The Causes and Effects of Water Pollution in Lake Huron Essay

The Causes and Effects of Water Pollution in Lake Huron - Essay Example Lake Huron suffers from a number of water pollutants that have greatly affected its flora and fauna as well as the freshness of its water. The lake endures point source pollution from industrial wastes and non-point pollution from fertilizer and pesticide runoff from surrounding farms. These pollutants result in adverse effects that contaminate soils, reduce the quality of its water and damage its ecosystem. The damage from pollution in this lake has harmful repercussions on the wildlife, fishes and human beings that depend on water from this lake. Point-source pollution This refers to the direct source of contamination in Lake Huron. This is often done when pipes or vessels direct their toxic wastes directly into the lake. Initially, paper and pulp industries located around the lake believed that water could dissolve anything and, thus, neutralize the toxicity of their wastes (Shear, 2006). This resulted in the companies dumping most of their wastes such as mercury into the lake. Ot her industries dump their wastes that contain harmful chemicals, heavy metals, organic toxins and oil by products into Lake Huron. In the recent past, fecal matter has been observed in the lake. This means that sewerage companies are directing wastes into the lake as well. This has resulted in the increase of harmful and disease causing bacteria in the lake. At the same time, the sewerage and other inorganic and organic wastes disposed off in the lake have resulted in a decline in the quality of Lake Huron’s water. Non-point source pollution This is pollution that does not come from a specific location. The most prevalent non-point source of pollution in Lake Huron is pesticide and fertilizer runoff. There are a number of farms surrounding Lake Huron. These farms depend on the lake for water that is vital for irrigation of the vast horticultural farms due to its constant and never-ending supply. These farms make use of a number of fertilizers and pesticides that are used to e nhance crop growth. However, the chemicals used in making these fertilizers and pesticides are often washed down from the crops by rain or irrigation water. These chemicals find their way into the lake through rivers and stream that empty their waters in the lake (Shear, 2006). This often results in the influx of harmful chemicals that greatly affects the lake’s ecosystem as evidenced by the large number of sea birds that are found dead along the lake’s shoreline. The fishes caught from this lake also have a lot of harmful chemicals in them. Residential waste Household waste has become one of the greatest Lake Huron pollutants. Residential wastes that contain organic or inorganic waste and detergents are major contributors to the lake’s water pollution. Organic waste is one which can be decomposed by bacteria such as fruit and vegetable remains. Inorganic waste includes wastes such as leather, plastic, paper, glass, fabric, metals and wood among other wastes whi ch do not decompose. These wastes cannot be broken down through the help of bacteria and is often referred to as non-biodegradable (Shear, 2006). Detergents are also not broken down easily by bacteria. This means that they remain active for prolonged periods after getting into the fresh water lake. This leaves the water polluted and results in the poising of aquatic organisms such as fish, birds and plants that reside in Lake Huron. Human and animal wastes

Islamic History Essay Example | Topics and Well Written Essays - 1250 words

Islamic History - Essay Example The history of foundation of Islam is clothed with the veils of legend and obscured by multiple conflicting accounts that make its true outline all but impossible to discern with any clarity. But it is incontrovertible that Northern-Arabia prior to Muhammad was a predominantly tribal environment, structured by exigencies of camel herding, trading, feuding, and raiding. The ‘civilized’ area of Arabia was not in the heartland where Islam was born, but rather had long been located in the coastal south and along the gulf. Inland, the only possible location for development of any sort of state was in the impoverished and remote region dominated by Mecca and the Quraysh clan, where ancient pilgrimage centers protected markets in perfume, leather, and other trade goods. But no such development occurred until the advent of Muhammad, who was born around 570, received his first revelations at the age of forty, undertook his momentous journey to Medina (the hijra) in 622 (year one in the Muslim calendar) and died in 632, having led his people in the conquest of the whole Arab peninsula, and having initiated their great and ultimately successful war against the surrounding Sasanid and Byzantine empires.The religion of Islam is from the Muslim point of view, â€Å"the religion of Abraham and Ishmael† the forefathers of the Muslims. According to Ibn al-Kalbi, who conveys also the belief of his predecessors, Ishmael settled in Mecca where he became the father of many children who supplanted the Amalekites of Mecca; to him is ascribed the origin of the Arabs. Arabs. The Qur'an states that Abraham and Ishmael "raised the foundation of the House" and established a "proper worship". The rites of the pilgrimage, the circumambulation, the visitation of the lesser pilgrimage, the vigil of Arafat, the sacrifice of the she-camels and the acclamation of the name of the deity "came down from the time of Abraham and Ishmael", according to Ibn al-kalbi, and they constitute a part of the religion.(Tamara) Islam had come upon the world scene in the seventh century in connection with the explosion of Arabic-speaking, horse mounted warriors out of the Arabian desert under the leadership of the Prophet Muhammad and his successors. The period of hemispheric history from 1000 to 1500 A.D., what we will call the Islamic Middle Period, witnessed a steady and remarkable expansion of Islam, not only as religious faith but as a coherent, universalist model of civilized life. The spread of Islam into new areas of the hemisphere during the Middle Period was given impetus by two major forces. One of these was the advance of Turkish-speaking of Muslim herding people from central Asia into the Middle East, a movement that began on a large scale with the conquests of the Seljuk Turks in the eleventh century. The second force was the gradual but persistent movement of Muslim merchants into the lands rimming the Indian ocean, that is, East Africa, India, Southeast Asia and China, as well as into Central Asia and West Africa south of the Sahara. A close look at the patterns of travel and migration in the post-Abbasid centuries reveals a quiet but persistent dispersion of legal scholars, theologians, Sufi divines, belle- lettrists, scribes and architects outward from the older centers of Islam to these new frontiers of Muslim military and commercial activity. (Spencer) The Islamic world in Ibn Battuta's time was divided politically into numerous kingdoms and principalities. Muslims on the move regarded the jurisdictions of states as a necessary imposition and gave them as little attention as possible. Their primary allegiance was to the Dar al-Islam as a whole. The terrible Mongol conquests of Persia and Syria that occurred between 1219 and 1258 appeared to Muslims to threaten the very existence of

English - School Lunches Research Paper Example | Topics and Well Written Essays - 1000 words

English - School Lunches - Research Paper Example As the school bell rings for lunch, children rush to the canteen to fill their hungry stomachs. Most schools have a menu from which children can select for their lunch. The lunch time for the kids is a time not only to energize themselves but also to sit with their friends and have a good time. However though, there are certain concerns which are going unnoticed by the school authorities. Concerns A lot of teachers have noticed a tired set of students attending the classes which are conducted after lunch. The reason for tiresome students has been the food they consume. Most schools though are not able to provide healthy food to the students. This has been a problem for most of the schools. In most schools, the menu for lunch reads a list of junk foods which is wrong. Looking at the menu, children have no other option but to consume them. The school authorities should take responsibilities and stop selling junk foods. One of the main reasons why junk food should be stopped is it affec ts the health of the children a lot. It is the major reason for child obesity. To be unfit and obese at a young age is a concern. Survey has shown that 32% of the youngsters are obese. One can accept the fact that such food is sold outside to earn money but it is unacceptable when such food is sold in schools. Due of the lack of fresh foods and healthy foods, students buy cheap junk foods. Pizzas, pastas, chips, cookies and burgers form the main menu in school lunches. Consumption of these means a lot of sugar is consumed by the children. School lunches have a high level of sugar content in them. Healthier food would mean that the obesity rate is reduced. Another reason why cafeterias should not serve junk food is that it keeps the energy levels of the children low. High energized food shall help the children to maintain good focus and participate in sports as well. Lunch is the most important since it falls in the middle of the day. Consuming junk food will extracts all the energy and reduces the physical activity. One cannot perform to their potential if they do not have enough energy. In one of the schools, children complained of less stamina while practicing soccer. When the coach investigated in their diet, he found out that most of them had a packet of chips and soda before practice. He advised them not to consume fried and fatty foods before exercising since it consumes most of the energy from the body. Studies have shown that the most commonly food consumed by children is cookies, candy, cakes and ice cream. This is also the reason for children losing energy during their noon classes. He stressed on the importance of consuming healthy and natural food which give energy to our bodies. Despite schools imparting knowledge to the children on how to remain healthy, sometimes they miss out on providing healthy food to them. The authorities should notice this and make sure that children are provided good food. Quality Most of the science classes teach the chi ldren that good food is the secret of a healthy life. However though, the same is not followed in schools. Authorities take a lot of effort to make sure that children get tasty food, but they miss out on the quality. In an era where health has been given primary importance, schools have neglected that. Parents have complained that their children are suffering from illness frequently and their immune systems have gone down. An inspection conducted by the officials brought a

Islamic History Essay Example | Topics and Well Written Essays - 1250 words

Islamic History - Essay Example The history of foundation of Islam is clothed with the veils of legend and obscured by multiple conflicting accounts that make its true outline all but impossible to discern with any clarity. But it is incontrovertible that Northern-Arabia prior to Muhammad was a predominantly tribal environment, structured by exigencies of camel herding, trading, feuding, and raiding. The ‘civilized’ area of Arabia was not in the heartland where Islam was born, but rather had long been located in the coastal south and along the gulf. Inland, the only possible location for development of any sort of state was in the impoverished and remote region dominated by Mecca and the Quraysh clan, where ancient pilgrimage centers protected markets in perfume, leather, and other trade goods. But no such development occurred until the advent of Muhammad, who was born around 570, received his first revelations at the age of forty, undertook his momentous journey to Medina (the hijra) in 622 (year one in the Muslim calendar) and died in 632, having led his people in the conquest of the whole Arab peninsula, and having initiated their great and ultimately successful war against the surrounding Sasanid and Byzantine empires.The religion of Islam is from the Muslim point of view, â€Å"the religion of Abraham and Ishmael† the forefathers of the Muslims. According to Ibn al-Kalbi, who conveys also the belief of his predecessors, Ishmael settled in Mecca where he became the father of many children who supplanted the Amalekites of Mecca; to him is ascribed the origin of the Arabs. Arabs. The Qur'an states that Abraham and Ishmael "raised the foundation of the House" and established a "proper worship". The rites of the pilgrimage, the circumambulation, the visitation of the lesser pilgrimage, the vigil of Arafat, the sacrifice of the she-camels and the acclamation of the name of the deity "came down from the time of Abraham and Ishmael", according to Ibn al-kalbi, and they constitute a part of the religion.(Tamara) Islam had come upon the world scene in the seventh century in connection with the explosion of Arabic-speaking, horse mounted warriors out of the Arabian desert under the leadership of the Prophet Muhammad and his successors. The period of hemispheric history from 1000 to 1500 A.D., what we will call the Islamic Middle Period, witnessed a steady and remarkable expansion of Islam, not only as religious faith but as a coherent, universalist model of civilized life. The spread of Islam into new areas of the hemisphere during the Middle Period was given impetus by two major forces. One of these was the advance of Turkish-speaking of Muslim herding people from central Asia into the Middle East, a movement that began on a large scale with the conquests of the Seljuk Turks in the eleventh century. The second force was the gradual but persistent movement of Muslim merchants into the lands rimming the Indian ocean, that is, East Africa, India, Southeast Asia and China, as well as into Central Asia and West Africa south of the Sahara. A close look at the patterns of travel and migration in the post-Abbasid centuries reveals a quiet but persistent dispersion of legal scholars, theologians, Sufi divines, belle- lettrists, scribes and architects outward from the older centers of Islam to these new frontiers of Muslim military and commercial activity. (Spencer) The Islamic world in Ibn Battuta's time was divided politically into numerous kingdoms and principalities. Muslims on the move regarded the jurisdictions of states as a necessary imposition and gave them as little attention as possible. Their primary allegiance was to the Dar al-Islam as a whole. The terrible Mongol conquests of Persia and Syria that occurred between 1219 and 1258 appeared to Muslims to threaten the very existence of

Reading Assessment Assignment Example | Topics and Well Written Essays - 250 words

Reading Assessment - Assignment Example The current immigrants are different from the earlier immigrants in the sense that they form the source of terrorists and other ill intention arrivals with an objective of destroying the United States. John Amagoalik quote emphasizes relevance of Nunavut to original inhabitants of Australia and Greenland, Canada. Amagoalik argues that preserving Nunavut would assist Inuit and Aboriginals in protecting the erosion of their culture and history. Therefore, Nunavut existence remains symbolic of Aboriginals and Inuit historical reality. Gurston Dacks quote contradicts ideas advanced by Amagoalik. He argues that Nunavut have no particular value. Dacks, further states that Nunavut existence would only revoke postwar ideals rather than infer benefits to Austrian or Canadian community (Smith, 1971). Clash of civilization theory proposes that post-Cold War would result from peoples’ religious and cultural identities. Media arguments and research findings support clash of civilizations theory. Media reports on continued disagreements between Islam community and the Western countries relates to the theory. Contemporary media news reports that Islamic communities have decided to form militant movements that reject Western values and way of living. Unfolding religious and cultural events prompts for analysis to support clash of civilizations theory. Cultural and religious differences between Islam and Christian community require insightful analysis and professional views to ascertain clash of civilizations

Cultural Barriers When Negotiating with Women and Minorities Essay Example for Free

Cultural Barriers When Negotiating with Women and Minorities Essay A hostage negotiation occurs when a criminal uses innocent people as bargaining chips. The scenarios for these circumstances vary from a desperate mother perhaps who in fear may barricade herself with her own child to a bank robber who utilizes the people around to assist in his getaway. In addition, a more publicized type of hostage situation would be the terrorist type situations where a completely new set of rules must be utilized to deal with these type incidents. For example, a mother may be desperate and reacting in fear. Most likely this type of person the mind set is not that of a criminal and she has no real intentions of hurting anyone but for the most part is reaching out for a solution of some type. The first job of the hostage negotiator should be to create safety. When a negotiator arrives on the scene there may be several armed officers with emotions running high and general confusion. The environment escalates the fear that is already present in this woman and she is most likely fearful for her life as well as the child or hostage she may be holding. Brute force would not be the best method to use in this type of situation as the woman most likely is not looking to harm anyone and is actually seeking some way of escape. For the most part the percentage of women who take hostages are considerably lower than that of a male committing the same crime. Upon arriving on the scene, it would be crucial for the negotiator to get organized and establish some sort of communication with the hostage taker to determine what her issue may be. If the negotiation looks like it might take some time it would be wise to consider a position that would offer some type of permanent accommodation. The next step would be to attempt to determine as much information about the situation as possible. For example, it would be important to know how many hostages and if possible their names. Then it is crucial to determine what they are demanding and from there determine what is it that they are really asking for. Since typically by nature, women tend to be more emotional it would be wise to determine where her frame of mind is at this time. The questions to consider is whether she is desperate and fearful or are her emotions running high with a sense of hopelessness where she feels she has nothing to lose? Also, if possible it would be beneficial to determine is she under the influence of any type of drug or alcohol as these factors could make the situation much more difficult as it is often times impossible to reason with a person under the influence. Their grasp on reality is greatly altered and what is plain logic will not register plainly to them. Another type of hostage situation to consider is a terrorist type situation where the person who the negotiator is dealing with is not from this country and then a whole new set of issues would require attention. Most terrorists who apprehend hostages may believe that they are truly doing a heroic act and it is most likely a religious type of motive. It is hard to reason with a person like this without understanding that this person has no fear of death. In fact, they most likely welcome it as they are under the impression that they will be greatly rewarded in the after life because of what they are doing. In addition, many times when dealing with hostage takers from the middle east they are so despondent as they have lost much in the way of possessions and more importantly they may have lost family members. In the case of these type hostage situations they are not holding the person, for the most part, in a building like perhaps a bank robber type situation. In these cases the hostages are more likely to be picked up from a public place and carried away to another secret location. The hostage takers in turn contact whomever they feel are the appropriate people and from that point make their demands. For the most part they may provide some type of proof alerting the authorities on the number of people taken and assurance that they are still alive. In these type instances they may appear, and often do, have the upper hand and it is the negotiator’s duty to balance the situation. It is imperative to determine at this point what the terrorists may be asking and if the request if realistic and one that could be honored. From this point the cooperation of several government officials may come into play and the decision on who to contact should be made considerably quick. Another type of hostage situation would be when an individual from an urban community is the criminal. Many times these people are desperate and will not be open to negotiation. Often times they are determined they will not be caught and their way of life has reduced the respect of other people’s lives, as they have no great respect for own. Another issue that is prevalent in these type situations would be there also may be the involvement of drugs and alcohol so the negotiator may not be dealing with a lucid personality.

Pathophysiology Of Emphysema

Pathophysiology Of Emphysema This essay will describe the pathophysiology of emphysema and the effect it had on a specific patient that I have chosen for this assignment. It will accomplish this by referring to the patients presenting symptoms and diagnosis and then by examining the changes that occur in the airways of an individual suffering from this chronic disease. The essay will continue by exploring the aims of treatment and how they may control the symptoms relating to the specific patient chosen. It will consider the relevant guidelines to treatment options in order to demonstrate evidence based practice. Emphysema is chest condition that falls under the umbrella term of chronic obstructive pulmonary disease (COPD). This term also includes chronic bronchitis and asthma. Shahab, Jarvis, Britton and West (2006) suggest that COPD is a major contributor to global mortality and morbidity and its worldwide prevalence is likely to increase further. They continue by suggesting that it is well established that smoking is the single most important cause of COPD, increasing the risk of developing and dying from this condition by a factor of thirteen. COPD is characterised by airflow obstruction and is usually progressive, not fully reversible, and does not change markedly over several months. Sharafkaneh, Hanania and Kim (2008) suggest that an imbalance between protease and antiprotease activity in the lung is proposed as the major mechanism resulting in emphysema. Patients with emphysema complain of breathlessness, particularly on exertion, cough, chest tightness and often a reduction in their quality of life. This essay will explore the changes that occur in the lungs of a patient with emphysema and how these changes transpire. The National Institute for Health and Clinical Excellence (NICE 2010) state that an estimated three million people in the UK have COPD. They also suggest that out of this figure only nine hundred thousand of these cases are confirmed, the remainder are people that have not yet presented with symptoms to their doctor. Exacerbation of COPD requiring hospital admission places a great burden on NHS resources. Davies (2009) suggests that costs directly related to caring for patients with COPD are over  £500 million annually. Background of patient.http://faculty.washington.edu/alexbert/MEDEX/Spring/Spirometry.jpghttp://www.ispub.com/ispub/ijtm/volume_1_number_1_66/strongyloides_induced_respiratory_failure_6/strongy1a.jpg To maintain patient confidentiality and for the purpose of this essay, the patient will be referred to as Janet. Janet is a 57 year old married woman. She has a history of smoking since the age of 15 and this equates to 42 pack years. She has worked in an office for her whole working life and enjoys walking. She attended the surgery as she was finding walking her dogs increasingly more difficult and was experiencing breathlessness on exertion. Janets weight was stable and she had not experienced any haemoptysis. Her baseline blood pressure and pulse where within normal limits and her body mass index (BMI) was in a healthy range. A full blood count (FBC) identified that Janet was not anaemic nor did she have polycythaemia which represents an abnormally high red blood cell count with a haematocrit greater than fifty percent. Janets peripheral oxygen saturation using a pulse oximeter was shown to be ninety four percent on air. Chest x-ray showing hyperinflation mdguy available at medpreponline.com Pulmonary Function Tests Medex Objectives 2003On examining Janets computerised records it was noted that she did not expectorate much sputum and she had only been prescribed one course of antibiotics for a chest infection in the past three years. Janet had been sent for a chest x-ray on her second visit to the surgery which had revealed hyperinflation of the lungs. Janet was subsequently referred for lung function tests at the local hospital where an obstructive pattern was identified. Spirometry is the test performed to demonstrate airflow obstruction however NICE (2010) state that airflow obstruction alone cannot be used as a diagnosis of COPD; it should only be used in conjunction with the patient demonstrating symptoms such as breathlessness or cough. A comprehensive history taking is very important as this can often identify COPD unaided. Janet was symptomatic and therefore was diagnosed with moderate COPD. Her spirometry showed she had a forced expiratory volume in the first s econd (FEV1) of 55% of her predicted value and a FEV1/forced vital capacity (FVC) ratio of less than 0.7. Predicted values for patients are predicted according to their height, gender, age and ethnic origin. The severity of airflow obstruction is graded according to the FEV1 reading. The updated NICE 2010 guidelines for COPD have reviewed the severity scales which mean that Janets spirometry readings fall into the moderate category. Janets degree of breathlessness was discussed and she graded herself as a level 3 on the Medical Research Council (MRC) dyspnoea score (Fletcher 1960). Emphysema often results in the patient having an increased residual lung volume which in due to air trapping; an inability to expel all the air from the lungs. Aetiology and pathophysiology Human lungs are the functional structure of the respiratory system. To understand Janets condition it is useful to look at how the normal respiratory system works. Its function is to supply the body with oxygen and to remove carbon dioxide (Marieb, 2004). Breathing is the movement of gases between the atmosphere and the lungs. For this to occur, there needs to be a system of open airways and pressure changes resulting from the action of the respiratory muscles in changing the volume of the chest cage. The diaphragm is the principal muscle of inspiration, assisted by the external intercostal muscles. The sternocleidomastoid and scalene muscles elevate the ribs and act as accessory muscles for inspiration. Expiration is aided by the elastic recoil of the respiratory muscles that were stretched during inspiration. Pulmonary gas exchange is conventionally divided into three processes: (1) ventilation or the flow of gases into and out of the alveoli of the lungs, (2) perfusion or flow of blood in the adjacent pulmonary capillaries, and (3) diffusion or transfer of gases between the alveoli and the pulmonary capillaries (Porth 2010). In addition to their gaseous exchange function, the lungs deactivate vasoactive substances such as bradykinin, convert Angiotensin 1 to Angiotensin 2 and serve as a reservoir for blood storage. COPD is characterised by an intense inflammatory process in the airways, parenchyma and pulmonary vasculature (Sinden and Stockley 2010). The lung inflammatory response is characterised by increased number of neutrophils, macrophages and T lymphocytes. The accumulation of inflammatory components contributes to the lung injury in these patients. The mobilization of inflammatory cells to the lungs leads to the release of potentially destructive mediators including proteases and cytokines, which directly contribute to the remodelling and destruction of tissues. Truder, McGrath and Neptune (2003) believe that a delicate balance between protease and antiprotease activity is required for proper lung maintenance. Sharafkaneh, Hanania and Kim (2008) suggest that derangements of this balance results in destruction and inappropriate repair of lungs. They also suggest that macrophages are activated by tobacco smoke and recruit neutrophils and lymphocytes leading to elastolysis and emphysema. Si milarly tobacco smoke activates airway epithelium to trigger airway remodelling. Both of these processes result in airflow obstruction. http://www.scielo.br/img/revistas/mioc/v100s1/a27fig02.jpg In addition to inflammation, oxidative stress caused by tobacco smoke inhalation plays a significant role in generating emphysema. Therefore Janets long history of smoking will have ultimately resulted in loss of elasticity to her lungs, retention of air in the lungs due to hyperinflation, expansion of the rib cage and flattening of the diaphragm. When the diaphragm is flattened, the muscles of the rib cage and abdomen take over the bulk of the work which is a less efficient and more tiring way of breathing. The alveoli are the terminal air spaces of the respiratory tract and the sites of gaseous exchange between the air and the blood. Each alveolus is a cup-shaped sac with thin walls and each structure is separated by alveolar septa. A single network of capillaries occupies most of the septa, so blood is exposed to air on both sides. There are approximately three hundred million alveoli in the human lungs. Emphysema jpg available at www.moondragon.orgEmphysema is characterized by a loss of lung elasticity and enlargement of the distal air spaces to the terminal bronchioles, with destruction of the alveolar walls and capillary beds. Several adjacent alveoli may rupture forming one large air sac that has a reduced ability to exchange oxygen and carbon dioxide. There is progressive destruction of the alveoli and the surrounding lung tissues as air is trapped in the damaged alveoli. This causes them to stretch which leads to hyperinflation and a reduced inability to exhale.http://www.moondragon.org/images/emphysema.jpg Smoking tobacco is a well established cause of COPD (Shahab et al 2006). The Department of Health (2010) indicate that tobacco is the leading cause of preventable death and of health inequalities. They also state that in 2008, more than 80,000 premature deaths in England were caused by smoking. Callum (2008) suggests that the current level of tobacco use is estimated to cost the NHS around  £2.7 billion every year. Cigarette smoke contains a range of toxic products and these have to be dealt with by the body. When cigarette smoke is inhaled into the lungs the cilia that normally sweep irritants out of the airways become paralyzed. The irritants therefore remain in the lungs infiltrating the alveoli where the damage process begins. Other causes of emphysema can be an inherited condition called alpha1 antitrypsin deficiency, an antiprotease enzyme that protects the lungs from injury. This accounts for approximately one percent of all cases of COPD. Occupation risks such as coal minin g can also be a cause of COPD as the irritants inhaled act as the instigators of the disease process. Interventions and treatments Smoking cessation advice would be the most important intervention for Janet. Smoking cessation has been shown to be the most significant intervention to slow the rate of decline of lung function (Fletcher and Peto 1977). http://www.biomedcentral.com/content/figures/1471-2458-7-332-2-l.jpg The use of the Fletcher and Peto graph that demonstrates decline in lung function and the benefit of stopping smoking could be utilised in the process of addressing Janets smoking habit. The use of a smoking addiction calculator such as the Fagerstrom (1978) test was used to determine the extent Janet was addicted to nicotine. Parkes, Greenhalgh, Griffin and Dent (2008) found that informing a patient of their lung age appears to encourage higher levels of successful smoking cessation and Janet was surprised by her lung age of seventy seven. The damage to Janets lungs could not be repaired however the rate of disease progression could be reduced by her stopping smoking. Janet was referred to a specia list stopping smoking service in order to achieve a higher success rate. Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity (NICE 2010). Gruffydd-Jones (2006) recommends that all patients with any chronic lung condition should have an annual influenza vaccination and a one-off pneumococcal vaccination unless contraindicated. This is beneficial in reducing the risk of severe lung infections precipitating potentially fatal exacerbations of COPD. Bronchodilators such as Salbutamol are frequently used as first line treatment for COPD. Treatment objectives include relieving symptoms such as dyspnoea and cough, slowing the accelerated decline in lung function, decreasing exacerbations, and improving quality of life. The NICE (2010) guideline for COPD recommends beginning treatment with bronchodilators. NICE are the guidelines used predominantly in primary care and will be used as guidance for treatment options in this assignment. In theory, bronchodilators, which act directly on the airways, should have limited benefit in emphysema. However, Diaz, Bruns, Ezzie, Marchetti and Thomashow (2008) claim that in clinical practice many patients with emphysema, benefit from bronchodilator therapy. Pellegrino, Antonelli and Mondino (2010) agree that it is clinically justified to use short acting bronchodilators (SABA) in patients with emphysema. The pharmacology of beta-2 receptorsSalbutamol is a beta-2 agonist. These bind to the beta-2 receptors on the smooth muscle of the trachea to the level of the terminal bronchioles. Binding of the beta-2 agonists to the beta-2 receptors activates a receptor associated G protein that in turn activates adenyl cyclase. This then converts adenosine triphosphate (ATP) to cyclic 35-adenosine monophosphate (c-AMP), which then activates protein kinase A. The activated protein A prevents phosphorylation of the myosin light chain as well as activation of the Na+/Ca2+ exchange pump. This results in a fall in intracellular calcium and leads to smooth muscle relaxation, as less calcium is available for the calcium-dependent myosin-actin interaction required for smooth muscle contraction (Barnes 1995). Black, Oliver and Roth (2009) suggest that short acting beta-2 agonists can mediate further physiological responses to include the stimulation of beta-2 receptors on mast cells, leading to the suppre ssion of inflammatory mediator release and the inhibition of extracellular matrix (ECM) protein release from airway fibroblasts.http://www.uky.edu/~mtp/adrenergic_pics/Beta2Effect.jpg Janet was commenced on Salbutamol one hundred micrograms, two puffs as required and was reviewed after a four week period where it was identified that Janet remained breathless particularly on exertion and therefore her symptoms had not been improved upon. Following the NICE (2010) guidelines for COPD it was agreed with Janet to add in a long acting bronchodilator (LABA). She was commenced on Salmeterol twenty five micrograms two puffs twice a day. Diaz, Bruns, Ezzie, Marchetti and Thomashow (2008) claim that long acting bronchodilators such as Salmeterol have an affinity for the beta-2 receptor that is approximately one hundred times higher than that of short acting bronchodilators such as Salbutamol. The duration of action of Salmeterol is around twelve hours and hence only needs to be taken twice daily often helping with concordance. The benefits of LABAs are to improve respiratory symptoms, airflow, quality of life, rate of exacerbations and exercise tolerance. Patients with emph ysema typically have a greater degree of hyperinflation than others with COPD and bronchodilators have been shown to improve hyperinflation at rest and during exercise. As Janet rated herself as level three on the MRC dyspnoea scale, NICE (2010) recommend that the patient be referred for pulmonary rehabilitation. Pulmonary rehabilitation is defined as a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patients physical and social performance and autonomy (NICE 2010). The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. The aims of pulmonary rehabilitation are to increase a persons exercise tolerance and give support and advice which may include smoking cessation. It incorporates people with COPD who have undergone additional training to act as buddies to fellow sufferers. Many patients look upon pulmonary rehabilitation as a social occasion and this aspect helps to improve their quality of life. Discussion. This essay has examined the case of Janet who presented at primary care with dyspnoea on exertion. Janet has a history of smoking and following a chest x-ray and lung function tests, she was diagnosed with having COPD. Due to the nature of her symptoms and hyperinflation demonstrated on x-ray, it was concluded that Janet had emphysema which falls under the umbrella term of COPD along with chronic bronchitis and asthma. The rest of Janets history was unremarkable and her observations and blood tests were found to be normal. COPD is characterised by airflow obstruction and is usually progressive, not fully reversible, and does not change markedly over several months. Patients with COPD often present in primary care with symptoms such as shortness of breath on exertion, cough or excessive sputum production. Usually the patient will already have damage to their lungs when they present with symptoms. The symptoms of COPD are extremely subjective and do not correspond to the FEV1 reading. For instance, two people could be seen with exactly the same reading of FEV1, but one patient would have very few symptoms and perhaps only need occasional use of a short acting bronchodilator whereas the other patient could be using two or more inhalers. Airway obstruction is diagnosed using spirometry and an FEV1 of