Operation management and service analysis

Operation management and service analysis 1. Task 1 1.a Introduction The Waterlander hotel is a part of major international hotel chain world-wide. The hotel was running but was without satisfactory results. Customers did not seem to be satisfied with their services. It was the day when one corporate customer seriously had a problem and was noticed by the senior management. Everyone was blaming each others fault. It was Plastix International Plc, who asked for the service at Waterlander hotel but could not express exactly what they wanted and they were dissatisfied by the service of the hotel. It actually wasnt the satisfaction level that Plastix International expected but unfortunately that they did not meet. The line managers who were not internally satisfied with the hotel system couldnt give the highest level of satisfaction. Hence total quality management was the only medium for customers to get satisfied and then only they would meet their satisfaction level. Total quality management refers to all operations related from lower level workers till managers like operation management, gap analysis, time management. Total Quality Analysis would be extremely useful for this situation for an organisation like Waterlander hotel. Here in the case study of the Waterlander hotel shows different time gap, information gap and deficiency in operation management. Mainly we see few internal characters of hotel as general manager, line managers, conference managers, head chefs and headwaiters and external were electrician, vice president of global marketing, Plastix International Plc and the photographer. There was no proper information flow from one person to another, which was the main cause of the whole disaster. Every one seemed to be upset due to problems in flow of information. The vice president of Global marketing, Plastix International Plc was mostly upset due to the poor quality service and told that he would not pay excessive charger for that banquet and wanted a written apology for the upset caused by the service they received. The manager of Aalsmeer electronics was upset since they were asked to set up by 7 PM and so they started to do their jobs at 4.30 PM but they were forced to wait for the hotel staffs to clear them for it. Hotel service managers got upset since they were not informed about the colours of flowers that client ordered which were red and yellow. The red would not look good against the dining room dÃÆ'Â ©cor. Suddenly electricians moved all the arrangements. When they got the needed flowers, electricians completely the rearranged themselves. The conference manager was upset since he was not told that the client wanted to use the video equipment, which was sent for maintenance. He did not have the checklist for the conference hall by the client. He could have hired one if he had known about the video equipment. Head chiefs got upset because he did all according to the detailed schedule he received from headwaiter. He made every thing on time but was not served when it was ready. Waiters were also badly behaved by the customers. The headwaiter the upset since they were not informed about the set-up that had to be done by electricians for loudspeaker and amplifiers. Those electricians told them to clear all the tables that were now ready to be used and which they had put everything right within half on hour. The photographer was upset since he was scheduled to come at 10 PM and they needed only for half an hour during the speeches. When he reached inside the conference hall, every thing was late and had to rush for another concert hall at 11 PM. He would have arranged another guy to take photographs if he were informed to start the program late. So here we see every person is blaming each other. This would have been better if the flow of information was correctly done. 1.b Operation management in Hotel Waterlander: The operation management refers to the framework for understanding operations management and its organisation and manager context .the nature of operations may be goods or services. According to Samuel K M Ho Operations and Quality management, Operation Management can be defined as the deployment of effective and efficient methods for the reaction and delivery of goods and or services to satisfy the needs of the customers. Without an effective and efficient operation functions, no organisation can hope to stay in business. Since it will fail on the key dimensions of competition quality, speed or price. Here in the case of Hotel Wanderlander, every where there is operations management. In the kitchen chefs convert raw foods into meals, waiting staffs provide meals to customers. Process in operation management Heart The transformation process. The customer gets the final output and they are the only way to evaluate the quality of service. There exist different operations inside an organisation for a service to be delivered. So for the proper management operation, the proper flow of information is needed, According to the above figure A, customers are attracted using different business competitive strategies. Customer has the right to choose an efficient and cheap service available in the market. There must be a proper planning and control of resources inside the organisation. As we see inside the Waterlander Hotel, every where are disturbances in the flow of information among service providers. The general Manager of the hotel was supposed to transfer the information to the right person in the right time, but he seems to be not doing his job properly. He was the only person to meet with customers to know what they really wanted in their services. The transformation process is greatly effected by the transforming resources either they are staffs or material. It they are not unsatisfied with their management, the quality services can be poor which reflect to the bad operation management. When those transformed resources of staffs and materials are in sufficient enough, then the only flow of information and planning and control makes efficient service. The proper concept of improvements and design also effect the quality of service which are directed by the operational strategy of the organisation how they are processed to be served for the customers. 1.c Problems in Waterlander Hotel: There are different information gaps between every individual. Customer expects the highest level of expectation and is they dont get it, the level of satisfaction is lowered. This situation is the worst for any business firms to loose valuable customers and have to bear losses. An author sees lots of gaps in the case study of hotel Waterlander. It is mainly with the customer and the management, how the service performance is and how much skill was used to maintain the standards of quality. As a whole, gap is seen in every factor. A big gap can be seen between consumer Expectation and service performance when the customer dont meet the desired expectation., Service performance is wholly interrelated with service standards. Every service is categorised with some standards and is they do not has good standards then there exists a gap with service performance. If the manpower dont use their skill properly, then they cannot maintain their standards, which then create a gap between skill and standards. If the proper skills were used but there is not good management, there also exists a gap. The gap is also seen between standard of service and customer expectation while the consumer doesnt meet the level of satisfaction. The huge gap can be seen between customer expectation and the management. Expectations: Plastix Internal Expectations: They had a minimum expectation like others. They just expected red flowers on the table, dinner on time, no food on dresses, simple things, video equipment, photographer, lastly smooth performance. Service: There was no exclusive standard to be measured. It was informally agreed standards, which didnt work while working in a team. Finally the expectation were not relevant to customers satisfaction. Standards: The organisation seemed to under skill. There were too many issues with internal staffs and huge gap was seen with kitchen staffs and waiting staffs. Management: A huge was seen in between persons skill and management since a manager was not able to handle them properly. He was the only person who was responsible to flow the information to its juniors who work under him. 1.d Solutions: The problem with the Waterlander Hotel can be overcome by efficient training to its staffs and quality of service offered, to its customers otherwise it falls under its standards. The solution can be found with the four main key issues as * management and supervision * employee perception of specification and rules * customer needs and expectation * lack of technological support Management seemed to be irresponsible to the organisation and not supportive in quality behaviour and lack in quality specification. The problem in skills is the main issue and the attitude of the person who cannot adjust. Recommendations for Improvement: * Sort out the internal problem occurring inside the management. Till it wont be sorted tout then the same situation will definitely repeat again. * Consider the employee Reward System. It could be the encouraging point for a staffs to have some reward of they do best, which will let them to do better in every moments. * Arrange training to internal staffs of Hotel that aware the impact of performance * Improvement of the recruitment process so that highly skilled can be available who can perform better even without certain training. * The execution of the quality system specification of organization, to improve by training and internal marketing. 1.e Conclusion: Total Quality Management refers to a quality emphasis encompasses the entire organisation from the supplier to the customer (Heizer, Jay, Operations Management 1999). The only problem with the hotel was mis-communication. The hotel should stop depending on the inspections to find out the problems, and should think to improve quality and service. It is the fact that every organisation has different views on quality. It is also known fact that customers have their own attitude on quality rather than on organisation. However internal staffs may have different aspects and definition, which could harm on organisation a lot, which could lead to unsatisfactory service by an employee. Which could lead with customer dissatisfaction like what happened with Plastix International. 2. The Mystery Shop 2.a Introduction: The author tries to select the fast-food service in the UK like Starbucks, McDonalds, Burger King, Pret A Manger. When there are choices among the before stated names ten definitely a student would choose Starbucks because the principle customers are students itself. They have cafÃÆ'Â © society where they can use most of their time in reading. It is also need to replace alcoholic bars to non-alcoholic Starbucks society. Starbucks also have wifi zone, which attracts college students and businesspersons for research purpose and business meeting locations. Starbucks: Starbucks is the largest company in the world having more than 13,100 stores world-wide spreading over forty countries. The stores sells drip coffee, espresso drink, tea, blended drinks, coffee mugs and other coffee accessories. Starbucks has entertainment division selling books, music and film. Starbucks was founded in Seattle, Washington in 1971, since then Starbucks Company spent a minimal account on advertising to promote the brand concept. 2.b Service Analysis of Starbucks of Ealing Broadway An author was at the Starbucks Coffee Shop at Ealing Broadway on December 6th, 2009. He entered there at about 3 PM. There were three employees who were serving customers. An author now prepares questionnaires regarding the services and level of satisfaction to be received by their service. Did they give an author a value when he entered the shop? What was the first reaction while an author was entering Starbucks? How much does he need to wait in the queue to get the service? How many choices of items were there in the shop? How many staffs were there for the service? Were they smiling while serving? How was the taste? How long is the speed of Internet provided freely inside the shop? How long can we stay inside the shop? How was the toilet facility? Did they understand authors language? What did an author ordered? Did he find the product he ordered satisfactory? Was the content of espresso, steamed milk and a dollop of foam quite good enough to drink? What about the location of the shop? What about the price? Was it competitive of expensive? What were the advert strategies? Were they good at customer management? Were the staffs skilful so that they served quickly? What was the quantity of drink in the cup? How was the environment? How did an author saw the life in Starbucks? How did an author rate the standard of quality? Did an author find any scrap pieces around him? Where the tables and floor regularly cleaned? Did anybody ask how was the service? How did they behave while getting out, did they greet? The author tries to find out the answers of above listed questions. It was a Sunday at 3 PM so there ware 4 customers in front of an author while he was in the queue. It took around 5 minutes to get his turn to order for a cup of Cappuccino. There was a guy who was taking my order. He didnt even saw me well saying what do I want. Then an author replied with bid cup cappuccino. He seemed to be rude while talking and asked to wait for 30 seconds but he had to wait for around two minutes to get the drink. A beautiful lady was shouting Cappuccino. So an author hurriedly answered yeah it is mine. An author didnt find it so easy with how they treated with him. All the tables were almost packed and finally an author went to tall chair placed beside entrance door facing to the road. The cappuccino was very hot to drink but the contents of espresso and milk foam was very tasty but much little in quantity. There were one guy taking order but other was preparing drinks and serving and the other one was roaming around cleaning some tables and picking up some scraps around. Since the environment was quite good but the disturbance was allergic. The place was congested. It seem like they emphasis mostly in take away rather than come and eat strategy. An author could see some guys with their laptops doing their work. The WIFI facility of Starbucks could attract youths, which could be seen by an author. An author could see only youths ranging from 20-40 of ages but could not attract people older than that. This could be seen as a disadvantage of Starbucks. He could also see very little business class people and most of them seem to be college students. While an author was there for about half an hour, he could see the life in Starbucks tough as there were only three peop le working outside to serve customers. An author sees there was a need of one more staff that would be enough to serve customers easily without hassle. An author also saw some scrap pieces below his table. It showed that staffs were not responsible to work. An author visits a restroom and finds to be satisfactory but without handicapped accessibility also there was no baby changing station. An author then gets out of the Starbucks but there was no one to ask how was the drink neither greets saying, have a nice day. The drink was somewhat expensive as compared with the market price but the flavour was superb. 2.c Backgrounds and problems The main objective of Starbucks is to serve customers within three minutes has some how added customers a loyalty. Starbucks attracted mostly students who only wish to study. The problems, an author faced during the service. * No greetings while entering to Starbucks. * Had to wait for more than five minutes to order the drink, the timelines were beyond the expectation. * The guy at the reception looked rude enough to talk. * Service was not satisfactory but the drink was the best. * Staffs didnt look qualified since they acquired a bit long time in their service. * No one asked for any thing or after sales reaction, saying how was the drink. * Some scraps around showed that the staffs did not paid attention in the hygiene. * Could not attract people of older ages. * No accessibility for handicapped and no baby changing station. GAP Analysis: During the mystery shop analysis, an author finds few gaps, which could be filled up. GAP 1 is in between the customer expectation and the service performance which was seen while an author had to wait more time in the queue to get a cup of drink. If staffs were qualified enough, they would have served it very fast. GAP 2 is seen in between service performance and standards. While some scraps were found near an author, the level of standards did not meet the customer satisfaction. GAP 3 is seen in between standards and skill when Starbucks staffs served an author with very hot drink which was not drinkable, showed to the skills of staffs. GAP 4 is seen between manpower of skill and management. The manager could manage the staffs especially when the flow of customers were high, he have to think of extra one extra staff needed that could easily serve customers. If customers had to stay longer in queue then customers could find another coffee shops. GAP 5 is seen between customer expectation and standards when an author could not get the standard service as expected. GAP 6 is seen between customer expectation when the management could not serve its customer as they expect. An author had not expected expensive drink and had to wait for long for a service. 2.d Solution: The solution for the problem in Starbucks services analysis could be achieved using Marketing Mix of 7 Ps. Product: Cappuccino was very hot to drink while it was served to an author. Very hot to drink while served to an author. Espresso content was satisfactory but the quantity of foam of milk was little bit less. They also have other different varieties of coffees express cappuccino, beverages, and music. Place: Since Starbucks is near at Ealing Broadway station, it is centre for customers to visit. It is nice place and the surround is also pleasant. Though it is very near to the station, it has focused in take away coffee shop by congesting the place to sit and eat. It is seen that small and congested space inside Starbucks. Price: The price of the products in Starbucks is found to be expensive then that of other coffee shops. Though it is expensive but they have got varieties of coffee like express, cappuccino etc. The products bought by customers can achieve the value of price. Production: Starbucks is found to be the company with least advertisement in compare with its rivals like McDonalds, Pret A manager, Burger King. People: Starbucks staffs were not found to be so much skilled according to on author. Stuffs were very slow in serving for that reason, customers had to wait for long time to get service. Starbucks staffs were not very good at customer management as an author was going out from the coffee shop, there werent any response from the staffs. Process: The process at Starbucks was found to be simple. The staffs did not avoid customers. Physical Evidence: With the flow of customers inside Starbucks we can find that Starbucks lovers and in many. People still believes in Starbucks knowing it contains wide variety of coffees. The major customers were student rather then elderly people. Staff members were also very young and fresh faces. Since Starbucks has been a best place for student to start up their career, every individual seems to be students. Due to free WIFI, people find it luxurious to go and stay. 2.e The important of quality Standards: Quality Standards means for planning, designing, developing, implementing, maintaining and improving customers service quality and customer satisfaction issues are important as companion attempt to differentiate their services and complete effectively in the market place (Paracisuraman, Zenthaml and berry 1988, Brown and Schwartz 1980) According to the above statement it is clear that every companies should make a target to provide quality service by satisfying their customers. Total quality management is the only way to maintain service standards to the customers. Here total quantity management is combined the way of managing for the future and is for wider in its application then just assuring product or service quality .It is a way of managing people and business. Processes to ensure complete customer satisfaction at every stage, internally and externally. Total quality management is combined with effective leadership results an organisation doing the right things right, first time. Customer Supplier Interface: The heart of total quality might is this customer supplies interface where the internal and external lies with many process. Their foundations of Total Quality management surround the core of customer supplier, which are commitment to provide quality. Communication of the messages within and outside the foundation and lastly the culture of the organisations in creating total quality and these foundations are back supported by key roles of people, process and systems in any organisation. Quality as a whole bundle consisting of performance, appearance, delivery, reliability, availability, maintainability, price and cost effective. As we compare the definition of quality with quality achieved by an author in Mystery Shop analysis, performance was not satisfactory so do price, appearance was also not so very fine but others were found to be somewhat satisfactory. Bad practices: Bad practices could be recognised in most of organisations and also was seen in the mystery shop analysis. * Managers not giving clear direction * Each department working only for itself * Confusing quality with grade When customers get bad impression they are least likely to choose the same service in the future since they have Varity of choices. So if staff members of service providers did not respond in good behaviour they will definitely loose their valuable customers. 2.f Recommendations for Improvement: * Consider the employee Reward System Large number of the staff are near the age of twenty to thirty so if they are rewarded then company will benefit with its service outcomes including benefits package which focus on medical, dental, and vision care, as well as the employee stock options. * Site does not have handicapped accessibility Condition of restroom was satisfactory but had no baby changing area * Prompt staff meeting * Training to the staffs * Changing method of selection Action Plan For Improvement: * Focus on hiring older employees more appropriate with the high interest to work. * Develop and maintain a reward system for staffs * Develop a system of regular staff meetings * Improve site accessibility and cleanliness * Upgrade front door and restrooms for handicapped accessibility * Add a baby changing station * Enhance Starbucks wide or big atmosphere 2.g Conclusion: Customers are always right seems to be the final conclusion of the mystery shop analysis. Customers are free to choose services anywhere so they want to be cared by the service provider. This could be possible only if the services provider follows customer care quality standards keeping in mind that customers are always behaved properly from the time they enter to the shop. While answering, greeting providing services within time scales, welcome any complains or suggestion. The analysis of mystery shop comes up with the conclusion of unsatisfied the level of satisfaction. There must be good coronation of mangers and staff members. 3. References Heizer R, Barry; H, Jay H, 1999, Operations Management, Fifth Edition, Prentice Hall Inc, USA. Business Link, 2009, Quality management standards [online]. Available from http://www.businesslink.gov.uk/bdotg/action/layer?r.s=slr.lc=entopicId=1074431977 [24 November, 2009] De La Salle University, 2009, Total Quality Management [online]. Available from http://www.dlsu.edu.ph/library/pathfinder/business/tqm.asp [25 November, 2009] Starbucks UK Corporate site, 2009, Homepage [online]. Available from www.starbucks.co.uk/en-GB/ [25 November, 2009]

POEMS Syndrome Symptoms and Treatment

POEMS Syndrome Symptoms and Treatment POEMS Syndrome: Paraproteinemic neuropathies, Organomegaly, Endocrinopathy, M-protein and Skin changes Abstract The POEMS syndrome, also known as Crow-Fukase syndrome, is a rare multi organ disorder characterized by polyneuropathy, organomegaly, endocrinopathy, M-protein spike and skin changes. Other associated features, such as sclerotic bone lesions, edema, ascites, hematological disorÂÂ ­ders and Castleman disease can also be present. We report a case of POEMS syndrome who presented with insidious onset, progressive sensorimotor polyneuropathy, pedal edema, ascites, hepatomegaly along with skin changes. X-ray pelvis showed osteosclerotic lesions. Thyroid function tests showed hypothyroidism. M-protein (IgG) monoclonal band was seen on immunoelectrophoresis. The patient was started on melphalan and corticosteroid combination therapy. We emphasis on the importance of recognizing a challenging diagnosis of a rare disease, which is shown to be treatment responsive. Introduction POEMS syndrome is a rare paraneoplastic disorder of plasma cell dyscrasias, which was first described in 1956 by Crow and then in 1968 by Fukase [1]. The name POEMS was given to it by Bardwick and co-workers in 1980 based on five salient features: polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes [1]. It is more prevalent in men, with male to female ratio of 2.5:1. It usually manifests in 5th and 6th decades of life. Its inheritance is uncertain and its pathophysiology is still not well understood. Case Presentation A 40-year-old male presented with progressive weakness, tingling and numbness sensation in both lower limbs for two years. He had swelling of lower limbs, abdominal distention and dermatologic changes in form of discoloration and thickening of skin over the cheeks, nose, hands and feet for one year. He had also gave history of erectile dysfunction and loss of libido for six months. There was no history of syncope, bony pain or drug abuse. He had no previous history of hypertension, diabetes or tuberculosis. On physical examination, the patient had bilateral pedal edema [Figure 1.c] and abdominal distention [Figure 2.a]. Skin was thickened and hyperpigmented over the face, fingers of the hands and shin (Figure.1a,b,c). Bilateral gynecomastia and testicular atrophy were present. Abdominal examination showed hepatomegaly and ascites. Higher mental functions and speech were normal. Fundus examination showed papilledema on both side and rest of the cranial nerves examination were normal. Motor power in upper limbs was normal and in lower limbs showed predominant distal weakness [Medical Research Council (MRC) 4/5 at hip joint and 4-/5 at ankle joint). Deep tendon reflexes in upper limb were diminished (+1) including biceps, triceps and supinator and absent in lower limbs. There was 30% loss in pain, touch and temperature sense in both lower limbs below knees. Posterior column sensations (joint position and vibration sense) were also impaired in lower limbs below the anterior superior iliac s pine. Romberg sign was positive. Hemogram, liver and renal function tests, muscle enzymes (creatine phosphokinase), serum ferritin and vitamin B12 level were normal. Serum total protein was 7.1 gm/dL, albumin 3 gm/dL, globulin 4.1 gm/dl, and A:G ratio 1:1.3. Fasting and postprandial blood sugar level were normal. Thyroid function test showed raised TSH level (16.62 ÃŽ ¼/ml). Luteinizing hormone (LH) and testosterone levels were 15 IU/L (1.8-8.6 IU/L) and 111 ng/L (300-1,000 ng/dL), respectively. Antinuclear antibody (ANA), Rheumatoid factor (RF), serum human immunodeficiency virus (HIV) ELISA test, hepatitis B and C markers were negative. Ultrasonography of abdomen showed hepatomegaly (16 cm), moderate ascites and enlargement of multiple lymph nodes along the iliac vessels. Fine needle aspiration cytology of mesenteric lymph node was inconclusive. Ascitic fluid examination revealed exudative nature (SAAG Discussion POEMS syndrome is a rare, multiple system disorder, characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein band and skin changes. Any three of the five features may be present to establish diagnosis [2]. However, some authors have proposed clinical criteria for diagnosis in which includes two major criteria, which can be either presence of polyneuropathy or plasma cell proliferative disorder. Minor criteria include sclerotic bone lesions, organomegaly, edema, endocrinopathy, papilledema or skin changes [2]. Polyneuropathy is a predominant feature of POEMS syndrome and is found in >90% of the cases. It is usually a sensorimotor, axonal and demyelinating type polyneuropathy [3]. As in our patient, both axonal and demyelinating polyneuropathy are seen on electrodiagnostic studies. The mechanism of neuropathy is not known but the recent evidence of the presence of anti-neural antibodies points to an immunological mechanism [4]. Endocrinopathies occur with a frequency of 60%-80% and the most common are gonadal failure (70%) and glucose intolerance/diabetes mellitus (50%). Hypo or hyperthyroidism, hyperprolactinemia and adrenal insufficiency have also been reported. The mechanism of endocrinopathy is also not obvious; however, involvement of direct acting antibodies against hypothalamo-hypophyseal-axis and endocrine end organs has been hypothesized [5]. In our patient, impotence, loss of libido and testicular atrophy and hypothyroidism on ancillary laboratory investigation were present. Increased levels of vascular endothelial growth factor (VEGF) are found in POEMS syndrome. VEGF increases microvascular permeability, thereby inducing edema, ascites and pleural effusions as were present in our patient [6,7]. However, measurement of VEGF level in ascites was not available in our patient. Papilledema may be seen in approximately 37% of patients and is not associated with the increase in intracranial pressure. The real cause of papilledema is not still known. Hepatomegaly may be seen in up to 50% of patients with splenomegaly and lymphadenopathy occurring less often. The hyperpigmentation over the face, legs and hands was also observed in our case. The skin changes usually observed in POEMS syndrome are hyperpigmentation, lichenification, hypertrichosis, sclerodermoid changes and glomeruloid hemangiomas. Skin biopsy may show inflammation, fibrosis, or nonspecific changes. Monoclonal protein is detected in more than 90% of patients and may become positive in the follow- up of patients who have no monoclonal gammopathy initially [8]. Nearly all cases reported in the literature show lambda positivity as in our patient. It may be rarely found in urine and cerebrospinal fluid (CSF). The natural course of POEMS syndrome is chronic, with a reported median survival for a decade (8-13.8ys). The morbidity depends on the extent and number of systems involved. The cause of POEMS syndrome is still unknown. It is tempting to incriminate the presence of lambda light chains in the pathogenesis because of their unexpected frequency (more than 95% of patients), but histopathologic review of affected organs and nerves does not support that it is a form of deposition disorder. Increased levels of cytokines IL-1ß, TNF-Ã ¡ and IL-6, more specifically VEGF, appear to play a pathogenic role in the disorder [9,10]. In view of the constellation of a mixed polyneuropathy, monoclonal gammopathy, osteosclerotic myeloma, extravascular volume overload, bilateral papilledema, skin changes and endocrinopathies, our patient was diagnosed as POEMS syndrome. However, other close differential diagnosis like tuberculosis and hemochromatosis were ruled out with appropriate investigations. Patient was treated with combination of alkylating agent melphalan and corticosteroid. To conclude, when a patient present with unexplained sensorimotor polyneuropathy, signs of extravascular volume overload and evidence of other system involvement, a high index of suspicion should be kept for a diagnosis of POEMS syndrome, to avoid missing this rare syndrome, which is amenable to treatment. Figure Legends Figure 1. Photographs of patient showing skin hyperpigmentation over the face, hand and limbs (thin arrows). Thick arrow showing pitting edema over the left leg. Figure 2. Photograph of patient (a) showing abdominal distention (free fluid was confirmed by ultrasonography). X-ray pelvic bone (b) showing multiple sclerotic lesion over right iliac crest (thin arrow) and one large osteosclerotic lesion (thick arrow) over the neck of left femur (b). Figure 3. Nerve conduction study showing axonal and demyelinating neuropathy in right median nerve. Figure 4. Bone marrow smear in centre reveals one large atypical plasma cell, which has prominent nucleoli and abundant cytoplasm. There is loss of normal nuclear configuration with fraying border. References Bardwick PA, Zvaifler NJ, Gill GN, Newman D, Greenway GD, Resnick DL. Plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, M proteins and skin changes: the POEMS syndrome: Report on two cases and a review of the literature. Medicine (Baltimore). 1980;59:311-322. Dispenzieri A, Kyle RA, Lacy MQ, Rajkumar SV, Therneau TM, Larson DR, et al. POEMS syndrome: definitions and long-term outcome. Blood. 2003;101(7):2496-2506. Min JH, Hong YH, Lee KW. Electrophysiological features of patients with POEMS syndrome. Clin Neurophysiol. 2005;116(4):965-968. Kelly JJ Jr, Kyle RA, Miles JM, O’Brian PC, Dyck PJ. The spectrum of peripheral neuropathy in myeloma. Neurology. 1981;31:31-34. Reulecke MD, Dumas M, Merrier C. Specific antibody activity against neuroendocrine tissue in a case of POEMS syndrome with IgG gammopathy. Neurology. 1988;38:614-616. DSouza A, Hayman SR, Buadi F, Mauermann M, Lacy MQ, Gertz MA, et al. The utility of plasma vascular endothelial growth factor levels in the diagnosis and follow-up of patients with POEMS syndrome. Blood. 2011;118(17):4663-4665. Watanabe O, Maruyawa I, Arimura K, Kitajawa I, Arimura H, Hanatani M, et al. Overproduction of vascular endothelial growth factor vascular permeability factor is causative in Crow-Fukase (POEMS) syndrome. Muscle Nerve. 1998;21(11):1390-1397. Miralles GD, O’Fallen JR, Talley NJ. Plasma cell dyscrasia with polyneuropathy; the spectrum of POEMS syndrome. N Eng J Med. 1992;327:1919-1923. Kanai K, Sawai S, Sogawa K, Mori M, Misawa S, Shibuya K, et al. Markedly upregulated serum interleukin-12 as a novel biomarker in POEMS syndrome. Neurology. 2012;79(6):575-582. Soubrier M, Dubost JJ, Serre AF, Ristori JM, Sauvezie B, Cathebras P, et al. Growth factors in POEMS syndrome: evidence for a marked increase in circulating vascular endothelial growth factor. Arthritis Rheum. 1997;40:786-778.

The Things They Carried Essay -- Literary Analysis, History

Joy Kogawa and Tim O’Brien: two authors that have wielded their mastery of the English language to yield literary masterpieces that reflect not only their own struggles, but the hardships of multitudes around them. In her acclaimed Obasan, Joy Kogawa illustrates the intense discrimination that was faced by Japanese-Canadians during World War 2, and provides many reflective anecdotes to give the reader some insight on her personal situation. Tim O’Brien accomplishes basically the same goal in The Things They Carried by giving the reader many brief stories about his time in the Vietnam War. These two books- though incredibly different on the surface - share a plethora of themes and symbology, as well as many similar events. They do not, however, emphasize or present these ideas in the same way. Each of these authors has a unique way of incorporating their own themes or values into their writing, which gives the reader an entirely different view of what may be happeni ng. The brain is an amazing thing. It allows us to think, blink, walk and talk; it enables us to run, hide, seek, and stride; but most importantly, it allows us to remember. Neither literary work takes a firm stance on their opinion of memories, as both have many different characters with many different opinions. Naomi views and even loosely mirrors Obasan’s opinions on memory; that the past be left to the past and the future will bear what is to come (65 Kogawa). This â€Å"Ashes to Ashes† stance is mirrored by Rat Kiley in The Things They Carried (SparkNotes Editors). Though Obasan has a much tougher exterior and is able to keep her composure, they are both haunted by cruel memories that they are trying to suppress. Rat, however, doesn’t have as much luck as ... ...n previously expected. Things aren’t always what they seem; a concept that applies to the characters themselves. Obasan is more than just a wrinkled old lady, just as Rat Kiley is more than just an infantry soldier. Don’t judge a book by its cover, and don’t jump to conclusions; everyone is different. Take some time to find out and get to know someone, and you might just be surprised by The Things They Carried. Works Cited SparkNotes Editors. â€Å"SparkNote on Obasan.† SparkNotes.com. SparkNotes LLC. 2007. Web. 22 Feb. 2012. SparkNotes Editors. â€Å"SparkNote on The Things They Carried.† SparkNotes.com. SparkNotes LLC. 2002. Web. 22 Feb. 2012. Kogawa, Joy. Obasan. 1981. New York: First Anchor, 1994. Print. The Purdue OWL. Purdue U Writing Lab, 2010. Web. Feb. 22 2012. O'Brien, Tim. The Things They Carried. New York: Houghton Mifflin Harcourt, 1990. Print.

A Portrait of Modern Life in Carnal Knowledge :: Carnal Knowledge Essays

A Portrait of Modern Life in Carnal Knowledge T. C. Boyle's "Carnal Knowledge" is a very funny, and at the same time truthful portrayal of some of the things which are going on in the world today. His description of the narrator and the way he thinks, as well as his portrayal of Alena Jorgensen, leaves the reader wondering if they have ever believed so strongly in something or acted the same way to help reach their goal. What makes this story so unique and is that takes place in our world, in a world were some people are "fond of Kentucky Fried Chicken or Chicken McNuggets" (245) and others "don't eat meat or fish or milk or cheese or eggs, and they didn't wear wool or leather or fur" (248). T. C. Boyle uses his sarcastic, yet at the same time believable, style to make the reader feel as if he was in the main character's shoes. The author guides the reader through the different stages of the character's evolution and shows how different aspects of society influence his thinking. In the end, the character concludes, just as I ha ve, that no matter what people say "it's only meat" (257). The story begins with the narrator being a man in his mid-thirties, with a stable job, and a normal life. The only thing missing in his life seems to be a female companion. He wants to find somebody he likes, understands and has something in common with, and he is sick of making the "acquaintance of a divorced computer programmer in her mid thirties with three kids and bad breath" (246) and her like. Thus when he meets Alena Jorgensen he becomes bewitched and begins to try to impress her, and establish common interests. He becomes almost totally submissive as their relationship grows and unconsciously begins to do things he never thought of or cared about doing before. T. C. Boyle shows this progression in the narrator's character by describing the character's changing behavior and aspirations. Thus he shows how a normal man with "twentieth century urban American sensibility" (Utley) becomes a radical activist for animal rights. "Something was happening to me I could feel it in the way the boards shifted under me, feel it with each beat of the surf and I was ready to go along with it." (249).

Impact of the Automobile from 1900-1945 :: American America History

Impact of the Automobile from 1900-1945 The impact of the automobile between 1900 through 1945 was immense. It paved the way for a future dependency on the automobile. To paint a better picture, imagine life without an automobile. Everyday life would be dull, cumbersome, and tedious. An individual's mobility would be very limited. Basically, the life without an automobile could not be fathomed. The importance of the automobile is often taken for granite. Society may not know what appreciate the impact of the automobile and effects it has created. The impact of the automobile had both positive and negative effects on America between 1900 through 1945. Automobile provided an outlet for individuals and spread the freedom of travel among all classes of people. It also helped to introduce rural dwellers to the aspects of urban life and vice versa. One of the negative effects was that automobiles helped to put of big decline in the use of railroads. Over the course of the paper, I will try to expose the huge impact of the automo bile an early twentieth century life. The image of a self-propelled vehicle dates back around the early thirteenth century. Europe is the birthplace of the automobile, but it was adopted by America. Roger Bacon had a vision of cars being made without animals so they can be at astonishing speeds and maneuverability . About three hundreds years later, Leonardo Da Vinci rejuvenate Bacon's idea with hopes of creating a military vehicle. His idea was transformed into the modern day tank. The first step in making a self-propelled vehicle was taken by Nicholas Joseph Cugnot. He was an eighteenth century French artillery officer. "In 1769 he built and ran a three-wheeled carriage mounting a steam engine of his own design, with the idea that it might be used for pulling guns"2. It was very clumsy vehicle that was shot into the air when it reached the top speed of three miles an hour. Cugnot's vehicle provided almost no improvement of the horse. In the early years of the nineteenth century an American and British duo had began an automotive experiment. Richard Trevithick, a British engineer, and American genius, Oliver Evans created a workable but crude vehicle propelled by steam3. This early experiment was an improvement, but the railroads and stagecoach companies joined together. With this new combining of forces the new steam vehicle, the Orkuter Amphibolos, was brought down.

Essay --

Holocaust Facts The Holocaust has many reasons to it. Some peoples’ questions are never answered about the Holocaust and some answers are. The Holocaust killed over 6 million Jews (Byers.p.10.) Over 1.5 million children (Byers, p.10.)They were all sent to concentration camps to do hard labor work. Jewish people weren’t the only ones sent to concentration camps. People such as people with disabilities, Homosexuals, Gypsies, Jehovah’s Witnesses, Communists, and Socialists (Byers.p.12). Everyone that was sent to concentration camps was sent via Train cars (www.historychannel.com). They had no food, water, or rest rooms up to 18 days. Many people died from the lack of food and water (Byers, p.15.). They children under 12 and elderly were sent to death camps because they were too weak or young too do the hard labor work so they were exterminated quickly (Byers, p.17.). Everybody at the camps were ordered to wear a certain colored star so they were easily spotted. The Holocaust went o n from 1939 to 1945. Throughout all those years it was BAD. The Holocaust started in 1939. In that time period the Germans and the Allied Forces were in war. When they were in war the Germans took all Jews (except the ones in hiding) to multiple concentration camps and death camps. When they were sent to concentration camps they were ordered to take off all their jewelry, gold teeth and clothes. They were provided with stripped pajamas with numbers on them so they can be recognized by their number and not by their names. They were also tattooed on their left forearm with the same number that was on their stripped pajamas. Everybody’s head had to get shaved BALD. After everybody got to get concentration camps they were forced to go into the hard labor imme... ... to be in order from which number they got. If one or two people were late they would have to wake up one hour EARLIER. They had to wake around 4-5 in the morning. So if they were late they would have to wake up way earlier than usual. If they would wake up early they would get no sleep, because they were done with the labor work at night. They would never get as much sleep as they should because the Germans didn’t care all they wanted was their work to get done. A few people survived the concentration camps. It was never promised they will see their family again. Most families were split up when they were taken away to the concentration camps. Some camps were split up by gender. They didn’t care if you were married or if you had kids. If you had kids under 12 years old you weren’t going to see them again because kids were automatically sent to death chambers.

Quentins Passion and Desire in The Sound and the Fury Essay example --

Quentin's Passion and Desire in The Sound and the Fury    As Quentin Compson travels through the countryside with his college friends, the reality of the situation becomes terribly confused by memories and past feelings. After a little girl follows him for miles around town, his own sexuality reaches the forefront of his consciousness and transforms itself into disjointed memories of his sister Caddy. Quentin's constant obsession in William Faulkner's The Sound and the Fury, surrounds a defining sexual act with his sister. Though the physical act never appears in plain language, Quentin's apparent lapse into an inner monologue demonstrates his overwhelming fixation with Caddy as well as a textured representation of their relationship. Sexual language pervades his inner consciousness - scents, sounds and colors represent his passion and desire. Elements of nature, when associated with his sister, become erotic; the tiers of description, no matter how seemingly mundane, tend to be steeped in sexuality. Quentin's lapse into past events with Caddy begins in the midst of typical conversation with his friends as they drive through town. His attention to reality is shattered by an unconscious slip into thoughts of his sister. As the eyes of the little girl snap Quentin into a reverie of sexual exploration, his words wander haphazardly, even before the image of his sister, prone on the banks of the river, comes to mind. "If I tried to hard to stop it I'd be crying and I thought about how I'd thought about I could not be a virgin, with so many of them walking along in the shadows and whispering with their soft girlvoices lingering in the shadowy places and the words coming out and perfume and eyes you could f... ... environment to evoke such passion. Although Faulkner rarely refers to sexual acts directly, the use of language through Quentin's consciousness and internal monologue is so rampant with erotic metaphor and passionate depth, that a simple object, such as a pocket knife, transforms into the most vital of symbols. Works Cited and Consulted Faulkner, William. The Sound and the Fury. New York: Vintage Books, 1984. Harold, Brent. "The Volume and Limitations of Faulkner's Fictional Method." Contemporary Literary Criticism. Vol. 11, 1975. Hoffman, F. J. and Vickery, O. W.   William Faulkner:   Three Decades of Criticism.   New York, Harbinger, 1960. Irwin, John T. "A Speculative Reading of Faulkner" Contemporary Literary Criticism, Vol. 14, 1975. Polk, N.   New Essays On:   The Sound and the Fury.   Cambridge, Cambridge University Press, 1993.