Pico Paper

Are kidney patients who received a radical nephrectomy at a higher risk of impaired renal function and cardiac related death compared to those who received a partial nephrectomy? Kiara Wilson Nursing 3163 Dr. Linda Upchurch November 12, 2012 Background Are kidney patients who received a partial nephrectomy at a lower risk of impaired renal function and cardiac related death compared to those who received a radical nephrectomy? When a patient is diagnosed with kidney damage, a surgical nephrectomy is often performed. Kidney damage may be caused by blocked blood vessels, kidney stones, masses, infection, and/or kidney cancer.With this procedure the kidney damage may be treated and also prevent further damage. A partial nephrectomy is a surgical procedure to remove a portion of the kidney. Partial nephrectomies are normally done laparoscopically with hand assistance or with robot assistance. A radical nephrectomy involves removing the kidney and the adrenal glands. A radical nephrectomy may be done laparoscopically or by open abdominal surgery. My patient was diagnosed with damage of the left kidney. Blood tests were performed and the patient was found to have a toxic WBC granulation. This toxic granulation led infection, inflammation and sepsis.An abdominal and pelvic CT scan found a 7. 8 x 5. 6 x 6. 2 cm, solid, enhancing left lower pole renal mass and parasitic vessels in the infected area. A hand assisted partial laparoscopic nephrectomy was performed. They removed the lower portion of her left kidney. The kidney was to be tested for malignancy. The concern with my patient is that she has a past medical history of hypertension, anemia, and deep vein thrombosis. She is at an increased risk of further cardiac and renal complications. I believe these factors influenced the doctors’ decision to perform a partial nephrectomy instead of taking the radical approach.To find research on this kidney condition, I accessed the Galileo database. I searched for infor mation on ways to treat renal masses and kidney cancer. I found multiple articles about laparoscopic and radical (open) nephrectomies. I found many articles that discussed the differences between the two and the affects they have on patients who receive them. I found an interesting study called â€Å"Partial Nephrectomy Is Associated with Improved Overall Survival Compared to Radical Nephrectomy in Patients with Unanticipated Benign Renal Tumours. I found it interesting because it was relevant to the health issues that were being addressed with my patient. There millions kidney patients who undergo these procedures each year. I wanted to discover which procedure provided the best outcome for my patient and others with similar kidney problems. Purpose According to this study, â€Å"a partial nephrectomy has been associated with improved overall survival in patients with localized renal masses compared to those who received a radical nephrectomy† (Weight, 2010).The purpose of this study is to test the overall survival rate of patients who had unanticipated renal masses. Another objective of this study is to also study the effect of these procedures on cardiac specific survival rates and other causes of death related to decreased kidney function. Hypothesis The hypothesis for this study are that the use of partial nephrectomies would be first line of treatment compared to radical nephrectomies in that partial nephrectomies provide better protection of renal function. Decreased renal function will lead to a low survival rate.Patients who undergo radical nephrectomies will have higher rate of cardiac related deaths Design A seven year, nonrandomized study was conducted using 499 participants. Of these 499 particiapants, 111 patients had received a radical nephrectomy while 388 patients received a partial nephrectomy. The choice of which surgery to do was left of the surgeon and the patient’s preferences. They took into consideration the mass size, th e appearance, the patient’s current health, life expectancy and the comfort of the surgeon in making their decisions.The patient’s comorbidities were assessed using the Charlson-Romano Comorbidity Index. Each patient’s vital signs were acquired using the Social Security Death Index. Anyone without a Social Security Number was excluded. The cause of death information from the patients’ medical records was reviewed. From there the participants were further categorized by the condition that caused the death. Cardiac deaths ranged from death related to ischemic heart disease, CHF, ischemic stroke, myocardial infarction, ischemic stroke, and peripheral vascular disease.Renal deaths were broken down into death related to renal failure, renal insufficiency, or nephritic syndrome. All other possible causes of death were group together. Perioperative, postoperative data and renal function tests were collected before and after the procedures. Preoperative data was used to create the propensity model that was utilized in a multivariate model of survival. They measured the overall survival rate of the participants and cardiac specific survival rates. Findings Radical nephrectomies are greatly associated with an increased risk of death from any cause.Patients with unanticipated benign tumors that were treated with RN were more likely to die from any related health problem than those treated with PN. Participants who received a radical nephrectomy were more likely to be older, with high comorbidity scores, and larger tumors. Those with smaller masses and tumors were more likely to have a partial nephrectomy. Radical nephrectomies are associated with an increased risk of death by 2 folds from any cause. The risk of cardiovascular death was substantially higher in those with decreasing post-operative renal function.Decreased kidney function was related to an increase in cardiovascular death and death from any other cause in overall majority patient s. Sixteen participants died of cardiac related deaths. Renal preservation was increased in the group that had the partial nephrectomy with majority of the patients having an eGFR above 60 %. Radical nephrectomy participants only had an eGFR of 30 % or lower. The higher eGFR is associated with an increase chance of survival in PN patients. Discussion Previous studies indicate that postoperative impaired renal function plays a role in the overall survival of patients with renal masses.The data concluded that no matter which surgery was performed there would be a decrease in kidney function. However, those patients who received a PN had a remarkable lower decrease in renal function. It can be stated that patients have decreased function are at an increased risk of cardiac related death and death by other causes. For many of those who don’t die from cardiac related death it can be concluded that other conditions that cause death are worsened by renal insufficiency. This study wa s relevant to the PICO question I asked.This study answered my question and provided the information necessary to make it a valid question. I believe the limitations to this study are that the researchers did not randomize their study. They picked which participants they thought would influence their study. The strengths of this article are that is discusses the importance of preserving renal function when performing a nephrectomy. It also provides evidence that patients should be educated on the risks of death and further complications associated with their procedures. It could allow for better planning and managing of the care for these patients.Implications As a nurse it would be my responsibility to knowledgeable about procedures such as these and how they will affect my patient. It would be my job to educate the patients on what to expect from this surgery and what it means for their health. I could also use this information to better assess patients before and after these proc edures. This research provides material that could be used to better treat and prevent life threatening conditions that could arise after surgery. References Landman, D. (2006). Open Partial Nephrectomy.Retrieved November 9, 2012, from Kidney Cancer Institute: www. kidneycancerinstitute. com/open-partial-nephrec. html Landman, D. (2006). Open Radical Nephrectomy. Retrieved November 9, 2012, from Kidney Cancer Institute: www. kidneycancerinstitute. com/open-radical-nephrec. html Weight, C. J. , & Leiser, G. (2010, April 29). Partial Nephrectomy Is Associated with Improved Overall Survival. EUROPEAN UROLOGY, 58, 293-298. Evaluation (to be completed by instructor)| Possible Points| Actual Points| Introduction of clinical problemComments:| 20| | Purpose/Aim of the study/articleComments:| 10| |Theoretical framework of the study/articleComments:| n/a| | Hypotheses/QuestionsComments:| 5| | DesignComments:| 5| | FindingsComments:| 10| | DiscussionComments:| 25| | ImplicationsComments:| 20| | ReferencesComments:| 5| | Grade| 100/100| /100| PICO Paper Grading Rubric (submit, along with PICO OAT form, with your paper) Student Name: _Kiara Wilson______________Date: November 12, 2012_____________ Are kidney patients who received a radical nephrectomy at a higher risk of impaired renal function and cardiac related death compared to those who received a partial nephrectomy?

Innocent Bystander

Innocent Bystander In the novel â€Å"The Tortilla Curtain†, by T. C Boyle, it tells a story about two completely different families; one family who is quite wealthy and the other who had illegally crossed the border and is barely making ends meet. In the story, a young lady by the name of America is taken to California by her husband, only to be victimized. Although she may not be the only victim in the book, she has been through a great ordeal of pain and suffering. America is a victim of immigration, racism, the American dream, and bad luck.America has left Mexico, with her husband Candido, to start a better life for not only themselves, but there unborn child as well. Immigration and racism has been a big issue for them throughout the story, even more so with America. Within the first few days upon arrival they both find themselves cornered by a couple of boys. These boys find whatever belongings both America and Candido had and when they realize there is a female present they say â€Å"fucking beaners, rip it up, man. Destroy it† (Boyle 62).Migrating to California illegally was difficult because in a situation like this, there could have been nothing done to stop them. All America wanted was to find work to help support her family. The struggle bore on from â€Å"dawn till noon and she didn't get work† (Boyle 57). America has risked it all mad no matter how hard she tries she cannot seem to find work. America had left everything behind in search of this American dream she had played over and over in her head. She had been told, by her husband Candido, she was going to live a wonderful life and he had promised her nothing but the best.America didn't need the finer things in life, all she desired was â€Å"a house, a yard, maybe a TV and a car too† (Boyle 29). She didn't need too much to satisfy her, but being that America and Candido started from the bottom, it was more than what he had to offer. As they walk further into the lan d which they call their home America can't help but gaze â€Å"out on the grounded constellation on the valley floor, grid upon grid of lights and every one house, an apartment†¦ everyone the promise if a life that would never again be this hard† (Boyle 206).America is again dreaming about the life she hopes to live in California and can only hope for the best outcome unto which she plans to bring a baby into place she knows so little about. She hopes that this is the America had gone through so much from the beginning of the novel. Candido had â€Å"taken America from her father so they could have a better life†¦ -and now he couldn't out food in her mouth† (Boyle 26). She had left the family she had ever known to risk it all to start a new life, and only to go day by day wondering how long she will have to go until her next meal.She had been victimized of racism and immigration from the first few days upon arrival and then she had to suffer statvation? It ca me down to where America told Candido she could not live like that. America had finally found a job, working for Jose Navidad, cleaning statues that he had imported. Just when things were starting to turn around, she is violated and raped by the man who had hired her. She tries to put the past behind her and think positive for her unborn child. After the baby is born America realizes she must have caught something from being raped because her baby cannot see.Candido was left with a â€Å"violated wife and a blind baby† (Boyle 353), and at the end Americas first born child is taken away by the current of the water. From the beginning things are not looking too good for America. She had been hurt emotionally and physically with hardly any sign of their life getting better. She had given in to so many promises, none of which were ever kept. The impact that immigration, racism, the American dream, and back luck, had left America with nothing. She was just an innocent bystander tr ying to better her life.

UP level accounting Essay Example | Topics and Well Written Essays - 750 words

UP level accounting - Essay Example When a semi-variable cost is treated as a variable cost for the purpose of variance analysis, the charge of overhead is exceeded. This is because semi-variable costs do not vary with each unit of activity, but change depending upon the level of activity achieved.Therefore, by granting the status of variable costs to semi variable costs, the overheads are hiked and thus profitability is reduced. Similarly, fixed costs remain fixed over a period of time, irrespective of the levels of activity. By assigning the status of fixed costs to semi-variable costs, during times of lowered levels of activity, there is a high overhead charge which significantly erodes profitability.The result of treating a step-fixed costs, for the purpose of variance analysis, as a variable one would be that, if the costs need to be calculated on the shortest time frame, there may not be material variations, but if taken on the long time, the impact of the step fixed costs would not be realized, or in other words , profits may be over stated. For example, the costs of running a single machine for several months would be different from running several machines for a single month. (Blocher et al, 2008) Thus by assigning the nature of variable to a step fixed cost would overstate profits over a period of time.When an operation entails both fixed and variable costs, and if all costs are taken as variable, it would wrongly inflate profits and underestimate costs. The element of fixed costs is generic to all cost centers, and very conspicuous in the cases of Health Care Providers, since investments in hospital machinery, equipments and infrastructure are quite substantial. (Blocher et al, 2008). In case of high level of activities, by not assigning the rightful fixed costs, profits become inflated; however, if all overheads are accounted for as fixed, during lowered levels of activities, costs become higher than booked and this could be disastrous, especially for smaller companies with low revenue generations. Question 2 (i) The key drivers for profitability in an organization would be the correct assessment and implementation of cost factors- fixed, variable, semi-variable and step-fixed costs since any mis-match could lead to derailed planning, execution and incorrect decision-making. What is even more important is the correct booking of the overheads, since overheads not booked at all, or wrongly booked could lead to a host of critical problems later. The top management takes strategic decisions based on the cost data provided and it is therefore, it is essential that it be factually correct. (ii) The two variances depicted in Exhibit 3 consider the recovery of fixed overheads when the actual procedures performed, instead of the standard 50,000 procedures, was actually only 49,000 procedures. Fixed costs were considered at $50, 00,000 for the predetermined standard 50,000 procedures. But the actual procedures billed were only 49,000 and therefore $ 100 X 1000 - $ 100,000 was unrealized. (Blocher et al, 2008). (iii) Regarding Exhibit 4, the mismatch occurred because the aspect of fixed cost overheads was not correctly judged. The mismatch occurred because of the 460 examinations made, only 310 were billed, leading to 150 examinations carried out but not billed and the profits have been inflated by (460 - 310) X $ 20 = $ 3000. This is the reason why the profits are overstated. (Blocher et al, 2008). Question 3 (i) Traditional standard costing is a system by which predetermined value / efficiency standards are assigned for each element of cost. The actual performance is then matched against their Standard costs, and the variances, positive or negative are determined. This is an invaluable management tool since there is a complete breakup of cost components and determinants, and for each item of costs, it is possible to know the standard, the actual and the resultant variances. Hence adverse variances could be effectively monitored by

Low carbohydrates diets lead to weight loss transformation, but leave Essay

Low carbohydrates diets lead to weight loss transformation, but leave lasting harms of mental illness and depression - Essay Example The most prominent and important consequence of a low carbohydrate diet are psychological problems such as depression. â€Å"Consumption of diets low in carbohydrate tends to precipitate depression, since the production of brain chemicals serotonin and tryptophan that promote the feeling of well being, is triggered by carbohydrate rich foods† (Sathyanarayana et al, 2008) Previously, most people in order to shed the extra pounds engaged in low fat diets where intake of fatty, oily and fattening food products were not consumes however low fat diet programs have been today replaced by the low carbohydrate diet program. This happened primarily because low fat diet program approaches that â€Å"decrease fat mass also result in undesirable loss of lean body mass† (Volek et al, 2010) since after the depletion of fats in the body the stored muscle proteins are targeted for energy extraction. Thus a diet program where the carbohydrate is restricted means that the lean body mass of a person would be preserved since right after energy extraction from stored carbohydrates the body targets the stored fats and not muscle proteins. In order to lose weight fast low carbohydrate diets are very much in vogue since they yield the results much faster and much more efficiently than other diet plans that are designed and followed. Today low carbohydrate diet is al so done as a treatment for several problems such as obesity, CVD etc. In an average person’s life the highest intake through food is mostly that of carbohydrates. An average person consumes carbohydrate in form of staple foods such as bread, rice, pasta etc. However when a person undergoes a low carbohydrate diet he/she is prohibited from consuming such easy digestible carbohydrate food products and is given a much more protein enriched and fat enriched diet such as meat, cheese, poultry etc. Improvement of body

What was the role of Ptolemy I under Alexander the Great How important Essay

What was the role of Ptolemy I under Alexander the Great How important was Ptolemy to Alexander - Essay Example When Philip was murdered by a faction of aristocrats in 336 B.C.E., Ptolemy went back to the court and backed up Alexander’s rights as heir to the throne (Yardley 1984, 64) As a result, according to Bingen and Bagnal (2007), Alexander employed Ptolemy as his custodian, protector, and friend. Ptolemy escorted Alexander on his battles in 336 B.C.E. in the Danube, and in Corinth and Thebes. Ptolemy strongly supported the fledgling king in his military campaigns (Bingen & Bagnal 2007). Ptolemy persuaded and helped Alexander’s conquest of Asia Minor, Syria, and Persia. These campaigns were carried out to liberate the Greeks from Darius III’s Persian Empire (p. 16). Ptolemy supported Alexander’s nonviolent invasion of Egypt and the building of the Alexandria city, and perhaps escorted Alexander to Zeus’s temple in Siwa. Ptolemy immediately saw the huge importance of Egypt, and a wholehearted concern for the country thrived within him. Ptolemy afterwards escorted the young king to northern Mesopotamia for the ultimate clash with Darius’s armed forces in 331 B.C.E. (Green 1990, 131). Ptolemy played a major role in the crusades of Alexander in India and Afghanistan. When the great king passed away Ptolemy seized control over a large portion of all the territories that Alexander had invaded, becoming overseer of Egypt. Ptolemy’s major objective all over his almost four decades in power was to erect a strong reign, the Ptolemaic dynasty (Green 1990, 291). This dynasty reigned throughout Egypt for three centuries and was the leader of all the empires which were indebted to the invasions of Alexander the Great. Ptolemy buil t his main city at Alexandria where he also constructed a museum and began bringing together written works for a grand library, which eventually became the hub for scientific study and the world’s greatest compilation of Roman and Greek papyri (Ellis 1994,

Jamaica Kincaid Essay Example | Topics and Well Written Essays - 1000 words

Jamaica Kincaid - Essay Example Antigua and Barbuda is country located north of Guadalupe in Caribbean. Being country of around hundred thousand locales, there are not many countries in the world with such smaller population. St. John's which has a population of around 25000 is the largest city in the Island (Financial Standards Foundation 2009). Elaine Potter Richardson (the childhood name of Jamaica Kincaid) had lived with her stepfather who was a carpenter till she was sent to work as an au pair at Westchester in New York. By then, she had done her secondary education in the elegant British education system. Antigua continued to be a British colony until 1967 before it achieved the status of an independent nation within the Commonwealth until 1981. The obvious detest about the white power and colonialism seems to be cultivated in her since her childhood, along with an intense love and appreciation for the English literature (Vorda 1993) She felt first-hand the negative effects of British colonialism as the colonists attempted to turn Antigua "into England" and the natives "into English" without regard for the native culture or homeland (Kincaid 1988). The anger that Kincaid has in her for a long time towards English and the Antiguans is expressed through and as the main thread of 'A Small Place'. ... In her attempt to bring out the social, cultural, educational and infrastructural issues of Antigua, Kincaid undermined the sovereignty of Antigua as a free nation. The exaggeration to a great extent helped the reader to understand the intensity of 'colonial, postcolonial and neocolonial myths, thereby interrogating the tourists' perspective and unraveling the continuing colonizing construction of a place legitimized only by its visitors' (Corinna McLeod). The following are some of the realities of Antigua as a nation. 'Antigua and Barbuda has no indigenous sources of oil, natural gas, coal or hydropower. It is largely dependent on imported oil to generate electricity. Oil imports are around 4,500 barrels per day. The IMF estimated the external public sector debt at US$520.4 million at the end of 2008, which was equal to 46.3 percent of GDP. Agriculture is a very small part of the economy with crop production accounting for just 0.9 percent of GDP in 2006. There are 1,165 km of roads (723 miles) of which 33 percent are paved. Traffic moves on the left. The US State Department's Travel Advisory for April 2, 2008 noted that the "major roads are generally in good condition." Drug trafficking has become a major illicit activity. According to a March 3, 2009 article on the St. Maarten Island Time. The largest individual investor and employer was Sir Allen Stanford. The billionaire financier had extensive real estate holdings and also owned the Stanford International Bank, the Bank of Antigua, two restaurants, a cricket ground and the Anguilla Sun newspaper. In February 2009, Stanford's financial empire disintegrated when it was

To what extent did domestic political considerations shape the Johnson Essay

To what extent did domestic political considerations shape the Johnson administrations conduct of the war in Vietnam, 196568 - Essay Example This rapid change of attitudes to the war raises a number of questions. The most important of them is, perhaps, how the USA domestic affairs affected the inclination of the war in Vietnam. Apparently, President's Lyndon Johnson decision to take the United States into a large-scale in Vietnam could not be completely understood without the assessment of domestic political issues and considerations in 1960s. In this project, I will examine all domestic sources of forces as well as forces themselves that shaped to one or either way, Johnson's administration conduct of the Vietnam War. Respectively, I will focus on the 1965-1968 period of the War known as "Escalation and Americanization of Vietnam"4. While analyzing this period of War, I will evaluate the influence of Johnson's administration that determined Presidents' decisions of deployment of combat troops in July 1965, escalation of troops' involvement in 1967, and Johnson's decision to limit the bombing of Vietnam as well as his later decision not to seek reelection. Historically, there are two dominant approaches in analysis of Johnson's administration decision making regarding Vietnam War5. ... Historically, there are two dominant approaches in analysis of Johnson's administration decision making regarding Vietnam War5. One approach emphasizes Johnsons and his administration's irrationality and isolation from critique that consequently resulted in disastrous decisions about Vietnam. This approach describes Johnson as a single-minded "hawk" and extremely ambitious President reluctant to listen to the experts' views6. The second approach implies that Johnson had an access to the full range of information about Vietnam from diverse points of view, particularly from his foreign policy advisers: McGeorge Bundy, Dean Rusk, Walter Rostow and Robert McNamara, as well as from more informal ones78. This view provides a more rational view of Johnson, though makes him a hostage of his informants9. Another question under concern is the extent, to which domestic issues determined Johnson's decisions about Vietnam. In the other words, how domestic economy ("economic crisis" of 1968), growing Congressional opposition, shaping of public opinion and public riots (pacifists' movements), rapid loss of Johnson popularity, etc. determined the way of Vietnam War conduct. As Barrett (1993) believes, this "Vietnam dilemma" has significantly influenced generations of historians and political scientists10. Gulf of Tonkin incident and beginning of Johnson's Vietnam War era Until the August of 2004 Vietnam War was rather a local conflict than an issue, which further preoccupied the minds of average Americans in late 1960s. However, the attacks of Northern Vietnamese on American navies on August 2-4, 1964 prompted the large-scale involvement of American troops in the country. It is still debatable, whether Vietnamese indeed attacked US