3 Article Reviews / 24 Hours

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Does America’s hot housing
market still need propping
up?
Fed officials debate whether and when to
taper support
Jul 1st 2021

“TRULY EXTRAORDINARY.” That was how Craig Lazzara of S&P
Global, the firm that compiles a widely watched measure of
house prices in America, described its reading for the month
of April, released on June 29th. House prices rose by 14.6%
year over year, the fastest rate in the 34-year history of the
index (see chart, top panel). Houses listed for sale are on
average snapped up in just 17 days, a record low. On Reddit,
a social-media site, would-be buyers bemoan missing out on
house after house because they are unwilling to forgo
inspecting the property on which they plan to spend
hundreds of thousands of dollars, something that most
successful buyers are apparently doing.

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The Federal Reserve still has monetary policy on ultra-loose
mode. Interest rates are anchored at zero and the central
bank is buying $120bn-worth of assets each month—$80bn
of Treasuries and $40bn of mortgage-backed securities—in
order to depress long-term interest rates. This stance is in
many ways still justified. There are 7.6m fewer jobs in
America than there were before the pandemic. A large
minority of adults remains unvaccinated. And yet consumer-
price inflation has climbed to an annual rate of 4.9%, and
commodities and labour are in short supply. A real-time
estimate of economic output compiled by the Federal
Reserve Bank of Atlanta puts annualised GDP growth in the
second quarter at a heady 8.3%. If true, America has
recovered all the output lost during the pandemic and even
added more.

The case of the housing market aptly illustrates how
different corners of the economy are pulling the Fed along at
different speeds, if not in different directions. The current
property craze is at least in part spurred on by loose
monetary policy. Low mortgage rates, which are a function
of prevailing yields on mortgage-backed securities, tend to
entice would-be homebuyers. Given that the housing market
is already fired up, it might seem odd that the Fed is juicing it
further by buying mortgage-backed securities and
suppressing mortgage rates.

Even some Fed officials
are discomfited by this
turn of affairs. In an
interview with the
Financial Times on June
27th Eric Rosengren, the
president of the Boston
Fed, said that America
could not afford a
“boom-and-bust cycle”
in the housing market
that would threaten
financial stability. He is
not alone. Robert Kaplan,
the head of the Dallas
Fed, has said that there
are “some unintended
consequences and side-

effects of these [mortgage-backed-security] purchases that
we are seeing play out”, including contributing to rocketing
house prices. James Bullard, the president of the St. Louis
Fed, told CNBC on June 18th that “maybe we don’t need to
be in mortgage-backed securities with a booming housing
market.”

At the Fed’s monetary-policy meeting on June 15th and 16th
Jerome Powell, its chairman, made clear that the central

bank is not yet ready to stop buying assets, but has begun to
discuss when might be appropriate. One option might be to
do what Mr Rosengren called a “two-speed taper”, slowing
mortgage purchases more quickly than purchases of
Treasuries. If housing needs less support than the wider
economy this seems a sensible step. The Fed has already
begun to offload corporate bonds bought through an
emergency programme launched in spring 2020, because
the liquidity crunch that prompted intervention has abated.

A two-speed taper probably would not dent the housing
market by much. For a start, the heat seems also to reflect a
fall in supply during the pandemic, rather than low rates
alone. And in any case, it is not as if the mortgage-backed-
security market operates in isolation from broad monetary
conditions. Yields tend to closely track those of Treasuries,
even when the Fed is not buying up assets (see chart,
bottom panel). If the central bank is not ready to tighten
monetary policy yet, then a hot housing market might be a
side-effect it has to live with. Still, it probably does not need
to egg property prices on. ■

A version of this article was published online on June 30th
2021

This article appeared in the Finance & economics section of
the print edition under the headline “On the simmer”

I signed the papers for that resI signed the papers for that research study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?earch study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?

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I signed the papers for that rest signed the papers for that research study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?earch study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?

An 85 year old client in a nursing home tells a nurse, “I signed the papers for that research study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?

An 85 year old client in a nursing home tells a nurse, “I signed the papers for that research study because the doctor was so insistent and I want: him to continue taking care of me.” Which client right is being violated?

a. Right of self determination
b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed

Summary of chapters be not anxious: pastoral care of disquieted souls

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Each chapter requires a written summary; it should be 1-2 pages in length for each chapter. The written summary should not be word for word from any part of the book. The outline must be typed in a 12pt time new roman font, double spaced , APA. Each chapter must be labeled. The title of the book is Be Not Anxious: Pastoral Care of Disquieted Souls

Describe how this ethical issue impacts patients, families, society, law, and economics. Describe the role of the nurse in the decision making process regarding the ethical issue. Describe any conflicts/concerns, legal and ethical responsibilities (what standards apply).

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Describe how this ethical issue impacts patients, families, society, law, and economics. Describe the role of the nurse in the decision making process regarding the ethical issue. Describe any conflicts/concerns, legal and ethical responsibilities (what standards apply).

 

Choose an ethical issue related to nursing. consider general areas technology, education, research, economics, and
legal issues for topic ideas. APA format 6th ed. and include headings level 1 and 2, 12font, roman times, double
spaced, running head. References other than text required (ethics and issues in contemporary nursing). Be aware of
the validity and reliability of sources used especially internet. Include introduction of issue, relevant
history/landmark events/rulings to give clear picture viewed in society. Discuss why its an ethical dilemma for
you, including ethical principles involved or conflicting, relevant values hold, ethical theory your ascribing to,
fallacies of reasoning that might interfere in your ethical decision making process related to this issue.
Describe how this ethical issue impacts patients, families, society, law, and economics. Describe the role of the
nurse in the decision making process regarding the ethical issue. Describe any conflicts/concerns, legal and
ethical responsibilities (what standards apply). Discuss actual or potential resolution of the issue with
attention to how it involves/affects the nurse, patient, family, society, the law and economics. Provide a
conclusion. There should be 5-8 pages of text.

As a nurse- you can have a great impact on the success or failure of the adoption of EHRs. It is important for nurses to understand their role as change agents and the ways they can influence others w

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As a nurse, you can have a great impact on the success or failure of the adoption of EHRs. It is important for nurses to understand their role as change agents and the ways they can influence others when addressing the challenges of changing to a drastically different way of doing things.

Everett Rogers, a pioneer in the field of the diffusion of innovations, identified five qualities that determine individual attitudes towards adopting new technology (2003). He theorized that individuals are concerned with:

· Relative advantage: The individual adopting the new innovation must see how it will be an improvement over the old way of doing things.

· Compatibility with existing values and practices: The adopter must understand how the new innovation aligns with current practices.

· Simplicity: The adopter must believe he or she can easily master the new technology; the more difficult learning the new system appears, the greater the resistance that will occur.

· Trialability: The adopter should have the opportunity to “play around’ with the new technology and explore its capabilities.

· Observable results: The adopter must have evidence that the proposed innovation has been successful in other situations.


Note:

You are not required to purchase Rogers’ book or pursue further information regarding his list of five qualities. The information provided here is sufficient to complete this Assignment. The full reference for Rogers’ work is provided below the due date on this page.

For this Assignment, you assume the role of a nurse facilitator in a small hospital in upstate New York. You have been part of a team preparing for the implementation of a new electronic health records system. Decisions as to the program that will be used have been finalized, and you are now tasked with preparing the nurses for the new system. There has been an undercurrent of resistance expressed by nurses, and you must respond to their concerns. You have a meeting scheduled with the nurses 1 week prior to the training on the new EHR system. Consider how you can use the five qualities outlined by Rogers (2003) to assist in preparing the nurses for the upcoming implementation.


To prepare

· Review the Learning Resources this week about successful implementations of EHRs.

· Consider how you would present the new EHR system to the nurses to win their approval.

· Reflect on the five qualities outlined by Rogers. How would addressing each of those areas improve the likelihood of success?

Write a 3- to 5-page paper which includes the following:

· Using Rogers’ (2003) theory as a foundation, outline how you would approach the meeting with the nurses. Be specific as to the types of information or activities you could provide to address each area and include how you would respond to resistance.

· Analyze the role of nurses as change agents in facilitating the adoption of new technology.

Management of Pain in Trigeminal Neuralgia

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Percutaneous management of pain in Trigeminal Neuralgia under computed tomography guidance



Corersponding Author


  • Dr. Mitesh Kumar



Main Author


  • Dr. Roy Santosham



Co Authors

  • Dr. Bhawna Dev
  • Dr. Deepti Morais
  • Dr. Rupesh Mandava
  • Dr. R. Jeffrey



Abstract

Trigeminal Neuralgia (TN) is a brief, excruciating and perhaps the most severe pain known to man affecting the hemifacial region. It occurs mainly due to tortuous vessel compressing the trigeminal nerves, though in many cases, the exact etiology and pathogenesis remain undetermined. The first line therapeutic option for patients affected by TN is the medical line of management and patients refractory to the same, are offered various invasive procedures like balloon compression, gamma knife surgery, radiofrequency ablation, etc. In this paper, we present percutaneous management of the pain by injecting neurolytic drugs in the foramen ovale under Computed Tomography (CT) guidance as the new and promising technique of treatment in TN.



Keywords

Trigeminal Neuralgia, percutaneous management, CT guidance, neurolytic drugs



Objective

To evaluate the efficacy and safety of Computed Tomography guided percutaneous management of pain in trigeminal neuralgia using neurolytic drugs.



Introduction

Trigeminal Neuralgia is also known as tic douloureux, a term given to this painful disease by Nicolaus Andre in 1756 [1] . TN is a pain which typically is intense, brief, usually unilateral, recurrent shock like involving the branches of fifth cranial nerve [2]. It can be mainly classified into two types. First being, the classical TN (Type I), which is due to neurovascular compression, the most common vessel causing the same being superior cerebellar artery followed by anterior inferior cerebellar artery [3]. Second type is atypical TN (Type II), secondary to causes like trauma, tumor, multiple sclerosis or herpetic infections. The distinction between these two types is mainly based on clinical symptoms [4, 5] as Type I pain is episodic in nature whereas Type II pain is more constant. TN is often called by many as “the suicide disease” [6] as the patients who suffer from it would rather take their lives than bear the pain.

The initial line of treatment for TN is medical management by drugs like Carbamazepine, Gabapentin, Oxcarbazepine among others. Patients of type I TN may also be advised microvascular decompression. Those patients who do not respond or have contraindications to the above mentioned drugs or experience no change in the intensity of the pain are called Refractory TN [7]. Such patients are advised invasive procedures like trigeminal nerve block neurolytic block, radiofrequency ablation, gamma knife surgery and balloon compression.

We describe our experience in percutaneous management of pain by injecting neurolytic drugs in the foramen ovale under CT guidance in six patients, suffering from TN.



Method and Materials used



Pre procedural work up

The pre procedural work up included clinical evaluation and thorough reading of the Magnetic Resonance Imaging (MRI) scans of all the patients to rule out any neurovascular conflict. Any patient with neurovascular conflict was considered an exclusion criterion in our study. These patients were reported taking the drugs for TN for over three months with no improvement in the pain. The pain score evaluation was done using Numeric Rating Scale [8] and Wong-Baker Faces Pain Rating Scale [9] as a baseline evaluating point to be compared to the same scoring system after the procedure. Routine investigations such as coagulation profile, liver function test, renal function test, HIV and HbsAg were done before the procedure.



Numeric Rating Scale

Patients rate pain on a number scale from 0-10, 0 being a depiction for no pain and 10 being the worst pain imaginable.

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Wong-Baker Faces Pain Rating Scale

The Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 (No Pain) to a crying face at 10 (Worst Pain Possible). The patient must choose the face that best describes how they are feeling.

Description: C:UsersRadiologyDesktop103010_color_faces.jpg

In our study, we use the Wong Bakers scale to assess the patients’ pain before and after the procedure.

The neurolytic drugs and materials used in the procedure were 22 G spinal needle for block, 25 G needle for skin infiltration, 2% xylocaine , Iohexol – Non ionic contrast medium, 100% alcohol, 1ml syringe and normal saline solution.

The patient was put in the supine position with head placed in reverse occipitomental position (chin up and neck extended), turned 30° to the opposite side of the block. The foramen ovale was identified under CT guidance and a virtual track was made starting from a point which was 2-3cms lateral to the angle of mouth on the skin to foramen ovale (Figure 1). Once the trajectory of the needle and the foramen ovale was confirmed on CT scan, the skin at the point of entry was infiltrated by 2ml of 2% xylocaine using a 25G needle. Then, a 22G spinal needle was inserted at the same point and aimed in the direction of planned trajectory towards the foramen ovale (Figure 2). To prevent the needle from entering the oral cavity, a finger from inside the mouth can be used to guide the same [10]. Though, we did not apply this in any of our patients.

Following this, negative aspiration was attempted to check for Cerebro Spinal Fluid (CSF) or blood aspirate. If the aspirate contained CSF or blood then the needle had to be readjusted. Then 0.5ml of mixture made from 1ml of iohexol and 2ml of 2% xylocaine was injected into the target site in order to check the spread of injectant and exact needle tip position. Once the tip of the needle touches the mandibular nerve root, the patient might complain of the exact similar pain which he/she has been suffering, thus confirming the accurate needle tip location. This injectant acts as a diagnostic block if the trigeminal ganglion is the pain generator with xylocaine providing anesthesia prior to alcohol injection.

A mixture containing 3ml of 100% alcohol, 1ml of iohexol and 1 ml of saline was made. Of this 1ml of the mixture was injected into the foramen ovale (Figure 3 and 4). Post procedure check scan was performed to rule out any complication.



Result

Exact position of the needle tip in the foramen ovale was seen in all the six patients thus achieving 100% technical success. All these patients achieved a significant level of relief with an average pain score of two immediately after the procedure. Twenty four hours after the procedure, they rated their reduction of pain at an average pain score of one.

Four out of the six patients ie Patient No. 1, 2, 4 and 6 were completely relieved of their pain with one year follow up without taking any medication.

In Patient No. 3, the procedure was abandoned as during the diagnostic block, the injectant was seen tracking into CSF cistern and fourth ventricle.

Patient No. 5 reported with a similar pain of TN within three months with a pain score of five, little less than the pre-procedure pain score of six. The pain was more severe in the pterygopalatine segment, hence a pterygopalatine block was carried out and the patient had a pain score of one twenty four hours after the procedure. Hence, the initial trigeminal neurolysis was partially successful in this patient.


Status
Pain Score

Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Pre Procedure 7 8 6 7 6 6
Post Procedure 2 3 – 1 1 2
At 24 hours 1 1 – 1 1 1
At 3 months 0 1 – 0 5 0
At 12 months 0 0 – 0 2 0

No post procedural complication was seen in any of our patients.



Discussion

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The trigeminal nerve arises from the lateral pons at its superior to mid portion. It travels forward in posterior fossa and merges with the trigeminal ganglion in the Meckel’s cave. The trigeminal ganglion is located lateral to the cavernous sinus. It gives three divisions – ophthalmic (V1) segment which emerges from superior orbital fissure, maxillary (V2) from foramen rotundum and mandibular (V3) from foramen ovale. The trigeminal nerve provides sensation for the face, mouth and supplies the muscles of mastication. TN mostly involves maxillary division and mandibular division of trigeminal nerve though it may also involve the ophthalmic division as well.

The reported annual incidence rate of TN is about 4.5 per 100,000 persons [11] but the actual figures may be even much higher because of diagnostic challenges associated with the disease. TN is more common in females than males with a ratio of 3:2 and is usually seen after 50 years of age [11].

Trigeminal nerve block is an upcoming treatment in TN patients who are refractory to medical line of management. It relieves the pain and also reduces the side effects of drugs which are used for the treatment. Earlier studies were mainly done using x-ray or fluoroscopic guidance which had its own limitations in terms of image quality and two dimensional views. In contrast to this, CT scan provides excellent and direct visualization of foramen ovale leading to correct placement of needle [12] and thus scoring over fluoroscopy. This reduces the chances of injecting neurolytic agents at improper locations and thereby reduces the side effects.

In our cases, initial check CT scan was done by injecting 1ml of iohexol to determine whether the needle is in exact location. This doubly ensured us about the location as well as the spread of injectant. This was different from previous studies done using fluoroscopy where a diagnostic block using xylocaine had to be given in order to confirm the location of the needle tip.

We used a mixture of 3ml of 100% alcohol, 1ml of iohexol and 1ml of saline for trigeminal neurolysis however, Han et al stated that trigeminal nerve block with high concentration of lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain and shorter duration of pain prior to the procedure [13].

Alcohol spreads easily and should be used cautiously. The other agents which can be used but were not used in our study are phenol and glycerol.

The side effects that may follow the procedure are numbness and hypoesthesia in the entire trigeminal nerve distribution. There can be abolition of corneal reflexes which can produce exposure keratitis and dryness of eyes. Improper injection of alcohol into CSF space can lead to arachnoiditis/ meningitis.



CASE 1, 2, 4 and 6

These patients were suffering from trigeminal neuralgia with pain score ranging from six to eight before the procedure. All these patients have been taking carbamazepine for more than three months with no relief from pain. MRI showed no neurovascular conflict. These patients had a significant relief of pain with pain score at three months and twelve months being zero. None of these patients had to take oral medicines after the procedures.

Description: C:UsersRadiologyDesktoptrigeminaltri1.jpg
Description: C:UsersRadiologyDesktoptrigeminaltri9.jpg

Fig 1: Site marked for needle Fig 2: Tip of the needle in foramen

insertion ovale

Description: C:UsersRadiologyDesktoptrigeminaltri4.jpg
Description: C:UsersRadiologyDesktoptrigeminaltri6.jpg

Fig 3: Dispersion of injectant in Fig 4: 3D reconstruction showing

the foramen ovale needle tip in foramen ovale.



Case 3

This eighty year old male came with complains of left sided trigeminal neuralgia. He had been taking carbamazepine for four months with no change in pain intensity. The procedure had to be abandoned as after injecting the diagnostic block, the injectant was seen tracking into the CSF cistern in the cerebello pontine angle and fourth ventricle (Figure 5).

Fig 5: CT scan showing needle tip in the left foramen ovale



Case 5

This forty seven year old female came with complains of right sided trigeminal neuralgia. She had been taking carbamazepine for three months without any relief in pain. MRI scans showed no neurovascular conflict. The procedure was successful with pain score of one immediately after and at twenty four hours after the procedure (Figure 6). However, this patient came back within three months of the procedure complaining of pain, which was more in the pterygopalatine segment. A pterygopalatine block was done with resultant pain score of one at twenty four hours after the procedure and two at nine months of the procedure. Hence, this patient showed partial response to trigeminal neurolysis carried out initially.

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Fig 6: CT scan showing the tip of the needle in right foramen ovale.



Conclusion

Percutaneous injection of alcohol, iohexol and saline mixture at the verge of foramen ovale under CT guidance is an effective and promising method to relieve pain in patients of TN refractory to medical line of management. This technique is inexpensive, cost effective and a relatively painless procedure. Being a minimally invasive technique, the chances of any infection and other post operative complications are less. Since our study involved only six patients, this technique needs to be further evaluated on a large sample size to substantiate the result of this procedure. Having said the above, we would like to emphasize that our initial experience of this procedure was quite impressing.



Abbreviations

TN – Trigeminal Neuralgia

CT – Computed Tomography

CSF – Cerebro Spinal Fluid

MRI – Magnetic Resonance Imaging



References

  1. Andre´ N. Traite´ sur les maladies de l’ure`thre. Paris: Delaguette, 1756
  2. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994. P. 59-71
  3. Jannetta PJ. Microvascular decompression of the trigeminal nerve for tic doloreux. In: Youmans ed. Neurological surgery 4th edn. WB Saunders Co. Philadelphia. 1996: 3404-15
  4. Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008; 15 (10): 1013-28
  5. Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence – based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008; 71 (15): 1183-90
  6. Michael D. Chan, Edward G. Shaw, Stephen B. Tatter. Radiosurgical Management of Trigeminal Neuralgia. In: editor Pollock Bruce, Intracranial Stereotactic Radiosurgery, an Issue of Neurosurgery Clinics. Elseiver Health Sciences. 2013. pp. 613-621
  7. Cruccu G, Truini A. Refractory Trigeminal Neuralgia. Non-surgical treatment options. CNS Drugs. 2013 Feb;27(2):91-6. doi: 10.1007/s40263-012-0023-0.
  8. Hartrick CT, Kovan JP, Shapiro S (December 2003). “The numeric rating scale for clinical pain measurement: a ratio measure?” Pain Pract 3 (4): 310–6. doi:10.1111/j.1530-7085.2003.03034.x. PMID 17166126.
  9. Wong-Baker FACES Pain Rating Scale Foundation: Retrieved 6 December 2009.
  10. Michael J. Cousins In: trigeminal nerve block. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine. Lippincott Williams & Wilkins, 29-Mar-2012, 410
  11. Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen, Jeffrey J. Schaider, Ghazala Q. Sharieff. In: Bell’s palsy and trigeminal neuralgia. Harwood-Nuss’ Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins. June 23, 2009, 786
  12. Víctor Whizar-Lugo MD, Francisco Anzorena-Vallarino MD, Roberto Cisneros-Corral MD, Ricardo Valdez-Jeres MD, Rogelio Hernández-Velazco DDS. Use of Computed Tomography Guide for Trigeminal Alcohol Neurolysis. Anestesia en Mexico: Volume 20 No. 1 (January-April 2008)
  13. Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008 Feb;62 (2):248-54. Epub 2007 Nov 23.

Inappropriate Use of Social Media in Healthcare

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The rapid growth and widespread use of social media has changed the way many people communicate and share information. Social media include various websites such as Facebook and Twitter which are the two most popular social networking providers, video sharing websites like YouTube, a variety of blogs which enable users to post their own articles and allow visitors to leave feedback, discussion forums and other social networking platforms of communication that people can use for educational or other purposes.

In recent years a huge number of people around the world have become active users of social media. Network of Global Agenda Councils Reports (2011-2012) showed that worldwide more than 1.2 billion of people use social media, a number that accounts for 82% of all internet users around the world (Councils, 2012). Many of these users explore internet in order to access medical information and other to share their concerns about health related issues or to seek out medical treatment. Furthermore many healthcare professionals such as physicians, pharmacists and nurses use social media as a platform of communication to promote patient health and safety as well as an education tool (Frances Griffiths, 2012).

However irresponsible and misuse use of social media can result to a number of unpleasant situations. Both healthcare providers and patients should be aware of the risks of using social platforms of communication. Potential risks among others include the breach of personal data, the publication of poor quality medical information and the underestimation concerning the seriousness of a situation from a healthcare professional either due to lack of adequate information or due to provision of incorrect or inaccurate data provided by a patient during an online consultation (Harlow, 2012).

In UK there is not any specific guidance provided from the Health and Care Professions Council, but it has been made clear that social media should be used within the relevant standards of conduct, performance and ethics. It recognises that social networking is a valuable way to communicate and share information but also points out that the healthcare professionals who will decide to use it as part of their work must make sure that will behave with honesty and integrity for the best interest of the public protecting patient confidentiality and exhibiting their professionalism at all times (Health Professions Council Newsletter: Issue 34 – April 2011).

Nevertheless in the past have been reported many incidents of inappropriate use of social media and unprofessional behaviour where patient’s personal data disclosed on the internet without their consent or cases where patients offended because of comments made from other users related to their health status. Guardian reported that between 2008 and 2011, were carried out 72 separate actions by 16 trusts against staff for inappropriate use of social media. Some of these cases were related to the breach of personal data and some other were associated either with posting of racists or sex comments or with sharing of inappropriate pictures and videos through public internet forums. These incidences encouraged British Medical Association to provide guidance to its members about how to use social media in an appropriate way. (Laja, 2011).

The use of social media allows patients to interact with healthcare professionals in a rapid and cost-effective way. Also gives them the ability to participate on their own care in order to manage their health and monitor their treatment by having quick access to medical journals and having view of different treatment options before and during consultation from their doctor and by using health related online applications. Likewise social media used from healthcare professionals to connect with individuals from different geographical areas in order to contribute on their health improvement by providing them with medical documents and by creating discussion forums on health related topics. This advantage gave them the opportunity to expand their activities introducing new services such as the online consultation and the provision of different treatment options at low cost. There are cases where social media used to promote communication both among patients and among Healthcare Professionals. Patients have the ability to share their concerns and discuss about common diseases or possible medical treatments and on the other hand Healthcare Professionals are enabled to share information, experiences and ideas supporting their lifelong learning (KPMG, 2011).

Some social networking platforms are free to the public but to some other the patients will have to pay if they need an online consultation by a healthcare professional or if they wish to discuss and share their concerns with other healthcare providers or other patients that suffering from the same condition. In UK operate websites like NetDoctor.co.uk which is provided and operated by National Health Service (NHS) and offer a wide range of services such as pregnancy email service and online doctor diagnosis from registered UK-based General practitioners, discussion forums and online applications like symptom checker that help patients to get a better understanding of their healthcare needs. NHS in UK uses social media in order to improve public health by providing health related information through NHS choices. Also it has been integrated to other social media such as Facebook, Twitter and YouTube to promote its services and offer a broad spectrum of applications. For instance online healthy life style advisor, smoking secession programmes and body mass index (BMI) health weight calculator.

These services and applications enable patients to decide whether or not they require visiting a doctor for further advice retaining their privacy. However this way of communication can be very ineffective, as examining and interpreting medical notes without the availability of a full medical history and with the absence of physical exams can be a serious threat to the patient (Britton, 2012). In addition diagnosis can become unreliable due to lack of information and accuracy of data provided by the patient or due to underestimation of the seriousness of the situation, making online consultation inferior to a face to face consultation.

Internet usage statistics showed that the adults that are active users of Facebook and Twitter in UK come to 37.4 million and 15.5 million respectively (Ayres, 2012). Considering this amount of people it is easy to understand how important is for Healthcare Professionals to use social media wisely and with professionalism.

Inappropriate use of social media can affect healthcare’s personal and professional life. Many of them choose to disclose patient’s personal data for maintaining an easily accessible online medical record for personal use but they are unaware that many of that information (including videos or pictures) they upload on the internet in some cases can be accessed, used and spread from the general public without control (Thompson LA, 2008).

It is therefore Healthcare professional’s ethical and legal responsibility to protect patient confidentiality at all times on the internet as well as to other media. Some social networking platforms give the ability to the users to set privacy settings in order to prevent uncontrolled distribution of data and to put restrictions to individuals seeking access to information that have been chosen to be kept private (Thompson LA, 2008).

However concerns have been raised in the past related to protection of personal data. Many social networks upload and share data without considering any legal or ethical considerations. Publishing personal information of patients without their consent can result to legal implications. In UK Data Protection Act limits healthcare providers from disclosing any personal information without patient consent with few exemptions. According Data Protection Act (1998) all personal data should be fairly and lawfully processed, they should be used for limited and specific purposes in a way that is adequate, relevant and not excessive, they should be accurate, held up to date and for no longer than its necessary and finally should be kept safe and not transferred to countries without adequate date protection.

Nowadays social media have become an integral part of our lives. General public uses them to obtain health related information, to connect with other users with the intention to discuss issues concerning their health, to get educated by reading medical documents so that will get a better understanding of their condition or their disease and to pursue new treatment options in a fast and inexpensive way. Social media have also become an essential way for healthcare professionals to provide their services in order to improve and monitor patient needs such as the online consultation. On the other hand the rapid and uncontrolled sharing of information can result to potential risks and have negative impact to the provision of health care and personal lives of both patients and healthcare professionals. Breach of personal data protection, publication of untrustworthy medical documents and faulty consultation due to lack of evidence can be some of the pitfalls that users may face.

In order to avoid these drawbacks both patients and healthcare professionals need to understand the limitations of the use of social media. Creating bounds between personal and professional use of social media is essential. Healthcare professionals who choose to interact with patients online must maintain appropriate boundaries concerning the relations between them. For instance, they should not discuss about health related matters on a friendly but only on a professional level.

Additionally in order to ensure that high quality information is provided and that a conversation between a patient and a healthcare professional will have a positive outcome, both of them must build a relationship of trust by being precise and honest to each other regarding the information they share. This will cause the patient to capitalize on the doctor’s consultation appropriately and follow essential tips for a better result and will make it easier to healthcare professional to give the most appropriate advice. Also in my opinion healthcare professionals should only share medical documents that based on scientific studies while patients should consult their health provider before taking any action based on information obtained using social media.

There are personal data that should not be allowed to be shared through social media as it is very likely patients to be offended. So individuals who use social networking platforms, especially for medical purposes should be able to consider whether is safe or not to share their data with the public. Healthcare professionals must recognize that they have an ethical and legal obligation to maintain patient privacy and confidentiality at all times and need to be aware that social media cannot be completed safe for protecting the information they share. For this reason they should use social networking platforms that privacy settings can be set and are secure to the highest level.

Finally I believe that healthcare professionals should be restricted from disclosing patient personal information on public internet forums and any health related data should be safeguarded and be disclosed only to the patient or other healthcare professionals if it’s necessary and only for the use of medical purposes and with the consent of the patient.

Should Ireland Have a Mandatory Folic Acid Fortification Policy

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Should Ireland have a mandatory folic acid fortification policy?

The objective of this report is to research the advantages & disadvantages of folic acid fortification and to conclude regarding a decision whether folic acid fortification should be mandatory in Ireland. Folic acid is the synthetic form of the B vitamin folate. The folate found naturally in foods has poor bioavailability and is unstable in food storage and preparation. As a result, folate’s effect on blood folate levels is quite minimal. However, folic acid is used in supplements and fortified foods as it is highly stable and bioavailable. Folic acid about twice as bioavailable as folate. There is conclusive scientific evidence linking low folate status with spina bifida and other related birth defects such as anencephaly. These conditions are known as neural tube defects (NTDs). These are major birth defects caused by the incomplete closure of the neural tube. The prevalence of NTDs in Ireland has risen in recent years, and Ireland has one of the highest rates of NTDs in the world. Such high rates are unacceptable in a developed country like Ireland. Folic acid fortification should be considered in Ireland as women of childbearing age require 700μg of folic acid per day (400μg supplement & daily adult needs of 300μg).

NTDs affect approx. 1 in 1000 pregnancies in Ireland, this equates to about 75 cases per year. Spina bifida is the most common, it accounts for 51% of all NTDs. NTDs are serious birth defects and are major causes of mortality & morbidity especially in childhood. Adequate folic acid intake before conception and during pregnancy can prevent up to 70% of NTDs such as spina bifida. A satisfactory level of folic acid is required to ensure the neural tube closes correctly. There is evidence to show that in Ireland, women do not get enough folic acid from foods (NANS, 2011). It is difficult to get the recommended amount of folate from diet alone, as a result of this a folic acid supplement is recommended. This brings attention to the possible need for a mandatory folic acid fortification policy in Ireland. It is recommended that all women of childbearing age who are sexually active should take a folic acid supplement (400μg) every day to help prevent neural tube defects (NTDs) in babies. This is paramount for at least 4 weeks prior to conception and during the first 12 weeks of pregnancy. Women who have given birth to an infant with an NTD, who are diabetic, obese or have a family history of NTDs should be prescribed a supplement of 4000μg of folic acid at least 4 weeks prior to conception and for the first 16 weeks of pregnancy to aid in the prevention of an NTD recurrence. Most women start taking folic acid after 5 weeks (35 days), which means it is too late as neural tube closure is usually complete by day 28. There is a lack of education in Ireland regarding the importance of folic acid supplementation. Poor compliance with folic acid recommendations increases the risk of the development of NTDs. It is currently estimated that only 36% of women of childbearing age in Ireland have blood folate levels that are adequate for optimal protection against NTDs (FSAI, 2016). This evidence shows that perhaps there should be a mandatory folic acid fortification policy put in place in Ireland.

Over half of pregnancies in Ireland are unplanned, therefore the healthcare professionals of Ireland should recognise this and educate the public and provide policies in order to prevent NTDs and other folic acid deficiency symptoms such as a lower birth weight (Scholl et al, 1996). According to the FSAI, women should eat foods fortified with folic acid such as cereals, and high folate foods such as green leafy vegetables, inclusive to taking folic acid supplement. In 2006, due to the low levels of folate intake, mandatory fortification of flour was discussed. This was delayed due to the link between high levels of folic acid intake with various types of cancer, specifically colon cancer (Cole et al 2007). It also might mask vitamin B12 deficiency (FSAI, 2006). The long-term effects of high folic acid intakes are still unknown. There are a few companies who voluntarily fortify their food in Ireland. Many breakfast cereals and breads are fortified with folic acid. For example, ‘Weetabix’ contains 170μg of folic acid/100g. The average rates of NTDs in Europe were recently calculated to be 1.6 times higher than in places where folic acid fortification is mandatory. Over 80 countries have introduced mandatory fortification of cereals and no evidence of any adverse health effects has been observed. In America, mandatory folic acid fortification has led to 600-700 babies born without a birth defect each year. This results in a saving of $400-$600 million saved per year.

The economy in Ireland has had a massive impact on folic acid fortification & the prevalence of NTDs. During the height of the Celtic tiger, people could buy a wide range of foods of which were fortified voluntarily. Companies often did this as a marketing ploy in order to increase prices, this showed a drop in the level of NTDs in Ireland. However, when the economy crashed people could no longer afford these fortified branded cereals and most avoided the more expensive fortified cereals or began to shop in cheaper shops such as Lidl and Aldi. These companies did not fortify their cereals, as it would have raised the price of the product for the consumer. These own brand foods were cheaper and became more popular. One’s priority was to put food on the table in these times, they were not concerned with the folic acid content of the products they were buying. A small team of researchers in D.C.U, found that there was a link between the increasing numbers of NTDs in the population with the change in shopping trends and the decreased availability of fortified foods. It was found that there were up to 100 fortified products in one mainstream supermarket at the time and only 1 in Lidl. The FSAI published in 2015, that the mandatory folic acid fortification of bread/flour is the most effective way of reducing Ireland’s rate of birth defects. Although despite this recommendation from the experts, the minister for health still only recommends that companies voluntarily fortify their products and women to take the recommended supplement of folic acid per day. Women from lower socioeconomic backgrounds are more likely not to follow current guidelines, therefore they are still left at a higher risk of their child developing an NTD. However, one can understand the delay in a mandatory fortification in Ireland as there are concerns with providing too much folic acid to those who don’t need it (e.g. elderly). Professor Mary Flynn, chief specialist in public health nutrition in the FSAI, stated that the voluntary fortification of foods does contribute to the reduction of pregnancies affected by NTDs. “It is estimated that the risk of NTDs is approximately 11-14% lower as a result of consumption of voluntarily fortified foods, e.g. ready-to-eat breakfast cereals, resulting from an additional average daily intake of 50-63 µg folic acid in women of childbearing age” (FSAI, 2016). According to NANS, women classed as a reproductive age (18-50) had median daily intakes of total folate of 260 µg/day, folate of 189 µg/day and folic acid from fortified foods and supplements of 52 µg/day. However, while 78% of women in this category consumed fortified foods, only 16% consumed folic acid supplements. There is a clear distinction between those who consume supplements and fortified foods. There is potential to significantly reduce the risk of NTDs in Ireland through the fortification of food.

Based on my research, mandatory fortification should be introduced in Ireland. “The mandatory fortification of bread or flour in Ireland would provide about 150 micrograms of folic acid per day in women of childbearing age. This could reduce the prevalence of NTDs by around 30%” (Deborah Condon, 2016). This is the most effective way of increasing folate levels and therefore, reducing rates of NTDs. Also, voluntary fortification of cereals etc could continue, and recommendations should still be followed by women of a childbearing age taking a folic acid supplement every day. As stated by the FSAI in 2016, there is unsubstantial evidence to show that voluntary fortification has the capability to reduce rates of NTDs from the current rate. A small amount of bread on the market could be excluded from fortification to provide choice for consumers who are worried about getting too much folic acid if they do not require it. If this legislation should come into place, monitoring should be done on folate levels and NTD rates in order to assess its impact and to determine health risks if any. Although the fortification of bread will significantly reduce the risk of NTDs, it will not provide adult women with the amount of folic acid they require. To conclude, there should be a mandatory folic acid fortification process in Ireland, and the provision of information to the Irish public about the importance of taking folic acid supplements. Information could be provided through schools, the internet, and advertisements amongst other marketing ideas.



References

  • Irish Health. 2018

    . Irish women need to consume more folic acid

    . [ONLINE] Available at: http://www.irishhealth.com/article.html?id=25350.
  • Department of Health and Children. 2006.

    Report of the national committee on folic acid food fortification.

    [ONLINE] Available at: https://www.indi.ie/images/public_docs/5_folic_acid.pdf.
  • Food Safety Authority of Ireland.2016.

    Update report on folic acid and the prevention of birth defects in Ireland,

    Dublin: F.S.A.I.
  • IUNA. 2011. NANS. [ONLINE] Available at: https://irp-cdn.multiscreensite.com/46a7ad27/files/uploaded/The%20National%20Adult%20Nutrition%20Survey%20%282008-2010%29.pdf.
  • Paul Cullen. 2016.

    Folic acid fortification. It’s a no-brainer

    . [ONLINE] Available at: https://www.irishtimes.com/life-and-style/health-family/parenting/folic-acid-fortification-it-s-a-no-brainer-1.2790867.
  • Food Safety Authority of Ireland (2011),

    Best practise for infant feeding in Ireland,

    Dublin: F.S.A.I.

Design a study to test the idea that stress level impacts the accuracy of human memory. Be sure to develop a study that is ethically feasible.

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Design a study to test the idea that stress level impacts the accuracy of human memory. Be sure to develop a study that is ethically feasible.

 

Cognitive psychology

Human memory is fallible. Rather than being like a recording of events experienced, our memories are vulnerable to errors and misinformation. Though highly arousing events have been thought to be particularly accurate, this idea has been challenged. Events that are highly stressful may be particularly prone to error.
Design a study to test the idea that stress level impacts the accuracy of human memory. Be sure to develop a study that is ethically feasible

2(a) Aluminium chloride exists in the form of dimer at room temperature. (i) Draw the Lewis structure of aluminium chloride when it is heated to 1000 °C. (2 marks) (ii) Mr Andrew plans to replace the

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2(a) Aluminium chloride exists in the form of dimer at room temperature. (i) Draw the Lewis structure of aluminium chloride when it is heated to 1000 °C. (2 marks)

(ii) Mr Andrew plans to replace the aluminium oxide used in Hall-Héroult process with aluminium chloride. As Mr Andrew’s colleague, state whether you agree with him. Explain your answer. (3 marks)

(iii) State your observation when the aqueous solution of aluminium chloride is tested with a blue litmus paper. Explain your answer with the aid of a balanced chemical equation. (4 marks)

(b) Write the balanced chemical equation(s) involved, if any, when aluminium is used to extract chromium and calcium from chromium(IV) oxide, CrO2 and calcium oxide, CaO, respectively. Provide an explanation if the extraction process is unsuccessful. (3 marks)

(c) Raymond attempts to coat an aluminium key with a protective layer of aluminium oxide via anodisation process. He completes the circuit by connecting the key to the negative terminal and a platinum strip to the positive terminal. Predict whether Raymond’s attempt is successful. Briefly explain your answer. (3 marks)