Reaction of a certain article Essay Example | Topics and Well Written Essays - 500 words

Reaction of a certain article - Essay Example The median is a measure of central tendency in that it is a statistic that generalizes the typical values of members of a sample or population. The median as a measure of central tendency and location parameter is robust and resistant to the effects of outliers, compared to the mean and mode. A data set can be symmetric or skewed. When a data set is symmetric, the right and left hand sides of the distribution are to a great extent balanced around the mean (Stuart 62). Typically, a symmetric distribution is one in which the mean, mode and median are equal or almost equal. The left and right tails of the distribution, therefore, have more or less the same length. On the other hand, when a data set is skewed, the right and left hand sides of the distribution are not balanced around the mean (Rider 149). The measures of central tendency associated with the distribution also tend to be unequal. Furthermore, the tails of the distribution tend to be unequal; one longer than the other. Generally, the skewness of a distribution may hint to the presence of outliers or measurement errors. In his article, The Median Isnt the Message, Jay Gould rightly defines median as â€Å"the half-way point† (Gould par. 2). Gould also rightly notes that the median is a measure of central tendency which, like the mean, can be exploited to one’s advantage when generalizing situations (Gould par. 2). In his article, Gould seeks to convince his audience that the median is not a perfect measure of a distribution and may be subject to misinterpretation. The author also seeks to clarify that in as much as the median is a measure of central tendency, its interpretation depends on whether or not the distribution is normal or skewed, and, if skewed, the direction of the skew. In his case for example, he would have assumed that he had just about eight months to live owing to his medical

Competitor Analysis and the Development of a Brand Assignment

Competitor Analysis and the Development of a Brand - Assignment Example ishwasher was widely accepted by the market with the result that Fairy could make way to launch further of its brand extensions which it did in the coming years. Fairy’s innovation appealed to the masses and its performance became anonymous with combating stubborn and burnt stains the best way (Datamonitor, 2011); fairy.co.uk, 2011; Superbrands.com). The promotions of the brand were strongly backed by Above the Line advertisements with celebrity endorsements to establish strong brand equity. As the brand moved into the future to meet the changing consumer tastes and preferences accordingly, Fairy’s packaging was changed to a transparent bottle which was easier to handle. After a massive success, Fairy Liquid was launched with a lemon scent. This was followed by Fairy non-bio laundry product for sensitive skin, anti-bacterial Fairy Liquid, Fairy Powerspray for tough burnt on stains. With these brand extensions, Fairy could cash in the revenue from every possible segment and sub-segment of liquid cleansers (Datamonitor Research Store. 2011); Datamonitor, 2011; fairy.co.uk, 2011; Superbrands.com). Fairy had and still has the advantage of a long-established equity along with a strong brand image with which it can tap into all the possible markets successfully through its brand extensions. Fairy currently operates in a mature market the product lifecycle of which has predominantly been extended by creating sub-segments of the dishwasher and sink sectors. Fairy has a whopping share of 57% in the sink washing sector and is second to Finish in the dishwasher category (Superbrands.com, Datamonitor, 2011). The launching of Fairy Active Burst and Active Powder Burst marks Fairy’s presence in both the categories of sink and dishwasher category. The brand extensions of Fairy Powerspray and Fairy Active Foam however can be considered as the most selling brand extensions. Following these developments, Fairy Active Foam was voted as the product of the year by the shoppers

Media Responsibility and the Privacy of Public Personalities Research Paper

Media Responsibility and the Privacy of Public Personalities - Research Paper Example Soon, the women were being interviewed by the tabloids, Anthony Wiener’s wife was being deluged by reporters, their family peace was shattered. Everywhere, one sees stories of the media trying to outscoop each other in scraping the bottom of the barrel, so to speak, and extracting information about, or even against celebrities, in order to profit. They then invoke the blanket right of press freedom and the Constitutional guarantee of free expression in order to absolve themselves from liability. Those who say that the media should be restrained give several examples of media irresponsibility. Indeed, it is extremely difficult to dispute examples of not only celebrities, but also ordinary people whose lives have been thrown apart by severe media incursions. Nothing is sacred anymore, privacy has become a value of the past. Even the most private confines of one’s home can become fodder for tomorrow’s newspapers. As a result, celebrity endorsements can be lost (Gorm an 1247). With Twitter and other social networking sites, it has become even worse. Everyone is a journalist, and it becomes easier for professional journalists to zero in on what is newsworthy. As stated by Felcher and Rubin (1577), this kind of publicity against real people can â€Å"disrupt their lives, hurt their feelings, or decrease their ability to profit from their names, likeness or other attributes.† However, this paper will argue that there are more disadvantages than advantages when one censors the media. Indeed, the costs of curtailing free speech outweigh the putative benefits of reining in abusive journalists and protecting the privacy of celebrities. This paper will talk about this on three levels. Firstly, this paper will consider it from the Constitutional principle of free speech, arguing that the freedom of expression of the press is one of the bedrocks of a thriving democracy. Secondly, it will argue that the media still remains to be one of the potent me chanisms against abusive public officials and that the risks of public officials abusing their office have greater damage on society than media professionals who abuse their profession. Finally, it will argue that there are corrective remedies to curb media wrongdoing that do not have to involve outright censorship. Free speech as the bedrock of democracy and human rights Free speech remains to be one of the firmest firmaments of democracy. It is usually the first to be taken away when a dictator wants to install himself into power as a free and healthy press is an important indicator of a free and healthy republic. According to Ira Glasser, who was the director of the American Civil Liberties Union, people often fail to realize that when government regulates speech, panoply of First Amendment issues comes to the fore. He states: â€Å"Liberals and Democrats have been the chief offenders in this scenario, favoring equity in the abstract but never seeing how the particular reforms t hey advocated made the problems they wished to remedy worse, and never seeing that giving the government the authority† (2). Free speech is not always the easiest thing to defend. In fact, in many circumstances, our gut tells us that it should be suppressed in favor of some other social policy. An example of this is the notorious case of Citizens United. By way of brief background, the case takes root in 2008 when a non-profit corporation, Citizens United, released a documentary entitled â€Å"

Teaching to Students of Different Learning Abilities

Teaching to Students of Different Learning Abilities Teachers in todays classrooms orchestrate instruction for students of various learning styles and ability levels. They make decisions based upon their knowledge of and experiences with the students, while incorporating theory and pedagogy as well as being cognizant of local, state and national policies and procedures. In this course, students will read, reflect and respond to information that is relevant to teaching in a mixed ability classroom. Students will design, prepare, analyze and reflect upon their instruction and upon their pupils responses to instruction. Participants will focus on understanding approaches for differentiating instruction in the classroom. Participants will: discuss the principles of Differentiated Instruction and how they apply to each individual student, learn effective strategies for managing flexible groups, and acquire ideas for providing students with a variety of options. Learning Outcomes: The student will be able to: Design lessons and materials based on differentiated instruction theory and strategies Examine his/her individual philosophy of education and incorporate principles of differentiated instruction Interpret state mandates, requirements and/or standards to develop lesson plans in accordance with these rules and regulations Prepare appropriate, differentiated assessments that correspond with explicit content areas and learning goals at various stages of instruction Analyze student learning needs to apply differentiated instruction methods when preparing lessons for Gifted and Talented students, English Language Learners, Bi-lingual students and Special Education students Describe major theories of learning that are relevant to the content of ones lesson plans and the selection of classroom materials Online Learning with Full Instructor Facilitation Our institution maintains an online platform that automatically grades student pre- and post-assessments, monitors their participation in the lecture, and awards them credit when they post in the discussion area. Instructors will monitor the progress and quality of work the students provide, including the threaded discussions, and will provide feedback and evaluate the midterm and final projects. Weekly Online Lecture Assignments: Week 1 Text Reading: Read Hall, T., Strangman, N., Meyer, A. (2003). Differentiated instruction and implications for UDL implementation. Wakefield, MA: National Center on Accessing the General Curriculum. Retrieved [insert date] from http://www.cast.org/publications/ncac/ncac_diffinstructudl.html Answer Questions (Open Ended) Briefly state your philosophy of education. How is it reflected in your lesson planning and teaching? Now consider the Hall, Strangman and Meyer article. How can you incorporate that information into your philosophy of education? Watch Video Clips Clip 1: http://www.youtube.com/watch?v=3lzzZbPN-8splaynext_from=TLvideos=QNXm4P0EbsM Differentiated Instruction: Some Ideas for the Classroom Clip 2: http://www.youtube.com/watch?v=nkK1bT8ls0Mplaynext_from=TLvideos=QNXm4P0EbsM Assignment: Create a Think-Tac-Toe (T-T-T) lesson for use in your classroom. Provide a rationale for the educational choices you made in the design of your T-T-T. Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Week 2 Text Reading: Read http://www.mcrel.org/PDF/Standards/5982TG_ModelsStandardsImplementation.pdf read pages 1-8 of this article Title: National Education Standards: Getting beneath the Surface. Policy Information Perspective, Author(s):Barton, Paul, http://www.ets.org Parrish, P., Stodden, R. (2009). Aligning Assessment and Instruction with State Standards for Children with Significant Disabilities. TEACHING Exceptional Children, 41(4), 46-56. Retrieved from ERIC database. Answer Questions (Open Ended): What did you learn about your states mandates, requirements and/or standards and how will this information drive your lesson planning and instruction? Watch Video Clips Clip 1: http://www.youtube.com/watch?v=HAMLOnSNwzA Dalton Sherman makes a keynote speech about educating students Assignment: Locate your states department of education website to review the mandates, requirements and/or standards for addressing the needs of special education students, English Language Learners, bilingual students, and gifted and talented pupils within a general education setting. Why should this drive your instruction or why not? How does what Dalton speaks about in Texas apply to your students and your teaching situation? Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Week 3 Text Reading: Read http://www.nsdc.org/news/jsd/stiggins202.cfm An Interview with Rick Stiggins, by Dennis Sparks, Journal of Staff Development, Spring 1999 (Vol. 20, No. 2) http://www.readingrockets.org/article/6016 Assessing Learning and Evaluating Progress By: Ann Bauer and Glenda Myree Brown (2001) Answer Questions (Open Ended) What is the relationship between pre assessment, ongoing assessment and post assessment? Watch Video Clips Clip 1: http://www.youtube.com/watch?v=njeK8BGqJq0feature=player_embedded Clip 2: Office Chat with Sharon Russell Fowler regarding assessment in a mixed ability classroom Assignment: Choose a learning goal. Design three assessments, one for pre-assessment, one for ongoing assessment, and one for post- assessment of mastery of the goal. Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Midterm Project Due Week 4 Text Reading: Read about Gifted and Talented and ELL Differentiation http://www.nagc.org/index.aspx?id=660 Teaching Gifted Kids in the Regular Classroom, Susan Winebrenner, Brooklyn, MI http://www.carolyncoil.com/ezine21.htm What is Curriculum Compacting by Carolyn Coil, Ed.D http://www.nagc.org/index.aspx?id=387 NAGC Position Statement: Differentiation of Curriculum and Instruction Watch Video Clips Clip 1: http://www.youtube.com/watch?v=9ITZxENq3C Clip 2: http://www.youtube.com/watch?v=MDJst-y_ptI Assignment: You have decided to use the Curriculum Compacting strategy in your classroom in order to meet the needs of your most able learners. Create a plan that identifies the topic to be compacted, the assessment and identification of targeted students and the alternate activities offered on the topic. Include a rationale that supports your decision to Curriculum Compact and how you will effectively infuse it into your classroom. Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Week 5 Text Reading: Read 1 Read about Special Education differentiation http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=14hid=108sid=10da0a0a-a285-47c0-8bcb-68e34677c7b7%40sessionmgr111 Lawrence-Brown, D. (2004). Differentiated Instruction: Inclusive Strategies for Standards-Based Learning that Benefit the Whole Class. American Secondary Education, 32(3), 34-63. Retrieved from ERIC database. Text Reading: Read 2 http://www.k8accesscenter.org/training_resources/differentiationmodule.asp Select the Differentiation Strategies Chart Watch Video Clips Clip 1: Answer Questions (Open Ended) Goldilocks and the Three Bears can be used as a metaphor for guiding differentiated instruction. If instruction is too simple, students become bored. If instruction is too difficult, students become frustrated. How do you determine what materials and instructional methods are just right for each student in an inclusive classroom? Assignment: http://www.k8accesscenter.org/training_resources/differentiationmodule.asp Select Differentiation Scenario Using the strategies described and insight gained while reviewing the Differentiation Strategies Chart complete the task described on the Differentiation Scenario page. Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Week 6 Text Reading: Read about Maslow, Dunn and Dunn, and Rimm: Read 1 http://psychclassics.yorku.ca/Maslow/motivation.htm A Theory of Human Motivation H. Maslow (1943), Originally Published in Psychological Review, 50, 370-396. Read 2 http://wps.prenhall.com/wps/media/objects/863/884633/Volume_medialib/dunn.pdf Dunn and Dunn Read 3 http://www.sylviarimm.com/parentingarticles.html Read Rimms Laws and select one article from the Parenting Articles tab to read Watch Video Clips Clip 1: http://teachertube.com/viewVideo.php?video_id=72041title=Understanding_the_Basic_Needs_of_Children__ Answer Questions (Open Ended) After watching the video, describe the courage you needed to muster to become an educator? Think of one of your students and draw his/her circle of courage or circle of fear. List at least 2 factors in each quarter of the circle to support your selection of elements. Assignment: Create a three circle Venn Diagram in which you compare and contrast the Hierarchy of Needs, Dunn and Dunns Learning Styles, and Rimms Laws. Then select two points from each article that you recognize as being present or absent from your classroom. Cite evidence from your classes to support your ah-ha moment. Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Final Project Due Discussion Board: Students must submit one unique comment each week in regards to each of the assigned text reading and reply to a fellow students comments at least twice each week. The comments should relate to the material the text reading discusses. Each comment should be at least three sentences in length. The week ends Sunday at 9:00 p.m. Pacific Daylight Time If a student works ahead during the six week course they should still post every week for the automatic scoring software to count the postings. Students are reminded to check the announcement section of the discussion board frequently for items of interest from the faculty. Students are also reminded to use the email, not the discussion board, to ask questions or make comments directed to their facilitator. Methods of instruction: Percentage of Course Credit Video Lectures 20% Textbook/Articles Readings 10% Midterm project 25% Final project 30% Discussion Board interaction (weekly submissions) 10% Participation 5% Grading criteria/system and evaluation activities: A faculty member will be reviewing students answers and providing feedback. Students will be evaluated on their creativity and ability to incorporate techniques from the lecture into the discussion board, research papers, examples, lesson plans and teacher work samples. University Grading Criteria Grade Equivalent 97-100% A+ 93-96% A 90-92% A- 87-89% B+ 83-86% B 80-82% B- 77-79% C+ 73-76% C 70-72% C- 69% or below U Attendance/Participation It is expected that students will attend all instructional sessions, complete all required activities, and field assignments. Students who do not post in the discussion area during the first week of class AND do not notify the instructor in advance will be dropped from the course and may be charged a course drop fee. University Computer Lab/Library Services Please refer to Section VI in the Student Handbook. Disability Services Please refer to Section VII in the Student Handbook. Due dates of major assignments and projects: Midterm Project Due Date: TBA Final Project Due Date: TBA Midterm Project 1: Lesson Plan Activity Using the strategies, concepts and rubrics presented in the course, design a lesson to be taught in an elementary, secondary, or high school classroom. The lesson plan should include the following: Lesson Objectives Correlation with the most recently adopted version of your states content standards Prior Knowledge/ Understandings of Students: Explicitly note the differentiated instruction based upon the varying population in your classroom. Clearly state the basis of your differentiated approach i.e. ability, interests, language acquisition, reading levels, learning styles (or other) Activities: Explicitly note in the lesson plan how the activities connect to the approach you used to customize instruction Materials and Equipment (including technology) Assessment Method (for example, Rubric, Checklist, Anecdotal Notes, etc.) Prior to teaching the lesson, write a reflective statement that focuses on your lesson planning. You may choose to audio or video tape the lesson to assist you in your post teaching lesson analysis. Also, using the Peer Review Checklist template, select criteria to guide a colleague in analyzing your lesson plan. After teaching the lesson, write a reflective statement on your strengths, weaknesses and how you might modify the lesson plan to maximize student success the next time you teach it. An audiotape, if available, of the lesson should be made to assist you in your self-analysis. Using the Self-Peer Review checklist, have a colleague review your lesson plan and provide you with written feedback. You are also to complete the checklist. Discuss the feedback with the peer reviewer. Compare your self-analysis of your strengths and weaknesses with those of the peer reviewer and include your reactions to this comparison in your final reflective statements. Submit a copy of your lesson plan, your reflective statements, the Self-Peer completed checklist, and the comparison of the self analysis to the peer review, to the course instructor. The assignment should be a total of 9-12 pages in length and include 3-5 references. Use APA format: Use the standard Cover Page and submit to your course facilitator. All assignments are done in 12 pt. Times New Roman font and in APA, 5th Edition format. Add a Reference page that lists items of the authors works cited in your document. Use APA format for the items. INSERT Self and Peer Reviewer Lesson Plan Critique Checklist Scoring Rubric for Assignment Total Value: 100 Points Content of Paper Value: 70 points Copy of your lesson plan, your reflections, and the self and peer reviewer lesson plan critique checklist, and the analysis. Quality of Writing Value: 20 points Written work shows superior graduate quality in verbal expression, attention to detail, and correct application of the conventions of the English language. In students written work, paragraphing is appropriate with clear thesis statements and supporting details. Sentences are clear and concise. Students vary sentence structure making use of subordinate clauses. Transitional words and phrases are used effectively. Points and ideas are well organized. Word choice is effective. English language conventions are applied correctly (i.e. spelling, capitalization, punctuation, agreement, pronoun usage, sentence structure).   Format Value: 10 points Cover Page, Reference Page and where applicable, citations and references are used correctly and consistently, with clear efforts made to include a wide range of relevant works. For any work requiring citations, students refer to a wide range of suitable sources. All non original ideas are cited correctly and referenced in a reference list. All works in the reference list are cited in the text. Students  should follow the Writing Format and Style as required by their institution. Should the student not have a home institution, they will follow the APA Format and Style Manual, 5th Edition. Final: Assignment: Critical Issues Report The purpose of the assignment is to increase the knowledge base, add to the repertoire of reading theories, and increase skills of reflection and problem solving through research and reading on topics that are current, controversial, or significant in understanding the theories behind why some students do not achieve at a satisfactory level and why some students surpass the standards set. Select a topic that is personally intriguing and is addressed in the content of the course: Critical issues in special education theory and learning Maslows hierarchy of needs Sylvia Rimms approach to underachievers Opportunities for gifted students to be engaged in appropriately differentiated learning experiences Modified Dunn and Dunn model of learning styles Reasons for pre-testing Knowing how to choose appropriate assessments for evaluation and planning for instruction The Name Card Method for working in pairs Understanding how to work with Gifted Children Understanding how to work with special education children Read a minimum of three (3) reference sources on the selected topic. Write a 8  ½ page report that includes:  · Cover Page  · Introduction: Background Information (1 page)  · Body of Report (6  ½ pages) General review and summary of the articles content Personal reaction to the information that has been summarized with specific attention to synthesizing the ideas found in the research with course concepts and personal background experiences (personal reaction/critique/reflections) Complete responses to each of the following questions: (Elementary Education Competencies and Skills) How did the information in the selected readings or online lectures increase your knowledge of emergent special education techniques specific to the identification of concepts in the course thus far? How did the information in the selected readings or online lectures increase your knowledge of the Maslow Hierarchy of needs, specific to the developmental stages and the syntactic, semantic, and graphophonemic cueing of the hierarchy? How did the information in the selected readings or online lectures increase your knowledge of the process of constructing meaning from a variety of texts, specific to essential comprehension skills? How did the information in the selected readings or online lectures increase your knowledge of gifted children? How did the information in the selected readings or online lectures increase your knowledge of effective listening and viewing strategies? How did the information in the selected readings or online lectures increase your knowledge of the nature of assessing? How did the information in the selected readings or online lectures increase your knowledge of developing different learning experiences for each student? How did the information in the selected readings or online lectures increase your knowledge and improve your understanding of how to set up a classroom that will effectively meet the needs of all students? Conclusion (1 page): Recommendations for using your research and knowledge base gain from the course to this point.  · Reference Page: List of cited references, following APA format or format required of your institution. Scoring Rubric for Assignment Total Value: 100 Points Content of Report Value: 70 points Introduction, content review and summary, personal reaction/critique, responses to questions related to Elementary Education Competencies and Skills, conclusion (recommendations for using research in the classroom). Quality of Writing Value: 20 points Written work shows superior graduate quality in verbal expression, attention to detail, and correct application of the conventions of the English language. In students written work, paragraphing is appropriate with clear thesis statements and supporting details. Sentences are clear and concise. Students vary sentence structure making use of subordinate clauses. Transitional words and phrases are used effectively. Points and ideas are well organized. Word choice is effective. English language conventions are applied correctly (i.e. spelling, capitalization, punctuation, agreement, pronoun usage, sentence structure).   Format Value: 10 points Cover Page, Reference Page and where applicable, citations and references are used correctly and consistently, with clear efforts made to include a wide range of relevant works. For any work requiring citations, students refer to a wide range of suitable sources. All non original ideas are cited correctly and referenced in a reference list. All works in the reference list are cited in the text. Students  should follow the Writing Format and Style as required by their institution. Should the student not have a home institution, they will follow the APA Format and Style Manual, 5th Edition.

Free Essays - Running From Prejudice :: Personal Narrative Essay Example

Running From Prejudice I look around and I see it, and then I read about it. But I never thought I would be faced with discrimination firsthand. It's my junior year in high school, with lots of opportunities, freedom and responsibility. I decided to join the cross-country team, and somehow I knew it wouldn't be easy, but I knew most of the team from classes and from running track. The first day of practice I disregarded the stares. As the season went on, though, I started to feel out of place, like an outsider. I was the only African-American and there was no one I could relate to or who could relate to me. I stayed to myself and kept thinking, Life is not always great, but I just have to get through this. There were certain people I was able to get along with, but even they would occasionally make racial comments. By then I was fully aware of how much respect they lacked. One day after a meet as we were preparing to leave, they started discussing how teens sometimes do crazy things. Then all of a sudden the issue of black and white surfaced and someone said, "Whites are superior to blacks, blacks have issues." The saddest part of this was realizing they knew I was there and didn't care. My world crumbled as they made comment after comment and laughed. Reality smacked me in the face. I'd had my first encounter with discrimination. The tears poured from my eyes as I headed for the bus. The only thought I had was how I had been deceived into believing these people were my friends and I could trust them. Even though some apologized, I don't have the respect for them I had had before. My insight on people will never be the same. After the incident, I took some time away from the team to reflect on what was important to me.

Crazy Eddie, Inc. financial fraud case Essay

Crazy Eddie was an American retail store chain run by the Antar family, which was established as a private company in 1969 in Brooklyn, New York by businessmen Eddie and Sam M. Antar. The fraud at Crazy Eddie was one of the longest running in modern times, lasting from 1969 to 1987. Crazy Eddie became a known symbol for corporate fraud in its time, but has since been eclipsed by the Enron, Worldcom and Bernie Madoff accounting scandals. Commencement of fraud The fraud began almost immediately, with the management of Crazy Eddie underreporting taxable income through skimming cash sales, paying employees in cash to avoid payroll taxes and reporting fake insurance claims to the company’s carriers. Eddie Antar, the CEO of the company who was the mastermind in the fraud, was skimming money from sales taxes that he only partially remitted to the government, while using part of the money to give steep discounts to customers. Much of the rest of the money he used to fund a partying lifestyle, while secreting a fortune at home and abroad. He also repackaged used and damaged electronics and resold them to customers as new. When electronics companies refused to supply him because he was selling the products to his customers below list price, he instead sourced the products from suppliers in other countries on the gray market. He used massive sales promotion strategy to promote his company’s name and products. The television ad of the company was very much popular that time. The company began to grow rapidly and had several branches across the country. As the chain grew in size, the Antar family started planning for an initial public offering (IPO) of Crazy Eddie and scaled back the fraud so that the company would be more profitable and get a higher valuation from the public market. This strategy was a success and Crazy Eddie went public in 1984 at $8 per share. The final phase of the Crazy Eddie fraud began after the IPO and was motivated by a desire to increase profits so the stock price could move higher and the Antar family could sell its holdings over time. Management now reversed the flow of skimmed cash and moved funds from secret bank accounts and safety deposit boxes into company coffers, booking the cash as revenue. The scheme also involved inflating and creating phony inventory on the books and reducing accounts payable to boost profits at the company. Concealment of fraud The electronics chain used the young, inexperienced, undereducated and under skilled auditors for the audit purpose. The chain was able to fool young auditors by showing them inventory stock rooms filled with empty boxes of electronics gear, while distracting them with attractive female workers so they wouldn’t bother to look at what was inside or behind the stacks of boxes. They had a concept that if the auditor was wearing a suit, it was sure he wasn’t going to get it dirty by moving the boxes. Eddie Antar was the mastermind behind the various schemes and hired his relatives to work at the electronics chain to help aid and abet the fraud. Eddie Antar paid for his cousin Sam E. Antar to learn accounting so he could eventually work at the growing company’s small auditing firm, Penn and Horowitz. In 1981, Sam passed the CPA examination with a 90% and scored in the top 1% in the country. He later became the Penn and Horowitz Company’s CFO in 1986. All the family members were bound together by a culture of crime and were working as a team for commitment and concealment of crime. Exposure of fraud The company was making so much money that Eddie Antar was having trouble finding places to put it. He ran out of hiding places in his office and home, and eventually began traveling to Israel and Switzerland to stash the money in secret bank accounts. However, the scheme began to unravel when his wife found out he was cheating on her, and the family took sides in the dispute. The fraud was finally uncovered in 1987 after the Antar family was ousted from Crazy Eddie after a successful hostile takeover by an investment group. The acquirer found out how overvalued Crazy Eddie really was and hired another outside auditor to look closely at the books. Crazy Eddie limped along for another year before being liquidated to pay creditors. Eddie Antar, the CEO of Crazy Eddie, was charged with securities fraud and other crimes, but fled to Israel before his trial. He spent three years in hiding until he was eventually tracked down by authorities in 1992 and extradited back to the U.S. to face criminal charges. Antar and two other family members were also convicted for their role in the fraud. In 1997, Antar was sentenced to eight years in prison and paid large fines. He was later released in 1999. Crazy Eddie Red Flags The red flags in the Crazy Eddie, Inc. financial fraud case which could notify the potential fraud were as follows:- The tight knit Antar family ruling Crazy Eddie had virtual absolute control over all aspects of the business. Very poor audit trails and documentation. Major self-dealing transactions and related party transactions by family members. Substantial increases in wages from below market wages before the company went public. In 1985, an attempt was made to falsify certain store inventories which was uncovered by the auditors. The auditors accepted an excuse that it was not sanctioned by management. Substantial increases in gross margins, profits, inventories, debit memos etc. from prior periods for no logical reason. Significant volume of outstanding deposits in transit at fiscal year end. Individual deposits in transit extremely high in relation to normal amounts at fiscal year end. Unusually high inventory volumes in stores where physical counts were not observed by outside auditors. Inventories in many individual stores were in excess of space capacity. Major differences between amounts confirmed from vendors for accounts payable and amounts reported on Crazy Eddie’s books and records. Use of â€Å"gross margin method† to value inventories during interim periods instead of taking interim inventory counts. Change of accounting methods for purchase discounts and trade allowances in 1987 from cash basis to accrual basis noted in footnotes with no accounting adjustments. Small CPA firm that conducted Crazy Eddie audits before (then big eight firm took over audits) had a significant revenue base from Crazy Eddie. Controller and later CFO for Crazy Eddie (Sam E. Antar) worked for small CPA firm that audited Crazy Eddie books. Biggest Crazy Eddie Audit Errors The reason, Crazy Eddie was able to conceal and commit the fraud for such a long time could be the inefficiencies of the auditor and the government to uncover the fraud. The government, auditors and investors were fooled by the company’s flamboyant founder and CEO, Eddie Antar and his family. Some of the biggest Crazy Eddie Audit Errors were as follows:- Assuming a proper audit can be conducted in the absence of credible internal controls. Under  educated, under skilled, and under experienced audit staff. Over using audits as training grounds for inexperienced audit staff. Lack of investigative or forensic accounting skills by auditors. Failure to ask proper questions to the concerned persons. Assuming the answers to good questions as correct without verification. Failure to ask follow up questions. Lack of professional skepticism. Allowing company staff to distract auditors from doing filed work by engaging in social conversations, thereby wasting time during audits so they have to rush their work in the end to meet the audit deadline. Failure to simultaneously observe inventory counts in all locations. From 1984 to 1987, the auditors did not observe all store inventories or inventories at all locations. Failure to take copies of full inventories taken when leaving the premises. Failure to conduct proper test counts of inventories by relying on company staff to count boxes and allowing company staff to take possession of test counts to make copies on behalf of auditors. Failure to follow through on analytical test issues. Failure to conduct all required analytical testing. Failure to conduct sales cut off testing at year end. Failure to examine items listed as deposits in transit at year end. Failure to age accounts payable. Failure to conduct adequate verification of accounts payable balances. Failure to contact vendors when major discrepancies were identified as vendors sent back verification requests. Failure to secure audit work papers left on premises during the audit by leaving keys to trunks containing audit documents on company premises. Allowing company personnel to view audit work papers in process. Auditors signed off on financial reports to outside directors and allowed the issuance of financial statements before the fiscal year 1987 audit was completed and backed into the numbers. Auditors made misrepresentations to the outside directors about certain questionable practices and directions from the outside directors to investigate them. Auditors made misrepresentations to the SEC about directions from the audit committee to investigate questionable accounting practices. The auditors  failed to follow up on recommendations of Crazy Eddie’s outside counsel law firm Paul, Weiss, Rifkind to investigate irregularities concerning sales to a trans-shipper in 1987. The auditors disagreed with recommendations by Crazy Eddie’s outside counsel law firm Paul, Weiss, Rifkind to provide more detailed disclosure on Crazy Eddie sales to trans-shippers and other issues. The Fraud Triangle The Crazy Eddie, Inc. financial fraud case, if linked up with the fraud triangle, following result can be obtained:- a. Incentives/Pressures Greediness Desire of Luxurious Lifestyle Expensive extramarital relationships of Eddie Antar Pressure to maintain social status Pressure to sustain in competitive market b. Opportunities Lack of internal and external controls Lack of audit trail Inability of the auditors to judge performance quality Lack of outsiders’ access to information c. Rationalization Sam Antar, former CFO of Crazy Eddie gave a statement, – â€Å"we committed crime simply because we could. Criminologists like to analyze white collar crime in terms of the ‘fraud triangle’ — incentive, opportunity, and rationalization. We had no rationalization. Simply put, the incentive and opportunity was there, but the morality and excuses were lacking. We never had one conversation about morality during the 18 years that the fraud was going on.† This statement shows that there was no rationalization used while committing the fraud, we could assume that following rationalizations could have been used by them:- Whatever they were doing did not hurt anybody else. Whatever they were doing was not wrong. Moral justification like, â€Å"Everyone else is doing it, so it must not be so bad to do this† could have been used. References 4 Massive Frauds You’ve Probably Never Heard Of. (n.d.). Retrieved from http://www.investopedia.com/articles/economics/12/four-unknown-massive-frauds.asp A Convicted Felon Speaks Out about White Collar Crime. (n.d.). Retrieved from http://www.whitecollarfraud.com/947660.html Crazy Eddie – Wikipedia, the free encyclopedia. (n.d.). Retrieved May 6, 2014, from http://en.wikipedia.org/wiki/Crazy_Eddie Crazy Eddie Masterminds [Video file]. (2012, January 7). Retrieved from http://www.youtube.com/watch?v=CP8iO5lvCoU Weirich, T. R., Pearson, T. C., & Churyk, N. T. (2010). Accounting & auditing research: Tools & strategies. Hoboken, NJ: Wiley.

Management Of Transient Ischaemic Attacks Health And Social Care Essay

The NICE guidelines and the National Stroke Strategy ( 2008 ) emphasises the importance of measuring all patients with a suspected TIA within a hebdomad and all high hazard patients within 24 hours. This is to enable originating appropriate direction. This includes life manner steps such as weight decrease, smoking surcease, cutting back on intoxicant etc. in add-on to turn toing hazard factors for shot. Suitable patients are referred for surgical intercession. This systematic reappraisal will look at all these issues and expression at the grounds for medical and surgical intercessions and the timing of the surgery, the type of surgery etc. Around 15,000 people per twelvemonth have a suspected TIA but presently merely 35 % of people are investigated and managed in a timely manner. There is a 20 % hazard of shot within the first 4 hebdomads after shot. Investigating and handling bad patients with TIA within 24 hours could bring forth an 80 % decrease in the figure of people who go on to hold a full shot. The hazard of shot after a TIA is approximately 12 % in the first twelvemonth and so about 7 % per twelvemonth thenceforth. There is a high hazard of shot in the seven yearss after TIA, perchance every bit high as 10 % . The hazard of shot, bosom onslaught or vascular decease is about 10 % a twelvemonth. This is approximately seven times the hazard in the background population. [ From thee Stroke Website ]PurposesThe intent of this reappraisal is to discourse the rapid appraisal and early direction aimed at cut downing ischemic encephalon harm, and in the instance of TIAs, forestalling subsequent shot. This will be achie ved by utilizing the most recent and up-to-date grounds from the literature.IntroductionA transeunt ischemic onslaught ( TIA ) is defined as an acute loss of focal encephalon or monocular map with symptoms enduring less than 24 hours and which is thought to be caused by unequal cerebral or optic blood supply as a consequence of arterial thrombosis, low flow or intercalation associated with arterial, cardiac or hematologic disease. [ Hatano 1976 – Page 1 G.Book ] . More late in 2002, Albers et Als proposed a revised definition for TIA, adding that there is no grounds of acute infarction on encephalon imagination. Infracted tissue is non ever obvious on imagination and so this definition has non yet been widely adopted. Stroke is the 3rd most common cause of mortality in the developed universe and there are a figure of preventable causes. Over the past 30 old ages, the direction of shot has changed at a phenomenal rate. New probes help direct patient choice for specific therapies and may well increase the opportunity of a successful curative result. Specialists have seen a broad scope of therapies introduced for the direction of TIAs and acute ischemic shot. These progresss have led to a theoretical account displacement in intervention, which is apparent in the protective direction of shot victims today.Methods( See ‘Methods ‘ in Appendix 1 ) .Epidemiology of TIAFor us to understand the clinical direction of TIAs and shots, to be after clinical services or to plan randomised controlled tests, and to mensurate the overall impact of interventions, it is of import to understand the epidemiology of TIAs and shots. Each twelvemonth at that place are about one million shots in Europe. [ Sudlow and Warlow – Pg 3 G.Book ] . Approximately 25 % of work forces and 20 % of adult females can anticipate to hold a shot if they live to be 85 old ages old and shot is the 2nd most common cause of decease worldwide. [ Murray and Lopez 1996 – Pg 3 G.Book ] . Mortality information underestimates the true load of shot since in contrast to coronary bosom disease and malignant neoplastic disease, the major load of shot is chronic disablement instead than decease [ Wolfe page 4 g.book ] . Strokes cause 23 % of healthy old ages lost and about 50 % of old ages of life lived with disablement in Europe. Stroke causes many secondary unwellness such as ; dementedness, depression, epilepsy, falls and breaks. In the UK the costs of shot are estimated to be about twice those of coronary bosom disease, accounting for about 6 % of entire NHS outgo. [ Rothwell 2001 – Pg4 G.Book ] . In add-on to shots, TIAs are besides common, and it is estimated that 54,000 TIAs occur yearly in England. Rothwell and Warlow estimate that about 20 % of shots are preceded by a TIA. MRI of patients who have suffered a TIA lasting longer than an hr shows that over 50 % have seeable countries of infarction. Technically they have non suffered a ‘stroke ‘ but a intellectual infarction. This emphasizes that TIA and shot are a continuum. The epidemiology of TIA is a batch more ambitious than that of shots since patients with TIAs are more heterogenous and present to a assortment of different clinical services, if they present to medical attending at all. Furthermore, dependable diagnosing of TIA requires early and adept clinical appraisal, as there is no diagnostic trial for TIA, doing epidemiological surveies really labour intensive and expensive.Aetiology and Clinical PresentationThe causes of TIAs are the same as the causes of shot, with the caution that the huge bulk of TIAs appear to be caused by ischemia instead than haemmorhage. In a TIA it is of import to find the site of the cerebrovascular lesion since this narrows down the likely implicit in aetiology and enables appropriate aiming of probes. The differential diagnosing of TIA differs from that of shot due to the transeunt nature of its symptoms. Hints in the history and on scrutiny can direct the tester to the likely underlying cause, enabling specific intervention to commence and secondary bar. [ Pg 113 G. Book – first parity ] A diagnosing of TIA is supported by a sudden oncoming and definite ‘focal ‘ symptoms, sudden oncoming and definite focal symptoms in the history and grounds of vascular disease on scrutiny [ manus et Al Pg 104 G. book ] . The most common of the symptoms can be seen in Table Ten:SymptomsFrequency ( % )Unilateral failing, weightiness, or awkwardness 50 Unilateral sensory symptoms 35 Dysarthrias 23 Transient Monocular Blindness ( Amaurosis Fugax ) 18 Dysphasia 18 Ataxia 12 Bilateral coincident sightlessness 7 Dizziness 5 Homonymic Hemianopia 5 Diplopia 5 Bilateral Motor Loss 4 Dysphagia 1 Crossed Sensory and Motor Loss 1 The symptoms of a TIA enable classification of onslaught by arterial district affected ; carotid in about 80 % or vertebrobasilar in 20 % . This has of import deductions for farther probe and secondary bar. There are no trials to corroborate a TIA, and the gilded criterion method of diagnosing remains a thorough clinical appraisal every bit shortly as possible after the event by an experient shot doctor, although the coming of new imaging techniques, peculiarly diffusion weighted MRI has allowed the diagnosing to be made or excluded with more certainty in some patients.Probes and Imaging/Diagnosing techniquesThe function of imaging in TIA is to corroborate the diagnosing, confirm the vascular district affected ( where the lesion may be ) , and to place those people who would profit from carotid intercession. [ 1- pg 8 Imaging Guidelines ] . The chief modes for imaging the encephalon parenchyma are CT and MRI. These are progressively being used to measure the intellectual vasculature in TIAs. In TIAs and minor shots neuro-imaging is required to: Exclude stroke mimics Distinguish between haemorrhagic and ischaemic events Determine the Aetiology, eg: carotid stricture with lesions in multiple vascular districts Identify patients at high hazard of early recurrent shot, in order to aim suited intervention. Sensitivity and specificity of different imaging modes varies with the pre-test chance, the nature of the lesion, the hold from event to imagination, whilst expertness in imaging techniques besides varies greatly. Hence when doing determinations about imagination after TIA, the pick of imagination will depend on all these factors, every bit good as patient safety, tolerability and contraindications. For illustration see Table X, for the advantages and disadvantage of CT versus MRI in TIA and minor shot. [ Page 132 – G.Book ] .Imaging ModalityAdvantagesDisadvantagesConnecticutLow Cost and broad handiness Low sensitiveness for little acute ischemic lesions Superior sensing of haemmorhage in early stage Low sensitiveness for mimics, particularly tumors. Radiation exposure IV contrast is nephrotoxic and potentially allergenic.Magnetic resonance imagingSuperior sensitiveness for shot mimics Patient tolerability and contraindications Provides predictive information. Superior sensing of bleeding in the subacute and chronic stage Table – Advantages and Disadvantages of CT and MRI in minor shot and TIA. In cohorts of patients with suspected TIA who were referred straight for scanning by primary attention doctors, prior to expert reappraisal by a shot doctor, rates of alternate diagnosings were high, likely reflecting high rates of misdiagnosis prior to imaging. [ Lemesle et Al 1998 – G.Book Page 132 ]Non-Radiological Probes for TIAFirst-line probes include ; basic blood and urine trials at presentation. Table Ten shows the baseline non-imaging trials for TIAs and shots.ProbeDisorders detectedFull Blood Count Anemia Polycythaemia Leukemia Thrombocythaemia/thrombocytopenia Erythrocyte Sedimentation Rate/ C-Reactive Protein Vasculitis Infective Endocarditis Hyperviscosity Myxoma Electrolytes Hyponatraemia Hypokalaemia Urea Nephritic Damage Plasma Glucose Diabetess Hypoglycemia Plasma Lipids Lipemia Urine Analysis Diabetess Nephritic Disease Vasculitis Second-line probes must be chosen suitably since the likeliness of a relevant consequence depends on the choice of patients and farther probe will incur more cost. [ Page 174 G.Book ] . Cardiac jobs such as AF – echocardiogram may demo atrial thrombus, aneurism of the anterior wall of the left ventricle with mural thrombus, atrial myxoma or left side valve disease. Cardiac monitoring may demo paroxysmal AF. Doppler surveies of the carotid and vertebral arterias may demo contracting. This probe may be followed by Carotid angiography and Carotid endarterectomy if stricture is a least 70 % . It may be argued that full probe for CHD should be initiated, as the most common cause of decease after TIA is MI. Table 1 Secondary probes by the specializer servicesShort-run forecast after TIARecent research has shown that the hazard of shot instantly after TIA is considerable [ Giles and Rothwell 2007, pg 195 G.book ] . However, this poses a challenge to clinical services because it leaves many TIA sick persons at a hazard of a major shot in the short term. Predictive tools have been developed to place patients at high and low hazard in order to inform public instruction, assistance effectual triage to secondary attention and direct secondary preventative intervention. Datas from population-based surveies and tests suggest that 20 % of patients with shots have a preceding TIA. [ Rothwell and Warlow 2005 – Pg 195 G.Book ] . A recent systematic reappraisal identified 18 independent cohorts, all published since 2000, describing shot hazard in 10,126 patients with TIA [ Giles and Rothwell 2007 – Pg 196 G.Book ] . 3.1 % shot hazard at two yearss and 5.2 % shot hazard at seven yearss.ABCD2 score – proof? i? See Document 48395 – Page 9 of 27.A new marking system for two twenty-four hours hazard of shot following TIA, dubed ABCD2. The Hazard factors employed in the ABCD2 marking system for 2 twenty-four hours hazard of post-TIA can be seen in table Ten:Hazard FactorValuessPointsAge a†°? 60 old ages1Blood Pressure lift ( either/or ) Systolic a†°? 140 millimeter Hg Diastolic a†°? 90 millimeter Hg1Clinical Features ( either/or ) Unilateral failing Speech damage without failing21Duration of TIA a†°? 60 min 10-59 min21Diabetess Yes/ No1( Reference = Johnston SC et al – Lancet 2007 369 ( 9558 ) :283-292. )Recognition of Symptoms and delays to directionPressing direction of patients with TIA depends upon the right acknowledgment of symptoms and appropriate action by patients and their fleet triage to specialist attention where probe and intervention are quickly initiated. Public consciousness and behavioral surveies are missing, nevertheless, one survey of cognition among the general populace indicated that 2.3 % of a indiscriminately selected sample of people in the USA have been told by a doctor that they had a TIA, based on self-report in a telephone study conducted in 2003 [ Johnston et al – Pg 239 G.Book ] . However an extra 3.2 % of respondents recalled symptoms consistent with TIA but had non sought medical attending at all and accordingly had non been diagnosed by a physician. Of those with ‘diagnosed ‘ TIA, merely 64 % had seen a physician within 24 hours of the event. Merely 8.2 % right related the definition of TIA, and 8.6 % were able to place a typical symptom. This suggests that frequent public instruction is required non merely on the nature of a TIA but besides what to make in the event of one.Recognition ToolsSeveral tools have been devised to help the right acknowledgment of shot and TIA symptoms. In the pre-hospit al scene, FAST, LAPPS and CPSS have been designed for usage by exigency services to guarantee rapid conveyance of patients to specialist attention. In the exigency puting ROSIER mark has been designed to help exigency doctors in diagnosing. The chief purpose of these tools has been to increase the Numberss of patients showing to hospital within three hours and, therefore, addition eligibility interventions. However due to the increasing accent on rapid direction for minor shot and TIA, their usage in informing public instruction and right diagnosing of minor shot and TIA is likely to go more widespread. The ABCD system was so developed to foretell the early hazard of shot following a TIA, and one of its chief utilizations has been in triage between primary and secondary attention. [ Rothwell et all 2005 – pg 241 G. book ] .Discussion of the Management of TIAs – Critical Reviewing( Use Diagrams and Tables ) Although the acute intervention of major shot, TIA and minor shot have many common elements, there are of import differences. In the acute intervention of TIA, the purpose is secondary bar of a disenabling shot, which might follow in the immediate hours and yearss after the initial event, as opposed to reversal of any neurological shortage caused by the shot itself. To cut down the hold in intervention, improved public instruction and improved triage to secondary attention and coordinated patient direction in specialist units are critical facets of intervention in TIAs. However there is a greater focal point on pressing, effectual secondary bar for TIA and minor shot. Although the construct of TIA arose in the 1950s and interventions for it were proven effectual, it was non until 2007 that the first studies were published on the feasibleness and effectivity of pressing appraisal and intervention of TIA in specialist units [ Rothwell 2007 – Pg 239 G.Book ] .Lifestyle AlterationAll tobacco users, including those with a history of shot or TIA, should be advised to halt, and intercessions such as guidance, nicotine replacing should be used if needed to assist them accomplish this. [ 257-263 ] . Avoiding extra intoxicant is reasonable and everyone including those who have suffered from a TIA or shot, should avoid heavy imbibing. Although a twosome of units of intoxicant per twenty-four hours may protect against future vascular events. [ 274-276 ] Reducing dietetic salt intake reduces BP, peculiarly in the aged with high BP, possibly ensuing in long term decrease in vascular events. It may besides assist those on antihypertensive medicine to halt their intervention without a rise in BP. It is advisable for old TIA or stroke sick persons to cut down consumption of concentrated fat, since it produces moderate decrease in cholesterin degrees, which are associated with little decreases in vascular events. [ 279-281 ] . Corpulent persons should be encouraged to lose weight utilizing dietetic or if necessary pharmacoligcal or surgical intercessions. All patients should have general advice about a healthy diet, low in concentrated fats, with plentifulness of fish, fruit, fiber and veggies. These intercessions have good effects on vascular hazard factors and seem likely to bring forth little decreases in vascular results despite there being no clear grounds that they do. [ 286-289 ]The Medical Management – Secondary PreventionNumerous interventions have been shown to forestall shot in the long term after a TIA, including antiplatelet agents such as acetylsalicylic acid, clopidogrel, and the combination of low-dose acetylsalicylic acid and extended release dipyridamole [ CAPRIE 1996 – pg241 GB ] ; blood force per unit area take downing drugs [ PROGRESS 2001 ] ; statins [ Amarence et Al 2006 ] ; anticoagulation for atrial fibrillation [ European atrial sibrillation test survey group 1993 ] ; and endarterectomy for diagnostic carotid arteria stricture & gt ; or equal to 50 % [ Rothwell 2003-04 ] . If the effects of all these interventions are independent, combined usage of all these intercessions in the appropriate patients would be predicted to cut down hazard of recurrent shot by 80-90 % [ Hackam and Spence 2007 Pg241 GB ] . However tests of intervention in acute shot suggest that the benefits of several of these intercessions are even greater in the acute stage, until late there has merely been few dependable informations on the benefits of ague intervention after TIA. NICE guidelines suggest that appraisal and probe should be completed within one hebdomad of a TIA. [ Wolfe 1999, Johnston 2006, NICE 2008 – pg 242 GB ] . Rapid intervention of TIA can forestall up to 80 % of recurrent shots. [ Rothewell Pg 285 GB ] . There is considerable grounds associating to the effectivity of assorted interventions to cut down the hazards of vascular events after TIA and shot. See Table 1:DrugTestTreatmentAspirinCastAspirin versus placebo within 48 hours of major ischemic shotISTAspirin versus placebo ( and SC heparin versus placebo ) acutely after major ischemic shot.Anti-thrombotic Trialists ‘ CollaborationMeta-analysis of tests analyzing antiplatelet agents in patients at high hazard of occlusive vascular disease. DipyridamoleClairvoyances 2Aspirin and Modified Release Dipyridamole versus placebo in a 2Ãâ€"2 factorial design started within 3 months of TIA or ischemic shot.EspritAspirin versus acetylsalicylic acid plus dipyridamole started within 6 months of TIA or minor shot. ClopidogrelMatchClopidogrel versus acetylsalicylic acid plus clopidogrel within 6 months of ischemic shot or TIA.CharismaAspirin versus acetylsalicylic acid plus clopidogrel in patients with cardiovascular disease or multiple hazard factors ( including ischemic shot )FASTERAspirin versus acetylsalicylic acid plus clopidogrel in the ague stage after TIA or minor ischemic shot. Antihypertensive DrugsAdvancementPerindopril plus or minus Indapamide versus placebo after TIA or ischemic shot in patients with or without high blood pressure. Cholesterol-lowering drugsHorsepowerSimvastatin versus placebo in patients with coronary disease or other occlusive vascular disease including TIA or shot.SPARCLAtorvastatin versus placebo started within 1 to 6 months of TIA or ischemic shot. Table: Major tests and meta-analyses lending to the grounds base for medical intervention in secondary bar after TIA and ischemic shotVariation in intervention worldwide:Unsurprisingly there is considerable international fluctuation in how patients with suspected TIA are treated in the acute stage, possibly due to the historical deficiency of grounds. For case, Gallic and German health care systems provide immediate exigency inmate attention and the average infirmary stay is about seven yearss [ albucher ] , whilst other systems ( such as Canada ) provide non-emergency outpatient clinic appraisal [ Johnston and Smith 1999, Goldstein 2000 – pg 242 ] . For illustration a Canadian survey showed that in more than one tierce of the patients, antithrombotic therapy was non prescribed on discharge. In the UK, the standard agencies of appraisal and direction is a neurovascular outpatient clinic ( â€Å" TIA Clinic † ) [ Intercollegiate working party for Stroke 2004 – Pag e 242 ] .Antiplatelet AgentsSeveral big controlled tests have now compared antithrombotic therapy ( antiplatelet or anticoagulant agents ) versus control in acute ischemic shot these have been big and have provided dependable grounds on safety or efficaciousness. Antiplatelet drugs such as acetylsalicylic acids can be effectual in the secondary bar of ‘serious vascular events ‘ ( Stroke, MI, and Vascular decease ) [ 12 from the IST survey ] . If taken for a few old ages after a myocardial infarction, ischemic shot, or transeunt ischemic onslaught ( TIA ) , antiplatelet therapy typically avoids about 40 serious vascular events per 1000 patients treated. In acute ischemic shot there is significant thrombocyte activation, which can be inhibited by acetylsalicylic acid. [ 2,14,15,16 from IST ] . Aspirin was by far the most widely studied antiplatelet drug in the ATT ( antithrombotics triallists coaction ) reappraisal. Among about 60,000 high hazard patients, excepting those with acute ischemic shot, aspirin entirely reduced the odds of a serious vascular event by one one-fourth. Almost 10,000 of these patients had a anterior TIA or ischemic shot. Aspirin significantly reduced the comparative odds of a serious vascular event by 17 % , matching to an absolute hazard decrease of 30 per 1000 over 3 old ages. Controversy has surrounded the most appropriate dosage of acetylsalicylic acid, clinicians have argued about doses runing from 30 milligrams to 1500 mg. [ 158-160 Big book chapter 16 ] . Theoretical grounds suggest lower doses might in fact be more good than higher doses. After sing all the available grounds from direct and indirect comparings in bad patients, it seems sensible to reason that acetylsalicylic acid at a dosage of 75-150 mg day-to-day is every bit effectual as higher doses and is most appropriate for long-run secondary bar of serious vascular events to maximise benefits and to minimise inauspicious effects. Doses below 75 milligrams day-to-day may be as effectual, but this still remains rather unsure. Patients with TIA or acute shot, should be treated with acetylsalicylic acid every bit shortly as operable after encephalon imagination has excluded bleeding. Sandercock et al 2003 reviewed two really big randomised controlled test ( International Stroke Collaborative Group 1997 ( IST ) and Chinese Acute Stroke Trial Collaborative Group ( CAST ) which together randomised over 40,000 patients. Sandercock clearly established that get downing aspirin therapy within the first 48 hours of acute ischemic shot avoids decease or disablement at six months for about 10 patients per 1000 patients treated. A farther 10 patients per 1,000 treated will retrieve wholly. intracranial and extracranial bleeding are reported with aspirin therapy but this has low rates, and it is offset by the benefit of excess lives saved. In the IST, patients were allocated, in an unfastened factorial design, to intervention policies of: 300 milligrams aspirin daily, Lipo-Hepin, the combination, or to ‘avoid both acetylsalicylic acids and Lipo-Hepin ‘ for 14 yearss. In the CAST, patients were allocated, in a double-blind design, to 1 month of 160mg aspirin day-to-day or fiting placebo [ Get references 156 and 157 from Chapter 12 -Big Book ] . There is no clear consensus about whether acetylsalicylic acid should be given before encephalon imagination. This is applicable in state of affairss where entree to imagination is delayed or where drugs could be administered by ambulance staff. [ IST 1997 ] There is besides no clear grounds that any peculiar dosage of acetylsalicylic acid is more effectual that others. However symptoms of aspirin toxicity are dose-related, so the smallest effectual dosage should be used. Initial dosage of 150-300mg per twenty-four hours is advised for the acute stage, followed by long-run intervention with 75-150mg per twenty-four hours. Patients intolerant to aspirin should be treated with clopidogrel or with dipryidamole, these newer agents are well more dearly-won than acetylsalicylic acids.Alternate Antiplatelet therapies/regimensAspirin acts on merely one of a figure of tracts taking to platelet activation and so thrombosis. Antiplatelet drugs moving through different tracts might hence be more effectual than aspirin if given as options to, or combined with, acetylsalicylic acid. Several recent big tests have provided information about alternate antiplatelet regimens. Clopidogrel V acetylsalicylic acid: A systematic reappraisal of RCTs of a thienopyridine V acetylsalicylic acid in bad patients identified 10 relevant tests in 26,865 patients. Aspirin was compared with clopidogrel in one test of 19,185 patients with ischemic shot and with ticlopidine in the staying nine tests in a sum of 7,633 patients, most of whom had a recent TIA or minor shot. Thienopyridines modestly and significantly reduced the odds of a serious vascular event compared with acetylsalicylic acid. [ 174 from chapter 16 BB ] . No important inauspicious effects were found in footings of bleeding. On the other manus the thienopyridines were associated with lower hazard of GI shed blooding. [ 174 ] . Few tests that have compared clopdogrel and ticlopidine have straight suggested better safety and tolerability with clopidogrel, doing it the theienopyridine of pick on safety evidences [ 183-185 BB ch 16 ] . In drumhead, clopidogrel is every bit effectual as acetylsalicylic acid and slightly perchance more so. The high cost of clopidogrel and the uncertainness of any extra benefit compared to aspirin do it unreasonable to propose that it should replace aspirin as the first pick antiplatelet drug for all patients at high vascular hazard. It is a sensible alternate antiplatelet drug for patients with a history of TIA or minor shot, who are truly allergic to aspirin. There is presently no grounds from RCTs to back up the usage of combination of clopidogrel plus acetylsalicylic acid to forestall vascular events in patients with TIAs. Antiplatelet therapy reduces the hazard of perennial vascular events after TIA. Most test informations concerns aspirin nevertheless, clopidogrel { CAPRIE Steering commission 1996 ) and drawn-out release dipyridamole ( Sivenius 1991 ) have besides been shown to be effectual in their ain mechanisms of action.Combination Antiplatelet therapy:The combination of acetylsalicylic acid and dipyridamole is more effectual than aspirin alone [ Diener et Al 1996, Halkes et al 2006 ) . This combination shows a comparative decrease in the hazard of perennial shot of around 30 % compared with aspirin entirely. On the contrary, the combination of clopidogrel and acetylsalicylic acid was non superior to clopidogrel entirely in secondary bar after shot, TIA or other vascular disease in the MATCH and CHARISMA tests. [ Diener et al 2004, Bhatt et al 2007 ] . However there was no important tendency towards benefit from combination antiplatelet intervention in the MATCH test, there was besides a higher hazard of bleeding after 18 months in the combination therapy, which was non evident until 4 months into the test. Consequently, it is possible that draw a bead oning along with a short class of clopidogrel may be effectual in the ague stage after a TIA and minor shot. Antiplatelet agents: – prevent extension of arterial thrombus, prevent thrombocyte collection in microcirculation, prevent re-embolisation from embolic beginning, cut down release of eicosanoids and other neurotoxic agents. Aspirin: – inhibits COX-1, cut downing dislocation of arachadonic acid to thromboxane A2 and thrombocyte granule release. Clopidogrel and other thienopyridines: – encirclement of thrombocyte membrane ADP receptors, suppressing ADP-dependent thrombocyte activation and granule release. Dipyridamole: – Inhibition of phosphodiesterase, doing lift of intracellular thrombocyte cyclicAMP and a attendant decrease in Ca suppressions ; this thrombocyte activation and granule releases. [ TABLE 24.2 – Page 287 G.B ]Anticoagulation and patients with AF:Immediate therapy with decoagulants such as LMWH, unfractionated Lipo-Hepin, and heparinoids in patients with acute ischemic shot is non associated with net short- or long-run benefit [ IST 2007 – Berge 2007, Wong et Al 2007 – Pg 258 GB. ] . These agents cut down the hazard of DVT and PE, but are associated with important hazard of intracranial bleeding, which is dose dependent. Patients in AF after a presumed TIA benefit from anticoagulation in the long-run to forestall a farther shot. However, the best clip to get down therapy after an ischemic shot is ill-defined as the hazard of bleeding is hard to foretell. [ IST – Donnell 2006 – pg 258 GB ] . Patients in AF who have a TIA should be given anticoagulation therapy if there are no contraindications [ European Atrial Fibrillation Trial Study Group 1993,1995 ] . Recent surveies have shown that Coumadin is every bit safe as acetylsalicylic acid in aged patients with AF [ Rash et Al 2007, Mant et al 2007 ] . Patients with presumed cardioembolic TIA or stroke secondary to other causes should surely have antithrombotic therapy. Besides they may profit from anticoagulation in other cardiac fortunes, but at that place have been no randomised controlled tests in state of affairss other than non-valvular AF. Anticoagulation is non effectual in secondary bar of shot for patients in sinus beat. Warfarin intervention to a mark INR of 3-4.5 was associated with important injury due to a big addition in major hemorrhage complications, particularly intracerebral bleeding, in patients with old TIA – in the Stroke Prevention in Reversible Ischaemia Trial ( SPIRIT ) [ Algra et al 1997 ] The subsequent Warfarin versus Aspirin in the Secondary Prevention of Stroke ( WARSS ) test of aspirin versus Coumadin for patient in fistula beat and without cardioembolic beginning or with more than 50 % CAS ( carotid artery stricture ) showed no extra benefit for Coumadin at a mark INR of 1.4-2.8 [ Redman and Allen 2002 ] . There has been uncertainness as to whether anticoagulation is preferred to antiplatelet intervention for the secondary bar of ischemia relate to intracranial coronary artery disease. A robust randomised dual unsighted test ( WASID – Warfarin-Aspirin Diagnostic Intracranial Disease ) test of Coumadin, to a mark INR of 2-3, versus acetylsalicylic acid to 1300 milligrams per twenty-four hours in patients with 50-99 % stricture of a major intracranial arteria showed no important benefit for Coumadin over aspirin [ Chimowitz et Al 2005 – pg 287 G.B ] . In fact, Coumadin was associated with increased rate of bleeding and other inauspicious events ; as a consequence the survey was stopped early. However patients having Coumadin were in the curative scope for merely 63 % of the clip. Curative INR appeared to be associated with a much reduced incidence of ischemic shot and cardiac events, proposing that anticoagulation may supply increased benefit over acetylsalicylic acid if curative INR can be maintained much more systematically.FASTER: [ Kennedy FASTER et Al 2007 – pg 246 ]The FASTER randomised controlled pilot test, studied the benefit of clopidogrel versus placebo and Zocor versus placebo initiated within 24 hours of symptom onset in patients with TIA or minor shot, all were treated with aspirin [ Kennedy et Al 2007 – pg246 GB ] . The survey was stopped early owing to failure to recruit patients, likely due to the increased usage of lipid-lowering medicines during the survey period.Blood Pressure and Lipid take downi ng agents:There is some robust grounds from randomised tests to demo that blood force per unit area and cholesterin lowering are effectual for secondary bar of shot. The PROGRESS survey of perindopril and Lozal showed that BP decrease with an ACEi and diuretic get downing several hebdomads or months after TIA reduces the hazard of subsequent shot by about a 3rd. There is a positive correlativity between cholesterin and hazard of ischemic shot. Cholesterol take downing with lipid-lowering medicines reduces the hazard of shot in patients with old shot, coronary or peripheral vascular disease or diabetes. The Heart Protection Study 2002 did non demo a decrease in hazard of perennial shot on lipid-lowering medicines [ Collins et Al 2004 – pg 288 ] , perchance because patients were at low hazard of shot return since the incident shots occurred on mean 4.6 old ages before the survey oncoming. However the subsequent SPARCL test of Lipitor in patients who had had a shot or TIA within one to six months before survey entry showed a reduced overall shot hazard [ Amarenco et Al 2006 – page 288 ] . However there was a important parallel addition in hazard of hemorrhagic shot had been found in the HPS in the 3280 patients with old shot or TIA [ Collins et Al 2004 pg 288 ] . Lipid-lowering medicines should non, hence, be used in patients with old intracerebral bleeding unless there is a strong indicant related to the hazard of ischemic events.Cholesterol-lowering drugs:Meta-analyses found that larger decreases in LDL Cholesterol led to larger decreases in hazard of major vascular events and its constituent results, proposing that attachment to a statin regimen bring forthing a 1.5mmol/L decrease in LDL cholesterin would take to a decrease of about one tierce in the comparative hazard of major vascular events. The full benefits of cholesterin take downing with a lipid-lowering medicine emerged over the 2-3 old ages of intervention and continued for each twelvemonth that intervention was continued thenceforth. HPS was the largest of the RCTs in this meta-analysis. It included over 20,000 people. In a subsequent RCT, the SPARCL test, non included in the meta-anlysis, patients with a recent shot ( about all ischemic ) or TIA and no known coronary bosom disease were indiscriminately assigned to either atorvastatin 80 mg day-to-day or placebo for 5 old ages. The difference between HPS and SPARCL in the effects of of shot or TIA could be explained by opportunity, different intervention regimens, enlisting of patients earlier after their event in SPARCL, or a different balance between ischemic and hemorrhagic shot results. Both tests found similar comparative decreases of approximately 20 % in ischemic shot, and a 70 % or more increased relation hazard of hemorrhagic shot. Both tests found comparative decreases with a lipid-lowering medicine of approximately 20 % in major vascular events. [ See 119-120 ref from BB page 811 ] . There is really good grounds for routinely sing the usage of drawn-out lipid-lowering medicine intervention to take down cholesterl degrees in allpateints at high hazard of any type of major vascular event, including those with a anterior ischemic shot or TIA, and irrespective of the baseline cholesterin concentration. Treating 1000 people with a anterior ischemic shot or TIA for 5 old ages with a lipid-lowering medicine will take to the turning away of over 50 major vascular events. The grounds clearly suggests that cholesterin take downing with a lipid-lowering medicine should be considered in everybody with a history of an ischemic cerebrovascualr event. Lipid-lowering medicines are non recommended for those patients whose untreated cholesterin or LDL choleserol degrees are below 3.5 mmol/L in cholesterin and below 2.6 mmol/L in LDL choleseterol. It is besides non recommended to order a lipid-lowering medicine for patients with a history of intra intellectual bleeding ( ICH ) but no ischemic vascular events, since really few of these patients were included in the two chief RCTs. For those patients with a history of ICH who are besides considered to be at peculiar high hazard of future ischemic shot or coronary events, it is likely sensible to order a lipid-lowering medicine [ Page 814 Big Book ] . Evidence besides suggests that it may be good to get down the lipid-lowering medicine therapy in the first few yearss after the TIA. [ 134 Large book page 815 ] . To reason on lipid-lowering medicines ; intervention tends to get down with a lipid-lowering medicine every bit shortly as the diagnoss is made of a TIA with a baseline entire cholesterin of & gt ; 3.5 mmol/L or LDL cholesterin & gt ; 2.6 mmol/L. Both simvastatin 40mg day-to-day and atorvastatin 80mg daily have been shown to be good in these patients.SURGICAL INTERVENTION120,000 people have a TIA or shot every twelvemonth in the UKat least 10,000 might be suited for CEA yet merely 4500 are being performed each twelvemonth. Recently published NICE guidelines suggest that CEA should be done on appropriate patients in 2 hebdomads of presentation. There have been unacceptable holds between symptom and surgery in the UK. Merely a fifth of diagnostic patients have surgery within two hebdomads, which is the recommended NICE guidelines. Diagnostic CEA is pressing and should hold precedence over elected surgery. The recent GALA test shows that the first 1001 UK patients had a average hold between symptoms and surgery of 82 yearss [ 7 from BLUE BMJ Research article )Carotid Endarterectomy – Evidence of its benefitSurgical remotion of the atheromatic plaque from within the carotid arteria – the carotid endarterectomy ( CEA ) . Tests have proven that it is an effectual intervention for the secondary bar of shot in selected patients. CEA is associated with a assortment of possible complications such as shot and decease [ Naylor Ruckley, Bond et al – GB Ch 25 ] . It is apparent that surgery clearly prevents stroke in patients with diagnostic terrible CAS, but at a monetary value: hazard of shot as a effect of surgery, cost of surgery, hazard of other complications of surgery, cost of probes for choosing suited patients. Nowadays there is concern in the UK as to which patients should be offered surgery. [ 374 375 – BB- Ch 16 ] . As a consequence of big RCTs, it is now clear that CEA of late diagnostic terrible CAS about wholly abolishes the high hazard of ischemic shot over a period of 2-3 old ages. [ 369-371,445-447- Ch 16 BB ] . A clear advantage to surgery is shown when the diagnostic stricture exceeds 80 % diameter decrease of the arterial lms utilizing the ECST method ( European Carotid Surgery Trial ) , which is different to 70 % utilizing the NASCET method. In the NASCET test, CEA reduced the comparative hazard of shot by 65 % compared to medical intervention. The hazard of shot in patients with less than 60 % ( ECST ) stricture is so low, the hazard of surgery is non worthwhile for them. For patients with between 60 % and 80 % ( ECST ) stricture there is still some uncertainness as some of these may be at immense hazard of shot who gain from surgery. Whether the benefits of CEA or stenting in patients with symptomless stricture warrant the hazards and cost is still ill-defined, peculiarly in an epoch of improved medical interventions. ACST and ACAS, had absolute decreases in five-year hazard of shot with surgery were similar: 5.3 % and 5.1 % , severally.Carotid Stenting:Carotid stenting is less unpleasant and less invasive than carotid endarterectomy, and is more convenient and quicker. It is carried out under LA. Some little tests have compare stenting with CEA, and suggested that the procedural shot complication rate of stenting was similar to that of CEA and that there are fewer shots in the long-run. They besides showed that stenting might hold a higher hazard of shot and decease than CEA, and a higher rate of restenosis. The SPACE test is the largest survey comparing CEA with carotid stenting.Timing of SurgeryOptimum timing of surgery has been a extremely controversial subject [ 473-474 – ch 16 BB ] . Surgery should be performed every bit shortly as it is moderately safe to make so, given the really high early hazard of shot during the first few yearss and hebdomads after the TIA in patients with diagnostic CAS. [ 16-475 – ch 16 ] . In stable patients there is no difference between early and subsequently surgery. Thus for stable patients with TIA, benefit from endarterectomy is greatest if performed within 1 hebdomad of the event. [ 390 ch 16 ] However in exigency carotid enarterectomy patients with germinating symptoms ( sucha s stoke in development, crescendo TIA ) had a high operative hazard of shot and decease of 19.2 % which was much greater than that for stable patients 9390 – 477 ch 16 ] . Therefore there is still uncertainness about the balance of hazard and benefit of surgery within 24-72 hours of the presenting event. [ 475 478 479 – hc 16 ] . Merely a minority of patients with TIA are possible campaigners for carotid endarterectomy ( CEA ) or stenting, make up one's minding on surgical intercession instead than medical intervention entirely can be hard. In the ECST 30 % of patients with 90-99 % stricture had a shot in three old ages, 70 % did non. Both ECST and NASCET have two values for the stricture and this difference has been down to the manner the two tests underwent at that place angiographic techniques and to what extent the techniques used to mensurate stricture were accurate. ECST i? 70 % NASCET i? 50 % – WHY THE Difference? ? THE BIG AUDIT The DoH stroke scheme recommends that CEA should be carried out within 48 hours of symptoms, when the hazard of shot is highest, in patients with TIA who are neurologically stable. [ 17 BMJ ARTICLE ] . To accomplish this, utilizing FAST will assist public to recognize TIA and early shot [ 17 BMJ article ] . And the ABCD2 mark helps primary and secondary services to place those patients with TIA who are at highest hazard of shot. [ 18 BMJ Art. ] .Future Directions – How Potential Future Research may be designed to get the better of spreads and challengesMentionsAppendix 1:MethodsLiterature Search StrategyA controlled hunt scheme was employed to obtain informations from medical databases such as PubMed, EMBASE, MEDLINE ( Via PubMed ) , Web of Science, Science Direct ( Elsevier ) , and The Cochrane Library. I besides used the University MetaLib system. I used the capable hunt subdivision and selected ‘Health and Medicine ‘ as the chosen subject of research. It helped further my hunt for e-journals and articles. The systematic hunts were performed in September 2010 to place suited surveies and reappraisals that were published from 2000 until the present twenty-four hours ( i.e from the past ten old ages ) . Although some robust randomised controlled surveies were included which were necessarily dated back beyond this day of the month scope. Drawn-out hunts were made via cyberspace web sites and manual searching of diaries. Recently published, well-conducted systematic reappraisals and primary surveies were selected for inclusion in this systematic reappraisal. Interlending and Document Supply was besides used as a service provided by the Lancaster University Library, to recover some diary articles.Key WordssTranseunt Ischaemic Attack, TIA, TIA Management, Treatment, Current therapy, Anti-coagulation, antiplatelet drugs, acetylsalicylic acid, clopidogrel, dipyridamole, combination therapy, cerebrovascular accident, secondary bar.Using MeSH and seeking different Fieldss by using bounds enabled me to polish my consequences from databases. Any articles found within this hunt were so critically appraised ; their relevancy to this systematic reappraisal was besides so decided.Relevant diaries that were non found on the library MetaLib system, were searched for on Google Scholar and the page was taken straight to the database beginning site and so searched within the peculiar database archives. These include: Stroke, The Lancet, New England Journal of Medicine, European Journal of Vascular and Endovascular Surgery, Journal of Vascular surgery, An nals of Vascular surgery.