Pathophysiology of Liver Diseases

Pathophysiology of Liver Diseases ONG SUAN LING Liver Failure The liver is responsible for regulatory, detoxification, metabolic and synthetic activities. Liver cell known as hepatocyte, is responsible for about 500 or more specific biologic processes [2]. Liver failure occurs when large parts of the liver become damaged and the liver is dysfunction [1]. Liver failure occurs over many years and gradually. However, the acute liver failure is difficult to detect initially and occurs rapidly (as rapid as 48 hours) [1]. Chronic liver failure is caused by excessive alcohol intake, Hepatitis B or C, malnutrition, Hemochromatosis (body absorb and store too much iron) and cirrhosis (irreversible inflammatory disease) [2]. Figure 1 show the stages of liver damage which eventually lead to cirrhosis. Liver Hepatitis Hepatitis means inflammation of the liver. Hepatitis B and hepatitis C is the most common hepatitis which can lead to the liver damage caused by their chronic forms. Viral hepatitis is cleared from the body in a period ranging from weeks to months, by the immune system but when it is not as seen in chronic hepatitis, the disease must be managed medically [5]. Hepatitis can also be brought on by excess alcohol consumption or inherited (congenital hepatitis)[5]. When hepatitis left untreated, it can damage the liver over many years, eventually resulting in cirrhosis [5]. Liver Cirrhosis Cirrhosis is a condition in which normal, healthy hepatocyte are damaged and replaced by nodular and fibrotic tissue. A cirrhosis-damaged liver can cause decreased hepatic function and widespread disruption of many body functions [3]. For cirrhosis, the biliary channels become obstructed and caused portal hypertension. The hypoxic necrosis is developed as a result of blood circulation is shunted away from the liver (due to neovascularisation) [4] Figure 2 shows the normal appearance of the cells of the liver, compared to cells of cirrhotic livers. Hepatopulmonary syndrome (HPS) Hepatopulmonary syndrome is the clinical relationship between hepatic dysfunction and the existence of pulmonary vascular dilatation which can result in a range of arterial oxygenation abnormalities [6]. HPS is defined by the presence of chronic liver disease; abnormal arterial oxygenation or an arterial partial pressure of oxygen in the absence of an alternate cause; and evidence of intrapulmonary vascular dilatations (IPVDs) [7] Pathophysiology Hepatopulmonary syndrome occurs mostly in patients who have established cirrhosis and portal hypertension [8]. From a pathophysiological point of view, abnormal intrapulmonary vascular dilatation is linked to portal hypertension, which in itself leads to altered bowel perfusion and an increased rate of enteral translocation of gram-negative bacteria and endotoxin. This process in turn stimulates the release of vasoactive mediators, which include tumour necrosis factor, haem-oxygenase-derived carbon monoxide, and nitric oxide. The increased production of nitric oxide in the lung plays a central part in the pathogenesis of the hepatopulmonary syndrome [8]. Increased concentrations of exhaled nitric oxide are positively correlated with the increase of alveoloarterial oxygen difference. The constitutive and the inducible isoforms of nitricoxide synthase have been implicated in this process. In addition, the endothelin system, especially abnormal activation and increased expression of endothelial type B endothelin receptors, is implicated in the pathogenesis of the hepatopulmonary syndrome [8]. In patients who have pulmonary hypertension, endothelin predominantly exerts vasoconstrictive and mitogenic effects due to activation of type A and type B endothelin receptors on pulmonary arterial smooth muscle cells [8]. (Refer to figure 3) Figure 3 show in presence of portal hypertension, hepatic production occurs of endothelin-1 and expression of endothelial type B receptors, but no type A receptors increase in pulmonary vasculature. Signaling via endothelially expressed endothelin B receptor leads to increase NO production by eNOS, with the overall effect of pulmonary vascular dilatation. Below is how defective synthesis and metabolism of pulmonary vasoactive substance lead to intrapulmonary Vasodilation. Due to the vasodilation and development of shunt, the blood flow is not uniform leading to ventilatation-pefusion mismatch and also restricts the oxygen molecules to reach the centre of the capillaries and hemoglobin in the erythrocyte [9]. (Refer to figure 4) Figure 4: Ventilation-perfusion mismatches the oxygen reach the capillaries and blood. The nonuniform perfusion blood flow may lead to the formation of functional intrapulmonary vascular dilations which is the major cause of hypoxemia and the defining feature of HPS [9]. The hyperdynamic circulation as well as the increased cardiac output which associated with liver disease reduces the transit time of blood in the lung vasculature, thus the time available for the oxygen diffusion is reduced. This in turn contributes to the hypoxemia [9]. HPS also caused a decreased arterial partial pressure of oxygen (PO2) as a result of the inability of oxygen molecules to diffuse to the center of the dilated pulmonary capillaries to oxygenate the haemoglobin in the erythrocytes [8]. Figure 5 shows illustration of precapillary pulmonary vascular dilatations. On the other hand, the increasing of alveolar PO2 with supplement oxygen may increase the blood arterial PO2 and improve the hypoxemia [8]. HPS patients have been reported to have decreased pulmonary vascular resistance and decreased hypoxic pulmonary vascular constriction [8]. Hepatorenal syndrome (HRS) Hepatorenal syndrome (HRS) is generally occurs in patients with cirrhosis and portal hypertension [10]. HRS is characterised by major disturbances in circulatory function and renal failure [10]. Intense vasoconstriction of the renal circulation has resulted in renal failure [10]. The HRS is the final consequence of extreme underfilling of the arterial circulation secondary to arterial vasodilatation in the splanchnic vascular bed [10, 11]. The principle abnormality in the systemic circulation is low arterial pressure caused by greatly reduced total systemic vascular resistance [11]. The prognosis remains poor, particularly when there is rapidly progressive renal failure [11]. HRS occurs in the setting of cirrhosis predominantly, but it can also be developed in other types of chronic liver disease like alcoholic hepatitis. Figure 6: Proposed pathogenesis of HRS in cirrhosis, according to the arterial vasodilatation [13] The mechanism of HRS is vasoconstriction of the renal circulation is multifactorial, involving disturbance in the activity and circulatory function of systemic and renal vasoactive mechanisms [13]. There is severe arterial underfilling in the systemic circulation which is related to the portal hypertension [13]. The arterial underfilling is caused by the vasodilatation of the splanchnic circulation related to increased splanchnic production of vasodilator substances, particularly nitric oxide [17]. The increased activity of the vasoconstrictor systems caused greatly reduce in renal perfusion and GFR however tubular function is preserved [13,14,16]. The vasoconstrictor system has resulted in the retention in free water (arginine vasopressin) and retention in sodium (renin-angiotensin and sympathetic nervous system) that occurs in advanced cirrhosis [15, 16]. In the early phases of decompensated cirrhosis, increased synthesis of renal vasodilator factors (mainly prostaglandins) caused maintenance of renal perfusion within the normal range because of [17]. In later phases of the disorder, renal perfusion cannot be maintained because maximum activation of vasoconstrictor systems caused by the extreme arterial underfilling, has decreased production of renal vasodilator factors, or both, and lead to HRS developement [17]. The activation of vasoconstrictor systems also results in vasoconstriction of some vascular beds other than the kidneys, including the legs, arms and brain. Due to the greatly increased local production of vasodilators, the splanchnic area escapes the effect of vasconstrictors [18]. References Webmd.com. (2014).Liver failure causes, symptoms, treatments, tests more. [online] Retrieved from: http://www.webmd.com/digestive-disorders/digestive-diseases-liver-failure [Accessed: 11 Jan 2014]. Vitaltherapies.com. (2014).Liver disease | vital therapies. [online] Retrieved from: http://vitaltherapies.com/liver-disease/ [Accessed: 11 Jan 2014]. Hn632campus.wikispaces.com. 2014.HN632campus Cirrhosis. [online] Available at: https://hn632campus.wikispaces.com/Cirrhosis [Accessed: 11 Jan 2014]. Buob, S., Johnston, A. N., Webster, C. R. L. (2011). Portal hypertension: pathophysiology, diagnosis, and treatment.Journal of Veterinary Internal Medicine,25(2), 169-186. Livermd.org. (2014).Hepatitis cirrhosis. [online] Retrieved from: http://livermd.org/hepatitis.html [Accessed: 11 Jan 2014]. Krowka, M. J., Cortese, D. A. (1994). Hepatopulmonary syndrome. Current concepts in diagnostic and therapeutic considerations.CHEST Journal,105(5), 1528-1537. Fritz, J. S., Fallon, M. B., Kawut, S. M. (2013). Pulmonary Vascular Complications of Liver Disease.American journal of respiratory and critical care medicine,187(2), 133-143 Hoeper, M. M., Krowka, M. J., Strassburg, C. P. (2004). Portopulmonary hypertension and hepatopulmonary syndrome.The Lancet,363(9419), 1461-1468 Zhang, J., Fallon, M. B. (2012). Hepatopulmonary syndrome: update on pathogenesis and clinical features.Nature Reviews Gastroenterology and Hepatology,9(9), 539-549. Ncbi.nlm.nih.gov. (2014).Hepatorenal syndrome national library of medicine pubmed health. [online] Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001519/ [Accessed: 12 Jan 2014]. Emedicine.medscape.com. (2014).Medscape: medscape access. [online] Retrieved from: http://emedicine.medscape.com/article/178208-overview#a0104 [Accessed: 11 Jan 2014]. Ginà ¨s, P., Guevara, M., Arroyo, V., Rodà ©s, J. (2003). Hepatorenal syndrome.The Lancet,362(9398), 1819-1827. Arroyo, V., Ginà ¨s, P., Gerbes, A. L., Dudley, F. J., Gentilini, P., Laffi, G., Schà ¶lmerich, J. (1996). Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis.Hepatology,23(1), 164-176. Arroyo, V., Guevara, M., Ginà ¨s, P. (2002). Hepatorenal syndrome in cirrhosis: pathogenesis and treatment.Gastroenterology,122(6), 1658-1676. Schrier, R. W., Arroyo, V., Bernardi, M., Epstein, M., Henriksen, J. H., Rodà ©s, J. (1988). Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis.Hepatology,8(5), 1151-1157. Schrier, R. W., Niederberger, M., Weigert, A., Ginà ¨s, P. (1994). Peripheral arterial vasodilatation: determinant of functional spectrum of cirrhosis. InSeminars in liver disease(Vol. 14, No. 1, pp. 14-22). Martin, P. Y., Ginà ¨s, P., Schrier, R. W. (1998). Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis.New England Journal of Medicine,339(8), 533-541. Angeli, P., Merkel, C. (2008). Pathogenesis and management of hepatorenal syndrome in patients with cirrhosis.Journal of hepatology,48, S93-S103.

Banquo - a Spiritual Force in Shakespeares Macbeth :: Macbeth essays

Banquo - a Spiritual Force in Macbeth      Ã‚  Ã‚   Who cannot learn from Shakespeare's Macbeth this moral lesson: That crime does not pay? And who can deny that the playwright created a spiritual force in the play in the person of Banquo? This essay is his story.    Lily B. Campbell in her volume of criticism, Shakespeare's Tragic Heroes: Slaves of Passion, discusses how fear enters the life of Banquo with the murder of Duncan and his two attendants:    And as Lady Macbeth is helped from the room, we see fear working in the others. Banquo admits that fears and scruples shake them all, even while he proclaims his enmity to treason. But Banquo fears rightly the anger or hatred of the Macbeth who has power to do him harm. (222)    In Shakespeare and Tragedy John Bayley discusses Banquo shortly before his murder:    [. . .] like Banquo, who, in the tense hour before the murder, expresses in more forceful form the idea of evil speculation and possibility as ranging in the mind:    Merciful powers, Restrain in me the cursed thoughts that nature Gives way to in repose. II.i.7-9    At such a moment the activities of the mind become almost palpable and express themselves in bodily form, as they do in the other two mind tragedies. In the speech which he imagines the thoughts that may come to him when he goes to rest, Banquo hands his sword to his son Fleance, and then - with a dream-like precision - hands over his belt with its dagger too:    Hold, take my sword. There's husbandry in heaven; Their candles are all out. Take thee that too. (188-89)    Clark and Wright in their Introduction to The Complete Works of William Shakespeare comment that Banquo is a force of good in the play, set in opposition to Macbeth:    Banquo, the loyal soldier, praying for restraint against evil thoughts which enter his mind as they had entered Macbeth's, but which work no evil there, is set over against Macbeth, as virtue is set over against disloyalty.   (792)    In Fools of Time: Studies in Shakespearean Tragedy, Northrop Frye explains the rationale behind Banquo's ghost in this play:    Except for the episode of Hercules leaving Antony, where mysterious music is heard again, there is nothing really supernatural in Shakespeare's tragedies that is not connected with the murder of the order-figures.

How Does Stress Affect the Policing Community?

cjs210Write a 200- to 300-word response addressing the following questions: How does stress affect the policing community? Stress has many effects on the policing community as a whole. Officers may lose sleep over the stress and become fatigued which in turn causes them to lack on their duties, or delay their reaction time. Officers may also get so stressed that they go through a post traumatic disorder. Post traumatic disorder can cause officers nightmares, or worse they can wind up committing suicide.How does police culture support police officers in evolving job situations? Police culture support officers throughout the evolving job situations by protecting each other. Officers have a brotherhood and a closeness that no other career has because of the daily struggles they go through. Due to the fact that an officer’s job is so stressful they build a bond and become a family for one another to lean on. Being able for them to help each other is important because they know wha t the other one goes through and what they see on a daily basis.Without the support from fellow officers I feel that many may not be able to make it through being a police officer. What resources exist to help officers handle stress? Some departments have their own psychiatrists that are always there when an officer handles a call that may be too stressful. There are also other ways that they cope like with private therapists, or working out. Exercise helps some, but not all which is why there are experts that are more equipped to deal with the daily problems officers may have.

Categories and Roles of School Governors Essays

Categories and Roles of School Governors Essays Categories and Roles of School Governors Essay Categories and Roles of School Governors Essay School governors are one of the countrys largest voluntary groups with around 300,000 contributing to strategic development and raising standards of achievement at more than 30,000 schools. School governors are members of their schools governing body, which is known as a corporate body. A corporate body has a legal identity that is separate from its members and as a result, individual governors are generally protected from personal liability as a result of the governing bodys decisions and actions provided they act onestly, reasonably and in good faith. Individual governors have no power or right to act on behalf of the governing body except where the whole governing body has delegated a specific function to that individual or where regulations specify a function is to be exercised in a particular way. School governors are drawn from different parts of the community and can be parents and staff or from the LA, the community and other groups. This helps ensure the governing body has sufficient diversity of views and experience but does not ean governors of a particular category represent that group on the governing body. For example, parent governors do not represent the parents at the school and do not report back to them. Responsibilities The governing body has a range of duties and powers and a general responsibility for the conduct of the school with a view to promoting high standards of educational achievement. Its responsibilities include but are not limited to: setting targets for pupil achievement managing the schools finances aking sure the curriculum is balanced and broadly based appointing staff reviewing staff performance and pay. The governing body has considerable discretion as to how to discharge its responsibilities but is required to constitute itself in line with the regulations and to appoint a chair and vice chair. The governing body may delegate certain of its responsibilities to certain governors or committees of governors, although in general, it is not compelled to do so. Categories and roles of school governors By shaza7

How I Messed Up On My First Jobâ€and What You Can Learn From My Mistakes!

How I Messed Up On My First Job- and What You Can Learn From My Mistakes! â€Å"Why?† This is a question asked by children incessantly all over the world. â€Å"Why† is an essential inquiry into how the world works. It seems some â€Å"why† questions are acceptable signs of curiosity, whereas others are met with â€Å"Because I said so.† As adults, it’s the same way. We are encouraged to get to the source of the â€Å"why† in science, for instance, but when we are given a task by a supervisor, we are often discouraged from asking why; managers can see the question as an affront to their authority. Do you get offended when someone asks you why? Are you afraid to ask because you might be considered recalcitrant? Consider this story. My First Job As a high school student, I got my first â€Å"real† job as a cashier at Carrot Top Pastries, a small bakery known for making the best carrot cake in New York City. After receiving brief instructions on how to use the register, I set out on my first day of work. Very quickly, I determined that it would be much faster to hit the â€Å"no sale† button to eject the cash drawer, rather than to enter in the amount of every purchase and go through all that extra work! After all, I was a math whiz at the Bronx High School of Science and knew how to make change! I didn’t need the cash register to tell me what to do! Things went on like this for several days before the owner of the bakery discovered she had no record of what had been sold at the end of each day, and no way to balance the accounting. Oops. From this experience, I took away that I am fallible, often in the moments when I thought I was being most impressive. That hurt. I also learned that not understanding the â€Å"why† behind a task greatly increases the possibility of error. Carrot Top laid me off after a couple of weeks, not due to my erroneous ways but because of a strike at the telephone company across the street- the source of most of the bakery’s business. Still, I left that job with a humility I had not experienced before. Good Managers Explain Why Later in life, I became a manager (in a role that kept me at a safe distance from cash registers). I learned that when employees understand the big picture- the â€Å"why†- of what they are doing, they are more motivated, loyal, and productive than when they are simply given a task to do. If the Carrot Top manager had told me from the get-go that entering amounts on the cash register was how they tracked their sales and balanced their books, I would not have made the mistake I made. When I am managing, or even editing, I make a concerted effort to explain the why behind my instructions and what value the task at hand will bring to the project, client and/or organization. In March, I was in charge of putting materials together to distribute at a workshop. Part of the work my assistants were doing included cutting some of the materials. I explained to them the importance of presentation, what the materials were for, and when they would be handed out. I also stood there while the assistants started the project to do quality control. The results were beautiful! What If It’s â€Å"Obvious?† Admittedly, explaining â€Å"why† is often easier said than done. In my role, often the reason for an instruction is so obvious to me that I can’t even conceive someone else would not automatically understand. It’s often when I skip over a â€Å"why† that mistakes get made. That’s what happened with my manager at Carrot Top. I would assert that as the person doing a task we have some responsibility too. Now, when someone gives me instructions that don’t make sense to me, or when I think I have a better idea of how something should be done, my first response is to ask â€Å"Why?† Sadly, this question is not always met with enthusiasm, as some people like to have their instructions followed unquestioningly. While I understand that perspective, as a manager I would always prefer people to ask me why they are doing something before they go ahead and do it their way- or before doing it my way but resenting it. I encourage all of you to ask and answer the question â€Å"Why?† when it will create communication flow and/or prevent unplanned, potentially dangerous system changes! A Tragic Note In writing this article, I did a Google search for Carrot Top Pastries and discovered that the owner committed suicide a couple of years ago. From what I could gather, she was feeling desperation in the face of a landlord dispute for the store she had owned for 30 years. This ending truly has me asking â€Å"Why?†

Case Study Example | Topics and Well Written Essays - 2000 words - 2

Case Study Example Designing and monitoring are the essential factors that come under evaluation to make sure that they have come under performances in the most effective and productive manner in the strategic management process that leads to attainment of the organizational goals on whole (Stahl & Grigsby, 1992). In more detailed words, strategic management process involves designing and setting up overall objectives and guidelines of the organization in a broad-spectrum, create and constitute precise and explicit strategies, plan and carry out implementation of the designed strategies and make modifications if required based on the monitoring or supervision of the outcomes. However, the below diagram clearly defines the process of strategic management in a much more comprehensive way (Mockler, 2002). Amongst numerous organizations that exercise the processes of strategic management, Utica National is an organization that provides its customers with the insurance services and products and is one of the good models that practice the strategic management processes in an appropriate way. However, the course of actions that carries out the strategic management techniques would come under discussion in detail about how this organization employs such practices. Utica National is an insurance group that dates back to early twentieth century that comprises of several companies namely Utica Mutual Insurance Company and Graphic Arts Mutual Insurance Company came under establishment as its principal companies. Utica National (2011) has come under recognition for its devoted and committed services to the policyholders since time immemorial. In the recent times, the popularity of Utica National (2011) has grown so much that it comes in the top rankings in the insurance organizations of the country (A.M. Best Company, 2008). Moreover, they provide the customers with a wide range of insurance products that take account of commercial coverages, personal coverages,

Does the Way in which Accounting Represents the World Facilitate the Essay

Does the Way in which Accounting Represents the World Facilitate the Control of Organizations - Essay Example As the discussion declares an organisation, first aims to control its internal activities through different mechanisms. One of the mechanisms which is considered very important when it comes to discuss the control of organisations is the use of accounting methodologies and practices. Various accounting control systems are considered very important to ensure the internal control of organisation and also to enhance the capability of organisations to fulfil its accountability towards the environment. In addition to the accounting control systems, organisations have also developed various other tools such as good human resource management practices, policies and rules and other mechanisms to ensure the control of organisation, however, it is generally believed that accounting is central to all kinds of mechanisms of control of organisations and it is the most effective mechanism to ensure the control of organisations. This paper explores that accounting plays a very significant role because it portrays the image of the company through various accounting methodologies and practices. How different accounting practices facilitate the control of organisation is directly linked with the areas of accounting that enhance the accountability of various aspects of businesses. Financial Accounting is the area of accounting in which the financial events and transactions of the company are identified, measured, recorded, classified, summarised, analysed, interpreted and communicated. Through this branch of accounting, the organisation seeks to keep the systematic records and communicates the financial performance of the company to the interest parties. Cost Accounting is the area of accounting which deals with the control of the cost of the product, process or operation. In this branch of accounting the costs are measured the information is used for decision making. Management accounting is the area of account ing which uses the accounting methodologies to provide the information that is important