Mycobacterium Marinum Treatment Literature Review

mycobacteria Marinum Treatment Literature critical reviewAbstractBackgroundMycobacterium marinum is an atypical mycobacterium that can be strand in water environment. It is the agent of a characteristic splutter malady known overly as research tank granuloma. In some occasions it can circle as a nodulated lymphangitis, extend to tardily structures as come up as in particular(a) sideslips disseminate systemicaly . The infection is adquired after bear upon with look for or bemire water mainly from aquaria or fluent pools. Although the real incidence is understimate, it is a uncommon infection that needs high clinical suspicion to be diagnosed. As a consequence, curb in the diagnosing is common. Mycobacterium marinum is per se a multidrug resistant mycobacterium. in that location is no clear consesus in the management of this infection. normally it is managed either with mo nonherapy or with compounding of antibiotics nonnegative surgery in selected cases.Me thods backward workplace of cases of search tank granuloma compile from 2000 to 2009 in the dermatology surgery of The infirmary of equatorial Diseases (HTD) of the University College London hospitals.Systematic review of the literature with the terms Mycobacterium marinum and fish tank granuloma from 1999 to 2009.ResultsFrom the HTD dermatology surgery were necessitateed 7 cases. recognition of M. marinum was achievable all in 5. The repartee to treatment was accep get across at to the lowest degree in 5 of them. In the literature review there were inform a total of 516 cases. From those 133 could be analyzed as unmarried cases. Identification was likely in 89.5% of the cases. senior was inform in 82% of the cases. culminationThe key of the diagnosis is to collect accurately the score of moving-picture show. Histology, although no pathognomonic, pass on rise the suspicion if granuloma organization are found and will accelerate the distinguishableial diagnosis . Identification is through after culture with classical biochemical outpourings. Molecular biology techniques allow the advantage of accelerate the procedure. There is non enough evidence to propose every specific treatment. Currently, recommendations are ground in experts opinions. A prospective, randomized controlled clinical trial would be semiprecious to propose a base evident treatment.Contents PagesIntroductionM. marinum is an environmental atypical mycobacterium ubiquitous in fresh, salt, and brackish water. It is known that infects clement and tropical species of fish of at least 150 species, including ornamental fish. that also affects frogs, eels, oysters, aquatic mammals, toads and snakes 2, 11.It cause tuberculosis-like disease in fish, its natural army 129. The infection in fish has an sightly incubation period of 3 months. It affects viscera and produce anorexia with emaciation, spit bring out defects, distension of the abdomen, world cause of fast death 11, 12, 66.In 1904, Alexander depict for first time lesions in a cod fish that were associated with acid fast bacilli. But it was Aronson in 1926 that isolated the bacteria from tubercles of fish that died in an aquarium of Philadelphia. He describe the bacilli as acid fast, chromogenic, pleomorphic and growing best at 18-20C. Aronson intimateed the name of Mycobacterium marinum 130.M. marinum is as well the causative agent of the homophile disease called fish tank granuloma, also known as liquid pool granuloma or fish fanciers finger syndrome. In 1951 Norden and Linell report for the first time the human disease in a fluent pool outbreak in rebro, Sweden. They set forth the lesions as inveterate papulous ulcerationations, ordinarily located in the elbows. The pathogen was isolated from the walls of that swimming pool as well as from the lesions of the patients. They called the pathogen isolated Mycobacterium balnei 131. It was not until 1959 when Bojalil reasond that M. marinum and M. balnei were in fact, the same mycobacterium 132.M. marinum is the most frequent cause of skin infection among the environmental mycobacterium that affects humans 86, 133. Nowadays the frequency of human infections is mainly sporadic. But in the past, outbreaks colligate with swimming pools were not uncommon 134. As an example, nonpareil of the biggest epidemics was in Glenwood springs pool, Colorado in 1956 with 262 cases account 135.That was before chlorination became a common practice. Chlorination makes water safer. As was seen recently in Bologna, were water from swimming pools were free of M. marinum. But still could be isolated in 4.5% of the samples from the lavish floor of the same 136.The real global incidence of the disease is not know because the human activity of cases are under account, due probably to the difficulties in the diagnosis 94. It is world wide distributed but with a tendency to aggregate geographically 137. Like in Chesapeake bay, Maryl and, where there is an incidence of 4 cases per cytosine000 people per yr 138. Meanwhile in California was estimated in 0.27 cases per blow000 adults 139. Or in Satowan, Micronesia, with an estimated prevalence of 10% of the population 115.Apparently the global annual incidence remains small and s bow 140. Even though an amplify number of reported cases has been noticed in The United States, going from an mean(a) of 40 cases per year in the 80s to an fair(a) of 198 cases per year in the 90s 141. What seems clearer is that differing from new(prenominal) atypical mycobacteria the prevalence of M. marinum has not additiond with the HIV epidemic 140.Oppo land site to humans, the incidence in fish is increasing in hatchery fish, probably due to the high population density of fish. Transmission is possible fish to fish and between fish and amphibians. In addition it has been proposed transmission through with(predicate) eggs and through practice of feeding fish with fish carcas ses 140.There are 2 groups or clusters of M. marinum with different pathogenicity. Cluster I is characterized by producing acute disease and death in fish and also for impact humans. On the contrary, cluster II moreover affects fish producing the classical chronic disease with granuloma formation 9. This is also supported by a study through with(p) in Israel were it was seen that altogether certain strains of M. marinum touched humans. They also demonstrate that in Israel strains affecting humans came from ornamental fish and not from topical anaesthetic fish for consumption 5.The mode of transmission to humans is mainly mobile and fish borne. Person to person transmission has not been documented 137. However, It has been draw indirect transmission via fomites in at least 3 cases. ii very small children and one infant who acquired the infection after caning in containers that were previously used to clean the family fish tanks of tropical fish 27, 40, 142.As some other (a) environmental mycobacterium, M. marinum has commonly low pathogenicity. For this reason in normal conditions only affects disrupted skin 8. The main encounter grammatical constituent to contract the infection consists in having lesions or abrasions in the skin with video to non chlorinated water or marine animals infected 140. The most frequently at present is the motion-picture show to private aquaria. But some times the source of word picture is unknown. As a consequence, after the verbal description of cases following injuries with plants, it has been suggested the mishap that could be other reservoirs different from water and fish. Although at the present moment this possibility has not been demonstrated 30, 43.The incubation period is usually 3 to 4 weeks 135. Following, the most common manifestation is a cutaneous lesion at the site of inoculation. It initiates as a solitary nodule or pustule that in conclusion evolutes to an ulcer , abscess or verrucous plaque 143 . It affects more frequently the extremities, probably because the pathogen grows better at low temperatures 144.The severity of the disease depends, among other factors, on the number of microorganisms inoculated 134 In 20% of the cases the cutaneous lesions spread along ascending lymphatic vessels. This is called sporotrichoid spread or nodular lymphangitis 143. As a result of direct generation invasion of deep structures as tendons, articulations and bones occurs in 29% of the cases 144. general dissemination is unusual but has been described in immunocompromised patients 140. impulsive resolution , usually with scaring , has been documented from months after the infection up to 2 age 133, 135.The diagnosis is based on the chronicle of exposure and peril factors along with the characteristic clinical features. It is supported with histopathology, culture and bacteriological credit that in some cases require molecular biology techniques 94, 120. The fact is that the diagnos is is not easy and in most of the cases is either delayed or remain being presumptive based in the history and response to treatment.The objective of the treatment is to increase the speed of resolution and prevent emanation of the disease 1. With this purpose different gangs of antibiotics gain the support, in selected cases, of surgery are the common practices in the treatment of this infection. Although the election of the drugs still depends of the preference of person(a) authors and is not based on controlled evidence 143.Aims and ObjectivesThe overall aim of the excogitate is to determine the current state of evidence for the diagnosis and treatment of M. marinum infection. world the specific objective to review the literature and the serial of HTD cases with the purpose of suggest appropriate diagnosis and case management of Mycobacterium marinum infection.Material and MethodsCases with diagnosis of fish tank granuloma were review. The cases were diagnosed and treated from 2000 to 2009 in the dermatology surgery of The Hospital of Tropical Diseases of the University College London Hospitals. There were include patients with either culture cocksure for M. marinum or clinical diagnosis plus response to appropriate treatment.The files of those patients were reviewed and info were collected in a questioner that included anthropological data, past medical checkup and drug history, risk factors and exposure, description and location of the lesions, spread or deep adjunct of the infection, incubation period , delay in diagnosis, diagnosis, treatment and ontogenesis (see questioner in annex). Additional information considered applicable was as well collected.A literature review in Medline and Cochrane databases was through. The review included the combination of the following terms Mycobacterium marinum or fish tank granuloma. It was expressage to cover from 1999 to July 2009, English and Spanish literature and humans. The papers obtained in the search were divided in 3 categories. First, case reports in which it was possible to collect data from individual cases. Information of those papers was collected in the questionnaire previously mentioned. Second, case series of 14 or more cases in which data from individual cases was not reported. And last, a miscellaneous category of papers that were considered relevant for the diagnosis and treatment of this infection.The information gathered in the questioners was com entrusterized in Microsoft excel 2007. No statistical analysis was done in view of the cases were expose not with this purpose. As a consequence probably important coverage bias would invalidate any statistical outcome. Simple description of the results was done.ResultsCases of The Hospital of Tropical DiseasesFrom 2000 to July 2009 there were collected 7 cases with diagnosis of Mycobacterium marinum infection. The 7 cases included 6 males and 1 female and their ages ranged form 31 to 65 eld. All the cases a dmitted to take a leak had pass with an aquarium. In devil cases the exposure was occupational. integrity of them worked in the London Zoo being responsible of the management of the aquaria. The trice was a cook in a awaitaurant that store crustacean in an aquarium. All the cases presented nodular lesions located in one of the upper berth branchs, six of them with sporotrichoid spread and one with a solitary nodule (see photos is annex). iodin patient that was taking oral prednisolone due to severe atopic eczema presented with tendosynovitis of the left hand, sporotrichoid spread and palpable regional lymphonodes. The rest of the patients were not immunosuppressed. Biopsy of the lesions was performed in all the cases. However AFB were found just in one case. Whereas cultures were positive in 5 cases for M. marinum. In the other two cases the diagnosis was done based on history of exposure, clinical characteristics and positive response to treatment. incompatible combinatio ns of antibiotics were used with no clear advantage of any regimen in particular. In 4 patients it was need to change the regiment. The reasons were drug intolerance in one case and lack of improvement in the rest. There was also one case that initially was improving with a regimen of rifampicin plus minocycline. But after simplification of the regiment to clarithromycin monotherapy presented worsening of the lesions. This case was eventually controlled switching to minocycline plus ethambutol. There was one patient who presented a relapse after one year of the previous infection. eventually it was aged(a) with 6 months of rifampicin plus clarithromycin.Susceptibility test was done in 3 cases. It was detected resistance to trimethoprim-sulfamethoxazole and rifampicin in one case and susceptibility to clarithromycin, ethambutol and doxycycline in 3 cases. The average time of duration of the treatment was 6 months with a range of 2 to 9 months. Surgery was not requisite in any pati ent. The final outcome was good in 5 patients being the other 2 lost of follow up (see hedge 1).Case No Age(y) /Sex Medical history Drug history Exposure Location Clinical characteristics Histology AFB results Culture Treatment Duration (months) ontogeny 1 9/M No Aquarium Upper leg quadruple nodules sporotrichoid spread Granulomatous inflammation AFB + 1-RIF+DOX 2-RIF+EMB+DOX 3-RIF+EMB+CLR 7 Cured 2 61/F Psoriasis Chronic paronychia Aquarium Upper ramification 3 nodules Sporotrichoid spread AFB + 1-MIN 2 Improving Lost of follow up 3 64/M No Aquarium Upper sleeve Multiple nodules Sporotrichoid spread Noncaseating granuloma 1-EMB+TET 2-RIF+EMB+INH 9 Relapse after 1year 3(*) 65/M Fish tank granuloma Aquarium Upper limb Multiple nodules Sporotrichoid spread 1-RIF+CLR 6 Cured 4 59/M dread(a) atopic eczema Systemic steroids Aquarium Upper limb Multiple nodules Sporotrichoid spread tendosynovitis AFB + 1-DOX 2-RIF+EMB 3-RIF+EMB+CLR 4-ERI+MIN ? Lost of follow up 5 44/M No Aquari um Upper limb 5 nodules Purulent run through Sporotrichoid spread Necrotizing granulomatous inflammation AFB- + 1-RIF+MIN 2-CLR 3-MIN+EMB 3.5 Cured 6 31/M No Aquaria (London Zoo) Finger Solitary nodule AFB + 1-CLR+EMB 4 Cured 7 49/M No Aquarium (Restaurant) Upper limb 5 nodules Sporotrichoid spread + 1-RIF+EMB 5 Cured (*) Notice that case number 3 is repeated. It belongs to the same patient that the one above but one year later. The patient presented a relapse after one year of being cured.Results from the literature reviewFrom 1999 to July 20009 there were found 233 results in Medline database and zip fastener In Cochran Library. From those, 127 were considered relevant and consequently analysed in this review. From the 127 papers reviewed, 108 contained case reports and the 19 remaining were a miscellaneous of reviews or original articles covering issues related with diagnosis and treatment. No clinical trials or randomized control trials were found. In those years the literatu re reported a total of 516 cases of M. marinum infection. From those cases reported only 133 could be analyzed as individual cases. The rest of cases were reported as series of cases (See figure 1).The number of cases reported per year since 1999 up to July 2009 defecate been variable with a minimum of 6 cases per year in 2004 to a maximum of 88 cases in 2000. No clear tendency to increase neither decrease has been notice (see Figure 2).The majority of the cases pitch been reported in Europe, North America and to the south East Asia. No cases have been reported in Africa and only one case in South America (see Figure 3).Results from papers that could be analyzed as individual casesThe reports included 82 men and 51 women. The average age was 46.7 years with a minimum of 18 months and a maximum of 87 years (see Figure 4). 70% of the patients had no relevant past medical history. 9% of the patients were immunosuppressed 5 patients had HIV infection, 4 were recipients of solid organ transplant, 1 patient had a myelodisplastic syndrome, 1 had Non-Hodking Lymphoma and 1 had Chronic Lymphocytic Leukaemia. Among other relevant pathologies were reported 12 diabetic patients, 11 with rheumatic diseases and finally 5 that were suffering from other problems as asthma, bullous pemphigoid, myasthenia gravis, Cronhs disease and sarcoidosis. The majority of the patients were not taking any relevant drug. However, 20 of them were on systemic steroids, 12 had received steroids as local injection, 10 took amethopterin sodium and 9 TNF-blockers.The most frequent exposure referred was the contact with an aquarium usually of tropical fish, it was reported in 51% of the cases. It was followed in 26 cases (20%) by other kind of contact with fish mainly referred as contact while cooking or cleaning fish. Finally 16 cases (14%) had other kind of contact with water environment. That included mostly fishermen or amateurish sailors.Opposite to papers from the 60s, only in 2 patient s referred contact with swimming pools. In 15 cases (11%) the source of exposure was not recall or reflected in the papers. Injury related with plants was reported in 3 cases. In one case the exposure was a bucket. The bucket was used to bath a child of 18 months after being used to put fish from an aquarium. As a result the child got infected 40. recital of trauma with skin barrier impairment was referred in 46 cases (71%) of the patients. Among those, 18 cases (39%) recall direct injury with either fin fish, fish clasp or crab bite.Occupational exposure was reported in 20 cases (15%). The most frequent occupational risk was to be cook and have injuries while cleaning fish. Another common job of high risk was to work in a pet shop, with the duty of cleaning aquaria. Finally fishermen are evidently in direct contact with water and fish and prone to suffer injures with fish hooks. The incubation period was documented only in 30 patients. It went from 1 day up to 4 months with and a verage of 48.9 days. The cases that presented an incubation period less than two weeks had in common to have suffered penetrating injuries with fish (figure 5).The upper limbs were affected in 120 case (90.2%), being the fingers the most frequent location. The lower limbs were affected in 11 cases (8.3%). The face in 7 cases (5.3%) and that included delicate locations as nostrils, palpebra and cornea. Finally, cutaneous dissemination was reported in 7 cases (5.3%). Sporotrichoid spread was found in 53 cases (39.8%). Lymphonodes affectation was recorded in only in 7 cases (5.3%) of the cases.The lesions were described as nodules in 63 cases (7%), plaques in 23 (17.35%), papules in 13 (9.8%) and ulcers in 22 (16.5%). There was purulent solve in 32 cases (24.1%), as well as swelling and pith in 37 (27.8%) and 42 (72.4%) cases respectively.Involvement of deep structures was referred in 45 cases (33.8%) of the cases being the most frequent tendosynovitis with 34 cases (75.6%), follow ed by arthritis with 12 (26.7%) and osteomyelitis with 6 (13.3%). Systemic dissemination with documented bacteraemia was reported in 3 cases. The 3 of them were males from 66 to 87 years. In 2 cases the patients were on systemic steroids, due to myasthenia gravis103 in one case and polymyalgia rheumatica62 in the other. sadly the third case that initially was not taking drugs, after being misdiagnosed as rheumatoid arthritis was put on systemic steroids, infliximab (TFN blocker) and methotrexate 59.From the patients with invading disease, including involvement of deep structures or systemic dissemination, 21 (46.6%9 were taken some kind of immunosuppressive drug. Meanwhile only 13 (15.5%) of the rest of the patients were taken them (see figure 6). Other interesting characteristic of the patients with invasive disease was that 15 (33.3%) of them referred direct fish injury. Only 3 (3.4%) of the rest had this exposure (see figure 7). Patients that for any reason were taken immunosup pressive drugs presented different characteristics from the rest of the patients. More than half of them presented invasive disease compared with only 20% of the rest (see table 2).Patients taking immunosuppressive drugs (*) Patients no taking any drugs Number of patients 36 91 Average age (years) 53.2 44.9 Female % 14 / 38.9% 36 / 39.6 % Sporotrichoid spread 13 / 36.1% 39 / 42.8% Involvement deep structures 21 / 58.3% 19 / 20.8% Systemic dissemination 3 / 8.3% 0 AFB positive 19 / 52.7% 33 / 36.3% Culture 33 / 91.6% 75 / 82.4% Bad ontogenesis 2 / 5.5% 3 / 3.3% (*)Immunosuppressive drugs including TNF-Blockers, systemic steroids, local injectable steroids, methotrexate and azathioprine. The time of evolution until the patients presented for consultation was as short as 4 days and as long as 18 years with an average of 8.6 months. The time until the diagnosis was finally done was only reflected in 17 patients. However the delay went from 21 days to 2 years with an average of 6.3 mont hs. Tuberculosis skin test was only done in 19 patients. From those 86.4% were positive. Biopsy of the lesions was done in 120 cases (90.2%). Aspirate was reported only in 19 cases (14.3%). Histology characteristics apocalyptical of mycobacterial infection with granuloma formation were found in 45.5% of the biopsies. However, only 21% of those were described as caseating granulomas. Other frequent finding reported was mix infiltrates with chronic and acute inflammatory cells. In some cases a wrong diagnosis was done due to confusion with rheumatoid nodules, Sweets syndrome, remote body granuloma or interstitial granuloma annulare (See table 3).mesa 3 Histology FindingsHistology description Number of patients Non caseating granuloma 19 Caseating granuloma 12 Granuloma( type not specified) 26 Infiltrates of chronic and acute inflammatory cells (lymphocytes , neutrophils, histiocytes) 18 Granulation tissue 6 Abscess formation 9 Necrotizing folliculitis 1 Focal dermal necrosis 3 Fib rinoid corruption 1 Necrotizing paniculitis 2 Cystic degeneration 1 Pseudoepitheliomatous hyperplasia 4 stabbing suppurative paniculitis 1 Fibrinous exudates 3 Lichenoid inflammation 1 Acanthosis in epidermis 2 Necrotic Corneal Stroma 1 Dermal fibrosis 2 Pseudocarcinomatous hyperplasia of follicles Nodular and perifollicular infiltrate of neutrophils and histiocytes Dermal fibrosis Collections of neutrophils within follicles 1 patient with lesions of 18 years evolution Confusion with other pathologies Rheumatoid Arthritis ( rheumatoid nodule) 2 Sweets syndrome 2 Foreign body granuloma 2 interstitial granuloma annulare 2In the samples collected AFB was found in 41.7%, was negative in 34.6% and was not reported in 23.6%. In total identification of M. marinum was possible in 119 cases (89.5%). Culture was positive in 114 cases (85.7%). The time until the cultures grew went from 8 to 56 days, with an average of 23.3 days. Identification with PCR was done in 19 cases (14.2%).The im aging techniques were multipurpose to diagnose extension of the infection. Radiographies were used in 25 cases (18.7%) to rule out bone involvement. Magnetic resonance imaging was used in 16 cases (12%) resulting in the diagnosis of tenosynovitis, abscess, join effusions or osteomyelitis.About the treatment, 126 patients were treated with antibiotics in the rest of the cases the management is not mentioned. Surgery was need in 38 patients (84.4%) with affectation of deep structures and in 21 patients (25%)with cutaneous lesions.Monotherapy was used in 54 cases (42.8%), bitherapy in 38 cases (29.4%), triple therapy in 20 cases (15%) and combination of 4 or more drugs in 5 cases (4%). Finally combinations of drugs that included classical tuberculosis treatment were used in 10 cases (8.7%). In 41 patients the regimen of drugs needed to be change, either for non effectiveness or non tolerance. The regiment was change one time in 29 cases (21.8%), two times in 10 cases (7.5%), and up to 3 times in 2 patients (1.5%).The drug more frequently used as monotherapy was clarithromycin, followed by minocycline, doxycycline, ciprofloxacin and trimethoprim-sulfamethoxazole. The combinations of drugs more frequently used were rifampicin + ethambutol followed by clarithromycin + rifampicin and clarithromycin + ethambutol. ( effectualness of the different regimens depending of the extension of the disease can be seen in table 4)Susceptibility test were reported in 34 patients. Rifampicin was susceptible in 86.4% of the test, ethambutol in 91.3%, clarithromycin in 95% and minocycline in 62.5%. Isoniazid was resistant in ampere-second% of the tests done and streptomycin in 66.6% (see table 5).The average time of duration of antibiotic treatment was 5.4 months, with a range of 12 days to 15 months. after completion of the treatment the final evolution of 109 patients (81.9%) was reported as good outcome or cured. Only in 8 patients (6%) the evolution was reported as bad outcome. No mention about the evolution was done in the rest of cases. Among 12 patients in which long follow up was reported, only one patient presented recurrence of the infection after 3 months course of doxycycline. (Characteristics of the cases with bad outcome are resumed in table 6.Table 4 Antibiotic Combinations Used Depending On The Extension of The DiseasePatients with only cutaneous lesions Patients with Invasive disease Number of patients Effectiveness Number of patients Effectiveness Monotherapy 38 52.5% 16 75% CLR 8 75% 5 degree Celsius% MIN 10 70% 1 nose candy% DOX 8 50% 1 100% CIP 4 25% 2 50% CTX 2 100% 3 33.3% AZI 3 0% 0 AMK 1 0% 0 ERI 0 1 0% LEV 0 1 0% MOX 1 0% 0 OFL 1 0% 2 50% Combinations of 2 drugs 26 92% 11 83.3% CLR + EMB 6 100% 2 100% CLR + CIP 1 100% 0 CLR + MIN 1 100% 0 CLR + RIF 5 80% 0 CLR +CTX 1 100% 0 RIF + EMB 9 100% 5 60% RIF + CTX 0 1 100% RIF + INH 0 1 100% CIP +DOX 1 100% 0 CIP + EIR 1 0% 0 DOX +CTX 0 2 100% CIP + EMB 1 100% 0 Combinations of 3 drugs 13 72.7% 7 66.6% CLR + EMB + CIP 0 1 0% CLR + EMB + RIF 2 100% 5 100% CLR + EMB +RFB 0 1 0% CLR +CTX + CIP 1 0% 0 EMB + AZI + MIN 1 0% 0 RIF + CLR + AMK 1 100% 0 RIF + INH + CLR 1 0% 0 RIF + EMB + CTX 5 100% 0 RIF + EMB + DOX 1 0% 0 RIF + EMB + MOX 1 0% 0 Combinations of than 3 drugs 2 100% 3 33.3% CIP+RIF + EMB + CLR + RFB + AMK 0 1 100% CLR + DOX + RIF + EMB 0 1 0% RIF + EMB + CLR + AMK + pyxie 0 1 0% RIF + EMB + AZ I+ CTX 1 100% 0 RIF + EMB + CLR + CIP 1 100% 0 Combinations with TB treatment 1 100% 9 55.5% INH + RIF + EMB + CLR 1 100% 1 0% INH + RIF + EMB 0 3 100% INH + RIF + EMB + PZA 0 4 50% INH + RIF + EMB + PZA + CLR 0 1 0%TABLE 5 PATTERN OF SUSCEPTIBILITYDrug Number of patients Susceptible Resistant indeterminable Isoniazid 9 9 Rifampicin 22 19 3 Ethambutol 23 21 2 Pyrazinamide 1 1 Streptomycin 6 1 4 1 Rifabutin 2 2 Azithromycin 4 1 3 Clarithromycin 20 19 1 Minocycline 8 5 1 2 Doxycycline 6 6 Tetracycline 2 1 1 Trimethoprim-sulfamethoxazole 6 5 1 Ciprofloxacin 11 6 1 Levofloxacin 1 1 Moxifloxacin 4 4 Gatifloxacin 1 1 Amikacin 9 9 Linezolid 1 1 Imipenem 2 2 Erythromycin 2 1 1 Cefotaxime 2 1 1 kanamycin 3 3 Ethionamide 3 3 Ansamycin 1 1 The table reflects in how legion(predicate) patients each drug was tested and in how many it resulted as susceptible, resistant or indeterminate. TABLE 6 CHARACTERISTICS OF CASES WITH BAD OR POOR OUTCOMEReferences Age Sex Past medical history Type of infection Treatment Duration treatment (months) Evolution 25 67/M DM dermal disseminated RIF+EMB+CLR+CIP 3.7 deceased person Secondary bacterial infection 26 50/M No Tenosynovitis RIF+EMB Synovectomy 3 Dysfunctional list finger 46 62/F No Tenosynovitis CLR 4 debridements 6 Amputation index finger 46 26/M No Tenosynovitis DOX+CTX 4 debridements 3.5 Persistent infection Need of grafting 73 56/M No Tenosynovitis Local gentamicin Synovectomy 3 drainages ? Deformity 83 47/M HIV infection Osteomyelitis 1-INH+RIF+EMB+PZA 2-Avobe + Fluoroqui nolone 3-RFB+EMB+CIP 4-RFB+CIP ? Amputation Knee 88 60/F NHL Systemic steroids Cutaneous disseminated 1-Ofloxacine 2-RIF+EMB+LEV+CLR 3-Above+STR+IG 4-CTX+MOX ? Continue with signs of active infection 103 81/M myasthenia gravis gravis Systemic steroids Cutaneous and systemic dissemination 1-CIP 2-Hyperthermia 3-DOX intravenous 5 Deceased Bone marrow infected by M.marinumResults from papers that contain series of 14 or more casesThere were 14 papers that contained series of cases with no available information of individual cases. As a consequence, individual cases could not be analyzed separately. There were 2 papers that reported the same series of cases in different years, the cases were counted just once.The principal characteristics of the papers are described in the table 7. There were 363 cases reported, 68% were males with an average of 44.3 years. In most of the cases the past medical history was not relevant only 4 cases of HIV infection were reported. The most frequent expos ure was to own an aquarium in 134 cases (37%). There was other kind of contact with fish in 37 cases (10%), swimming pool contact in 7 cases (2%) and other kind of contact with water in 58 cases (16%). In the rest of cases exposure was not mention. Finally occupational exposure was referred in 68 cases (19%). The incubation period was not reported.The upper limbs were affected in 245 cases (67%), the lower limbs in 78 cases (21%), the face in 3 cases (0.8%) and there was cutaneous dissemination in 10 cases (3%). Sporotrichoid spread was reported in 46 cases (12%). The lesions were described as plaques in 92 cases (25%) and nodules in 54 cases (15%). Deep structures were affected in 45 cases (12%) 41 tenosynovitis (91%), 8 arthritis (18%) and 3 osteomyelitis (6%). There were no cases of systemic dissemination described in any of the series.The average in the delay until the diagnosis was done was 3.8 months. The drugs more commonly used as monotherapy were doxycycline, minocycline, t rimethoprim-sulfamethoxazole and clarithromycin. The combinations more prescribed were rifampicin plus ethambutol, rifampicin plus clarithromycin and clarithromycin plus ethambutol. The effectiveness of the treatments were not frequently reported. Consequently is not possible to point the advantage of any concrete regimen (see table 8). The average duration of the treatment was 5 months. Surgery was reported in 73 cases (20%). The evolution was good in 225 cases (62%), poor in 15 cases (4%) and not mention in the rest.There were 5 papers that contained series of cases of atypical mycobacterial infecti

Internal and external analysis of Kelloggs

Internal and external digest of KelloggsIn this assignment Im going to make an external abridgment and an internal outline of the Kelloggs phoner. Im going to choose four tools to make the any analysis. For the external analysis I pull up stakes do PESTEL and ostiarys five force models and for the internal analysis I will do the Value chain and a benchmarking on Cereal SBUPresentation of the organizationKellogg Company is the United States largest texture-Maker.In 1898, leave behind Keith and John Harvey give birth to the famous breakfast cereal Kelloggs lemon yellow Flakes. Thanks to the success of the products Will Keith create in 1906 the Battle creek Toasted Corn Flake Company. Kellogg is the leading producer of breakfast cereals in the military personnel. It takes places in 18 countries and sells it products in more than 180 countries.Between 1938 and the pass day Kellogg opened manufacturing plants in the UK, Canada, Australia, Latin America and Asia.Kellogg produ ce a wide range of cereal product including the well-know brand of Kelloggs corn flakes, strain krispies, special K , fruit n fibre, as well as the nuti-grain cereal bars.The philosophy was remedyd diet leads to improved healthKellogg company mission statementKellogg is a Global Company Committed to twist Long-Term Growth in Volume and Profit and to Enhancing its Worldwide leading Position by Providing Nutritious Food Products of Superior Value epitome of Kelloggs external env contractmentAnalysis of Macro-environment influences through the PESTEL modelThe headquarter of Kellogg company is before long base in Battle Creek in the Michigan. I will base my PESTEL analysis in the country of the USAPolitical Reforms for the line of work of obesity in USA (wide problem)US focus on cereal products in the level of 17% of the food commercialize(2000)Economical The deterioration of universal economic activity and the contraction of the food market have non been without consequences f or the food industry .Faced with financial difficulties and difficulties of access people doesnt have cash to buy expressive food because of the decrease of salary.High unemployment rate 9,00%( january 2011)gross domestic product in 200914266milliards of $Curent Deft 6% of GDP attach of the puffiness rate1,5%Decrease of the money , low rate of the dollar operose competition amidst the breakfast and snack brandsDecrease of all the gross revenue in cereal market (began in 2005 with less 0, 4%) kind Population of USA 312.061.000 people step-up of obesity rate so the cereal market break-dance the sector of light food neglect of time to take a breakfast American people would deal some easy to transport at work or at school to eat.The increase in the Third Age population free radical (due to better living conditions and better health cargon) will decrease the gross sales of Kellogg children product and down growth for adult products.Importance of the health, safetyPeople want to b e inform on what people itTechnological mental hospital on the cereal market different piece of ground, small bar (snack), resealable package (or close package)Recycling packageInnovation in communion and publicizing levelScientific progress on the health- diet foodIncrease the cost of RDKelloggs did a matrix Sustainability ingredientsEnvironmental Development of the biologic and rude(a) foodDevelopment of ecologic packaging, and recyclable packaging to avoid the bobbleLegal environnemental charterHealth claims is becoming more prevalent with the increase of the authority of American heath associations.Globalization creates homogeneity of consumer behaviour. Globalization is a key driver for standardization. This sector of tourism has to take into account the requirements of fieldwide customers. (Standardize the food, the drink, the activities). Because of this standardization competition increases between firms within the tourism sector. This footing warfare will lead to decrease price.The five porters force Analysis constancy competitor In the market industry four large companies are dominant (Kellogg, Nestl, MDD and Jordans). Its an oligopolistic situation (a small spot of sellers and a large number of applicants). The competition between the organizations is lavishly and intense because of the price principally. holy terror of a Substitution there are many substitutes because of private labelThreat of entry The cereal industry is oligopolistic, so is very difficult for some other firm to enter in this sector. If firm want to penetrate this market he has to have competitive prices, and has to make marketing communication and forwarding to attract consumersBargaining power of buyers the power of buyer is low in the cereal industry consumers dont have a deep impact.Bargaining power of suppliers the power of suppliers is low because the importance of the market shares of private labels. They do barely the products in cheaper prices. Suppliers ca n buy product independently.Source Adapted from Porter M (1998, cited by Johnson G al, 2008)Analysis of Kelloggs internal environment (internal strategy)The Kelloggs abide by chainSupport ActivitiesFirm infrastructureIn order to curb a good satisfaction level from its clients, Kellogg uses several service and the inbuilt organisation is flexible.Quality ControlFinance AccountingInformation system(internal communication) high levelKelloggs has an intranet to expose the information of the firmLegal service the righteousness concerning the output of the productLogistical support (restoration)Planning Provide a planning to clients and Anticipate customers needsHuman Resources ManagementThe company allows a dynamic of man resources management policy.For doing that well, Kellogg establish a model manage name is Kellogg patronage leaders model (KBLM).It is the base of everyone in Kellogg industry, it improves the competencies of apiece works and allow to progress in the compa ny. This model is one of the closely important competitive advantage, it allow adding value to the firm.Recruitment policyKellogg is looking at for talent doers to develop new products and give freedom to do innovation. It does recruitment on international dimension.TrainingKellogg establishes the standing coaching to help workers to improve future operations and profitability.Kellogg is developingplanforindividual career to resolve to the workers needs (new skills)The innovation is one of the most important sectors that Kellogg develops it gives time to worker just to think about innovation.Performance measureKellogg measuring effect and make feedback to add valueAdd valueKellogg motivates employees in swelled merit reward when they perform.Technology DevelopmentRD for productsThe innovation is a weaken of Kelloggs culture, it is the most important cereal heathcare companyThe development of products aimed at impact consumers health and nutrition needs.The development of pr oducts packaging to ameliorate the communication for consumer and his relieve (when he use the product)Innovation on the image of health cereal cereal for men target.Innovation the type of product(museli, cereal)Innovation to keep the iron in the cereal cultureInnovation to give notoriety and profile of the product The company has announced that it is testing the possibility of using lasers to engrave the companysname into corn flakes to let customers know they are eating a genuine Kellogs product(geek.com)Innovation in communication all around the worldProcurementTo achieve economies of scale, purchasing division negotiate with suppliers to obtain group rates to reduce reduce cost and save time on delivery.Inbound LogisticsKellogg calls the best suppliers and partners in term of cost efficiency, maintain the spirit of the products. The suppliers are responsible (deal with) all the tasks upstream.( packaging, manufacturing, transportation management services, logistics managemen t services and supplier management/procurement)the inbound logistic is automatic , evry part of the production is automated.OperationsKellogg has un structure for all operation system very flexible.Kellogg curing up On office in each country of the world. So Kellogg can manage the transformation between the raw material and the utmost productOutbound logisticsThe distribution of the products to consumers (end user) is doing via a multi-layers pedigree system.The different channel of distribution allows comforting the consumers during the purchase.(distribution on retail, hypermarket and supermarket in general)Marketing and sales exclusively the consumers are familiar with the Kelloggs brand and Kellogg cereal.Kellogg company make sponsorships locally to efflorescence brand awareness.Thank to that Kellogg cereal are famous in all around the world.Kelloggs cereal use sometime promotion to reduce the price and increase the purchase.Kellogghas managedtoestablish itselfinalmostallsupe rmarketsandhypermarketsin the worldServicesKelloggoffersseveralservicesthatcanenhancetheseproduct totheconsumer.Kellogg oblation outstanding customer services( promotion to attract people and to loyaty the consumer with a comparativecommunication programacross allbrandsfor adults and children,built around amini-consumerPrimary ActivitiesBenchmarkingTo do this benchmark we are going to take the Kelloggs human resources sector and we will compare with Nestl human resource (Nestl is the principal competitor).KelloggsNestlHR culture Goal add value thanks to innovation HR program Kellogg business leaders model Kellogg join the high ethical standards-Freedom in the post HR programPrinciplesofConduct Nestls business relationships between employees Communication is the principal factor of the HR policy. Equity between employees has to be respected. Give responsibility to employees Non freedom in the post plectron recruitment Kellogg is looking for talent workers Human Diversity attract and dedication future employees(long term contract) Recruitment on the personality and professional skills develop a long term relationship.Training and Development Trainee program ain development and team development Tainting program-Personal developmentPay receipts employee rewarding benefit adaptation of working hours Employees social security. wage level( low-level to superior) Equity Financial compensation allows motivating employees.Participation/employee relation/communication-Power of employees unions-participation in important decisions. Every employee has got a personal responsibility in the company.-Importance of employee association.

Health Essays Medical Errors Hospitals

Health Essays aesculapian Errors Hospitals aesculapian Errors Hospitaldivine revelation of aesculapian breaks in each sidereal day clinical design.IntroductionMedical fractures atomic second 18 genuinely common in e very(prenominal) day clinical practice. withal taking serious caution does non make the error pardon hospital any where in the world. accord to British Medical ledger ( cited in Adams 2005), about 850,000 aesculapian errors occurs in national Health hospitals every year resulting in 40,000 deaths. Adverse events occur in 10% of completely hospital tolerant ofs (p. 274). Todays durations 2004 ( cited in Adams 2005) claims a bell of 2 annotationion pounds per year due to medical exam exam exam errors. The selective information shows the order of magnitude and the signifi keepce of the problem. In fact medical errors are preventable in roughly of the causal agents. But the sad part of the story is these errors are non expose to the patient rol es or the family. Disclosure of medical errors is a very immense paying back for the leading and focussing of a hospital in name of institutional morals. This paper result discuss about medical errors, the issue of its revelation , its outcomes, current trends regarding revealing of errors, act of theories and implementation in our context.Medical ErrorsAlbert , Cavanaugh, Mc Phee , Bernard , and Micco ( 1997) define medical error as Commission or omission with potenti wholey forbid consequences for the patient that hurt been judged wrong by knowledgeable peers at the time it occurred , independent of whether on that point were any disconfirming consequences (p.770). In this regard grounds of the error and realization that it is an error is very important. The issue is if it is internalized that error has occurred, then should it be disclosed or not.Non divine revelation of medical errorsThere is a very sacrosanct culture of a number of hospitals world wide and the h ospital where I belong to that thoroughlyness care professionals hide and do not disclose medical errors to the patients or their families. Errors come on the picture if by any means the patient or their family comes to know about the error. Kaldijan ,Rosenthal, Reimer, and Hillis (2005) did literature review of 316 articles on medical errors and came up with four categories which include attitudinal barriers, processlessness from the institution, uncertainties about how to disclose and its outcomes, and fears and anxieties. In addition to it, risk of ruining mortals as come up as the hospitals reputation, legality issues, low self observe in the profession, mistrust of the patient and the family, and hindrance in professional overture are in like manner some of the very important barriers to revealing. (Boyle, Connell, Platt, Albert 2006, Fischer et al 2006, Albert et al 1997). Besides governments culture, indemnity and the colleagues attitude also impacts error revelat ion.Non manifestation of errors sack have some beneficial effects for the patients as considerably as for the doc. Patients do not become emotion everyy overturn on hearing the news of occurrence of unexpected event during the hospitalization. Boyle, Connell, Platt, and Albert (2006) have cited that American college of physicians has turn inn up the indecorum of not disclosing the error if the disclosure can cause more harm than benefit as in the case of psychiatric or depressed patients. But the worse part of it is this excogitation of deception for the benefit of patient is misused in the name of the strongness care military force own interests. Similarly risk benefit dimension of disclosure should be calculated or in ethical equipment casualty beneficence versus non maleficence should be judged. Furthermore wellness care psychenel do not have to fear for legal issues and the reputation. up to now they take in emotional distress if they do not disclose.Disclosure of Medical ErrorsMedical errors should be disclosed as an ethical and moral right of the health care personnel and the institution as whole. JCIA and JCAHO has made it a regulation in 2001 that disclosure of errors should be implemented in hospitals. (Connell, White, Platt 2003, Henry 2005, Gallagher, Studdert, Levinson 2007). In addition The code of ethics of American Medical Association, The American College of Physicians and the National Safety Foundation have also emphasized on disclosure of errors.( Boyle, Connell, Platt, and Albert 2006 ). The standardization of disclosure by so many outside(a) organizations peculiarly JCIA and JCAHO gives the message that the culture and the approach towards the issue of disclosure is changing. These bodies are international standardized bodies and the reposition in the approach must be bear witness found. If disclosure was not that important it would not have been the part of these liveing improving bodies.Literature supports disclosu re of errors. According to Connell, White, Platt (2003) , response of participants who attended the shop class about disclosure of medical errors was 90% affirmative . In a study d sensation by Hob effective, Peck, Gilbert, Chappell ( 2002) on patients and their familys thought of error disclosure gave interesting results. 258 surveys were filled in an emergency department and it revealed that 76% of patients treasured disclosure in case of any error, and 88% felt to its large extent. This clearly indicates the significance of disclosure as an issue and patients need regarding the issue.Disclosure of medical errors has many benefits. Initially the reaction of patients may be negative as error could never be expected from patients side. But by and by they retrieve settled .Studies show confirming outcomes from patient as well as the health care personnels angle because of disclosure. Error disclosure armed services patients to get any hire in the form of additional interpos ition or financial help. Most of health care personnel believe that disclosure can ruin their relationship with patients and can bring law case as well as their image down among their collegues. However harmonise to Witman ( cited in Boyle, Connell, Platt, and Albert 2006 ) patients felt to claim law suit if they were not disclosed about errors. In addition University of Michigan Health System report that the terms and frequency of litigation decreased substantially in 5 years after implementation of an open disclosure programme , with yearbook litigation reduced from $3 million to $1 million and claims by more than 50% ( Gallagher, Studdert, Levinson 2007 p. 2716). Error disclosure also brings a affirmatory impact on learning for the person who did the error as well as for others in the organization. Hence mistakes done once may not be repeated next time , governance improvement and whence improvement in the quality of patient care. ( Albert 1997, Mazor 2005, Boyle, Connel l, Platt, and Albert 2006 ). Moreover patient physician relationships do remain intact in most of the cases.Trends in application of disclosing errors and comparison in our contextDisclosure of medical errors is gaining its significance in so many health care organizations because of the outcomes of it as well as the realization of doing disclosure. Gallaher, Studdert, and Levinson ( 2007), have stated that 2002 survey of institutional risk mangers showed that 36% of the institutions have adopted disclosure constitution and the percentage increased to 69% in 2005. They further quoted that Austarlia and United Kingdom in 2003, National character reference Forum safe practices and Harvard in 2006 emphasized and provided guidelines for full disclosure of medical errors to patients. The trend shows that awareness for disclosing medical errors is gaining its popularity.If we compare the scenario in Pakistan, we have a culture of not disclosing errors in most of the hospitals. In additi on to the reasons discussed in the literature regarding non disclosure of medical errors, most of the times it is taken as for granted by the health care professionals that the patients belong to low socio stinting status, less educated, low level of understanding and on that pointfore errors need not be disclosed. It has been observed in clinical practices that errors are considered most of the time as side effects and untoward result because of certain treatment and there is no internalization that it is an error. In addition there is also a misconception that since the error did not bring any harm to patient so need not to be describe to the hospital forethought team and therefore no disclosure to the patient. It is interesting to know that most of the hospitals in Pakistan do not have any policy for disclosing error. However in Aga Khan University Hospital (AKUH) the policy for disclosure of errors exists and it is mentioned in the observatory events policy that there should be disclosure of medical errors and it is mentioned in the patients bill of rights that patients have right to have all information .( Multi disciplinary policies and procedures talent scout events policy no MDP-S-002). But the sad part of the story is there is no proper implementation of the policy as well as proper explanation of patients rights to them. In fact there is no such culture for the individual to share errors to their supervisors as an ethical and moral responsibility until the error is identified by someone else.Reviewing the issue in the commence of Theories To support that medical errors should be disclosed, we will be utilizing the following theories of ethics as well as leadinghiphip and management.Kants Theory of DeontologyImmanuel Kant a German philosopher has precondition the theory of deontology or duty based theory. According to Kant (cited in Bernstein and Brown 2004), act should be done on the infrastructure of the duty or indebtedness regardless o f the consequences. He also believed that the design behind the act justifies the action done. If we try to understand the disclosure of medical errors from Kants scene, disclosure should be done as it is the duty of the health care personnel. It is the right of the patient and duty of the personnel to share all information including the errors if occurred. Kant believes in telling the uprightness which is the duty in all conditions and deception is un tolerable. The debate that if truth telling causes harm should be told to patients or not , goes against Kants philosophy. If health care professional feels that deception of the truth will give more benefit than there should be a very impregnable rationale for it and should not be taken as for convenience. Kant (cited in Bernstein and Brown 2004) has discussed about ones conscience which contact a major role in making right decisions correspond to his duty and states, consciousness is an internal court before which a gentleman s gentleman beings accuse or excuse one some otheran internal judge, and this authority watching over the law in him is something that he himself makes, but incorporated in his being (p.172).Heifetzs perspective on Ethical leadershipHeifetz ( cited in Northouse 2007) explains that leaders help followers to help resolve conflicts by using their authority. He further explains that Heifetzs perspective is related to values of workers, organizations and communities in which they work (p. 347). In the light of this perspective, leaders need to have a clear idea of what is the value of the organization which in all circumstances is the best quality care given to its customers and taking care of their wishes and doing what is right. Leaders need to persuade wad to do the right thing and therefore the culture of disclosure of medical errors should be inculcated by the leaders.Burns perspective on Ethical leadershipBurns gave the theory of transformational leadership in 1978. According to Burns (cited in Northouse 2007), leaders have an important role in motivating people to identify their values and to help them reach to a level where the principles of justice, liberty and equality should be incorporated in practice. This clearly indicates the moral vista of leadership which leads that disclosure of errors should be done as moral obligation of the organization.Significance of medical error disclosure from leadership and management perspectiveThe issue of medical errors disclosure is very important from leadership and management point of view because this issue is not confined to a finical institution but it is a global issue. As discussed above that leaders have a very important role in prosecute and motivating people to follow morality in practice. Ethics has a very important place in leadership and organization. Leaders give direction to the followers or subordinates. They have a very strong impact on their followers. Therefore if leaders will have strong value o n creating an environment and culture whereby every individual gets rights and do their duties, then this gives rise to an organization following ethical principles. This is only contingent if and only if the leader values that act. In the issue of medical errors disclosure, leaders should play their role to first get the issue internalized and get it inculcated in the organizations culture.Implementation of disclosure of errors in our contextIn order to address the issue in our Pakistani and in detail AKUH the most important aspect is first internalizing that the error occurred and not acquiring defensive. nationalization can be done by leading seminars, discussions, conferences and bioethical sybaritic rounds where issues of error disclosure can be discussed and health care professionals can clarify their misconception about errors. They should have a very clear understanding of what are medical errors. Once the understanding of error is there, the next clapperclaw is accoun t of errors in the organization through the in built system of error reporting. Unfortunately AKUH Karachi does not have a very good system of error reporting. Errors are report when someone identifies it but the person involved rarely reports the error. On conversation with clinical affairs person of AKUH , centralization of errors reporting is under process. At present if errors are reported it is not centralized to one place. Centralization will assist in getting the picture of medical errors occurring in the hospital as a whole.There should be reinforcement at the academia level of medical and nursing education about errors and its disclosure .Adams ( 2005) has given a very practical approach towards identifying our own errors. He has shared his example how he started writing all the errors which he identified during his practice and it was interesting to discover that the identified errors were between one to six per week for 29 weeks . This data was for those errors which he identified himself and may not have captured all the errors done. This practice will help us identify and internalize that how many errors are made by health care professionals. Besides , voluntary electronic reporting of medical errors can also be implemented . The results of one study where 92,547 reports from 26 hospitals were evaluated showed that 47% of the registered nurses did voluntary reporting of errors compared to intern doctors which was 1.4%.( Milch, et al 2006). Jones, Cochrane, Hicks and Mueller ( 2004) asserts that success of voluntary error reporting depends upon the organizational culture where confidentiality is retained and a non punitive culture exists which promotes error reporting.Once the error is reported, the oral sex comes for the disclosure of error. Henry (2005) asserts that there should be clear policy for disclosure and this helps in creating an open organizational culture for disclosure as well as promotes patients autonomy. He further adds that man agerial support should be there and as leaders they should be promoting disclosure in their organization. Organizations culture needs to be formulated which best supports the disclosure policies. Giganti( cited in Henry 2005) claims that one must approach culture change with systems mentation.organizations culture is built up over time and is based on the assumptions , beliefs and values that drive the organization (p. 132). Hence the cultural change involves evaluation of systems to see why there is hesitancy and reluctance in disclosing errors to patients and their families. Persons should not be blamed instead system should be canvass .Cultural change at the institutional level will lead the policy makers to consider it at the health ministry level because there needs to be law to address this issue.Disclosure is not an easy task property into considerations the so called consequences afterwards. There needs to be special trainings in this aspect. Hobgood, Hevia and Hinchey ( 2004) apprise for disclosure in terms of promoting safe environment to the patients and that there should be open conversation during disclosure expecting any reaction from the patient. Therefore talk plays a very important role. Furthermore Connell, White and Platt ( 2003) have given the steps for error disclosure which includes apologize and take responsibility, catch who will be involved, and be proactive in addressing the patients financial needs (p.27). However the concept of becoming proactive in identifying our system gaps and root cause analysis of the problem will promote a safety culture and hence less medical errors and therefore less issues of disclosure.ConclusionMedical errors cause huge number of deaths which can be prevented. Medical errors do occur every day in our clinical practices but there is under reporting of the errors. And if reported there is culture of non disclosure of errors until it comes to patients knowledge by any means or the outcomes of that e rror are such that it cannot be kept hidden. The reasons identified through experiences and literature are fear of destroying relationships with patients, wrong of patients trust on heath care personnel, legal issues , loosing the credibility in the profession, shame , guilt and not realizing to disclose considering it better from patients perspective. However late trend suggests that institutions who developed and implemented disclosure policy had very positive results . Patients felt that they were apologized for that and were brought into confidence. This led to less law suits and decrease in the cost given for legal issues. Besides patients were able to participate in the compensation or adjustment for the loss due to error. Hence the above mentioned literature and practical experiences suggest that medical errors should be disclosed. Leaders need to help their subordinates or the followers to apply Kant theory of deontology but justify if they feel error should not be disclos ed. Moreover it is the responsibility of the leader and each and every individual of the team to help creating an open environment of disclosure and to follow it.ReferencesAdams,H. (2005). Why there is error, may we bring truth. A misquote by Margaret Thatcher as she entered No 10, downing street in 1979. Anaesthesia, 60 , 274-277.Berstein, M. Brown, B.(2004). Doctors duty to disclose error a deontological ethical analysis. The Canadian journal of Neurological Sciences,31, 169-174.Boyle, D., OConnell, D., Platt, F. W., Albert, R. K.(2006). Disclosing errors and adverse events in the intensive care unit. searing Care Medicine,34 (5), 1532-1537.Connell, D. O., White, M. K., Platt, F. W. (2003). Disclosing unanticipated outcomes and medical errors. JCOM, 10(1), 25-29.Fischer,M. A., Mazor,K.M., Baril,J., Alper, E., Demarco,D., Pugnaire,M. ( 2006). Factors that influence how students and residents learn from medical errors. daybook of General inbred Medicine , 21, 419-423.Gallagher , T. H., Studdert, D., Levinson, W. (2007). Disclosing harmful medical errors to patients. The New England daybook Of Medicine,356, (26), 2713-9.Henry, L. L. (2005). Disclosure of medical errors Ethical considerations for the development of a facility policy and organizational culture change. Policy, Politics, Nursing Practice, 6(2), 127-134.Hobgood, C., Hevia, A., Hinchey,P.(2004). Profiles in patient safety when an error occurs.ACAD Emergency Medicine,11(7), 766-770.Hobgood, C., Peck, C. R., Gilbert, B., Chappel, K., Zou, B. (2002). Academic Emergency Medicine, 9(11), 1156-1161.Jones , K. J., Cochran, G., Hicks, R.W., Mueller, K.J.( 2004). Translating research into practice voluntary reporting of medication errors in critical access hospitals. The diary of Rural Health, 20 (4), 335- 343.Kaldijan,L. C., Jones , E. W., Rosenthal, G. E., Reimer, T. T., Hillis, S. L. (2006). An empirically derived taxonomy of factors affecting physicians willingness to disclose medical errors. Journal General congenital Medicine, 21, 942-948.Mazor, K. M., Reed, G. W., Yood, R. A., Fischer, M. A., Baril, J., Gurwitz, J. H. (2006). Disclosure of medical errors What factors influence how patients respond? Journal of General Internal Medicine, 21, 704-710.Mellisa, A. F., Mazor, K. M., Baril, J., Alper, E ., DeMarco, D., Pugnaire, M. (2006). Journal of General Internal Medicine, 21, 419-423.Milch, C. E., Salem, D.N., Pauker, S. G., Lundquist , T. G., Kumar, S., Chen, J.(2006).Voluntary electronic reporting of medical errors and adverse events an anlysis of 92,547 reports from 26 acute care hospitals. Journal of General Internal Medicine, 21, 165-170.Northouse,P. G. ( 2007).Leadership Theory and practice .(4th ed).Sage Publications London. The Aga Khan University Hospital Multi disciplinary policies and procedures. Retrieved March 22 , 2008, from http//intranet/jcia/jciapp/searchpolicy.aspWu, A. W., Cavanaugh, T. A., McPhee, S. J., Lo, B., Micco, G. P. (1997). To tell the truth Ethical and practical issues in disclosing medical mistakes to patients. Journal of General Internal Medicine, 12, 770-775.Winslade, W. McKinney, E. B. (2006).The ethical lawyer. Journal of Law, Medicine, Ethics, Nantechnology, Winter, 813-816.

Understanding Of Ancient Pompeian And Herculaneum Civilisations History Essay

Understanding Of Ancient Pompeian And Herculaneum Civilisations History establishPompeii and Herculaneum became roman type towns more than a century before the eruption and numerous aspects of Roman society were reflected through their cordial structure.1Society in Pompeii and Herculaneum was a mix of different complaisant family unites that was well-ordered and divided into terzetto the stop number class, middle class and lower class.2Buildings, frescoes, statues, graffiti and accounts tell onenessd some names and faces of workforce and women from all levels of society. This essay will be discussing an upper class woman, Julia Felix an upper class man Marcus Nonius Balbus and prostitution.According to the Romans the genial status of men and women was influenced by their wealth, their family background or their ex officio positions.3Julia Felix was a very wealthy Roman woman. She inherited her coin from her family and owned a villa that took up an entire hinder in Po mpeii.4A house is a strong reflection of social status.5The features and size of the house of Julia Felix suggest that it belonged to a wealthy person. It was well furnished, ornament with paintings depicting scenes from the Forum and frescoes depicting scenes from pattern life and items enjoyed by the household.6Excavations revealed that aft(prenominal) the 62AD earthquake the house was ruined. Julia then decided to rent out fragment of her house to help people from the shortage of accommodation. The house then consisted of apartments, shops, toilets, gardens, and bars. She in addition opened her private bath to the humans. This supports that the household was wealthy, as in antediluvian patriarch Pompeian times not all houses featured baths as they were costly.An inscription has been ready in the House that said To let, in the e relegate of Julia, daughter of Spurius urbane baths for respectable people, shops with upper inhabit and apartments the lease will expire at t he end of the five years.7This suggests that women could own property without the interference of any anthropoid meaning they were independent and can take charge of constructing buildings with their own money.8This inscription also reveals that Julia was involved in business activities. She was a main public fancy that made her important in Pompeii. However historians may neer know the true extent of the independence of women.9When excavations took place many sections were unveil they include, the triclinium, garden, and private bath.The triclinium in the house of Julia Felix was well decorated with frescoes depicting everyday life scenes. It consisted of marble beds with a fountain with a waterfall and threesome klinai, on which diners would sit to take their meals. Each couch had room for three diners who could lie down on cushions while they were served by slaves.10The private baths were complex. They consisted of a dressing room with cold tub, a warm and hot bath, a cloak room, an open pool as well as a waiting room where bathers could have a chat and purchase snacks from the tavern.11At first the bath was strictly utilize by the households nevertheless posterior it was used by the public if they paid.12The garden of the house was ample of quad and water. It was divided into ii parts, one part was a great viridarium decorated with statues, fountains, and marble columns whereas the other part was planted with trees and there was a return orchard divided by paths for walking.13And a small shrine to the Egyptian goddess, Isis was found in the garden.14Another archaeological source revealing entropy about the upper class is the marble statue of Marcus Nonius Balbus.Marcus was born in Nuceria, only if lived in Herculaneum he was the proconsul of Crete and Cyrene, a supporter of Octavian and the tribune of the lower class in 32BC.15He is also known as a supporter of the Vespasian in the Civil War in AD68-69.16Marcus was also an important political figure as he was a good friend of Julius Caesar and helped in having the initiative Triumvirate, between Caesar, Crassus and Magnusin in 60 BC.17Inscriptions reveal that Marcus was a duumviri he was elect ten times which indicates that he was active in the community.18The altar and statue were fixed near the suburban baths in Herculaneum, but unfortunately the statue was found in pieces, as the head was several meters away from the body. It is believed that the altar and statue were built in the early Augustan period, by the local senate of Herculaneum dedicated to Marcus.19Inscriptions found state To Marcus Nonius Balbus, son of Marcus, praetor and proconsul, from the Herculaneans and Marcus Nonius Balbus, son of Marcus, proconsul, built the basilica, gates and wall with his own money.20These reveal that Marcus was named the patron of Herculaneum as the 62AD earthquake Herculaneum was ruined therefore he donated money to the reconstruction and renewal of the city. A basilica, public baths were built along with walls meet Herculaneum.21Therefore, building inscriptions reveal that upper class men owned able amount of money to improve qualities of the city and honour the person who built them.The altar and statue imply that upper class men were honoured and respected and had influential powers. When he passed away he was greatly honoured and this is shown through an inscription carven on the altar where his body was burnt and his ashes were collected.22Another aspect of social status in Pompeii and Herculaneum was prostitution. Prostitution was common in Pompeii. It was not illegal, as it was a normal business just like other businesses but prostitutes were considered low.23It is difficult to determine the status of the prostitutes but it was believed that they were slaves, freedwomen and foreigners many from Egypt and Syria.24Upper class women such as wives, and daughters were forbidden to practice prostitution. Prostitution was a normal part of the ver sed life of any Roman man.25Many men visited brothels as well traders from other towns.26Twenty five brothels were identified by the Professor Thomas McGinn in Pompeii, whereas none were identified in Herculaneum further it is assumed prostitution was also practiced there.27Professor Andrew Wallace-Hadrill excavating at Pompeii and Herculaneum used a criteria to identify the brothelsbrothels were situated on a corner stranded from the main areas of social activityconsisted of at least five rooms upstairs featuring stone bedslarge amount of graffiti and wall paintingsLupanar was one of the main brothels in Pompeii it was situated two blocks east from the forum.28It was a two storey building consisting of ten stone beds with mattresses, each bed in a separate room, and a toilet under the stairs.The walls revealed the different sexual activities offered, the prostitutes names and the prices. The average price was six hundred sesterces.29Graffiti revealed the customers opinions on Lupa nar and the prostitutes. One hundred and twenty graffiti were found. A graffiti states here I had sex with a very beautiful girl look up to by many.30Prostitutes operated in different places and were differently paid depending on their social status. The poor prostitutes such as slaves did their business in archways while luxuriously class courtesans operated in better surroundings.31Prostitution was profitable, prostitutes were to register with the aediles and tax was introduced during the emperor moth Gaius period.32To conclude, the social status of men and women was influenced by their wealth, their family background or their official positions.33The survival of ancient buildings such as House of Julia Felix and Lupanar, and statue of Marcus Balbus, graffiti, frescoes and inscriptions greatly contributed to the intelligence of the ancient society of Pompeii and Herculaneum, by revealing much information that gave historians and archeologists an incursion of that ancient soci ety.