Postoperative Nausea and Vomiting: Causes and Treatments

Postoperative Nausea and Vomiting: Causes and Treatments Postoperative nausea and vomiting is the nausea and vomiting symptoms which occurred after a surgery, medicines intake or anaesthesia usage. Around 18 to 30 of surgical patients have PONV and the nausea and vomiting symptoms are usually self-limiting in most cases.1 Uncomplicated PONV usually resolve within 24 hours after an operation whereas intractable PONV involve various triggering factors and resist to medical treatment, making it harder to treat. Studies revealed that most patients dislike chronic PONV more than postoperative pain as it is a more distressing illness and it may lead to several serious clinical consequences if left untreated. In the case of repeated vomiting, PONV patients might suffer from dehydration and have a higher chance of developing hiatal hernia, a condition where the upper part of stomach protrudes into the thorax through the opening of diaphragm. Other than that, patients might also experience anorexia, gastrointestinal discomfort, headache, weakness, dizziness and nausea while not vomiting. Chronic vomiting can also cause complications like dental damage and sore throats due to exposure of oesophageal lining and mouth cavity to the low pH gastric acid. Moreover, PONV may induce serious problems like pulmonary aspiration, electrolyte abnormalities, wound dehiscence, increased pain and oesophageal rupture.4,5 Despite causing patients discomfort, patients also have to pay more for the delayed hospital discharge. Each incidence of vomiting has increased postanaesthetic care unit (PACU) stay duration by 20mins. Therefore, to reduce the unanticipated hospital admission and the financial burden broug ht by PONV, there is a need to understand the disease pathophysiology so that precise and mechanism-based treatment strategies can be developed to tackle the emesis problem. The vomiting centre and the chemoreceptor trigger zone (CTZ) are the two main parts of the brain controlling the vomiting action. The vomiting centre is located within the medulla oblongata and the emesis action is initiated via the stimulation of five primary afferent pathways. They are the chemoreceptor trigger zone, vagal mucosal pathway of the gastrointestinal system, neuronal pathways from the vestibular apparatus system, inputs from the periphery glossopharyngeal nerve and reflex afferent pathways from  cerebral cortex C2,3 and midbrain afferents. Next, efferent nerve impulses are sent to various place of the body such as the pharynx, larynx, diaphragm, intercostals muscles and gut to initiate the vomiting reflex. During the ejection phase of the vomiting reflex, the diaphragm and abdominal muscles  simultaneously contract and the elevated intra-abdominal pressure leads to the throw up and expulsion of gastric contents. A variety of receptors are participated in the emesis action. They are the histaminergic(H1), dopaminergic(D2), serotonergic(5-HT3), muscarinic and neurokinin-1 receptors. Consequently, pharmacological agents which target on these receptors can be utilized to treat PONV. However, the British National Formulary (BNF) had advised that antiemetic agents should only be used once the causative factor for nausea and vomiting was identified. This is because the use of antiemetic is sometimes dangerous and inappropriate in clinical cases like diabetic ketoacidosis, digoxin or antiepileptic overdose.6 Hence, the aetiology and possible causative factors of PONV should be investigated to guide the planning of the pharmaceutical management steps and the antiemetic selection for treating PONV. There are patient-specific factors, surgical factors and anaesthetic risk factors which contribute to PONV prevalence. Patients who aged 6 to 16 year old, female, non-smoker, obese or have a history of motion sickness or PONV are proven to be the high-risk patient group. Moreover, patients who have chemotherapy, migraine and gastroparesis problems are also susceptible to PONV. Other causative factors include elevated intracranial pressure, metabolic abnormalities, gastroduodenal ulcers, dehydration and infections of the gastroesophageal lining. As for the surgical factors, PONV is related to the premedication side-effect, prolong fasting, conditions of gastric inflation during mask ventilation, use of long-acting opioids, nitrous oxide, volatile anaesthetics and high dose neostigmine in surgery. In addition, frequent head movement of patient and early intake of food after surgery can also potentiate the nausea problem.1 Some types of operations have higher chance of developing PONV, they are the gynaecological surgery, ear, nose and throat operation, intra-abdominal and squint correction surgery. Furthermore, the surgical duration is also an important contributor which predisposes patients to a higher risk of PONV. Every 30 minutes extension in surgical time can increase risk of PONV by 60% as patient is taking in more anaesthetics into the body. Hence, healthcare team should control and minimize the surgery duration such that risk of getting PONV is reduced. Although it is not relevant to discuss anaesthetic techniques in this case scenario, it is important to note that regional anaesthesia should be preferred over general anaesthesia during surgical process. According to SOGC guideline, there is an 11-fold increase in the PONV risk when using general anaesthesia rather than regional anaesthesia. Apart from that, volatile anaesthesia, long-acting opioid and neostigmine should also avoid in surgery as these agents predispose patient to PONV. If the use of general anaesthesia is unavoidable in a surgery, propofol can be a suitable induction agent because it induces less PONV incidence. A thorough assessment should be carried out to serve as a rationale for the management plan of PONV. The past medical history, frequency and nature of the vomiting episode, blood electrolyte test and physical examination can be evaluated to identify the severity of disease condition and the aetiology of PONV. Subsequently, the appropriate pharmacological agents which target on the responsible pathway of emesis can be given. Many antiemetic preparations are available in the market and patients can choose between formulations of solution, buccal tablets, rectal suppository and subcutaneous (SC), intravenous (IV) or intramuscular (IM) injections when oral route is not feasible.6 As no single agent provides complete control in emesis, most hospital has adopted a multimodal approach and a combination strategy where different antiemetics which target on different receptors are utilized in the treatment of PONV.1 Combination therapy becomes the preferable way to treat PONV and the generally used combination is 5-HT3 receptor antagonists with droperidol or dexamethasone. Granisetron and ondansetron are examples of 5-HT3 or serotonin receptor antagonists. They exert their effects in the chemoreceptor trigger zone and at vagal afferents of the gastrointestinal tract. Previous studies showed that no single agent performed exceptionally well than the others of same class as all 5-HT3 antagonists illustrated similar safety and efficacy profile. Yet, a recent meta-analysis which includes 85 randomized controlled, double-blind studies with 15,269 patients involvement had established that the antiemetic effect of granisetron is significantly superior to ondansetron and dolasetron. Ondansetron was also found to be more cost effective than granisetron. 1-2mg of granisetron or 4-8mg of ondansetron can be delivered in intravascular route at the end of surgery for PONV treatment. Long-acting serotonin antagonist with higher binding affinity to 5-HT3 receptors, palonosetron, is also available in the market with a long half-life of about 40 hours. Patients receivin g these agents might experience headache, constipation and dizziness problems. Droperidol is a butyrophenone which acts competitively on central dopaminergic receptors in the chemoreceptor trigger zone (CTZ). It is applied in 0.625-1.25mg IV route at the end of surgery. A systematic review of 24 randomized studies was carried out by Schaub and team, they concluded that droperidol decreases PONV incidence regardless of the dose given to patients. However, this drug is only used as a third-line antiemetic for intractable PONV when other alternative treatments failed because droperidol can lead to adverse effects associated with QT prolongation and torsades de points, sedation, anxiety, hypotension and extrapyramidal symptoms. Due to its possibility in causing fatal arrhythmia, electrocardiographic monitoring is compulsory each time upon its usage. Nonetheless, a double-blinded randomized clinical study which included 120 patients stated that there was insufficient evidence to prove the QTc prolongation effect induced by droperidol after surgery. Dexamethasone is classified under corticosteroids and often delivered in a 4 to 5mg one-off dose via IV or IM route.19 The exact mechanism of action is unknown but it is related to the peripheral inhibition of prostaglandin synthesis and its ability to reduce 5-HT turnover in the CNS. Although dexamethasone is not licensed for the indication of PONV, this drug is as effective as other conventional antiemetic drugs like droperidol and serotonin antagonists. A single blinded, randomized-controlled interventional study had illustrated that the administration of dexamethasone is useful for the reduction of PONV episodes (30% in contrast to 70% of the placebo group).20 Moreover, Ormel et al. illustrated that the addition of dexamethasone to droperidol and ondansetron showed a profound amplification in the efficacy profile of these triple agents combination. It stands as a good alternative for PONV treatment due to the advantage of cost-effectiveness issue and its characteristic of long ac tion duration. As dexamethasone can increase plasma glucose level, it is not recommended for diabetic patient. Furthermore, unfavorable side-effect like postoperative euphoria, impaired wound healing, irritability and adrenal suppression can happen in patient taking long-term corticosteroids. Metoclopramide is a gastroprokinetic agent which acts on the D2 receptors of the gastrointestinal tract. It can accelerate the gastric emptying rate of gastroparesis and GI obstruction patients.2,6 Despite blocking the D2 receptors, it also has antagonist action on 5-HT3 receptors in the CTZ and vomiting centre when delivered in high doses. 5 to 20mg dose of metoclopramide in subcutaneous, oral or IV route is commonly taken by patient before meal and before bed.6 This medicine is commonly administered as combination therapy because there is conflicting evidence stating that metoclopramide alone is ineffective for PONV and it should not be use unless the causative factor for PONV is gastric stasis. Yet, a recent meta-analysis has proved that 10mg IV metoclopramide does well in preventing nausea and vomiting problems after the general anaesthesia surgery. As with the phenothiazines discussed below, both drugs have limited use in practice due to the adverse reactions like extrapyramidal effects and dystonia disorder particularly in pediatric and young adults population. Phenothiazines is an example of strong dopamine antagonist which also act on medullary CTZ. Promethazine, prochlorperazine and perphenazine belong to this group and take part in the prophylaxis and treatment of PONV.24 Prochlorperazine is often administered as a 12.5mg deep intramuscular injection or in a 3 to 6mg dose buccal preparation 12 hourly after the surgery. These agents show superior efficacy in treating opioid-induced PONV. However, high-dose metoclopramide and phenothiazines are now less likely used in clinical practice because of their significant side effects like acute dystonic reactions, sedation, dizziness and extrapyramidal symptoms.9,25 A systematic analysis consisting of 19 non-randomized and randomized clinical trials had demonstrated that most studies supported the effectiveness of promethazine in reducing PONV occurrence when compared to placebo and that combination therapy is always preferable and more effective than promethazine alone. Cyclizine is an antihistamine drugs which block the H1 sympathetic pathway in the vomiting centre. The antimuscarinic and antihistamine properties of cyclizine render it to become an antiemetic drug in PONV treatment. A randomised double-blinded study which involved the participations of 960 women had shown that patients who received cyclizine monotherapy showed a slightly greater antiemetic effect than granisetron alone (PONV incidence of 24% with cyclizine compare to 23% in granisetron group).26 Cyclizine can be given orally, intramuscularly or intravenously, with common antimuscarinic side-effects like sedation and dry mouth. Severe heart failure patient should avoid taking this medicine because it leads to detrimental haemodynamic effect.6 The acidic pH of cyclizine at 3.2 also causes pain and irritancy to body upon injection.10 As a result, patients usually have 50mg of cyclizine IV injection every 8 hours after proper dilution. A lower dose of 25mg in oral, IM or IV preparation s can also be applied in elderly patient. Scopolamine has anticholinergic property which inhibits the muscarinic as well as the histaminergic receptors in the vestibular apparatus and the nucleus of the tractus solitarus.3,9 Patients who undergo middle ear surgery or use opioids as postoperative anaesthetics are recommended to take scopolamine for their profound efficacy in reducing PONV.3 Scopolamine requires 2 to 4 hours for onset of duration. Hence, a fast-acting antiemetic or a loading bolus dose is needed in urgent case. It is available in transdermal form as a 1.5mg patch which can be placed behind the ear. This slow-release formulation can have sustained effect up to 72 hours. Apfel C et al. had reported that transdermal scopolamine had significantly reduced the risk of PONV when compared to the placebo group although it has the main side-effects of dry mouth, sedation and visual disturbances.28 Furthermore, a comparative study between the combination use of ondansetron plus scopolamine patch and ondansetron alone als o proved that the earlier group significantly decrease the nausea and vomiting incidence after surgery. Other than a mechanism-based approach, less conventional therapeutic agents can also be used to treat intractable PONV cases. An antidepressant with a novel indication, mirtazapine, is able to ease the nausea and vomiting symptoms because it can antagonize 5-HT3 receptors. A small scale randomized trial which compared the therapeutic outcome of mirtazapine and ondansetron had showed that patients using mirtazapine were less anxious and had fewer PONV episodes than the ondansetron group. Next, olanzapine which is recognized as an atypical antipsychotic drug also proved to have potential in treating PONV. It can inhibit several receptors such as the dopamine, acetylcholine, histamine and 5-HT3 receptors. Ibrahim M et al. had conducted a randomized controlled study which involved 82 surgical patients. The result proved the efficacy and safety profile of olanzapine against PONV especially during the late postoperative stage. Other than medications approach, non-pharmacological interventi ons also show potential therapeutic efficacy in PONV management. Acupuncture, acustimulation or acupressure serves as a good alternative or adjuvant therapy for PONV patients as it shows good tolerability and safety profile. The P6 point (Neiguan) which located at 5cm near to the ventral wrist is the target site of these alternative approaches. Transcutaneous electrical stimulation delivered to the P6 point of the pericardium meridian has been proved to be an efficient way in preventing emesis. Patients only complain of light side-effects like needle fainting, allergy, needle site pain, anxiety or lethargy problems when using this method. In order to solve the labour intensive and time-consuming issues of traditional Chinese acupuncture, the acupressure and acustimulation wristband are introduced in the market (Sea-Band and ReliefBand). Sea-Band applies steady, continuous pressure on the P6 point whereas ReliefBand is a watch-like device which conducts low current to P6 point via electrodes in contact with the skin. Based on the well-established efficacy profile and good evidence-base literature support, healthcare professionals can involve more acupuncture interventions in treatment practice as part of the multimodal approach. In this case, the intractable emesis symptoms experienced by the old woman might indicate the failure of prophylaxis treatment or the need to start a primary antiemetic treatment. Before the initiation of a rescue treatment, a bedside examination and a patient interview should be done to find out whether the PONV symptom is associated to issues such as morphine analgesia, surgical pain management, infection, intestinal obstruction, hypotension, hypoxia, blood in the pharynx, anxiety or removal and insertion of nasogastric tube. 5-HT3 antagonist is the recommended drug for patients who previously do not receive a prophylaxis treatment. Patient can start with a low dose regimen such as ondansetron 1 mg, dolasetron 12.5 mg and granisetron 0.1 mg. If drugs for prophylaxis had been given but fail, patients can then try other class of antiemetics to tackle more diverse receptor pathways. For instance, Habib et al. had found that the failure of prophylactic ondansetron or droperidol can be replaced with rescue agents like promethazine (12.5-25 mg IV), prochloperazine (12.5mg IM) or cyclizine (25-50mg IV or IM) to achieve a better outcome. This is because consensus guideline support that the repeat use of 5-HT3 antagonist within the initial 6 hours postoperative period provides no extra recovery response. If patient use dexamethasone as prevention agent, small dose 5-HT3 antagonist (25% of prophylactic dose) can then be given as a rescue approach. A study also concluded that the cost-effectiven ess of ondansetron in low dose treatment group was higher than that in the high dose prophylatic group. Moreover, in the case of the aggressive treatment failure, such as those who had taken 5-HT3 antagonist, droperidol and dexamethasone altogether but failed, repeat dosing of same prophylactic regimen except dexamethasone can only be considered 6 hours after the surgery though the optimal dosage and timing for readministration still remain unknown. Transdermal scopolamine can also be prescribed for outpatients as it is a more convenient preparation than the parenteral drugs. Prolong use of opioids for pain control after surgery should also be minimized as side-effects like nausea and vomiting are correlated to the prescribed dose. Alternative analgesics like NSAIDS can be used to substitute the causative opioids. In persisting case, pharmacist can review the prescription and anaesthetic charts to ensure adequate maintenance of analgesia, antiemetic and oxygen supply. Dose escalation under safety and therapeutic dosage range can also be worked on. However, pharmacist should be cautious on polypharmacy problem as it may aggravate nausea and vomiting in susceptible patient. Non-oral drug preparations can be considered over oral route to avoid burdening of patient with excessive pills at one time. If necessary, the acupuncture treatment can also be applied to attempt a multimodal approach. Pharmacist should also concern about the possible dehydration risk that might be encountered by chronic PONV patients. For this reason, the blood pressure, hydration and perfusion level of patients have to be checked on a regular basis. Patients should be told to report of symptoms like dry or sticky mouth, sunken eyes, reduced urination or dark yellow urine. If constipation or diarrhea happens, intravenous fluid replacement therapy, osmotic or stimulant laxative can be given to solve the issues. For the dietary measures, patients should avoid oily or spicy food which might aggravate the nausea. Small, frequent meal is preferable over big heavy meal as light meal reduce the possibility of gastric discomfort. Patients should be advised to not move around too often to avoid triggering the vomiting centre. Furthermore, in post-discharged nausea and vomiting (PDNV) case, the antiemetic efficacy profiles are different from PONVs as they have dissimilar underlying cause. Droperidol should be avoided as it is ineffective in treating PDNV.2 If the patient still not responsive to all these approaches, specialist intervention should be initiated to treat intractable nausea and vomiting symptoms. Serious causative factors like surgical complication might be suspected and further investigations are required to treat this disease. In a nutshell, the optimization management of PONV disease requires the participation of the multimodal approach. Patients should be treated accordingly after the accurate disease assessment and further modifications of treatment approaches like (dose-adjustment, introduction of new agents or alternative approaches) can be done to control patients nausea and vomiting symptoms. Lifestyle modification and non-pharmacological interventions also play an important part in treating PONV. Proper patient education about symptoms management should be delivered and follow-up session can be arranged to assess patients rehabilitation progress. Apart from that, reassurance and full supportive care from healthcare teams also play an important role in reducing patient distress and anxiety level.

American Airlines

The involvement of bearable costs is the most prominent reason of irregularity of demand and supply. It means, once handling capability has been shaped, despite the stage of capability consumption, it may require the involvement of huge preventable costs genuinely. In result of this situation, industries face an abnormal demand supply at a cost change due to several economic factors. Additional states of the abnormal situations in demand and supply, concern to the volume of any firm’s capability to the universal market.The focus of the market depend upon the mass of an industry’s ability, more the volume of industry’s ability directly proportional towards the capturing the market. On the other side, the existence of potential consumers is associated with the more delicately isolatable demand. A general airline industry considerably fulfills numerous conditions, essential and adequate, reliable with the arrangement of an empty core. A Scheduled airline works in a sense like to the ocean liner industry. It has at least for limited distances has pre-arranged preventable cost whereas, in large investment regarding in a commercial airplane, shows a ruined cost.Nevertheless, once the industry has dedicated to a meticulous convoy and schedule it cannot alter productivity without acquiring considerable adjustment cost. â€Å"Yet, as emphasized in the opening chapter, airline management is about matching the supply of air services, which management can largely control, with the demand for such services, over which management has much less influence. To be successful in this an airline can be a low-cost operator or a high-cost operator. † (Doganis, 2002) As far as the cost condition of an airline is concerned on the supply side, per mile price goes down as the covers miles increased.Any how, the technological limitations entail that by dipping the capacity of plane, distance covers could be augmented. Similarly, price per traveler depends on t he number of seats packed on a plane lifts up to full competence. Effects of Economic Change And Influential Externalities Recent economic collapse has affected every area and industry of the global economy. Consequently of the externality to airline industry could not be measures easily as yet, because they are linked with different related elements which are in the process of being retained on their past positions.It could be possible that the requirement would descend within an uncertain global market. The constant change in market buying behavior points out that the flexibility of market demand impact is lot more dependable on economic influences and change in international rules and regulations for relevant industries. In an international scenario the perfect flexibility of demand, eradicates the potential barriers for achieving consumer satisfaction. Eventually, any magnitude could be acknowledged by the market at the specified price and there would be remote chances to plug c apacity by aggressive pricing feedback.When externalities are important, there is a need to either enforce solutions or give the preference to the interests of society. It may be done through delegate democratic system or something else. â€Å"Many sources can agree upon the fact that it should not be classified a natural monopoly. The airline industry will continue to swerve up and down according to market conditions, and the same externalities will be in existence. † (Externalities Affecting, 2007). Hence, Political economy means the observations of consequences and means regarding collective choices and benefits that are unlimited to only individual transactions.As far as the thoroughly explained liberal political tradition is concerned, there is a negation found between socialized production and individual decision-making. Wages Inequality Doganis, in his book The Airline Business in the Twenty-First Century, does not feel any difficulty to find out mechanisms which is he lpful to know the government planning regarding sharing wage in the previous race. Economists firmly believed in the policy analysis while other said that there is no need of such mechanism which could brief the rise in wage dissimilarity.They might or may not be able to determine the ups and downs of economics very effectively, due to some lack of training but he, assured bout the existence of mechanism in about every where. Take an example of a Court Judge who was telling workers of Northwest if they would go to prison in case of refusal to toil for the income / wages that the company intended to pay them. Actually, this is not complete speech of the judge; he never intended to pressurize the workers but convinced them that, it was a policy matter. † It is for this reason that controlling labor costs is so crucial for airline managers.In the early years of the 21st century it is the key to cost control because, unlike fuel and other inputs whose prices are externally determi ned, airlines can and must influence their labor costs. † (Connor, 2001) In other case, if Flight Attendant Services Corporation (FASC) which provides services of to other companies, did not accept lower wages offered from Northwest for its workers, then would any judge be able to intimidate the FASC with prison? â€Å"Statistics indicate that wage inequality created a high occurrence of turnover. When the wage increase occurred, the turn over rate reduces, and work efficiency rose.† (Wage Inequality, 2007) In last quarter century, many such examples of The New York Times published news about a potential strike by flight attendants at Northwest Airlines that was blocked partially by a federal Judge and recommended that the management and the workers should have been on table talk. In that case, the company Northwest was suffered in industrial action by the employees. Fiscal & Monetary Policies in the Airlines Industry After the incident of 9/11, the airline industry suf fered in great economic disaster pertaining to decline in number of passengers as well as considerably higher fare.Only few airlines were in profitable condition even before that day year 2001. It was being said that some deregulations caused problems for industry as well as passengers. â€Å"While there has been some relaxation of reporting requirements, consistent with the regulatory reform trend, much data are still filed and available to the public. These records show traffic and revenue, broken down in various ways such as by passengers and cargo, and aircraft statistics. Of course there are balance sheets and income statements.† (Connor, 2001) The under noted analysis will suffice to the some extent about airline deregulation history and possible policy changes that help to develop competition in coming era. Nature of Airline Competition Amalgamation of firms within competitive environment encouraged the growth in the airline industry. As, in 1979, the U. S. airline sho wed a marvelous performance while following the rule of combination with competition. â€Å"In air travel demand estimations, income and prices of other relevant goods should be included in the estimation equation† (Air Travel, 2009)In 1983, Canada maintained her ticket average prices as compare to the U. S. Consumers were suggested a slice of benefit, but some spectators of that time disagreed with the idea that airline rivalry was beneficial for people. By the attack on World Trade Center, the airline industry has been badly affected in respect of its economic and monetary policies. This incident influenced the industry astonishingly in the form of increasing prices in base tickets excluding taxes called September 11th Security Fee. Public preference in flying had been least.People were afraid of this journey or prices of the tickets also created hindrances in deciding to fly. Many airline companies paid-off their workers. The Travel agencies were also facing declining in t heir sales. In shore, these reasons were directly responsible for some airlines ruined. â€Å"The Airline industry continues to be affected by the overall condition of the nation's economy. When healthy spending exists and pleasure travel is frequent, air carriers are able to fill flights, raise prices, and maintain a stable economic environment.† (The Airline, 2008) Passengers are people who came to know factual positions of the airlines regarding uncertainty while flying or steep high fares. In order to deal with any miss-happening occurs, an airline should keep minutely checking its financial position either it could stand longer or not. An airline should make their policies in such way that there is a chance of any amendment according to the circumstance. Conclusion With this above findings we have come to know that the American Airline Industry has changed in a great deal over the last few years.Possible reason for this often related to uncertain international environmen t based on changing buying behavior, security situation and change in mandatory / fiscal policies. If we have security threats in future, we might see heavy down sizing, inflation in rate and other negative economic influences. References American Pilots (2008) â€Å"American Pilots Fight for Return to 1934 Wages with Adjustments† Retrieved On March 23 2009, from, Air Travel (2009) â€Å"Air Travel Demand Elasticities: Concepts, Issues and Measurement†Retrieved On March 23 2009, from, Connor, William E. O’ (2001). An Introduction to Airline Economics. Praeger: Westport, CT. P. 69. Doganis, Rigas. (2002) Flying off Course: The Economics of International Airlines. Routledge: London. P. 180. Doganis, Rigas. (2001) The Airline Business in the Twenty-First Century. Routledge: London, p. 101. Externalities Affecting (2007) â€Å"Externalities Affecting the Airlines Industry† Retrieved On March 23 2009, from, Raghavan, Vedapuri S. & Raghavan Jayathi (2005) Ap plication of core theory to the U. S. Airline industry, Journal of the Academy of Business and Economics. The Airline (2008) â€Å"The Airline Industry: The Effects of Monetary and Fiscal Policies† Retrieved On March 23 2009, from, Wage Inequality (2007) â€Å"Wage Inequality in the Airlines Industry† Retrieved On March 23 2009, from, American Airlines According to the Chinese Philosopher Xun Zi, Man is really evil in nature and can only be good if he is trained to be one (Co, 1992). This could be a main reason why rehabilitation and harsher punishments were imposed on different prison camps. However, another Chinese Philosopher in the name of Meng Zi tells us the opposite. He tells us that Man is naturally good because he has a sense of pity, right and wrong, truth and falsity, and good end evil.Man is only tempted to commit mistakes because of negligence, wrong environment, and the willful desire to become evil (Co, 1992). This makes us realize that even if they commit mistakes and are proven responsible for that act, no matter how grave it is, they still deserve to be treated as man. Can our current approach to sentencing and corrections be successful and continue? Our current approach to sentencing and corrections can be successful, but not for a very long time as more people clamors for changes in the policies of the correctio nal system.In our present time, we believe that incarceration is the best way to rehabilitate an offender, but we were wrong as other methods can be used like fines, probation, community service, treatments and other sanctions (Stemen, 2007). The report of Mr. Don Stemens (2007) tells us that further intensification of incarceration is not the most effective way to increase safety in the community, since it only has less significant effects, and has greater effects on the taxpayers. From 1985 to 2004, it was recorded to hit a 202 percent increase.In one of the studies, it was even said that higher incarceration rates would mean higher crime rates. Furthermore, crime rate is really influenced by the economy, society, demography, culture, politics and incarceration rates of a county (Stemen, 2007). Still, the Declaration of Principles serves as the foundation of the country’s prison management for 100 years (Mega essays –). This Declaration is the result of the Cincinnat i conference. Things in the crime and punishment system of the United States really changed after liberty in 1970’s.From the introduction of the first American penal colony in Philadelphia in 1870, to the prohibition of cutting body parts and other ways of torturing as a way of punishing the culprits, to the introduction of the Auburn Model, to the beginning of vocational training, education, parole, and the division between the prison cells for young and adult prisoners (Mega essays, n. d. ), the correctional system is doing its best to provide its citizens the security that they need (Raver, 2007).Other innovations would include the medical model of prison management and rebirth of indefinite sentencing. Another discovery is the indeterminate sentence method, where in every five days of good behavior would reduce one day of sentenced imprisonment for the convicted prisoners (Mega essays, n. d. ). As there are only town operated jails before they are the only department that can deal with felons (serious offenders) in the absence of state of federal prisons. Pain through the beating of physical punishments was applied to the prisoners.But instead of using pain, the country’s leaders would now want the convicts to be sanctioned from practicing their liberty (Mega essays, n. d. ). Aside from that, it is true that before, and in some cases, even today, convicted criminals were controlled and punished by intervention, ethical education, and isolation (Mega essays, n. d. ). Isolation would mean that they are not allowed to communicate with others, and will only get a chance to work with others without communicating again when working together in silent labor prison factories, just like what is according to the Auburn Model.The Auburn Model was first implemented in New York State prison. According to the Auburn Model, imprisonment of a convicted culprit must be the period for him or her to let her body and soul dominate that can be achieved through ha bit and regimentation provided by the very authoritative control system. But this did not happen as an environment of slavery was created in the prison camps. (Raver, E 2007). But this is already too much. From the report of Mr. Stemen, he mentioned about the report of Mr. Michael Jacobson, the Director of the Vera Institute of Justice.Mr. Jacobson said that harsher punishments and strengthened rules for imprisonment will decrease the threat imposed by the increase in crime rates. Insufficiency of the date is not a problem as they now have sufficient data to support their claim. When that time comes, then it would be easy for policy makers to understand complex policies. A 10 percent increase in the number of incarcerations would only decrease 2 to 4% decrease. From 1970 to 2005, an increase of 628 percent in the construction of state and federal institutions was reported, with a number of 1.5 Million incarcerated criminals in U. S prisons and 750, 000 persons imprisoned in local ja ils per day. 5. 6 Million of the U. S population experienced being in prison. From 1992 to 1997, it was recorded to have a 25% effect in reduction of crimes, and the rest was caused by other reasons (Stemen, 2007). If they really want to reduce the crime rate, governments must focus on the increase in the number of police per capita, real wage rates, and education, and the decrease in unemployment rate (Stemen, 2007). Will rehabilitation continue as a primary correctional goal?Because on the belief of the efficacy of incarceration in the rehabilitation of prisoners, it is expected that more prison camps will be constructed which will come largely from the revenue collected by the states to go to this objective. In the 21st century, more funds are reserved for the construction of new penal colonies. In fact nowadays, they are more than the churches and the schools (Raver, 2007). The plan is that penal colonies will now provide different facilities that will further promote the rehabi litation of adult prisoners and for juvenile delinquents as well.Just like the North West Ohio Juvenile Detention, Training and Rehabilitation Center that has individual detention cells, control room, multi-purpose room, classrooms, intake area, nurse clinic, gymnasium, library, and a secured outdoor recreation area (Patrick, 2007). This will help the juveniles to develop their skills and talents while serving their sentence, so that once they are released, they will be able to help their community, the country. They have a highly structured curriculum where in the teachers are licensed by the Ohio Department of Education.There is an admission exam that will test their knowledge in math, science, and the language arts. This is for the placement in the Center’s computer based education curriculum. There is also the Accelerated reader program that will uphold their reading comprehension level that is suitable and proper to them. The Centre also has one hour per day organized gr oup large muscle activity that that follows the 5139-37-18 of the Ohio Administrative Code. Aside form this. There are one hour additional recreational activities, calisthenics, and leisure activities. Group sessions and total family sessions were also held.Aside from that, they conduct mental health assessments, and counseling. But according to the findings of Senator Whitmire and Rep. Madden, the real problem of the increase in crime rate is no other than the faulty and weak criminal justice policies and practices (high revocation rates of probationers, lack of in-prison or community-based treatment and diversion options, and low parole grant rate). They think that what was done in the past is already enough. They think that the money should be more spent on more quality projects that the population can enjoy.Their goal is to lessen the expenses appropriated by the federal government in constructing too many prisons (The PEW Center on the States, 2008). The two legislators do not believe in building more prisons. For them, what is important is to treat the drug addicts, alcoholics, and to those individuals on parole and on probation that are having some difficult time coping with problems, this will prevent them to go out of the prison and eventually commit the same crime, or commit a new one (The PEW Center on the States 2008).Legislators instead must pass bills that will give correction agencies computers that will have Compstat program that will be used to trace their caseloads (Public Safety Performance 2007). Presently, more and more correctional agencies are emerging in the idea that they can help in the progress of public safety thru helping the offenders to complete their period of rehabilitation (The PEW Center of the States 2007). The expansion of the country’s prison system does not actually decrease crime rate if their aim is to only imprison many of the citizens without really reducing the rate of criminal offenses.It is said that incarce ration is the best way to avoid one from doing crimes, but is not effective in punishing and debilitating those persons, but it works (Stemen, 2007). For example, it said that the imprisonment of drug criminals will defeat the purpose and efficacy of this system to decrease the crime rate. Its predominantly negative implication on drug criminals were also reported (Stemen, 2007). Will supervision of offenders in the community change on approach? What should be focused on is to provide the centers with different facilities where they can mold their talent, skills, etc.where they can use when they go out. In the Pennsylvania system, guards have a complete supervision of the prisoners in the centers (Mega essays, n. d. ). We cannot prevent that there might be some special incidents that can happened in the detention place, like acts of aggression, disorderly behavior, attempts of the juvenile to harm himself, and threats in security. This is where the guards are most needed. In 2007, i t is recorded that there were 40 special incidents in the North West Ohio Juvenile Detention. But before doing all of this, they must first provide solution to the correctional system first.The Correctional system has different problems like its rising cost, the overcrowding of prison cells and the increased hazard for both the inmates and the correctional personnel (Raver, 2007). For example in Texas, they will have to a lot additional $900 million to add more beds in prison camps (The PEW Center on the States, 2008). Some of the solutions given to these problems were the following: First, prohibit the unsupervised release of the prisoners just to solve the overcrowding of convicts in the prison cells. This will rather increase the risk of the security of the citizens.It will be appropriate to have it supervised. In this way, the rehabilitation of the prisoner and the security of the community will not be at stake. When we say rehabilitation, this would include counseling, therapy and traditional probation (Raver, 2007). Second, White collar criminals or non-violent offenders do not need to be imprisoned anymore. This will only occupy space, and waste the money of the government (Raver, 2007). The parole system does not only let ex-convicts to enjoy a free life. Even if these people were already outside, the authorities still monitors them (Mega essays, n. d. ).They need to make sure that they will completely supervise them, just to prevent those persons to repeat their crimes, or to do another crime. But of course, this will not be easy for the released prisoners. But if this will not be prevented, if they commit the same mistakes, or does a new crime, it is important that the following must be considered first: the degree of the crime committed, the danger it imposed to the community, and the cost. Senior administrators must be there to review the violation, and most importantly issue policy and guidelines for responding to these parole related violations ( The PEW Center of the States, 2007).Those under parole will find it very hard to earn some money and to find a permanent job because employers’ sets high standards that in some point they were not able to meet or they are just discriminated and pre-judged. If not, they are just limited to some certain dirty jobs, thus some of them would find solution by venturing into illegal jobs (Stemen 2007). Once again, the role of the authorities is important, especially the policy makers. Prison-based education programs will not only help the prisoners to change themselves, but it can also serve as a tool to prepare them before going inside and join their community.Another one is for the policy makers to train better probation and parole officers (Stemen 2007). Do we need a new paradigm for sentencing and corrections? It is suggested that the kind of system that the United States have must be re-examined and re-evaluated based on its total performance (Raver, E 2007) The prison system i n the eyes of the convicts is inefficient in terms of really playing its purpose because of some hostilities inside the penal colonies which should not happen.The facility should train, educate, and mold the person to a person that is ready to face the challenges if the time comes that he’ll leave the prison. But this is not what is really happening in these places (Raver, 2007). Community corrections agency are expected to produce report at least once a month, but instead the report contains only a list of their activities annually. Community corrections agency is expected that they should have a system to determine and manage movement towards the prevention of crime and addiction.They should not only monitor the progress of paroled person, and the individual managers in their effort to promote the achievement of their objectives. Incentives will also be given to managers and staff (Public Safety Performance, 2007). So far, it is said that the United States has the highest r ate of incarceration amounting to 450 people for each 100, 000 people (Mega essays, n. d. ). The effects of increased incarceration rates will still be affected by different factors such as the range of in state prisons population, which has actually less effect and crime rate (Stemen, 2007).In Florida, both the rate of crime rate, and the rate of incarceration increased, that eventually destroys the society, especially the family, steals the time of some imprisoned parents to take care of their children, and can also take the present and future income of the community where this people belong, and would only cater to the feeling of bitterness towards the present legal system, thus overall creating social disorder that makes way for the further push of crime rates in a higher level (Stemen, 2007).The North West Ohio Juvenile Detention, Training and Rehabilitation Center accepts into its custody those delinquents that is physically and emotionally threatened or hurt, run away child, abandoned child, and or is ordered by court, as stated in the Rule 7 of the Ohio Ruled of Juvenile Procedure. Other private institutions and groups that give leadership training and change for the youth, family, and the community, should increase their role in this issue. What the government cannot provide, they can supply (Stemen, 2007).What the citizens think now is to make some policies that will quickly respond to the real cause of crime and not just simply facing it. In a survey in 1994, 48% believes on this, that later on increased by 2001 reaching a rate of 65%. On the other hand, 42% believe that using a harsher sentence will decrease crime rate, and became 32% in 2001 (Stemen, 2007). They suggest that authorities must reconsider their thoughts about incarceration, that they must consider more the mentioned aspects in policy making (Stemen 2007).Can we reduce the impact of prisonization and improve the successful reentry of prisoners to the community? Yes we can. Treatment o f services, conditions and intensity of supervision, release, and responses to violations are appropriately assigned which paves the way for an increase in crime rate because of its inefficiency. They should be supervised heavy-handedly grave offenders, and light-handedly on those light offenders, with no intensive interventions included (The PEW Center of the States, 2007).But the establishment of institutions like The Bureau of Federal Prisons, and structures like Alcatraz were primarily built as a way to decrease the crime rate in the country, and to make sure that the most dangerous criminals are caught and kept imprisoned. This is the only way that the federal government can answer the challenge of those big time criminals who have more power and weapons than the law enforcers (Raver, 2007). The common problem for those freed convicted criminals is that they were viewed by others as a threat or danger to the peace and orderliness of the community.Some of them are always impriso ned, whether they commit another crime, or they repeat what they did. The people from the community believe that instead of changing into a better person, which should be the real purpose of imprisonment, they only got worst inside, which reflects the people’s disappointment in the country’s correctional system (Raver, 2007). Policy makers should have a statistics of the percentage of those who were revoked for violating the rules of their parole, and the percentage of those who were revoked for committing new crimes.Judges, the parole board and the agency must be well coordinated in order to prepare the prisoner for the world outside the prison and detention center. They should continuously promote the prevention of crime, and not just the revocation of supervision (The PEW Center of the States, 2007). It is also said that consequences for different violations are not maximized. Policy makers must make sure that every violation is faced with an appropriate punishment. It is said that in order for supervision agencies to react appropriately to the needs of the culprit, they must have community based services and sanctions.They can use electronic monitoring or day reporting centers (The PEW Center of the States, 2007). Aside from providing the needed facilities for the prisoners, they must, at the same time, evaluate the third generation instruments that can unchangeable and changeable. It is concluded in one report that rewards are more effective than penalties in molding one’s behavior (The PEW Center of the States 2007). They can also use incentives that will encourage the prisoners to comply with the conditions and to prohibit themselves from doing another crime or repeating the crime again.It can be in a form of gift, certificates, reducing the treatment requirements, and minimal supervision (The PEW Center of the States 2007). References Co, Alfredo P. , 1992, Philosophy of China: The Blooming of a Hundred Flowers, Manila, Philippines : University of Santo Tomas. Mega essays. , –, American Corrections†¦A History. Available from: Patrick, Brian, 2007, North West Ohio Juvenile Detention, Training, and Rehabilitation Center Annual Report 2007 Available from: Public Safety Performance, July 2007, You Get What You Measure: Compstat for Community Corrections No. 1. Available from: Raver, Edward, 2007, Understanding the American corrections system. Available from; Stemen, Don, January 2007, Reconsidering Incarceration: New Directions for Reducing Crime. Available from: < http://www. vera. org/publication_pdf/379_727.pdf The PEW Center on the States, January 2008, Changing Direction: a Bipartisan Team Paves a New Path for sentencing and Corrections in Texas No. 4. Available from: The PEW Center of the States, November 2007, When Offenders Break the Rules: Smart Responses to Parole and Probation Violations. Available from: >

Michael Levin’s the Case for Torture (Review)

Michael Levin’s â€Å"The Case for Torture† argues that there are various reasons for allowing torture to exist in the United States of America. Levin would love to see society change its negative views on torture so that, under certain circumstances, torture would be permissible. The article starts off with a very brief description of how he believes society views the subject of torture as a negative thing. He leads on to oppose that way of thinking and provides three cases in which he believes torture must be administered with various reasons attempting to support his thoughts. The hypothetical cases Levin uses range from very extreme situations, to a situation where we may sometimes see on the news. Levin makes it clear to the audience that he does not agree with torture as a punishment and focuses on exactly what it should be used for. He also stresses that there is an important difference between terrorists and victims and he believes it would stop the talk of â€Å"terrorist rights†. Levin also writes on his belief that most terrorist do their crimes for publicity and because of that, the terrorist shall be fairly easy to identify and later be tortured. He closes the article by saying torture would cause little danger to western democracies and predicting what he believes will happen in the future. After many through readings of Michael Levin’s article, I feel the attitude he carries along thorough the article presents him as an aggressively self assured person. Most of the reasoning he gives is heavily based on pathetic appeals. The force of pathos he puts into the reader is very compelling but does not fulfill the argument as well as it should because of the lack of good logic and reasoning. Levin uses three main points to convince readers why torture should be used. The first major point includes three hypothetical cases as big reason to why it‘s important. His second point explains the reason for the need of torture. Finally he states who gets to receive the torturing and briefly describes what the outcome may be. Levin's biggest point is generated from the three hypothetical cases he provides the reader with. In my opinion, they are clearly work more as an emotional example and not a sound reason. The 1st case is one in which an atomic bomb is planted on Manhattan Island and will blow at noon. The suspect demands money and release of his friends from jail. He is caught at 10 A. M. and the man won’t disclose any information on the bomb. â€Å"What do you do† (201)? The 2nd case speaks of a bomb on a jumbo jet. The suspect's demands cannot be met. Won’t we do anything to the extortionist to the save the passengers (201)? The 3rd hypothetical case is provided with results from a four person poll. The case is one in which a newborn baby is kidnapped from a hospital. Would you allow the torturing of the kidnapper in order to get him back? I feel that all three hypothetical situations have something about them that do not make me feel convinced. The first situation in which the bomb is planted Manhattan Island seems too unrealistic due to reasons that you don't always hear of this kind of stuff on the news and also that the bomber is captured. Even if a person demands money and release of his friends from jail, Levin does not explain how somebody would go about finding this person wherever he is hiding? Levin also has a very weak spot in explaining the situation because when he speaks of the bomber, he says â€Å"Preferring death to failure – Won’t disclose where the bomb is. †(201). Saying to readers he prefers death to failure would logically mean that, even if tortured, the man is still not going to disclose the information because he would rather die than failing his mission in receiving his needs. The second situation's weakness' comes from a lack of critical information and once again the rareness of the situation. The situation involves a Jumbo Jet in which a bomb has been planted which can be defused ONLY by the bomber which is in police custody. Levin says â€Å"Surely we can, we must, do anything to the extortionist to save the passengers† (201). Once again, what exactly is torture going to do in this situation if the bomb is in the air on the plane? How exactly is the bomb going to be defused? I feel that this situation could have made much better of an argument if he would have taken the time to clear up exactly how the bomb was going to get defused. Later in the paragraph Levin adds in, â€Å"If you caught the terrorist, could you sleep nights knowing that millions died because you couldn't bring yourself to apply the electrodes? â€Å"(201). It is clearly an emotionally loaded sentence. He purposely italicizes the word â€Å"you† because he wants you to sink into that thought and make you feel really bad about the situation. The third hypothetical case, which I consider weakest, is explained with results of an informal poll based on the situation. In the poll, four mothers are asked if they would approve the torturing of the kidnapper that kidnaps their child if that were necessary to get them back. All four mothers said they would approve of it. I feel this argument does not give a great example of what makes torture acceptable. It is more of an example to show what someone would do for their loved ones. Its weakness is clearly seen in the number of participants in the poll that he is using and in the biased opinion they most likely already had. The best part of Levin’s reasoning is expressed when he speaks of why exactly he believes torture should be accepted and not viewed upon as something horrible. In the article, Levin says â€Å"I am advocating torture as an acceptable measure for preventing future evils. †(201). He does a good job of making it clear exactly what he means. In doing so, he briefly explains an argument he believes people against the death penalty use. The argument is that by killing the murderer, you are not bringing back the victim that was killed. Levin explains that instead of killing after a murder has occurred, he advocates that torturing someone stops the innocent from being dispatched. Levin makes it clear that torture should ONLY be used for the saving of lives. This leads to what he believes is the most powerful argument against torture. People would insist that such practices disregard the rights of the individual. Levin first counter-argument is presented when he says â€Å"Well, if the individual is all that important, and he is, it is correspondingly important to protect the rights of individuals threatened by terrorist. â€Å"(201). It seemed like a very sound argument to me because of the way he used anti-torture line to support his pro-torture argument. Levin later says â€Å"Unlike his victims, he (the terrorist) volunteered the risks of his deed. By threatening to kill for profit or idealism, he renounces civilized standards, and he can have no complaint if civilization tries to thwart him by whatever means necessary. (202). He thinks if a person decides to oppose civilized standards, he should not expect to be treated with the same rights as the people who do follow civilized standards. Although it sounds reasonable, he does make an assumption here. Levin assumes that the suspect KNOWS they are going against civilized standards. Does this mean that a sociopath that cannot distinguis h between civilized standards would not be tortured? I feel a bit more of clarification could help this argument. Levin addresses the issue of torturing the wrong person. He starts off by making an assumption terrorist proclaim themselves and perform for television and public recognition. Levin says â€Å"After all, you can’t very well intimidate a government into releasing your freedom fighters unless you announce that it is your group that has seized its embassy. †(202). It is just another hypothetical situation to bend things his way without providing documented evidence of a real life situation where the terrorist actually identified themselves. It is as though in his eyes, he thinks finding the right perpetrator is a very simple task. Finally, in the last paragraph he says â€Å"There will be little danger that the western democracies will lose their way if they choose to inflict pain as a way of preserving order. I noticed that his claim seems a bit modified in the last paragraph. Levin starts the article speaking of torture ONLY for the saving of innocent lives, but now, he speaks of torture for preserving order. Does this broaden up the whole claim? He also predicts that someday soon many lives will be threatened and torture will be the only way to save them. This prediction is supported by no evidence what so ever and is clearly only to provide fear to the person reading it. The discussion of key terms was decent in this article. When he speaks of torture the closest description I found that define torture to Levin is: â€Å"Subjecting someone to the most excruciating pain. † This may seem like a great description of what we see as torture but the example of torture he mentions is â€Å"having the electrodes applied†. I really wasn’t sure what he was referring to until I looked it up online and read that electrodes are what kill you in the electric chair. I believe he did not provide any better example of this because it can very well make a reader oppose of the torturing right away if he speaks of a more gruesome example. Levin also uses the word moral cowardice to describe allowing the death of millions of innocent lives. He does a good job by explaining that it means the unwillingness of dirtying ones hands. Regarding tone and ethos, the author starts off taking a big risk by introducing the topic of torture as something societies reject outright, then saying he opposes the beliefs of society on that topic. Not only does he just oppose it, he says it is unwise. I think by doing that, he may give the reader a sense that he thinks only his beliefs are wise and that he does not respect any other ideas. Throughout the article, Levin continues to carry the attitude of a know it all. Levin says â€Å"Opponents of the death penalty, for example are forever insisting that executing a murderer will not bring back his victim. â€Å"(201). In case you didn't notice, he says â€Å"forever insisting†. This presents an assumption in a way to make it seem like fact that death penalty opponents ALWAYS insist executing will not bring back his victim. Not only does his statement risk offending the death penalty opponents, it can also continue to promote his know it all attitude which can surely annoy other people too. Another occasion of his overly aggressive attitude is when he says â€Å"Once you concede that torture is justified in extreme cases, you have admitted that the decision to use torture is a matter of balancing innocent lives against the means needed to save them. â€Å"(201). Whether or not it makes sense, he is clearly making an assumption that we admit to something by agreeing on another thing. The way he worded that may seem a bit too aggressive for a general audience. On the other hand, some people can also see that attitude as a good thing because they feel the person they are listening to actually knows what they are talking about. Even though he carries the cocky attitude through most of the article, when it comes to speaking of his hypothetical cases he tries to change his tone to more of an emotional one that is more likely to affect the reader. This however is a good thing, because it can make the reader a bit more vulnerable to falling into his emotional example. Ultimately then â€Å"The Case for Torture† is very mixed in effectiveness. The hypothetical cases sound a bit too rare and unlikely to appen but it can cause the audience to think it out. Only minor elements of his reasoning are sound and effective. But his reasoning needs a bit more of support from some other place and his hypothetical situations can certainly use some actually documentation of the occurrences he speaks of. I do not believe this essay does the total job in changing people's minds from anti-torture to pro-torture. But I do think that the people who were already anti-torture surely hate this guy a bit more especially because of the attitude. I think this essay leaves a large amount of places for it to be attacked by a person who does not believe in torture.

Swot Analysis Of At T - 1243 Words

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