Assisted Reproductive Technology (ART) Strategies

Assisted Reproductive Technology (ART) Strategies INTRODUCTION Live birth with healthy child is the ultimate goal of ART cycles. There is a complexity of interlinked events that decides the final outcome of ART. This event can be categorised as, Clinical (stimulation protocol, opu, embryo transfer, pregnancy rate etc), Patient related (age, diseases) and Laboratory (ART Lab- oocyte, sperm, embryo, media, etc). There cannot be any single thumb rule for success in any ART cycle due to numerous variations in each categories. However by setting up Key Performance Indicators (KPI) and interpreting the data statistically we can have a better understanding of our success combinations as well as flaws. In this topic we will restrict our discussion upto laboratory category. ART lab and equipments are designed to mimic intra-uterine/ intra- fallopian tube environment. Thus by giving minimum stress to gametes a better embryo or blastocyst can be achieved which may result in healthy pregnancy. In order to have significant pregnancy rate various studies have been performed keeping in mind variables like, co2, pH, temperature, media etc. To have an insight of entire process majority of KPI are directed towards maintaining the above controls and also the clinical aspect of patient. This KPI gives us entire picture from patient age, stimulation protocols, drugs, opu, gametes, zygotes, embryos as well as record of temperature of work stations, room temperature, humidity, incubators conditions, ph, air quality , infection control policy. Thus KPI makes us more vigilant and observes the pattern of success or failure of our lab. By using our KPI we can have customised settings of our monitors and set protocol for a cycle. This Gametes and embryos are in artificial environment mimicking natural environment a stricter control on ph, temperature, air are perhaps most crucial. It is believed and observed that a compromise in any of this parameters does cause detrimental effect on embryos. Usually laboratories have protocols of checking the incubator settings, media, temperature daily. We do observe success rate to vary routinely. Where a drop in preganacy rate is to be considered more seriously , this makes us ponder over our KPI which should reflect the cause. We have observed many instances but we discuss about three such scenarios which caused damage to our pregnancy rates and KPI helped us. First Scenario- opening incubator door frequently On one occasion we observed more number of patients than usual in a batch of ART, while other KPI parameters were within accepted range. This observation lead to the fact that increased number of patient resulted in increase in number of oocytes.. This means that the load on incubator was much higher than usual. This load can be described by frequent opening of door to make fresh plates , transfer embryos, change media, observe growth, and embryo transfer. We used a conventional front load door incubator. Our KPI did not have a count or time period of incubator door openings, though it was handled to be bare necessity. To establish this assumption few studies observed that, there is a difference in temperature throughout the incubator where front and upper shelf had temperature nearer to 37 c as compared to other locations. Temperature displayed on screen of incubator was just an average. Temperature probe recorded average temperature of inside the incubator and hence KPI recordings were quite stable . However an important study observed that incubator door opened for 5 seconds takes a temperature recovery time of around 20 minutes whereas dishes took 30 minutes to come back to 37c. This can be explained due to cooler air from room entering the incubator and also cold co2 gas being pumped in due to decrease in co2 concentrations. IVF work station also has heating mechanism adjusted to 37 c but even that is average temp. And we do see different tempertaure in different parts of table. Further work station is also cooled by laminar air flow . Studies have proven that prolonged temperature variations impacts fertilisation especially high temperature affects cytokinesis of embryos. However we did not record absolutely mass failed fertilisation or mass embryo arrest .Though the number was less but the embryos progressed to blastocyst formation and also gave pregnancies. This leads to debate of optimal temperature required for embryo culture. Researchers have proved that core body temperature of reproductive axis to be 1c less than 37c. Interestingly a study observed difference in blastocyst formation from culturing the embryos at 36c .however fertilisation rate and implantation rate at both 36 c and 37 c were similar. With the concept of mimicking natural environment it was observed that preovulatory follicle had 2.3c less temperature than 36c. This could explain why even after temperature fluctuation we could still get good blastocyst as well as implantation. Another possible theory is a temperature regulating mechanism in embryo which remains an interesting research. Temperature fluctuations have an impact on pH also . Considering the importance of temperature and as most study design are carried out at 37c and better success rate at this temperature makes us accept cell culture to be at 37c. In order to set things right measures were initiated to reduce the number of patients or oocyte in one incubator. On an average not more than 2/3 patient with 6-8 dishes were kept in an incubator. Open culture system was changed to closed culture. Procedures like Dish equilibration, sperm swim up where carried out in mini incubator rather than routine incubators. Another way of controlling this could be use of embryo scope or using single step media or bench top incubators. But we preferred the older method to be cost effective. Second scenario- pH of media, calibration of instruments. Our KPI includes routine CO2 check by CO2 analyser and they were fairly within accepted range and settings were adjusted depending upon observed value to maintain co2 at 5 % or 6% . this percentage varied according to media manufacturing company like, SAGE needs equilibration at 5 % while vitrolife needs it at 6% . As co2 is used to maintain Ph . Despite being vigilant there was drop in overall blastocyst formation and implantation rate. A study of KPI statistics revealed more or less steady co2 and temperature with no changes in protocols . A detailed study questioned co2 analyser observation and it was found that co2 analyser was not serviced or calibrated over 6 months. Investigations confirmed Co2 analyser reading to be faulty. This scenario explains a lot about calibration of our instrument which are meant to check and control our functioning instruments like incubator.Routinely a calibration tolerance of 0.1 was accepted by us. We were using colourless media( vitrolife) rather than â€Å"pink† media ( phenol) hence changes in ph of media were unnoticed. literature supports ph to be most crucial for gamates. Routinely a ph of media scaling of 7.2-7.4 is accepted for cell culture. ph of media is also very dynamic and influenced by temperature,co2, volume of media. This leads to debate of optimal ph of media. Studies have revealed variable ph,that is alkaline in oviduct and acidic in uterus. Oocytes also showed varied ph from Germinal vesical stage ( 7.04 +/- 0.07) to MII stage ( 6.98 +/- 0.010). while amphibian oocytes shows rise in pH during fertilisation but unseen in humans. This opens a theory of intracellular ph regulatory system to mai ntain optimal Ph as required . This balance of CO2 and HCO3 in media sets the extracellular ph(phe) while intracelluarly (pHi) HCO3/Cl ad Na+/H+ regulatory systems maintain stability in cell. This self regulatory system of embryos seems to maintain the balance inspite of fluctuations and hence we see blastocyst formation and even implantation rates. Oocytes maintain their pHi through combination of follicular fluid, granulose cells. Hence denuded oocyte are more vulnearble and depends only up on pHe of media. Studies observed that raising ph to 7.4 or lowering to 6.8 affected the embryo metabolism where alkalinine media caused more damage. Thus ph around 7.2 seems to be more stabilising. Studies have observed ph irregularities to affect actin, cytoskeletal elements, meiotic spindle, cell apoptosis, mitochondria position in embryo. This problem was addressed by calibrating our co2 analyser every 3 months. Media tubes should be capped off immediately after opening to prevent evaporation which can cause ph fluctuation.KPI included servicing dates of each instruments with due date notifications.† Pink media† was not used considering toxicity of phenol and above all in subsequent cycles pregnancy rates were up with above correction.

Free College Essays - Tolerance of Sin in Hawthornes The Scarlet Letter :: Scarlet Letter essays

The Scarlet Letter   Ã‚  Tolerance of Sin The Scarlet Letter   Ã‚  Ã‚  Ã‚  Ã‚   There are changes occurring in our society constantly, in many different ways. We witness these changes through religion, politics, and family. In the novel The Scarlet Letter by Nathaniel Hawthorne, a Puritan woman named Hester Prynne is sentenced and ridiculed for committing the sin of adultery.   The situation with Hester in this novel is not relevant to today’s society because of the acceptance and tolerance of sin in contrast to the Puritan times. The common people of the Puritan society in which Hester resides, consider her to be an outcast and disappointment to their community. Hester is ostracized from the district and decides to move out to a cottage by the sea. Today’s society is much more open and able to overlook sins of the past. In much the same situation as Hester’s, one would receive support from her family.. The government takes this information into account and does not hold formal punishment for such a sin today. When contemplating the decision of whether to convict Hester Prynne, one woman of the self-appointed judges became outraged. â€Å"This woman has brought shame upon us all, and ought to die. Is there no law for it? Truly there is, both in the scripture and the statute-book. Then let the magistrates, who have made it of no effect, thank themselves if their own wives and daughters go astray!† [sl02.html#g07]. This took place in the novel, and afterward Hester was tried and convicted of adultery, for which she served a sentence of three years.   This would not happen in today’s society, but instead the woman would have some big decisions of her own to make. There are many possibilities that come into play such as abortion and adoption that all young mothers must consider. This decision can influenced by the authority in terms of the mother’s and the baby’s best interest. However, for most cases, the government does not determine the happenings of the child by force. Hester Prynne was a Puritan woman, but she was forced aside from the group when the news of her sin arrived to the common people. She was a member of â€Å"as befitted a people amongst whom religion and law were almost identical...that the mildest and the severest acts of public discipline were alike made venerable and awful† [sl02.

Risk Managements Assessment Summary

Health care organizations use risk management methods to guard their assets against likely threats brought on by legal liability. An important component of risk management programs inside the long-term care setting is the ability to reduce the amount of avoidable accidents and injuries and to reduce the financial severity of claims. Long-term care facilities offer a wide array of services to residents, and possible injuries is significant to the frail, elderly population they assist.Knowing how to recognize risks and plan proper methods and policies to lessen them necessitates frequent attention from leaders within the organization. The purpose of this summary is to focus on several examples of common risk elements in a long-term care facility and the ppolicymaking process used to evade or decrease their impact. Risk Management Risk management programs inside any organization involve a sthrong obligation from its leaders to be successful. Implementing documented processes for managi ng risk that supports the organization’s mission and goals aids leaders give employees and consumers self-assurance in the organization.Directors and senior leadership benefit from fostering functional collaboration promoting accomplishment of its programs among departments (Jones & Cotta, 2009). Risk management allows a facility to nurture a work environment that encourages growth through training and education reduces risk. Organizational strength demonstrates innovative decision-making and openness to change. Nurturing a work environment that encourages growth through training and education reduces risk (Chee, Kamal, & Wingender, 2011).Loss prevention efforts help to decrease risk expenses, permitting more funds for medical equipment, hospital facilities, and physician’s salaries, therefore increasing the value of the organization. A get-up-and-go risk-management approach aids in meeting business expansion plans. Risk management helps to recognize risk factors vital to shareholders. Money saved through risk-management activities can be openly reinvested back into the organization and community (Ceniceros, 2008). By devising policies in place and following procedures arrange for documentation of action, an essential tool in any legal proceeding.Quality Management A vital aspect of quality management is correct training of work processes. Implementing quality-management policies in agreement with regulatory guidelines helps guarantee quality of care in compliance with laws. Having solid leadership, committed to quality care helps to creates unity of determination and direction within an organization (Carroll, 2009). The organizational culture affects outcomes, such as ethical decision-making, performance, and promise. High pperforming organizations support cultures that have good communication skills.Knowing how one fits in with the rest of the organization gives employees a common sense of community and self-importance in one’s work (Che e, Kamal, & Wingender, 2011). Upholding a sthrong organizational culture helps to increase patient’s quality of care. Quality management policies help strengthen confidence in the quality of care given and make medical outcomes better while reducing lawsuits. Policies in place offer a process for handling adverse events and giving stakeholders assurance that difficulties are being dealt with properly (Carroll, 2009).Identifying Risks Former lawsuits, allegations, and patient, or staff complaints first govern the documentation of health care risks in the long-term care facility. Data collected from sources, such as employee and staff incident reports, resident satisfaction surveys, workers compensation claims, and state licensure surveys are valuable in recognizing areas that pose risk (Candlin & Candlin, 2002). Through analyzing former loss exposures, leaders can anticipate future problems permitting them to improve proper standards and guidelines to improve the quality of ca re.Risk analysis is the process of evaluating the possible loss linked by a specific risk identified and its probability of occurrence. Defining these two factors helps leaders select a suitable risk treatment ppolicy (Carroll, 2009). In a long-term care setting, management must have procedures in place for observing performance, both operational, and that connecting to the care of residents. Setting policies that bring into line with the organization’s mission and strategic goals, which consist of high-quality care will help safeguard compliance tthroughout the organization.Common Risks Three shared risks inside a long-term care facility consist of resident well-being, employee grievance, and medical mistakes. Each of these risks conveys the would-be for negative consequences that may end in lawsuits, worker’s compensation claims, or potential loss of life. By examining each risk and determining their bad effects on the facility and its stakeholders, the risk manageme nt professional can improve and apply a risk management plan and make the essential changes to organizational policies (Carroll, 2009). Resident SafetyThe expectation is for long-term care facilities to deliver residents quality care in a safe and secure environment. Making certain resident safety involves taking ample measures to offer an environment free of dangers, upholding safety standards by averting any type of injury to the residents’ physical, psychological, and emotional well-being (Rhodes, 2001). Continuing persistence in recognizing hazards and decreasing them must be a main concern of care giving. The most often reported incident in long-term care facilities is falls. Three out of four residents will fall each year and many result in a lawsuit.The most common reason for falls is existing health conditions affecting muscle weakness or trouble walking (Occupational Safety and Health Administration, 2009). Even though falls are unavoidable in a long-term care settin g, risks can be cut-down with fall prevention strategies as well as staff education, decreasing risk factors like low lighting, wet floors, and inadequately fitted wheelchairs, and bringing together exercise programs to strengthen muscles and increase balance. Most essential, everyone working inside the facility from nursing to maintenance staff must be involved in fall prevention (Rhodes, 2001).Employee Injuries The nursing home industry has a highest rate of employee sickness and injury amid all of the United States businesses according to 2002 Bureau of Labor statistics. The most widespread threats include musculoskeletal ailments, and contact of blood and other communicable materials (United States Department of Labor, 2005). Obeying Occupational Safety and Health Administration (OSHA) regulatory requests regarding education and safety procedures, help alleviate these risks. Giving care for residents is physically trying on nursing staff.Activities such as lifting, moving, and w alking residents increase the risks of injury to staff. Risk factors connected with these activities as defined by OSHA include: †¢Force- the amount of physical effort essential to do a task. †¢Repetition- regularly pperforming the same motions. †¢Awkward postures- Doing positions that put pressure on the body (OSHA, 2003). Recurring exposure to these risks can cause substantial musculoskeletal injury to employees. Loss linked with employee injuries include staffing shortages causing reduced quality of resident care, bigger workload for remaining staff, and workers compensation claims.To lessen the severity and occurrence of employee injury and illness management must offer solid support by developing clear goals and provide essential resources (OSHA, 2009). Providing mechanical lifting devices and demonstrating training in good body mechanics are two ways of decreasing risk of musculoskeletal injury. Medical Error According to Kapp (2003), a medical error is â€Å"d efined as mistakes, inadvertent occurrences, or unintended events in health care delivery that may result in patient injury. The population living in long-term care facilities, on average, is elderly or disabled and necessitates assistance with three or more activities of daily living (ADL) for instance dressing, bathing, and eating. The likelihood of error in giving this care can be limitless. Furthermore, dementia, the most mutual health condition amid residents living in nursing homes, constrains the ability of many residents to take a significant role in planning and overseeing of their own care (Kapp, 2003). Errors come in many forms in nursing homes.The high occurrence of illness amid residents calls for a significant amount of drugs ordered and dispensed. This leaves chance for meducation errors and adverse drug events (ADEs), which older individuals are most vulnerable. To increase resident safety, financial return, and clinical outcomes, policies, procedures, and systems th at make sure safe meducation delivery are critical (Kapp, 2003). Another problem common in long-term care facilities is pressure ulcers, contained areas of skin damage over bony areas of the body, such as heels, buttocks, and hips.Risk factors for pressure ulcers include immovability, resistance, shear, incontinence, and poor nutrition, which are all preventable. Steps to escape pressure ulcers should be iincluded in routine quality care. Regular repositioning, skin examinations, the use of pressure releasing surfaces, and suitable nutritional intake should be constant during each shift for residents at risk of developing pressure ulcers. If these actions are not taken, quality care does not happen, opening the door for a lawsuit claiming neglect (Kapp, 2003).Conclusion Risk management efforts are difficult and leaders must attempt to safeguard every possible risk factor. These possible risk factors are linked with residents, medical staff, employees, and property that subject the l ong-term care facility to probable liability or loss. Risk factors need to be recognized and appropriate policies and procedures need to be put in place to reduce their occurrence. The high occurrence of medical error occurrences in long-term care has led to a highly controversial environment.

The Odyssey Characters Descriptions, Significance

The Odyssey is a character-focused epic poem. The first word of The Odyssey in the original Greek text is andra, which means â€Å"man.† (By contrast, the first word of The lliad is menin, meaning wrath.) The characters of The Odyssey include royalty, deities, war heroes, monsters, witches, nymphs and more, spread all over the Mediterranean Sea. All of these characters, realistic and fantastical, play significant roles in the action of the epic poem. Odysseus The protagonist of The Odyssey, Odysseus, is the king of Ithaca and a Trojan War hero. He has been absent from his home for the past 20 years: the first ten spent at war, and the second ten spent at sea during his attempt to return home. However, Odysseus runs into countless obstacles along his journey that delay his travel to Ithaca. In Homeric epics, characters names are associated with an epithet that describes their personality. Odysseus epithet, which recurs more than 80 times in the poem, is â€Å"with much cunning. Odysseus name is etymologically associated with the concept of â€Å"trouble† and â€Å"annoyance.† Cunning and nimble-witted, Odysseus uses clever tricks to get himself out of tricky situations, most memorably when he escapes Polyphemus cave by saying his name is no-man or nobody. He is an anti-heroic hero, particularly when considered in contrast to Achilles, the classical hero of HomersThe Iliad. Telemachus The son of Odysseus and Penelope, Telemachus is on the brink of manhood. He knows very little about his father, who left for Troy when Telemachus was an infant. On the advice of Athena, Telemachus goes on a journey to learn more about his father, with whom he ultimately reunites. Together, Telemachus and Odysseus successfully plot the downfall of the suitors who are courting Penelope and seeking Ithacas throne. Penelope Penelope, Odysseus wife, is cunning and loyal. She has awaited her husband’s return for the past 20 years, during which time she devised various strategies to delay marrying one of her many suitors. In one such trick, Penelope claims to be weaving a burial shroud for Odysseuss elderly father, stating that she will choose a suitor when the shroud is finished. Every night, Penelope undoes part of the shroud, so the process never ends. Penelope prays to Athena, the goddess of cunning and handicrafts. Like Athena, Penelope is a weaver. Penelopes affinity for Athena serves to reinforce the fact that Penelope is one of the poems wisest characters. Athena Athena is the goddess of cunning, intelligent warfare, and handicrafts like carpentry and weaving. She helps Odysseus’ family throughout the poem, typically by disguising herself or disguising the identities of other characters. Penelope has a particular affinity to Athena, as Penelope is a weaver, an art form that Athena lords over. The Suitors The suitors is a group made up of 108 noblemen, each of whom is vying for Ithacas throne and Penelope’s hand in marriage. Each suitor mentioned by name in the poem has distinct traits. For example, Antinous is violent and arrogant; he is the first suitor Odysseus slays. The wealthy and fair Eurymachus is sometimes referred to as â€Å"god-like.† Another suitor, Ctesippus, is rude and judgmental: he mocks Odysseus when he arrives in Ithaca disguised as a beggar. Residents of Ithaca Various residents of Ithaca, including servants in the home of Penelope and Odysseus, play a key role in the narrative. Eumaeus is the faithful swineherd of Odysseus. When Odysseus arrives in Ithaca disguised as a beggar, Eumaeus does not recognize him, but still offers him his coat; this act is a sign of Eumaeus goodness. Eurycleia, the housekeeper and Odysseus former wet nurse, recognizes the disguised Odysseus upon his return to Ithaca thanks to the scar on Odysseus leg. Laertes is Odysseus’ elderly father. He lives in seclusion, overwhelmed by grief at the disappearance of Odysseus, until Odysseus returns to Ithaca. Melanthius the goatherd, betrays his household by joining the suitors and disrespects a disguised Odysseus. Likewise, his sister Melanthos, Penelope’s servant, has an affair with the suitor Eurymachus. Witches, Monsters, Nymphs and Seers During his adventures, Odysseus encounters creatures of all kinds, some being benevolent, others being downright monstrous.   Calypso is a beautiful nymph who falls in love with Odysseus when he happens upon her island. She holds him captive for seven years, promising him the gift of immortality should he want to remain with her. Zeus sends Hermes to Calypso in order to convince her to let Odysseus go. Circe is a witch presiding over the island of Aeaea, who promptly transforms Odysseus’ companions (but not Odysseus) into pigs. Afterwards, she takes Odysseus as her lover for a year. She also teaches him how to summon the dead in order to speak with the seer Tiresias. The Sirens are songstresses who charm and kill the sailors that dock on their island. Thanks to Circe’s advice, Odysseus is immune to their song. Princess Nausicaa helps Odysseus at the very end of his travels. When Odysseus arrives in Scheria, the land of the Phaeacians, Nausicaa gives him access to her palace, which allows him to reveal himself and make a safe passage to Ithaca.   Polyphemus, a cyclops, is a son of Poseidon. He imprisons Odysseus and his comrades in order to eat them but Odysseus uses his wits to blind Polyphemus and save his companions. This conflict causes Poseidon to become the main divine antagonist. Tiresias, a famed blind prophet devoted to Apollo, meets with Odysseus in the underworld. He shows Odysseus how to get back home and allows him to communicate with the souls of the departed, which would otherwise be prohibited. Aeolus  is the master of the winds. He presents Odysseus with a bag safely containing the adverse winds in order for him to finally reach Ithaca. However, Odysseus’ comrades mistake it for a bag full of gold and open it.