Beta Thalassemia: Causes and Treatments

Beta Thalassemia: Causes and Treatments Thalassemia is an inherited autosomal recessive blood disease that affects the bodys ability to produce haemoglobin, the protein that red blood cells use to carry oxygen. It reduces the rate of production of globin chains that make up haemoglobin, which are either alpha (ÃŽÂ ±) chain or beta(ÃŽÂ ²) chain. Beta-Thalassemia Major disorder occurs when both the beta globin chain are affected by mutation or deletion, resulting in the abnormalities in the formation, size and shape of red blood cell. Patients suffering from beta-thalassemia have to endure the pain from severe anemia, fatigue, enlarged spleen, and also bone problems besides jaundice. Thalassemia is found in almost every country worldwide, however it is more commonly found in Mediterranean and Asians. The data from the National Thalassemia Registry shows that currently there are 4,768 thalassemia patients registered in Malaysia. Based on the screening conducted by Ministry of Health, the carrier rate averages at about 5 %, which means about one in 20 Malaysians carry the thalassemia gene. The diagram attached in the next page shows an overview of the pathogenesis of ÃŽÂ ² thalassemia. Thalassemia can be treated and prevented by many different screening test and treatments. However, thalassemia is not curable yet. So, what are the current available treatments to help relieve the disorder symptoms? A POSSIBLE SOLUTION The treatment for thalassemia depends on the severity of the conditions. For example, people who are carriers or have a mild ÃŽÂ ± or ÃŽÂ ² thalassemia trait which usually does not have any symptoms, need little or no treatment. People with moderate and severe condition of thalassemia need treatments as soon as possible or else they are under dangerous situation that can cause fatal. BLOOD TRANSFUSION As the red blood cells of thalassemic patients are little and not healthy, it couldnt carry out its normal function of carrying oxygen efficiently which may cause the patient to have difficulties in breathing and other related problems. Therefore, the most effective treatment for these patients is blood transfusion therapy. Blood transfusion therapy is the main treatment for thalassemic patient. It is given through a needle into the vein, which gives healthy red blood cells with normal haemoglobin. Since the lifespan of the red blood cell for thalassemic patient is less than 120 days, the patient requires a regular blood transfusion. A person with moderate thalassemia needs blood transfusion when the body is under stress such as during infections. However, people with major thalassemia, Cooleys anemia, need more regular blood transfusion which is every 2 to 4 weeks.9 Basically, there are reasons why thalassemic patients need regular red blood cells transfusion. First of all, it is to correct anemia and make sure that tissues get normal amount of oxygen and carry out body functions. It is proven by research done by the scientists and doctors, where a thalassemic patient who receives a regular transfusion could live up to 50years compared to the one not receiving any treatment whom could survive only unti l childhood. Regular transfusion also helps to keep the haemoglobin level near normal and the production of ineffective haemoglobin could be stopped.7,12 This treatment helps to improve childs growth and well-being and usually prevents heart failure. 1 The blood transfusion in thalassemic patients is not the same as normal blood transfusion. As we know, blood contains different types of components and this component has its advantage that the components are in small volumes with higher concentrations of a particular product for specific indications. Therefore, thalassemic patients are given packed red blood cells instead of whole blood to improve the oxygen carrying capacity.13 However, regular blood transfusion leads to another medical problem known as iron overload. Regular blood transfusion creates an excess of iron in the body because the haemoglobin in red blood cell is an iron rich protein. As there is no natural way of eliminating it from the body, it is stored primarily in spleen, liver, endocrine organs, and heart, and becomes toxic in tissues and organ. Iron overload can cause these organs to malfunction and damages it if untreated.14,15,16 In order to remove the iron overload, a therapy known as iron chelation is done. A test called serum ferritin test is carried out to determine the amount of iron in the body as it is an important iron-storage protein. Injections of Desferrioxamine (Desferal) is given to the patient 5-7 nights per week with 8-12 hours supply which is done during sleeping time. It is injected under the skin from a small pump. Desferal works by carrying out excess iron through urine.22 Thus, iron level in the body can be reduced. So, in conclusion, the main treatment for thalassemic patients is regular blood transfusion and iron chelation therapy as blood transfusion makes the iron stored in the body overloaded. However, one sad thing about what thalassemic patients undergoes is that they started doing this since they are infant and continues this painful treatment for the rest of their lives and endure the side effects of both treatment. SOCIAL AND ECONOMIC IMPLICATIONS People suffering from thalassemia seem to have some emotional and psychological problems that disturb their routine lives. As we know, the people suffering from thalassemia have certain physical symptoms such as enlarged spleen which makes the stomach looks big and the head of the patient would be slightly in oval shape as the diploetic fibres in skull extend from the internal lamina. This makes them feel awkward and shy to meet people and other people also might look at them in different way. Based on the experience of Noor Hafiza Noor Hamdan, 33 a thalassemic patient interviewed for The Star newspaper, she said that : Before this, I was shy and solemn, and I did not like to smileà ¢Ã¢â€š ¬Ã‚ ¦. When people smile at me, I would ask myself, why? Maybe its because I have a sickness this lines are quoted from what she said in the interview. This shows that thalassemic patients lack of confidence and ashamed of themselves being in that condition, so they interact less with the public. This makes them feel lonely and leads to depression, another psychological disorder. Some people outside even discriminate them. Many thalassemic patients suffer in getting jobs besides being neglected by the parents and also the public. According to Pn. Noor Hafiza, she was not lucky with several other employers before working in a fast food outlet as she was not given the job opportunity after she showed her medical check-up which states that she has thalassemia.17 Some patients even tend to commit suicide as they couldnt cope with the pain and treatments that gives them more pain. Patients who couldnt cope with the treatment which requires not only money but also almost half of their hours in a day makes them think that its better to die rather than suffer and being a burden to the family. Besides that, they feel embarrassed by their limited ability to do things by their own. 4,19 On the other hand, economic implications also give a big impact to the patients life. Beta- thalassemia major patients require a regular blood transfusion of every 2 weeks, which cost them a lot of money. Not only transfusion, patients have to undergo many blood test and to be forgotten, the iron chelation therapy. Desferal is a controlled medicine that is very expensive medicine. This is one of the reasons why thalassemic patient couldnt continue their treatment. 1997 1998 (as from February) Thalassaemia association RM138.90 RM153.00 Goverment purchase (via Remedi) RM157.20 RM157.20 Pharmacy/clinic RM190.00 RM209.00 HUKM non-formulary purchase RM194.00 Customer purchase RM211.00 RM261.00 This research done by Prof. Elizabeth George shows the Desferals price increase from year 1997 to 1998, by 2009, the price had increased in the range of from RM500 to over RM1000 which is definitely not affordable for low class and middle class families. Thus, it becomes a financial burden to the family. As the patient gets older, the blood requirement increases as well as the Desferal. This directly increases the cost of living for a thalassemic patient. 20 There is no other way for the patients besides taking Desferal as without it, they have an average lifespan of only 20years only.5 WORD COUNT: 1463words BENEFITS AND RISK Benefits of blood transfusion are that it helps the body to have new and healthy red blood cell with normal haemoglobin. As we knew, thalassemic patients suffer from abnormal red blood cells with mutated or deleted haemoglobin, hence their red blood cells couldnt carry out its function and creates health problems such as the most severe ones is anemia. With this blood transfusion, a person could live longer to an average lifespan of 50years besides growing normally. Blood transfusion also helps the patients bones to form normally. As blood is given externally, the bone marrow does not have to work hard to produce red blood cell so it can concentrate on the formation of proper and normal bones. On the other hand, iron chelation helps to remove iron and prevents the organs like endocrine organs and liver from being damaged. 21 However, there are risks in both treatments. The most common risk of blood transfusion is infections and rejection. The patient has to get the same blood group in order to avoid rejection. There are chances of infection during transfusion either due to the blood itself or improper handling of the needle and syringe. Although a person receives regular Desferal, over time, the iron will be deposited in the spleen and liver and causes it to be damaged. Besides that, the patient has to cope with the side effects of both blood transfusion and Desferal which includes nausea, dizziness, and problems in hearing.22 ALTERNATIVE SOLUTION SPLENECTOMY Splenectomy is a surgical way of removing spleen. Old and damaged red blood cells are removed in the spleen. Since the red blood cells in a thalassemic patient are weakened, it is destroyed when passed through spleen. This makes the body to have fewer red blood cells. Removing spleen can help to lower the number of red blood cells that are lost, besides being removed due to the enlargement which causes pain to the patient. Splenectomy is done to patient above 11years old and after the removal, patient might need antibiotics to prevent infections as without spleen a person is more prone to infections. Patients can also get pneumococcal vaccine (Pneumovax) before the surgery to prevent infections.2 BONE MARROW STEM CELLTRANSPLANT Bone marrow transplant is another possible solution for thalassemia patient. The first successful transplant was performed in 1981 to a six-month baby from Italy.23 Bone marrow transplant involves the replacement of healthy stem cells as the patients stem cells are not producing healthy blood cells. The transplant procedure is similar to blood transfusion where it is infused through central nervous catheter. The stem cells migrate to the bones from the blood stream to stimulate the production of new bone marrow that migrates to the large cavities of bones and produce new blood cells.24 The most commonly used stem cell is the embryonic stem cell because it is easier to extract and have more advantage compared to adult stem cell as it is totipotent and not yet undergo differentiation and determination. 25 However, there are risks in getting stem cell transplant. First of all, risk of getting a suitable stem cell that matches the body to prevent rejections. Besides that, risk of infection is another problem during the process. According to Dr. Revathy Raj, Consultant Paediatric Haemato Oncologist, Apollo Speciality Hospital, Chennai, as the immune system will be lowered by immunosuppressant drug to reduce the risk of rejection, the body is now more prone to other infections.6,26 EVALUATION http://www.penthal.org/thalassaemia.htm is the website from a non-profit organization that aimed to give information about thalassemia not only to the patients but also to those who wants to know about it. In my opinion, this website is trustable and reliable as the information is factual and valid. This organization is an active group and always updated with latest new. Besides that, they are reviewed by some doctors and also origins from Penang, which means the information is more specific to Malaysians. It is also trustable as the basic informations on thalassemia given are the same as other resources used in this report such as http://www.medindia.net/patients/patientinfo/Thalassemia.htm , http://www.thalassemiapatientsandfriends.com/index.php?topic=1571.0 Information are also obtained from a paper cut : The Star Online, My blood is Different which is based on the personal experience of Noor Hafiza Noor Hamdan and some information from Ministry of Healths Thalassemia website, www.mytalasemia.net.my. The experience shared by the patient gives a lot of reliable information on treatments and their risks. The Ministry of Healths website is also very helpful in providing all kind of information by using videos and slides shows which makes it more clear and understandable. However, it gives only a brief and limited input regarding thalassemia as its main purpose is to provide brief information about this disease. It is hard to find any specific book related to thalassemia as the disease is still considered as new and unpopular in Malaysia. Most of the book sources that I referred are books related to genetics and pathology as thalassemia is related to both. However, the book, Robbins Basic Pathology, 7th Edition by Vinay Kumar and others as stated in bibliography is the most reliable and useful among all. The diagram taken from the book is very useful in explaining the pathogenesis of ÃŽÂ ²-thalassemia as it couldnt be found in any website I explored. Besides that, the explanations given in the book are also simple, clear and understandable. For example this sentence that describes about ÃŽÂ ² thalassemia: Î’-thalassemia, associated with total absence of ÃŽÂ ²-globin chain, and characterized by reduced synthesis of the chain in homozygous state. Genes obtained from thalassemic patients has revealed more than 100 different mutations responsible for it. Controlling Operative and Postoperative Pain | Literature Controlling Operative and Postoperative Pain | Literature Review of literature is a key step in research process. The literature review is to discover what has previously been done about the problem to be studied what remains to be done, what methods have been employed in other research and how the result of other research in the area can be combined to develop knowledge. It is essential step; it can be done before and after selecting the problem. It can help to determine what is already known about the topic (A.P.Jai, 2005). This chapter attempts to present a review of studies done methodology adopted and conclusion attained by earlier investigators which helps in this study. The sources are internet search, textbook, published journal, editorials published and unpublished thesis. In this chapter, the researcher presents the review of the literature under the following headings, Section-I: Studies related to importance of postoperative pain management. Section-II: Studies related to Using Numeric Rating Scale for pain Assessment. Section-III: Studies related to effectiveness of music therapy among General Surgical Patients. Section-IV: Studies related to Effectiveness of Music Therapy among Post Caesarean Mothers. Section-V: Studies related to Gate Control Theory of Pain (Melzack and Wall (1965). Section-VI: Conceptual Framework Based on Gate Control Theory of Pain (Melzack and Wall (1965). SECTION-I: STUDIES RELATED TO IMPORTANCE OF POSTOPERATIVE PAIN MANAGEMENT. Kolawole and Fawole, (2003) conducted a study on Postoperative pain management following caesarean section in University of llorin Teaching Hospital (UITH).llorin, Nigeria. Prospective descriptive design was used to assess the effectiveness of various common methods of analgesia used in hospital following caesarean section. This study was conducted over a period of 18 months. Pain assessment was carried out by 4-point Verbal Rating Scale of None, Mild, Moderate, and severe. The first 24hrs postoperatively was particularly painful for the patient with 79.6% and 54.6% reporting moderate to severe pain in the recovery room and day 1 respectively. They concluded that the pain remains a significant problem following surgical operation in our environment. (PMID.15008293) Seers and Carroll, (1998) conducted a study on Relaxation techniques for acute pain management. They were used a systematic review of randomized controlled trials and seven studies involving 362 patients were included. Three of the seven studies demonstrated significantly less pain sensation or pain distress in those who had relaxation, four studies did not detect any difference. It was concluded that the well designed and executed randomized controlled trials are needed before the clinical use of relaxation in acute pain management can be firmly underpinned by good quality research evidence. So we can recommend that the relaxation in acute pain settings is carefully evaluated and not used as the main treatment for the pain management. SECTION-II: STUDIES RELATED TO USING NUMERIC RATING SCALE FOR PAIN ASSESSMENT. Yaakov Beilin, Jabera Hossain, and Carol, (2009) conducted a study on Numeric Rating Scale and Labor Epidural Analgesia, in this study a Numeric Rating Scale(NRS) used to evaluate pain in research studies, they define desire for additional analgesic medication as a clinically relevant outcome in research studies about pain and compare it with the results of the NRS. A post hoc analysis of three studies that conducted previously in concerning labor epidural analgesia was performed. In all three studies, score was obtained before and 15 min after analgesia. They found that the very few patients (2%) with a score of 0-1 wanted more medication. When the score was 2 or 3, 51% of the patients wanted more medication, and score was >3, almost all patients (93%) wanted more medication. Grouping the final NRS scores into 3 categories (0 or 1, 2 or 3, and >3) is more useful to the clinician than using individual NRS scores. Cinzia Brunelli, (2009) did a study on Comparison of Numerical and Verbal Rating Scales to measure pain exacerbations in patients with chronic Cancer pain. Crosses sectional multicentre study conducted on a sample of 240 advanced cancer patients with pain, background pain and BP were measured by 6-point VRS and 11 point NRS. In order to evaluate the reproducibility of the two scales, a subsample of 60 patients was randomly selected and the questionnaire was administered for a second time three to four hours later. The proportion of inconsistent evaluations was calculated to compare the two scales capability in discriminating between background and peak pain intensity and Cohens K was calculated to compare their reproducibility. It concludes that NRS revealed higher discriminatory capability than VRS in distinguishing between background and peak pain intensity with a lower proportion of patients giving inconsistent evaluations (14% vs. 25%) (Cohens K of 0.86 for NRS vs 0.53 for VRS) while the reproducibility of the two scales in evaluating background pain was similar (Cohens K of 0.80 vs. 0.77). Nathalie Dieudonne, Alexandra Gomola, Philippe Bonnichon, and Yves M.Ozier, (2008) conducted a study on Prevention of postoperative pain after thyroid surgery. In this study double-blinded, randomized, placebo-controlled trial used to evaluate the analgesic efficacy of bilateral superficial cervical plexus blocks performed at the end of surgery. Ninety patients were randomized to receive 20 mL isotonic sodium chloride or 20 mL bupivacaine 0.25% with 1:200,000 epinephrines. Postoperative pain was assessed every 4 h using an 11-point numeric rating scale (NRS-11). All patients received acetaminophen every 6 h. In addition, morphine was administered following a standardized protocol if the NRS-11 score was à ¢Ã¢â‚¬ °Ã‚ ¥4. The main outcome variables were pain scores (NRS-11), the proportion of patients given morphine at any time during the 24-h period, and the amount of morphine administered. The Bupivacaine group had a smaller proportion of patients given morphine (66.0% vs 90.0%; P = 0.016), and lower initial median pain scores (P = 0.002). SECTION-III: STUDIES RELATED TO EFFECTIVENESS OF MUSIC THERAPY AMONG GENERAL SURGICAL PATIENTS. Sigma Theta Tau International, (2009) conducted a study to assess and compare the effect of music therapy on postoperative pain of patient undergone elective abdominal surgery. A quasi-experimental design was used and convenient samples of 30 (15 in each expcontrol group). Pain was measured by Verbal Rating Scale. Music therapy was given as per patients wish to experimental group and intensity of pain was monitored before and immediately after recovery from anesthesia, during the 1st and 2nd postoperative day for both the groups. Results revealed that those patients who listened to self selected music tapes had significant differences (p Tse MM.Chan Me. Benzie, (2005) conducted a study to find the effectiveness of music therapy on postoperative pain and analgesic use following nasal surgery. Sample size was 57 patients (24females33 males) who were matched for age and sex and then non-selectively assigned to either an experimental or a control group. Music was played intermittently to members of the experimental group during the first 24hrs postoperative period and pain intensity was measured by Verbal Rating Scales. It shows the significant decrease in pain intensity over time were found in the experimental group compared to the control group (p Nilsson, Unosson and Rawal, (2005) conducted a study on Stress reduction and analgesia in patients exposed to calming music postoperatively. The randomized controlled trial was designed to evaluate the effectiveness of music therapy. Seventy-five patients undergoing hernia repair in day care surgery were allocated to three groups: intraoperative music, postoperative music and silence (control group). Patients postoperative pain, anxiety, blood pressure (BP), heart rate (HR) and oxygen saturation were studied. The postoperative music group had less anxiety and pain and required less morphine after 1hr compared with the control group. The result concluded that intraoperative music may decrease postoperative pain, and that postoperative music therapy may reduce anxiety, pain and morphine consumption. SECTION- IV: STUDIES RELATED TO EFFECTIVENESS OF MUSIC THERAPY AMONG POST CAESAREAN MOTHERS. Arastirma TAF pre Med Bull, (2009) conducted a study to evaluate the effectiveness of music therapy on postoperative pain after Caesarean section. The sample size was 100 and randomly allocated into two groups (50 in each group).Group 1, patients listened to music through a headphone for 1hour immediately before surgery where as in group-2, not listen to any music during the same period. In the postanaesthesia care unit patients were connected to I.V. PCA device when they were able to respond to commands. The patients level of satisfaction with perioperative care was assessed by a 10cm Visual Analogue Scale and the severity of postoperative pain was assessed by VAS. The results shows that the postoperative tramadol consumption, total amount of tramadol consumption, additional analgesic use and all VAS values were lower in group-1(p Amin Ebneshahidi, and Masood Mohseni, (2008) conducted a study to evaluate the effect of patient selected music on early postoperative pain, anxiety and Hemodynamic profile in Caesarean section. The sample size was 80 who were undergoing elective C.S.surgery enrolled randomly to listen 30 minutes of music or silence by head phones postoperatively. Pain and Anxiety were measured with visual Analogue Scale. Results says that the pain score and postoperative cumulative opioid consumption were significantly lower among patients in the music group (p SECTION-V: STUDIES RELATED TO GATE CONTROL THEORY OF PAIN Marial, (2007) did a study to assess the effectiveness of back massage on pain during first stage of labour among mothers in selected maternity centre at tirupur. 60 samples were selected by using convenient sampling method for the study (experimental group-30 and control group-30). Experimental group received massage were as the control group did not. She used Melzack pain gate control theory for conceptual frame work. Data was collected using behavioral intensity and visual analogue scale. The statistical calculation done was frequency mean, SD, chi-square andt test. The result of the study shows that massage is a cost effective nursing intervention that can decreases the pain perception during labour. Jacintha, (1995) did a study on the effect of back massage during the first stage of labour. She divided the samples in to two groups of 30 each. The experimental group received back massage for 10 minutes per hour. She used non participatory observation technique to observe the maternal behavioral every hour. She used Melzack pain gate control theory for conceptual frame work. The experimental group was interviewed regarding their experience and feelings of back massage before shifting them to the post natal ward. 100% of mothers remembered massage given to them during labour, with feeling of comfortable in 76.66% and relaxed in 43.33%. All the mothers were of the opinion that all mothers in labour should be given back massage. Locsin, (1981) did a study to assess the effectiveness of music on the pain of selected postoperative patients during first 48 hrs. The 24 female gynecology and/ obstetric patients were assign to two groups (control and experimental). The measurement of the experimental variable was done by an Overt Pain Reduction Rating Scale (OPRRS) which is devised by the writer. Significant differences were found between the groups of postoperative patients in their muscular-skeletal and verbal reactions during the first 58hr at the 0.05 level. The conceptual framework of the study was based on the concept of distraction following the Gate Control Theory of Pain by Melzack Wall (1965). The finding says that the music can be used as a nursing measure for postoperative patients. SECTION-VI: CONCEPTUAL FRAMEWORK BASED ON GATECONTROL THEORY OF PAIN (MELZACK AND WALL (1965) The conceptual frame work for the present study was derived from Gate Control Theory of Pain (Melzack and Wall, 1995) Application of Gate Control Theory of Pain Polit and Hungler, (1965) state that a conceptual framework is inter related concept on abstraction that is assembled together in some rational scheme by virtue of their relevance to a common scheme. It is a device that helps to stimulate research and the extension of knowledge by providing both direction and impetus. The present study was aimed at determining the effectiveness of music therapy on intensity of post operative pain among primipara mothers who had Caesarean Section. The conceptual frame work of this study was derived from gate control theory of pain. Gate Control Theory of Pain: Many theories of pain have been presented in the literature. These include specificity, pattern, affect and psychological/behavioral theory (Mander 1998). The most widely used and accepted theory is that of Melzack Wall (1965). These researchers have established that gentle stimulation actually inhibits the sensation of pain. Their gate control theory states that a neural or spinal gating mechanism occurs in the substantiate gelatinosa of the dorsal horns of the spinal cord. The nerve impulses received by nociceptors, the receptors for pain in the skin and tissue of the body, are affected by the gating mechanism. It is the position of the gate that determines whether or not the nerve impulses travel freely to the medulla and the thalamus, thereby transmitting the sensory impulse or message, to the sensory cortex. The pain impulses will be carried out by the small diameter slow conducting A-delta and C fibers. Impulses traveled through small diameter fibers will open the pain gate and the person feels pain. Pain gate is also receiving impulses produced by stimulation of thermo receptors or mechanoreceptors transmitted via large diameter; myellindated A-delta fibers inhibit superimpose the small diameter impulses. (Myles -2003) If the gate is closed, there is little or no conduction, for example distraction, counseling and massage techniques are ways to release endorphins, which close the gate. This prevents or reduces the clients perception of pain (Freeman and Lawlis, 2001) If the gate is open, the impulses and messages pass and are transmitted freely. Therefore, when the gate is open, pain and sensation is experienced. (Potter and Perry, 2009) Many non pharmacological procedures such as hydrotherapy, music therapy (distraction), application of heat or ice, massage, vibration, TENS and movement stimulate the nerve endings connected with large diameter fibres which can produce a reduction of pain by closing the pain gate. Based on the principle of gate control theory, the following conceptual framework was developed. Method used to reduce intensity of postoperative pain is instrumental music which is composed by violin among Primipara mothers who had Caesarean Section. Stimulation of Pain Receptors: Surgical trauma of the uterus due to Caesarean Section stimulates pain receptors in lower abdomen and lumbar area of the back. In the control group there was more stimulation of pain receptors in these areas due to the close contact between the contracting uterus and abdominal and lower back structures. In case of experimental group(Music therapy), there was less stimulation of free nerve ending in the lower abdomen and lumbar area of back compared to the control group due to the distraction caused by music therapy. Travelling of Pain Impulses: Normally pain impulses are traveling through small short conducting A-delta and C fibres. Impulses from stimulation will be distracted by instrumental music and decrease in pain perception produce a reduction of pain by closing the pain gate in experimental group. Gating Mechanism: Pain impulses after the Caesarean Section are transmitted through the spinal nerve segment of T11-12 and accessory lower thoracic and upper lower sympathetic nerves, which are traveled through (A-delta and C) small diameter and slow conducting amyelinated fibres and reach the pain gate and open the gate thus the mother perceives pain in the lower abdomen and lower back. Impulses reduced by music due to decreased in pain perception to travel through fast conducting myelinated A-delta fibres which impose small fibres and close the pain gate. SUMMARY This chapter dealt with the studies related to importance of postoperative pain management, application of music therapy and conceptual frame work based on gate control theory of pain.

Evaluate the effectiveness of the responsive regulation model with reference to the regulatory powers and responses available under the Consumer Protection from Unfair Trading Regulations 2008.

Introduction Regulating consumer and commercial law has proven extremely difficult, especially in the new digital age where online trading has advanced significantly over the years.[1] There is now more likelihood that consumers will be subjected to unfair and unlawful trading practices and so it is vital that all corporations are being regulated effectively. This will enhance consumer confidence and will have a beneficial effect upon the market in general. It has been said that markets work best when consumers have confidence in the corporations they are dealing with, yet the increase in rogue traders has significantly diluted such confidence. At present much confusion exists as to how regulators should control corporations in order to ensure that they are complying with the obligations that have been imposed upon them. Consequently, the powers that have been provided to regulators under the Consumer Protection from Unfair Trading Regulations 2008 appear somewhat ineffective on the basis that th ey still do not provide sufficient protection to consumers. This study will therefore consider whether the influential model of ‘responsive regulation’ that was proposed by Ayers and Braithwaite will be more effective in ensuring compliance of all corporations. This will be reviewed in light of the 2008 Regulations and consideration as to whether consumers will be better protected under the new model will be made. In doing so, an overview of consumer protection will first be provided, followed by a review as to how effective the 2008 Regulations. Once this has been done, the responsive regulation model will then be analysed and consideration of its effectiveness will be made. Consumer Protection A consumer has been described in Lloyd Shuhfabrik Meyer & Co GmbH v Klijsen Handel BV[2] as an individual or group of individuals that consumes goods and services generated within a social system. Concerns have been raised in recent years as to whether consumers are being adequately protected from unfair and illegal trading practices.[3] Hence, it has been argued that the current regime dealing with consumer protection is ineffective in that regulators do not deal with wrongful or fraudulent traders in an appropriate manner. As shown in Macaulay v Scroeder Publishing Co Ltd[4] and Esso Petroleum Co Ltd v Harper’s Garage (Stourport) Ltd[5] parties to an agreement often have unequal bargaining power, which highlights the importance of being able to provide protection to vulnerable consumers. Companies will have greater knowledge of the industry than private consumers and so it is integral that regulators are capable of provided appropriate protection to consumers in the event of unfairness. As noted by Lord Denning in Lloyds Bank v Bundy;[6] â€Å"many of the traditional defences to contract enforcement were properly seen as merely exemplary of a general doctrine of ‘inequality of bargaining power’ and all provided testimony to the fact that the age of laissez faire was outwearing its judicial welcome.†[7] This demonstrates how a free market economy no longer exists as there is often an ‘inequality of bargaining power’ resulting in the need for vulnerable parties to be provided with more protection than they have required in the past. Consumer Protection from Unfair Trading Regulations 2008 The Consumer Protection from Unfair Trading Regulations 2008 was established in order to act as a safeguard for consumers against unfair trading practices. These Regulations implemented the Unfair Commercial Practices Directive 2005/29/EC (UCPD) which intended to provide regulators with the power to impose obligations upon corporations to trade fairly. Various consumer protection laws were replaced by these Regulations as the consumer protection regime prior to 2008 was deemed unsatisfactory in protecting consumers.[8] As put by the Office of Fair Trading: â€Å"The Regulations introduced a general duty not to trade unfairly and seek to ensure that traders act honestly and fairly towards their customers.†[9] Although the Regulations address business to business practices, the primary focus was on the protection of private consumers as identified in Office of Fair Trading v Purely Creative Ltd and Others.[10] Corporations found to be in breach of the Regulations may have crimin al sanctions imposed upon them by regulators and, as noted by Worthington and Britton, these â€Å"extend criminal liability beyond simply misleading practices to include, in part, aggressive practices such as coercion and harassment.†[11] The regulatory powers and responses of regulators are therefore considered more effective under these Regulations as corporations will now be more likely found liable for adopting unfair and unlawful practices than they would have in the past. This provides greater protection to consumers who will be a lot more confident when entering into commercial transactions. These Regulations were thereby said to â€Å"herald a new era in consumer regulation,†[12] especially where online transactions are concerned as there was a great reluctance to purchase goods or services on the internet for fear of unfairness being created.[13] In Tiscali UK Ltd v British Telecommunications Plc[14] it was noted that the Regulations â€Å"make it easier for traders based in one Member State to market and sell their products to consumers in other Member States.†[15] This is economically beneficial in that it contributes to the growth of the internal market. Conversely, not all agree that the Regulations are effective and instead believe that online trading still poses many risks.[16] This is mainly due to the fact that not all e-traders are a signatory to the Regulations and as such regulators will be unable to control many cross-border transactions. As a result, it is imperative that consumers are aware of the risks when purchasing goods or services onli ne and should only purchase from those traders who are a signatory to the Regulations. This should be easy to identify because traders will be prohibited from claiming that they are a signatory to the Regulations if they are not.[17] Regardless of this it seems as though the Regulations are not as effective when it comes to the protection of consumers as it was hoped. Furthermore, even if protection is acquired under the Regulations, there is no guarantee that consumers will be compensated. This is because there is no direct right to claim compensation and instead consumers have to rely on existing civil law. [18] Responsive Regulation Model The current law therefore appears out of date, complicated and too extremely restrictive[19] and therefore highlights the need for further changes to be made. A number of proposals have been put forward to rectify the current problems that exist, yet the extent to which these are viable is a debatable subject. Differing views as to how Regulators should deal with corporations to ensure compliance exist between â€Å"those who think that corporations will comply with the law only when confronted with tough sanctions and those who believe that gentle persuasion works in securing business compliance with the law.†[20] A model of ‘responsive regulation’ was thereby proposed by Ayers and Braithwaite which adopts a responsive approach by enforcing compliance strategies at first and then applying more punitive deterrent responses later on if the regulated corporation fails to comply with their obligations. They believed that corporations would be more likely to comply i f an explicit enforcement pyramid was in place. An enforcement pyramid would thus include a range of enforcement sanctions ranging from persuasion, warnings and civil penalties to criminal sanctions, licence suspensions and licence revocations.[21] Consequently, it would be presumed under this model that regulators would always start at the bottom of the pyramid and then work their way up for more serious compliance failures. This model appears to replace blanket commitments with deterrence and compliance models and has been viewed as â€Å"hugely influential worldwide.†[22] This model is currently being employed by many different governments and regulators and has since been expanded upon by Braithwaite into a comprehensive regulatory and democratic ideal, which incorporates notions of deliberative democracy and restorative justice.[23] This responsive regulation model does appear to be more effective than the approach that is currently being taken under the 2008 Regulations since there is no guarantee that consumers are being provided with appropriate protection. This is due to the fact that there is a lack of compensation being provided to consumers and regulators are likely to be a lot more lenient when it comes to sanctioning corporations.[24] Under the pyramid model, corporations will be most likely to adopt a self-regulatory approach to ensure compliance. This is because corporations will be aware of the consequences that will be imposed if they do not comply with their obligations and will have been given a number of chances to change any unfair practices that have been assumed. The Australian Law Reform Commission believes that this is the ideal approach since regulators have access to severe punishments if needed and are able to persuade corporations to undertake appropriate behaviours to ensure compliance.[25] This approach promotes self-regulation and provides corporations with the ability to change, through effective persuasion, before the use of penalties arises. Only those who ignore the persuasive practices of regulators will be penalised, which ensures that only corporations who deserve to be punished will be.[26] On the other hand, it has been argued that voluntary compliance at the bottom of the pyramid may prove impossible as a result of the constant threats of more punitive sanctions at the top.[27] Furthermore, it cannot be said that corporations will actually respond to the pressures imposed by regulators since it has been said that corporate behaviour is not driven by regulatory pressure but rather cultural or competitive pressures.[28] In accordance with this, it could be suggested that the responsive regulation model will be appropriate for many corporations, though there will be some corporations where this approach will be ineffective. It would therefore be better for corporations to be analysed individually in order to consider what the best approach would be to ensure compliance since there will be certain circumstances whereby the pyramid approach will not be appropriate.[29] An example would be where there are potentially catastrophic risks that are being controlled. Here, it wo uld not be appropriate to use a step by step approach to regulation since the regulator would need to go straight to the top of the pyramid when choosing an appropriate sanction. Conversely, there may be a situation whereby the risk is minimal and so mere persuasion would be needed. This situation is ideal for the responsive regulation model, though the former is not. Arguably, whilst the responsive regulation model may be better at ensuring compliance with consumer protection laws than the current 2008 Regulations are in some situations, this will not be the case for every situation. Nevertheless, given the criticisms for both approaches, it appears as though some reform to this area is needed if the regulatory approaches that are currently being adopted are improved. Conclusion The current consumer protection regime is extremely complex when it comes to ensuring that corporations are complying with their obligations. As a result, consumers are still being put at risk when entering into commercial transactions. Although the Consumer Protection from Unfair Trading Regulations 2008 attempted to act as a safeguard for consumers against unfair trading practices, it cannot be said that these are being fully realised. This is because of the limited powers that are provided to regulators when imposing sanctions upon corporations. Consequently, it seems as though further changes need to be made to the existing regime in order to guarantee the protection of consumers. Ayers and Braithwaite model of responsive regulation does provide regulators with appropriate powers to imposes relevant sanctions upon corporations, whilst at the same time providing them with the ability to make necessary changes. This step-by-step approach does appear fair in that corporations are in itially given the chance to rectify their non-compliance activities. Nevertheless, because this model will not be applicable to all corporations, it has been considered largely ineffective in making sure that corporations actually respond to regulatory pressure. Corporations should therefore be analysed individually in order to consider what the best approach to take would be. This will prevent unfairness and will enable consumers to have greater confidence when entering into commercial transactions. This will be a lot more beneficial for the economy overall and online trading will be likely to increase even further. Bibliography Books F Sudweeks and C T Romm., Doing Business on the Internet Opportunities and Pitfalls with 39 Figures (United States: Springer, Business & Economics). I Ayres and J Braithwaite. Responsive Regulation (Oxford: Oxford University Press, 1992). I Worthington and C Britton., Business Environment, (6th edn Pearson Education, 2009). R Baldwin, M Cave and M Lodge., Understanding Regulation: Theory, Strategy and Practice (Oxford: Oxford University Press, 2011). R Kagan and J Scholz., ‘The Criminology of the Corporation’ in K Hawkins and J Thomas., Enforcing Regulation (Boston: Kluwer, 1984). Journal Articles D Hertzell., ‘Time to Redress the Balance’ (2011) 161 New Law Journal 683, Issue 7466. F Haines., Corporate Regulation: Beyond Punish or Persuade (Oxford: Oxford University Press, 1997). H Thorpe., ‘Consumer Protection from Unfair Trading’ (2008) 32 Company’s Secretary Review 2. J Braithwaite., ‘Responsive Regulation and Developing Economies’ (2006) 34 World Development 884. L Timmermann., ‘Consumer Protection from Unfair Trading Regulations 2008, Part 2’ (2009) Trusted Shops, [Accessed 13 April 2014]. M J Trebilcock., ‘The Doctrine of Inequality of Bargaining Power: Post-Benthamite Economics in the House of Lords’ (1976) 26 University of Toronto Law Journal 4. Office of Fair Trading., ‘Consumer Protection from Unfair Trading Regulations 2008’ (2008) Information for Businesses on the Consumer Protection from Unfair Trading Regulations, [Accessed 13 April, 2014]. P Stokes., ‘New OFT Powers in the Credit Clamp-Down’ (2005) 155 New Law Journal 236, Issue 7164. R Baldwin and J Black., ‘Really Responsive Regulation’ Law Society Economy, Working Papers, 5 [Accessed 12 April 2014]. S Brown., Protection of the Small Business as Credit Consumer: Paying Lip Service to Protection of the Vulnerable or Providing a Real Service to the Struggling Entrepreneur?’ (2012), 41 Common Law World Review 1. Case Law Esso Petroleum Co Ltd v Harper’s Garage (Stourport) Ltd [1968] AC 269 Lloyd Shuhfabrik Meyer & Co GmbH v Klijsen Handel BV [1999] ETMR 690 Lloyds Bank v Bundy [1974] 3 WLR 501 Macaulay v Scroeder Publishing Co Ltd [1974] 1 WLR 1308 (HL) Office of Fair Trading v Purely Creative Ltd and Others [2011] EWHC 106 (Ch) Tiscali UK Ltd v British Telecommunications Plc [2008] EWHC 3129 (QB) [1] F Sudweeks and C T Romm., Doing Business on the Internet Opportunities and Pitfalls with 39 Figures (United States: Springer, Business & Economics) 9. [2] [1999] ETMR 690 [3] P Stokes., ‘New OFT Powers in the Credit Clamp-Down’ (2005) 155 New Law Journal 236, Issue 7164. [4] [1974] 1 WLR 1308 (HL) [5] [1968] AC 269 [6] [1974] 3 WLR 501 [7] M J Trebilcock., ‘The Doctrine of Inequality of Bargaining Power: Post-Benthamite Economics in the House of Lords’ (1976) 26 University of Toronto Law Journal 4, 359. [8] S Brown., Protection of the Small Business as Credit Consumer: Paying Lip Service to Protection of the Vulnerable or Providing a Real Service to the Struggling Entrepreneur?’ (2012), 41 Common Law World Review 1, 59. [9] Office of Fair Trading., ‘Consumer Protection from Unfair Trading Regulations 2008’ (2008) Information for Businesses on the Consumer Protection from Unfair Trading Regulations, [Accessed 13 April, 2014].

The Impact Of Diversity On Workforce Diversity Essay

The increasing globalisation in today’s world means more interaction between people from different ethical and cultural backgrounds than ever before. Maximising and Capitalising on Workforce diversity is the aim of most organisations today. However, workforce diversity presents both opportunities and challenges in organisations as ideas and practices from different backgrounds combine together, sometimes causing challenges such as communication and benefits such as productivity and creativity. This essay will further analyse the opportunities and challenges that are present in today’s organisations due to workforce diversity. Understanding workforce diversity is crucial for most organisations today. Diversity is described as â€Å"understanding, accepting, valuing, and celebrating differences among people with respect to age, class, ethnicity, gender, physical and mental ability, race, sexual orientation, spiritual practice, and public assistance status† (Esty, Griffin, Hirsch, 1995). 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He Conformity s Judgement Is Based On What Gender They...

he Conformity In Grease The behavior towards people’s judgement is based on what gender they are can be summarized in one movie Grease. Grease made 159 million dollars in the year 1978 alone, but the movie itself shows the double standards on gender with two main a groups of teenage high school students. The testosterone filled group of males known as T- Birds and the Barbie pink female group known as The Pink ladies, make up the popular crew in their school. If you aren’t part of these two groups than you are considered a lack of interest and a waste of existence. The movie also contains viewpoints of conformity taken place in high school that many teenagers experience in real life, by this I mean the movie is a reflection of what is taught in society since birth. There has to be a reason as to why some films can have controversial language, physically inappropriate gestures, sexist comments are exceptional. In a recent research it gave a simple explanations towards why this is. 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