Project Management Essay Example | Topics and Well Written Essays - 3750 words

Project Management - Essay Example Kerzner (2009) points out four different phases of the a project life cycle and these are the Conception Phase, Definition Phase, Execution Phase, and Operation Phase. On the other hand, Hira and Parfitt (2004) provide five phases in the project cycle which are Identification, Preparation, Appraisal, Implementation, and Evaluation. Perhaps the most popular view divides the project cycle into five stages, or process groups as some references have called them, which are initiating, planning, executing, monitoring and controlling, and closing (Rubin, 1995; Owen & Rogers, 1999; Elia, 2004; Elearn Limited, 2005; Heldman, Baca, & Jansen, 2007; Sanghera, 2008; Mihelcic, 2009). Within these stages, there are also a set of processes involved that are part of the knowledge required to manage a particular project. These knowledge areas are Communication Management, Cost Management, Human Resource Management, Integration Management, Procurement Management, Risk Management, Scope Management, and Time Management (Sanghera, 2008). While a large portion of this paper will focus mainly on the different stages of the project cycle and the processes within each of these stages, the discussion will also incorporate these knowledge areas. ... s important that a particular emphasis is placed on this stage because if this stage is merely skimmed over because the group is rushing to get started on what most would perceive as the actual work, the group will have a hard time implementing the project, not to mention needing more time to achieve it and thus, the project will most likely fail. This is the phase which examines and decides whether the project is worth doing or not. This process group provides approval to commit the organization’s resources to working on the project or phase (Heldman, Baca, & Jansen, 2007). The most important objectives of the project are identified and defined and financial commitments are undertaken to determine exactly what resources will be needed to complete the project (Elia, 2004). The project manager is assigned and authorized to begin working on the project. This is also the stage where the expectations for the project are formalized and communicated to all of the stakeholders. More specifically, the processes involved in this stage include the development of the project charter and the preliminary project scope statement, which are covered by the knowledge area of integration management (Sanghera, 2008). These outputs become inputs into the Planning process group. The Initiation phase for a contractor most likely starts once the firm is awarded a contract and has received a notice to proceed. Sometimes, there are also companies who move forward with less certain conditions. The estimate now becomes a project and a job or work order number is given to it. The project manager is assigned who then prepares to receive the handoff, or the transitional stage between project phases, from the estimating department (Elia, 2004). Planning The planning phase is which involves the

Scene comparison between the movie Il Gattopardo (The Leopard by Essay

Scene comparison between the movie Il Gattopardo (The Leopard by Visconti) and the novel - Essay Example The battle scenes, was developed from various Italy regions depending on the armies constitution that were involved in the battles. The resulting movie captivated all the senders. The film has recreated the atmosphere of19th century in a thorough manner; on their fittings and interiors, time of day, color, scorching heat, coolness search, and the dust that covers the noble when making their way to the Castle Donnafugata, the cloths used, the coaches interior, and the filthy cloak of clergyman, the furniture, and the single frame of the ball sequence accounts for a quarter of the film and which seems to be unending. This is the world that is portrayed by the author, in the disappearing verge, and in the look of the most proustian film that has ever been shot. For the miracle to achieve a collection of outstanding talents was collected veterans seasoned by multiple Viscotian battles. The Palermo aristocrats played in the sequence of dance but also lent the producer a lot of mise-en-sce ne. The film is the work where the author challenges the impossible, selecting to recreate realistically events which took a century earlier. The achievement of the author is magnificent that it appears the various echoes of 19th century outlook in the film have not been highlighted. The painting on the wall of the house participated in a dialogue with the prince of Salina and protagonists. During the dancing break, while contemplating a Jean Baptista famous painting. The prince of Salim is involved in death attempt for the first time and he imagines the next departure of young Tancredi. In the film, the director appeared to embrace contradictions. How did the Italian neorealism progenotir, which emphasizes the mise en scene naturalistic, eventually move towards making the operatic costume dramas and grand? According to Salvador Dali, he describes the producer and the communist that like luxury. The multiple questions are generated when watching the film. To fully understand the puz zle, the film story need not be told without mentioning its source (novel). The historical time is Risorgimento; collection of conflicts that resulted to the formation of a single political entire of Italy, and within the events of the 1860 that same the Garibaldi’s army helped by local militia that rebelled against the Bourbon

Finance and Accounting, Literature Review Example | Topics and Well Written Essays - 3000 words

Finance and Accounting, - Literature review Example Controversies such as those linked to the former GE CEO, Jack Welch and the NYSE CEO Richard Grasso have made many companies to create a guideline that will be used to limit how much company executives can earn. It is important to note that even in the cases of the above CEOs, their work and performance on the job was impeccable and many would believe that they earned what they had worked hard for (Jensen and Murphyn 2004:15). However, there is a perception that there was a lot of inadequate disclosure and that they received a little ‘too much’ despite their performance. According to the general conference convened by the International Labor Organization in 1951; the term remuneration was defined as (Yang 2008:654): â€Å"the ordinary, basic or minimum salary and any additional benefits that are payable whatsoever directly or indirectly, whether in cash or in kind, by the employer to the worker and arising out of the worker’s employment.† Success on the oth er hand is mainly defined by the amount of output acquired as a result of one’s ability to utilize the opportunity given to them to lead, supervise, mentor and motivate others effectively. Though many believe that performance is imperative, others postulate that traits and effective practices determine who one becomes and how much they achieve while at the executive position (Yang 2008:654). Others believe that the successful ones are not necessarily the most effective and the debate may go on for a long time. However, the main aim of this report is to look into the issue of remunerations and how they are determined based on performance, success and commitment rather than astuteness to ascend to higher positions quickly. Analyzing Remuneration Packages The past history, if anything to go by, teaches the corporate world that managers, however effective, require having a maximum for the company to remain afloat even when they leave. Attention is mainly given to those who draw s o much that the divide between them and the employees widens every other day. People are entitled to get the maximum they can from their hard work. However, placing a cap on how much one can draw is also important for effective running of the company. Many however argue that the lack of proper and adequate disclosure on how much each of these executives earns has placed a barrier between them and other employees (Jensen and Murphyn 2004:13). Many believe that they are receiving record salaries and bonuses. As a result of this, the 1951 convention sought to bring all the remunerations at par within the companies without watering down the motivation of all the employees. For instance, GE’s CEO had planned for some lavish retirement benefits that were kept secret to the board and the shareholders (Fama and French 2001:23). The reputation of one of the world’s greatest entrepreneurs was questioned. This incident led many to believe that this is what all the other CEOs were receiving. The case of the NYSE CEO was no different. He was accused that he was bound to receive a retirement benefit of close to $190 million in 2003 which was also not disclosed to the board (Jensen and Murphyn 2004:15). These cases bring about a lot of questions that the report will try to answer. The issue of disclosure is very vital in any organization based on the sensitivity of the remunerations issue. However hardworking these executives are, the

Scene comparison between the movie Il Gattopardo (The Leopard by Essay

Scene comparison between the movie Il Gattopardo (The Leopard by Visconti) and the novel - Essay Example The battle scenes, was developed from various Italy regions depending on the armies constitution that were involved in the battles. The resulting movie captivated all the senders. The film has recreated the atmosphere of19th century in a thorough manner; on their fittings and interiors, time of day, color, scorching heat, coolness search, and the dust that covers the noble when making their way to the Castle Donnafugata, the cloths used, the coaches interior, and the filthy cloak of clergyman, the furniture, and the single frame of the ball sequence accounts for a quarter of the film and which seems to be unending. This is the world that is portrayed by the author, in the disappearing verge, and in the look of the most proustian film that has ever been shot. For the miracle to achieve a collection of outstanding talents was collected veterans seasoned by multiple Viscotian battles. The Palermo aristocrats played in the sequence of dance but also lent the producer a lot of mise-en-sce ne. The film is the work where the author challenges the impossible, selecting to recreate realistically events which took a century earlier. The achievement of the author is magnificent that it appears the various echoes of 19th century outlook in the film have not been highlighted. The painting on the wall of the house participated in a dialogue with the prince of Salina and protagonists. During the dancing break, while contemplating a Jean Baptista famous painting. The prince of Salim is involved in death attempt for the first time and he imagines the next departure of young Tancredi. In the film, the director appeared to embrace contradictions. How did the Italian neorealism progenotir, which emphasizes the mise en scene naturalistic, eventually move towards making the operatic costume dramas and grand? According to Salvador Dali, he describes the producer and the communist that like luxury. The multiple questions are generated when watching the film. To fully understand the puz zle, the film story need not be told without mentioning its source (novel). The historical time is Risorgimento; collection of conflicts that resulted to the formation of a single political entire of Italy, and within the events of the 1860 that same the Garibaldi’s army helped by local militia that rebelled against the Bourbon

Archaeology and Mayan People Essay Example for Free

Archaeology and Mayan People Essay 1. According to Principle 3 of the American Archaeology Statement on Ethics, an archaeologist should drop and avoid any activities or words that would enhance the buying and selling of archaeological Mayan objects. This is demonstrated in the Apocalypto movie, especially those Mayan objects that have not been introduced to the public view, or available for scientific study and display. For example, if the black knife of one of the main warriors in the Apocalypto film was valuable to Mayan people, then the archaeologist who reviews the movie should not mention nor speak about the knife’s value or its estimated price to the public world. If he failed to do so, the object might be sold. Therefore, that action will destroy the important information that is needed to understand the archaeological record of the Mayan people and their cultures. 2. The village life is peaceful, joyful, and they dressed in small pieces of rags. The houses are made of dry leaves and trees. Their source of light is bon fires, and they usually gather around at night to tell stories. The city life is quite harsh. The place is dried up with limited, dirty water. Slaves are the only one working; they’re covered in white pounder. City people have colorful body paint, dresses, and hats. Their ritual is the sacrificing people from the villages. Andrea Stone stated that Mayan rituals always structured in precise time and positioning under the ranked and hierarchy people in specific order, along with beautiful dance prior to them. But the movie portrayed that time as chaos and mad cheering. Also, massive slavery labors is an unfamiliar in that period of time. Stone implied that Mayan villagers don’t lie around in dirt near the fire like hunter-gatherers. Moreover, Mayan woman put their hair up in neat bun and they don’t wear beads unlike Jaguar’s wife. Additionally, Mayan warriors wield clubs, spear, and shield not smashing heavy-metal savage showed in the film. And Mayan territory has scarlet macaw, not blue and gold macaw and howler monkey. Andrea also said that some of the costumes in the movie came after the Classic period such as turquoise jewelry and gold bead, and hair inaccurately putted in corn row. The movie made an assumption that Mayan has stick through the nose. This is a stereotype and inaccurate, Stone wrote.

Infectious Complications of Kidney Transplantation

Infectious Complications of Kidney Transplantation Introduction: Infections that develop after transplantation may be life-threatening and may affect outcomes. Infection follows cardiovascular disease as the second most common cause of death with a functioning graft in kidney transplant recipients. Post-transplant infections develop in approximately 40% of recipients within the first year in spite of prophylaxis. Both the type and occurrence of infections in the immunocompromised transplant recipient follow a timetable pattern. HBV, hepatitis B virus; HIV, human immunodeficiency virus; HSV, herpes simplex virus; LCMV, lymphocytic choriomeningitis virus; MRSA, methicillin-resistant Staphylococcus aureus; PCP, Pneumocystis carinii pneumonia; PML, progressive multifocal leucoencephalopathy; PTLD, post-transplantation lymphoproliferative disorder; SARS, severe acute respiratory syndrome; VRE, vancomycin-resistant Enterococcus faecalis; VZV, varicella-zoster virus. Reproduced from Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601-14. With permission from the Massachusetts Medical Society.  © 2007 Massachusetts Medical Society. Risk Factors for Posttransplant Infectious Complications Pretransplant host factors: Underlying medical condition e.g. Diabetes Mellitus Chronic infections e.g. Hepatitis C viral infection Latent infections e.g. Tuberculosis, Dimorphic fungi Colonization with resistant bacteria Recipients preexisting immunity e.g. Varicella Zoster Virus Prior medications e.g. Antimicrobials, Corticosteroids Transplant factors: Allograft derived e.g. Cytomegalovirus Surgical duration, instrumentation, wound, abdominal fluid collections, technical issue e.g. type of anastomosis Blood transfusion Immunosuppression Immunosuppressive agents and additional treatment for episodes of rejection Time posttransplant Epidemiologic exposure Urinary Tract Infections: Urinary tract infections (UTIs) are the most common bacterial infections following transplantation, which develop in approximately 20% of recipients. Female sex, genitourinary tract manipulation during transplantation, prolonged bladder catheterization, ureteric stenting, age, and delayed graft function (DGF) are independent risk factors. UTIs are independently associated with the development of bacteremia, and untreated UTIs are associated with subsequent rejection (3). Post-transplant vesicoureteric reflux occurs in up to 40% of transplant recipients, although is not associated with the UTI risk (4). Ureteric stents mitigate the risk of ureteric strictures and leaks after transplantation. Center practices vary, with stenting of all patients at some centers and more selective stenting at others. Wilson et al. performed a Cochrane analysis of seven randomized controlled trials (RCTs) encompassing 1,154 patients that examined the practice of allograft ureteric stenting (5). The incidence of major urologic complications including urine leak and obstruction was significantly reduced (relative risk [RR], 0.24; 95% CI, 0.07 to 0.77; P=0.02; number needed to treat = 13) by universal prophylactic stenting. However, UTIs were more common in stented patients (RR, 1.49; 95% CI, 1.04 to 2.15), unless the patients were prescribed trimethoprim/sulfamethoxazole (TMP/SMX), in which case the incidence was equivalent (RR, 0.97; 95% CI, 0.71 to 1.33). Stents were generally well tolerated, although studies using longer stents (à ¢Ã¢â‚¬ °Ã‚ ¥20 cm) for longer periods (> 6 weeks) developed problems mo re frequently with encrustation and migration. Typical pathogens include Escherichia coli, Klebsiella, Proteus, Enterococcus, Enterobacter, Staphylococcus, and Pseudomonas. In the case of recurrent infections, abscesses or other nidi of infection should be sought out by means of imaging with ultrasound or computed tomography. Early catheter removal decreases the incidence of UTI in renal allograft recipients. The use of TMP/SMX to prevent Pneumocystis jirovecii pneumonia and UTI has long been the standard of care after kidney transplantation. Wojciechowski et al. performed a single-center study comparing TMP/SMX for 6 months (group 1) versus TMP/SMX for 6 months plus ciprofloxacin for 30 days (group 2) for prophylaxis after kidney transplantation (6). At 1 year, more patients in group 1 developed UTIs (23.6% versus 10.8%; P=0.01) and the mean time to first UTI was shorter. There was a similar incidence of enteric Gram-negative antibiotic resistance to TMP/ SMX (75% versus 80%; P=1.00) and ciprofloxacin (16.7% versus 30%; P=0.39) in groups 1 and 2. For groups 1 and 2, the proportion of first UTIs requiring hospitalization was 48.9% versus 40.6%, respectively. A clean-catch midstream urine specimen should be submitted for quantitative bacterial and fungal  culture. Antibiotic therapy should be tailored according to the offending microorganism and drug susceptibility tests. Septicemia: The incidence of hospitalizations for septicemia among renal transplant recipients is approximately 42 times that of the general population. The urinary tract is the most common source of septicemia, followed by the lungs, the surgical wound site, and the abdomen. Most cases occur within the first six months after transplantation. Among patients with bacteremia, poor outcome is associated with Gram-negative species, multidrug-resistant organisms, and Candida species, especially when the empiric antimicrobial therapy is inappropriate or delayed. Bige et al. retrospectively studied 83 kidney transplant recipients (KTRs) admitted for sepsis, severe sepsis, or septic shock to their intensive care unit over a 10-year period (1). The main sites of infection were the lung (54%), urinary tract (24%), and bloodstream (22%). Eighty percent of infections were bacterial. Mechanical ventilation was used in 46 patients (56%), vasopressors in 39 patients (47%), and RRT in 34 patients (41%). The 90-day mortality rate was 22%. By day 90, among the 65 survivors, 39 (47%) had recovered their previous graft function, and 26 (31%) had impaired graft function, including 16 (19%) who were dependent on RRT. Some studies suggest that bacterial sepsis increases the risk for CMV infection because of high levels of tumor necrosis factor-ÃŽÂ ± (TNF-ÃŽÂ ±) or dysregulated immune response to CMV in the context of serious bacterial infections. For detection of bloodstream infection, two sets of blood cultures should be obtained before initiation of antimicrobial therapy. If intravascular catheter-associated bacteremia is suspected, the device should be removed and the catheter tip should be cultured. Pneumonia: The incidence of pneumonia in kidney transplantation is the lowest among all solid organ transplants (8 to 16 percent). However, pneumonia is the most serious infection, leading to death in up to 50 percent of cases. The infectious agent in the majority of patients is never determined. This is likely because of the low yield of blood and sputum cultures and the efficacy of antibacterial therapy. In patients who are hypoxic on presentation or do not respond to initial therapy, a bronchoscopy and bronchoalveolar lavage (BAL) is almost always warranted. Patients should be referred if possible to a transplant center to improve the likelihood of diagnosing the etiologic agent. Common causative organisms include Streptococcus pneumoniae, nontypable Haemophilus influenzae, Moraxella catarrhalis, Chlamydia pneumoniae, Mycoplasma pneumoniae, and respiratory viruses such as influenza, adenovirus, and respiratory syncytial virus (RSV). Less commonly, patients may present with opportunistic organisms such as P. jirovecii and L. pneumophila. Silver stains for direct fluorescent antibody for Pneumocystis should be done on sputum or BAL specimens. A urine Legionella antigen test should be done on all patients on initial work up. Mycobaterium tuberculosis: Among the infections, tuberculosis is an important cause of morbidity in renal transplant recipients in developing world. The incidence of post-transplant tuberculosis in India has been reported to be highest in the world at 5.7 to 10 percent in various studies. Most cases of Mycobacterium tuberculosis infection in kidney transplant recipients are due to reactivation of latent tuberculosis lesions. Important risk factors for reactivation include nonwhite race, history of active tuberculosis, presence of marked abnormality on a chest radiograph, exposure to person with a confirmed case of tuberculosis, and skin test positivity. In transplant patients, the clinical presentation of tuberculosis may be atypical and extrapulmonary and miliary tuberculosis is seen more frequently than in the normal population. Tuberculosis presents numerous diagnostic difficulties in renal transplant recipients. Because of high frequency of anergy in immunosupressed patients, the Mantoux test is generally unhelpful as a diagnostic tool. e classic picture of apical involvement in the general chest X-ray is seen in only a minority of renal transplant recipients with pulmonary tuberculosis. Demonstration of acid-fast bacilli in the sputum smear requires repeated examination on several occasions and has a low yield. Identification on culture takes four to six weeks. Treatment of post-transplant tuberculosis presents problems both in the choice of antitubercular agents and in the duration of therapy. Rifampicin is a well-known hepatic P-450 microsomal enzyme inducer, increasing the clearance of both prednisolone and cyclosporine A. The dose of prednisolone needs to be doubled and that of cyclosporine increased to three- to four-fold to maintain therapeutic blood levels. e latter increases the cost of therapy and is unacceptable to a vast majority of patients. An alternative regime that has been successfully used for these patients consists of a combination of isoniazid, pyrazinamide, ofloxacin, and ethambutol. e optimum duration of therapy is also a matter of debate but is usually for 9 to 12 months. e duration needs to be increased to 18 months in patients who are on cyclosporine and are not receiving rifampicin. e role of INH prophylaxis after transplant in endemic areas is controversial. Cytomegalovirus (CMV): CMV is a significant cause of morbidity and mortality among kidney transplant recipients. Between 60 and 90 percent of adults are seropositive. Symptomatic disease ranges from a relatively mild syndrome of fever, leukopenia, thrombocytopenia, and elevated liver enzymes to severe disseminated disease that involves multiple organ systems, such as the lung, liver, and GI tract. CMV disease has been implicated as a cause of acute and chronic graft dysfunction as well as long-term graft loss. CMV can also suppress the immune response which predisposes the host to infections with other viruses, bacteria, and fungi. The incidence and severity of CMV disease has been most strongly associated with the CMV serostatus of the kidney donor and recipient. Seronegative recipients who receive a kidney from a seropositive donor (D+/R-) are at greatest risk for severe primary infection during the first three months post-transplant. Rapid and accurate diagnosis of CMV is important because delayed recognition results in increased morbidity. Quantitative real-time polymerase chain reaction assays for CMV DNA and pp65 antigen detections are the most commonly used means to detect CMV viremia. e shell vial viral culture method remains a reliable way of detecting CMV in sputum. Multiple strategies have been used to reduce the morbidity and mortality of CMV infection and its associated costs (see Table 4). Avoiding CMV sero- mismatching through organ allocation is not feasible or worthwhile. Universal prophylaxis refers to giving prophylactic therapy to all kidney transplant patients regardless of their CMV serostatus. Selected prophylaxis refers to giving prophylaxis to patients at high risk for CMV, namely the D+/R- category or those receiving lymphocyte-depleting therapy. e preemptive treatment approach treats asymptomatic CMV infection in an e ort to prevent CMV disease. Each approach has its advantages and disadvantages, and there is no de nitive consensus on optimal preventive strategy. Prophylactic Therapy: Prophylactic therapy is effective in preventing CMV disease in high-risk patients. Ganciclovir and valganciclovir are equally efficacious. Ganciclovir 1,000 mg PO three times daily and valganciclovir 900 mg PO once daily are used. Valganciclovir is contraindicated in patients with a creatinine clearance of less than 10 ml/h. Prophylactic therapy is usually given during the first 100 days post- kidney transplant. A concern with the prophylactic strategy is that 20 to 30 percent of high-risk patients go on to develop late-onset CMV disease after the prophylaxis is stopped, and the incidence of ganciclovir resistance may be higher in those who receive prophylaxis. Preemptive Therapy: Preemptive therapy of CMV infection involves monitoring for CMV viremia and starting treatment before the development of signs or symptoms of disease. It has been shown to be as effective as prophylactic therapy in preventing CMV disease. Both oral ganciclovir and valganciclovir have been shown to be effective in treating viremia. Preemptive therapy has the advantage of avoiding the costs and complications of antiviral therapy in low-risk patients while at the same time initiating treatment early to avoid symptomatic disease in high-risk patients. It has also been shown to decrease the development of late CMV disease. Its major limitation is the need to perform frequent determinations of CMV viremia. Ganciclovir Resistance: Ganciclovir resistance is becoming more common among solid-organ transplant recipients. In one study, 6.2 percent of CMV isolates had UL97 or UL54 mutations. Viral strains with mutations in the UL97 gene, which encodes for a viral protein kinase, remain susceptible to foscarnet and cidofovir. Mutations in the UL54 gene that encodes DNA polymerase can result in resistance to ganciclovir, foscarnet, and cidofovir. e emergence of ganciclovir-resistant CMV underscores the importance of optimizing preventive strategies. BK Virus (BKV): BKV is associated with post-transplantation nephropathy, hemorrhagic cystitis, and ureteral obstruction. It has a tropism for genitourinary tract and usually remains dormant in the urinary tract and circulating leukocytes after the primary childhood infection and becomes reactivated during immunosuppression. Adult seroprevalence rates for BKV range from 65 to 90 percent and BKV reactivation can come from the recipient or the donor. BK viremia occurs in 13 percent and BK nephropathy in 8 percent of kidney transplant recipients. Analysis of risk factors for reactivation has underscored the central role played by serologic status of the donor, immunosuppressive regimens, injury to the uroepithelial tissue, and acute rejection. Distinguishing between BK infection and allograft rejection is of paramount importance, since BK infection necessitates reducing immunosuppression and allograft rejection requires the opposite. Among kidney transplant recipients who are receiving immunosuppressive therapy, 10 to 60 percent have reactivation of BKV accompanied by shedding of urothelial cells. Shedding is inconsistently associated with allograft dysfunction. Once the virus has reactivated, an ascending infection via cell-to-cell spread occurs. e overall state of immunosuppression is the primary determinant of BKV reactivation. Viral replication begins early after transplantation and progresses through detectable stages-viruria, then viremia, then nephropathy. Viruria can be detected by PCR for BKV DNA, reverse transcription (RT)-PCR for BKV RNA, cytology for BKV inclusion bearing epithelial cells termed decoy cells, or electron microscopy for viral particles. Viremia is a better predictor of nephropathy than viruria. Although higher levels of viremia correlate with the risk of developing nephropathy, there are no established thresholds of viremia to indicate nephropathy. The gold standard for establishing BK nephropathy remains a kidney biopsy with positive immuno- histochemical or immunofluorescent staining for the SV-40 large T antigen. An effective screening strategy is to check blood for BKV DNA by PCR monthly for the first 3 months and at 6 and 12 months after transplantation, at the time of any unexplained rise in serum creatinine, and after augmentation of immunosuppression. Because BKV nephropathy is preceded by BK viremia, asymptomatic BK viremia should prompt empiric immunosuppression reduction and continued monitoring. Currently, no established antiviral treatment is available, and control of viral infection is tentatively obtained by means of reduction of immunosuppression. Treatment attempts have included immunoglobulins without proof of efficacy. Other options include deoxyspergualin, cidofovir, leflunomide, uoroquinolones and gyrase inhibitors. Cidofovir use is limited by its nephrotoxicity. Fungal Infections: The incidence of fungal infections in renal transplant recipients is less than that reported for other solid organ transplant recipients, the mortality from fungal infections remains high and is related to the pathogenicity of the  organisms, site of infection, impaired host inflammatory response, limited diagnostic tools, potential for rapid clinical progression, failure to recognize a high-risk patient, and comorbidities, such as renal failure and diabetes mellitus. Colonization with yeasts and molds occurs frequently in transplant candidates with ESRD and after transplantation because of exposure to broad-spectrum antibacterial agents, domiciliary and hospital exposures, immunosuppressive therapy, especially corticosteroids, and the presence of urinary catheters and endotracheal tubes. Isolation of Candida species from cultures of stool, respiratory, and urine samples occurs commonly in kidney transplant recipients receiving corticosteroids and broad-spectrum antimicrobials and does not necessarily imply infection. However, repeatedly positive fungal cultures from a single or from multiple sites may herald invasive candidiasis in the appropriate clinical setting. Candida species, Aspergillus species, P. jiroveci, and C. neoformans are the most common fungal pathogens reported in renal transplant recipients. Candida infections occur most commonly during the first month following transplantation and are usually associated with transplant surgical technical complications, early rejection, and enhanced immuno- suppression. Candida infection is most commonly associated with an endogenous source of colonization. C. albicans is the most common species, followed by C. glabrata, C. tropicalis, and C. parapsilosis. Speciation is clinically useful because nonalbicans Candida species vary in in vitro susceptibility to amphotericin B and azoles. Sites of Candida infection include mucocutaneous candidiasis and esophagitis; wound infections; cystitis, pyelonephritis, and ureteral obstruction by Candida elements or fungal ball; intra- abdominal infections, including infected perigraft fluid collections or peritonitis; and intravascular device- associated fungemia. Renal parenchymal infection most often results from candidemia and hematogenous spread, although ascending infection from the bladder can oc cur. Candiduria is typically asymptomatic but may be associated with cystitis or upper tract infection. Patients with genitourinary tract stents and recurrent funguria often require removal of foreign body to eradicate the infection. Cryptococcus often presents as meningitis but may cause space-occupying brain lesions; pulmonary, dermatologic, skeletal, organ-specific disease; aspergillosis-pneumonia and other tissue-invasive forms, including genitourinary, central nervous system, rhinocerebral, GI, skin, wound, and musculoskeletal disease. Patients at risk for aspergillosis include those receiving repeated courses of enhanced immuno- suppression for rejection and those with chronic graft dysfunction, diabetes, comorbid medical illnesses, or CMV infection. Diagnosis of aspergillus infection depends on a high clinical suspicion, isolation of Aspergillus species from a sterile body site or repeated isolation from the respiratory tract, and typical radiographic findings. Radiologic appearances of pulmonary aspergillosis in kidney transplant recipients include nodules, di use or wedge-shaped opacities, empyema, or cavitary forms. Serial measurement of aspergillus galactomannan in the serum may aid in the early diagno sis of invasive aspergillosis in the high-risk setting. Historically, invasive candidiasis, cryptococcosis, coccidioidomycosis, histoplasmosis, and aspergillosis were treated with amphotericin B deoxycholate (AmB). The lipid formulations of amphotericin B are all associated with lower risks for nephrotoxicity, metabolic derangements, and infusion-associated side effects than is AmB. Higher therapeutic dosages can be administered, and broad-spectrum antifungal activity is generally maintained. Voriconazole appears to be superior to conventional AmB for the treatment of invasive aspergillosis and also has in vitro activity against a wider range of organisms. Available in both intravenous and oral formulations, the drug is generally well-tolerated, but some patients experience visual hallucinations or severe photosensitivity. Oral posaconazole has excellent activity in vitro against Candida, Aspergillus, and Mucor species, but experience in solid organ transplant recipients is limited to date. Although itraconazole has good in vitro activity against Aspergillus species, its use is generally reserved for treatment of less-severe aspergillosis or maintenance therapy following initial response to lipid amphotericin or voriconazole and for treatment of endemic mycoses. Fluconazole is the first-line agent of the treatment or prevention of reactivation of coccidioidomycosis in renal transplant  recipients. The echinocandins, including caspofungin, anidulafungin, and micafungin, inhibit synthesis of fungal cell wall protein ÃŽÂ ²1-3 glucan and are fungicidal for Candida species, including fluconazole-resistant species. Available only as intravenous formulations, the echinocandins are effective, well tolerated, and have few drug-drug interactions.

Historic Jonesborough, Tennessee :: Descriptive Essay About A Place

Historic Jonesborough, Tennessee Jonesborough is the oldest town in Tennessee; consequently, it draws people from all over the world. The town is known for its great amount of visitors during the story telling festival, Jonesborough Days, and during the fall, when some just like to roam the streets to check out the many interesting shops. For the first-time visitor, I recommend that your first stop to be to the Visitors Center. There are so many things to do in this small town you really need a plan to get you started. The Visitors Center offers several brochures and maps of local attractions and festivals in the area. For $1.00 you can also purchase a map that gives a brief description of each of the shops and cafes. The map also gives the location and description of the downtown inns and bed and breakfasts in the area. The Visitors Center also offers several gift items and souvenirs, such as postcards and books written about the town’s rich history. Several different types of tours of the town are offered, including a horse drawn carriage ride throughout the town. Individual or group tours are also available at varying rates. An individual tour can cost between ten to twelve dollars per person and a large group tour cost as high as three hundred dollars per person. Jonesborough.http://www.historicJonesborough .com/index.html. Another place to visit is the Lollipop Shop. This store is quite unique because it offers over 400 different types of candy. If you have a sweet tooth, this is the shop for you. The kinds of candy they offer are the old-fashion candy sticks I used to buy for a dime, different flavored hard candies, several types of gummy candies, gum, and of course lollipops. While we were there, my wife and I inquired about services the Lollipop Shop offers, such as birthday party packages available through the shop. The bear parties are very unique, and we hadn’t tried them before. The children are given a choice of one of about twenty different choices of stuffed animals. They then go to stuff the animal and fluff it. They also offer to give their creation, which comes with adoption papers, a name. This party is offered for fourteen dollars per child. With another package, for eighteen dollars per person, in addition to stuffing their animal of choice, they get to decorate a cookie, and the y get a slushie.