Monday, September 30, 2019
As an American psychologist, philosopher, pedagogue, societal critic and political militant influenced the universe of instruction in ways that even he could n't hold dreamed of. His thoughts about instruction and the value of philosophical thought and composing were set Dewey apart from his fellow pedagogues and led to his connexions to the term progressive instruction. He believed that school should stand for society, in its Ã¢â¬Ë ends for doing critical believing members of society, every bit good as be run in a democratic mode ; to mock the interior workings of the outer universe. Dewey voiced these positions in his work, School and Society, published in 1889, Ã¢â¬Å" Democracy has to be born anew every coevals, and instruction is its accoucheuse Ã¢â¬ ( John Dewey & A ; Education ) . He denoted his dissatisfaction for schools and their deficiency of advancing personal geographic expedition and growing in their pupils ; repressive in nature, simple and secondary schools were denying pupils of indispensable chances for their personal advancement. Modern twenty-four hours schools like Centennial High School, vocational schools, on-line schools, and other alternate schools encourage the types of indispensable chances that Dewey felt pupils need to win. The traditional environment was non contributing to the instruction of every kid ; Dewey acknowledged the demand for alteration. So he wrote, every bit good as aided in execution, of assorted reforms that he hoped would back up schools as a Ã¢â¬Å" major bureaus for the development of free personalities Ã¢â¬ ( Sidorsky, p. thirty ) . Much like our modern art and executing art categories do for pupils in modern twenty-four hours school scenes. Dewey Ã¢â¬Ës dreams ab initio became a world when they opened the University of Chicago Ã¢â¬Ës experimental school in 1896. The experimental school was merely one manner Dewey Ã¢â¬Ës beliefs gained physical presence in the educational system. His beliefs that Ã¢â¬Å" school should learn pupils how to be problem-solvers by assisting pupils larn how to believe instead than merely larning rote lessons about big sums of information Ã¢â¬ ( John Dewey & A ; Education ) . These types of patterns have come to the surface in current educational practices-like the demand for vocational schools when regular school is n't a realistic option for some pupils. The thought that schools needed to refocus their attending on the pupils Ã¢â¬Ë ability to utilize judgement instead than rote-memorization to roll up cognition was his manner to promote kids to develop into grownups who can Ã¢â¬Å" go through judgements pertinently and discriminateingly on the jobs of human life Ã¢â¬ ( Campbell, 1995, p. 215-216 ) . Among his other beliefs about the function of school, Dewey felt that school should promote pupils to larn to populate and work hand in glove with other people. Students need to cognize how to populate and work with the community around them-this is another 1 of Dewey Ã¢â¬Ës thoughts that we still see in modern twenty-four hours athleticss, nines, and schoolroom activities-everyone has a sense of belonging and duty to keep a safe and respectful environment for themselves and the people around them. In School and Society Dewey wrote, Ã¢â¬Å" In a complex society, ability to understand and sympathise with the operations and batch of others is a status of common intent which merely instruction can secure. Ã¢â¬ Dewey Ã¢â¬Ës positions of schools as a democratic scene meant that he encouraged pupils to lend to determinations that affect them and their instruction. Students needed to be advocators for their ain instruction, but still be respectful of the community around them, including grownups. In add-on to these concerns for pupil rights, Dewey was determined to see that the rights and academically based liberty of instructors needed to stay integral as good. It comes to no surprise that Ã¢â¬Å" Dewey was a member of the first instructor Ã¢â¬Ës brotherhood in New York City, and his involvement in and concern with academic freedom in universities led to his function as a laminitis of the American Association of University Professors Ã¢â¬ ( John Dewey & A ; Education ) . His rank in the brotherhood reaffirmed his thoughts of protecting the instructors and their rights. Even though Dewey passed off, his thoughts live on through a current educational diary, Educational Theory, which cont inues to function as a oasis for duologue about thoughts around instruction that Dewey and his co-workers foremost dissected. Pragmatism: Pragmatism is defined as Ã¢â¬Å" the first autochthonal motion of philosophical idea to develop in the United States Ã¢â¬ ( Sidorsky, 1977, p. twelve ) . Along with other intellectuals, Dewey aided in the development of pragmatism and its Ã¢â¬Ë function in education-bringing doctrine into the schoolroom. Cultural critic George Santayana identifies American pragmatism as a signifier of connexion of Ã¢â¬Å" the American experimental and imaginative attitude Ã¢â¬ with old philosophical thoughts. Dewey Ã¢â¬Ës educational beliefs were clearly advanced and ambitious, it is no admiration that his matter-of-fact beliefs ensued. The thoughts make sense-children, like grownups, do things to profit themselves-at school childs may make good on an assignment to acquire good classs and so on. Pragmatism plays many functions, but one basically aspect that it ties into is American spiritual traditions and ideals through its cardinal point of Ã¢â¬Å" human intents. . . derived from their wants and demands Ã¢â¬ ( Sidorsky, pp. xv-xvi ) . Dewey felt that school should function a larger intent than rote memorisation. Harmonizing to historian Morton White, Dewey Ã¢â¬Ës matter-of-fact doctrine Ã¢â¬Å" lays the foundation for a more effectual construction for American societal ideals Ã¢â¬ by c ontracting the infinite between types of knowledge-scientific and others. School is supposed to learn kids to be effectual members of society. Pragmatic and democratic educational positions led to a list of eternal possibilities for Dewey and his pupils ; it was their opportunity to go advanced leaders in their society. In Dewey Ã¢â¬Ës head, Ã¢â¬Å" cognition was an interaction of being with environment in which the agent actively intervened to foretell future experience and to command it Ã¢â¬ ( Sidorsky, pp. xxxv-xxxvi ) . Harmonizing to Sidorski, Dewey Ã¢â¬Ës matter-of-fact beliefs were, Ã¢â¬Å" a memorial to that period in American civilization which made possible a confident, optimistic vision of the possible application of the methods of the scientific disciplines to the dominant traditions of doctrine and the major establishments of society Ã¢â¬ ( p. lv ) . The connexions between scientific discipline and the remainder of the universe can still be seen in modern twenty-four hours schoolroom, and a batch of this sustainability can be linked back to Dewey. He non merely bucked up pupils to be critical minds, but he showed them the world of the relationships between scientific cognition and the other signifiers of cognition and how they can work together to promote pupil success inside and outside of the schoolroom. He taught pupils to draw the trigger on their ain educational ends and demands. Despite the fitful tendencies in instruction of the 20th century, Dewey maintains the involvements of psychologists, philosophers, pedagogues, societal critics and political militants likewise and continues to see occasional resurgence.
Saturday, September 28, 2019
Over the years, racial stereotypes have always played a big role in our society. Till today, everyone attaches racial stereotypes and injustice thoughts towards a person without knowing or saying a word to the person. Signs of race and ethnicity are everywhere in our media culture and people are judged based on inaccurate information given by the media such as television, cartoons, dramas, movies and even comic books. These stereotypes will influence the younger generations, create tension between groups and affect people in many ways.The way that television portrays different races can be very subtle like main character status, level of interaction between races, activity levels, and social status (Maher, 2008). The characters demonstrated in certain television programs are formed by what the writers believe and they take the basic features of a character and expand it thinking the viewers will enjoy it, leading to racial and ethnic stereotypes by using Ã¢â¬ËmisinformationÃ¢â¬â¢ through movies, shows and news reports. Egyptians in this case are being portrayed as uneducated, unethical, raise desert animals, terrorists and uncivilized.These false information is what the media uses as techniques to portray Egyptians as humans of the underworld and Egypt as a deserted country. Egyptians have been stereotyped as desert residents for many years even though Egypt has been advanced now as a country. They have been looked at as uneducated but fact is there is an American University built in Cairo where many Egyptians have gotten their Bachelors, Masters and PhDÃ¢â¬â¢s from, but however the media still influence the public to view the Egyptians as desert people.In the movie Ã¢â¬Å"The MummyÃ¢â¬ which was shot at Egypt, individual Egyptians are filthy, greedy, slimey pigs. The Egyptian masses are mindless, murderous zombies who chant the name Imhotep. This has affected Egyptians as well as other stereotyped ethnic groups everywhere. The threat does not only aff ect the life of the adults but the children as well. In a research done by the University of California about the consequences of racial stereotypes on children, it was said that it has a direct effect on the academic performance of the stereotyped children.One of the sayings in this research is: Ã¢â¬Å"African American and Latino children who are aware of broadly held stereotypes about academic ability perform more poorly on a cognitive task when that task is described as a measure of ability that when the same task is described as a problem-solving task. Ã¢â¬ (Carol Hyman 2003). This applies to all race and ethnic groups everywhere in our world Racial and ethnic stereotype in media not only in fluencies the adults but is also adapted and carried over with the children who are the youth of tomorrow and we wouldnÃ¢â¬â¢t want this stereotype to continue on in the years to come.It is easy to give out information with no factual back up, but the public preference is what can eithe r stop media propaganda from affecting the public opinion or simply fuel such dangerous aspect of the media, stereotypes. Hyman, Carol (2003). Ã¢â¬Å"Awareness of racial stereotypes happens at an early age, has consequencesÃ¢â¬ , UC Berkeley News. Online at:Ã , consulted on May 2003.
Friday, September 27, 2019
President Washingtons inaugural address - Assignment Example 3). The president stressed that he would act in accordance with the Constitution. According to his speech, Washington sees presidency as the institution aimed at making sure that the major law is followed and people have an opportunity to live proper lives. The president is a guard who makes sure that the nation develops and achieves all the goals set. Of course, the major goal is wellbeing and prosperity, but there is also an aim to be respected in the world. It is necessary to add that a number of political ideals mentioned by Washington especially animate his speech. First of all, the reference to the Constitution is one of these ideals as the nation was built on the idea of equality secured by the Constitution. Americans have always been sure that there should be the governance of law. The president promised that there would be Ã¢â¬Å"no local prejudices, or attachmentsÃ¢â¬ , no Ã¢â¬Å"party animositiesÃ¢â¬ (WashingtonÃ¢â¬â¢s inaugural address, 1789, para. 3). He promised that all decisions would be made in accordance with the major law of the country. Admittedly, this was an important political ideal for Americans who took pride in their Constitution. The president also mentioned Ã¢â¬Å"the voiceÃ¢â¬ of his country a number of times (WashingtonÃ¢â¬â¢s inaugural address, 1789, para. 1). In this case, he appeals to another political ideal: peopleÃ¢â¬â¢s ability to vote and choose the President of the country. This is an important pillar for the American democracy as people take the responsibility and make their major decision affecting the future of their country. Clearly, Americans knew (or at least wanted to make it happen) that there was political equality, and each citizen could express his ideas and his voice could be heard. Washington paid specific attention to another important political ideal. The president stressed that he (as any other politician should) would try his best to make the nation prosperous and
Multimodles in Education - Research Paper Example their use of technological tools in their academics and a majority of the students, some 50% rated themselves as basic, while 22% and 27% rated themselves as professional and advanced respectively (Alawami). These statistics can be said to show that a large number of students are competent enough in the use of technological tools to ensure that their learning process and environment is as comfortable as possible. It is well known that life in the current age is highly influenced by the era of technology, and the latter has come to play an important role in today's human social development. Based on this fact, it has become obligatory to take advantage of the modern technological facilities in aiding the development of education because to do otherwise would mean that there would be a considerable loss in the productivity of students in the modern age. There are, however, other hi-tech implements that can be made the most of in academics besides computers and each of these tools has i ts specific benefits and application. But while this may be the case, in order for the students to use these tools successfully, they should be familiar with the use of all types of computers as well as the Internet, and be able to interact with the techniques needed for the use of these tools. This has been the case in many academic institutions because when asked whether they had used some form of technology in their academic institutions before, all of the respondents stated that they had indeed used it. One of the greatest ideals that have come to be widely appreciated in the world today has been the development of educational technologies whose purpose has been the intended uniting of students from different cultures. Students from diverse cultures tend to have different ideas... This paper approves that a lot of value should be placed in students through the development of technological empowerment programs, which ensure that they get the opportunity to advance in the use of the technology. This is the reason why students have to be taught in an environment that has multi-modals because those who study in such an environment are likely to know exactly how such technology works and will not need a lot of time to learn. It has been found that the studentsÃ¢â¬â¢ experience in the use of technology, which is likely to have been developed after years of using its different forms, tends to work in their favor when conducting their studies. In fact, it is very likely that such students will get work done faster than those who would have studied in an environment devoid of technology because technology, such as the internet, allows students to access the information that they desire almost instantly. The experience that students gain using technology in the classr oom ensures that they know what it lacks and what it has and this enables them to work towards strengthening the knowledge they have gained further while also working towards using even more advanced technology to enhance their learning process. This essay makes a conclusion that the increasing popularity of the use of multi-modals in education is because of the fact that it is most convenient since it enables individuals to easily access information at their own convenience. This is corroborated in a survey question asking students whether they had ever taken online classes before, and fully half of those who responded stated that they had indeed taken such classes.
Thursday, September 26, 2019
Open Topic - Research Paper Example Do the benefits of transporting hazardous material by rail outweigh the costs and damage on the environment? The following study into quantitative and ecological risk analysis of the transportation of hazardous chemicals by train across the United States. The study employs findings and conclusions made by former literature conducted over the effects of transporting hazardous material by rail and the environment. The study also analyses geographic data surrounding rail systems in the United States involved with transporting hazardous contents. Ecological features of these surroundings build towards probabilistic approximations of exposure to various spill cases the history of AmericaÃ¢â¬â¢s rail system. This risk analysis integrated approximated cleanup expenses that accrued, effect of dispute on the distribution of soil, underground water, the contributions of yearly traffic, the rates of accidents, and deployed safety measures. A number of factors influence the risk and scale of the criticality of the consequence of spilling hazardous material on the environment during transportation by rail. First, the difference in safety performance of the standard tank cabin layouts is a significant risk factor (Anand et al., 2006). The higher the difference in cabin miles among various hazardous materials, and the difference in yearly accident-induced spill rate. Second, in approximating the effect expenses, hazardous substances that dissolve less in water incur more soil and groundwater cleanup expenses due to longer remediation periods (Xie et al., 2012). Third, in approximating the evacuation expenses, hazardous material moved along routes with more populations incur more evacuation expenses. Lastly, scheduled delay expenses may range from 3 to 8% of the entire effects costs in contrast to from 76 to 88% of cleaning up hazardous substances spilled into the soil and groundwater (Spraggins, 2011). The
Wednesday, September 25, 2019
Summaries - Assignment Example s, the Canada natives argue that people settled in northern America due to a land bridge created by water being blocked by glaciers, which led to the increase in the level of ocean later forcing them to migrate to higher grounds. The land bridge thus formed the first settlement area for these people. Archaeology suggests that the people of Canada practiced the marine culture. These people moved to the north during spring and summer to obtain certain resources and then they would return South during winter (Nelson, 2006). These people came to settle in the North, along the coast due to the warm climate, and they started families, thus increasing their numbers. The Shield Culture is believed to have originated from the Plano culture. This culture brought together many bands of communities together (Nelson, 2006). This led to intermarriages between these different bands. It is clear from the discussion above that the origin of groups of people was dependent on their social activities. These include the Shield Culture, and their economic activities such as hunting and nomadism. In addition, they were determined by natural calamities like the floods. Different groups practiced various activities as
Tuesday, September 24, 2019
Analysis of Virtual Distance Learning - Essay Example To this effect, it can best be answered that distance learning will not face out the traditional classroom, though elements of these two modules are likely to be fused to enhance learning standards in both models. The wider pool of intelligentsia which comprises students and lecturers, college departmental heads, and education policymakers serves as the wider audience. The paper specifically intends to win over those who are postulating that since virtual/ distance learning is becoming increasingly popular, it will elbow out into inexistence, the traditional mode of learning. The lecturers supervising this paper and the heads of department form the basic audience. The secondary audience is made up of those who may later refer to this academic piece later. Students, lecturers, education policymakers and researchers from the secondary audience. This means that the audience is complicated since it is trifurcate of those who may endorse the position statement, those who may repudiate it, and the neutral parties. Above all, the audience is part of the intelligentsia. This means that the paper or the argument must be above partisanship, logical fallacies, and factual inaccuracies. First and foremost, fusing traditional classes with elements of e-learning will be helpful in ensuring a comprehensive and concise coverage of the topic being covered. For instance, having a traditional classroom watch an excerpt of Noam ChomskyÃ¢â¬â¢s illustration of Universal Grammar will greatly help in inculcating concepts needed by the second language acquisition class. Elements of virtual learning can also be used by students of the traditional model of learning for further referencing and extensive learning. This is especially the case when virtual learning materials are availed in libraries of traditional teaching models.
Monday, September 23, 2019
My Six Millennium Development Goals - Essay Example While the world most powerful countries boost of their economic achievement, some communities in developing nations lavish in extreme poverty. The stories about people living in extreme poverty are not only sickening but also heartbreaking. It is arguable that when a person lives in poverty, he or she is not able to acquire other necessities such as education, good healthcare among others. The World Bank and the UN have indicated that they have made incredible work in ameliorating the poverty scourge. If I were to assign a letter grade to this specific goal, I would give it an A. This is due to the fact that the United Nations shows efforts to eradicate poverty irrespective of the fierce financial crisis. The target for the extreme poverty MDG is to reduce the current prevalence by half. The UN report shows that many communities leaving under extreme poverty lacked essential needs such as water, food, and shelter. The aforementioned needs are critical to human existence. The progress ive report indicates that the project would meet its deadline. Liberty activists contend that extreme poverty is an indication of deprived rights. Most governments are part of UN accord, which advocates for human liberty. Hunger hampers social and economic development because it influences the ability of an individual to contribute towards nation building. This MDG is critical to the future of the world because the liberty that the society claims to enjoy is evident through social interactions.... The aforementioned needs are critical to human existence. The progressive report indicates that the project would meet its deadline. Liberty activists contend that extreme poverty is an indication of deprived rights. Most governments are part of UN accord, which advocates for human liberty. Target 1 B/ Fight against Hunger Hunger hampers social and economic development because it influences the ability of an individual to contribute towards nation building. This MDG is critical to the future of the world because the liberty that the society claims to enjoy is evident through social interactions. Social theorist believe that the fabric that holds the society depend on human satisfaction. Unfortunately, hunger influences a personÃ¢â¬â¢s contribution to social growth. Factors, which limit individual independence, may attract social delinquency in meeting these needs. For instance, a hungry society may not be able to think beyond a means that would enable it to receive food. This means criminal activities are options that the community can adapt to fight hunger. The grade I would assign United Nations in this goal is A- since fighting hunger with the present financial and climate instabilities is hard. The target of this goal is halve the prevalence rate by 2015. The United Nations and the World Bank have contributed in reducing the prevalence of hunger by initiating projects that will empower the affected communities. The UN and World Bank have collaborated with the respective governments in the affected regions such as Sub Saharan Africa, funding sustainable agricultural projects in order to empower the society. The aim of such project intends to
Sunday, September 22, 2019
Teacher preparation is critical to providing successful quality math education Essay Example for Free
Teacher preparation is critical to providing successful quality math education Essay It is possible to make every student a successful student. Here success could mean different things to different students and their teachers. When the full potential of a student is realized in the chosen avocation, one can infer that success is achieved. Teaching and learning happen the best when there is perceived interest in both the teacher and the learner. Nurturing education through better teaching and learning methods can enhance the ability of a teacher for providing quality mathematics education1 (Chism,1998). Because of the inherent anxiety in math education, additional preparation in terms of understanding the psychology of the students is a critical success factor. Many times we find impediments to teaching and learning either because there is no evident interest in the teacher or the learner or both; or there is no proper supporting mechanism/ system to augment the teaching and learning. In the following paragraphs, an outline of various teaching / instructional methodologies for the teachers and learning strategies for the students are outlined for best possible outcomes for both sides of the equation. These are meant for any teaching including mathematics. Based on my own personal experiences of teaching and learning and professional research, I outlined a few of the many methodologies.Ã Mention is also made of the importance of overall learning environment. Teaching / Instructional Methodologies2 (New Horizons For Learning,2002) a. Action Research Action Research is a very powerful strategy for instructional improvement and provides teachers the necessary skills for solving problems specific to their classrooms and their schools. By using a five step process Ã¢â¬â question, data collection, data analysis, findings and action plan Ã¢â¬â teachers can improve their own teaching skills while improving their classroom/school outcomes3 (Reed, 2000) b. Differentiated Instruction Differentiated Instruction takes into account the various ways in which students learn as against Direct Instruction which focuses mainly on memorizing facts and skills. Differentiated Instruction on the other hand focuses on concepts, understanding, readiness and interest. c. Environment for Learning: The definition or perception of Learning Environment from a curriculum and instruction based learning is changing to an environment for successful learning which is based on a variety of emotional, intellectual, visual and spatial stimuli. Schools located in such environs as zoos, museums, culture are redefining the way learning takes place and learning environment is created. d. Accelerated Learning Accelerated learning is based on the original work of Ã¢â¬ËSuggestologyÃ¢â¬â¢4 (Dr. Lozanov, 1978) which included relaxation, visual arts and music for teaching foreign language students. Accelerated learning takes into account various beliefs/theories such as Learning is dual-planned; there is no single stimulus etc. The Core Elements for Accelerated Learning include Physical Environment, Music, Teacher, Positive Atmosphere and a teaching Frame. Teaching Frame in turn includes three phases Ã¢â¬â Preparation, Active and Passive. e. Teaching for Understanding: This approach seeks to get answers to the three key questions: 1. What does it mean to understand? 2. How do we teach for understanding? 3. How do we assess understanding? Using the concept of Ã¢â¬ËthroughlinesÃ¢â¬â¢ a teacher can engage the students continuously and throughout the year on the goals set out for understanding the concepts based on a set of predefined questions. Classroom based Learning Continuum Tool The Northwest Evaluation Association launched a tool Ã DesCartes: A Continuum of Learning. This tool is designed for teachers and principals to simplify the task of translating assessment data into specific skills and concepts5 (Business Wire, 2004). The tool is used to map mathematics, reading, and language usage skills along a continuum of learning, and connects each skill with test score ranges and state standards for all the states Teachers can use DesCartes information for: Ã¢â¬ ¢ Identification of specific skills and concepts students need Ã¢â¬ ¢ Selection of materials based on the diversity of skill levels within a class, and find appropriate materials for students at the extreme ends of the learning spectrum. Ã¢â¬ ¢ Creation of flexible learning groups based on students performance and Ã¢â¬ ¢ Collaboration with staff to successfully meet the needs of all learners6 (Grasha, 1996). Conclusion Teaching and Learning have become very critical in not only realizing the full potential of the learners but in doing so have become necessary tools to build a productive workforce. Teaching styles6, improvements in technology and expectations of parents, society have contributed to the growth of new methods of teaching, learning and creating new Learning Environments. Hence it is important that we assess the teachers for their ability and aptitude and also assess the learnerÃ¢â¬â¢s ability and aptitude. A match making of these two would most definitely produce successful teaching and learning outcomes. Many of the methods discussed above would definitely make it is possible for every student to become a successful student and every teacher a successful teacher.
Saturday, September 21, 2019
Health Essays Myocardial Infarction Mortality Myocardial Infarction Mortality 1.0 Introduction In the UK, about 838,000 men and 394,000 women have had a myocardial infarction (MI) at some point in their lives, (NICE clinical guideline 48, 2007). The latest statistics from the British Heart Foundation state that approximately 227,000 people suffer from an acute MI (heart attack) each year (British Heart Foundation Statistics Website). To put this figure in to perspective this equates to one person every 2 minutes. Mortality is at approximately 30% which is 68,100 deaths in the UK per year. The National Service Framework (NSF) for Coronary Heart disease (CHD) is a 10-year programme published by the Department of Health in 2000 and has set key standards for the prevention and treatment of CHD. Access to the right treatment for those who suffer from an AMI, is essential to reduce morbidity and mortality and improve clinical outcomes. People with diabetes mellitus constitute a group of patients who have a higher risk of having an MI and also a poorer prognosis post infarction. The higher death and complication rates appear to be multifactorial but a significant finding in the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) Trial showed to reduce one year mortality by 30% (Malberg et al., 1995). ItÃ¢â¬â¢s recommended 1.1 Primary Objective To determine the relationship between HbA1c and prognosis of patients in East Lancashire having a myocardial infarction. 1.2 Secondary Objectives To assess the prognosis of patients below the glucose cut off threshold for DIGAMI treatment and whether or not this borderline category falls in to the highest risk group in terms of mortality and morbidity. To determine if there is both a clinical and analytical case to use fluoride oxalate tubes for plasma glucose and HbA1c collection and analysis in East Lancashire. To ascertain the effect of a previous DIGAMI audit conducted in 2006 by the Clinical Audit Team and reflect on any improvements of conformance to the protocol two years later. If there is a significant relationship between HbA1c and prognosis then a risk stratification chart and a more clinically and analytically robust inclusion criteria on to the intensive treatment protocol (DIGAMI Regime) can be determined. This could lead to a better prognosis for a group of patients that fall into a borderline category that are not currently treated under the current protocol who potentially should be depending on the results of this study. 1.3 Cardiovascular Disease 1.3.1 Incidence of CHD The incidence of CHD follows different trends across the UK depending on various factors including regional, socio-economic and ethnic differences. There is a definite North-South gradient, and mortality rates are at the highest in Scotland and the North of England. Social class inequalities in mortality rates show that male manual workers are 58% more likely to suffer premature death from CHD than non-manual workers. Statistics also show that South Asians (Indians, Pakistanis, Bangladeshis and Sri Lankans), are more likely to suffer premature death with figures of 46% for men and 51% for women. This ethnic grouping the highest risk (Figure 1.). The East Lancashire NHS Trust provides a service for over half a million people offering care across four hospital sites. The population of East Lancashire falls into one of the higher risk areas in the UK with local authority statistics for reflecting this fact. Age-standardised death rates per 100.000 in Blackburn with Darwen, Burnley, Rossendale, Nelson and Pendle show that these areas fall into the upper fifth quintile for men and upper fourth and fifth quintile for women (Coronary Heart Disease Statistics 2005). In the Lancashire NUTS-2 area, which includes Blackburn with Darwen Unitary Authorities 93.4% of the 1.41 million residents classified their ethnic group as white British, Irish or other white background. A further 5.3% gave their ethnic group as Asian or British Asian. This figure is 1.3% above the national average. Even more pronounced is when the East Lancashire population is singled out, where the percentage rises to 10.8%. (Appendix ). The sub region of East Lancashire contains the highest proportion of ethnic minorities which is a contributing factor to the high incidence of CHD in addition to the socio-economic differences compared with other regions. Myocardial Infarction 1.4.3 Risk Factors Pathophysiology 1.4.2 Morbidity and Mortality 1.4 Diabetes Although there have been significant advances in the care of many of the extrapancreatic manifestations of diabetes, acute myocardial infarction continues to be a major cause of morbidity and mortality in diabetic patients. Factors unique to diabetes increase atherosclerotic plaque formation and thrombosis, thereby contributing to myocardial infarction. Autonomic neuropathy may predispose to infarction and result in atypical presenting symptoms in the diabetic patient, making diagnosis difficult and delaying treatment. The clinical course of myocardial infarction is frequently complicated and carries a higher mortality rate in the diabetic than in the nondiabetic patient. Although the course and pathophysiology of myocardial infarction differ to some degree in diabetic patients from those in patients without diabetes, much more remains to be known to formulate more effective treatment strategies in this high risk subgroup. J Am Coll Cardiol, 1992; 20:736-744 Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and prognosis RM Jacoby and RW Nesto Myocardial function is further impaired in diabetic patients by the metabolic changes that occur in the early stages of myocardial infarction: insulin resistance and hyperglycaemia are induced by release of catecholamines, cortisol, glucagon, and growth hormone.10 At the same time, secretion of insulin by the pancreatic islets is reduced,11 which impairs the ability to compensate for this state of insulin resistance. The combination of low insulin concentrations and elevated catecholamine concentrations increases release of non-esterified fatty acids, which augment myocardial oxygen requirements and depress mechanical performance. 12 BMJ 1996;313:639-640 (14Ã September) Editorials Insulin infusion in diabetic patients with acute myocardial infarction 1.4.1 Pathophysiology Mention stress hyperglycaemia 1.5 Glycated Haemoglobin Glycation is a nonenzymatic process of adding a sugar residue to amino groups of proteins. Normal adult haemoglobin usually consists of Hb A (97%), Hb A2 (2.5%), and HB F (0.5%). HbA1c is one of a group of a minor haemoglobins separated from the major constituent Hb A. It has become the dominant measure of glycated haemoglobin because of improved analytical techniques and ease of routine separation and quantification. HbA1c is formed by the condensation of glucose with the N-terminal valine residue of the haemoglobin Ã ²-chain to form an unstable Schiff base followed by dissociation or a Amadori rearrangement to form the stable ketoamine (Figure ). The glycation of haemoglobin is essentially irreversible and its level depends on the lifespan of a patientÃ¢â¬â¢s red blood cell and the blood glucose concentration. Tietz p791 HbA1c is primarily used as an indicator of glycaemic control and used in diabetic monitoring. The feasibility study of the DCCT trial (diabetes control and complications) published in 1993 provided evidence for the much hypothesised opinion that better glycaemic control would decrease long term complications of diabetes mellitus and that the HbA1c test can be used as a measure of this. The UKPDS (U.K. Prospective Diabetes Study) followed on from these findings and conducted the largest clinical research study of diabetes focussing on reducing life-threatening complications by appropriate treatment including maintaining a HbA1c result of 7.0% or below (see section 1.5.1). 1.4.1 Utility of HbA1c Type 2 diabetes can be diagnosed using two different criteria, the fasting plasma glucose (FPG) and the 2 hour glucose value of the oral glucose tolerance test (OGTT) which is the Ã¢â¬Ëgold standardÃ¢â¬â¢. The FDG cut-off value of 7.0 mmol/L has been calculated to roughly correlate to the OGTT 2 hour diagnostic value of 11.1 mmol/L and provides greater reproducibility. A major disadvantage to the patient is the requirement to fast prior to both of these protocols. Glycated haemoglobin concentration is an indicator of the average blood glucose level over approximately 90 days. Though the lifespan of a red blood cell is normally 120 days, the contribution of the plasma glucose concentration to glycated haemoglobin differs depending on the time interval, with the largest influence on the HbA1c value being the most recent. It provides a retrospective index of integrated plasma glucose levels and has been suggested to have a role to play in the screening and diagnosis of diabetes in addition to its primary role of monitoring diabetic control. The debate of whether an HbA1c result could be used for diagnosis continues despite the generally accepted argument that the test as a single entity is not sensitive enough to provide definitive cut-off values and determine reference ranges because the values of the two populations; non-diabetics and diabetes overlap. An HbA1c result above the upper reference limit however is specific for glucose intolerance. Another concern is the limitations of the HbA1c result in individuals with abnormal haemoglobinopathies and anaemias, especially when the latter is secondary to haemolysis or iron deficiency (Kilpatrick, 2005). Glycation depends on the lifespan of a patientÃ¢â¬â¢s erythrocyte and the blood glucose concentration so in these groups the results will not be accurately representative of metabolic control in comparison to reference ranges based on the general population. 1.4.2 Reason for the Study It is highly unlikely that the HbA1c test will replace routine glucose testing for the diagnosis of type 2 diabetes but it may still have an invaluable role in this area. HbA1c levels may be less influenced by acute stress induced by an ischemic event compared with plasma glucose and therefore could be useful as a tool for differentiating patients with diabetes, and identifying undiagnosed cases in the inpatient setting. Although the increased risk of CHD with type 2 diabetes is universally accepted, a study conducted by Khaw et al. of the general population showed that medically diagnosed diabetes only accounted for 20% of all CVD fatalities. The majority of fatal events came from apparently healthy individuals with a glycated haemoglobin > 6% in the absence of diabetes and this relationship was independent of other risk factors (Khaw et al., 2002). Minor glycometabolic dysregulation may be associated with an increased risk yet this route of research has been poorly explored. If a strong correlation exists then HbA1c could be used as a routine test in the primary prevention of CHD, and patients with suspected acute coronary syndromes can be diagnosed with dysglycemia. In this identified group of individuals, intensive treatment could improve the long term prognosis of the patient. 1.5 Previous Studies DIGAMI 1 and 2 DCCT VA Cooperative Study UKPDS 1.6 Current Situation at the RBH East Lancashire Hospitals NHS Trust provides a range of health care and acute services to the Boroughs of Blackburn, Burnley, Hyndburn, Pendle, Ribble Valley and Rossendale with a population of approximately 515,000 falling into its catchment area. The primary purpose of the Pathology Department at Blackburn Royal Infirmary is to provide a high quality testing service for the diagnostic, screening and monitoring of patient samples. Recent drivers for change revolve around The Pathology Modernisation Programme which was launched in 1999. This aims at improving the quality and efficiency of NHS pathology services and encourages the introduction of new technologies and practices to deliver high quality patient care and matching capacity with increased demand. EnglandÃ¢â¬â¢s National Health Service has embarked on an ambitious program of system reform. The Labour Government has committed to increase NHS spending to implement changes of streamlining services and improving quality of service. One of East Lancashire Hospitals NHS Trusts Key Objectives is to streamline diagnostic services and to reduce overheads as part of a Trust wide cost improvement programme. The aim is to work Ã¢â¬ËsmarterÃ¢â¬â¢ rather than Ã¢â¬ËharderÃ¢â¬â¢ to balance activity with demand. However, current capacity to meet demand is almost at saturation point and we have reached the inevitable point in which processes have to change. 1.6.1 Post MI Management DIGAMI 1.6.2 Laboratory Service to Users The decision of treatment for some patients with a suspected MI can rely on the venous glucose result. It is therefore paramount that the result validated is accurate and precise. 184.108.40.206 Glucose Stability The MI patients treated as per DIGAMI protocol are diabetic patients or non-diabetics with a glucose of >11.1mmol/L. An area of contention is the fact that for inpatients, serum glucose is collected in Startedt S-MonovetteÃ ® gel tubes containing no preservative and analysed on the VITROS 5,1 FS chemistry system. The manufacturersÃ¢â¬â¢ guidelines state the stability of glucose decreases by approximately 8% for every half an hour prior to separation of the serum from the cells (VITROS datasheet ). Though samples from A+E are dealt with urgently this is a short timeframe from collection to result. Some bloods are taken via a paramedic collection on route to the accident and emergency department and therefore are delayed even longer prior to analysis. The stability of serum glucose is a well known problem hindering the accuracy of results this is the reason that samples arriving from GP surgeries are processed routinely on the Thermo Konelab analyzer using blood collected in tubes containing a fluoride oxalate preservative. It has been discussed to also use such tubes for ward samples, with all glucoses being run on the VITROS analyzer. Up to now the stability issue of hospital samples has not been thought of as a clinical hindrance because they are prioritised and processed sooner than the GP samples and therefore there has been a Ã¢â¬Ëmedically allowed toleranceÃ¢â¬â¢ The importance of the admission blood glucose result has come to light as it can be a deciding factor for the inclusion of MI patients on to the intensive DIGAMI treatment protocol, and as a direct consequence, will have a clinical impact on the prognosis of a patient. Due to the glucose being metabolised by the cells and giving a falsely lower result, a group of borderline patients may not meet the inclusion criterion for DIGAMI as a result and have a worse prognosis than they should have. Therefore this is an issue of great clinical importance. This project should indicate to what extent the stability is a problem and approximately how many patients it affects. If the HbA1c result could be utilised as a complimentary test to be used in conjunction with known diabetic status and admission plasma glucose then the inclusion criteria would be both more clinically and analytically reliable. Historically HbA1c analysis is performed by the haematology department on EDTA blood samples for logistical reasons. If analytical stability and comparison studies show that fluoride oxalate tubes can be used accurately and precisely for glucose and HbA1c analysis then one biochemistry tube would be sufficient for both tests. Laboratory practice for diabetic diagnosis and monitoring could then be a leaner process for cascade HbA1c testing in terms of archiving, retrieval and storage of samples. 1.7 Clinical Audit Clinical audit is a quality improvement process which is a component of clinical governance within the NHS introduced to improve patient care through a systematic review against explicit criteria and the implementation of change. Participation is recognized by the General Medical Council as an integral part of good practice and the results should be used to improve the quality of care. The Myocardial Infarction National Audit Project (MINAP) is funded by the National Institute of Clinical Excellence (NICE) and is carried out by the Royal College of Physicians (RCP). It was established in 1999 as a method of clinical audit to examine the quality of management of myocardial infarction and shows how hospitals in England and Wales are performing against targets in the NSF for CHD. 1.7.1 Summary of 2006 DIGAMI Audit In 2006, the clinical audit team conducted an audit with one of itsÃ¢â¬â¢ main objectives being to assess whether the DIGAMI protocol was being adhered to. This was a retrospective study in which the casenotes of 46 patients were viewed and information extracted. These patients were either known diabetics or had a plasma glucose of >11.1mmol, and had presented with cardiac pain. A summary of the baseline characteristics was that over half of the patients were of Asian descent, there was a slight female prevalence and the majority included were known diabetics. They also concluded that the DIGAMI regime was only initiated in 24% of the cases, whereas all 46 patients should have been treated as per current protocol. Another non-conformance to the protocol was the fact that approximately 50% of the patients did not have a venous blood glucose checked by the biochemistry laboratory (Bharucha et al., 2006). The results of this audit will be re-addressed in this study to ascertain the effectiveness of the recommendations and the impact of the results two years on. Reasons for undertaking this project According to estimates there are as many as a third of undiagnosed diabetics (as cited in Greci et al., 2003). The DIGAMI regime is an intensive treatment protocol for the management of myocardial infarction in patients known to have diabetes mellitus or in patients with hyperglycaemia on admission. At East Lancashire NHS Trust, intensive treatment with intravenous dextrose and insulin reduce and control blood glucose levels to between 4-9 mmol/L. Currently, there is a standardised inclusion criterion and treatment protocol rather than a treatment programme which is graded in intensity, and tailored to individual glycometabolic status. Hospital glucoses are analysed using serum collected in Starsedt Monovet 4.2 ml gel tubes. The manufacturersÃ¢â¬â¢ guidelines state the stability of glucose could decrease by 7% every half an hour prior to separation of the serum from the cells. Although samples from A+E are dealt with urgently this is a short timeframe. Paramedic collection of samples on route mean even longer time delays before separation.