Causes of Hypothyroidism

Causes of Hypothyroidism INTRODUCTION Hypothyroidism is the most common prevailing endocrine disorder among all endocrine maladies. It is an altered metabolic state, when the body produces insufficient amount of thyroid hormone. Hypothyroidism is not only a disorder of endocrine system, it also affects almost all the organ system of our body. It shows a wide range of disease severity from asymptomatic state to coma and made it an elusive clinical entity9 . Thyroid hormone in addition to governing the rate of metabolism of fats, carbohydrates and proteins, it also regulates the timing and pace of the CNS development. It is extremely important for the growth of cerebral , cerebellar cortex, axonal proliferation, branching of dendrites, synaptogenesis, and myelination . Thyroid hormone enhances the wakefulness, response to various stimuli like auditory sensation, learning and memory capacity1. By enhancing the gene expression it influences the synthesis of myelin. Myelin synthesis is an important factor determining the speed of impulse transmission along the complex neural pathway which mediates the evoked potential3 . Sometimes hypothyroidism is referred to as â€Å"Silent Disease† because the early stage of disease it is asymptomatic. About 1.6 billion people are at risk of getting thyroid disorders worldwide4. According to NHANES III approximately 4 – 5% of population in the developed world is suffering from hypothyroidism and about 4 – 15% of people by subclinical hypothyroidism5 . In a developing country like India, iodine deficiency is the most common cause of hypothyroidism. In India, hypothyroidism is classified under the group of Iodine Deficient Disorder (IDD) 6. Since 1983 India has been following the Universal Salt Iodization Programme. As a result of it, there has been a decline in the prevalence of IDD 7. In 2004, WHO assessment of global iodine status documented that India has optimal iodine nutrition and now India is undergoing transition from iodine deficiency to sufficiency phase8 . But a nationwide comprehensive epidemiological study done in the eight cities of India found that the prevalence of hypothyroidism was 10.95%. One third of them (3.47%) are not even aware of their disease. Subclinical Hypothyroidism was observed in 8.02% of people. Females are more prone to have hypothyroidism than males (15.86% to 5.02%). Unnikrishnan AG et al has also observed high prevalence of hypothyroidism among the Indian adult population6 . The well-known symptoms and signs of hypothyroidism are dry skin, weight gain, cold intolerance, muscle cramps, hoarseness of voice and constipation10 . As thyroid hormone is essential for the nervous system maturation , central and peripheral nervous system dysfunctions are also important consequences of hypothyroidism. About 60 – 90% of the patients may have features of peripheral nervous system dysfunction like weakness, paraesthesia and postural imbalance . The CNS manifestations of hypothyroidism seen in 60 to 80% of patients which include delayed mentation, sensory deficits, depression11 . It also produces delay in the neuronal conduction velocity, alterations in hearing threshold and sensation of smell . All these neurological complications of hypothyroidism will resolve completely with thyroid hormone replacement especially when diagnosed at the early stage12. The peripheral nervous system dysfunction has been studied in hypothyroid patients by a variety of techniques. But the studies in favor of quantification of CNS dysfunction were very sparse. The CNS involvement in hypothyroid patients can be identified with the help of existing advanced electrophysiological studies. Among the electrophysiological studies evoked potentials provide a more reliable and objective measure of the functional integrity of the related sensory pathway13 . Among the various evoked potentials tests, Brainstem Evoked Response Audiometry (BERA) has been emerged as an effective method of revealing the involvement of auditory pathway even in asymptomatic stage itself11 . Brainstem Evoked Auditory Response are produced in response to brief auditory stimulation14,15 . In this technique following a brief acoustic stimulus, a series of potentials are generated which corresponds to the sequential activation of peripheral, pontomedullary, pontine and midbrain portion of auditory pathway. So BERA helps to evaluate the integrity of the auditory pathway13 . Persons who are having abnormal brainstem response to auditory stimuli more prone to develop Sensorineural Hearing loss16 . In 1948 Means states that Hearing loss is one of the troublesome symptom of hypothyroidism and it may be conductive, sensorineural or mixed hearing loss. About 25 to 30% of the hypothyroid patients having loss, but the exact incidence not yet known. So many researchers did study to find the type of hearing loss in hypothyroid patients. Howarth and Lloyd proposed that perceptive deafness is the type of hearing loss in hypothyroidism. (9) Rau et al, Bhatia et al, Von’t Hoff and Stuart , Parving et al and Isam et al were also accepted that sensorineural hearing loss was the predominant type of hearing loss in hypothyroidism people. Malik et al said that the site of lesion in auditory pathway remains speculative , may be at several levels viz in the middle ear, at cochlea and retrocochlear sites 17. The integrity of the auditory pathway is essential for the capture of the acoustic signal by the external ear to the coding of signals in the auditory cortex13 . Hearing loss is an invisible abnormality which will lead to so many devastating consequences in interpersonal communication, psychosocial wellbeing, quality of life and economic independence. Hearing loss in infants and children due to congenital hypothyroidism results in serious impairment in language, communication skills, cognitive and emotional development. In adults hearing loss will lead to loneliness, social isolation, psychiatric disturbances, depression, occupational stress and relatively low earnings18. There are literatures pointing out that early treatment of hypothyroidism will reverse the hearing loss 19-22. Electrophysiological testing for finding the functional integrity of auditory pathway is rarely performed in hypothyroid patients in neurology and otolaryngology practice. Now a days BAER is mainly used for screening the preterm infants and also prior to cochlear implantation. But it was proved that the delay in the auditory processing time may provide the information about the subclinical involvement of central as well as peripheral neuropathy in hypothyroid individuals 8. So they can be used to assess both normal and abnormal auditory function in the field of research. So that BERA can be used as a screening test to find the CNS involvement and the hearing loss in hypothyroid patients even in the earlier stage itself. In this study an endeavor has been made to find the changes in the brainstem auditory evoked responses in newly diagnosed hypothyroid individuals.

Majestica Hotel In Shanghai Essay

Majestica, a luxury hotel management service business began in 1970 in Western Europe. Majestica gradually expand to United Kingdom, United States, North America, Asia and so on. After a gradual expansion in Asia, Majestica become the world’s largest operators of luxury hotel and resort. Majestica earn by hotel ownership operation and hotel management but last five years they are concerning to managing hotel. All over the world, owner and developer of luxury hotels are attracted by Majestica because of their excellent quality. Their key success factor is management pointed to a service culture that they had fostered for decade. Moreover, their service culture is personal service oriented. Majestica’s try best to delight their customer by response to unusual request of the guest. This unique service culture leads Majestica to icon in hotel management business in the world. They had two strategies to expand their business those are cautious to increase number of hotel and resort in their portfolio and operating philosophy. In Asia pacific region Majestica didn’t take first moving advantage because of high cost to established new industry and they didn’t convince about political situation stability and existence of service culture. Majestica follow other major international luxury hotel chain and enter in Asian market. In 1990, Majestica changed its strategy to enter Asian market because it was the alarming time for them. China becoming the most competitive hotel industry and china’s economic develop and open door policy leads to china the second largest foreign direct investment recipient in the world. Finally, Majestica took the right decision to change strategy and enter in Asia’s largest competitive hotel business market. China was sixth most popular destination for business and tourist and would be first positioned by 2020. In 2004, there were 423 hotels with 68000 rooms which expected to increase 11 percent by 2005. Shanghai Tourism Administrative Commission also forecast that tourist visiting will increase by 5 percent. Mid 1998 international luxury hotel chains took the advantage of changed government policy soon they took place in Shanghai. Shangri-la, Hyatt international etc established and imbued thoroughly Shanghai luxury hotel market. On that time Shanghai was the best location for Majestica because of market demand, future benefit, resource, competition as well as government policy. While CPS was publicly listed in Hong Kong gave Majestica more confidence about business transparency and independence from government influence. Majestica’s excellent performance and reputation attracted CPS and property owner to invest in Shanghai. As a result Majestica and CPS signed an intent and start negotiation. The challenging issue was the length of the contract and the control over the management of the hotel. First of all, Majestica wants the agreement for 55 years while it was 10 years normal hotel management term in china. So both CPS and Majestica had to change their policy and agreed to 30 years operation period with a option to extend operation period. Secondly, Majestica expect to design and construct by their senior people while CPS interfere to take decision. Than Majestica convince CPS that it is important to take senior people to keep chain of consistency of a world class luxury hotel construction. Selecting the name of the hotel, Majestica don’t want to compromise. Then, Majestica want experienced person as general manager who will accountable for over all operation. CPS wants a Chinese person to be a general manager though there was not any enough experience Chinese person. Then about expatriates, CPS wishes Majestica to train the local employees and eventually use them to replace the expatriates. Then CPS requested to Majestica to take a Deputy General Manager. In negotiation, CPS suggested to Majestica for purchasing all necessity from the local market. Majestica disagreed to CPS for allowing access to hotel rooms because of confusion. Finally, Majestica want to appoint a third party to resolve any condition but CPS didn’t agree to interfere of a third from outside China. For foreign investment law of China Majestica had to take 25 percent equity by the Majestica had to change the upper limit minority investment policy. To increase the market share Majestica should relax its operating philosophy and take the opportunity to grave the leadership position in hotel industry  in the world. If Majestica could change their philosophy and business practice than not only china but it could lead whole world and become global. To take this position Majestica need to change their management policy, market segmentation, human resource policy and aggressive expansion of hotel operating business.

Example of Reflective Journal - 757 Words

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Definition and Examples of Rhetorical Schemes

Scheme is a term in classical rhetoric for any one of the figures of speech: a deviation from conventional word order. Here are examples of scheme in use by famous authors, as well as definitions from other texts: Examples and Observations Tom McArthur: Schemes include such devices as alliteration and assonance (that purposefully arrange sounds, as in The Leith police dismisseth us) and antithesis, chiasmus, climax, and anticlimax (that arrange words for effect, as in the cross-over phrasing One for all and all for one). Wolfgang G. MÃ ¼ller: There is a theory dating back to classical times that rhetorical figures or schemes originated as forms of expression used naturally by people in states of extreme emotion (Brinton 1988:163), that they are, in fact, imitative of emotional states. . . . Thus, rhetorical figures of omission, unusual word order or repetition are held to be imitative of actual disturbances of language in emotional contexts, which, in turn, reflect feelings and emotional states such as anger, grief, indignation or consternation... Now while it is undoubtedly true that such schemes as aposiopesis (breaking off an utterance before it is completed), hyperbaton or repetition are frequently related to emotional states, it must also be realised that the whole reservoir of rhetorical schemes represents a system which provides a multitude of possibilities of expressing meanings, among which emotions form only one variety. Functions of Schemes Chris Holcomb and M. Jimmie Killingsworth: In addition to structuring reality, the schemes help writers organize and orchestrate their relationships with readers. As vehicles for social interaction, they can: Signal the level of formality (high, middle, low) as well [as] local shifts across these levels;Control the emotional intensity of prose--cranking it up here, ratcheting it down there;Showcase the writers wit and command over his or her medium;Enlist readers into collaborative relationships, inviting them to desire the completion of a pattern once they get its gist (Burke, Rhetoric of Motives 58-59). Tropes and Schemes in The Garden of Eloquence Grant M. Boswell: [Henry] Peacham [in The Garden of Eloquence, 1577] divides his treatment of figurative language into tropes and schemes, the difference being that in the Trope there is a chaunge of signifycation, but not in the Scheme (sig. E1v). Tropes are further divided into tropes of words and sentences, and schemes are also divided into grammatical and rhetorical schemes. Grammatical schemes deviate from customs of speaking and writing and are subdivided into orthographical and syntactical schemes. Rhetorical schemes add distinction and doe take away the wearinesse of our common and dayly speach, and doe fashion a pleasant, sharpe, evident and gallant kinde of speaking, giving unto matters great strength, perspecuitie and grace (sig. H4v). Rhetorical schemes apply to words, sentences and amplification.