Advanced breast cancer

Advanced breast cancer Background Cancer accounts for 13% of all deaths in 2007, making it the largest cause of mortality worldwide and is the leading cause of premature death in Scotland. 2,22 Out of the staggering figure of 27,500 new cases that were diagnosed on that same year in Scotland, 4044 of them are breast cancer cases, making breast cancer the most commonly diagnosed cancer among Scottish women.3 In the UK, 16-20% of women have advanced breast cancer and approximately 40-50% of those diagnosed with early or localised breast cancer may eventually develop metastatic disease. Breast cancer is usually defined using a staging system known as the Tumour, Node and Metastasis Staging System (TNM) and stage III and IV are known as advanced stages of the disease with stage III being locally advanced and or has spread to regional lymph nodes and stage IV describing the presence of metastases at distant sites such as the bone, brain, or lung.23 In the elderly group of female cancer patients, the prevalence of breast cancer is highest at 4% and these post-menopausal women make up 80% of all breast cancer patients, hence proving that the risk increases with age.1 Apart from age, other factors like family history, uninterrupted oestrogen exposure, early menarche, late menopause, late first pregnancy, hormone replacement therapy, obesity, not breast feeding, taking oral contraceptives and past breast cancer may all attribute to a higher risk of developing breast cancer.9 Over the last decade, mortality rates from breast cancer have dropped by almost 14%, despite having more women diagnosed with the disease. In 2000-2004, the survival rate for breast cancer patients has also bumped up to 84% compared to a mere 64% 20 years earlier.4Improvement in prognosis, screening techniques such as mammography, ultrasound and Magnetic Resonance Imaging(MRI), earlier diagnosis of cancers in women participating in the Scottish Breast Screening Programme, a myriad of new hormonal and chemotherapy treatments, and better organisation and patient care plans has attributed to the substantial increase in incidence and survival rate of breast cancer patients. Women today are also encouraged to perform self breast examinations, hence are familiar with the shape and feel of their breasts, as well as to look out for abnormities like a new discrete lump, nipple discharge, unilateral persistent pain especially in post-menopausal women or pain associated with a lump and skin changes comprising of skin tethering, ulceration, abscess or inflammation.However, there is still a disparity between women from different social classes in terms of combating this disease. Women from more affluent backgrounds are more likely to have their breast cancer diagnosed earlier, have slower disease progression from the time of diagnoses and higher survival rates compared to women from poorer socioeconomic backgrounds. Women from more deprived communities are more likely to be diagnosed with the advanced stage of the disease. Pathogenesis Cancer or malignant neoplasm which literally means new growth is a disease manifested in the form of uncontrolled cell proliferations, dedifferentiation and loss of function, invasiveness and metastasis.6 Breast cancer usually forms from the inner lining of milk ducts or the lobules that supply the ducts with milk. In patients with Breast Cancer, women who inherit a single defective copy of tumour suppressor genes BRCA1 or BRCA 2 have a marked higher risk of developing breast cancer in their lifetime. The presence of a defective BRCA1 or BRCA 2 gene can invoke changes in several cellular systems including the signaling pathways and receptors of growth factors and cell cycle tranducers, the apoptotic machinery which responsible for programmed cell death that normally disposes of abnormal cells, the secretion of telomerase, and local blood vessels which results in tumour-directed angiogenesis to supply nutrients to these tumours both aids the proliferation of cancer cells.7,8 Breast cancer cells are able to invade other tissues like the lymph nodes as they no longer exercise the same restraints as the normal cells and they also secrete enzymes like metalloproteainase to break down the extracellular matrix, conferring them mobility. Metastases are secondary tumours normally found in the advanced stage of breast cancer formed by cells released from the primary tumour and have reached and have established themselves at other sites like the lung brain or the bones which are common sites for metastatic cancers of breast origin through blood vessels and lymphatics. The tissues of lung, brain and bone origin express high levels of CXR4 chemokine receptors produced by the breast cancer cells, facilitating the selective accumulation of the cells at these sites.6 Treatment Options There are three main approaches to treating breast cancer, namely surgical excision, irradiation and a host of systemic disease-modifying therapies or a combination and is chosen based on the stage of breast cancer. However, when caring for patients with advanced breast cancer, the goal of treatment of advanced breast cancer is to palliate symptoms, improve survival and quality of life. There are notably three types of systemic disease-modifying therapies to treat advance breast cancer namely endocrine therapy, chemotherapy and biological therapy. Endocrine Therapy Oestrogen exposure has been instrumental in inducing mutations that can lead to breast cancer as they can stimulate cell growth in most of human breast cancer cell lines expressing Oestrogen Receptor (ER) ÃŽÂ ± .8 Clinical studies have proven that more than half of breast carcinomas are ER ÃŽÂ ± positive and respond fairly well to endocrine therapy. Drugs are aimed either to change the ER signaling pathways or prevent estrogen synthesis.7 Tamoxifen and 3rd generation Aromatase Inhibitors (AI) have been used for advance breast cancer with the former being effective in premenopausal, perimenopausal and post menopausal women. Pre-menopausal and perimenopausal cancer patients with ER positive tumours should be offered Tamoxifen tablets 20 mg daily, an oestrogen -receptor antagonist and ovarian ablation or the administration of LHRH agonists such as Buserelin or Goserelin as first-line treatment.5,12 Both options are just as effective in terms of tumour response and overall surviva l rates. The latter group of drugs, AI, are the preferred choice for post-menopausal women only with no prior history of endocrine therapy or have been previously been treated with Tamoxifen. AI work predominantly by suppressing oestrogen levels in post-menopausal women by blocking the conversion of androgens to oestrogens in the peripheral tissues. However, they do not inhibit ovarian oestrogen synthesis, hence can cause an elevation in oestradiol levels in pre-menopausal women. Anastrozole and Letrozole are non-steroidal AIs are known to be as efficacious as Tamoxifen as first -line treatment of metastatic breast cancer. 14Exemestane is a steroidal AI used as second-line treatment in advanced breast cancer in post-menopausal women in whom anti-oestrogen therapy has failed. Fulvestrant, an oestrogen receptor antagonist also confers short term benefits in the clinical setting for post-menopausal women who was previously prescribed a non-steroidal AI, delaying the need for chemotherapy. 13AI h ave been associated with an increased progression-free survival and 13% decrease risk of mortality and lower incidence of vaginal bleeds and blood clots. However, patients given AI are more prone to hot flushes and gastro-intestinal symptoms. 5 Other endocrine therapies available include older and less popular therapies such as progestogen and androgen for pre-menopausal women and stilboesterol and trilostane for post-menopausal women. 5 Chemotherapy Both ER positive and negative patients with advanced breast cancer would benefit from either a choice of two or three regiments of chemotherapy and classes of drugs commonly prescribed includes antharacyclines, taxanes, capecitabine, vinorelbine, gemcitabine, alkylating agents like cyclophosphamide and platinum based drugs like carboplatin.5 Anthracyclines such as Epirubicin, Mitoxantrone and Doxorubicin are prescribed as first line chemotherapy as they boost modest survival advantage in patients with advanced breast cancer and are superior to non-anthracycline regimens.1,5Doxorubicin is commonly given via injection into a fast running infusion at 21 day intervals as extravastation can cause severe tissue damage. It exerts a cytotoxic effect by interfering with DNA and RNA synthesis by inhibiting DNA toposiomerase II action. The metabolites are excreted through the bile, hence elevated bilirubin levels are indicative of a need to reduce the dosage. 6,12 Higher accumulation of doses may result in cardiopathy precipitating to heart failure, hence cardiac monitoring is deemed important in managing cancer patients taking it and a limit of total cumulative doses is set at 450 mg/m2.Other symptoms of toxicity includes myelodysplasia and neutropenic sepsis. Doxorubicin is also available in liposomal formulations which are safer in terms of reduced incidents of cardiotoxicity and local necrosis but is not recommended by the Scottish Medicines Consortium for treatment of metastatic breast cancer.1,12 Both Epirubicin,an anthracycline derivative, and Mitoxantrone ,an anthracenedione derivative,are structurally related to Doxorubicin, hence similar drug activity could be predicted for all three drugs.12 Mitoxantrone given intravenously is licenced to treat metastatic breast cancer and has been well tolerated by patients.However, side effects like myelosuppression and cardiotoxicity are evident and cardiac examinations are recommended after a cumulative dose of 160 mg/m2.12When both drugs are compared in a clinical trial, Epirubicin boosts higher response rates despite demonstrating a higher percentage of toxicity related side effects.20Clinical trials suggest the efficacy of Epirubicin in treating advanced breast cancer is comparable to Doxorubicin as similar response rates were recorded when equal doses were given. These trials also indicated that patients taking Epirubicin had fewer episodes of congestive heart failure and other complications resulting from cardiotoxicity. Therefo re, it could be surmised that Epirubicin is the drug of choice in this regimen .However,a limit of 0.9-1 g/m2 was still imposed when Epirubicin is given to avoid cardiotoxicity. 1,12 Due to the ineffectiveness of single-agent anthracycline therapies in impeding disease progression, combination therapies are often considered for the treatment of advanced breast cancer after failure of with anthracycline monotherapy, provided that the patient is able to tolerate additional toxicity and have a higher chance of response.5 There are clinical evidence suggesting that a combination of anthracycline and taxanes like Doxorubicin and Docetaxel have resulted in better tumour response, delayed progression time compared and reduce risk of mortality to anthracycline monotherapy. The benefits of this synergistic combination, however, did not include improved survival and side effects experienced were more numerous such as thrombocytopenia, alopecia in 75% of these patients,a 10% increase in peripheral neuropathy and neutropenia in 40 to 68% of these patients.1,5 A combination of Epirubicin and Docetaxel would be a better choice as it is just as potent as the Doxycycline and Pac litaxel combination but deemed free of side effects like cardiotoxicity and fluid retention whereas neutropenia was the dose-limiting toxicity .21 Systemic chemotherapy should be offered to patients whom antrhracyclines are contraindicated in cases of cardiac disease hypertension,the elderly, those who have received myocardial irradiation ,those receiving radiotherapy for breast cancer or had receive prior adjuvant treatment with anthracycline. Docetaxel monotherapy is prescribed as the first-line drug followed by single-agent Vinorelbine or Capecitabine as the second-line treatment. Third-line treatment encompasses the use of either Vinorelbine or Capecitabine of which was not offered previously.5 Docetaxel, a member of the taxane group derived from a naturally occurring compound from the bark of yew trees, is licensed to treat locally advanced or metastatic breast cancer. It acts by stabilizing microtubules in the polymerized state, preventing cell division. Side effects associated with Docetaxel are myelosupression, peripheral neuropathy, cardiac conduction defects with arrhythmias, alopecia, muscle pain, nausea and vomiting . Patients currently on Docetaxel are also susceptible to leg oedema and hypersensitivity reactions, which can be ameliorated by taking Dexamethasone orally.1,6,12 Antimetabolites like Capecitabine is a rationally designed tumour-activated and tumour-selective fluoropyrimidine carbamate thatis metabolized to generate 5-fluorouracil at the tumour site which would then be converted to fluorodeoxyuridine monophosphate (FDUMP), a fraudulent nucleotide and interact and inhibit thymidilate synthetase,preventing the synthesis of 2-deoxythymidilate (DTMP),which is vital for DNA synthesis.17Capecitabine has a role in second-line or third-line treatment of chemotherapy for patients of locally advanced or metastatic breast cancer either in combination with Docetaxel or given orally alone at a dose of 1250 mg/m2 twice daily for a forthnight and subsequent courses are repeated after a 7-day interval. Vinorelbine is a semi-synthetic analogue of vinblastine, a vinca alkaloid derived from Madagascar periwinkle. Unlike taxanes, it is targeted at tubulin of mitotic microtubules to form tubulin dimers which prevents spindle formation in dividing cells leading to mitotic arrest at metaphase resulting in cell death. 6 Besides inhibiting mitosis, its effects are also significant in inhibiting leucocyte phagocytosis, chemotaxis and axonal transport in neurons. Hence, side effects includes neutropenia which was found to be the dose-limiting, peripheral or autonomic neuropathy which manifests as peripheral paraestesia, loss of deep tendon reflexes and motor weakness,constipation and abdominal pain. Neurotoxicity caused by Vinorelbine is considered relatively mild compared to other vinca alkaloids even at maximum tolerated dose as it preferentially binds to mitotic over axonal microtubules. 6,12 Vinorelbine is an option to anthracycline or taxane pre-treated patients with advanced breast canc er as second-line or third-line chemotherapy given via intravenous administration at a dose of 30mg/m2 in 250 ml of normal saline over 1 hour. Alternatively, Vinorelbine can be given orally at a dose of 60 mg/m2 for 3 weeks and can be increased if the patient shows good tolerance to the regime to maximum dose of 160 mg once weekly. A clinical response rates of 16-60% was seen with Vinorelbine as a single agent, 28-77% in combination chemotherapy.5, 16 A study comparing Vinorelbine in intravenous(i.v.) form used in combination with Capecitabine given orally and a combination therapy of Vinorelbine and Capecitabine both in oral formulations was done to observe the efficacy of both combinations in anthracycline and taxane pretreated patients with metastatic breast cancer. Despite showing a marginally higher percentage in control of the disease in the oral group,improved survival rates and lower incidence of neutropenia and thrombocytopenia were associated with the i.v. group.17 This study has also shown that a combination of Vinorelbine with Capecitabine therapy may confer advantages as both have unique mechanisms of action, different proposed mechanism of drug resistance and relatively non-overlapping toxicity profiles. However, this combination has yet to be recommended by the NICE or SIGN guidelines as it has yet to be proven to be cost-effective. The recommendation for systemic chemotherapy by NICE is done following a cost-utility analysis which compares chemotherapy regiments in terms of survival, quality of life and associated costs of 17 different strategies drawn up. From the table below, strategies that gives the best survival rates and quality of life are combinations 3,4,13 and 15.However,combinations 3 and 4 that offer Gemcitabine and Docetaxel as the first line are somewhat more costly by approximately  £ 10 000 in total costs compared to combinations 13 and 15.It is also proven here that offering Docetaxel as a first-line drug is also superior to Paclitaxel as survival rates and quality of life are slightly poorer in combinations 8 and 10. 5 Biological Therapy New agents to specifically target molecular processes have been developed over the last decade like Tratuzumab, Bevacizumab and Lapatinib which are all used to treat advanced breast cancer. Tratuzumab, the sole drug of its kind recommended by NICE for use in the UK, is a recombinant humanized monoclonal antibody which binds to Human Epidermal Growth Factor (HER2) on the cancer cells with HER2 over expression and impedes the growth. Hence, HER2 status should be assessed before commencing this therapy as only a quarter of patients with advanced breast cancer have HER2 positive tumours. Tratuzumab is given intravenously in combination with Paclitaxel, Docetaxel or Vinorelbin has been well tolerated. 5,11However, once disease progression occur outside the central nervous system, Tratuzumab should be discontinued. Bevacizumab is another monoclonal antibody aimed at affecting the growth of tumour blood vessels and Lapatinib affects the metabolic pathways of the HER2 and Epidemal Growth Fac tor Receptor (EGFR). 5,23. Surgery Surgical intervention comprises of conservation surgery which involves the removal of the tumour with a rim of surrounding breast tissue with retention of the breast followed by radiation therapy and mastectomy which is usually followed by breast reconstruction. However, these surgical procedures are limited to patients diagnosed with primary operable breast cancer or as palliative surgery for locally advanced breast cancer as they may not confer much benefits to patients diagnosed with later stages of breast cancer.1,11,19 Some patients may have already underwent surgery which was not very successful in eliminating the disease.1 Treatment Recommendation Hormonal therapies are the recommended first-line therapy for patients with an ER positive tumour, are widely used and are said to be appropriate for 70 % of patients who have hormone receptor -positive advance breast cancer. However, in circumstances whereby the disease is life-threatening or the patient has an ER negative tumour, the hormonal therapy would be of no benefit to these patients. At the time of initial diagnosis, the oestrogen receptor (ER) was accessed and the results came out positive before considering commencing on endocrine therapy. Several factors like previous endocrine therapy including adjuvant therapy, the extent and period of response to the therapy and menopausal status have to be taken into account before prescribing hormonal therapy. 5The patient is 62 years of age and is considered to be post-menopausal, hence would benefit tremendously when given aromatase inhibitors(AI),regardless of whether she is tamoxifen naÃÆ' ¯ve. A choice of non-steroidal AIs o f either Anastrozole 1 mg daily or Letrozole 2.5 daily could be given orally. However, if she has a prior history of non-steroidal AIs and she failed to respond well to it, she should be given either Exemestane 25 mg orally or Fulvestrant 250 mg via intramuscular injection into the gluteal muscle every 4 weeks.5,12 Chemotherapy would be the second choice of treatment following failure to respond to hormonal therapy. If anthracyclines are not contraindicated for this patient, Epirubicin would be a good choice. Initial doses of 75 mg/m 2 of Epirubicin could be given intravenously every three weeks.20The addition of Docetaxel 75 mg/m2in combination with Epirubicin 90 mg/m2 both by intravenous infusions could be given should Epirubicin monotherapy fails. Docetaxel monotherapy could also be given as an intravenous infusion at a dose of100 mg/m2 as a 1-hour intravenous infusion every 3 weeks should anthracyclines be contraindicatedas first-line chemotherapy. Vinorelbine monotherapy could be given intravenously at a dose of 30 mg/m2 for days 1 and 8 of a cycle or whereares Capecitabine monotherapy could be given orally at a dose 1250 mg/m2 twice daily for two weeks. If the patient fails to respond to the entire treatment, the last resort would be to offer support and palliative care to this patient. Pain Management Pain is usually associated with progression of cancer with three quarters of patients with advanced cancer reporting pain during treatment. The principles for treating pain in cancer patients are outlined by the World Health Organisation (WHO) analgesic ladder: Patients are the prime assessor of pain and should have treatment outcomes monitored regularly using visual analogue scales, numerical rating scales. Patients usually start with non-opioids and then progress stepwise to step 2 and step 3. However, critics have debated that the progression to step 2 analgesics was obsolete as inadequate pain control was an issue despite having to endure similar adverse effects when given step 3 analgesics and recommended a immediate step up to step 3. Most patients with advanced breast cancer will be on step 3 for pain control. Oral morphine with an initial dose of 5-20 mg every four hourly, adjusted according to patients response, would be the first-line therapy to treat severe pain in cancer before switching to a modified release preparation once the patient is stabilized on it. Breakthrough pain should be managed while on a modified release preparation by prescribing oral morphine at 1/6th of the total daily dose to be taken when necessary. The use of adjuvants such as antidepressants like Venlafaxine and anticonvulsants like Gaba-pentin are recommended for neuropathic pain. 18 Managing Complications Complications that may arise from treating patients with advance breast cancer includes lymphoedema,cancer-related fatigue,uncontrolled local disease,bone metastases and brain metastases. Lymphoedema may occur due to damage to lymph nodes and vessels following surgery and radiotherapy or as a sign of loco-regional disease progression. This condition can be managed through manual lymphatic drainage, multi-layer lymphoedema bandaging,goos skin care and remedial exercise. Cancer-related fatigue may be well managed by identifying the factors causing lethargy which may be a host of psychological, nutritional and cognitive factors apart from the cancer itself and them treating them accordingly. Patients may also develop local disease characterized by ulceration on the chest wall and axilla, fungating tumours that may bleed and exude discharge, causing pain and giving off repulsive odours. Hence, good wound management should be adopted in relation to preventing dire consequences when wounds are left unattended. Out of the three categories, cancer with distant metastases is the hardest to treat and is considered an incurable disease with palliative care being the sole priority in treatment plans. A diagnosis of metastatic disease could be confirmed with the use of positron emission tomography fused with computed tomography (PET-CT) and bone scintilography.1As bone metastases may be a long-term condition, management involves prevention of skeletal events, pain control with Biphosphonates,radiotherapy and cementoplasty and treating complications such as fractures,immobility and spinal cord compression.5,18 Brain metastases may develop in multiple sites in these patients as most drugs used in chemotherapy cannot penetrate the blood brain barrier, especially in women with HER2-overexpressing tumours. Diagnosis of brain tumours ultimately mean a loss of independence, physical deterioration, communication difficulties,psychological distress and issues regarding body image.Treatment regimens includ es surgery for patients who have solitary metastasis, corticosteroids for symptomatic relief of inflammation and radiotherapy.

Helping Children From Broken Homes Essay -- Community Service, Service

"Love cannot remain by itself — it has no meaning. Love has to be put into action and that action is service." - Mother Teresa This past summer I had the opportunity to perform community service and participate in an event called â€Å"Upward Bound†. The purpose of this event is to reach out to children who come from broken homes, and help them to become leaders in their homes, schools and communities. This was my second year to volunteer with Upward Bound. The first year I was helping with elementary children, but this year I was a counselor for junior high students. This experience is one I will never forget. On a Sunday morning I met the kids I would be responsible for during the following week. From the first moment I knew it was going to be an interesting week. My kids each brought...

Leadership Study Essay -- Leadership

The ability to be a leader has been studied extensively. Throughout this extensive study, some have pointed to leadership being a born trait (Northouse, 2012) while others point to the ability to learn the skills associated with becoming a great leader (Hughes, Ginnett and Curphy, 2012). While each side has its own valid points, one way to argue either way to see these skills in action. Whether these skills are seen in a high school student government association or the office of a large nationwide non-profit, they are present. The study of leadership has led to the description of several different styles of leadership. These styles include legitimate, expert, information, connections, referent, coercion and reward power. No matter the type of experiences a person has, they will most likely see these types of power. Legitimate power may be one of the easiest forms of power to identify. Hughes and colleagues (2012) refer to legitimate power as one’s formal or official authority. This power is mostly appointed, but can be given through democratic processes (Sager, 2008). A leader who asks someone to complete a task or assigns a specific role to someone can be seen as legitimate. Local culture, as defined by the bureaucratic and chain of command within an organization, is a great way to identify who has legitimate power. A call center environment is a great example of this legitimate power hierarchy. Within one such environment the company was divided amongst several different leaders. The top of the hierarchy was the channel manager, who is held accountable to the client. Below this level are two managers who assign the task of contacting customers to those employees who make direct contact with clients. These two managers mon... ...l and the organization. Works Cited Culley, M.R. and Hughes, J. (2008). Power and public participation in a hazardous waste dispuit: A community case study, American journal of community psychology, 41, 98-114. DOI: 10.1007/s10464-007-9157-5. Hughes, R., Ginnett, R., & Curphy, G. (2012). Leadership: Enhancing the lessons of experience. (7 ed.). Montouri, Amsterdam: McGraw-Hill/Irwin. Northouse, P. (2012). Leadership: Theory and practice. (6 ed.). Thousand Oaks, California: Sage Publishing. Sager, J. (2008) Sources of power. In Rothman, J, Erlich, J.L. and Tropman, J.E. (Eds.), Stratgeies of community intervention (pp. 425-446). Peoesta, Iowa, Eddie Bowers publishing co. inc.. Strom, S. (9 July 2008) Funds misappropriated at 2 non-profit groups. New York Times. Retrieved from http://www.nytimes.com/2008/07/09/us/09embezzle.html?_r=1 on May 25, 2012.

Management 497 Assignment Week 2

Audit Exercise Paper Two Student Name MGT/497 – Strategic Technology Planning for Organizations Professor Name January 16, 2012 Introduction This paper will refer to two audit exercises from Chapter three and Chapter four of the textbook. The first one will refer to demand for product, competitive response, level of novelty of the innovation, factor that could block the good outcome of an innovation, and other factors. The second audit exercise will involve the assimilation of a checklist for innovation with respect to the considered organization. It will also determine the readiness of the organization to implement an innovation strategy. The company chosen for these audit exercises is Apple. Everyone has heard about this company and knows that the products of it are very important in our lives. According to Apple Inc. (2012), they mission statement says that they design Macs, the best personal computers in the world and they lead the digital music revolution with their iPods and iTunes online stores. The mission statement also says that the company has reinvented the mobile phone with their revolutionary iPhone and that they define the future of mobile media and computing devices with the iPad. The goal of this company is to make the best mobile product from their phone. Remember what Steve Jobs said when people asked him about the purpose of this company. He said that the company will try and offer with their mobile phone what the people need and not what they want. Audit Exercise Chapter 3 This audit exercise will address demand for the product or products of Apple, factors possible to block the success of an innovation, their standards, competitive response, the level of novelty of the innovation, as well as other factors. White and Bruton (2011) give the following factors to determine the value of an option: favorability of demand for products, factors to speed adoption, factors to block the success of an innovation, the chances of strong competitive response, the likelihood that the possible competitive advantages are sustained, factors inside the company that allow setting standards, the costs to commercialize, the resources available to commercialize, the level of novelty that is captured by the innovation, development costs, certain opportunities that could be advantageous, and possible areas where damage might occur. In dealing with all these factors, we will refer to the iPhone, the innovation that took Apple on its highest peaks of success. First we refer to the demand for this product. Ever since it was released to the public this product has been nothing but a success. The early prototype that went on sale in June, 2007 blew up the market. According to Vogelstein (2008), analyst were speculating that customers would snap up about three million units by the end of 2007, making from this phone, the fastest-selling smartphone in the history. It was the same story with the following generations of the smartphone and the demand was higher even though they had their first powerful competitor by the end of 2008 when Android came to life with they G1 smartphone. In order to speed up the adoption of this product the company needs to make sure that they keep their quality standards as they are now. Innovation could be blocked if Apple makes structural changes inside the company or if the key employees in this position want to leave the company. Apple has received a big hit when the heart of this company left us. Steve Jobs was the brain behind all the innovation at Apple and people will remember him a lot of years from now. Their direct competition is the Android operating systems with all the smartphone adopting it. Android is a powerful competitor which has gain a lot from the market of the smartphone and as it currently is, Google’s Android has a higher portion of the market in this area compared to Apple. To sustain a competitive advantage, Apple needs to keep innovate and offer quality to their dedicated customers. When it comes to costs of commercialization, the company does well enough because the prices of producing the product are small compared to the prices at which the product is sold in the market. It seems that Google with their Android OS is a little in front of Apple with respect to technological advancement; this is why Apple need to direct some of their costs to research and development to keep up or become better than their competitor. They could leverage opportunities by being able to maintain their devoted customers and offer to them discounts or special promotions for the products. This would attract other potential customers. The potential damage may occur if Apple is not able to stay in the competition or cannot innovate; they are threatened if Google’s Android is advancing faster and faster because people like to stay in touch with the technology and would choose the best product in the market. Audit Exercise Chapter 4 This audit exercise from the end of chapter four requires analyzing a figure which contains a checklist for innovative organizations to consider. The questions at hand refer to ways of using the checklist in determining a company’s readiness to implement a strategy that would be innovative. It requires identifying at least a major area to be examined and addressing important considerations from this area. Figure 4. 7 is divided into four categories. It talks about vision, leadership, processes, and resources. We would refer to all of them in consideration to the company Apple. This time the chosen product will be the iPad. The same way Apple was ingenious by bringing the iPhone to the world, the same way was the story about the Ipad. It was the same brain behind this product as well. The iPad was the first tablet pc in the world. People have seen the concept only in science fiction movies and they were very thrilled when the product came out to the market. It had the same success, the same higher demand as the iPhone did. Now, referring to the vision category and to the first question which asks whether or not the team (or the company here) has a clearly articulated vision, mission, or set of objectives, it has to be noted that Apple has it all clear up, even though things have declined a bit when Steve Jobs died. However, all the employees in the company need to share the same vision so that they could put all their efforts in continuously creating the same quality products as they did so far. However, not everyone participated in creating the vision because this would be a tough thing to do. The vision came from Steve Jobs and it was shared progressively with all the important players from this company. The vision was to offer the people what they need most and not what they want. This is attainable; however, it is attainable with a higher price because the company needs to invest time and resources in research and development to spot the necessities of the client and to try to satisfy them. When it comes to leadership, Steve Jobs is the name that perfectly connects to this term. According to Miami University (2007) leadership is the reciprocal process of mobilizing by individuals with specific values and motives, various politic, economic, and other resources in an environment of conflict and competition, to be able to realize goals independently or mutually held by both the followers and the leaders. It may be a complex definition, but it has the power to point out all the important aspects of this discipline. The textbook asks: â€Å"Is excellence of central importance to the team? † The answer in the context of Apple is â€Å"yes† because they are reaching their purposes through excellence, hard work, and a lot of skill. All the employees in this company are committed to fulfill the same vision and the present leader Tim Cook has the purpose of taking forward the words of Steve Jobs and encourage open idea exchanges. The next category from the checklist for innovation strategy is about processes. At Apple probably not all the employees participate in decision making because this would not be appropriate. Imagine how would be to give a worker in assembly the power to make decisions about marketing strategies for the company. It would surely not be appropriate. However, all the employees are welcome to share their ideas and make recommendations to improve processes or products. They are even rewarded if their propositions are efficient. There is a climate of trust inside this company and it is mportant to maintain it because without good relationships, without communication, there will be conflicts, which lead to inefficiency and to lower productivity. When it comes to resources, Apple has a good way of managing them. Not only they try to make their quality products with a lower consumption of resources and money, but they have the possibility to charge more for their products in comparison with ot her companies in the same sectors. They are successful; however, this may not be the best strategy on the long-term. They should considering lowering a bit the prices; this would most likely increases their sales. Conclusion Apple is a market leader and it represents a business model to other companies. Its position offers the company the ability to innovate, invest extensively in research and try to be better than it self. The company has been around for a while now, so they know how to do business efficiently. However, recent competition has absorbed some of its market. This should not be seen as a bad thing in the company but as a motive, as a spark to make the company constantly innovate and make the world a better place with their products. References Apple Inc. (2012). Apple Corporate Information. Retrieved from http://investor. apple. com/faq. cfm? FaqSetID=6 Miami University (2007). What is Leadership? Retrieved from http://www. units. muohio. edu/saf/leadership/students/whatisleadership. html Vogelstein, F. (2008). The Untold Story: How the iPhone Blew Up the Wireless Industry. Retrieved from http://www. wired. com/gadgets/wireless/magazine/16-02/ff_iphone? currentPage=all White, M. A, & Bruton, G. D. (2011). The Management of Technology & Innovation: A Strategic Approach (2nd Ed. ). Mason, OH: South-Western/Cengage Learning.

Holt Case Essay

The Holt Case relates to the company’s snapshot, case situation and key management issues pertaining to the Holt Renfrew which was being operated in Canada. Company Snapshot Holt Renfrew was constituted as a hat and fur shop in Quebec City in 1837. The company is recognized as one of the elite high-end retailers of Canada. Almost 10 stores were operated by the company in seven cities of Canada in which cosmetics and designer fashions were being sold such as Oscar de la Renta, Gucci, Prada, Dolce & Gabbana and Armani. These products were usually imported from Asia, Europe and the United States. The top quality was the base of Holt Renfrew brand which included private-label and branded assortments and designers that were exclusively for men and women. The Holt Renfrew was then owned by Galen Weston who is a Canadian business leader heading The Wittington Group. Case Situation During the observation of case situation, it was revealed that the staff used to spend much of the time in telephonic communication for adjusting and confirming previous orders. The stock of merchandise was quite high due to which staff remains busy on phone lines for orders tracking, delivery status, confirmation and shipment with transportation service providers and suppliers. The goods were delivered to the distribution centre by suppliers without prior intimation which used to cause inconvenience in scheduling routine tasks. Even it was not possible to determine whether right quality and quantity is being received. Warehouses were so much loaded that only in DC; inventory was stored around $40 million worth which created a hindrance in tracking the shipment in a timely manner. Even the complaint was lodged by store managers regarding overstocks of merchandises which prove the worse condition of warehouses. Key Management Issues The key management issues could be the closure of secondary warehouse and the consolidation of operational warehouse into DC. It would be useful for DC if the addition of mezzanine floor up to 20,000 square feet with a cost of $1 million could be practiced. Additionally, the warehouse problems arose due to overloaded stock. The reason behind this fact was the less sales target being accomplished and improper system involving excessive merchandises which was ordered without prior requisition or sanction and the same was too seriously complained by the store managers.

Communication Skills for Health Professionals Essay

Introduction Communication skills are important for health professionals because they deal with different situations and people every day. Furthermore, an example to use the appropriate communication is when the professional has to give bad news of an unfavourable diagnostics. For instance, the dentist to give the diagnostics of oral cancer for their patient, this situation is necessary to have correct communication to do the treatment and to give the correct support for their patient such as empathy and touch. Body Firstly, most of people who seek a professional health is because they are in unfarovable health condition and need special care. Also, it is very common in dental treatment because many people feel afraid when to go the dentist. It is proved that many of them feeling very anxious when they go to a dental treatment (Cockburn and Walters).Principally, in unfavourable diagnostics, for example oral cancer. In this context, the health professional have ability to provide the appropriate communication such empathy. For professional to be empathy is very important for all principally in bad news that involves patient and sometimes to their family fully to give information and to help continuing the treatment.(Mundada, 2012). A patient with an unfavourable diagnostics need of feel comfortable on various parameters and the empathy as communications is very helpful like dealing with your anxiety, expectations for your family can follow the treatment. The empathy interferes On impacts of the t reatment procedure and the expectations of what will be the treatment. This type of communications is extremely important in case the conversation, clarify doubts and speak as will be the treatment for the patient to be aware of what can happen and not have unexpected reactions. Secondly, it is very important factor and has a good ability of communication such as touch because it helps to support psychological care during treatment. Sometimes many doctors have difficult to deal with kind of situations such as painful, physical suffering impending death and bereavement (Cockburn and Walters, 1999). Also, it is known that many undergrade students are not trained in communications skills and many medical schools do not insist in this subject. Its represents the lack of  touch in a long time (Cockburn and Walters, 1999). The communication such as touch in the treatment sometimes is difficult to many doctors because they attend many people in the same day and they will have this situation for a long time.(Cockburn and Wlaters,1999) that occurs common factor and many times it is interfere in the patient treatment because they do not have the adequate type of this. Principally, with bad diagnostics that usually is not expected for anyone. One of the most difficult tasks for some doctors is to break bad news to a patient, such as a diagnosis of cancer. (Cockburn and Waterls, 1999) That may causes stress, familiars problems, emotional factors. The most appropriate commination skills is helpul to create a field to the patient feel comfortable and freely to do the procedure and touch in extremely important in this situation. The most important factor for the communicate is with professionalism and use the communication that can better confidence and quality of care in the patient.(Mundada,1992).Its helps the patient expects dentists to listen and understand their needs.(Mudunda,1992). Conclusion Take everything into account communications skills are essential for all health professionals. Sometimes, in medical schools this subject in not trained to undergrade (Cockburn and Walters). Also, lack of communication can interfere the patient treatment principally when is necessary give bad news that involves many emotional problems such as psychological and anxiety. Obviously, the professional cannot support all problems to their patient but give the appropriate support with professionalism and empathy and touch good cues of communication and it help the professionals to have a great impressive and attend the necessity of their patients.(Mundada and Walters). Reference: Annette Hannah, Ph.D.; C. Jane Milliamp, Ph.D.; Kathryn M.S. Ayers, M.D.S. A Communication Skills Course for Undergraduate Dental Students. Journal of Dental Education. Volume 68, Number 9 J. Cockburn and W. A.W. Walters. Communication between doctors and patients. Current Obstetrics & Gymecology (1999) 9, 34400 1999 Hat-court Brace & Co. Ltda. Mundada,Vikek. Effective communication skills and professionalism for better dentistepatient relationship. Indian Journal of Dentistry 2012.July e September Volume 3, Number 3; pp. 182 e 183.

African American and American Society Essay Example for Free (#2)

African American and American Society Essay African American (597) , African (466) , Racism (370) , American society (32) company About StudyMoose Contact Careers Help Center Donate a Paper Legal Terms & Conditions Privacy Policy Complaints ? African Americans No matter where or when a person lives, skin color, beliefs, class, or history he/she will see a difference in the way every ethnic group is treated. This world has never been fair for anyone. Life can treat a person with the greatest of care or it will treat a person as if he/she is lower than dirt. African Americans are no different. They have faced great hardships and triumphs throughout the years. Since they had been forced from their homeland they have been treated as if they had no rights or thoughts of their own. They were placed in the status of slaves even though they were human beings too. No matter if they were placed in the minority group by the dominate majority group of white Americans they remind structurally pluralism by keeping to their beliefs and traditions. Before and after slavery African Americans did not receive equal treatment. â€Å"Even when slavery ended, Jim Crow laws went into effect meaning that the very best of everything was reserved for white’s only-school, jobs, neighborhoods, hospitals, etc. † (Moore, 2008). In other words, the African Americans took the subordinate status to the dominant white Americans. Their race was used to dictate what rights they would be allowed to have in America. At one point, they did not have the right to be free and over the years they were given that right back. Even though they regained their right to be free, they still were not very free. They were only allowed to eat in certain places, drink from certain fountains, and ride in the back of the bus. This is not what would be called very free. They were not even given the opportunities to receive a quality education or to vote. â€Å"With the 1896 Supreme Court decision in the case of Plessy v. Ferguson, the separate by equal doctrine was upheld, and the system of segregation in the South was securely in place† (Merger, 2012, pg. 169). When it came to getting a quality education, they were placed at the bottom of the totem pole. The whites receive the best opportunities for receiving a quality education while the African Americans were not. It was not until the Brown v. Board of Education of Topeka case that African Americans were allowed a better education. â€Å"Separate schools were inherently unequal and imposed an inferior status on black children, causing irreparable psychological change† (Merger, 2012, pg. 173). The rights as citizens were also being denied by not allowing them to vote and make a proper living to take care of theirfamilies. Years ago, African Americans were not allowed to vote, so they had no say in the laws that were made that would deny them their rights as American citizens or human beings. This kept them from changing the laws that kept them from achieving economically and politically. The Civil Right Movement began a new era for African American. It was their gain of the right to vote and be elected to office that gave the some power over their rights as human beings and citizen in the economic and political environment. Even after everything that the African Americans have gone through, they still face prejudice and discrimination in all areas of their lives. It is no wonder that for some it feels as if it is never over. No matter what a person looks like, how he/she talks, their beliefs, where he/she lives, how much money he/she has, or what race he/she may come from we all bleed red and where cut from the same cloth. We all deserve to have the opportunities and resources that are out there to help better ourselves. African Americans are human beings too and they have the same rights as everyone else. African American and American Society. (2016, Dec 19).