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H.H Holmes: Serial Killer

Eloisa Luzuriaga Herman Webster Mudgett better known as H. H Holmes was one of the first serial killers in America. He was born on May 16, 1861 in Gilmanton, New Hampshire, to a wealthy family (H.H. Holmes). As a young boy Holmes was constantly bullied. His bullies found out about his fear of the local doctor’s office so they took him there and forced him to touch a human skeleton. Instead of getting scared he was fascinated by the experience. Since that day his interest in human anatomy was born. Holmes became obsessed with death, he started dissecting dogs, cats, or any homeless animal he could find. His experiments with animals were just a rehearsal for what was yet to come. On July 8, 1878, New Hampshire, Holmes married Clara A. Lovering of Alton. She was the daughter of a rich local farmer. They had a son named Robert Lovering Mudgett, he was born on February 3, 1880, in Loudon, New Hampshire. His marriage with Clara had failed apart. One year later he left New Hampshire to attend the University of Michigan Medical School. It was there that he gave himself his own nickname “Dr. Henry Howard Holmes.” He stole corpses from medical laboratories. He disfigured the corpses and planted them where they would be found as accidents. He collected the insurance money from policies of the corpses and then he would claim they were the relatives of H.H. Holmes. He graduated from Medical School in 1884 (Herman Webster Mudgett). After graduating he moved to Chicago. There he was involved in some businesses like real state and promotional deals. He married Myrta Z. Belknap on January 28, 1887, in Minneapolis, Minnesota. Although he was still married to Clara Lovering this made him a bigamist. He had a daughter with Myrta named Lucy Theodore Holmes, born 4 July 1889 in Englewood, Illinois. Myrta’s father was a wealthy businessman, a man Holmes had unsuccessfully tried to kill. The family of three lived in the Chicago suburb of Wilmette. Holmes started working at a pharmacy. The owner was Dr. E.S. Holton who suffered from cancer and his wife was in charge of the pharmacy. She was an old woman that needed an assistant. Holmes got the job and manipulated her into selling him the pharmacy. They made an agreement that she could still live in the upstairs apartment even after Holton died. When Holton died, Holmes murdered Mrs. Holton. She became Holmes first known killing. He told people that Mrs. Holton moved to California (H.H. Holmes – Serial Killer – Part 2 of 4). Holmes bought a lot across from the pharmacy, where he built his three story building that was later nicknamed “Murder Castle.” This hotel was designed by Holmes and was opened in 1893 for the World’s Columbian Exposition. His sole purpose for the hotel was to lure, trap, dismember, and murder guests. During the construction of the hotel he often fired builders as they became suspicious about the design of the hotel. From the outside the building looked like a Medieval fortress, complete with turret. The first floor had Holmes relocated drugstore and various shops like a jeweler. The other two upper floors contained his office as well as a maze of trap doors, secret compartments, and hidden stairways. The most disturbing room was the basement which was equipped with medical tools, poisons, torture devices, and acid filled pits. From his bedroom Holmes controlled gas pipes that led up to the basement to specific rooms so he could put his victims unconscious. For a period of three years, Holmes picked female victims from among his hotel guests, employees, and lovers to torture and kill them. Some were locked in soundproof bedrooms shaped with gas lines that allowed him to asphyxiate them at any time. Others were locked in a vast bank vault near his office so he could sit and enjoy the show as they screamed, panicked, and suffocated due to the soundproof vault. The bodies of the victims went by a secret chute to the basement, where some were dissected, stripped of flesh, crafted into skeleton models, and then sold to medical schools. He also placed the bodies in lime pits and cremated them for destruction. Holmes performed hundreds of illegal abortions and some of his patients died during the procedure. He was able to easily sell skeletons and organs because of the connections he made through medical school (A Double Dose of Macabre). Following the World’s fair, with the fall of the economy and with creditors closing in, Holmes left Chicago. He moved to Fort Worth, Texas where he inherited property from two sisters, he had promised one of them marriage but he murdered both of them. He planned to construct another castle but he abandoned the idea because he found the law enforcement climate in Texas inhospitable. In July 1894, Holmes was arrested for the first time, for a horse swindle that ended in St. Louis. While in jail he met a convicted train robber named Marion Hedgepeth. Later he was bailed out of jail. Holmes had a plan to bilk an insurance company out of $20,000 by taking out a policy on himself and then faking his death. He promised Marion a $500 commission in exchange of a lawyer he could trust. He was led to Colonel Jeptha Howe who found Holmes plan brilliant. But his plan failed when the insurance company became suspicious and refused to pay. He made another plan with his sales associate Pitezel. Pitezel agreed to fake his own death so that his wife could collect the $10,000 policy, which she had to split with Holmes and Howe. The plan would take place in Philadelphia and Pitezel would set himself up as an inventor, named B.F. Perry, and then be killed and disfigured in a lab explosion. Holmes had to find a cadaver to play the role of Pitezel. But Holmes killed Pitezel and collected the policy of his corpse. He then manipulated Pitezel’s wife into allowing three of her five children to stay in his custody. Only the oldest daughter and baby remained with Mrs. Pitezel. He traveled through the northern U.S. and into Canada with the rest of the children whose names were Alice, Nellie, and Howard. He lied to Mrs. Pitezel about her husband’s death and her children whereabouts. A detective from Philadelphia had tracked Holmes and found the decomposed bodies of the two Pitezel girls in Toronto. He then followed Holmes to Indianapolis where Holmes had rented a cottage. He was reported to have visited a drugstore where he purchased the drugs that he used to kill Howard, and a repair shop to sharpen the knives he used to chop the body before he burned it. Howard’s teeth and bits of bone were discovered in the cottage’s chimney (Herman Webster Mudgett). In 1894 the police were tipped off by Marion because Holmes refused to pay him the $500 that he promised him. Holmes was finally arrested in Boston on November 17, 1894. The police investigated the castle and uncovered Holmes methods of committing murders and the disposing of his corpses. In August 19, 1895, a fire of mysterious origin consumed the castle. The site now serves as a U.S. Post office building. While Holmes was in prison in Philadelphia the Chicago police began to unravel what really happened to Pitezel and his three missing children. Holmes was put on trial for the murder of Pitezel and he confessed to 27 murders in Chicago. He was paid $7,500 by the Hearst Papers in exchange for his confession. One of Holmes most famous quotes published in the North American Philadelphia on April 11, 1896, was “I was born with the devil in me. I could not help the fact that I was a murderer, no more than the poet can help the inspiration to sing — I was born with the “Evil One” standing as my sponsor beside the bed where I was ushered into the world, and he has been with me since” (Mysterious Chicago Tours). On May 7, 1896 Holmes was hanged at Moyamensing Prison. Before his death Holmes remained calm and affable. He showed few signs of fear, depression, or anxiety. His neck didn’t snap immediately, he died slowly, strangling for fifteen minutes before being pronounced dead twenty minutes after the trap was sprung. He requested that he be buried in concrete and that no one would be allowed to dissect his body. His request was granted. On March 7, 1914, a story in the Chicago Tribune reported the death of the caretaker of the castle, his name was Pat Quinlan. He committed suicide by taking strychnine and the newspaper reported that his death meant the mysteries of the castle would remain unexplained. Quinlan’s relatives claimed that he had been “haunted” for several months before his death and that he couldn’t sleep (The San Francisco Call). Works Cited “H.H. Holmes.” Biography.com. A

ITS 532 Abcott Institute Pros and Cons of the Virtualization Types Discussion Paper

ITS 532 Abcott Institute Pros and Cons of the Virtualization Types Discussion Paper.

The discussion questions this week are from Chapters 8 – 9 (Jamsa, 2013). 50-words max per topic to discuss and present your answer.Describe the various types of virtualization. (50-words)List the pros and cons of virtualization. (50-words)Define and describe the hypervisor. (50-words)Define and describe green computing. (50-words)Define and discuss hyperjacking attacks. (50-words)Define and discuss guest-hopping attacks (50-words)This assignment should be in APA format and have to include at least two references (Use two or more APA in-text citations). By submitting this discussion, you agree to a Plagiarism check with all the existing internal student papers and outside external references.
ITS 532 Abcott Institute Pros and Cons of the Virtualization Types Discussion Paper

How Historians Study History by Use of Religion Essay

professional essay writers Every discipline has its own subject matter. In the case of the history discipline, the main subject matter is the past (Hepp 5). In the discipline, past facts and interpretations give meaning to the things that shape people’s current way of life. Facts refer to “persons, places, things, and events that people agree are true or have happened” (Hepp 3) while interpretations refer to “the processes of selecting facts and making sense of them” (Hepp 3). Some of the things of the past, which determine the way people act, and what they believe in include people’s culture and religions. By inferring that people’s actions and beliefs are shaped by culture, it means that the people’s “customs, institutions and achievements” (Hepp 24) influence their beliefs and actions. On the hand, religion encompasses “a belief in and the worship of a superhuman controlling power” (Hepp 24). Since the thesis of this paper is how historians study history by deploying religion, the paper will answer this by focusing on how beliefs and worshiping super deities impact people’s actions and way of life. One of the fundamental aspects that define differing societies is their inability to fully embrace each other. This means that they indulge in conflicts with one another. A historian seeking to understand why some communities or societies have animosities with one another would endeavor to garner facts of the likely historical circumstances that may lead to conflicts among the two societies under concern. Subscripting to different religions is one of such incredible departures that may prompt people to engage in conflicts. For instance, the battle between Palestinians and Israelites may be attributed to their religious historical differences (Hepp 24). Similar religion-ignited conflicts were also observed among Catholics and the Protestants (Fernandez-Armesto 502). However, it is crucial to note that not all conflicts that are experienced in the world surface themselves as having been ignited by religious differences. Rather, such battles surface as conflicts over a certain tangible material such as land even though the perspectives of religion may be enshrined in the conflict. Get your 100% original paper on any topic done in as little as 3 hours Learn More History is concerned about the narrative past of the way of life of people and how it not only impacts their past but also their present way of life. Therefore, it is substantive to argue that historians investigate the cultural artifacts of people. Such artifacts are inseparable from religion (Fernandez-Armesto 225). This makes people to have different beliefs even though they may believe in the same God. To exemplify this argument, Hepp argues, “the god of Christianity is not only the god of Judaism but also the god of Islam” (32). This means that cultural artifacts of people such as the heroes of the religion or the prophets who interpreted the religion create the boundaries in what the people subscribing to particular religion believe in. Therefore, historians seeking to understand and explain the differences between ways of life of people that are differentiated along their religious affiliations will not seek to base facts on the super deity that the members of a given religion worship but on the religious heroines who attached meaning of what a person subscribing to particular religion demands to do. For instance, Islam “revealed its final form by Prophet Mohammad” (BBC Para.7) while Christianity is “based on the teachings of Jesus Christ” (BBC Para. 5). Indeed, rationalization of people’s actions is based on religious faith inclinations. Even though this may not be the case in the modern world in which people embrace change, in the traditional world, this argument may be sufficiently true. Hepp reinforces this argument when he argues, “in a traditional society, where change is often seen as bad, people turn first to religion to make sense of their world” (33). Consequently, religion has played central roles in making people’s cultural history. The development of the world civilization is owed to the existence of differing religions. For instance, it is immensely difficult to study the development of both social and economic pillars of regions such Asia specifically in countries such as India without referring to Buddhism and Hinduism (Fernandez-Armesto 332). We will write a custom Essay on How Historians Study History by Use of Religion specifically for you! Get your first paper with 15% OFF Learn More In this perspective, Hepp particularly believes that both religions “share a common heritage and both have key roles in the historical development of eastern civilizations centered on India and spreading throughout Asia” (37). Similarly, western religions also have common paradigms that are shared amid the religious divide. They all share the belief in a common deity of Judaism. Religions stand as ample foundations on which historians can base historical facts of people in a bid to trace changes in the ways of interaction as time progresses from the time of inception of the religions to their current state. Unlike the modern age where people have become integrated and united, the history of how different religions started is a subtle indicator that people were traditionally segregated either on racial or tribal lines. For instance, Hinduism was a tribal religion when it started in about 4000 years ago (Hepp 38). Essentially, the Aryan tribe, which was nomadic, subscribed to the region. It is based on three pillars. These are the belief in multiples gods, “a castle system of fixed social classes, and the belief in almost endless cycle of reincarnation” (Hepp 38). Even though it entailed a small region established on tribal basis, it has now grown to attract membership of about 900 million people across the world. Similarly, Judaism also started as a tribal region. This means that the main mechanism of increasing membership was through growth of the tribes subscribing to the religion. While it was only open to people sharing common ethnic backgrounds and cultural traits, as time advanced, it opened up to welcome even people of different cultural and ethnic backgrounds. The two examples make it clear that, apart from the modern technological developments, which have made people more integrated, evolvement of religion constitutes an additional mechanism of integrating people across the globe despite the fact that differences in between religions exist (Fernandez-Armesto 417). Therefore, historians’ attempts to study history through deployment of religion as one of the scholarly facets remain valid and instrumental. Without religion, mechanisms of tying people of different social and ethic divides together would significantly be reduced. Consequently, it could be immensely hard to have places, things, events, and persons that a collective number of people significantly perceive as true. Therefore, studying about the past of the various people would end up being hard since it is almost impossible to study the past of people across the world by studying people individually. Not sure if you can write a paper on How Historians Study History by Use of Religion by yourself? We can help you for only $16.05 $11/page Learn More Conclusively, the focus of the paper was to develop an argument on the manner in which religion capacitates historians to study history. In this end, the paper held that religion enables historians to trace the variations of the interactive process of people besides fostering development for world civilizations. It also forms the foundation of understanding the present ways of life of people based on their past occupations. Additionally, it aids in explaining why some people would engage in conflicts with others. Works Cited BBC. Religions: Featured Religions and Beliefs, 2012. Web. www.bbc.co.uk/religion/religions Fernandez-Armesto, Felipe. The World – A Brief History, Combined Volume. New Jersey, NJ: Pearson, 2009. Print. Hepp, John. Lecture Notes: Historical Foundations of the Modern world. The US: Wilkes University. Print.

Ankylosing Spondylitis (AS) Causes and Treatment

Ankylosing Spondylitis (AS) Causes and Treatment. This case shows a 45 year old male patient with severe ankylosing spondylitis. Ankylosing spondylitis is a form of arthritis that occurs at the lower back of the body. It is a chronic inflammatory disease that affects the spine and also the sacroiliac joints, which can be located between the sacrum and iliac bones. The sacrum bone is located right above the tailbone whereas the iliac bones are the bones that can be found on the either side of the upper buttocks. The term ankylosing is defined as the fusion of joints and spondylitis is the inflammation of the spinal bones, also known as the vertebrae. This condition causes the tendons that are being attached to the bones and also the joints between the spinal bones to be inflamed. When inflammation occurs, the body will produce new bones to repair the damage, which will eventually fuse together, causing the spine to have permanent damage such as losing spinal mobility and also the development of a “question mark posture” called neck hyperextension. Ankylosing spondylitis does not just affect the spinal bones but it is also a systemic disease which will spread to other parts of body and joints such as neck, eyes, heart and lungs and sometimes the kidney. Around 70% of patients complained of having neck pain while 10-40% of patients suffered from AS will develop cardiovascular disease during the course of the disease. During the later stage of the disease progression, up to 40% of patients with AS will develop uveitis, which is the inflammation of the eye that can lead to scarring and blurring of vision and even blindness if not treated carefully. The prevalence of AS is around 0.25%-1% in the general population. So it is roughly estimated that around one in 200 men and one in 500 women in UK develop AS. The mortality rate is significantly high; with patients having 1.5 to 4 times likelihood to die from this disease especially since AS may increase the risk of developing cardiovascular diseases. AS usually affects young people and patients will present symptoms of the disease around the age of 30. Men are twice as more likely to develop AS than women and their symptoms are also more pronounced compared to women whereby some men will have structural changes such as a “bamboo spine” whereas women might not have such obvious symptoms. Symptoms of AS can be as mild as none which occurred in 10% of the patients during the early stages and can also be as severe as losing spinal mobility due to irreversible structural damage. The common symptoms for AS patients are lower back pain that radiates to the hips with alternating buttock pain which is made worse by rest. Patients are often awake at night due to unbearable back pain and they also experience spinal morning stiffness for more than 30 minutes that can be relieved through exercise. The other common symptoms would be fatigue, and certain patients developed enthesitis, whereby there’s an inflammation at the insertion site of tendon or ligaments into the bone especially on the heels such as Archilles tendonitis and also inflammation of the finger known as “sausage digit”. Other extra articular symptoms includes aortitis, ulcerative colitis and also acute anterior uveitis (AAU), as the prevalence rate of AS with AAU for antigen HLA-B27 positive is 0.4% in the population and 0.02% in HLA-B27 negative population. For a patient who suffers from a chronic condition such as ankylosing spondylitis, their life expectancy would be 1.5 times lower than normal people and their quality of life would be greatly affected by it as the onset of the disease occurs at an earlier stage of life. This affects mostly the working class individuals. About one third of individuals with AS would quit their job prematurely due to fatigue, impaired physical functioning, and low self esteem. The reduction in labour force can seriously damage the economy. AS also affects patients in a social context due to increased concern about their medical condition and lesser time spent for leisure. Besides, they had to attend for routine medical checkups which will reduce the time spent with their friends and family. Besides, drugs to relieve inflammation such as NSAIDs create more pain for the patient because of it undesirable gastro-intestinal side effects. AS also affects patients’ quality of life because it causes pain and disables them to a different extend, with certain patients having to undergo surgeries to replace joints and hips or even spinal surgery for patients with severely deformed spine. Patients with suspected AS are commonly diagnosed based on physical examination, clinical features and radiology evidence. The Modified New York criteria 1984 for ankylosing spondylitis is the most widely used diagnostic tool for AS4. They must fit the clinical criteria of having more than 3 months of lower back pain and morning stiffness which can be relieved through exercising, a reduction of spinal mobility and also a restricted chest expansion. MRI scan is also useful to detect any structural changes to the spine and to detect if any inflammation is present. Aetiology (Cause) of disease The cause of the disease is still unknown. However, there was a strong association between AS and the human leukocyte antigen B27 (HLA-B27), which is said could trigger inflammatory response towards infectious agents. The relationship between HLA-B27 and AS is more common among the Caucasian population. A study done by the University of Leeds showed that 90.2% of their AS patients with HLA-B27 positive gene had a significantly longer duration of disease compared to AS patients with HLA-B27 negative gene even though their age is similar8. Over 90% of Caucasian AS patient are positive for HLA-B27 antigen but only 6-8% of the general population that are HLA-B27 positive will develop AS. Therefore, the HLA-B27 antigen is only responsible for 20-50% of patients that developed AS and most people with HLA-B27 positive antigen still remains healthy and free from AS3,13. A recent study shows that AS is not only caused by one gene, but it’s a polygenic disease. The other genetic markers that are also linked to AS includes interleukin-1 (IL-1) gene cluster, aminopeptidase regulator of TNFR1 shedding (ARTS1), and the interleukin-23 receptor gene (IL-23R). Despite having theories regarding environmental and genetic predisposition that leads to AS, there are still no concrete evidence to what causes this disease and what is the mode of action for it. Treatment options The main aim for treatment and management of AS is to relieve the disease symptoms, which is morning stiffness and also to reduce lower back pain, improving patient’s quality of life and slow down disease progression15,16. So far, there are no specific literature guidelines for treatment of AS. However, the International Assessment in AS (ASAS) society and the European League against Rheumatism (EULAR) came out with evidence based recommendations for treatment of AS that involves 3 main types of drug treatments4. The first line drug treatment for AS would be the use of NSAIDs to minimise inflammation and to relieve pain and stiffness. If the patient couldn’t tolerate NSAIDs or pain is not managed, adjuvant therapy with low dose corticosteroids, analgesics and muscle relaxants are given15. The second line treatment comprised of disease modifying antirheumatic drugs (DMARDs) treats only peripheral arthritis and not for the treatment of axial manisfestations17. Lastly, the use of anti tumour necrosis factor (TNF-α) such as infliximab and etanercept had been approved by the food and drug administration (FDA) and European countries to treat severe active ankylosing spondylitis only if certain criteria had been fulfilled15. Other non pharmacology treatment options include frequent exercising to reduce morning stiffness, physiotherapy and patient education about the disease14,15. Side Effects, Costs, Advantages and Disadvantages compared with other drugs NSAID has been the most commonly prescribed treatment option for ankylosing spondylitis because of its ability to relieve pain and stiffness and one can even slow radiographic progression of the disease and inhibits new bone formation16. Studies showed that up to 68% of patients in UK received NSAIDs as part of their treatment for AS17. It had been the primary treatment option for over 5 decades because it is a useful treatment for rheumatoid arthritis (RA) and there was no extensive research done for the treatment of AS18. However it should be noted that while some of the treatments such as DMARDs may work on RA, it may have limited effect on reducing radiographic progression in AS19. NSAID inhibits cyclo-oxygenase (COX) enzyme, hence reducing the production of prostaglandins released during inflammation11. There are 2 types of COX enzyme namely COX-1 and COX-2. COX-1 inhibitor will cause side effects such as gastro-intestinal discomfort and even bleeding because COX-1 is being induced to release mediators with gastro protective function whereas COX-2 is only being induced to secrete prostaglandins during inflammation12. Therefore, extensive research had been carried out for selective COX-2 inhibitors (coxibs). Other unwanted side effects of NSAIDs are renal impairment, headaches and confusion, and haematological side effects such as agranulocytosis12. There are a lot of NSAIDs choices out there with different duration of action and clinical efficacy but the most common drug that AS patients had been prescribed is phenylbutazone15. In European Union, phenylbutazone is only been allowed a maximum of 600mg daily for short term treatment only for arthritis and this dosage had been approved for treatment of AS17. However, 32 randomised controlled trials which tested the efficacy of NSAIDs showed that none of the NSAIDs are better than another of the same drug class20. Out of 5 randomised controlled trials, only 2 concluded that phenylbutazone showed a better result than the comparator drug20. The main drawback of phenylbutazone is that it causes aplastic anaemia and hepatic injury which is life threatening and therefore it is not wise to use it for long term treatment22. Patients with high risk of cardiovascular diseases are contra-indicated for treatment using NSAIDs and those with previous episodes of gastro-intestinal bleeding are advised to continue treatment alongside with proton pump inhibitor such as lansoprazole, histamine H2-receptor antagonist such as ranitidine or prostaglandin analogues such as misoprostol as protective agents11,12. Since phenylbutazone is the first generation NSAID and it’s not been used as widely nowadays as indomethacin, the estimated cost of phenylbutazone per week if patients take 300mg daily would be around £20 which is reasonably cheap as it is requires a long duration of treatment. Clinical Outcome (% of success rate) NSAIDs had anti-inflammatory properties to control pain and stiffness but not much evidence to support that it can slow down the disease progression. A trial concluded that up to 80% of patients acknowledged that NSAIDs are excellent against in controlling their symptoms but only about 15% of AS patients with non-inflammatory caused lower back pain gave similar responses17. However, a study was done and showed that treatment with celecoxib continuously for 2 years could slow down the disease progression compared with another group which only receives treatment during flare-ups17,21. Celecoxib is being indicated for AS and the dosage in BNF is 200mg daily in divided doses and increased to maximum 400mg daily if necessary. They’ve also advice to discontinue treatment if no improvement was shown after 2 weeks on maximum dosage11. Coxibs might be safer to the gastrointestinal tract but it causes patients to have a higher cardiovascular risk. A cancer study showed that celecoxib had dose dependant increase in cardiovascular risk compared to placebo22. Another study shown that 9% of AS patients on continuous celecoxib treatment with maximum 400mg daily will develop hypertension which can lead to 2.8 fold risk for cardiovascular events16,17. The cost of celecoxib weekly would be around £5 if patient is on 200mg daily dose11. NSAIDs are fast acting drugs which effects can be seen within 2 days of drug intake. However, this leads to rapid relapse of AS once the treatment had been discontinued. Therefore, it is debatable whether NSAIDs should be given continuously as it is a chronic condition but at the same time contemplating the fact that this drug could cause damage to the gastrointestinal tract and cardiac toxicity6. Clinical Evidence of efficacy (Journals) There was no concrete evidence to support that analgesics such as paracetamol could be beneficial in AS. In a questionnaire involving 15 people, 87% said that analgesics are not as effective as NSAID but no further analysis of the questionnaires had been carried out23. The second line for treatment of AS would be DMARDs such as sulfasalazine (SSZ) and methotrexate. So far no DMARDs had been approved as treatment for AS unless patients couldn’t tolerate NSAIDs19. Both the drugs showed no effect in treating axial manifestations of AS and only effective during early disease and peripheral arthritis19,23. A randomised trial involving 85 patients with active AS showed that SSZ is more pronounced for its effectiveness in reducing morning stiffness and inflammatory markers such as erythrocyte sedimentation rate (ESR) for patients with peripheral arthritis compared to those with axial manifestations compared with placebo24. A randomised controlled study involving 242 patients with early AS was given SSZ or placebo and the group with only inflammatory back pain and less spinal structure damage responded better24. There is also a 6 months trial whereby patients had been given a maximum of 3g daily SSZ and results showed that there’s significant reduction in ESR and improvement in patient’s overall assessment but not on pain nor morning stiffness and 16% of patients quit the trial due to adverse effects23. There were 2 meta analyses done involving SSZ, one with limited amount of studies and the second with 11 randomised controlled trials. The first analysis showed that SSZ improved pain, morning stiffness, overall physical assessment and reduce ESR while the second recent analysis showed SSZ only reduces ESR and improves spinal stiffness, which is sign of inflammation significantly but showing no superiority to placebo in other aspects16,24. The common side effects of SSZ are nausea, vomiting, loss of appetite and sperm abnormalities which can lead to infertility and also hypersensitivity reactions that occur rarely. SSZ of a maximum 3g daily would cost a patient roughly £8, which is more expensive than NSAIDs with lesser efficacy11. Trials involving methotrexate failed to show its efficacy for this disease therefore would not be discussed further23. Recently, they’ve made a breakthrough by identifying anti tumour necrosis factor (TNF-α) drugs as a probable treatment option. 2 of the drugs which are infliximab and etanercept had gone through randomised controlled trial and the results were tremendous4. Both drugs had been approved by FDA and recommendations given by ASAS must be followed for the treatment to be started4. So far, there were no trials done to compare infliximab, etanercept and adalimumab. A 3 month randomised controlled trial involving infliximab concluded that it is better than placebo in terms of improving spinal activity and function, peripheral arthritis proves that infliximab is efficacious for short term treatment25. Another 6 weeks randomised controlled trial involving patients with active AS receiving 5mg/kg every 2 weeks showed 53% of them had significant improvement in terms of reduction in ESR, overall health assessment and quality of life23. A 3 year ongoing study to prove the safety and efficacy of infliximab was done to 70 patients with severe or active AS. They received 5mg/kg every 6 weeks for 3 years and 70% managed to complete while 30% dropped out due to adverse reactions. Only 40% managed to achieve 50% improvement in BASDAI value24. BASDAI value is an index to assess axial and peripheral pain, fatigue and spinal stiffness25. Before commencing treatment with anti TNF-α, it is a requirement to screen for Tuberculosis(TB) as continuous infusion could cause systemic infection. Other adverse reactions include hypersensitivity reactions11. Infliximab is given 5mg/kg at week 2 and 6 intially and every 6-8 weeks after that. That’ll cost a 50kg patient £60 per infusion which is very costly11. Etanercept is another anti TNF being approved by FDA and European countries as treatment for AS. A dose with 25mg twice weekly or 50mg subcutaneous injection is the standard regimen of treatment. A randomised controlled trial showed both regimens are as effective as the other. Another randomised controlled trial with placebo involving 277 patients with active AS showed that after 24 weeks, 59% of patients had ASAS 20 improvement, which means that they had 20% improvement in terms of pain, inflammation, spinal function and overall well-being in at least 3 of the criterias without any significant deterioration of the 4th element. 9% of them showed signs of flare-ups and was restarted with the regimen and follow up till week 102 and showed more than 50% achieved BASDAI 50, with improvement of 2 elements or 50% improvement of 3 criterias. A similar trial was done with 257 patients for 192 weeks and showed 81% achieved ASAS 2024. Etanercept carries similar adverse effect as other anti TNF drugs but it’s slightly better in terms of patient susceptibility to TB compared to infliximab and adalimumab20,23. Etanercept 25mg twice weekly would cost £178.75. Adalimumab is also approved as treatment for AS. The standard dose is 40mg subcutaneous injection on alternate weeks and discontinue if no improvement for 12 weeks. In a large randomised controlled trial with placebo, 58% of patient achieved ASAS 20 with significant improvement in ASAS 40 and BASDAI 50 in week 12 and 1423. 2 open label study using 40mg subcutaneous injection in alternate weeks with 15 and 20 AS patient each showed 47% and 53% respectively achieved ASAS 40 and BASDAI 50 with improvement in spinal inflammation24. Cost of 40mg vial is £357.5011. In conclusion, NSAIDs are still the first line recommendation for treatment for AS as they’re able to control inflammation and also slow radiographic progression. Only when patients failed to tolerate NSAIDs and they are still in early stages of the disease are they been advised to commence treatment using DMARDs as they are only effective against peripheral but not axial symptoms of AS. When more than 2 NSAIDs failed as treatment then patients are advised to be started on anti TNF agents. Only when there is a long term efficacy established by anti TNF agents should they be used as first line treatment because anti TNF agents are really costly. Hopefully early detection of disease progress using MRI with appropriate treatment plus frequent exercise could help to slow down the disease progress as the mode of action for this disease is still unknown. Ankylosing Spondylitis (AS) Causes and Treatment

Application of Marketing Theories to Practice

Introduction This report shows the different field of businesses and the methods that our company was using in SimVenture comparing with theories. Marketing and Sales Our company’s main marketing tool was advertising but we were using different like direct marketing, exhibitions and our website. However, digital marketing is limited only to website in the game, although this is getting more popular these days (Pittsburgh Post-Gazzette, 2006). Digital marketing defined by Jobber, 2007: “The application of digital technologies that form channels to market (the Internet, mobile communications, interactive television and wireless) to achieve corporate goal through meeting and exceeding customer need better than the competition.” Digital marketing is almost completely missing from the game, it is only limited to website. Network theory studies relationships of all sorts, whether between people, animals or things. Social network analysis is an overlapping tool for learning about patterns that develop within social networks and how they influence behaviour. Digital marketing channels such as Facebook, Twitter, Foursquare and Instagram are useful in this regard, as they allow marketers to listen to what consumers are saying, and they allow marketers to leverage the power of influential users to spread messages throughout their networks (Harvard Business Review, 2006.). Generational marketing theory holds that consumers born of the same generation — defined as a 20-year period — have common attitudes and behaviours because of shared experiences that influenced their childhoods and shaped their views of the world. The relevance of generational theory to digital marketing is primarily in the ways in which each generation communicates and the online places where marketers can reach them (Zickuhr, 2010.). The customer research in the game is only limited to where the customers heard about but nothing who they are (age, gender, education, etc.). All in all the game had good opportunities in traditional marketing channels like direct marketing and advertisement but digital marketing part is really limited which makes it less realistic. Operations Efficient operations management is a key element to make a company successful. Without supply network a company cannot exist. A supply network perspective means setting an operation in the context of all the other operations with which it interact some of which are its suppliers and its customers. Materials, parts, other information, ideas and network of customer-supplier relationships formed by all these operations (Slack, Chambers, Johnston, 2004.). The supply network view can also help in decision making about the design. The design activity in operations has one overriding objective: to provide products, services and processes which will satisfy the operation’s customers. During the game our company used ‘Just in time’ method for the production because if there was more order then our organisation was able to produce then we contracted some out when it was financially possible. Furthermore, in the meanwhile of last year in the game, all of our production was contracted out because the four employees weren’t enough to build the product and to handle other task that were essential to run the company at the same time. High dependency theory is one of the explanation of the ‘Just in Time’ approach to operations management. With high inventories insulating each stage in the production process, the dependency of the stages on one another was low. Take away the inventory and heir mutual dependency increases. The ‘Just in Time’ practice of empowering ‘shopfloor’ staff makes the organisation dependent on their actions (Slack, Chambers, Johnston, 2004.). However, this theory perfectly suits with SimVenture, thus it is realistically show the opportunities and limitations of ‘Just in Time’ delivery and production because in the first year when financially it was not a possibility to contract out some of the production we bumped into some limitations according to the ‘Just in Time’ manufacture technique. Finance All investments carry with them some degree of risk. In the financial world, individuals, professional money managers, financial institutions, and many others encounter and must deal with risk. Investors can either accept or try to mitigate the risk in investment decision-making (Baker