incur because they would still need to sell 150,000 units. If it accepts the offer, FPC would be producing only 120,000 units for only $8,700 in variable costs.Although outsourcing results in savings of $1800, it is outweighed by the additional purchasing costs of $2400 for the 30,000 units at $8 per 100 brochures from Bradley. Choosing to accept the offer would result in a reduction to current profits by $600. The total costs of maintaining the current production level is $600 cheaper than outsourcing 20% of production volume. It costs FPC $22,500 to produce 150,000 units and $23,100 to produce 120,000 units while outsourcing 30,000 units. There is no reason to spend more purchasing product than it will cost to produce it in-house.Therefore, FPC should stick to full production of its orders. Potential Problems Johnson refusing to help them completely could result in broken relationship between Johnson and Bradley. In the future, it is possible that Johnson can end up in a similar situation as Bradley and the industry could remember him as the one who had denied help. FinePrint also has to deal with the fact it is still operating at near capacity. If it has customers come in with an order that exceeds capacity they may end up spending more or losing business.

Gaps of Service Quality

Measuring Perceived Service Quality Using s e rv q ua l: A Case Study of the Croatian Hotel Industry ? s u z ana m ar k ovi c Faculty of Tourism and Hospitality Management Opatija, Croatia s an j a r as p o r Polytechnic of Rijeka, Croatia The purpose of the study is to examine customers’ perceptions of service quality in the Croatian hotel industry. The aim is to assess the perceived service quality of hotel attributes and to determine the factor structure of service quality perception. A modi? d s e rv q ua l scale was used to assess service quality perceptions from the perspective of domestic and international tourists. Data were collected in 15 hotels in the Opatija Riviera (Croatia), using a self-administered questionnaire. Descriptive statistical analysis, exploratory factor analysis and reliability analysis were conducted. The study results indicate the rather high expectations of hotel guests regarding service quality. ‘Reliability,’ ‘empathy and com petence of staff,’ ‘accessibility’ and ‘tangibles’ are the key factors that best explained customers’ expectations of hotel service quality.The results of the quantitative assessment of perceived service quality may provide some insights on how customers rate the service quality of a particular hotel. Thus, the ? ndings can be used as a guide for hotel managers to improve the crucial quality attributes and enhance service quality and business performance. Key words: service quality, servqual, factor analysis, reliability analysis, hotel industry Introduction In the highly competitive hotel industry, service becomes one of the most important elements for gaining a sustainable competitive advantage in the marketplace.Consequently, the efforts of service managers and academic researchers are directed towards understanding how customers perceive the quality of service. Customers are likely to view services as a variety of attributes that may, in d ifferent ways, contribute to their purchase intentions and perceptions of service quality. Although researchers (Gronroos 1984; Parasuraman, Berry and Zeithaml 1985, Parasuraman, Zeithaml and Berry 1988; Zeithaml, Parasuraman and Berry 1990) have focused m anag e m e n t 5 ( 3 ) : 195–209 195 ?Suzana Markovic and Sanja Raspor on different aspects of service quality, they all agree that the emphasis should be on customers. The most common de? nition of the concept is attitude, which results from a comparison of customers’ expectations with perceptions of performance (Parasuraman, Berry and Zeithaml 1985, Parasuraman, Zeithaml and Berry 1988). What is more, customers perceive service quality as a multidimensional concept. The speci? c nature of services makes it dif? cult to provide, measure and maintain their quality.However, Parasuraman Berry and Zeithaml and Parasuraman, Zeithaml and Berry (1985, 1988) presented the s e rvq ual scale, which became the most popular ins trument for measuring service quality. The model has been applied in various service industries, including tourism and hospitality. In most of the researches the instrument was modi? ed to suit the features of a speci? c service. The study has several objectives. The ? rst objective is to determine the level of perceived service quality in Croatian hotels.The second aim is to establish the number of dimensions of perceived service quality in the hospitality industry, using the modi? ed s e rvq ual model. Finally, the third objective is to test the reliability of the modi? ed s e rvq ual model. Conceptual Background p e r c e i ve d s e rvic e q ual i t y The service quality construct is mostly conceptualized in the context of service marketing literature (Lee, Lee and Yoo 2000). Therefore, it deals with the concept of perceived service quality. According to Zeithaml, Parasuraman and Berry (1990), perceived service quality is the extent to which a ? m successfully serves the purpose of customers. Customers determine the perceived or cognitive value of service based on their experience with the service delivered. Ghobadian, Speller and Jones (1994) stated that customers’ expectations, service delivery process and service outcome have an impact on perceived service quality. Yoo and Park (2007) found that employees, as an integral part of the service process, are a critical element in enhancing perceived service quality. Furthermore, Edvardsson (2005) pointed out that service quality perceptions are formed during the production, delivery and consumption process.The author concluded that customers’ favorable and unfavorable experience, as well as their positive and negative emotions may have an important impact on 196 m anag e m e n t  · vo lu m e 5 Measuring Perceived Service Quality Using servq ual perceived service quality. Similarly, O’Neill and Palmer (2003) have reported that customers’ perceptions of service quality may, to a la rge extent, be in? uenced by the degree of their prior experience with a particular service. In the hospitality industry, several studies have examined hotel attributes that guests may ? d important when evaluating the performed service quality. Literature review suggests that cleanliness (Atkinson 1988; Knutson 1988; Gundersen, Heide and Olsson 1996), security and safety (Atkinson, 1988; Knutson, 1988; Gundersen et al. 1996), employees’ empathy and competence (Atkinson 1988; Knutson 1988; Barsky and Labagh 1992; Gundersen, Heide ? and Olsson 1996; Choi and Chu 2001; Markovic 2004), convenient location (Knutson 1988; Barsky and Labagh 1992), value for money (Atkinson 1988; Gundersen, Heide and Olsson 1996; Choi and Chu ? 001) and physical facilities (Choi and Chu 2001; Markovic 2004) are attributes that hotel guests perceive as being important. It should be noted that according to some authors, perceived service quality has been accepted as an antecedent of customer satisfact ion (Churchill and Suprenant 1982; Oliver 1997). What is more, Rowley (1998) argued that perceived service quality is an attitude related to, but not the same, as satisfaction. It is evident that the relationship between these two concepts is complex and that they have a causal ordering. e rvi c e q ual i t y m e as u r e m e n t One of the main research instruments for measuring quality in service industries is the s e rvq ual model, developed by Parasuraman Berry and Zeithaml and Parasuraman, Zeithaml, and Berry (1985; 1988). The model contains 22 items for assessing customer perceptions and expectations regarding the quality of service. A level of agreement or disagreement with a given item is rated on a sevenpoint Likert-type scale. The level of service quality is represented by the gap between perceived and expected service. The s e rvq ual model is based on ? e service quality dimensions, namely tangibles (physical facilities, equipment and personnel appearance), reliability ( ability to perform the promised service dependably and accurately), responsiveness (willingness to help customers and provide prompt service), assurance (knowledge and courtesy of employees and their ability to gain trust and con? dence) and empathy (providing individualized attention to the customers). During the last few years a variety of service quality studies have been conducted (Ladhari 2008). Among others, service quality was n u m b e r 3  · fal l 2 0 1 0 97 ? Suzana Markovic and Sanja Raspor measured in: accounting and audit ? rms (Ismail 2006), health spas ? (Snoj and Mumel 2002; Markovic, Horvat and Raspor 2004), higher ? ? education (Russel 2005; Markovic 2006), hotels (Markovic 2003, 2004; Juwaheer 2004; Wang, Wang and Zhao 2007; Raspor 2009), insurance (Tsoukatos, Marwa and Rand 2004), public-transport (Sanchez Perez 2007), restaurants (Andaleeb and Conway 2006; Namkung and Jang 2008), travel agencies (Martinez Caro and Martinez Garcia 2008), and web-sites (Parasura man, Zethaml and Malhotra 2005; Nusair and Kandampully 2008).Despite its wide usage, the model has been criticized by a number of academics (Carman 1990; Babakus and Boller 1992; Teas 1994). Criticism was directed at the conceptual and operational base of the model, mostly its validity, reliability, operationalization of expectations, and dimensional structure. However, there is general agreement that s e rvq ual items are reliable predictors of overall service quality (Khan 2003). As a result of these criticisms, alternative measures of service quality for speci? c service settings were developed.In the tourism and hospitality industry, Knutson et al. (1991) developed l o d g s e rv, a model utilized to measure service quality in the lodging industry. The model is based on ? ve original s r evq ual dimensions and contains 26 items. Getty and Thompson (1994) introduced another speci? c model for hotel settings, called l o d g q ua l, as did Wong Ooi Mei, Dean and White (1999) who de veloped a h o l s e rv model. The l o d ge q ual model identi? ed three dimensions, namely tangibles, reliability and contact. On the other hand, the h o l s e rv model includes 27 items, grouped in ? e original s e rv q ua l dimensions. Furthermore, d i n e s e rv is a model used for measuring restaurant service quality (Stevens, Knutson and Patton 1995). It contains 29 items and ? ve s e rv q ua l dimensions. O’Neill et al. (2000) developed the d i ve p e r f model for assessing perceptions of diving services. The model consists of ? ve servqual dimensions and 27 items. e c o s e rv was introduced by Khan (2003). It was utilized to measure service quality expectations in eco-tourism, using 30 items and ? ve s e rvq ual dimensions. All of these models represent modi? ations of the s e rvq ual instrument, aiming to improve its original methodology. However, Cronin and Taylor (1992) argued that performance is the measure that best explains customers’ perceptions of serv ice quality, so expectations should not be included in the service quality measurement instrument. They developed a performance-only scale called s e rvp e r f and tested it in four industries. Results indicated 198 m anag e m e n t  · vo lu m e 5 Measuring Perceived Service Quality Using servq ual that the s e rvp e r f model explains more of the variation in service quality than s e rvq ual; it had an excellent ? in all four industries and it contains only half the number of items that must be measured. These results were interpreted as additional support for the superiority of the servperf approach to the measurement of service quality. Several authors used the performance-only approach to assess service quality in tourism and hospitality settings. Travelers’ perceptions of hotel attributes were measured in Hong Kong’s hotels (Choi and Chu 2001), hotels of Mauritius (Juwaheer 2004) and Malaysian hotels (Poon and Lock-Teng Low 2005).The question of whether service quality should be measured as the difference between customers’ perceptions and expectations, or whether some alternative approach is more appropriate remains part of an extensive debate in service quality literature. Methodology Hotel guests’ perceptions were measured with a self-administered questionnaire. The questionnaire was developed on the basis of a literature review and adopted to suit the speci? c features of a hotel setting (Parasuraman, Zeithaml and Berry 1988; Zeithaml et al. 1990; ? Snoj and Ogorelc 1998; Pizam and Ellis 1999; Markovic 2003). As a foundation or questionnaire development, the s e rvq ual model was used. The original items were slightly modi? ed to suit the hospitality setting. For example, instead of ‘x y z Company has modernlooking equipment,’ the statement was modi? ed to the ‘Hotel has modern-looking equipment. ’ The original item ‘Guests feel safe in their transactions with employees’ was replaced by the item ‘Guests feel safe and secure in their stay. ’ The reason for this change is the confusing meaning of the word ‘transactions’ and the fact that safety and security are regarded as an important factor in a hotel stay. Moreover, in order to measure attributes speci? to the hotel environment, the following items were added: ‘parking area’ (Pizam and Ellis 1999), ‘appropriate location,’ ‘available and clear information,’ ‘variety of facilities’ (Snoj and Ogorelc 1998), ‘clean and tidy hotel,’ ‘feeling safe and secure,’ ‘ease of ? nding a way around the hotel’ ? and ‘typical service quality for hotel category’ (Markovic, 2003). All the statements in the questionnaire were positively worded. Finally, the modi? cation resulted in the deletion of one original s e rvq ual item and the inclusion of eight new items, leaving a total of 29 hotel attributes . These attributes represented seven dimensions: ? e original servqual dimensions (tangibles, reliability, responsiveness, as- n u m b e r 3  · fal l 2 0 1 0 199 ? Suzana Markovic and Sanja Raspor surance, empathy) and two new dimensions, named as accessibility and output quality. The questionnaire consisted of two parts. The ? rst part measured guests’ perceptions of hotel attributes using a modi? ed s e rv q ua l model. Service quality perceptions were measured on a seven-point Likert-type scale ranging from 1 ‘strongly disagree’ to 7 ‘strongly agree. ’ The second part was designed to capture respondents’ demographic and traveling characteristics, hich included country of residence, age, gender, purpose of visit, duration of staying at a hotel, level of education, and hotel category. The target population of the survey was guests staying in hotels on the Opatija Riviera (Croatia) during the summer of 2007. Questionnaires were distributed i n 15 (2-, 3- and 4-star) hotels, after hotel managers agreed to participate in the study. Reception desk employees were asked to administer the questionnaires to guests during their hotel stay, and to collect them after completion. In each hotel questionnaires were randomly distributed to the guests.Of 265 returned questionnaires, 12 were not included in the analysis because of incompleteness. Thus, data analysis is based on a sample of 253 valid questionnaires. The response rate was 26 per cent. Descriptive statistical analysis was used to describe respondents’ demographic characteristics and to evaluate service quality perceptions of hotel guests. An exploratory factor analysis was performed on the 29 perception attributes included in the questionnaire in order to determine underlying dimensions of hotel service quality perceptions. Principal component analysis with varimax rotation was conducted.Items with eigenvalues equal to or greater than 1, factor loadings above 0. 4, and factors which contain at least three items were retained (Hair et al. 2006). Furthermore, a reliability analysis was performed to test the reliability of the scale and inner consistency of extracted factors. For this purpose, Cronbach’s alpha coef? cients were calculated. Results In order to achieve the study’s goals, descriptive analysis, factor analysis, and reliability analysis were performed. The results are presented as follows. First, respondents’ demographic and traveling characteristics are provided.Next, the results of descriptive analysis of guests’ perceptions are presented. Third, the results of factor and reliability analyses are interpreted. The statistical analysis was conducted on 253 valid questionnaires. The demographic and traveling characteristics of the respondents 200 m anag e m e n t  · vo lu m e 5 Measuring Perceived Service Quality Using servq ual tab le 1 Demographic pro? le of the respondents Items Percentage Gender Items Percentage Age Male 51. 8 16–25 3. 6 Female 48. 2 26–35 15. 4 Purpose of visit Business Visit friends, relatives Vacation Others 36–45 26. 1 . 1 46–55 19. 4 4. 3 56–65 25. 7 86. 2 0. 4 Level of education Primary school 66 and above 9. 9 Country of residence Austria Croatia 16. 6 Secondary school 29. 2 Italy 20. 9 Higher education 24. 1 Germany 14. 6 University and above 36. 4 Others 36. 8 Others 3. 6 11. 1 6. 7 Duration of staying at a hotel Hotel category 4-star 53. 3 1–3 days 19. 0 3-star 33. 3 4–7 days 49. 8 2-star 13. 4 8–15 days 28. 1 are presented in table 1. The sample included domestic (16. 6 per cent) and international tourists (83. 4 per cent). There were slightly more males (51. 8 per cent) than females (48. per cent), and most of the respondents (55 per cent) were older than 46 years. More than 60 per cent of hotel guests in the sample had a university or college education. About 86 per cent of the respondents indi cated that the main purpose of their visit was vacation. Most of them stayed at a 4-star hotel, for between four and seven days. The results of the descriptive statistical analysis of guests’ perceptions in the hotel industry are shown in table 2. The range of service quality perceptions items was from 1 (very low perceptions) to 7 (very high perceptions). The mean scores of guests’ perceptions ranged from 4. 7 to 6. 34. The lowest perception item was ‘offering a variety of facilities,’ which indicates that hotels do not provide enough suitable facilities that could enhance hotel quality. On the other hand, hotel guests’ highest perceptions were regarding the ‘ease of ? nding a way around the hotel,’ Furthermore, guests highly assessed the following hotel attributes: ‘feeling safe and secure,’ ‘willingness for helping guests’ and ‘courteous hotel staff. ’ These indicate that a hotel’s staff has one of the crucial roles in n u m b e r 3  · fal l 2 0 1 0 201 ? Suzana Markovic and Sanja Raspor tab le 2Average scores of service quality perceptions in hotel settings Attributes Mean St. dev. v1 Modern-looking equipment 5. 31 1. 48 v2 Visually appealing physical facilities 5. 53 1. 23 v3 Neat hotel staff 6. 13 0. 90 v4 Visually appealing materials (pamphlets, web-sites) 5. 53 1. 23 v5 Clean and tidy hotel 6. 06 1. 05 v6 Appropriate location 6. 19 1. 00 v7 Parking area 4. 96 1. 87 v8 Performing service in the promised time 5. 98 0. 93 v9 Interest in solving guests’ problems 6. 09 1. 00 v10 Performing services right the ? rst time 5. 99 0. 89 v11 Service without delays 6. 02 0. 84 v12 Error-free service 5. 81 . 98 v13 Knowing the exact time when service will be performed 6. 00 0. 90 v14 Hotel staff provides prompt service 5. 98 0. 91 v15 Willingness to help guests 6. 25 0. 80 v16 Hotel staff has time to answer guests’ questions 6. 13 0. 94 v17 Hotel staff instil ls con? dence 6. 14 0. 92 v18 Courteous hotel staff 6. 25 0. 82 v19 Hotel staff has knowledge to answer questions 5. 99 0. 90 v20 Feeling safe and secure 6. 29 0. 81 v21 Providing individual attention 5. 81 1. 03 v22 Convenient opening hours 5. 94 1. 01 v23 Hotel staff provides personal attention 5. 86 0. 98 v24 Guests’ best interests at heart 6. 02 0. 87 25 Understanding guests’ speci? c needs 5. 86 1. 01 v26 Ease of ? nding one’s way around the hotel 6. 34 0. 85 v27 Available and clear information in the hotel 6. 17 0. 89 v28 Offering a variety of facilities 4. 77 1. 66 v29 Typical service quality for hotel category 6. 03 1. 09 Overall mean for 29 attributes 5. 92 performing high service quality. The overall mean score for service quality perceptions items was 5. 92. This score indicates rather high perceptions of hotel guests regarding service quality. The exploratory factor analysis extracted ? ve factors, which accounted for 65. 1 per cent of variance in th e data. Since the ? th factor contained only two items, it could not be considered as a factor and is not interpreted. The results are presented in table 3. Most of the factor loadings were greater than 0. 60, implying a rea- 202 m anag e m e n t  · vo lu m e 5 Measuring Perceived Service Quality Using servq ual Factor analysis and reliability analysis results of hotel guests’ perceptions (n = 253) Items (n = 29) Factors f1 f2 f3 f4 f5 Communalities v9 0. 751 0. 688 v12 0. 732 0. 703 v13 0. 671 0. 595 v11 0. 658 0. 675 v10 0. 648 0. 615 v14 0. 623 0. 664 v22 0. 623 0. 557 v8 0. 586 0. 584 v3 0. 505 0. 614 v25 0. 731 0. 793 v16 0. 725 0. 748 v23 . 723 0. 776 v21 0. 713 0. 711 v19 0. 688 0. 616 v17 0. 632 0. 688 v27 0. 622 0. 683 v6 0. 693 0. 580 v26 0. 686 0. 625 v20 0. 618 0. 679 v18 0. 554 0. 685 v5 0. 549 0. 509 v24 0. 537 0. 632 v29 0. 529 0. 447 v15 0. 482 0. 598 v2 0. 784 0. 778 v1 0. 748 0. 723 v4 0. 501 v28 % of Variance Cronbach alpha Number of items 0. 684 0. 675 0 . 669 2. 577 1. 514 18. 879 14. 774 8. 887 5. 222 65. 104 0. 869 0. 785 — 0. 953 8 3 2 v7 Eigenvalue 0. 562 0. 771 5. 551 4. 953 4. 284 19. 142 17. 079 0. 916 0. 917 9 7 sonably high correlation between extracted factors and their individual items. The communalities of 29 items ranged from 0. 47 to 0. 793 indicating that a large amount of variance has been extracted by the factor solution. Only one item (‘typical service quality for hotel category’) was below the suggested value of 0. 50 (Hair et al. , 2006). n u m b e r 3  · fal l 2 0 1 0 203 ? Suzana Markovic and Sanja Raspor The four remaining factors are labeled as follows: f 1 – ‘reliability’ (solving guests’ problems and performing error-free service at promised time), f2 – ‘empathy and competence of staff’ (staff knowledge and ability to provide individual attention), f 3 – ‘accessibility’ (appropriate location of the hotel and ease of co mmunication and ? ding the way around the hotel) and f 4 – ‘tangibles’ (appearance of the facilities, equipment and communication materials). The ? rst factor contains most of the items and explains most of the variance. Thus, hotel service reliability is an important determinant of perceived service quality. The results of the reliability analysis showed that Cronbach’s alpha coef? cients of the extracted factors ranged from 0. 785 to 0. 917. That is well above the minimum value of 0. 60, which is considered acceptable as an indication of scale reliability (Hair et al. 2006). Thus, these values suggest good internal consistency of the factors.Finally, Cronbach’s alpha value for the overall perception scale is 0. 953 and indicates its high reliability. Discussion and Conclusion Perceptions of hotel service quality are the degree to which hotel guests ? nd various hotel attributes important in enhancing their satisfaction with the hotel stay. In the present study, it was revealed that the main dimensions of perceived service quality in hotels are ‘reliability,’ ‘empathy and competence of staff,’ ‘accessibility,’ and ‘tangibles. ’ Two of these are similar to the s e rvq ual model, while others overlap with the original s e rvq ual dimensions.However, the studies conducted in the hotel sector identi? ed different outcomes with regard to the number and interpretation of dimensions guests use to assess perceived hotel service quality. Akan (1995) reported a seven-dimension structure, labeled as ‘courtesy and competence of the personnel,’ ‘communications and transactions,’ ‘tangibles,’ ‘knowing and understanding the customer,’ ‘accuracy and speed of service,’ ‘solutions to problems’ and ‘accuracy of hotel reservations. ’ Wong Ooi Mei et al. (1999) identi? ed ‘employees,’ ‘t angibles’ and ‘reliability’ as key dimensions of service quality in the hospitality industry.Moreover, Choi and Chu (2001) reported the following seven dimensions: ‘staff service quality,’ ‘room qualities,’ ‘general amenities,’ ‘business services,’ ‘value,’ ‘security’ and ? ‘i d d facilities,’ Markovic (2003) identi? ed a three-dimension solution, interpreted as ‘empathy and assurance of hotel staff,’ ‘reliability,’ and ‘physical quality. ’ This implies that the number and de? nition of the dimensions depend on the measurement context. 204 m anag e m e n t  · vo lu m e 5 Measuring Perceived Service Quality Using servq ual Furthermore, the ? ndings of this study reveal that among the four dimensions, reliability’ has emerged as the most important predictor of perceived service quality. In the hospitality industry, this dimensio n refers to solving guests’ problems, performing error-free service at the promised time, providing prompt service, convenient opening hours of hotel facilities. This ? nding is similar to Knutson et al. (1991) and Juwaheer’s (2004) research conducted in hotel settings. The indicators of factor and reliability analyses are also consistent with similar studies conducted in the hospitality industry. The proposed factor structure of the present study, as well as in the studies ? onducted by Choi and Chu (2001) and Markovic (2003) have explained the rather high percentage of variance in original data – 65. 1 per cent, 67. 2 per cent and 73. 9 per cent, respectively. The Cronbach alpha values are 0. 95 (this study), 0. 94 (Choi and Chu 2001) and 0. 92 ? (Markovic 2003) and indicate high reliability of the instruments. It can be concluded that the modi? ed version of the s e rv q ua l model is suitable for use by hotel managers in gaining easily interpretable and reli able data on hotel guests’ attitudes regarding perceived service quality.The results of this study suggest that solving guests’ problems, performing error-free service, employees’ attitude, appropriate location, and the appearance of the facilities are the key attributes for a hotel’s success on the Opatija Riviera. Thus, the ? ndings can be used as a guide for hotel managers to improve crucial quality attributes and enhance service quality and business performance. There are several limitations that need to be acknowledged. The data were collected in a small although important tourist destination in Croatia. The questionnaires were distributed during the summer months.Thus, the results’ interpretation should be limited to this group of hotel guests. It is possible that guests staying in hotels out of the main tourist season might have different perceptions of the service quality. Also, the measurement of hotel guests’ perceptions was limite d to 29 hotel attributes. Even though these attributes were included in other studies as well, there could be other relevant hotel attributes that are likely to in? uence hotel guests’ perceptions. In order to be able to generalize the ? ndings, it is suggested that similar studies be conducted in other Croatian tourist destinations as well.Moreover, this study was focused only on hotels. Future research should test whether the factor structure proposed in this study is valid in other types of accommodation in the region (e. g. camps, private accommodation, hostels). Additionally, future research could also assess hotel staffs’ perceptions of service per- n u m b e r 3  · fal l 2 0 1 0 205 ? 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