Tecumseh Essay Example | Topics and Well Written Essays - 1000 words

Tecumseh - Essay ExampleThis made the treaties that had allowed this annexation void since it was signed by individual chiefs (Klinck 43). He was also a skillful speechifier and a brave warrior. These traits made the Americans and the British admire him (Klinck 36). Although Tecumseh was the leader of the confederacy during the Tecumseh war and war of 1812, the relationship between the Shawnee and the Iroquois compact was a mixed one, with most Iroquois speaking people being friendly and allied to the Shawnee and the others who were enemies to them. While the other groups were enemies to the Shawnee, the Mingo and the Huron groups were their allies (Edmunds 23). The reason for this mixed relationship between the Iroquois Confederacy and the Shawnee is the following the Iroquois Confederacy pursued a territorial expansionism policy which caused a conflict with its neighbors. Consequently, the neighboring communities, such as the Mingo and the Huron (Wyandot), cooperated with the Sh awnee people due to the threat of territorial loss they go through from the Iroquois Confederacy (Klinck 45). However, the relationship between the Shawnee and the Iroquois Confederacy was that of enmity since the Iroquois Confederacy embarked on invading the hunting grounds previously owned by the Shawnee, eventually evicting the Shawnee from their infixed cuts of Ohio. The Iroquois made the Shawnee their dependents (Edmunds 40). During the American war of Independence, the Shawnee, Native American tribe, opted for connecter the British in the fight against rebel colonists. The Shawnee planned to become British allies since they hoped that joining hands with the British would help them evict the colonists from their territory and draw them back across the mountains (Klinck 49). Considering that the invasion of the British and the consequent treaty signed with the Iroquois Confederacy had allowed many a(prenominal) Colonists to settle in the native Shawnee lands, they needed s ome support to evict the colonists, which - they hoped - the British would grant them since the colonists had rebelled against the British colony (Edmunds 54). This saw the Shawnee ally with the British during that war. The concepts of land use advocated for by the British caused friction between the Indians and the whites. Notably, the signing of the Royal Proclamation of 1763 which sought to draw a line of territory between the Whites and the Indians sparked a great conflict (Klinck 62). This treaty sought to establish a reserve for the Indians but eventually ended up causing the encroachment by the whites into the areas where the Indians had previously occupied. Additionally, the treaty signed between the British and the Iroquois Confederacy over land use angered the Shawnee who were the native occupants of these lands before they were evicted by the Iroquois Confederacy (Edmunds 22). Thus, these concepts of land will power and land use sparked off conflicts between the Indians and the whites. Tenskwatawa was a Shawnee religious leader who advocated for the Indians to revert to their traditional lifestyle (Edmunds 47). There were various reasons why the teaching by Tenskwatawa became very attractive to the Native Americans. First, these teachings advocated for a return to the traditional ways of living for the Indians. He advocated for the traditional lifestyle that was not influenced by the white cultures (Klinck 50). Additionally, his teachings advocat

International Financial Institutions Essay Example | Topics and Well Written Essays - 2000 words

International Financial Institutions - Essay ExampleIt depends on the establishment of the receiving system countries as to the utilization of attention funds and grants. Foreign assistance in the form of aid plays vital role in maturation of an develop country to the extent that they are utilized properly. Government institutions have also a significant role in the utilizing this amount. Good government policies not however help country in its development but also help in utilizing the donors money properly.Existing research e.g. sideburn and Dollar (1997), Mosley, Hudson and Verschoor (2004), Dalgaard, Hansen, and Tarp (2004), Burnside and Dollar (2000) etc. suggests that academicians and scholars stress greatly on the importance of pass catcher countrys policies in the effectiveness of aid. These authors regard aid as highly effective in scantness reduction and economic development only if the recipient countrys policies are growth and development oriented. This suggests t hat although aid can contribute a lot towards economic development and prosperity, the result could be entirely opposite.Burnside and Dollar (1997) strongly opine that foreign aid leads to growth in poor countries with sound economic policies (p4). The authors identify true good policies that lead to long-term growth in recipient countries including open trade regimes, fiscal discipline and avoidance of high inflation (p5). They take typesetters case of Botswana and Indonesia as countries that performed well after receiving foreign aid whereas the countries like Tanzania and Zambia could not perform well. They studied the provision of bilateral aid in the period of shivery War and found that foreign aid provided to countries with poor economic policies such as Tanzania or Zambia was thoroughly wasted whereas it could lead to growth and development in countries with good economic policies. They argue that, in a sound policy environment, aid attracts private investment, whereas in a poor policy environment, it displaces private investment. (p5). Hence, if the recipient countrys economic policies are good or growth oriented, infusion of foreign aid can accelerate the process of economic development. For instance, if the existing policies of a recipient country accentuate open trade environment and encourage private investment, aid can be effective in removing the financial hurdles in the way of industrialization. The element of good and bad government policy is highly evident in the literature. The concept of good economic policy highlights the importance of aid allocation to the areas where it can be the most effective in bringing the desired results. Mosley, Hudson and Verschoor expound that the marginal aid dollar should flow to where its effectiveness is highest, at a lower place the joint influence of existing policies and levels of poverty, not necessarily to where it is high (2004, F218). Hence, the policies of recipient government which are relevant t o the process of aid allocation truly teach the extent to which aid becomes effective in poverty reduction and economic growth or is simply wasted on less important issues. For example, if the finis of aid provision Dalgaard, Hansen, and Tarp sufficiently poor economic management,

Current Trend in Telecommunications Research Paper

Current Trend in Telecommunications - Research Paper Example oneness of the sectors that demonstrate this fact clearly is mobile telecommunications which has been growing tremendously over the last decade all around the world, with competitive entry and the setting up of technological standards playing a key part in dissemination of technology (Gruber 2005). The size of the mobile communications industry is growing by the day and the next set of devices that will be availed to consumers will adopt cutting edge technology for better services at even lower costs. The schooling and growth in technology has been steady from 1G, then 2G, to 3G and now 4G (Mobile Communications, 2007). It was inevitable that these knowledges would lead to 4G Long Term Evolution, as operators all over the world atomic number 18 tending to shift from voice-driven revenue to broadband and to an extent video (Nolle, 2010). As a result, one of the most exciting fields of study in price of current trends in the telecommunications industry is 4G LTE wireless networks, where its history, a detailed description of the technology involved, the most probable future trends, the companies involved, the regulatory issues and finally the implications especially with intercourse to globalization form a good basis of study.Background of Wireless NetworksIt is important to first study the history of wireless technologies that finally led to the development of 4G LTE. The development of mobile communication technologies has been divided into distinct generations. To begin with there was the 1G, which describes the initial analog mobile phone technology examples of which are the NMT and AMPS technologies (Mobile Communications, 2007). 1G cellular wireless system featured analog modulation and was primarily designed to deliver voice-based services. They were the first to use a cellular system and automati discovery switch an on-going call (Arunabha et al, 2010). 2G technology then came about, descr ibed as the first digital mobile phone systems. 2G enabled users to access digital speech services and data capabilities from their devices, albeit to a control extent. Examples of 2G technologies include GSM, IS95 CDMA and PDC. An enhanced version of 2G was then developed and dubbed 2.5G availing considerably high data rates and packet data services. GSM led the way in this with their progress and GPRS systems. This is what is mostly available to many users across the world as of now (Mobile Communications, 2007). 2G technologies brought several advantages mainly including improvement of system capacity and voice quality (Holma et al, 2007). The tertiary generation or 3G/UMTS/W-CDMA are designed to give high speed mobile net profit, quality services and video telephony (Mobile Communications, 2007). In comparison to 2G, 3G provided higher data speeds, better voice capacity and in an altogether new concept, support for advanced applications such as multimedia services. 3G techn ologies enabled better voice services, games, seek and email, streaming multimedia services among others, and thus a clear improvement over 2G (Arunabha et al, 2010). After the 3G technology, operators then envisioned something beyond it they could adopt HSPA, deploy WiMAX or deploy LTE. LTE provided an option for many operators who had not yet adopted 3G to bypass HSPA (Arunabha et al, 2010). When it was conceptualized, it was pictured that 4G would provide never before experienced high speed internet with a high capacity, protocol based service that would be available at lower costs per bit. It was to be a combination of several live technologies optimized for efficacy, including celluart network, wireless LAN, 3G and others, all connected together using relevant

Use of water from underground Essay Example for Free

Use of urine system from under build EssayWater from underground sources has been ill-used for many years to be used in homes, for livestock as well as irrigation. As Howsam (2007) clearly explains, though, the exact way of how piss materialise underground may not be well understood by the people using the water, successful abstraction methods has been used to abstract water from mingled sources and under varying conditions. However, there is need to treat and assess the quality of the ground water before using the water.Generally, the method of interposition will highly depend on the source and the properties of abstracted water. Consequently, for water abstracted from upland reservoir in an atomic number 18a of a sheep farming argona which is known to be soft and to have unacceptable penchant and colour with a pH of 5. 5, its give-and-take strategies will differ from that from a network of pumped wells delivering anaerobic groundwater from a chalk aquifer. This paper thus aims at comparing and contrasting the various treatment strategies that could be used.Quality tests recommended Turbidity mea convinced(predicate) Turbidity of water involves measuring the amount of light that could pass through water this will indicate how cloudy that sample of water is. Turbidity results from particles that be hang up in water being assessed and it is a crucial control measure of how water disinfection has performed. Water turbidity measurement occurs at two varied points at the treatment plant and at the consumer taps. Chemical quality water assessmentThe regulations set by the water Quality of 2000 outlines all the minimum tests that are needed for each chemical as well as physical parameter. The parameters that are measured include but are not limited to colour, odour, taste, ammonium train, aluminium level, iron, manganese, sodium among other chemical properties. An critical aspect in quality assurance of water when using chemical in water treatment i s make sure that the used chemicals are those that are specified and does not harm consumers or change the properties of water. Treating water form upland reservoirTastes and odours In water from the ground bid from sheep reservoir, the taste and the odors come from the hydrogen sulphide and other organic substances together with dissolved minerals such as manganese, iron, zinc and copper. Even though these substances are usually not dangerous in amounts normally found in the many of the groundwater, the presence of these substances could result in consumers refusing such water. Thus, such water has to be treated. Adjustment of PH Adjusting the pH is very important in water treatment especially that those meant for drinking.The removal of coagulation, corrosion and controlling softening all are aspects that assist in adjustment of pH. Stabilizers Waters from the reservoir that is considered to be soft could be hardened slightly through use of cation resin exchange. To improve the l evel of softness in the water, calcium magnesium is added to the water to give the water the right texture Adsorption This is a treatment strategy that involves physical handle that happens when liquids are suspended or dissolved in a matter so that the particles in that water could be adsorbed in an adsorbent medium.In or so cases carbon filters are used as adsorbent medium Pumped wells delivering anaerobic groundwater from a chalk aquifer Ultraviolet treatment This water treatment method uses ultraviolet light in order to disinfect water. That is to decrease the amount of bacterial that is found in the water. Removal of algae The bad taste could be due to toxic or because of odorous algal blooms that could be present in the reservoirs. In many cases, copper sulphate. However, before using chemical treatment, the possible impacts on water reservoir biota (Faust and Aly, 1998).The build-up of chemicals used in water treatment such as copper could have a forbid impact on the downs tream treatment. More so, the quality of water treated has to taken into consideration. Coagulation and flocculation The main application of coagulant as well as flocculant chemicals is removing the suspended and as well the colloidal solids like clays. In particular, coagulate are significant in treating surface waters. The elimination of the solids is attained through aggregating small suspended substances into big flocs.The coagulant as well as the flocculant chemicals at the same time is able to eliminate various organic substances, color and other micro-organisms like bacteria, algae and viruses. The amount and strength of the formed floc is able to be controlled and managed according to the treatment method used. Sedimentation or filtration could be used to abolish the floc. Disinfection Generally, disinfection of water is used alone or as the last step in treatment of water subsequent to either clarification or filtration.In many cases, disinfection is mainly applied to pre vent bacterial, viruses or any other protozoa that could get into the distribution system. Generally, chemicals that are used to disinfect drinking water are strong oxidants like chlorine, ozone as well as hydrogen peroxide. However, the effectiveness of disinfection mostly depends on the sources of water that is being treated. In addition, the effectiveness of disinfection also could be affected by the turbidity of the water, pH and the organic substances.The objective of water treatment processes applied before disinfection ought to result in water that has the utmost level of turbidity and organic substances. Too much particulate substances in water could result in protection of micro-organisms against the disinfection chemicals. Conclusion However, as Howsam (2007) states, all chemicals that are used in water treatment whether in chalk or reservoir, ought to be assessed for possible contaminants and restrictions ought to be known. Generally the main aspect of carrying out water treatment is to ensure that the quality of the water is right and does not adversely impact the consumers.Water treatment chemicals are mainly used in treating water to essentially reduce or remove the cases of waterborne disease, public heath issues, and also to improve the taste and quality of that water. However, as American Water works Association (1997) notes any chemical that is used in treatment of water has to be effective, to produce the desired wishes, should not present any public wellness worry and ought not to result in any chemical or contaminants that exceed drinking water stipulated values.ReferenceAWWA (American Water Works Association) (1997) and ASCE (American Association of polite Engineers) Water Treatment Plant Design, 3rd edition. McGraw-Hill Professional, USA Faust, S and Aly O (1998) Chemistry of Water Treatment, 2nd edition. Ann Arbor Press, Michigan Howsam, P (2007) Bio fouling in swell and Aquifers Water and Environment Journal Volume 2 Issue 2, Pages 209 215 (Available online). Letterman R (2002) Ed). Water Quality and Treatment A Handbook of Community Water Supplies, American Water Works Association, 5th edition. McGraw-Hill Professional, New York

The Cell Cycle Essay Example for Free

The Cell Cycle EssayI. Concept 12.1- Cell air division results in genetically identical daughter carrellsA. Overview1) The continuity of life is based on the reproduction of kiosks or cellphone division. 2) The cell division process is an total part of the cell rung, the life of a cell from the time it is first formed from a dividing p bent cell until its own division into deuce cells.B. cellular Organization of the Genetic Material1) A cells endowment of DNA, its genetic information is called its genome. 2) Before the cell can hotshot out to form genetically identical daughter cells, all of the DNA must be copied and then two copies separated so that each daughter cell ends up with a complete genome. 3) The replication and distribution of DNA is manageable because the DNA molecules are packaged into chromosomes. 4) The nuclei of a human somatic cell (all body cells except the productive cells) each contain 46 chromosomes made up of two sets of 23, one set inherited fro m each parent. 5) Reproductive cells or gametes-sperm and eggs-have half as many another(prenominal) chromosomes as somatic cells, or only one set of 23 chromosomes. 6) eucaryotic chromosomes are made of chromatin, a complex of DNA and associated protein molecules.C. Distribution of Chromosomes During Eukaryotic Cell Division 1) After DNA duplication, the chromosomes condense Each chromatin fiber becomes densely coiled and folded, making the chromosomes much shorter and thick. 2) Each duplicated chromosome has two sister chromatids. The two chromatids, each containing an identical DNA molecule, are initially attached along their lengths by adhesive protein complexes called cohesins. This attachment is known as the sister chromatid cohesion.3) The duplicated chromosome has a narrow waist at the centromere, a specialized region where the two chromatids are most closely attached. 4) Later in the cell division process, the two sister chromatids of each duplicated chromosome separate and move into two new nuclei, one forming at each end of the cell. 5) Mitosis, the division of the nucleus is usually founded immediately by cytokinesis, the division of the cytol. 6) You produce gametes by a variation of cell division called meiosis, which yields nonidentical daughter cells that have only one set of chromosomes.II. Concept 12.2- The mitotic shape alternates with interphase in the cell cycleA. Phases of the Cell Cycle1) The mitotic phase (M) phase, which includes both mitosis and cytokinesis, is usually the shortest part of the cell cycle. 2) Mitotic cell division alternates with a much longer layer called interphase, which often accounts for about 90% of the cell. It is during interphase that the cell grows and copies its chromosomes in preparation for cell division. 3) Interphase can be divided into subphases* G1 phase (first gap)* S phase (synthesis)* G2 phase (second gap)4) Mitosis is conventionally broken down into five stages prophase, prometaphase, metapha se, anaphase, and telophase.B. The Mitotic Spindle1) Many of the events in mitosis depend on the mitotic spindle, which begins to form in the cytoplasm during prophase. This construction consists of fibers made from microtubules and associated proteins. 2) In animal cells, the assembly of spindle microtubules starts at the centrosome, a subcellular region containing material that functions throughout the cell cycle to fig out the cells microtubules. 3) An aster, a radial array of short microtubules. The spindle includes the centrosomes, the spindle microtubules, and the asters.4) Each of the two sister chromatids of a replicated chromosome has a kinetochore, a structure of proteins associated with specific sections of chromosomal DNA at the centromere. 5) During prometaphase, the spindle microtubules attach to the kinetochores which then moves the chromosomes toward the pole from which those microtubules extend. 6) At metaphase, the centromeres of all the duplicated chromosome are on a plane middle(prenominal) between the spindles two poles. This plane is called the metaphase plate.C. Cytokinesis1) Cytokinesis occurs by a process known as cleavage. The first sign of cleavage is the appearance of a cleavage furrow. 2) The contractile ring of actin microfilaments act as drawstrings. The cleavage furrow deepens, until the parent cell is split in two, creating two daughter cells. 3) In launch cells, vesicles from the Golgi apparatus move along microtubules to the middle of the cell, where they coalesce, producing a cell plate.D. Binary Fission1) The asexual reproduction of single-celled eukaryotes includes mitosis and occurs by a type of cell division called binary fission, meaning division in half. 2) Prokaryotes overly reproduce by binary fission, but the prokaryotic process does not direct mitosis. 3) In E. coli, the process of cell division is initiated when the DNA of the bacterial chromosome called the origin of replication, producing two origins. 4) T he origin replicates while the other origin moves to the opposite end of the cell. The cell elongates and replication finishes and a new cell wall is deposited, which in result creates tow daughter cells.E. The Evolution of Mitosis1) Since prokaryotes evolved before eukaryotes, mitosis may have evolved from binary fission. 2) accepted protists exhibit types of cell division that seem intermediate between binary fission and mitosis.III. Concept 12.3-The eukaryotic cell cycle is regulated by a molecular control systemA. Evidence for Cytoplasmic Signals1) Hypothesis The cell cycle is driven by specific signaling molecules present in the cytoplasm 2) Evidence comes from an experiment where they induced cultured mammalian cells at different phases of the cell cycle to fuse.B. The Cell Cycle Control System1) The sequential events of the cell cycle are directed by a distinct cell cycle control system, a cyclically operating set of molecules in the cell that both triggers and coordinates k ey events in the cell cycle. 2) A checkpoint in the cell cycle is a control point where stop and move signals can regulate the cycle (using signal transduction pathways). 3) If a cell receives a go-ahead signal at the G1 checkpoint, it will usually complete the G1, S, G2, and M phases and divide. 4) If it does not receive a go-ahead signal at that point, it will exit the cycle, switching into a nondividing state called the G0 phase.C. The Cell Cycle Clock Cyclins and Cyclin Dependent Kinases 1) Rhythmic fluctuations in the abundance and body process if cell cycle control molecules pace the sequential events of the cell cycle. These regulatory molecules are mainly proteins of two types protein kinases and cyclins. 2) Many of the kinases that drive the cell cycle are actually present at a constant concentration in the growing cell, but much of the time they are in inactive form. 3) To be active, such a kinase must be attached to a cyclin, a protein that gets its name from its cyclic ally fluctuating concentration in the cell. 4) Because of this requirement, these kinases are called cyclin-dependent kinases, or Cdks. 5) The activity of a Cdk fluctuates with changes in the concentration of its cyclin partner. 6) MPF (maturation-promoting factor) is a cyclin-Cdk complex that triggers a cells passage past the G2 checkpoint into the M phaseD. Stop and Go Signs Internal and foreign signals at the Checkpoints 1) An example of an internal signal is that kinetochores not attached to spindle microtubules send a molecular signal that delays anaphase 2) A growth factor is a protein released by certain cells that stimulates other cells to divide. 3) Different cell types respond specifically to different growth factors or combinations of growth factors. For example, platelet-derived frpwth factor stimulates the division of a human. 4) The found of an external physical factor on cell division is clearly seen in density-dependent inhibition, a phenomenon in which crowded cel ls stop dividing. 5) Most animal cells also exhibit anchorage dependence. To divide the must be attached to a substratum, such as the inside of a culture jar or the extracellular matrix of a tissue.E. Loss of Cell Cycle Controls in Cancer Cells1) Cancer cells do not heed the normal signals that regulate the cell cycle. They divide excessively and invade other tissues. In addition to their lack of density-dependent inhibition and anchorage dependence, cancer cells do not stop dividing when growth factors are depleted. 2) A logical hypothesis is that cancer cells do not need growth factors in their culture medium to grow and divide. 3) The problem of cancer begins when a single cell in a tissue undergoes transformation, the process that converts a normal cell to a cancer cell. The bodys immune system unremarkably recognizes a transformed cell as an insurgent and destroys it. 4) If the abnormal cells remain at the original site, the lump is called a benign tumor. 5) In contrast, a ca ncerous tumor becomes invasive enough to impair the function of one or more organs. These tumors can proliferate and spread to locations distant from their original site in a process called metastasis.

Darwins Theory of Evolution by Natural Selection Essay Example for Free

Darwins Theory of organic evolution by Natural Selection EssayThe mechanisms for individuals in a population to survive heterogeneous habitats have been a sinewy debate within the scientific community. The native European Littorina obtusata are a great model organism to study Darwins Theory of Evolution by Natural Selection. This is because of their vast phe nonypic characteristics, particularly their evolving pillory thickness throughout history due to predatory pressures of the new arrival of Carcinus maenas.Here we psychometric test whether L obtusata three most critical tenants of Darwins theory of evolution by natural selection variation within a population, heritability, and selection. By observant the shell thickness of East edge of N. America L. obtusata where predatory C. maenas are common versus the West Coast of N. America where C. maenas are not found, it will besides provide evidence whether these shell thickness differences are due to natural selection predat ory or phenotypic plasticity occurring. This was tested by placing band crabs in both East and West populations of L. btusata and observing how their shell thickness decreased, make headway proving that L. obtusata cannot sense or smell the presence of C. maenas. These findings provide further evidence for Seeleys research that the accelerating morphological changes of L. obtusata shell thickness was in response to strong selection by C. maenas and not because speciation occurring.Some believe that Darwins theory of evolution by natural selection is operating the morphological breaks found in fossil records within a population. Darwins book On the Origin of Species listed four basic postulates to natural selection there must be variations among individuals in a population, variations must be heritable, survival and reproduction must be variable and non-random (Darwin, 1859). As a result, every generation there will be slight changes in the population.One scientist in particular, R obin Seeley, assay understanding Darwins theory of Natural Selection by studying the thickness of shells of flat periwinkles, Littorina obtusata, of Appledore Island and the new arrival of predatory green crabs, Carcinus maenas. Seeley historied acceleration in natural selection that normally is not observed within the L. obtusata population in response to strong selection by C. maenas. This is because shell thickness affects the survivability and reproduction of L. obtusata when C. maenas claws break them to meal (Trussel, 1996).The observation confirmed that when C. maenas were introduced in the East Coast of N. America, L. obtusata range of shell thickness increased compared to the West Coast of N. America L. obtusata populations where predatory C. maenas were not found (Seeley, 1986). These vast morphological differences in their shell thicknesses was thought to occur because of the C. maenas selection for the thinner-shelled L. obtusata. Seeleys research further showed that sp eciation was not occurring within the intertidal snails as many previous scientists claimed.

Case Study On A Patient With Oesophagitis Nursing Essay

Case Study On A Patient With Oesophagitis Nursing EssayThe persevering was a female, age 89, with a BMI of 15.4 kg/m2 (underweight). Her presenting complaint was nausea and vomiting, bringing up coffee ground vomit, fatigue and loss of appetite since two years ago. Her past medical history included atrial fibrillation, paranoid psychosis and iron deficiency anaemia. She also had a cholestectomy done in year 2000. She was single and lived solo she neither smoked nor drank. in that respect was no relevant family history recorded for her case. On admission she was pickings medication stated in Table 1 be demean-ranking. She was known to be allergic to ciprofloxacin.Table 1 Repeat medication interpreted on admissionDrugDoseDigoxin125 g at once periodicalLisinopril2.5 mg once in the morningFurosemide40 mg once dailyClopidrogel75 mg once dailyQuetiapine fumarate125 mg in two ways dailyTramadol hydrochloride100 mg twice dailyCodeine phosphate60 mg one to be taken as requiredParaceta mol500 mg four times dailyFolic acid5 mg once dailyFerrous fumarate322 mg twice daily (Last prescription dated three months ago)clinical data and diagnosisOn admission, her temperature was 36.4C, pulse was 83 beats per minute, and her blood pressure was 124/46 mmHg. Her telescoped Mental Test (AMT) score was 7 forth of 10, indicating mild confusion. A full blood count, renal function test, liver-colored function test, and an electrocardiogram (ECG) were carried out. Her liver function test came back normal. The ECG showed some ST depression, but the patient denied any chest discomfort. Her haemoglobin levels were low at 9 g/dl (11.5-16.5 g/dl), while platelets were low at 108109/l 150-400109/l). her plasma urea was elevated at 38.2 mmol/l (2.5-7.5 mmol/l), and her creatinine was 273 mol/l (50-80 mol/l for female). Her creatinine dynamic headroom was calculated to be 8.1 ml/min, which indicated severe renal impairment. The diagnosis was acute renal failure, and gastritis or peptic ulcer disease.Clinical progressOn mean solar daytime 1, patient was dehydrated and had some upper abdominal discomfort (Dyspepsia). The plan was to stop tramadol, clopidogrel, lisinopril and furosemide, due to the coffee ground vomit and acute renal failure. Two units of RCC (Red cell concentrate) and IV fluids were given up. A urinary catheter was used to monitor urine output. Patient was continued on ferrous fumarate and given gaviscon 10mls. Quetiapine fumarate was not given as it was not available.On day 3, patient was paranoid as quetiapine fumarate was still not available, haloperidol 1 mg was given as an intramuscular injection according to the hospital guidelines. Her haemoglobin levels were back to normal (12 g/dl) and her creatinine clearance meliorate to 33.3 ml/min measurements were taken again because the values were so different. The catheter was taken out, but she was to receive subcutaneous fluids hourly. Patient was passing black stools. She was given Peptac 10 mls for abdominal discomfort and was scheduled for an endoscopy the next day. Quetiapine fumarate was given on day 4 and patient was taken off haloperidol.On day 6, the patients confusion was thought to be influenced by digoxin levels were checked and base to be 1.1 g/l (0.5-2.0 g/l) however dit of digoxin was decreased to 62.5 g. a rectum examination was conducted to make sure patient was not bleeding from the lower gastrointestinal tract. The gastroscopy report came back stating patient had grade D oesophagitis (Reflux oesophagitis), that is an extenxive mucosal breaks engaging at least 75% of oesophageal circumference. She was also fix to have a large chronic duodenal ulcer, non-bleeding with visible vessels. The plan was to saltation the patient on IV proton-pump inhibitor (PPI, pantoprazole 8 mg/hr) for 72 hours, oral omeprazole 20 mg daily, and eradicate H. pylori if infection was present (CLO test).On day 9, the CLO test came back negative. Patient was taken off IV PPI an d put onto oral PPI (omeprazole 40 mg daily). A repeat endoscopy was scheduled for the week aft(prenominal).Disease OverviewPrevalenceOesophagitis is the inflammation of the lining of the oesophagus, usually caused by irritation due to jut acid ebb.1,2 It is included under the boarder term of gastro-oesophageal ebbing disease (GORD), which also includes endoscopy-negative reflux disease.3 In the UK, there is a 28.7% prevalence of GORD, and the risk is found to increase with age, especially for those over 40 years of age. There is an estimated of over 50% of GORD patients between 45 and 60 years of age.4 About 25 to 40% of people with GORD atomic number 18 found to have oesophagitis on endoscopy.5Pathophysiology, risk and diagnosisAcid reflux can occur because of incompetence of the lower oesophageal sphincter, a transient complete relaxation resulting from a failed swallow, that is, a swallow without the usual peristalsis wave (Found in 65% of patients). It can also be caused by a transient increase in intra-abdominal pressure (17% of patients), or a spontaneous free reflux due to the lower oesophageal sphincter having a low resting pressure (18% of patients).6Possible risk factors for GORD are pregnancy, excess alcohol consumption, smoking and hiatus hernia. Obesity is thought to be a risk factor, as substantially as certain foods like onions, citrus fruits and coffee. Drugs that are thought to relax the lower oesophageal sphincter like calcium channel blockers are thought to extend a role in promoting GORD. There is however very limited evidence to support these claims.4,5 It is now thought that more than 50% of GORD risk is genetic, as it is found that a first degree relative of a person with GORD is four times more at risk of getting the disease.4Diagnosis of GORD is ground importantly on the patients symptoms, predominantly acid regurgitation or heartburn.7 An endoscopy is usually the main diagnostic procedure done to confirm GORD.Pharmacological give-and-takes and mechanisms of actionThe main drug used for this disease is a proton-pump inhibitor (PPI). PPIs are one of the most prescribed drugs for the treatment of acid-peptic diseases, including GORD and peptic ulcer disease.8,9 They are substituted 2-pyridyl methysulfinyl benzimidazoles, with pKa around 4, and have a very short plasma half life of one to two hours. They are weak bases that are lipophilic, which allows them to cross the membranes of the parietal cells easily. Once inside the parietal cells, where the pH value is less than 4, they protonate into the activated tetracyclic sulphenamide form of the drug and accumulate inside the cells. Here they form covalent bonds with the cysteine residues in the hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) enzymes, forming disulphide bonds, inhibiting the acid secretion activity of the pump irreversibly. Due to the covalent bonds, their duration of action exceeds their plasma half life. To resume acid product ion, the parietal cells must wherefore generate, or activate, new proton pumps.8,9 Examples of PPIs are omeprazole, lansoprazole, pantoprazole, and rabeprazole, the last of which has a pKa of 5, and is activated at a broader range of pH compared to the other three, leading to a higher acid-suppression activity.The crude side-effects of PPIs are nausea, diarrhoea, abdominal pain and headache. Diarrhea seems to occur because of a change in the gut flora brought about by the PPI, and appears to be age-related.8 PPIs, especially omeprazole, are known to alter the activity of cytochrome P in the liver, an important consideration for patients taking drugs with narrow therapeutic windows like warfarin and phenytoin. They also cause a prominent gastric pH increase, and are able to inhibit or decrease the absorption of weak bases that require acid for absorption, like iron salts, griseofulvin, and vitamin B12.8former(a) drugs that may be used in this case are H2 receptor antagonists, whic h inhibit the secretion of acid by stopping histamine from binding to the H2 receptors on the parietal cells and prokinetic drugs, usual examples like cisapride, metoclopramide and domperidone, which work by increasing the pressure of the lower oesophageal sphincter, and accelerating gastric emptying.10Evidence for treatment of the conditionThe National Institute for Health and Clinical Excellence (NICE) guidelines state that, for the management of oesophagitis on endoscopy, patients are to be given full dose PPI for one to two months. If there is a response to the treatment, low dose PPI is given, probably on an as required basis. If there is no response, the dose of PPI is doubled for another month, before switching to low dose PPI. If there is no response to the doubled dose of PPI, treatment is then switched to a histamine H2 receptor antagonist or a prokinetic.11Klinkenberg-Knol EC et al1 compared the effects of omeprazole and ranitidine in a randomise, double-blind, endoscop ically-controlled trial done on patients with reflux oesophagitis. Omeprazole was given at a dose of 60 mg daily while ranitidine was given at 150 mg twice daily. The symptoms were evaluated before starting the trial, and at the second, fourth and eighth week. Endoscopy was done at the start of the trial, and repeated during week 4, with another after 8 weeks if there was an absence of improve at week 4. For patients taking omeprazole, 19 out of 25 patients improved from Grade 2 or 3 (erosions or ulcerations) to Grade 0 or 1 (erythema and friability)12 after 4 weeks while for patients taking ranitidine 7 out of 26 showed similar improvement (P = 0.002). At week 8, corresponding improvement was shown in 22 out of 25 for the omeprazole group, and 10 out of 26 for the ranitidine group (P = 0.001). Omeprazole showed a significantly higher meliorate rate, which was reflected in a better improvement of reflux symptoms as well. Patients receiving omeprazole experienced a more profound an d faster relief of heartburn, which was the most common symptom complained by the patients (P = 0.0001). After 2 weeks, 92% (23 out of 25 patients) of patients receiving omeprazole reported that their reflux symptoms were either gone or had improved, while only 65 % (17 out of 26) of the ranitidine group reported the same (P = 0.01). This reflect however, only showed the superiority of omeprazole over ranitidine in the short term treatment of reflux oesophagitis. Further studies were needed to evaluate the effects of omeprazole in long term management and at a lower dose.Havelund T et al12 performed a double blind study on patients with Grade 1, 2 and 3 reflux oesophagitis. Patients were allocated randomly in this study to a treatment with omeprazole (40 mg once daily), and ranitidine (150 twice daily), for a period of 12 weeks. It was found that patients treated with omeprazole had a faster response to the treatment than those taking ranitidine (P 0.0001). For the omeprazole grou p, healing rates were reported at 4, 8 and 12 weeks to be 90%, 100% and 100% respectively for those with Grade 1 reflux oesophagitis. For Grade 2 and 3, corresponding healing rates were 70%, 85% amd 91%. While for the ranitidine group, healing rates were 55%, 79% and 88% for Grade 1, and 26%, 44% and 54% for Grade 2 and 3. This pointed to a superiority of omeprazole at a lower dose (40 mg) over ranitidine. Sandmark S et al13 did a similar study, but with an omeprazole dose of 20 mg daily. Healing of oesophagitis was targeted in this study to be a complete healing of all ulcerative and erosive lesions in the oesophagus. At 4 weeks, healing rates were shown to be 67% in the patients taking omeprazole and 31% in those taking ranitidine (P 0.0001). Corresponding healing rates were 85% (Omeprazole group) and 50% (Ranitidine group) after 8 weeks (P 0.0001). This was also reflected in a more profound and faster- improvement in reflux symptoms in the patients taking omeprazole (51% by th e end of the first week compared to 27% for patients taking ranitidine).Robinson M et al14 conducted a study to compare, in patients with erosive oesophagitis the efficacy and tolerability of omeprazole at a dose of 20 mg daily to ranitidine at a dose of 150 mg twice daily together with a prokinetic drug metoclopramide at a dose of 10 mg four times daily. It was found that healing rates for omeprazole were significantly greater than that for ranitidine in combination with metoclopramide. Omeprazole also provided a more profound relief for patients with reflux symptoms. More side effects and treatment-related withdrawals were found among the patients allocated the ranitidine-metoclopramide combination. Omeprazole was thus found to be more effective and better tolerated. Iskedjian M and Einarson TR conducted a meta-analysis15 of the three drugs cisapride, omeprazole and ranitidine for GORD treatment. At 12 weeks, 95% of patients were cured in the omeprazole group (40 mg daily), 81% in the ranitidine group (600 mg daily), and approximately 60% in the cisapride group (40 mg daily). In mild GORD, healing rate was 56% for cisapride versus 38% for ranitidine, while healing rates for cisapride and omeprazole showed no significant difference. In severe GORD, the healing rate for cisapride was only a half of that of omeprazole (43% versus 87%), while showing no significant difference when compared to that of ranitidine (50%). Thus it was concluded that omeprazole is favoured for treating severe GORD, while cisapride may be that of mild GORD.Vigneri S et al16 compared 5 living therapies after an initial treatment of omeprazole 40 mg daily for 1 to 2 months, and healing was confirmed by endoscopy. Patients were then randomly assigned 12 months of treatment in the 5 following groups cisapride (10 mg three times daily), ranitidine (150 mg three times daily), omeprazole (20 mg daily), ranitidine and cisapride, or omeprazole and cisapride. At 12 months 54% of the cisapride g roup, 49% of the ranitidine group, 80% of the omeprazole group, 66% of the ranitidine-cisapride group, and 89% of the omeprazole-cisapride group were found to be in remission at 12 months of maintenance therapy. Omeprazole showed a significantly better efficacy than cisapride (P = 0.02), and ranitidine (P = 0.003). Ranitidine-cisapride combination therapy was found to show a more profound improvement than ranitidine alone (P = 0.05). Omeprazole-cisapride combination therapy showed better efficacy than cisapride (P = 0.003), ranitidine (P 0.001), and also ranitidine and cisapride combination therapy (P = 0.03). Omeprazole as monotherapy or in combination with cisapride is found to be more effective for maintenance therapy of reflux oesophagitis, compared to ranitidine or cisapride alone. Omeprazole in combination with cisapride shows more efficacy than ranitidine and cisapride.The effects of newer PPIs lansoprazole (30 mg daily), rabeprazole (20 mg daily) and pantoprazole (40 mg dai ly) were compared with that of omeprazole (20 mg daily), ranitidine (300mg daily) and placebo in randomised clinical trials brought together by Caro JJ et al.17 The healing rate ratios noted for the newer PPIs as well as omeprazole were as follow lansoprazole 1.62 rabeprazole 1.36 pantoprazole 1.60 and omeprazole 1.58. There was a greater decrease in the heartburn symptoms in patients taking PPIs than those taking ranitidine (P 0.002), as well as in the healing of ulcers (P 0.05), and lapsing (P 0,01). Compared to placebo, the PPIs obtained a much more profound relief of reflux symptoms (P 0.01), healing of ulcers (P 0.001) and relapse (P 0.006). From this study, it was found that there is not much difference between the newer PPIs and omeprazole when it comes to relief of reflux symptoms, ulcer healing and rate of relapse, while all PPIs are better than ranitidine and of course, placebo in terms of treatment for erosive oesophagitis.Kahrilas PJ et al18 compared esomeprazole and omeprazole efficacies in reflux oesophagitis patients. It was found that more patients (P 0.05) on esomeprazole 40 mg and esmoprazole 20 mg were healed after 8 weeks of treatment compared to omeprazole (94.1% and 89.9% compared to 86.9%). Adverse effects were common in twain treatments. Esomeprazole was found to have a greater efficacy compared to omeprazole in reflux oesophagitis and both have a similar tolerability profile. Rohss K et al19 showed that esomeprazole at 40 mg daily had better acid control than omeprazole 40 mg daily. Since maintenance of intragastric pH 4 is important for the effective management of GORD, the mean percentage of a 24 hour period with intragastric pH 4 was taken as an indication of the efficacy of the treatments. Measurements were taken on day 1 and day 5, and on both days esomeprazole showed a greater mean percentage (P 0.001) at 48.6% and 68.4% versus 40.6% and 62.0% for omeprazole.Wahlqvist P et al20 compared,from the perspective of the Nat ional Health Service (NHS),the cost effectiveness of the actue treatment of esomeprazole (40 mg daily) with omeprazole (20 mg daily) in reflux oesophagitis patients.It was estimated that, taking into consideration of the healing probabilities over 8 weeks, treatment with esomeprazole saves up toa total of 1290 pounds compared to treatment with omeprazole. Esomeprazole was found to provide a greater effectiveness at a lower cost. This is reflected in another study conducted by Plumb JM and Edwards SJ,21 which found that esomeprazole is cost effective in comparison to all other PPIs for the treatment of reflux oesophagitis.ConclusionThe treatment given to this patient was appropriate in terms of the algorithms stated in the NICE guidelines she was started on a full dose PPI after eosophagitis was confirmed on the endoscopy. As stated above, PPIs are proven to have superior effects in comparison with histamine H2 receptor antagonists and prokinetic drugs, both providing relief of reflu x symptoms but not healing the oesophagitis itself.10 Among all the PPIs currently available, esomeprazole, the S-isomer of omeprazole, has been found to show more improvement than all other PPIs. Current studies have shown that the treatment of reflux oesophagitis with esomeprazole is more cost effective than treatments using any other PPI, providing a greater healing rate at a lower cost. Thus it might be in the interest of the NHS to treat this patient with esomeprazole than omeprazole.(2271 words)