Exocrine Pancreatic Insufficiency (EPI)

Exocrine Pancreatic Insufficiency (EPI) The pancreas performs both exocrine (secretes into a duct) and endocrine (secretes directly into the blood) functions, that are vital for correct metabolic function. One such role, is the secretion of digestive enzymes by pancreatic acinar cells, essential for the breakdown of nutrients in the small intestine.    Exocrine pancreatic insufficiency (EPI) is a degenerative disease caused by the insufficient production and secretion of pancreatic digestive enzymes; this leads to maldigestion (an inability to breakdown nutrients) in the duodenum and if untreated, ultimately death through starvation, regardless of how much the dog may seem to be eating (Foster, 2017). EPI is often accompanied by a secondary condition, known as Small Intestinal Bacterial Overgrowth (SIBO). Due to the nature of EPI, bacteria take advantage of the undigested food in the intestine, which often leads to many of the same symptoms as EPI, especially bowel discomfort and flatulence (GlobalSpan, 2013). Cobalamin (Vitamin B12) deficiency, is another secondary condition that more than 80% of dogs with EPI have (Steiner, 2011). This is because cobalamin requires intrinsic factor (IF), produced by the pancreas, for protection and absorption from the small intestine (SI). In addition to low IF levels, SIBO can also lead to reduced cobalamin uptake, as the bacteria bind it and prevent uptake from the SI (PetMD, 2017). Cobalamin deficiency can prevent weight gain and even has neurological side effects, which may affect the animals behaviour (Steiner, 2012). The pancreas is an elongated gland, located close to the small intestine, with the pancreatic duct emptying into the duodenum at the hepatopancreatic ampulla (Figure 2) (Ross Pawlina, 2015). The pancreas is split into exocrine acini and the endocrine Islets of Langerhans, these are interspersed around the acini. The functional exocrine portions of the pancreas look similar to a grape vine and are made up of three types of epithelial cell, acinar, centroacinar and duct cells, as shown in figure 3 (Yuen Dà ­az, 2014). The acinar cells produce inactive digestive enzymes (see table on page 5 for key zymogens produced), as well as store them within zymogen granules (figure 3.) ready for secretion into the acini lumen (Ross Pawlina, 2015). Once secreted, duct cells transport the zymogens along with their own bicarbonate secretions to the duodenum, where they will be activated and then proceed to digest and breakdown the chyme into absorbable nutrients. Exocrine cell Stimulation of enzyme secretion Secretion Function Acinar Upon the arrival of food into the duodenum, enteroendocrine cells release Cholecystokinin (CCK), which stimulates the acinar cells to secrete zymogens into the acini lumen. Acinar cells are also under the control of the parasympathetic nervous system. Proteolytic endopeptidases (trypsinogen and chymotripsinogen) Proteolytic exopeptidases (procarboxypeptidases and proaminopeptidase) Amylase Lipase Nucleolytic enzymes (deoxyribonuclease and ribonuclease) Endopeptidases digest proteins by cleaving internal peptide bonds. Trypsinogen is particularly important, as, after being activated itself by enterokinases secreted by the enterocytes of the duodenum, it then goes onto activate the other zymogens in the pancreatic juice (Pandol, 2015). Exopeptidases digest proteins by cleaving the terminal peptide bond Amylase breaks down carbohydrates into maltose by cleaving the glycosidic bonds Lipase cleaves the ester bond in triglycerides, resulting in fatty acids Nucleolytic enzymes cleave the nucleotide link between DNA or RNA, leaving mononucleotides Ductal cells Secretin is secreted by the cells of the duodenum in response to acidic pH conditions in the small intestine. It acts on the duct cells of the pancreas, stimulating them to secrete bicarbonate ions (Bowen, 2003). Bicarbonate ions These neutralise the acidic chyme when it enters the duodenum from the stomach and establish optimum pH for the pancreatic enzymes. Abnormal physiology Any physiological change that prevents pancreatic enzymes from reaching the duodenum can lead to EPI. This includes potential damage to the enteroendocrine cells of the duodenum (which secretes cholecystokinin (CCK), essential for stimulating pancreatic enzyme secretion (Gartner Hiatt, 2005)) or an obstructed pancreatic duct, due to cancer (Parambeth Steiner, 2011). However, the most common physiological change that causes EPI is the loss of the pancreatic acinar tissue. This typically comes about in one of two ways, pancreatic acinar atrophy (PAA) or chronic pancreatitis, although the exact pathogenesis of either is still unknown (Steiner, 2017). PAA is the selective destruction of the acinar cells and is thought to be caused by an auto-immune response (Morgan, 2009). This is supported by pancreatic biopsy analysis, which show a high prevalence of intra-acinar T lymphocytes in affected dogs, however there is still a lack of evidence to fully support or explain the exact cause (Morgan, 2009). PAA is the cause for approximately 50% of all EPI cases and appears to be a hereditary disease that occurs most commonly in German shepherds, rough-coated collies, and Eurasians (Westermarck, 2012). Originally thought to be passed on by an autosomal recessive allele (Clark, et al., 2005), new research points towards it being a polygenic disorder with possible environmental factors (Clark Cox, 2012). Dogs affected by PAA are typically young adults (1-2 years old), with German Shepherds generally being the youngest when diagnosed (Parambeth Steiner, 2011). Figures 4 and 5 provide a good illustration of the stark changes to the pancreatic physiology after acinar atrophy. Normal pancreatic structure is scarcely recognizable, becoming thin and typically transparent with prominent ductal structures. Histologically, early subclinical EPI may be visible as partial acini breakdown; however, when clinical signs become apparent, all acinar tissue has been destroyed, with atypical tissue left behind, often adipose in the case of PAA (Westermarck, 2012). Another cause of EPI, that can occur in all dog breeds, although generally later in life than PAA, is chronic pancreatitis. This refers to the recurring inflammation of the pancreas. Under normal conditions the pancreas secretes digestive enzymes as inactive forms to help prevent autodigestion; however, when inflamed the pancreatic enzymes are activated. If the pancreas remains inflamed long enough, then pancreatic atrophy (Figure 5.) and fibrosis can occur leading to both exocrine and endocrine diseases, such as EPI and diabetes mellitus (IDEXX Laboratories, 2016). Chronic pancreatitis can cause the pancreas to shrink and become nodular with fibrotic growth. Histologically, chronic pancreatitis displays extensive fibrosis and increasing acini destruction the longer the inflammation occurs (Westermarck, 2012).   Clinical signs develop due to maldigestion and malabsorption of nutrients ingested and begin to show when 85-90% of the pancreatic acinar cells are lost (Parambeth Steiner, 2011). Severity of the disease can vary, as well as the time it takes for symptoms to develop. In some patients, signs begin to show within a few weeks, but also take much longer in others. This may be because dogs can have subclinical EPI (no recognizable symptoms) for months, sometimes even years, before it becomes noticeable (Kennedy, 2009). The key signs associated with EPI are typically pronounced (Foster, 2017). The most noticeable sign is a rapid loss of bodyweight, due to a reduction of body fat, and muscle atrophy, making the dog look severely anorexic (Figure 1). This is especially apparent when the dog is eating normally or showing signs of polyphagia (excessive hunger/appetite) (Steiner, 2017). In some cases, coprophagia (consumption of faeces) and/or pica (consumption of non-nutritional substances) can occur (Bilton Veterinary Centre, 2011). Other signs of EPI and generally the first to present themselves are revolved around changes to the dogs faeces and defecation patterns. This includes passing extremely malodorous faeces, an increase in faecal volume and frequency of defecation (>3/day) (Parambeth Steiner, 2011). The faeces are commonly a distinctive pale yellowy colour and have a cow-pat consistency, as illustrated in Figure 4. Although somewhat dependent on the dogs diet, the faeces can appear greasy (steatorrhea) and undigested (Steiner, 2017). Increased flatulence and borborygmus (rumbling noises, due to movement of fluid/gasses in the intestine) are also common occurrences. Due to nutritional deficiencies, dogs may also have an extremely poor coat quality and seem nervous, aggressive, or irritable (GlobalSpan, 2013). Clinical signs, as well as signalment are useful for raising suspicion of EPI, however many of the symptoms are non-specific to EPI and can be seen in other disorders.   Reliable diagnosis can be made based on a pancreatic function test. The most consistent and reliable being the canine serum trypsin-like immunoreactivity (cTLI) test (Whitbread, 2016). Canine serum trypsin-like immunoreactivity (cTLI) As trypsinogen is exclusively produced by the acinar cells of the pancreas cTLI can measure its ability to produce enzymes (Suchodolski, 2012). Performed after a fasting period of 12-15 hours, cTLI tests for concentrations of trypsinogen and trypsin circulating in the blood, via radioimmunoassay. Under normal conditions, small amounts of trypsinogen enter the serum from the pancreas and have a reference cTLI range of 5.7-45.2  µg/L (Suchodolski, 2012). However, due to loss of acinar cells, dogs with EPI have a much lower concentration of trypsinogen in the serum and may even be undetectable. Values below 2.5  µg/L are considered to be highly diagnostic for dogs with EPI, especially considering clinical signs are almost always present at these levels (Parambeth Steiner, 2011). Results between 3.5-5.7 µg/L rarely coincide with any clinical signs of EPI, however may represent subclinical EPI. At this point it is recommended that the patient is tested again after a one month resting period (Kennedy, 2009). TLI tests are species specific, making them highly sensitive to EPI and considered almost 100% accurate (Bilton Veterinary Centre, 2011). Faecal pancreatic elastase 1 (FPE 1) Although cTLI is considered the gold standard for EPI diagnosis, an enzyme-linked immunosorbent assay (ELISA) forFaecal pancreatic elastase 1 (FPE 1), another inactive enzyme produced solely in the pancreatic acinar cells, can be used(Parambeth Steiner, 2011). A value of 40  µg/g shows normal pancreatic exocrine function (Morgan, 2009). However, FPE 1 tests should be conducted alongside cTLI serum tests, as the rate of false positives have been shown to be as high as 23% (Steiner, et al., 2010). Although restoration of pancreatic acinar cells is currently not possible, EPI is entirely manageable with the correct enzyme supplementation and dietary changes. Follow-up care is also essential for recovery and management, especially monitoring body weight and faeces. Enzyme supplementation The preferred method of treatment involves the supplementation of pancreatic enzymes (lipase, amylase and protease). Raw and powdered enzymes are more effective than tablets, especially those with an enteric coating, as pancreatic bicarbonate is needed to remove the coating (Morgan, 2009). Dogs should initially be provided with 1tsp/10kg of bodyweight, mixed with each meal (Parambeth Steiner, 2011). However, once clinical signs have been resolved, this can be slowly reduced until the lowest effective dose has been reached (cTLI can be used to monitor this while still supplementing with enzymes, as it is unaffected by exogenous enzymes). Raw pancreas can be used as an alternative to powder, in this case 30-90g should be used per teaspoon of powder (Steiner, 2017). Response to enzyme supplementation should see results within a few days, however an increased dose or a change from porcine to bovine enzymes and vice versa may be needed (GlobalSpan, 2013). Around 3 in 25 dogs suffer from oral bleeding, although this appears to correct itself once the dose was lowered (Steiner, 2017).   Dietary considerations A highly digestible diet, with a low fibre % (below 4%) is recommended, as fibre inhibits pancreatic enzyme activity. Another consideration is the provision of a raw diet, as raw meat contains its own enzymes that aid in digestion (GlobalSpan, 2013). More than 80% of dogs with EPI suffer from cobalamin deficiency, which prevents weight gain regardless of enzyme supplementation; for this reason, regular cobalamin and folate serum concentration tests should be performed and if necessary, cobalamin injections provided (Steiner, 2017). Some dogs will only need short term cobalamin supplementation, while others may need it for the duration of their life. With SIBO being a common condition alongside EPI, antibiotics may need to be administered initially and potentially followed up with probiotics to help restore gut flora. Client considerations Potential for a normal and long life is extremely favourable with the correct management, however clients need to be made aware that EPI is a lifelong condition and can be extremely expensive, with some enzyme supplements alone costing over  £3000 a year, although this can be reduced by shopping around (epi4dogs, 2012).   Ã‚  

Red Badge of Courage :: essays research papers

Red Badge of Courage Book Report The main point in The Red Badge of Courage is Henry Flemings fear about how he will do in his first skrimish in the Civil War. Henry was a young man who lived on a farm with his mother. He dreamed about what fighting in a war would be like, and dreamed of being a hero. He dreamed of the battles of war, and of what it would be like to fight in those glorious battles. His mother was wise and caring. She did not want him to go to war. She gave him hundreds of reasons on why he was needed on the farm and not in the war. He didn't want to stay in the farm and do nothing, so he enlisted in the miliatary. After joining he found himself, with nothing to do. He became friends with two other soldiers, John Wilson and Jim Conklin. John was an obnoxious soldier, but he becomes one of Henry's best friends. Jim was tall, he was a childhood friend of Henry's. They all were exiceted about going to war. They started marching. After a few days Henry realized that they were going around in circles. They just continued marching without a reason. During this time Henry starts to think differently about war. He becomes scared about running away from a battle. Lieutenant Hasbrouck, a young lieutenant of Henry's regiment was an extremely brave man. He, unlike the other officers, cared about and defended his troops performance, and made sure that they got the recognition they deserved. He was a true leader and Henry and John wanted to be just like him. After a while, they finally discover a battle taking place. Jim gives Henry a yellow envelope with a packet inside. He is sure that he will die, and says that this will be his first and last battle. The troops manage to hold off the rebels during the first attack, but the rebels came back again and again with more reinforcements driving the soldiers back. Henry becomes scared, confuse, and goes into a trance when he sees his forces backing down. He finally gets up and starts to run like a "chicken", who has lost the direction of safety. After he has run away he starts to think about his actions. At first he thinks of himself as a coward for running, and later he feels that he was just saving himself for later. He thinks nature does not want him to die, eventhough his side was losing. He believed he was intelligent to run, and

The Power of Love in Louisa May Alcott Little Women Essay -- Louisa Ma

The Power of Love in Little Women  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   "Truly, love does work miracles!" (335)   The March family portrayed in Louisa May Alcott's Little Women, was the classic American family. The father is fighting in war, the mother is all knowing and wise and the four daughters are budding seeds of independence. In the beginning of the novel we are introduced to all four of the sisters. Meg, the oldest, is wise and very concerned with class and the styles of the times. Jo was the least like any of her sisters. She longs to be a boy and not have to worry about such petty things as her hair and what she is wearing. Beth is a kind gentle soul who is always contented with what she has. Amy, the youngest, is very conceited. She is always concerned with her looks and who she will marry. "'It's so dreadful to be poor!' sighed Meg, looking down at her old dress. 'I don't think it's fair for some girls to have plenty of pretty things and other girls nothing at all,' added little Amy, with an injured sniff. 'We have Father and Mother and each other,' said Beth contentedly, from her corner . . . . Jo immediately sat up, put her hands in her pockets, and began to whistle. 'Don't Jo-it's so boyish!'{Amy said} 'That's why I do it'" (p.3-4). Though different in many ways, they all loved each other. It was, however, love from, and for, other people that changed them all in so many ways. Being the oldest sister, Meg felt a lot of pressure on her to marry into the right class. She longed for pretty things and large house. She wasn't as conceited as Amy, but continually let Jo know how disappointed in her she was. Jo's unladylike tendencies disgusted her. After going to a coming out party for Annie Moffat, Meg was a changed pers... ...n any other love. In her short life she changed many people for the better. The March family survived many hardships and surpassed many obstacles. Without the love for each other, they wouldn't have made so far. Many years later, Mrs. an Mr. March are sitting back, watching their daughters and grandchildren romp in the orchard. They both see how much they have all grown and changed, Mrs. March turn to Mr. March and says, "Truly, love does work miracles! How very, very happy they must be"(335) Work Cited Alcott, Louisa May. Little Women. New York: Signet, 1983. Douglas, Ann. Introduction. Little Women. By Louisa May Alcott. New York: Signet, 1983. vii-xxvii. Elbert, Sarah. A Hunger for Home: Louisa May Alcott and Little Women. Philadelphia: Temple Press, 1984. Hollander, Anne. "Portraying 'Little Women' Through the Ages. New York Times 15 Apr. 1994.

Essay --

The 1960s was one of the most eventful and perhaps the most troublesome decade in India’s post-Independence era. This decade saw major events like the two wars – one each with China and Pakistan, the annexation of Goa, the deaths of Nehru and Shastri, the Bihar famine,the abolition of privy purses etc. Near the end of the decade, the then prime minister of India, Indira Gandhi, took another major policy decision -- the bank nationalisation. In 1969 the Government of India decided to nationalise 14 major private commercial banks. Bank nationalisation was not a new concept for India as in 1955 the Imperial Bank of India was nationalised and renamed as State bank of India (SBI). In 1959 seven subsidiaries of SBI were formed by nationalising seven state banks. But it was the 1969 nationalisation that caused maximum impact on political and economic spectrum so much so that even Jayaprakash Narayan called this step as ‘a masterstroke in political sagacity’. Decision to nationalise the banks, which has both political and economic undertones, has to be analysed by considering the then prevailing conditions. After centuries of foreign rule and economic exploitation, the independant India had just started its march towards socio-economic development with a dream of creating equitable society by alleviating the widespread poverty. India had adopted the path of planned economic development which envisaged social i.e. governmental control over the means of production. First two plans laid stress on creating heavy industries which would serve as base of economic development. From third plan major emphasis was given on agricultural development with the aim of achiving self-sufficiency in food production and thus tackle the grave issue of ... ... like Uttar Pradesh, Bihar, Orissa etc. After nationalisation the professional management made way for public maganemet which caused lower efficiency. As social welfare took precedance over profits many banks started suffering heavy losses. The political interference in daily administration of banks increased which led to rampant corruption. Although the banking habits in rural areas improved significantly menace of illigal moneylenders could not be curbed in large parts of India. In conclusion, it has be accepted that despite all the demerits the nationalisation of banks was a major step in towards the creation of equitable society. Public sector banks later went on to become catalyst in success of green revolution. In an agrarian economy, bringing banking system under public control was a major shot in the arm for the socialist government of Indira Gandhi.

Being a Nutritionist Essay

What is a nutritionist? A nutritionist is an health practitioner who works with a person’s diet to help heal or prevent disease. A doctor who calls himself/herself a nutritionist may have several different levels of education. They could have a degree in Nutrition or Dietetics from a University or certification in Nutrition Education or Counseling from a professional training school. Most people who have a degree in Dietetics in the United States will be registered with the national board and will call themselves Registered Dieticians or R.D.’s. These professionals have a slightly different perspective from the more holistically oriented Certified Nutrition Educators or Counselors also called C.N.E’s and C.N.C’s. While a nutritionist may have a vast scientific knowledge of the body and nutrition, they are often quite strict in their approach to patient care. Their focus is entirely within the focus of western medicine, meaning they have guidelines when it comes to dietary recommendations. They often work directly with medical doctors or in hospitals. In many ways, they are trained to treat the disease rather than the person as a whole. They might help a patient by helping them make a diet plan, or even suggesting them to other kinds of doctors that can help the patient recover or prevent an illness. For example, the reason the patient is not getting many nutrients since he/she doesn’t eat much food could be because of stress or not getting enough sleep; therefore, the nutritionist would send the patient to the sleep holistic doctor, or a stress management program or professional. One important fact that makes nutritionist so important is that they link the patient with many other doctors that could help them. They help make the connection between proper diet and a good holistic health. They can make the link on how eating the right food can either prevent a disease or even treat a disease. They are the experts in the area of food, nutrients, and vitamins. It is imperative that once a patient faces a problem with diet, he/she must visit a nutritionist. Since most health problems are linked to some kind of factor, nutritionists are connected to other kinds of doctors, such as social coordinators and sleep holistic doctors. Nutritionists are important in the field of disease treatment and prevention. Visiting a nutritionist can increase better knowledge on one’s diet and what they should eat more. Finally, they are the kind of doctors that can change one’s life.

Basic Life Support Essay

Basic Life Support or BLS is that level of medical care for those in a life-threatening situation until the arrival of proper medical care. BLS can be provided either by emergency medical personnel, trained medical professionals or by laymen trained in BLS. The techniques in BLS are mainly focused on airway maintenance, breathing and circulation. Use of automated external fibrillator or AED for defibrillation is a recent advance in BLS and has resulted in improved cardiac survival in cardiac arrest cases. This new intervention is important because majority of the deaths in cardiac arrest cases are due to ventricular fibrillation which can be reverted using a defibrillator in the electrical phase of ventricular fibrillation. Thus, basic life support consists of chest compressions and ventilations and also early defibrillation. Advanced Life Support or ALS is that form of medical care prior to reaching hospital and which can be delivered only by trained medical personnel or paramedics. This form of medical care involves many invasive and non-invasive procedures like transcutaneous pacing, intravenous cannulation, cardiac monitoring cardiac defibrillation, intraosseous infusion, needle or surgical cricothyrotomy, , advanced medications through enteral and parenteral routes and endotracheal intubation. Whether BLS or ALS is critical in improving outcomes in cardiac patients is a much debated topic. According to a multicentric controlled study conducted by Stiell et al (2004) on the benefits of advanced life support in out-of-hospital cardiac arrest patients, advanced life support interventions did not have any added advantage over basic life support. The study revealed that when compared to BLS with rapid defibrillation programs, ALS programs did not have any added benefits. The authors recommended that cardiopulmonary resuscitation by bystanders and rapid-defibrillation responses must be encouraged and should be a priority for EMS resources. The study concluded that though advanced life support increased the rate of admission to hospital significantly; the rate of survival did not improve, placing more importance on basic life support. In a recent study by Markel et al (2009), the authors aimed to study the outcomes in cardiac arrest patients after they were delivered with basic life support and advanced life support. Their study revealed that BLS-to-ALS survival was an important predictor of survival to hospital discharge. Every minute of decrease in the arrival of ALS following delivery of BLS was associated with 4% decrease in survival chances. The authors concluded that shorter BLS-to-ALS time is associated with increased survival chances and hence ALS interventions must be utilized for additional benefits. However, the researchers pressed the need for early CPR and defibrillation which is BLS. Different reports were produced by an old study by Bissell et al (1998). This study reviewed extensive literature pertaining to delivery of ALS and BLS to cardiac arrest patients. Of the 51 articles reviewed, eight articles reported that ALS was in no way better than BLS; seven reported that ALS was effective in some application and the remaining articles concluded that ALS was superior to BLS. The researchers concluded that ALS may be clinically superior to BLS in some patients with certain pathologies. Despite different clinical opinions, it can be said that BLS plays a critical role in the survival chances of a cardiac arrest patient. There are 2 reasons for such an impression. 1. Any bystander can provide BLS if he or she has received some amount of training in BLS. 2. Most of the cardiac arrest cases are due to ventricular fibrillation and defibrillation is â€Å"the treatment† for that condition Current studies being conducted into new methods, drugs and/or equipment being studied to improve cardiac survival. Over the past few decades, many new methods, drugs and interventions have been introduced to provide optimum support for patients with cardiac arrest so that the chances of survival are enhanced. Every year, newer approaches are coming up to provide the best possible care for cardiac patients. This article explores the recent trends in cardiopulmonary resuscitation of cardiac patients in a prehospital setting. Latest international guidelines for cardiopulmonary resuscitation have stressed the need uninterrupted cardiopulmonary resuscitation or CPR so that there is continuous delivery of adequate coronary artery perfusion pressure which is one of the key determinants for return of spontaneous circulation. To facilitate uninterrupted CPR, a new concept of â€Å"hands on† defibrillation has been developed. Research has shown that when CPR is continued with gloved hands during defibrillation, there is absent or minimal shock to the resuscitator (Roppolo et al, 2009). According to the American Heart Association (2005), in children, the chest compressions must be provided at the rate of 100 per minute without any interruption for respiration. According to a study by Bobrow et al (2008), implementation of minimally interrupted cardiac resuscitation increases the survival-to-hospital discharge in those who suffered cardiac arrest out of the hospital. A recent research proved that ‘noise reduction’ automated external defibrillator and cardiac monitoring analysis can allow certain advanced devices to distinguish a CPR infarct from V-fib (Roppolo et al, 2009). Another new approach aimed at cardiac survival is the cardiocerebral resuscitation or CCR. This method is mainly composed of 3 aspects: continuous chest compression by bystander, new EMS algorithm and vigorous post-resuscitation care. There is no mouth-to-mouth breathing in this approach. The approach also favours defibrillation, either in the early or late stages (Ewy and Kern, 2009). Recently an automated, load-distributing band chest compression device has been introduced for cardiac resuscitation in a prehospital setting. Ong et al (2006) compared the outcomes of resuscitation between manual and automated cardiac resuscitation. Their study concluded that automated cardiac resuscitation use by EMS is associated with better outcomes. The previous decade has seen much research in the combined use of active compression decompression CPR and impedance threshold device. Frascone et al (2004) reviewed literature pertaining to this emerging therapy. The authors concluded that use of this new technology should be encouraged as this combination therapy provided optimum vital organ blood flow. References American Heart Association. (2005). 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics, 117(5), e989-1004. Bobrow, B. J. , Clark, L. L. , and Ewy, G. A. (2008). Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA, 299(10), 1158-65. Bissell, R. A. , Eslinger, D. G. , and Zimmerman, L. (1998). The Efficacy of Advanced Life Support: A Review of the Literature. Prehospital and Disaster Medicine, 13(1), 69- 79. Ewy, G. A. , and Kern, K. B. (2009). Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation. J Am Coll Cardiol. , 53(2), 149-57. Frascone RJ, Bitz D, Lurie K. (2004). Combination of active compression decompression cardiopulmonary resuscitation and the inspiratory impedance threshold device: state of the art. Curr Opin Crit Care, 10(3), 193-201. Markel, D. T. , Gold, L. S. , Farenbuch, C. E. , and Eisenberg, M. S. (2009). Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation. Prehospital Emergency care, 13(3), 329- 334. Ong, M. E. , Ornato, J. P. , Edwards, D. P. (2006). Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation. JAMA, 295(22), 2629-37. Roppolo, L. P. , Wigginton, J. G. , and Pepe, P. E. (2009). Minerva Anesthesiol, 75301-5. Stiell, I. G. , Wells, G. A. , and Field, B. (2004). Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. The New England Journal of Medicine, 351, 647- 656. Appendix Please download articles from these links provided: http://www. ncbi. nlm. nih. gov/pubmed/16651298? ordinalpos=1&itool=EntrezSystem2. PEntrez. Pubmed. Pubmed_ResultsPanel. Pubmed_DiscoveryPanel. Pubmed_Discovery_RA&linkpos=5&log$=relatedarticles&logdbfrom=pubmed

The company requires a short description of the proposed project

A prominent publishing company, has contacted you about the possibility of writing a new textbook for the first semester History of World Civilizations course, a potentially very lucrative undertaking.The company requires a short description of the proposed project that includes:   a possible table of contents; an overview of the purpose of the book (and what will be unique about it); a rationale for the book's organization; and an explanation of the key themes to be developed.Please take the time to organize your thoughts in a logical manner and cite evidence to support your analysis.The 21st century is filled with technological innovations and scientific discoveries that have significantly improved how the human race subsists. Since the beginning of time, man has constantly aim for development and progress.As a result, numerous changes have transpired which paved the way for the occurrence of civilizations. Without these developments, the contemporary society would not be able to enjoy and at the same time benefit from the modern conveniences that were all made possible through the ingenuity and intelligence of the ancient people.Most of the history books have almost accurately tackled the advancement of the political, social, cultural and economic aspects of the society in the six continents of the world namely: Africa, Europe, Asia, Australia and North and South America. However, this book that I am proposing would discuss the relationship between nature and civilization.There have been previous studies conducted that argued that civilization is a â€Å"by-product of these social adaptations to environmental change† (Rockets, 2006). More so, based on several archaeological expeditions, scientists and historians have theorized that the â€Å"development of civilization was simply the result of a transition from harsh, unpredictable climatic conditions during the last ice age, to more benign and stable conditions at the beginning of the Holocene per iod some 10,000 years ago† (Environment News Service, 2006).Because of this notion, I have decided to write a book that would provide historical accounts on how man and nature have evolved that contributed to the formation of civilizations which have become the core of human existence. Through this book, readers would be enlightened on how the interaction between man and nature and their development have played a role in the advancement of humanity.Moreover, this undertaking would provide answers on why climate has changed and determine the contributions of man in the present environmental phenomenon. This book offers a timely subject matter and revealing historical information that would give a new perspective on World Civilizations.