Performance Review Memo Essay Example | Topics and Well Written Essays - 500 words

Performance Review Memo - Essay Example The different writing styles are now deeply entrenched in my writing and can be selected interchangeably depending on various course requirements. For example, most of the assignments given required that we use either APA or MLA referencing styles. Moreover, the course has helped in the acquisition and improvement of such skills as teamwork that would have otherwise not been learned. The group work helped in learning how to collaborate with other members in achieving a certain goal. The nature of the work, for instance, allowed us to divide the various aspects amongst ourselves and later compiled the work together. Group members were given the liberty to choose the areas that they felt adeptly knowledgeable therefore making the quality of the work better. In addition, and most importantly, the course has improved the ability to develop good research questions and strategies for meeting the research objectives. This ability was enhanced by the step-by-step approach employed by the lecturer. To help in the effective functioning of the group, we broke down the assignment into four parts one for each of us. Delegation of duties is one role that we highly appreciated in a bid to hasten the process of research. All the group members were helpful in achieving the set objectives. Most importantly, each of us selected the areas of the assignment that we were most conversant with. I contributed highly in the area of consumer education as a response to reducing theft of beauty products at the fresh market. Ali’s contribution in the group was most visible in the aspect of employee education as an effective tool of reducing theft of beauty products at the Fresh Market. This is an area that he is well versed in and most of his points came from real experience coupled with supporting literature review. Sara’s contribution was as important as everyone else’s and she did her job

The case of Mabo Essay Example | Topics and Well Written Essays - 2250 words

The case of Mabo - Essay Example The amendment aimed at establishing a strategy of making land grants based on the trust of Torres Strait islanders and the aboriginals of which the Murray Islanders did not agree with it. The plaintiffs had the representation of the Grey Mclntyre, Brian Keon-Cohen, and Ron Castan (Curthoys, Genovese and Reilly, 2008). At first, the case was brought in as a test aimed at determining the legal rights of the people of meriam to land in the Murray island and Waier and Dauar in Torres Strait. This was so because; such got heavy stimulation to the Queensland in 1879. Before the British contacted the Meriam people, they had lived in the land as subsistence economists who majored in fishing and cultivation. At those times, the land was not for the whole community or public, but rather, was for certain individuals. At some point in 1985, the government attempted at all means to discontinue the proceedings through the enactment of a declaratory act referred to the Queensland coast island. This declaration stated that on the land annexation in 1879, the island title was vested in the Queensland state, and as a result, free from claims, interests, and rights whatsoever. According to the Mabo versus Queensland number 1 of 1988, the high court stated that this was not in line with the legislations provided by 1975 racial discrimination act. As a result, the plaintiffs decided to come up with inter alia declarations ruling that the Meriam people had a right for the Land of Murray Island. This meant that they were the owners, possessors, occupiers, or people who have a right to enjoy the use of the land. According to the plaintiffs, they argued that they needed a possessory title because of the long period, which they possessed the land.

Reactivity of M-C bonds and catalytiv formation of heterocycles Essay

Reactivity of M-C bonds and catalytiv formation of heterocycles - Essay Example The second key element is the CH activation process and this process usually helps in electrophilic metal and acetate activation. The activation is achieved through combination of deprotonation as well as acetate which is an intramolecular base. Currently, close to 95% of all phenyl group activation relies on CH activation (Anastas & Warner, 1998). Current studies have showed the ease of activation of different types of CH bonds and some of these bonds are NH or NR types. This type of bond falls in type 1 of the heterocycles ligands and the second type is the vinyl group. This group is characterized by the formation of rings such as M ring which at times is an equivalent of p-cymene. The vinyl group which is type 2 of the heterocycles in ligands is able to react with alkynes after the process of CH activation. The ease of insertion of the various M-C bonds which comprises of the heterocycle, phenyl, and vinyl with alkynes are not yet known. This is because very limited research has b een done on this area. The activation of these M-C bonds with the alkynes is expected to give type 3 of the heterocycles in ligands (Chen et al., 2009). Some of the end products of catalysis with heterocycles produce effects during the activation process and update such kind of effects have never been researched. Therefore, the effects that they are capable of producing are not well known. Basically, this project will tend to unveil the synthesis of complexes in group 2 like D, 1,2-Diphenylethane-1,2-diol (II) and their various reactions with the alkynes to form either group 3 or group 4 heterocycles ligands (Sanford & Lyons, 2010). The obtained experimental results will therefore, be compared to the various results that are obtained through computational chemistry. These computational chemistry results will be the ones that were obtained by the various collaborators who were present at the University of Heriott Watt. PREPARATION OF FUNCTIONALIZED HETEROCYCLES STARTING MATERIALS AND PRODUCTS The starting materials are 1-chloro-isoquinoline together with benzotriazole. The two are combined through nucleophilic substitution method. The combination of these two gives ligand 1. The use of deprotonation can also be used in the preparation of these functionalized heterocycles such as NH or NR. The deprotonation is carried out on imidazolium chloride salt together with a strong base as the solvent. The reaction time is at an interval of 10 to 15 minutes before the next step is undertaken. Reaction pass this time at times yield wrong results and therefore, keen observations of this reaction time is recommended for purposes of accurate results. The preferred chemical apparatus is Schlenk flask together with stir bar. Stir bar is used to prevent heat loss during the homogeneous mixing of the reactants. After the formation of ligand 1 the cyclometallated complexes 2 which is ligand 2 is formed from the reaction of 2-vinylpyridine and trithiazyl trichloride (Ng, Zhou & Yu , 2012). The ligand 3 is also formed from the reaction of rubeanic acid and double cyclocondesation of oxalamidoxime. These kinds of ligands are useful during the formation of multinuclear and mononuclear metal complexes. The other products formed are Diisopropoxytitanium (III) Tetrahydroborate, 1(2 mmol) and lithium bis (2,4,6-triisopropylphenyl)hydroboratylmethylpolystyrene (9) A reaction between tetrahydroborate 1 of heterocycles 1 equivalent took place with a-hydroxyketones also of 1 equivalent for a time ranging between 5 to 15 minutes. The

T-Moblie Essay Example | Topics and Well Written Essays - 500 words

T-Moblie - Essay Example public, Austria, Hungary, Croatia, Montenegro, Macedonia, Poland, the Netherlands, United Kingdom and the Slovakia– including the US Virgin Islands, US, and the Puerto Rico. On the global level, the International subsidiaries of T-Mobile possess total subscribers which are roughly 150 million in number, which makes it the twelfth-largest service provider of mobile phone in the entire world in terms of subscribers. Besides this, T-Mobile bags the rank of the third-largest multinational and stand after Spains Telefà ³nica and UKs Vodafone. T-Mobile, in the year 2010, became the segment of the agreement of joint venture with the UK mobile-network provider of France Telecom, Orange UK. These companies combined and formed the largest mobile-network operator of UK and called itself Everything Everywhere. However, even after forming the joint venture, the Orange brands and T-Mobile go on to co-exist in the markets of United Kingdom. T-Mobile complies with all the laws which are applicable to the state and federal codes of laws and regulations. The management of the company does not indulge in any activity which violates the policies of the company such as non-retaliation, non-discriminatory and non-harassment policies. The unacceptable conduct in the company constitutes of violation of company laws and policies, removal of the property of company without permission, willful or neglectful damage or defacing of the company property, dishonesty, fraud, improper record keeping and all the related activities. Any criminal conviction amongst the employees results in their termination from the company. Besides this, all the secret trade laws and other legal information are kept confidential from others except the concerned parties. The company makes the decisions in the business by giving proper consideration to the social, ethical and legal regulations. The T-Mobile makes returns to the society through the afterschool community outreach program. The company makes efforts to

The Coffee Company Report Essay Example | Topics and Well Written Essays - 4000 words

The Coffee Company Report - Essay Example Out of the 5 running stores, two are not able to generate any profit and the managers believe that this is because of the locations of the stores. One of the partners suggested consulting a marketing research firm however, the other partners think of it as a costly endeavor. The concept of using GIS technology for combining the business information with the demographic data for assessing the proper location for the stores is also being considered by the business partners. However, balancing the financial issues with the strategic planning problem is a complex process for the firm which urged the partners to cancel the bespoke software development and other IT projects of The Coffee Company.  Ã‚   Based on the given case, the partners of The Coffee Company have selected two options for generating their profit earning process. The first option is to focus on the relocation of the two stores that are not operating in a profitable manner and the second option is to improve the customer service process of the concerned stores for increasing the volume of customer footfalls. In the words of Reid and Hinkley (2006), the location of a business house has a major influence on the operational and strategic decision-making process of a firm. Newby (2009) specified that factors such as consumer convenience, the presence of target consumers, market competition, transpiration for procurement of resources, demography and cultural background can the help the business in assessing the contribution of a location for business sustainability.  Changing the location of the stores for The Coffee Company has to be conducted based on proper information that would allow them to make quick decisions and implement them.  

Revelation Essay Essay Example for Free

Revelation Essay Essay The opening lines of the poem initiate the main themes; â€Å"Black bull† introduces one of the themes which are gender stereotyping. This suggests the bull is powerful, strong and very angry. Females are then introduced in the poem, â€Å"eggs and milk†. This suggests females are pale, delicate and easily broken. The poet highlights the theme of stereotypes by placing â€Å"black bull† above â€Å"eggs and milk†. This is to effectively state that the black bull is on top of eggs and milk which emphasises on the importance of gender stereotyping. The second theme is introduced which is innocence and experience, â€Å"They call him Bob – as though perhaps you could reduce a monster with the charm of a friendly name†. Tone her is cynical. The bull has been given a cheery, friendly name which is a irrelevant name for the harsh animal. The key words of the quote are â€Å"monster† and â€Å"friendly†. This is a very striking contrast between the idea of the name Bob being friendly, cheery and approachable, but in actual fact behind the cheery name lays a monster. The quote, â€Å"at the threshold of his outhouse†, is the turning point in the story. Look more:  first poem for you essay This is a symbolic quote that states you must go over a line before starting a new life. In the poem a young girl is standing in the area between safety and danger. The line is significant as the pause creates a series of tension building up to a sense of danger. The girl’s initial perceptions of the creature are conveyed in, â€Å"At first only black, and the hot reek of him†¦Ã¢â‚¬  The girl’s sensory impressions of the bull are that the word â€Å"black† represents danger. The words â€Å"hot reek† represents the smell and stench of the bull. Her over all sensory impression is the smell of the bulls pungent aroma that is its natural smell and the limited sight gives her a sense of the unknown danger. The poet continues to reference the main theme of gender stereotyping by developing it, â€Å"We was immense†, This quote highlights masculinity and power. It shows that males are bigger, more powerful and the dominate gender. The theme of innocence and experience is also developed, and the bull and the girl are compared to each other. The girl is full of fear and innocence. She is extremely intimidated by the bulls presence. The poet powerfully, reinforces the contrasting thematic dichotomies suggested in verse one. In the first instance this is done by including details in verse two which contract with details from the first verse. The poet has reinforced the theme of innocence and experience as he shows that the bull knows he is restrained. Also reinforces the theme of gender stereotyping – girl and boy. This is done as it is dark and the girl cannot see what the bull is doing, whilst the girl is unaware of this, the bull is trying to break free from where he is chained up too. The poet condenses the contrast by highlighting them in a few lines of verse two. â€Å" I had always half known he existed† Here, the poet points out that the girl had always knew the bull was there, just she had never seen the bull and didn’t want to come to terms with the reality. Verse three is effective as it shows that the girl is fearful of her encounter with the bull. The girl is terrified by the bulls presence and runs away from the farm. She runs past a group of boys. Here the writer links the bull and the boys together by the use of harsh sound effects. It is important that this link is made as it makes a direct comparison between the bulls aggression and the boys cruelty. It highlights that they both share the same characteristics. Finally, the girls attention is redirected to the parlous state of the eggs and milk, due to the flight, â€Å"scared of the eggs shattering† While she’s too busy protecting the eggs it shows the reader that females are protective towards anything precious. In the girls eyes the eggs and milk are precious, and she wants to protect them from any harm. â€Å"in case the milk should spill† The precarious position of the milk is highlighted in the small hands of a weak girl, who has been charged with the responsibility of looking after the eggs and milk. She is protecting what is important to her. The poet seems to be suggesting that her experience shows that females are scared of males and have to protect themselves from any harm. Females protect all forms of life, they are caring and sensible creatures.

Hydration Management in Acute Stroke Patients

Hydration Management in Acute Stroke Patients Introduction Stroke is a global public health concern with many sufferers presenting with varying levels of confusion (Oh and Seo 2007). Management of hydration in acute stroke patients is not standardised and variations in practice can be very wide between different continents. The sheer number of possible comorbidities and the relative ease with which hydration can trigger concomitant problems can lead to increasing incidence and prevalence of long-term patient care resulting from inadequate hydration management. Optimum hydration assessment and management are key clinical activities; however, inadequate hydration controls by health professionals persist (Oh and Seo 2007). Research shows that to guide fluid management to desired levels, a regular assessment of the volume status has to be made Scope This literature review is based on works that are found on Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cumulative Index to Nursing and Allied Health literature (CINAHL), Cochrane, Department of Health (DoH), National Institute of Clinical Excellence (NICE), National Medical Council (NMC), World Health Organisation (WHO), Wiley Interscience and CKS databases that relate to hydration in stroke patients and nursing awareness of hydration in stroke patients. There is wide literature on different aspects of stroke and many authors have studied the effects of hydration in stroke patients. This review looks at literature that discusses management of hydration and/or the impacts of variations in hydration management on acute stroke patients outcomes like method of feeding, time- compliance in taking readings or measurements, legal issues and ethical issues. Relevance to clinical practice This literature review looks at relevant studies by experts that are found on credible databases. The purposes of the expert studies are reviewed and analysed to inform better understanding of current nursing practice in hydrating acute stroke patients. Several studies on hydration highlight specific difficulties relating to the assessment and management of hydration in acute stroke patients. There are differences between the management and the assessment of hydration in different hospitals and these complicate improving awareness of managing hydration for nurses in practice. If optimum hydration is directly linked to improved outcomes in acute stroke patients, research will be required to identify and overcome barriers to effective hydration management, including the development of specific tools (and knowledge base) to facilitate interventions that promote optimum hydration in seeking improved outcomes in acute stroke patients. Methods of search and documentation n on-line literature search of MEDLINE, CINAHL, COCHRANE, DOH, NICE, NMC, WHO and CKS from 1999 to May 2009 failed to identify enough relevant articles on hydration in stroke patients. Other sources were then reviewed for available literature on medical journals including the BMJ and American Family Physician. For the on-line computer-based literature searches, the following keywords were used: stroke, fluid balance, hydration, cerebrovascular accident (CVA), dehydration, stroke outcome, cerebrovascular disorders, medical management, artificial nutrition and hydration, dysphagia, dysphasia, pyrexia, acute brain infarction, enteral tube feeding, fluid and electrolyte balance, neurology, withholding treatment, pathophysiology and nurses and hydration Hydration and hydration management in acute stroke patients This literature review looks at one of the issues encountered globally in the treatment of acute stroke patients optimum hydration. It takes a particular look at the nursing awareness, measurement, assessment, methods of intervention and the legal issues associated with hydration in acute stroke patients. Stroke is a debilitating condition and can be caused by an ischaemic event or a subarachnoid/intracerebral bleeding. Stroke patients usually present in hospital with co-morbidities (Oh and Seo 2007). Variations exist in stroke fatalities across geographical regions even within the same continent. Studies by Bhalla et al (2003) across four European centres (London, Dijon, Erlangen and Warsaw) have shown significant variation (after adjusting for case mix) in stroke case fatality, in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity. There were also significant intervention differences between centres in intravenous fluid use, enteral feedin g, initiation of new antihypertensive therapy and insulin therapy, with the London centre having the lowest uptake of interventions. In another European BIOMED Programme, significant variations in case fatality for stroke between European centres (after adjustment for stroke severity) were observed, with the United Kingdom (UK) centres having the highest case fatality and the lowest levels of independence (Wolfe et al., 1999). There were lower intervention rates in the UK centre to correct abnormal physiological parameters in the acute phase which may reflect a difference in philosophy of acute medical supportive care compared with other European countries (Wolfe et al., 2001). Awareness of optimal hydration balance and assessment of the patients hydration condition (in the care of acute stroke patients) is a fundamental part of critical care nursing and optimising the hemodynamic situation can be seen as a team-effort. One of the important factors determining quality of the circula tion is the amount of circulating blood (Hoff et al 2008). Following a stroke, patients may have swallowing impairment and other changes of the gastro-intestinal (GI) tract that could affect nutritional and hydration status and that lead to aspiration pneumonia (Schaller et al 2006). Such changes affect the ability of the acute stroke patient to lead a normal nutritional life. Although the Schaller et al (2006) work did not show a direct link between hydration and other comorbidities, they agree that impaired hydrational status is associated with reduced functional improvement, increased complication rates, and prolonged hospital stays. Hydration and hydration status Hydration balance is a measure of the bodys ability to manage fluids and electrolytes. In order to identify the urgency of interventions, nursing staff should characterize an individuals fluid and electrolyte imbalance as mild, moderate, or severe based on pertinent information including lab tests and other relevant criteria. It is important to recognize that the main electrolyte in extracellular fluid (ECF) is sodium and that of intracellular fluid (ICF) is potassium (Edwards, 2001). Toto (1998) pointed out that large increases or decreases in fluid volume can cause infarct, coma and confusion. This knowledge becomes significant in maintaining cerebral blood flow and in preventing secondary brain insult after an acute stroke. In a complication, respiratory or metabolic acidosis will promote the movement of potassium from the ICF and give rise to high serum potassium levels, which may affect cardiac function (Edwards, 2001). This phenomenon can be seen in many traumatic insults to th e brain. A basic knowledge of this physiology in addition to the homeostatic mechanisms for fluid and electrolyte balance is a vital foundation for nursing practice, and essential to the nurses role in hydration management. Cook et al (2005) highlighted the significance of fluids and hydration in the neuroscience patient and in Cook et al (2004) they highlighted that an understanding of the physiological mechanisms that surround stroke is important for nurses to monitor and treat such patients. Kelly et al (2004) in their study of dehydration and venous thromboembolism (VTE) after acute stroke believed dehydration after acute ischaemic stroke (AIS) is strongly independently associated with VTE, reinforcing the importance of maintaining adequate hydration in these patients. Their study of hydration over a 9-day period showed indication that dehydration was largely hospital acquired and that the association was causal. Although the possibility that VTE was already present at entry to hospital cannot be discounted, tests have shown that VTE is rarely present before the second day post stroke, and then it becomes increasingly prevalent over the next few days. This could be for one of many reasons including poor communication between patient and hospital staff, change of environment for the patient and the physiological impacts of stroke Hydration balance and nutritional/electrolyte balance The differences in how hydration is assessed in different hospitals have been subject of study for some time. The significance of fluid electrolyte homeostasis becomes very relevant in trauma and shock situations such as subarachnoid haemorrhage where an inflammatory response is triggered which causes a significant change in capillary membrane permeability in a short period of time. In such situations, water, electrolytes and albumin move into the interstitial space to permit the site of injury to receive the required factors (third space shift) (Edwards, 2001). A number of physiological mechanisms are required to maintain homeostasis of hydration status, all of which inform proactive nursing assessment, intervention and evaluation. Those with trauma to the nervous system are vulnerable to disruption to the homeostasis of fluid and electrolyte balance (Cook 2005). Older adults may have a poorer capacity to adapt to shifts in acute fluid balance, leading to the possibility of cardiac and renal functions being impaired and, as a result, a lower glomerular filtration rate (Sheppard, 2001). Managing the fluid balance of the stroke patient by intake and output measures needs to be exercised cautiously because even though the patients fluid volume may not have changed, his/her circulatory volume may be significantly lower in instances of major trauma (Edwards, 2001) Good hydration has been shown to reduce the risk of urolithiasis (category Ib evidence) (see Appendix 2), constipation, exercise asthma, hypertonic dehydration in the infant, and hyperglycemia in diabetic ketoacidosis (all category IIb evidence), and is associated with a reduction in urinary tract infections (UTIs), hypertension, fatal coronary heart disease, venous thromboembolism, and cerebral infarct Complications of measurement/control Naso-gastric v PEG, enteral v parentera Patient history taking on presenting in the hospital differs from hospital to hospital. History taking should include assessment of fluid intake and loss, baseline hydrational status, skin turgor, heart rate, blood pressure and urinary output. Normal fluid intake for the average adult is approximately 2-2.5 litres, obtained from food, fluids or metabolic by-products (Edwards, 2001). Methods of measurement are not standardised across hospital settings with Wise et al (2000) showing that faecal fluid losses are often neglected in daily fluid balance charts with the possibility of inaccurate hydration assessment. Fluid assessment must include estimating, as accurately as possible, the quantity of fluid taken in. It must take into consideration the entire processes by which water, potassium and sodium are obtained. Measurements are often mainly focused on the extremes of hydration (optimal hydration and extreme dehydration) and this should not be the case. Assessment of hydrational statu s and need is continuous and begins somewhere along a continuum of severe hypovolaemia/ dehydration to severe hypervolaemia/ overhydration. In looking at dehydration, not only extreme dehydration should be noted. Manz and Wentz (2005) highlight that there is increasing evidence mild dehydration may also account for many morbidities and play a role in various other morbidities. The way in which stroke is managed acutely, such as measures maintaining physiological homeostasis may also vary between different populations (Bhalla et al 2003). The physiological indicators of acute deficits in fluid balance may be masked in individuals where compensatory mechanisms are intact. A history of acute events, mainly from baseline documentation and history taking, may enable better identification of such imbalances (Sheppard, 2001). Fluid and electrolyte homeostasis is brought about by the interaction between the renal, pulmonary, neuroendocrine, integumentary and gastrointestinal systems (Edward s, 2001). According to (Cook 2005), fluid and electrolyte management is a fundamental aspect of the role of the neuroscience nurse. Artificial feeding and fluids are the options for a patient who has an advanced, life-threatening illness and is dying. The patient, family members and doctor can talk about these options and the benefits and risks (Ackermann 2000). Hydration and electrolyte status are crucial mediators to the extent of the neuro-hormonal response to trauma. Edwards (1998, 2001) highlighted that homeostasis is maintained by a constant movement of water, sodium and potassium between intra- and extracellular compartments. While the movement of water and electrolytes between the cellular compartments is highly significant, it is important to recognize that in acute and chronic illness intracellular fluid (ICF) is reduced and extracellular fluid (ECF) increased almost to the extreme (Edwards, 2001). This is highly relevant for cerebral metabolism, because transport of oxyge n, glucose, proteins and other products for cellular metabolism—and their by-products—may be severely impaired. Stroke may affect ones level of alertness, perception of thirst, ability to access liquids, and ability to swallow them when offered. Stroke victims with such impairments may be at increased risk for diuretic-induced dehydration (Churchill et al 2004). Managing hydration balance is of crucial importance and the mechanisms for the adequate monitoring and controls need to be in place. Nursing management questions in the assessment of hydration in acute stroke patients should include whether use of intravenous fluids during the first week of stroke was recorded. Questions should also include whether the patient was fed orally, by nasogastric tube, through percutaneous gastrostomy tube, by intravenous methods or not at all? The fact that these questions can be raised enforces the need for adequate documentation and recording of acute stroke patient records. Bhall a et al (2002) says that the use of artificial ventilatory support with intubation or nasal intermittent positive pressure ventilation should be documented as well as the use of supplemental oxygen given through nasal catheters or masks. Enteral tube feeding is a vital means of feeding and balancing hydration levels in patients with stroke. There are no set standards for hospitals in the UK and hospitals have recorded much variation between them in the timing of the start of enteral tube feeding and whether a nasogastric or percutaneous endoscopic gastrostomy (PEG) tube is used (Ebrahim and Redfern 1999). Some clinicians delay tube feeding for 2 weeks or more, and although early nutrition is unlikely to be harmful, whether any nutritional benefits offset the difficulties and complications of initiating and maintaining early enteral tube feeding is unclear. If the timing or route of enteral tube feeding does affect outcome, the present variation in practice means that large numbers o f patients are being denied best treatment. Whether enteral tube feeding via PEG rather than nastrogastric tube or early initiation of enteral tube feeding improve outcomes was tested in the FOOD trials and no evidence of significant benefit from PEG rather than nasogastric tube feeding was found. Neither was any hazard from early tube feeding found (The FOOD collaboration 2003). The explanation for any difference between PEG and nasogastric groups is not clear, but one factor might be the effect of a long-term PEG tube on dependency since more patients in the PEG group were still receiving such tube feeding than in the nasogastric group at follow-up (The FOOD collaboration 2003). The survivors in the PEG group were also more likely to be living in institutions and had lower quality of life. Another intriguing finding was the excess of pressure sores in the PEG group, raising the possibility that those with such tubes might move less or be nursed differently. Weaknesses in this test results include insufficient statistical power to exclude more modest differences between groups; no information about the proportion of eligible patients enrolled in each centre; our use of an informal (although reliable and highly predictive) assessment of nutritional status; absence of precise monitoring of patients daily intake of nutrients (rather than fluids); absence of on-site source data verification or collection of information on changing nutritional status (e.g. in-hospital weights); possible bias due to masking of secondary outcome measures. Although compliance was not 100%, this fact results from the inevitable difficulties of adhering to rigid schedules when patients conditions change. Difficulties with nasogastric feeding in stroke patients (who are often confused and uncooperative) have led to increasing use of PEG tubes at an early stage. Enthusiasm for this method has been encouraged by the results of a trial that reported much lower case fatality rates in patien ts fed via PEG (13%) rather than nasogastric tube (57%) (The FOOD trial collaboration 2003). Due to significant alterations in fluid balance after enteral tube-feeding in patients, close attention to the recording of fluid balance such as intake/output measurements, body weights and simple bedside assessments is needed to detect fluid imbalances and other serious complications at an early stage (Oh and Seo 2007). One explanation for the varying and inconsistent readings in fluid hydration between enteral and PEG might b Stroke patients and the impacts of stroke on life Difficulty with swallowing is a common problem in acute stroke patients, and can lead to aspiration pneumonia, dehydration, and exacerbation of any existing malnutrition (Finestone and Greene-Finestone 2003). In Oh and Seo (2007) the authors set out to examine the fluid and electrolyte complications after enteral tube feeding in acute brain infarction patients. The background is that inconsistencies in the results of the water and electrolyte complications associated with enteral tube feeding are partly because of uncontrolled disease-related variables. The implication is that these variables were not adequately managed. Stroke patients very often present with dysphagia and this is very commonly dehydration associated with undernutrition (The Food Trial 2005). Up to half of stroke patients in hospital have dysphagia, which precludes safe oral nutrition for the first few days and can persist for long periods (Mann et al 1999). Although a 50% prevalence can be considered to be high, th e nutritional/fluid status of a stroke patient can rapidly deteriorate in hospital. The difficulty in feeding stroke patients with dysphagia coupled with the discomfort associated with stroke can exacerbate undernutrition and/or dehydration. Studies show that undernutrition shortly after admission is independently associated with increased case fatality and poor functional status at 6 months (The FOOD trial collaboration 2003). The current financial burden of efficiency savings and reduced budgets in the NHS hospitals results in reduced staff numbers so that patients can not be attended to on a one-on-one basis so that ensuring appropriate hydration levels is done by periodic but regular monitoring of charts. An option for the future in this area may be to involve the patients family members in hydration monitoring and provide them with appropriate training if evidence can show that being around loved ones improves outcomes and early warnings. In acute stroke, artificial nutrition t hrough an enteral route is needed because of dysphagia and since oral feeding is unsafe in some dysphagic patients, enteral nutrition is often administered as nasogastric or percutaneous endoscopic gastrostomy (PEG) tube feeding (Finestone and Greene-Finestone 2003). Naso-gastric tube feeding (a prevalent enteral method) has been reported to improve clinical outcomes more than the parenteral route in brain-injured patients (Rhoney et al 2002). Oh and Seo (2007) in their study used 85 subjects, but their work was limited by the fact that it was performed retrospectively and some of the subjects records were incomplete. Also, because the patients in the study were from one hospital it is not conclusively known whether the results can be generalised to the whole population./p> Legal and other aspects Japanese physicians attitudes towards artificial nutrition and hydration (ANH) as a life-sustaining treatment (LST) were examined to find out if they withhold or withdraw the LST when treating older adults with stroke-caused profound impairment with no hope for recovery. The study findings show that the informants held different views towards LST because most doctors considered ANH to be indispensable and ANH is automatically provided to patients (Aita and Kai 2006). With the advancement of medical technology, decisions to withhold or withdraw LST are among the most difficult to make for health professionals (British Medical Association 2001). Physicians caring for stroke patients often encounter comatose or semi-comatose patients with severe stroke for whom it is difficult to determine whether or not to continue care (Asplund and Britton, 1989). By administering LST, some patients in this patients group, whose bodily functions other than brain function could remain stable, could pot entially survive for months or years without achieving awareness or being able to interact with others (Aita et al 2008). Certain Japanese physicians have criticized the current efforts regarding life prolonging as Aita et al (2008) states: Prolonging the process of dying like this constitutes the violation of dignity and human rights. The life-prolongation only serves hospital operators who want to make profits by keeping hospital beds occupied. They also said this practice impacted the carers and that some nurses also feel emptiness toward the manipulative life-prolongation when taking care of these elderly patients. In the West, some countries have worked out nation-wide guidelines related to withholding or withdrawing LST that say stroke-caused profound impairment with no hope for recovery is a potential reason to withhold or withdraw LST (British Medical Association, 2001). Ackermann (2000) believes withholding and withdrawing therapy challenge family physicians to be excellent communicators with patients and families and recommends that family physicians should continue to be strong advocates for dying patients. Sprung et al (2003) highlighted differences between withholding and withdrawing therapy showing that withdrawal of therapy is followed by a nearer and more rapid death than withholding therapy, and that physicians and nurses were more inclined towards withholding rather than withdrawing therapy. Food and water are considered symbols of caring (Ackermann, 2000), therefore, it may be natural for physicians to give a special status to ANH as food and water. Whether to withdraw ANH from a patient in persistent vegetative state has also drawn substantial media attention in the U.S. (Casarett et al., 2005; Ganzini, 2006). The findings of the study also suggest that the physicians double standard is partly based on their subjective judgment whether the treatment is ordinary or extraordinary. However, the standard of ordinary/extraordinary care has long been criticized as too vague to guide decision-makers in the U.S. (Beauchamp and Childress, 2001). It is believed the current legal framework has also inappropriately led some physicians to simply continue care regardless of the patients conditions, thus resulting in putting an unnecessary burden on patients. The physicians subjective interpretation of the current legal framework may lead to decisions not to initiate mechanical ventilation in some older adults for fear of facing a situation in which physicians cannot withdraw it at a later stage Conclusion Hypovolemia and hypervolemia occurred frequently after acute stroke but were often not recognized as such by nurses. The nurses predictions of current volume status do not seem sufficiently reliable to serve as a basis for therapeutic decisions. More advanced techniques for bedside assessment of volume status may be indicated for optimizing volume status in patients with acute stroke (Hoff et al 2004). Whereas studies have looked at the optimal method of improving hydration, whether correcting dehydration in stroke improves outcome is not very clear. Given the complexity of the cell death cascade following brain ischemia, novel approaches and combination therapy are inevitable for victims of stroke (Fisher and Brott 2003). The review indicates that standards vary from country to country in the legal framework for withdrawing and withholding hydration and nutrition during end stage care.