Glasgow Coma and Glasgow Outcome Scales for Brain Injury

Glasgow Coma and Glasgow Outcome Scales for Brain Injury ABSTRACT Traumatic brain injury (TBI) is a leading cause of death in adults under the age of 45 and an estimated 7.7 million people in the European Union are living with a disability caused by TBI. The severities of these injuries are differentiated by the use of the Glasgow Coma Scale (GCS), and the outcome is assessed by the Glasgow Outcome Scale (GOS). These scales can be used to develop a prognosis for individuals with TBI’s in various ways. Primarily, the lower the GCS score the more severe the brain injury and therefore the worse the outcome for the patient. The GOS is applied 6 months after injury and provides a score of 1-5 with a lower score indicating the worse outcome, death. To conclude GCS by itself cannot be used to provide a long term prognosis for brain injuries. GCS can be used in addition to other factors such as presence of a midline shift on Computer Tomography and fixed pupil dilations are significant in determining prognosis. The presence of lesions on the brainst em correlates with the GCS and GOS scores allowing reliable and valid prognosis’ to be made. INTRODUCTION Traumatic brain injury (TBI) affects an estimated 1.4 million people every year in the United Kingdom (UK)[1], and is a leading cause of death in adults under the age of 45. [2] It is currently estimated that at least 7.7 million people in the European Union are living with disabilities caused by TBI’s. [3] TBI’s account for 6.6% of the Accident Emergency (AE) attendees. [4] 95% of all TBI’s presented at AE are mild, 5% severe and moderate injuries. [5] It is extremely important to determine the severity of the TBI as it has implications on the treatment and later rehabilitation of the patient. TBI can be open or closed injuries, with open TBI injuries being linked to worse functional outcomes and increased mortality. The most common method of assessing TBI is the Glasgow Coma Scale (GCS) and a common method for addressing the outcome of a patient is the Glasgow Outcome Scale (GOS). WHAT IS THE GLASGOW COMA SCALE? The GCS is a test to ascertain the consciousness of a patient after being subject to a TBI. The maximum score with this scale is 15 and the minimum 3, this is comprised of three sections: eye opening, verbal response and motor response. (Table 1). GCS is included in National Institute for Health and Clinical Excellence (NICE) guideline on head injury3 to provide information on survival rates for patients suffering different severities of TBI. The guideline also indicates that GCS is a measurement that should be taken at the scene of the injury by paramedics. If this is not possible it should be taken at admission to AE as early indication of TBI severity is imperative in the later treatment. The GCS differentiates between the severities of head injury by score ranges. A GCS of 13-15 indicates a mild head injury, 9-12 moderate and 3-8 severe. The GCS score can be affected by the time it is applied after injury, therefore in order to universalise this, GCS is often used once the patient has been stabilised.4 The GCS can be difficult to use in trauma cases, as localised trauma, swelling, sedation and intubation can affect testing the eye and verbal responses. [6] [7] In a survey performed by The European Brain Injury Consortium only 49% of patients could be tested fully against the scale after being stabilised in resuscitation.[8] Feature Response Score Total Eye Opening Spontaneously 4 To speech 3 To pain 2 No response 1 E: /4 Verbal Response Orientated 5 Confused 4 Inappropriate words 3 Incomprehensible words 2 No response 1 V: /5 Motor Response Obeys commands 6 Localises pain 5 Withdraws from pain 4 Flexion to pain 3 Extension t pain 2 No response 1 M:/6 Total Score GCS /15 Table 1- Glasgow Coma Scale Components of the GCS and how each section is scored individually Adapted from: Bethel J. 2012, Emergency care of children and adults with head injury, Nursing Standard, 26(43), 49-56 The GCS is considered by some to have acceptable inter-rater reliability[9] when used by experienced practitioners. However mistakes are made consistently by inexperienced users of up to 1 mark per section. Inter-rater reliability was shown to improve after exposure to a training video.[10] Reliability with scoring is imperative in making accurate TBI severity diagnosis, and then the relevant treatment associated with them. In severe TBI’s the motor component of the GCS is the best indicator of prognosis, this is due to verbal and eye scores not being able to be performed. [11] This has led to an adaption of the motor score of the GCS, called the simplified motor score (SMS). The SMS has 3 scores: 2 obey commands, 1 localises pain and 0 withdrawal to pain.[12] It was found that the SMS and GCS were useful in indicating whether neurosurgery was needed and also intubation. Overall GCS was better in predicting chance of death, however SMS was able to be used to assess patient involved in trauma more effectively as intubation and eye swelling would not be detrimental.12 This indicates that SMS may be better used in conjunction with GCS with patients who present to AE with severe head trauma. HOW CAN THE GLASGOW COMA SCALE BE USED IN BRAIN INJURY PROGNOSIS? A more severe TBI will lead to a worse 6-month functional outcome for the patient. 30% of patients with initial GCS [13] and 50% of patients with GCS ≠¤8 after being stabilized in resuscitation will die.6 Patients who have a GCS score of 3-5 have a 5% chance of survival 6 months after injury.[14] There is no direct correlation between GCS score and the patient’s ability to function in daily life afterwards. This is due to varied functional outcomes being linked to different scores on the GCS.[15] Patients with GCS ≠¥8 had 85% chance of favourable prognosis, if this score was obtained 24 hours post-admission.[16] The predictive value of GCS scores alter according to the time at which the score was obtained. GCS scores obtained at least 24 hours after trauma were linked to the grade the TBI was classified by MRI data. These grades are associated with brain stem lesions, grade 4 being the worst and grade 1 the best. The higher the GCS score the lower the grade of brainstem lesion and therefore the better prognosis in terms of functional outcome for the patient. 14 In a study performed by Utomo et al there were no patients with GCS 3-8 that were living independently 6 months after injury. In addition patients with this GCS score were 24 times more likely to die when compared to patients with GCS score 13-15.[17] GCS alone cannot accurately predict the brain injury prognosis for a patient. However, if GCS is applied with computer tomography (CT) evidence and pupil dilations, then a prognosis of possible functional outcome can be made for an individual patient.[18] WHAT IS THE GLASGOW OUTCOME SCALE? The GOS was developed to assess functional recovery of patients with brain injuries.[19] The GOS is based on a structured interview that assesses 7 areas: consciousness, independence at home, independence in the community, work, leisure and social events, relationship with family and friends and finally return to normal life.[20] The area in which the patient is living is not taken into account with the GOS but is taken note of separately. GOS is often split into two broad outcomes: favourable and unfavourable. Favourable outcome encompasses good recovery and moderately disabled. Unfavourable outcome includes: death, persistent vegetative state and severely disabled.9 The standard GOS has a 5 point scale (Table 2) but was extended after concerns were raised that it was not sensitive enough in detecting minor disabilities that may restrict the patient in returning to work. This led to the GOS extended (GOSE) being devised. Guidance has been published to increase the universal reliability of the GOSE[21], but there are still issues with its application. This is mainly due to the time period between the TBI and the GOSE being applied, this is normally taken at 6-12 months post injury. A GOS assessment at 12 months was more reliable than at 6 months[22], but it may increase the number of patients lost in follow up. 10% of patients who were moderately or severely disabled at the 6 month GOS test improved by one category. GOS GOS(extended) 1 Death 1 Death 2 Persistent Vegetative State 2 Persistent Vegetative State 3 Severely Disabled 3 Lower Severely Disabled 4 Upper Severely Disabled 4 Moderately Disabled 5 Lower Moderately Disabled 6 Upper Moderately Disabled 5 Good recovery 7 Lower Good Recovery 8 Upper Good Recovery Table 2 Glasgow Outcome Scale Shows on the left hand side the original GOS (5 point scale) and on the right the extended GOS (8 point scale) Adapted from: Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following major head injury: Coma scales and checklists, Injury, 42(3), 281-287 The 5 sections of the GOS refer to the functional ability that will ultimately be achieved by the patient. Vegetative state refers to the patient being unable to respond; severely disabled patients cannot live on their own; moderately disabled patients can live by their selves but have reduced ability to work; good recovery infers that the patient returns to work fully.[23] It is also possible that the patient when interviewed presents a more positive outlook of their situation leading to the GOS score being faulty. In addition to this a patient may be given a GOS score of 5 indicating a good recovery, but this only refers to the patient being able to return to work. With a good recovery prognosis may still have changes in personality and an inability to cope in social situations.20 This leads to the GOS not fully indicating a good recovery, again highlighting the reason why the GOSE was devised. Under these circumstances a patient can be given a GOSE score of 7 indicating a lower good recovery. The GOS and the GOSE scores can be obtained via phone call increasing their practicality as a scale. This scale is reliable when performed over the phone due to the standardized interview which informs the score that the patient will receive.19 HOW CAN THE GLASGOW OUTCOME SCALE BE USED IN BRAIN INJURY PROGNOSIS? When applied to the GOS a patient with a severe TBI had 40% likelihood of death; 4% chance of being in a vegetative state; 16% severe disability; 19% moderate disability and 21% chance of a good recovery.6 This was a 40% likelihood of a favourable functional outcome at the 6-month GOS test. This is compared to mild brain injury that had 9% chance of dying; 0% of being in a vegetative state; 14% of severe disability; 24% of moderate disability and 53% of having a good recovery.6 This has a 77% overall prognosis of a favourable outcome for individuals with a mild brain injury. This shows that the GOS will make a differentiation in functional outcome for different severity of brain injury. This score is unlikely to change from an unfavourable to favourable outcome after this time period although some small improvements may be seen.18 Any further improvement is probably linked to rehabilitative treatment, and not the improvement of the patient’s TBI. There is a 94% chance of a good recovery with GCS >8.5 (9 +) and age ≠¤49.5 years. This is compared to an 81% chance of good recovery with GCS >8.5 (9 +) and age ≠¥49.5 years. This highlights how age can affect the probability of a patient achieving a good recovery from their brain injury.[24] Patient’s aged >75 years with a moderate or severe TBI were three times more likely to die from their TBI than patients aged 65-74 years. It was also less common for patients aged >75 years to be living independently 6 months post-injury than patients that were younger.15 The age of the patient and the severity of their TBI need to be taken into account when deciding on treatment. The prognoses for individuals in the 75+ age range are unfavourable according to the GOS. 15 Due to this treatment should be decided based on this factor. There is a correlation between the GOC score a patient is given and the grade of their brainstem lesion that is provided by MRI data. A higher grade of brainstem lesion correlates to a more unfavourable outcome for the patient.14 CONCLUSIONS Overall the GCS cannot by itself provide either long or short term brain injury prognosis. This is because there are too many variables that affect each GCS score, including the fluctuation of the GOS associated with these scores and the difference in reliability depending on who has applied the scale. The GCS is used to assess the severity of a brain injury and to allow medical professionals to constantly monitor the patient’s progress. GOS can be used to give prognosis 6 to 12 months after injury; if the scale is used before this time then the score will not indicate the full functional outcome of the patient. This time period of scoring is not beneficial for prognosis at such a time that it will be used to inform treatment of the patient. The GOS does not provide a long term prognosis for brain injury as over time and with rehabilitation improvements can be made past what is predicted. Due to the time period necessary for GOS to be more accurately applied, the GCS can be used for the interim on a general scale in order to infer the likely GOC score a patient may receive. This score will be linked to other factors such as age, pupil dilation and presence of a midline shift on computer tomography, in addition to initial GCS score.18 To conclude the GCS and GOS are vital in identifying the severity of brain injury and are still the most used scales for their purpose due to their simplicity and acceptable reliability. The use of these scales in brain injury prognosis helps direct treatment for individual patients, and allows realistic individual rehabilitation goals to be made for that individual. References [1]Hodgkinson D, Berry E, Yates D. 1994, Mild head injury – a positive approach to management, European Journal of Emergency Medicine, 1(1), 9-12 [2] Moppett I. 2007, Traumatic brain injury: assessment, resuscitation and early management, British Journal of Anaesthesia, 99(1), 18-31 [3] Roozenbeek B, Maas A, Menon D. 2013, Changing patterns in the epidemiology of traumatic brain injury, Nature Reviews Neurology, 9(4), 231-236 [4] Swann I, Walker A. 2001, Who cares for the patient with head injury now?, Emergency Medicine, 18(5), 352-357 [5] National Institute for Health and Clinical Excellence (NICE) 2014 Head Injury; Triage, assessment, investigation and early management of head injury in children, young people and adults Available at: http://www.nice.org.uk/guidance/cg176/resources/guidance-head-injury-pdf (Accessed 18/03/2015) [6] Chieregato A, Martino C, Pransani V, Nori G, Russo E, Simini B et al. 2010, Classification of traumatic brain injury: the Glasgow Coma Scale is not enough, Acta Anaesthesiologica Scandanavica,  54(6), 696-702 [7] Kushner D, Johnson-Greene D. 2014, Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury, Journal of Rehabilitation Research Development, 57(7), 1057-1068 [8] Murray G, Teasdale G, Braakman R et al. 1999, The European Brain Injury Consortium survey of head injuries, Acta neurochirurgica, 141(3), 223-236 [9] Rowley G, Fielding K. 1991, Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users, Lancet, 337(8740), 535-538 [10] McLernon S. 2014, The Glasgow Coma Scale 40 years on: A review of its practical use, British Journal od Neuroscience Nursing, 10(4), 179-184 [11]  Lingsma H, Roozenbeek B, Steyerberg E, Murray G, Maas A. 2010, Early prognosis in traumatic brain injury: from prophecies to predictions, Lancet Neurology 9(5), 543-554 [12] Singh B, Murad H, Prokop L, Erwin P, Wang Z, Parsaik A, et al. 2013, Meta-analysis of Glasgow Coma Score and Simplified Motor Score in predicting traumatic brain injury outcomes, Brain Injury, 27(3), 293-300 [13] Thornhill S, Teasdale G, Murray G, McEwan J, Roy C, Penny K. 2000, Disability in young people and adults one year after head injury: prospective cohort study, British Medical Journal 320(7250), 1631-1635 [14] Maas A, Stocchetti N, Bullock R. 2008, Moderate and severe traumatic brain injury in adults, the Lancet Neurology, 7(8), 728-741 [15]  Udekwu P, Kromhout-Schiro S, Vaslef S, Baker C, Oller D. 2004, Glasgow coma scales score, mortality, and functional outcome in head-injured patients, Journal of Trauma and Acute Care Surgey, 56(5), 1084-1089 [16] Woischneck D, Firsching R, Schmitz B, Kapapa T. 2013, The prognostic reliability of the Glasgow Coma Scale in traumatic brain injuries: evaluation of MRI data, European Journal of Trauma and Emergency Surgery, 39(1), 79-86 [17] Utomo W, Gabbe B, Simpson P, Cameron P. 2009, Predictors of in-hospital mortality and 6-moth functional outcomes in older adults after moderate to severe brain injury, Injury, 40(9), 973-977 [18]  Husson E, Ribbers G, Willemse-van Son A, Stam H. 2010, Prognosis of six-month functioning after moderate to severe traumatic brain injury: A systematic review of prospective cohort studies, Journal of Rehabilitation Medicine, 42(1), 425-436 [19]  Brooks D, Hosie J, Bond M, Jennett B, Aughton M. 1986, Cognitive sequelae of severe head injury I relation to the Glasgow Outcome Scale, Journal of Neurological and Neurosurgical Psychiatry, 49(5), 549-553 [20] Jourdan c, Bosserelle V, Azerad S, Ghout I, Bayen E, Aegerter P, Weiss J, Mateo J, Lescot T, Vigue B, Razarourte K, Pradat-Diehl P, Azouvi P. 2013, Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury: results from PariS-TBI study, Brain Injury, 27(9), 1000-1007 [21] Wilson J, Pettigrew L, Teasdale G. 1998, Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: Guidelines for their use, Journal of Neuro-trauma, 15(8), 573-587 [22] Nalt J. 2001, Prediction of outcome in mild to moderate head injury: A review, Journal of Clinical and Experimental Neuropsychology, 23(6), 837-851 [23] : Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following major head injury: Coma scales and checklists, Injury, 42(3), 281-287 [24] Oh H, Seo W. 2013, Development of a decision tree analysis model that predicts recovery from acute brain injury , Japan Journal of Nursing Science, 10(1), 89-97

Gangs and Violence in The Prison System Essay -- Criminal Justice

Gangs and Violence in the Prison System Introduction Gang violence is nationwide and is one of the most prominent problems in the prison system today. Gangs are known to attempt to control the prisons/jails, instill fear within the prison system and throughout the society, and bring negative attention to the system. â€Å"Gang affiliated inmates comprise about 18 percent of the 18000 inmate population.†(Seabrook) A growing numbers of inmates and a large amount of them serving longer sentences for violent crimes suggest a notable increase in gangs and violence in the prison system in the upcoming future. History â€Å"Prisons began to bulge with gang members when states enacted tougher laws for gang-related crime in the mid to late 1980s.†(Martinez) On one hand the laws enacted helped get gang members off the street, but in another way it backfired by not stopping the gangs’ activity. â€Å"In many ways their number and power grew even more in prison.†(Martinez) The problem of gangs and violence has been addressed many times throughout the years by the United States Correctional Board but the board has yet to take the problem seriously. Background Most gang members in prisons are introduced to the â€Å"gang life† at an early age and enter prison a member, but some become a member once behind bars mainly for the protection the gangs are known to provide. Gangs are known to purposely intimidate other inmates, thus reinforcing the reason why â€Å"one out of every ten male inmates† becomes a member once behind bars. (Knox) Most of the people who enter prison a member were sentenced for drug offenses. Prison gangs are well known for the handling of illegal substances, alcohol, or tobacco inside the correctional facilities, this is only a ... ... of Gangs and Security Threat Groups." National Gang Crime Research Center. 2005. Web. 28 Jan. 2012. . Martinez, Pila. "Novel Attempt to Curb Prison Gang Violence." The Christian Science Monitor. The Christian Science Monitor, 1 July 1999. Web. 28 Jan. 2012. . "Prison Gangs -- Gangs and Security Threat Group Awareness." Florida Department of Corrections. Florida Department of Corrections. Web. 28 Jan. 2012. . Seabrook, Norman. "Prison Violence on the Rise." USA Today. Buisness Library, Sept. 2005. Web. 28 Jan. 2012. . Yanez, Dominick. â€Å"Security Threat Group’s in the Correctional System Overview.† Sam Houston State University, Huntsville. 13 April. 2012. Lecture.

Essay --

Marxism and Christianity are two influential doctrines which have shaped our world in profound ways. While they differ on certain fronts, one cannot help but wonder that if there were some way that the two could coexist, that their synthesis could change the course of humanity inevitably. This discussion will be divided into two sections. The first one will be a brief summary and critique of Karl Marx’s rejection of religion, Contribution to the Critique of Hegel’s Philosophy of Right. By dissecting this piece, it is hoped that we may cast doubt on its effectiveness; in the process of rejecting religion, Marx may have excluded many potential supporters from his revolutionary cause. As well, an attempt will be made to propose that atheism should no longer be a necessary central tenet of Marxism. The second section will be concerned with providing evidence of both early and contemporary Christian teachings which mirror Marxist principles. Finally, our discussion will turn briefly to Liberation Theology to confirm that Marxist and Christian schools can, and do converge. By pursuing these ends, this analysis will show that, at a fundamental level, Christianity shares many core principles with Marxism, and as such, Marxists are misguided in their dogmati c and mechanical rejection of religion and more specifically, of Christianity. For Marxists to realise their goal of a classless society that is based upon equality and justice, they must be more inclusive and allow those who practice religion, especially Christians who share similar aims, into their revolutionary dialogue. In his criticism of Hegel’s Idealism, Marx asserts that religious devotion represents a, â€Å"reversed world consciousness† , the result of wh... ... that both Marxists and Christians are concerned with the perils of human alienation and that each doctrine’s prescription to cure its causes is similar. Finally, Liberation Theology proves that Marxist and Christian ideals can synthesise and that their intercourse has created a new and possibly revolutionary stage of human existence. Christianity and Marxism both seem to have become detached from their original aims, which were to provide a method by which humanity may achieve the best possible life; for both, this will be realised through the practice of mutual aid, equality and love. All other points of contention between them seem polemical and counter revolutionary. One 20th century Christian revolutionary wrote that, â€Å"solidarity, in spite of all divergences, is absolutely essential if a revolutionary project is to be successful.† That is indeed the case.

Kroger Company Case Analysis Essay

A. Case Abstract This is a comprehensive strategic management case that includes the company’s financial statements, organization chart, competitor information, and industry trends. Sufficient internal and external data are provided to enable students to evaluate current strategies and recommend a three-year strategic plan for the company. The Kroger Company, Inc., with headquarters in Cincinnati, Ohio (513-762-4000), operates over 2,500 supermarkets, 795 convenience stores, and 436 jewelry stores. The Kroger Company employs approximately 290,000 employees. The company achieved annual revenues of $56.4 million in fiscal year ending February 2005, compared to $53.7 million in 2004. Kroger is ranked #19 on the Fortune 500 list and is ranked as the third largest retailer in the world, behind Wal-Mart (#1) and the Home Depot (#2). The company has been in existence for over one hundred years and is the # 1 pure grocery chain in the United States with over 3,770 (including subsidiary businesses) sto res in 32 states. Kroger and its subsidiary operations market food, pharmacy, and jewelry products. B. Vision Statement (proposed) Our vision is to be America’s supermarket, and to continue to provide innovation and unparalleled value to our customers, employees, and shareholders. C. Mission Statement (actual) Our mission is to be a leader in the distribution and merchandising of food, pharmacy, health and personal care items, seasonal merchandise, and related products and services. (proposed) 1. Provide the freshest food, highest quality products, and exceptional service to our customers all at reasonable prices; 2. Be a leader in the distribution and merchandising of food, pharmacy, health and personal care  items, seasonal merchandise, and related products and services; 3. Strive to have a prominent, profitable presence and positive name recognition in all 50 states and the District of Columbia; 4. Employ the latest and most innovative technology to improve distribution, enhance customer service, anticipate customer needs, cut costs, and compete using an arsenal of consumer data; 5. Continuously review the performance of each and every Kroger store, manufacturing facility, employee, and private label product to insure that every element of the company is contributing to its growth and financial strength; 6. Hold fast to our corporate values of honesty, integrity, respect for others, diversity, safety, and inclusion; 7. Uphold the motto of our founder, â€Å"Be partic ular. Never sell anything you would not want yourself.† 8. Contribute generously to causes that relieve hunger and provide medicine to the poor; and 9. Compensate our employees in a manner that is consistent with the exceptionally high quality of customer service that is expected of them, striving to maintain positive relationships with the labor unions that represent our many associates across the country. This mission statement incorporates all aspects of the company’s interests. The first point relates to the fact that Kroger must differentiate itself on the basis of fresh food, high quality products, and exceptional service. In this respect, Kroger has a strategic advantage, since rivals like Wal-Mart are weak on customer service, and since Kroger manufactures many of its own items, it therefore has more control over quality and prices. The third point is important since Kroger now has a very weak presence on the East Coast. Kroger is missing opportunities by not having grocery stores in places like New Jersey, Maryland, and Florida. The fourth point is supported by Kroger’s new relationship with dunnhumby, a database management company from the United Kingdom, which is partnering with Kroger to better utilize consumer information to improve sales. This is an overwhelming strength against Wal-Mart, which does not even issue loyalty cards to its customers, and therefore, does not have access to nearly as vast a customer database as Kroger does. Point five is key, since Kroger must have the management dexterity and courage to close underperforming stores, execute make-versus-buy decisions, and implement enterprise-wide changes quickly when necessary. D. Class Discussion Questions and Issues 1. Considering Kroger’s current position in the industry, would you advise an international expansion strategy? If so, in what international market(s)? How would you suggest entrance with respect to location selections and number of units? Currently, Kroger has no existence in international markets, it would be advisable for Kroger to enter, perhaps Mexico and/or Canada, with a limited number of locations so it can test and strengthen the market at one or both international arenas. While Wal-Mart seems to exist everywhere, Canada is a promising economy to test 3 to 5 store locations. 2. If international expansion is one recommended strategy, discuss the pros and cons of considering hiring expatriate leadership/management teams. Leading/operating in international markets requires a thorough cultural understanding of the respective country. It’s difficult for expatriates to serve in such a capacity without having a conceptualization of the culture. It is advisable to recruit local leaders from the countries and perhaps examine local operational functions to ensure they are adaptable to business/cultural standards abroad. The use of expatriates can be considered a strength as they are aware of the corporate functions/culture and can operate with minimal direction abroad. 3. Discuss cultural diversity/sensitivity management, as it applies to Kroger Company, Inc. How might it differ and what should Kroger consider/incorporate if international expansion efforts are proposed? Cultural diversity is critical regarding workforce. Kroger should consider recruiting proposed international market leaders and training them at their headquarters. This would constitute leadership that represents the sociological culture of a respective country coupled with the values/operational functions of headquarters as a result of training, etc.  There is more of a ‘buy-in’ when local cultural leaders are in power, where transfer of objectives would take place much easier. 4. Discuss how Kroger can take advantage of the concept of synergy. Kroger operates over 40 manufacturing facilities and should continue to focus on this business to operate the system more lean, where it can achieve optimal operating costs, converting to manufacturing savings and better pricing for consumers relating to corporate brand (55%) goods (www.kroger.com). Moreover, Kroger can benefit from manufacturing dairy/bakery, etc., goods at a reduced price that it sells in its grocery stores, which can be considered a strategic advantage. 5. How can Kroger, if at all, keep competitors at a distance? In your response discuss expansion in the United States, abroad, product line(s), and portfolio management. Kroger should continue to focus on its core business, grocery, by identifying emerging markets (population > 20,000) and expanding. Additionally, continue to focus on product lines (grocery), with respect to buying power and sales. Incorporate more self-checkout units in stores to cut employee costs. Also, expand the jewelry business into more states and perhaps consider international expansion into Mexico and/or Canada too. 6. How effective is the â€Å"Strategic Growth Plan†? Would you change and/or recommend any additions? The growth plan in its current state is worthy; however, should include specific language/objectives with respect to international expansion to better compete with rival competitors. The focus should be to operate more lean and expand businesses that are achieving lucrative sales. 7. What influence, if any, may consumer purchasing behavior affect an organization’s (grocery retail) considerations to transition abroad? Please discuss: Specialty outlets, such as butcher/meat shops, produce and flower outdoor markets, etc. Sociological factors, such as diet and grocery purchasing frequencies, etc. Kroger should always focus on behavior patterns of consumers; one way to monitor this may be by use of a â€Å"club card† where consumer transactions are able to be recorded and reviewed. This is especially valuable abroad as behavior patterns are obviously different, simply just by physically noticing what is purchased and the quantity also. In Europe, butcher, flower markets, and outdoor produce markets are all highly common, where prices are lower as a result of operating expenses are being trimmed. Moreover, a greater part of the world (Asia and Europe) consumption patterns are minimal compared to the United States. It is common for consumers to visit the grocery store to purchase enough items to store in a shopping basket, as opposed to an average shopping visit in the United States which may require the use of a shopping cart. Obesity factors should be considered too. E. External Audit Opportunities 1. Supermarket sales of drugs grew 6.9% to $27 billion in 2004. 2. Wal-Mart has a large, recruitable low-paid, nonunion workforce. 3. Organic food sales are up 19.5% annually over the last 5 years. 4. Hispanic shoppers spend $117/week vs. $87/week average on groceries. 5. Hispanic population growth rate = 13% = 4X average. 6. Margins for private-label products are 35-45% vs. 27% for national brands. 7. 87% of consumers have tried private-label products. Threats 1. Traditional drugstores are focusing on customer service and merchandising. 2. Mail-order pharmacies are the fastest-growing format in the industry (up  17.9%). 3. Health plans allow larger supplies of drugs for Mail-order pharmacies. 4. Drug price inflation has led to illegal drug importation. 5. Supercenters are dominating the market share of grocery sales. 6. Wal-Mart is tops in logistics technology.  7. Labor costs account for >50% of operating expenses.  8. Price pressure was the cause of the Southern California strikes.

Palm Inc – from handhelds to smart phones

From Handheld to smart phones. The pioneers of Palm Inc. Palm had been the leader in the market of hand-held computers with high market share and profitability as well as a brand name recognition level to which many other firms could only dream. Palm's brand has faded substantially and as of April 2010, the company was acquired by HP for $ 1 -B. Below , I have listed Palm Inch's list of errors that the organization made over Its life cycle and necessary recommendations. Error 1 . Palm Inc. Did not establish a great enough sense of urgency. Since Palm Inc. ‘s inception, no formal business strategy was designed and implemented.Based on the â€Å"Ecology Theory† Palm Inc. Entered the market as a r-Specialist and eventually transited as a K-generalist, by approaching different product markets. However, Palm Inc. Failed to be successful as a k-generalist due to operating with outdated skills and competencies. The company has failed to examine the market and competitive realit ies for potential crises and untapped opportunities. Palm's efforts stopped at the PDA product, while the competition has managed to find ways of implementing he Pad's features Into cell phones market. Error 2. Palm did not create a powerful enough gulden coalition.Based upon the â€Å"Institutional Theory† firms that do survive – they become legitimate In the eyes of the shareholders. Chances of survival increase by adopting the rules and codes of conduct found In the Institutional environment. Despite having started as the industry leader, Palm's development over the years did not look as rosy. Palm failed to get the shareholders, board of directors, senior management and even a customer representatives together to help them evolve a shared assessment of their company problems and opportunities, and create a minimum level of trust and communication.Error 3. Lack of vision. Palm had no clear vision – of what was the picture of the future that the company wanted to achieve ( product , customer target,etc). The company changed its name several times , and also changed its vision and strategy. From the case, we know there was no new product offerings during 2001 thru 2008. At the same time, other competitors Injected the marketplace with new Innovations, Palm gradually became a small and marginalia player In the Industry. The Innovation Is the basic power of the company,but Palm doesn't have the strong impetus. Demographic change.Customers and clients that are being targeted are ever changing. In earlier times, smart phones were necessary for business members who would need to keep up with e-mail. However, these days there is the prevalence of a much younger generation using smart phones for a variety of reasons (social networking, picture taking, communication etc. ). Palm Inc. Must adapt with these changes and keep up with the demographic changes of its relevant customers. Palm Inc. Needs to create a Sino to direct the change and effort bu t also to develop strategies for realizing that vision.It Is essential that the organization communicate the vision both inside the company as well as with their partners. Error 4. Under communicating the vision help If they believe that useful change Is possible. Without credible communication the hearts and minds are never captured. It is imperative that Palm Inc. Established Also ,employees and managers from all levels of the organization adopt the change. In 2001 Palm Inc. Initiated a radical internal restructuring and decided to reduce the cost base making the first-ever layoffs.Microsoft had reduced staff during the technology recession too , but they made more research money available for developing mobile software – But Palm Inc. Failed this aspect. Error 5. Not removing obstacles to the new vision. Palm Inc needed to empower other to act on the vision by creating a value proposition for employees. In 2001 Palm Inc. Initiated an internal restructuring by separating th e hardware and software divisions into two distinct units. The split resolved the inherent conflict of interest by licensing software or its win competitors in the hardware market.The hardware innovations were features that could be added to the phones and music players. Palm spent too much cash to develop the new SO and new smart phone. And the marketing capitalization is much shorter than the competitor. This situation causes Palm to not balance the money within each department. So the whole company can't run efficiently. For example, Palm can't self-finance marketing campaigns and in-store training of sale staff. In 2003 Pal Inc. Decided to spin off the software business and to use the raised cash to rather invest into the development of new smoothness.Palm Inc. Could have saved time and money by completely focusing on smart phones. Palm can't bring up the effective marketing strategy. The price of a new phone is more expensive than the ‘phone. The competitiveness is tiny t han other brands. After failing to seizing the market with new phone, Palm made an â€Å"attractive† product bundle on its phone. That turns out to be stressful to Palm. Failure of negotiation ability. Nevertheless Palm's new product was delayed because of certification issues with the carrier. At the same mime, Palm has a conflict with the dealer. Error 6.Plan for and create short term goals. In 2001 Palm Inc. Initiated an internal restructuring by separating the hardware and software divisions into two distinct units. The spiff produced good short-term results and due to high quality the software was used in phones for some time. In 2004 Palmate devoted more resources to smoothness and expanded Tree Family . The new Tree series was relatively successful with good margins. Error 7. Declaring victory too soon. After a few years of hard work, managers got tempted to Clare victory with the first clear performance improvement.Palm had a huge success in 2006, with the Tree series . Tree smart phones let Palm earned 30 percent of market share in the United States and brought Palm back to life. Having this success experience, Palm could have used this experience to bring out more great ideas and make them come true. However, between 2007 and 2009 new Palm product launches were rare, while the demand for the Tree and Centre fell quickly or never took off as expected. Error 8. Not anchoring changes in the corporation's culture.Until new behaviors are rooted in social norms and shared values, they are subject to degradation as soon as the pressure for change is removed. In order to overcome this issue many organizations need to invest in leadership development and succession plans consistent with the new approach. Recommendations : 1 . Apply R skills in new areas and diversify Palm's business : operating system know how could have been ported to other applications and platforms. E. G. : Possibility to enter new related businesses with high market growth rates: Ta blets, Notebooks. 2.Overcome entry barriers in the smartened market: increase the negotiation power by teaming up with major players like Samsung. 3. Limiting their development and costs by encouraging the open source development community to develop applications. 4. Entering other market segments by making use of Palm's â€Å"know how' by starting to develop commercial applications for other smartened operating systems. Fill smaller niches in the smartened market with respect to general environment forces: Coloratura and Political and Legal Forces: Smartened operating systems with high data regulations for users with sensitive data.As the fear of theft of personal information's or sensitive data is rising in certain groups of society (e. G. Decision makers like politicians and managers). Demographic Forces: Senior Friendly Smoothness for aging societies with health or special care features. Remote GAPS tracking, monitoring and streaming of health parameters to doctors and relative s. Global Forces: Provide a low-cost operating system which runs on cost effective hardware for the growing low income population of the world (Reverse Innovation). 5. Invest in leadership development and succession plans consistent with the new strategy.

“The Street” by Ann Petry Essay

In this novel, The Street by Ann Petry, tells just how hard life can be on the streets of Harlem. Reading Petry’s Novel, I mentally put myself in the shoes of, Lutie Johnson. Lutie is an African American woman who is also a single mother. Lutie tries her best to provide the best life she can for her and her son, Bub. Lutie experiences racism in the novel, and also discrimination and sexism. To get the life that she wants for herself and for Bub, Lutie must make some very hard decisions. This book took me through all the hard work and steps that Lutie must make and go through to make her and her son’s life better. This novel begins in November 1944, a cold and windy day in New York City. Petry glorifies the tendency for human independence by developing a plot in which she has to provide for her and her son all by herself, she is put threw racism, sexism, and hardship. The Street is a classic example of Petry’s naturalistic talent. Petry illuminates the anger, frustration, and resignation felt by Negroes during World War II. The story is written in the third person omniscient point of view. Although Lutie is the main character in the novel, Petry provides powerful insight into the lives of Bub, Min, Jones, Mrs. Hedges, and Boots. Each character’s point of view weaves together with the others to better show what a devastating impact racism, poverty, and gender had during that timeframe. The adult male characters in the story show what little respect they hold for women. They see the women as little more than sex objects. The women in the story show how their past experiences and current circumstances makes it virtually impossible for a black woman to ever achieve anything more than what they have managed to achieve thus far. In our society of today, there are many images that are portrayed through media and through personal experience that speak to the issues of black motherhood, marriage and the black family. Wherever one turns, there is the image of the black woman in the projects and very rarely the image of successful black women. Even when these positive images are portrayed, it is almost in a manner that speaks to the supposed inferiority of black women. Women, black women in particular, are placed into a society that marginalizes and controls many of the aspects of a black woman’s life. Therefore, many black women do not see a source of opportunity, a way to escape the statistics of their everyday existence. For example, if I were to ask a black mother if she would change her situation if it became possible to do so, some women would change, but others would say that it is not possible; This answer would be the result of living in a society that has conditioned black women to accept their lots in lives instead of fighting against the system. A lot of women today fall victim to system and actually content with that life style. If more women had the amount of determination that Lutie Johnson had it would defenliaty be a lot more successful black women in today’s society. The reason I chose Ann Petry, novel; was because the message that she is sending is real, granted this novel was written in the 1940s, the same experiences that she had to face, black women are still dealing with them today. The only differences are the black women in today’s society lack the drive and determination of Lutie. I personally see young black females go though the same issues, but now days they are looking for the easy way out. Which would more than likely be, Mrs. Hedges, a older lady in Lutie apartment building who runs a little whore house. â€Å"If you live on this damn street you’re supposed to want to earn a little extra money sleeping around nights. With nice white gentlemen.† Chapter 3, Pg 86 So in order to make a long story short, Ann Petry novel Street, portrays, realism The tendency to view or represent things as they really are. The meaning of realism and the novel goes hand and hand. The novel was very much straight forward; or maybe it was just easy to understand the struggle that Lutie was in counting, is the same thing a lot of females that I know personally got though every day. That moment when you can read something or see something, and it makes you remember; that just when you think that you have it bad, it always someone who has it even worst. In Lutie case no matter how hard she tries to get her head above water, it always something to drag her rite back down. So I say that to say this, â€Å"you never know the hand that you being dealt, but you have to play to win.†

Prejudice and the Colonial Condition in Post-Colonial Caribbean Essay

Prejudice and the Colonial Condition in Post-Colonial Caribbean Literature - Essay Example This approach has also built strong prejudices towards a certain community. The stereotype about certain people, culture and community inclines towards hatred, atrocity among different community. In the research paper the racial prejudice has been discussed thoroughly in context to colonialism. For the study, the three major literary works have been taken for discussion. They are â€Å"Small Island,† by Andrea Levy, â€Å"In the Castle of My Skin,† by George Lammings and a memoir of Jamaica Kindcaid called â€Å"A Small Place.† The three novels focus on the stereotypical view and bigotry among the colonizers and colonized people. Various characters from these books are the representatives of the contemporary human psyche. It’s a struggle between masters and slaves, between hatred and helplessness, between colonizers and colonized. The writers want to focus that the colonialism is a psyche and it will take a long time to disappear it from the minds of the c olonized. Colonization suppressed self-respect, self-identity, and local religion of the native people of the colonies. With the help of other references, the paper throws the light on the racism, prejudices of both colonizers and colonized, and the colonial and post-colonial situation in the Caribbean Islands. Racial prejudice has been a sinister social disease, spread all over the world for centuries. So called advanced White people still are backward in their views, intolerant and narrow minded towards the people from other race. The racial prejudice is the consequence of the differences in hair colour, eye colour, facial structure, size of limb and most important the skin colour. Racial prejudice takes place when people are judged on the basis of their superficial character and outward appearance. In American history the racial prejudice resulted into the exploitation of black people. During Second World War, Hitler had an extreme hatred towards Jew community. It resulted into relentless atrocities towards black people and Jews. To remove this social stigma, the modern societies have drafted and enacted various laws and statute to ensure that all the people from different races should get respect and should be considered equal. The racism has become one of the hot topics for debate espe cially after the Second World War. Caribbean islands had previously been the one of the major colonies of British Empire. Much has been written on colonial condition and racial prejudice in Caribbean literature. The authors like Laura Niesen De Aruna have written about racist and imperialist current in Caribbean literature. Frances A. Della Cava and Madeline H. Engel also have given examples of racial prejudice against Blacks, Jews, and Women in their fiction. After World War II people from Caribbean island were migrating to England. The impression about England was very noble among its colonies. They called England as â€Å"Mother Country,† but when they came on the land they found that they had no value in Britain and they were been treated as aliens. Our study throws light upon the post colonial racism and racial prejudices. The stigma of racial discrimination has been reflected in post colonial Caribbean Literature. The problems of immigration, the insecure feeling, uncer tainty and biased, bigotry approach of English community towards the migrants had been the major issues depicted by the authors like Andrea Levy, George Lammings, Jamaica Kindcald and other writers. Keywords: Caribbean literature, racial prejudice, colonial conditions, bigotry, immigration During the World War II, the British colonies had no choice but to hold up with their masters, their British Empire. The colonized, for British people