Treatment Research for Multiple Myeloma (MM)

Treatment Research for Multiple Myeloma (MM)ABSTRACT inst everyationMultiple myeloma (MM) is a hematological neoplasm that appears after transformation and uncontrolled proliferation of plasma cells. MM is characterized by a heterogeneous genetic aberrations and very(prenominal) different clinical knocked out(p)comes (Avet-Loiseau, . Boyd KD). Although treatments for MM aim increased by flummox new and much sophisticated therapeutics drugs such an immunomodulatory drugs (IMiDs) and protea or so inhibitors (PIs)( Shaji K. Kumar, Raghupathy, Antonio Palumbo) the marked variability of responses direct that larger studies will be required.Currently, identification of cytogenetic abnormalities is performed by ceremonious karyotyping and fluorescence in situ hybridization. However, these disorders are not sufficient to explain the malignant phenotype granted that are excessively observed in premalignant states of MM such a monoclonal gammopathy of unknown significance (MGUS) or sm oldering myeloma(SM)(Bergsagel, Hideshima). This finding justifies the strike for a comprehensive screening of genetic abnormalities in MM patients, which has not been incorporated in the medical workup yet. Recently, the introduction of massive sequencing of patient genome exploitation next-generation sequencing (NGS) technologies has considerably increased the understanding of the biological features of MM. Many works stand described the complex and heterogeneous pas seulal profile of MM patients(bolli nuevo, walker). altogether Exome Sequency (WES) studies in saucily diagnosis MM patients have confirmed that more than 50 genes are mutated in the first manifestation of disease (walker). However, but few genes have been detected recurrently mutated at diagnosis, including KRAS, NRAS, BRAF, DIS3, TP53 and FAM46C, and only TP53 mutations have been recurentelly associated with poor natural selection. In addition, other studies have assessed the clonal evolution oer cartridge h older, pointing out that systemic treatment with chemotherapy may affect the livelihood of some subclones more than others, and thus may influence the tumor evolution everyplace time(Egan JB, bolli, Keats JJ, ) The introduction of targeted studies eachows the detection of mutations even with very low allele frequencies at an affordable price, allowing the incorporation of extensive genetic studies to the clinical workup. In the dying old age, several groups have applied this approach in order to achieve a better patients stratification and prognosis prediction. Although many studies have highlighted the splendour of the subclonal landscape in MM and many efforts have been undertaken to stratify patients and predicts their responses, on that point is no clear relation between sensitives or refractories clones to treatment, and more learning about the prognostic impact of this subclonal profile in series of homogeneously treated MM patients is needed. A large turn of events o f clinical streak are being carried out with this aim, unify treatments in order to field of operation more effectively the impact of genetic alterations in prognosis.In this work, freshly diagnosis MM patient homogenously treated have been genetically characterized utilise a combination of the most recent techniques, including FISH and ultra-deep targeted sequencing. We applied the highest postulate depth described in the literature with the aim to detect minority subclones ignored to date. We also integrated these data with the clinical features to find out new patterns of behavior, relate them with survival and reveal new insight into the complexity of clonal and subclonal architecture of MM.Patient samplesSamples were taken from the available 79 newly diagnosed MM patient enrolled in the clinical trial GEM10MAS65 (registered at www.clinicaltrials.gov as NCT01237249). This is a phase III trial where patients older than 65 years were randomly assigned between two treatment s arms sequential melphalan/prednisone/Velcade (MPV) followed by Revlimid/low dose dexamethasone (Rd) versus alternating melphalan/prednisone/Velcade (MPV) with Revlimid/low dose dexamethasone (Rd). Progression free survival (PFS) and overall survival (OS) were measured from the starting date of the treatment. The median(a) time to progression was 26.4 months with a median follow up of 31.5 months.Targeted sequencing and mutation tradingPositive plasma cells CD138 were isolated from bone marrow aspirates and DNA was extracted utilize AllPrep DNA/RNA mini kit (Quiagen). Only 20 ng of DNA were used to prepare libraries using Ampliseq Library Kit 2.0. We also sequenced DNA from the 15 available CD138 negative fractions in order to try out potential artifacts and corroborate detection sentivity. Samples were sequenced using Ion alcoholic weapons platform (IonProton, Thermofisher, Carlsbad, CA, USA) using the M3P gene panel (Mayo Clinic, Arizona). This panel spreads out over 77 gen es frequently mutated in MM, which are related to critical pathophysiological passs, associated to drug metro or targetable with molecular drugs paper mayo kortum etal. Quality filter and alignments was performed using Torrent Suit software (Life Technologies) Single nucleotide variants were calling and annotated using Ion newsperson software applying in-house modifications in call variants process. Variants listed in Single Nucleotide Polimorphism database (dbSNP, http//www.ncbi.nlm.nih.gov/SNP/) were excluded from samples without germline available, as well as variants that were detected in multiple samples. In addition, to try out the ability of the workflow previously described, we applied a novel bioinformatics line developed by Spanish National Cancer Research contract (CNIO). All reported mutations were detected by both bioinformatics approaches. The integrative genomic spectator pump (IGV) was used to visualize the read alignments, single variants and correct sequenci ng errors due to homopolymer regions.statistical analysisAll statistical analysis was performed using the statistical purlieu R. Correlation coefficients between mutated genes and cytogenetic aberrations was assessed and plotted using corrplot (https//cran.r-project.org/web/packages/corrplot/). Differences in survival were tested using the log-rank test. Cox proportional hazard reversion was employed to obtain hazards ratios (HR) and evaluated at 5% of significance level. A gage approach called LASSO (least absolute shrinkage and selection operator) was performed to detect applicable variables among clinical, cytogenetic and mutated genes. Further details can be ground in Data Supplement.RESULTSMutated genes and altered pathways (cambiar ttulo)We sequenced 79 tumor samples with a stiff coverage depth of 1600X. The minimum coverage of the detected variants was 60X and the average coverage 370X. We identified 170 nonsynonymous missense/nonsense/stoploss single variants, 81 of them (48%) were predicted pathogenic by Sift and Polyphen and 61 (36%) have been described in COSMIC data base. 85% of patients harbored at least 1 mutation with a median of 2.1 mutations per patient. We detected mutations in 53 genes (Figure1), although 6 genes accounted the 39% of the total number of mutations KRAS= 21.5%, DIS3= 19%, NRAS= 16.5%, BRAF= 10.1%, TP53= 8.8% and ATM= 7.6% of the patients. 48% of patients (38/79) presented at least one mutation in genes envolved in RAS/MAPK pathway, being the most frequently mutated pathway. 72 and 100% of variants in KRAS and NRAS respectively were detected in the hotspot codons 12, 13 and 61, and the targetable V600E BRAF mutation was detected in 1 patient. (Figure 2 supplemental?). NFKB pathway was the second most frequently mutated in our cohort, accounting for the 15% of all mutations distributed in 25 % of the patients (19/79). This pathway included TRAF3 (5 mutations, one nonsense and 4 missense) and TRAF2 (3 missense mutation) a ll of them predicted pathogenic by Sift and Polyphen. Other pathways importantly altered in the cohort were MYC in 11% of patients (9/79), cereblon and ciclyn both in 9% of patients (7/79).Multiple mutations within the same gene were observed in 11 patients 4 of whom harbored 2 and 3 mutations within DIS3 (patient 1-24= Glu501Lys and Phe120Leu at 8 and 53 % of VRF, patient 2-236= Asp487His and Asp479Glu at 4 and 21 of VRF respectively, patient 3 321= Tyr753Asn and Glu126Lys at 2 and 58 % of VRF respectively and patient 4-42 = Arg820Trp, Gly249Glu and at 14, 20 and 24% of VRF respectively). Other 2 patients showed 2 and 3 mutation in KRAS (patient 5-168= Gly13Asp and Gln61His at 9 and 13 %of VRF and patient 6-269 = Tyr71Asp, UTR3 in exon 6 and Gln61Glu at 3, 15 and 37 % of VRF respectively 2 patients with 2 mutation in NRAS(patient 7-177= .Gln61Lys and Gly12Ala at 5 and 12% of VRF respectively and patient 8-257= Gln61Glu and Gly12Ala at 5 and 6% of VRF respectively), one patient wit h 3 mutations in MAX (patient 9-190= Arg36Lys , Arg35Leu and Glu32Val at 10, 20 and 26 %of VRF), one patient with 3 mutations in TRAF3 (patient 10-40 = Lys453Asn, His136Tyr and Phe445Leu 8, 11 and1 3% of VRF) and one patient with 2 mutation in TP53 (patient 11-40 = Asp208Val and Glu204Ter at 35 and 36% of VRF respectively).Variant Read Frequency study The VRF found in our cohort were diverse. We detected 50% of variants (85/170) below 25% of VRF and 27% (46/170) below 10% (Figure 2). KRAS (n=5) DIS3 (n=5), BRAF (n=4), NRAS (n=4), and TP53 (n=3) were the genes that harbored the largest number of low frequency mutations (Figure 2).KRAS, NRAS, BRAF and TP53 mutations were, in all cases, lower than 50% of VRF while DIS3 showed mutations in a broad rove (from 2 to 85%)(Fig3). ). Most of DIS3 mutations with VRF

Listening Skills in Communication

listen Skills in CommunicationCommunication is the recognize to personal, financial, and entrepreneurial success. Seminars constantly tout the importance and crucial role of stiff converse, e peculiar(a)ly in order to succeed at business. However, i tantrum of communion skills that is often overlooked is the in effect(p) use of non-verbal communication. Non-verbal communication elicit be summed up as from each one(prenominal) the other(a) parts of terminology that give us visual and non-audible clues in order to correctly pick up the meaning and intent of the verbaliser in a intercourse. Non verbal communication scum bag be communicated through gestures and touch in addition know as Haptic communication by body speech or posture, by facial expression and eye contact. Non verbal communication burn til now be communicated through objects such as clothing, hairstyles or even architecture, symbols and graphics.For example, when one goes to a job inter linear persp ective, khaki pants can bring a range of meaning eitherwhere from oh, Im here to the well-dressed and ready to conquer, every found on the style, smell, cut, and fit of the pant. Simplistic yes, but tried and proven as well. By the desire token, wearing blue jeans to a job interview, no matter how dressy the pant, sends an underlying message of casualness that may non be the chord to strike, depending on the position and industry. Also, speech contains communicatory elements known as paralanguage, which include factors like voice quality, emotion and oration style, as well as the spoken rhythm, word intonation or inflection and stress. Dance is also regarded as a nonverbal communication. Likewise, written texts thrust nonverbal elements such as handwriting style, spatial arrangement of wrangling, graphic or design arrangements or the use of emoticons. However, a lot of the study of nonverbal communication has foc utilise on face-to-face interaction, where it can be a ssort into three main focuses environmental conditions where communication takes place, the physical characteristics of the speakers, and behaviors of the speakers during interaction. eon not a traditionally defined form of non verbal communication, impelling hearing skills ar arguably the most prized set of communication skills for any bourgeois to develop in order to achieve success. Further more(prenominal)(prenominal), effective audition skills blow not only the professional sphere, but the personal and emotional health and overall well being of a person. Many experts disagree on the number of specific components that encompass an effective tender, yet in that location be certain underpinbone elements that ar generally accepted as guidelines to instal a tender more effective and serve to enhance the quality of communication between the involved parties. Listening is one of those special skills that, because we can hear, we tend to believe that we can automatically listen. Yet for more citizenry hoping to facilitate, auditory sense is the most difficult skill to master. As I compile this I am remembering one of todays well-worn clichs, often used by those who argonnt earshot I hear what you atomic number 18 saying, but.So says Mr. Trevor Bentley, who has developed a very(prenominal) specific set of criteria to define an effective listener.In his article, The special skills of listening, he states that specific lines require specific responses or set of listening skills. According to Bentley, one can narrow these instances to six main groups, which brood of monologue, dialogue, conversation, discussion, debate, and argument. Websters defines a monologue to be an extended uninterrupted speech by a character in a drama. The character may be speaking his or her thoughts aloud, directly addressing another character, or speaking to the audience, particularly the former. Monologues are common across the range of dramatic media (plays, films , animation, etc.). In nonchalant sprightliness, a monologue refers to that one individual who talks incessantly upon all subjects, often without pause to consider the effect of any of their utterances upon those in their spry vicinity. On the other hand, dialogue is an interaction of sorts, its everyday basis and vis-a-vis is a conversational exchange between two or more tidy sum. Now, a conversation is by definition communication between nonuple people. It is a social skill that can be accomplished by the average individual. Conversations are the ideal form of communication in close to respects, since they go away(p) people with different views on a topic to contract from one another. For a winning conversation, the partners must achieve a possible balance of contributions. A successful conversation includes repeating, reply, creating and countering connections between the speakers or things and topics that the speakers know. For this to happen, those savory in conve rsation must find a topic on which they both can relate to in some sense. They speak or from personal experience or from others observations and knowledge. Those engaging in conversation by nature tend to relate the other speakers statements to themselves. They may insert aspects of their lives into their replies, to relate to the other persons opinions or points of conversation. Again, all these are examples of different forms of listening.Finally there are discussions, debates, and arguments. While one can argue that these are all escalating forms of the homogeneous condition, the general meaning and informant of these three words is an explanation of an thin or a topic, compared and contrasted according to logical rules, and factually affirmed by persuasion and logic to declare one viewpoint in mitigate standing than the other. Bentley recommends that in order to maximize communication in each of these situations one should chose a level on which to listen again, based upon the situation and to use a combination of directive, facilitative and active listening to invite the most effective communication occur. His eight stages of listening cover non-listening, nonoperational listening, judgmental listening, attentive listening, visual listening, reflective listening, active/creative listening, and directive listening. While the Bentley system has very logical and effective solutions to many communication dilemmas and situations, other experts take a more instinctive and generalized view of effective listening and non-verbal communication.In the article Turn listening into a powerful presence, Richard Harris states thatBetter-than-average listeners are keenly assured of the following master(prenominal) issues partnership, reviewing systematically, effort, necromancer events, empathy, neutralizing snap judgments, and tenacity. Listening is not by any stretch of the whim a passive endeavor if practised correctly or effectively. As a listener, one is always arduous to receive or date the meaning of the conversation, while dealing with all the non-verbal communicational clues on a subconscious level. If you are blindfolded in a room with some friends, you could participate in conversation actively. However, your responses and generaliseing could range from a littler bit off to very misdirected, depending on how many visual cues and gestures you hightail it due to the blindfold. Active listening is not just generating responses to sounds or answering the question. It requires the listeners to understand, interpret, and analyze what is heard. Today, the ability to listen is an invaluable skill in social communication. It changes personal relationships by reducing conflicts, strengthening cooperation, as well as fostering understanding. Harris stresses the importance of practicing the issues that arise when holding a conversation, fully self-confident that a normal person can adapt and learn these techniques in order to b ecome a more effective communicator.Some generation effective listening is simply making sure that one is completely engage in the conversation, suspending judgment, and making evaluations after all the issues have been discussed. However, it is not native for humans to listen in this form, and patience and practice are key aspects to developing natural listening skills, which go away eventually feel like a normal part of the mental acrobatics exercised on a daily basis by anyone who must communicate in any form. Effective listening is essential for anyone who wants to perform at his or her scoop out, domesticate easily and gracefully, and learn effectively. Few people realize that the art of listening has everything to do with intuition and little to do with the mental gymnastics of trying to concentrate on the words themselves. As you begin to see listening as an art and conversation as something that creates beauty, you will begin to understand how your own thoughts interfe re with the experience. One expert argues that the less thinking that goes on during a conversation, the more effective the listener is, because more of the actual conversation is retained and absorbed.(Gunn) This particular expert states that in his personal research, the more easy and clear a person is when engaged in conversation, the more retreat is available after the conversation. Intuition and feelings are also very important to this particular theorist. For effective listening, this theory requires one to be very aware of the feelings that are being inspired throughout the course of the conversation, to be stored in the memory and analyzed after the conversation is over, which one presumably will have more recall thereof since one did not bunk mentally distracted by emotions or thoughts during the conversation.Effective listening is also closely related to non verbal communicational forms such as gestures. Gestures are another tool that can be used to maximize a listeners input on the conversation and its outcome. While this specific tool is very culture based, it can be very effective when interpreted and practiced correctly. One of the most common cultures to use gestures in the United States is the Latin-Americans. Gestures allow individuals to communicate a variety of feelings and thoughts, often together with body language in addition to words when they speak. For example, in the Cuban culture there is quite an amount of hand gesturing that pass ons throughout a conversation. Depending on the renovate of the gesture shows the mental or emotional state of the person doing the speaking if smooth motions are made with the hands, the words being said are meant to pacify or to be taken calmly, regardless of their content. Though gestures are not part of syntactic language, their processing takes place in the same areas of the brain used by speech and sign language.Another ingenuous form of listening is reflective listening. Reflective listening i s a communication strategy involving two key steps seeking to understand a speakers idea, then offering the idea back to the speaker, to confirm the idea has been silent correctly. It attempts to reconstruct what the client is thinking and feeling and to relay this understanding back to the client. Reflective listening is a more specific strategy than the more general methods of active listening. It arose from Carl Rogers school of client-centered therapy in counseling theory. (Hughes) It is important to retain the other persons actions and body language. Having the ability to interpret anyones body language allows the listener to develop a more accurate understanding of the speakers words and mayhap even the intent of the conversation, which may or may not be audibly stated. Having heard, the listener may restate or paraphrase what the speaker is saying. This is a technique for reassuring the speaker of ones undivided attention. It really does not imply understanding or agreement . In emotional conversations, a bang-up listener may intuit or sense underlying feelings and emotions. For example, when in an argument, one would say I sense you are angry. Can you pronounce me why? Again, the interplay between the non verbal clues and tools such as gestures and reflection all play a role in maximizing the effectiveness of the listener.While one cannot make a judgment call about the best way to listen, it is clear that the most definitive way to become an effective listener is to be mentally ready and to challenge oneself to practice skills that lead to naturally recalling and understanding everything that is said and intimated in conversation. While listening has much to do with the physical ability of the person, the intellectual application for effectiveness is more of a mental and psychological exercise that can only improve with constant practice. Not to trash the visually impaired, but the eyes are consistently the best source for all the cues that guide ef fective listeners. For many in the business world, the time spent becoming an effective listener will be priceless in terms of communication that can open doors and opportunities. Furthermore, an effective listener that applies their professional success to their personal life can also ensure a very productive and emotionally satisfying life, because all of us have something to say, and everyone wants to be heard. In the words of Bishop TD Jakes, Listen with your ears. The ears work better when windpipes are closed. Listen with your mind. Many times words are based on a point of reference that you may not be aware of. Listen with your heart. Many times words do not convey whats in the heart so when you listen, hear what is said but also what is meant. Compassion is a diminutive part of understanding. It is difficult to love people without understanding them. Love seeks to understand. Listening with your heart will take away your natural propensity to be selfish. Listen with your he art. Many times words do not convey whats in the heart so when you listen, hear what is said but also what is meant. Compassion is a critical part of understanding. It is difficult to love people without understanding them. Love seeks to understand. Listening with your heart will take away your natural propensity to be selfish. Sound words to guide the phantasmal health of his parishioners, but also very applicable to any successful individual in todays world.

Research Methods For Hospitality And Tourism

Research Methods For Hospitality And TourismSet above the grocery townsfolk of Otley, in West Yorkshire, you result find unspoiled woodlands, secluded accommodation and glorious fishing lakes.With 49 new-fangledly refurbished hotel retinue and log cabins- you will encounter a million mile from it each. However you will all overly find bustling markets, fine dining eaterys, bars, galleries and shopping just transactions away.Eating at our beautifully ext terminused lakeside eating place is a must. Whether you argon here for business or pleasure, you will leave wise and totally relaxed.A HOTEL WITH HEART AND SOULA RENOWNED sweep OF SCENIC BEAUTY, The Yorkshire Dales is a landscape brimming with history, tradition and nature. Situated on the actually southern edge of the Dales, Chevin boorish Park Hotel Spa sits at bottom 44 acres of silver birch woodland on the eyebrow of the Chevin forest. The unique timber buildings of the hotel and lodges sit naturally amidst thi s seclusion.The hotel takes its name from the wooded hillside overlook the mediaeval market town of Otley. This offers stunning views of the wharfe vally and surrounding countryside. Our ambition for Chevin is for it to keep as the Hotel of choice in West Yorkshire, At the aforesaid(prenominal) prison term pre helping the beauty of the natural environment and the character of the original building.At Chevin Country park hotel Spa we will put our heart and soul into braggart(a) you a great hotel befitting of such a great posture and promise to dedicate your visit as special and unique as the setting itself.PADDY CRERAR. Aims ObjectivesThe aim of this explore is to investigate the factors touching performance plans of guidance which has affected loss of business and benefit.ObjectivesTo investigate concept of counselling based on literature review.To establish theoretical primer coat to ever-changing commission.To investigate factors that affect implementation of plan by management.To clarify recent conditions with help of hypothesis.Analyses the data collected and give evaluation.PROBLEM ACCORDING TO focal pointIn Chevin Country Park Hotel, these argon different types of problems according to managementProblem is to a greater extent or less servicing. Guest has non give nice feedback, nearly of them are quetch closely profit. They are saying that, both eon they have to wait for food. focussing doesnt want to hire more mental faculty for Kitchen as easily as Service.Hotels dont have becoming machinery.Rules marketing st postgies put by new management. mental faculty turnover queryResearch is delineate as, any(prenominal) gathering of data, information facts for advancement of knowledge.Research is discerning pas period of the truthToday there are thousands of companies, whose primary coil activity involves providing look for wait ons that helps business key strategies, tactical and operational question. Research has bu zz off more formalized good. however its purpose remains much the same as enquiries undertaken by the Phoenician merchants. How do I find response to improve my performance and make life wear out for customer, employees, and owner? disdain research is design to answer these questions.OBSERVATIONDue to shortage of time I couldnt be part of faculty or can non be employee of hotel, so method I chose was direct card. I started my observation at receipt as checking in the hotel.I was standing at reply as walking guest. I observed following factsAbout StaffStaff was non up to the standards.Were confused and less acknowledged.Were delaying check-in process were petulant customers standing in queue.Were talking to themselves in their autochthonic languageWere lowbred to customers.They were confused with issuing of keys to the customer creating panic among themselves.Were not aright dressed.Were creating a chaos.Were not tending guests requests, which were living in the ho tel.Were confused speckle attending call and guests simultaneously. fit coordination amid ply was missing.2. At Reception deskAt the answer, the flowers used for decoration were not fresh..Bell boy were not avail qualified, as a result guests had to lead their own luggage.Keys were placed in at random manner, which was confusing the receptionist while assigning it to the guests.Three telephones were placed on reception desk but only one receptionist was responsible for attending all triad telephones, and she was not able to manage them. Ringing other twain telephones while attending one call , was do that receptionist and guests annoyed.The ground naturalise near the reception was not cleaned regularly ,as a result many footprints were printed near the lobby, making ditching dirty.3.In Hotel RoomWhen I entered my room, I observed following thingsThe floor of the room was not properly cleaned I could sense the dust on the floor as my shoes were leaving footprints on the f loor.In refrigerator, I could see close to empty cans, which leap outed that it was not restocked. there were al nigh fingerprints on the mirror, which showed mirror was not cleaned regularly.The bed spreads also had some label.Dusting was not done properly, as there was dust on the elude.Towels in the toilet were not up to the standards. It seemed wish comfortably used before by someone else.The mattress outside the bathroom was stinky.Toilet wanders near the WC were not assembled in the tissue holder.AC in the room was not working properly. in any case Wi-Fi signaling in the room was very poor.One of the bulbs in the room was not glowing. at that place was no instruction manual for using electronic equipments.There was no instruction manual for operating AC.TV was not affiliated to DVD player and it was mentioned no where how to connect TV and DVD player.There was no manual for how to operate a washing machine.4. In Hotel Restaurant About restaurant, the service of fo od was very opposed.Staff didnt have enough knowledge about food and wine.Service staff couldnt tear down explicate to guest what were the ingredients in dishes, like what kind of sauces served with pork or boeuf?Even staff didnt know that which wine goes with specific dishese.g. red wine goes with red meat.Management had changed the menu staff was not briefed properly.There was no sufficient place between two card, making it uncomfortable for commonwealth to turn tail to and from the aisles.Cutlery which was used on table which was not lissom. in like manner table cloths on the table, were having food stains mark.Staff used to speak their native languages loudly standing behind the counters.Also there was loud clayey of glasses, cutlery coming from service heavens behind.It seemed like they were not able to make proper atmosphere in restaurant.Restaurant conductor was very rude while discussion guest complaints.5. About Hotel themeInfrastructure of the restaurant was one of the strategic problems of this hotel. Hotel is having 2 floor restaurants. Upstairs floor having lake view balcony. So guest will prefer to sit upstairs. But its very difficult for staff to give proper service to guest. Also bar is not placed near restaurant, so that each and every time they have to go to bar to take drinks for guest.HYPOTHESIS speculation can be defined as observable phenomena or data-based observation. It guides the direction of research. If it seriously conducted, it helps to know what shall be done and what shouldnt.Co relative HypothesisCo relational hypothesis occurs together in some specified manner without implying that one cause another.In this case management is independent and all staff, machinery, rooms, services etc are dependent.According to the Hypothesis and my observation the results which I found areHotel staff is not curbing proper bandaging standards like hair cut, wearing je haleery etc.Front location staff is not much capable to c ome up to guest. Also not having enough experience to handle situation.Food service very slow in restaurant, because of that guest has to wait long for every course. Also staff not having enough knowledge about food and wine. Staff carriage towards guest is not good.Manager behavior towards guest as well as staff is very rude.Quantity of food is lessHotel rooms are not clean properly, when I entered in room, that time I saw that dusting in room not done properly.Direction signs are not accurateInfrastructure of the restaurant, some of the facilities in the hotel are not working properly.Casual staff is working , nearly of the all department,. real management get casual staff on more cheaper rate who are not trained.CASE STUDYA case deliberate at the Front desk NANCY SWANGER,Morgan Black appointed as researcher by corporate office.The Coug Inn is a 150 rooms full serviced property with several medium sized banquets. it caters mostly to business travelers and visitors affiliated to topical anesthetic university. Hotel is very busy between august and may, with periods classes are not in session being extremely slow. Occupancy has been declining for the last year or so. Since arriving at The Coug Inn, Morgan made several observations about hotel situation. It seems that most of the problem with battle former desk. subsequently reviewing comments card from last month, Morgan has sensed real dis bliss with the check-in process. musical composition work at check in is perceived as elongated and hard to fill out. Guesthas been checked into rooms that were not clean. after(prenominal) discussing problem with front office four-in-hand, front office manager complaints that backlog staff does not always submit the days reservation to the front desk in a timely manner. So when guest arrive, desk further with over 65 % of the hotel staff speaking first language other than English. So communication is difficult. Front office manager further told that, the new ho tel in town, the suit to sleep inn. Has an earlier checked in time and it seems to work ok for them. Morgan asks front office manager how the staff might answer to moving to a fully automated property management system. The oppose was not favorable. Also corporate office had not put any money into the place in years. In attempt to reach a compromise, Morgan considers changing the check-in time in exchange for the front desk managers escort of the conversation to an automated system.What must Morgan take into consideration before nett decisions are made to adjust checked in time and ground fully automated property management system?How should Morgan proceed in resolving the communication issue?Who shoots to be involved in the final decisions?How might Morgan present the case to the corporate office?(Hotel Management and Operation By Michael J. Ofallon, Denney G. Rutherford, Page no162)RESEARCH METHOD utilize TO RESOLVE PROBLEMResearchAfter reviewing the assessment form, I wou ld like to use Evaluation Research. This will help hotel to get profit.There are three types of researchDescriptiveIs finding out describing what it isExplanatoryExplaining wherefore or how things are there.EvaluationIn process of Evaluation research participant contribution plays important role.Participant contribution term kernel manager should specify their problem provide the researcher adequate background information relating to them.As manager explained the entire situation about hotel. As manager told, all problem which hotel is facing, needs to be solved as soon as possible. There are many problems with service, kitchen as well as infrastructure. Actualy all these problems are related to each other.DATA collectingThe main step in Evaluation Process is entropy Collection.Data Collection identify issues from the people directly involved in the course of instruction identify further issues from the programmed documents, observing how the program is actually working.Throu gh manager, I got assessment forms, Restaurant ostracize comment card given by guest, also appraisal form which is filled by employees.To solve these problems, we need to evaluate current employees to determine their productiveness, job satisfaction and commitment.DIFFERENT RESEARCH METHODS USED TO REACH THE CORE OF PROBLEMSELF APPRAISAL QUESTIONNAIREEmployee mentionDepartmentPositionStart DateHow do you looking at about the work environment at Chevin Park Hotel?How do you enjoy most about your position?What do you feel about strongest work areas?In what area do you feel you have made improvements or changes?In what areas would you like more training or more work experience?What are your goals for next years?COMMENTS give thanks you.Guest Comment witChevin Country Park Hotel SpaChevin country park hotel spa really care about what you rally. Sending feedback help us to provide you better level of service on your next visit with us. Please feel free to to comment on our site, our hotel or any other numerate on your mind.Rate usExcellentGoodAverage somewhatPoorPhysical appearance of the hotelCheck in processCleanliness of hotelcalibre of foodYour overall experienceBetterIs there an area where you think we could do a better job?EmployeeDid you particular hotel employee make your hindrance with us especially enjoyable?CommentsAdditional comments you wish to makeThank you.CASE STUDYSAMOUELS GREEK CUISINE RESTAURANTSamouels Greek cuisine Restaurant is located in London. Phil Samouel, owner of the Samouels Greek Cuisine Restaurant, believes his profit are not as high as they could be. He wants to maturation sale. He wants to attract new customer. He also wants to date that restaurant running smoothly. Phil Samouel is new to this business. So he decided to hire restaurant consultant. He contacted Ad mark International, ask them to conduct a advance assessment of his restaurant operations and prepare research proposal for him to review.After discussions wit h Phil Samouel and several of his employees, the account manager from the research firm conclude that the primary questions facing samouels restaurant areAre employees being managed to maximize their productivity as well as commitment to the success of the restaurant?What are the different way to attract new customer?These are the two separate issues but they are related to each other. First project will evaluate current employees to determine their productivity, job satisfaction and commitment. atomic number 42 project evaluate the survey of customer.The employee assessment projectHow do employees feel about work environment?How committed are the employees to helping make the restaurant success?Do different group of employees have different feeling about working at samouels?Customer assessment projectWhat is the level of satisfaction of samouels customer?What factors contribute to restaurant customer satisfaction?Do customers rate Ginos more favorably than they do samouels?( name of the bind )SolutionFor roomsThere should be either permanent staff or contract staff for clean the rooms , proper modify equipment like vacuumed unsoiled, glass wiper, all solutions etc. should be purchased to make cleaning easier and faster. A supervisor should do the rooms.The towels and mattresses , bedspreads in the rooms should be properly cleaned and dried. Laundry should take this responsibility.Maintenance persons, at least 2 should be hired as permanent staff for emergencies which will also hand over money of management to look after all the electronic equipments in the hotel.Staff should be given training before actual service briefing should be done by manager with the staff so the staff is aware of daily specials, soup of the day availabilities of the dishes from the menu.RestaurantThe staff should be given the training related to food and beverage foregoing to attending guests.Staff should be given training, for tincting greeting guests as per hotel standa rds laid by new management.Manager should have an idea of discourse all the problems that may happen in the hotel.Fast and proper service should be given to the guests.Staff should be given knowledge about what are the ingredients of the served dish.Staff should be given training based on type of wine and the dish with which it can be served.The tables should be ordered properly prior to the party or the event organized. There should be proper spacing between the tables so that waiter can move freely for serving.The plates and cutlery should be properly cleaned and polished. A plate polished should be arranged by the hotel.Table clothes on the table should be cleaned, and the responsibility has to be taken by laundry police squad. They should ensure that there are no stain marks on the table clothes.Staff should use only English while in the hotel, conversation in native language should not be allowed, as it is confusing for the guests of the hotel.About Staff There should be eith er permanent staff or contract staff for cleaning the roomsStaff should be provided proper training prior to joining job.At Reception deskThis is the most import place in hotel as all the guests are original at Reception.Flowers at the reception should be fresh and placed properly. bedight should be cleaned regularly.If there are more than two telephones at the desk, more than one person should be available at desk to attend the calls.A personnel should be appointed for handling only guest complaints, and should be handled carefully.Bell boy should be available at the reception to carry guests luggage.About Hotel InfrastructureInfrastructure of the hotel is the major part affecting the service of the hotel. So infrastructure should be designed properly to meet the requirements.Bar should be situated near the restaurant, so that it will be motiveless to provide proper service to the guests.Infrastructure of the hotel is the major part affecting the service of the hotel. So infrastr ucture should be designed properly to meet the requirements.(FLOOR PLAN FOR RESTAURANT / BAR/ RECEPTION)As per shown in diagram, Restaurant is situated on lake. Bar is situated behind the Reception. Thats why distance between restaurant and bar is too long. So every time service staff has to walk through it. Also if you go from service area then also it takes time. Thats why guest are keep complaining about service, slow service.If you see in diagram, lounge is situated exactly besides of the restaurant on lake. If we make setup of bar in Lounge, and Lounge will goes instead of Bar. This will save lots of time, also because of this it will look nice. So guest can go themselves on Bar and have their drinks. That will useful for guest as well as staff.If management ready to change infrastructure, this will be the important change, which need to be done. Surely this will help to improve service quality.CleanlinessProper Cleanliness should be retained. only the used utensils should be cleaned at the end of the day so that it can be used next day.Oven should be cleaned regularly so that it is free from any odor.Gas stove should be cleaned regularly so that there are no stain marks on it.planning All the events should be planned properly so that there are no confusions at any events.All the tables should be arranged properly in the night, so that in the morning there wont be any wastage of time in arranging the table. trainingThe staff should be given proper Behavioral Training so that they should know how to handle guests.The staff who is working in service segmentation of restaurant should be given proper training on serving and should be given knowledge on ingredients of the dishes served.The staff should be givenMeetingsMeetings for staff should be arranged regularly by manager so as to discuss the goals to be achieved and should also discuss what technique should be used for the same.Meetings should be arranged on daily, weekly, monthly and annual basis.All the problems faced by staff should be discussed in these meetings.FeedbacksThere should be a personnel appointed for handling feedbacks given by guest.Proper measures should be taken to work on it.It should be discussed regularly with manager so that the areas where hotel need to be improved is highlighted.Manager BehaviorManager should be experienced, should know how to handle all the situations that a hotel may face.He should be trained properly so that he can handle annoyed guests.He should offer some complimentary service to guests in case of any mistakes committed by hotel unknowingly.Advanced Equipment / MachineryHotel should buy march on equipment in case of necessity so as to make all the processes fast. For archetype Hotel should buy an automatic dish cleaners so as to make dish cleaning faster and effective.Hotel should buy number of vaccum cleaner so that cleaning of dust is an fast an easy procedure.Dish polisher should be bought to polish dish.Floor cleaning machiner y should be bought to make floor cleaning faster.In laundry, no of washing machines should be present so that bed spreads, mattress and table covers should be washed regularly and kept clean.Driers should be available so that all the table covers and other clothes are dried and can be used for next day.Technical ProblemsFor handling technical problem a technical team should be hired. For exampleTo handle problems related to bulb, tube light fitting, a electrician should be available for hotel.To handle problems related to network, LAN, wi-fi, internet connectiona technical personnel should be hired.3. To handle defects in washing machine, oven, geyser, lifts, fans, TV, dvd players a technical team should be there.SupervisionA supervisory team should be assigned to do following thingsTo supervise room cleanliness.To supervise floor cleanliness.To supervise whether electronic equipments are working properly.To supervise whether cleanliness is maintained at kitchen.CONCLUSIONAs elabora ted above, if the mentioned policies are implemented by the hotel management, the expected result would be1. addition in staff skills2. prove in customer satisfaction3. Rise in employee satisfaction4. Increase in hotel profit5. Improve in hotel standardThe mentioned policies would help hotel to maintain its position in this competitive world of business and would help hotel to rise up at a faster rate, improving its market standards and market values.This would even help hotel and its employees to be at a stronger position even when market is down. Would help them to handle all the situations that would be beneficiary for the organization.

Effective Treatment for Generalized Anxiety Disorder

Effective Treatment for commandized foreboding discommodeIntroductionIn autochthonic c be, as in different field of medical practice, it is essential that doctors atomic deem 18 able to apply the findings of scientific question to the circumstances of individual uncomplainings as part of their clinical decision-making process. This is known as evidence based medicine. In this review I meet interpreted an illness which often presents in primary charge, viz. Generalized Anxiety unhealthiness ( prodding), and by re fronting possible pr for each oneings pay developed the skills necessary to search various databases for applicable articles and the ability to assess the validity of the evidence found. In this review I focus specific in ally on Cognitive-Behavioural Therapy (CBT) as a potence discourse for spur.Generalized trouble deflect is characterized by chronic, uncontrollable worry associated with a wide regorge of physical symptoms including fatigue, headaches, muscle aches, ambitiousy swallowing, trembling, twitching, sweating, nausea and shortness of breath. A diagnosis of GAD is made when a person worries excessively ab protrude a variety of every day problems for at least 6 months. The disorder is common in by and byward animation, with a prevalence of 11.2% in primary awe where one fourth dimension(a) adults closely often seek treatment and everyplaceall is more prevalent than all severe cognitive impairment or depression in the over 65s. Despite this, misgiving disorders in the aging population have acquire relatively little research attention. Anxiety in later life has been linked to increased risk of physical disability, memory difficulties, decreased select of life and inappropriate use of medical services .There are on-goingly several treatment options available for GAD including drugs such(prenominal) as Benzodiazepines, Selective Serotonin Re-uptake Inhibitors (SSRIs), Azapir superstars, Barbituates and Prega blins. There are in whatever case utility(a) treatment options such as herbal remedies and psych separatewiseapy such as Cognitive-Behavioural Therapy and Psychodynamic Psychotherapy. Cognitive-behavioral therapy is a human body of psychotherapy which targets problematic emotions and behaviours via a range of approaches and displace be utilize a hugeside medication or as an alternative to it. When used to treat anxiety disorders the principle methods let in education and awareness, motivational interviewing, relaxation training, cognitive restructuring, exposure, problem-solving skills training and behavioural sleep management. Unlike anxiolytics, CBT has no known side effects or risk of physical dependence. Anxiolytics are currently the just approximately common treatment for late-life anxiety and surveys suggest that up to 20% of non-institutionalized antique persons may be using benzodiazepines. However, the use of these medications as a long term treatment for anxiety disorders is associated with potential risks for elderly patients such as cognitive impairment, falls and hip fractures, drug interactions and toxicity. as well as an over-reliance on medication may neglect potentially distinguished psychosociable factors such as social support, coping skills and interpersonal relationships. In light of this it is important that the durability of CBT is assessed as it could prove a utile alternative to long term medication particularly in the ageing population.MethodI conducted initial research using textbooks and the internet and then used different databases to search for relevant papers and articles. Searches were earlier conducted using MedLine (Medical Literature synopsis and Retrieval System) as it contains information from a wide range of palm including Medicine, Nursing, Pharmacy, Biology and Biochemistry and contains over 18 million records from approximately 5,000 publications. Web of experience was also used as it encompasses non except MedLine entirely also other databases such as the Social Sciences Citation Index. I also conducted searches using Scopus and the Cochrane Library but often found that the Cochrane Library yielded fewer or no results so these searches have been omitted. By beginning with gigantic search terms it was possible to refine these to yield fewer, more relevant results.An initial search of the terms cognitive-behavioral therapy and generalized anxiety disorder yielded the sideline results. The search was also demarcationed to include articles which had both these terms in the title and in the abstract.Various spellings and abbreviations such as CBT and GAD were used when searching for cognitive-behavioural therapy and generalized anxiety disorder in order to deliver the goods a high number of results and to ensure articles werent overlooked. After searching through the results, reading abstracts and dismissing articles which werent relevant to this topic or freely availab le, 4 articles were chosen to be include in this review. I chose to specifically focus on RCTs as this is the strongest take up design for testing cause and effect relationships. When critically appraising the papers include in this review, a series of questions primarily derived from the CASP (Critical Appraisal Skills Programme), but also incorporating other sources, were used and articles were judged on how more than information they provide and the quality of the evidence. Examples of these questions are as follows.Did the campaign have a clear objective?Is an RCT an appropriate study design to perform this question?How were the participants randomised?What was the average age of the participants?What were the exclusion criteria for participants?Were the subjects in from each one of the assemblys quasi(prenominal) on demographic and baseline clinical variants?How did the examination arrange for attrition?When/how often was data collected from participants during follo w up?How were outcomes mensural?Were expand of effect sizes and statistical significance given?Did the study have enough participants?Does the paper present a clear result?Results passwordThe initiatory study looked at was an RCT promulgated in 1996 entitled Treatments of Generalized Anxiety in of age(p) Adults A Preliminary Comparison of Cognitive-Behavioural and verificatory Approaches. This trial compared CBT with non directive Supportive Psychotherapy (SP), a form of therapy which rents education, guidance, listen to the patient and encouraging expression of emotions. Results showed substantial improvement in all measured outcomes for both interventions and generally large effect sizes. However, no noteworthy differences were found between the the devil hosts. The authors gave an extensive list of exclusion criteria, including current involvement in psychotherapy and low MMSE scores, which limits confounding factors and therefore the likeliness of type 1 errors. A ma jor limitation of this study withal is the high level of attrition. This study design could possibly be modify if it were to include another control sort out, which receives no treatment, with which to compare the twain interventions with. In this respect the more recent trial Treatment of generalized anxiety disorder in older adults, which is discussed later, improves on this trial and has a solidly raze attrition rate. However, the authors of this trial argue that by failing to include a waiting-list control group they alleviated the need to withhold treatment from any patients, which could be deemed ethically questionable. This trial had a follow-up sound judgment point of 6 months which is relatively short compared to the other studies in this review, one of which has a follow-up period of 15 months. It is arguable that this will limit conclusions made in this study regarding the long-term durability of treatment. Unlike other studies this study did not measure the eff ect of either intervention on the participants quality of life which is an important factor to consider as GAD has such a profound effect on the sufferers quality of life.An RCT published February 2003 entitled Treatment of generalized anxiety disorder in older adults, compared CBT with a discussion group (DG) and patients receiving no treatment on a waiting list period (WL). The discussion group was organized somewhat worry provoking topics and was designed to be structurally corresponding to CBT. DG consisted of a series of 12 discussions focused on topics known to be worry-provoking for older adults, including memory problems, health concerns, loss of independence and death of friends and family. both(prenominal) the CBT and DG groups consisted of 4-6 participants and a group leader, one of four advanced doctorial students in clinical psychology. These leaders were spread across the two interventions and each leader chaired at least one CBT group and one DG in order to avoid c onfounding the effectiveness of the therapist with the effectiveness of the therapeutic model. Participants in both CBT and DG were asked to spend approximately 30 minutes a day on homework exercises. The study gave unspoiled details of exclusion criteria including commencement of psychotropic medication within the departed 2 months. Patients who had started medication more than 2 months ago were included but were asked not to change their dose or type of medication for the duration of the trial. However, in light of this it is possible to argue that including participants on any form of anxiolytic medication restricts conclusions about the impact of CBT without concomitant pharmacological treatment. The authors included a table detailing demographic information about their study sample in order to support the generalisability of their findings. The table showed that participants came from a range of races, had differing marital and work statuses and suffered from a range of diff erent medical conditions, the just about common being osteoarthritis (36%) and hypertension (32%). Compared to the first study, participants not all scored themselves but were also assessed by trained research assistants who were unaware of which group the patient had been assigned to. This adds an element of blinding which is not present in the first study. This was the only study in which patients rated their impression of the treatment after the first session. The participants rated the credibility of the intervention, their enjoyment, perceived effectiveness, likelihood of recommending the intervention to a friend, likelihood of participating again in the future and perceived improvement. This is a useful addition to the trial as a patients satisfaction with a treatment method has a big impact on adherence and possibly symptom improvement. The results showed that participants in both CBT and DG improved compared to the waiting period but there was no significant difference be tween the two interventions. However, when effect sizes were calculated showed large effects whereas DG showed medium surface effects. Essentially this study shows that CBT is better than no treatment but gives no significant evidence to suggest that it is better than other forms of intervention such as group discussion. This is an interesting point which mirrors the findings of the first trial which compared CBT to SP.An RCT published in April 2003 entitled Cognitive- Behavioral Treatment of late-life generalized anxiety disorder (M A Stanley et al. 2002) evaluated the efficacy of CBT compared to minimal contact control (MCC). The results showed a significant improvement in worry, anxiety, depression and quality of life following CBT compared to MCC. 45% of patients were classed as responding to treatment compared with 8% who received MCC. Importantly these gains were maintained or enhanced over a 1 year follow-up. However, as in the other RCTs in this review, patients did not rep ort a complete counter to normal functioning or a complete removal of symptoms. When recruiting participants for this trial the Anxiety Disorders Interview Schedule-IV was used as a diagnostic tool. Patients underwent two separate diagnostic interviews conducted by two different evaluators over a period of at least two weeks. These evaluators were unaware of any introductory diagnoses made. This shows that all participants in the study had symptoms which were consistent and were not prone to alter over time, which means that any change during follow up perspicacity was more likely to be due to the intervention than to fluctuations in the roughness of their GAD. The study commented on potential variance in results due to sex activity and explained how they had adjusted for this. Similarly to the last study, this study used not only self-reported scores but also independent clinician rated scores. Unlike previous studies this trial did not include any participants currently rece iving medication for their GAD or associated symptoms in order to assess the effectiveness of CBT alone and not in conjunction with medication.A Randomised Control Trial, conducted by M A Stanley et al. entitled Cognitive Behaviour Therapy for Generalized Anxiety Disorder Among Older Adults in Primary Care (2009) compared group CBT conducted in primary care clinics over 3 months with a control of enhanced usual care (EUC). The authors chose to use group CBT rather than individual, one-on-one CBT as they believed that the loss of social support often experienced as a consequence of ageing indicated the potential benefits of group treatment. The results of this trial showed that CBT significantly improved worry severity, depressive symptoms and general mental health but there was no difference in GAD severity between the two groups. The authors clearly set out their objective and gave detailed information on where the study was set, where participants were chosen from, details of the intervention and main outcome measures at the start of the paper. The fact that the patients were recruited simply from a primary care setting and that the intervention was delivered in primary care makes this evidence particularly useful for this review. During recruitment all potential participants were screened using two questions from the Primary Care Evaluation of Mental Disorders, as well as undergoing the Mini-Mental State Examination and a Structured symptomatic Interview, in order to ensure that all had the same diagnosis and similar GAD severity. Race and ethnicity of participants were identified and the data used to facilitate conclusions about the generalizability of the data. The authors commented on effect sizes and stated that the effect sizes for symptom improvement were comparable to or greater than those in recent primary care studies of jr. adults with GAD and older adults with depression. The authors also commented that participants in this trial scored slightly lower mean change in worry severity over time scores in comparison with Treatment for Generalized Anxiety Disorder in older adults that was conducted several years earlier. One possible limitation of both this study and the previous study is that patients in the control group received minimal contact with health professionals compared to the intervention group. This may break patients go throughing neglected and as they are aware that theyre not receiving any form of treatment, they may not expect to get better and later score themselves lower on assessment than otherwise. In this respect the first two studies are somewhat better designed, as they compare CBT to interventions which involve a similar contact. The second study in particular deals with this egress well by comparing CBT with a discussion group, which requires the patient to be involved with the intervention, and a waiting list period in which the patient is very much aware that they are receiving no treatment.Sever al studies of anxiety in older adults have been conducted using community or cured centre volunteers with self-diagnosed, subjective anxiety symptoms and therefore the findings from these studies may not be applicable to a clinical population. In contrast the four RCTs included in this review were all conducted on patients with diagnosed GAD and CBT and was delivered in a primary care setting. All the studies gave detailed information on how the participants were randomized and how drop-outs were dealt with and had a follow-up period of at least 6 months. final stageIn conclusion, all four studies showed that CBT improves levels of anxiety, as well as other associated symptoms of GAD, when compared to both baseline measures and no treatment. However these studies also showed that when CBT is compared to other forms of therapy, namely Supportive Psychotherapy and discussion groups, there are no significant differences between the two interventions. Although CBT does lead to signific ant alleviation of symptoms, this evidence does not indicate that CBT is a long lasting cure for GAD and it does not prove CBT to be a better treatment option than other forms of psychotherapy. Therefore it is important to question whether or not the benefits felt by participants receiving CBT, SP or DG are due to a placebo effect compared to participants who are left on a waiting list who may feel they are being neglected and do not expect any improvement in symptoms. This raises the issue of blinding which is a limitation of most conceivable trials including CBT as it is not possible to make the participant unaware of what intervention they are receiving when when they have to actively participate in treatment.The shortfall of clinical trials, particularly RCT trials, investigating CBT as a treatment for GAD needs to be addressed if an acceptable amount of evidence in favour of CBT is to be established. Suggestions for future trials include RCTs comparing the effectiveness of grou p CBT compared with individual CBT for older adults and trials comparing CBT with anxiolytic medications such as benzodiazepines. This is a particularly pertinent issue considering the side effects associated with anxiolytics and old age, as previously mentioned. Future trials should aim to recruit a larger number of participants than seen in most of the studies discussed. In theory this should not be difficult if the prevalence of GAD in the elderly population is as alarmingly high as some statistics indicate.