Writing essay
Paper Writing Websites
Tuesday, August 25, 2020
The Big Lebowski Essay Example For Students
The Big Lebowski Essay The entirety of the connections among the components in the film the Big Lebowski may appear to be baffling with one another, yet this style of film makes an incorporated arrangement of disunity. The Coen siblings show this style through different themes all through the film, from the fundamental characters name to what he drinks. The film is an ideal case of a film which has the topic of disunity. In the film the fundamental character Jeffery Lebowski, alludes to himself as the Dude. This component of the story turns into a theme. The Dude is alluded to, and alludes to himself as the Dude since it speaks to his character, which is an accommodating cool character. The basic Western culture slang which is related with the word man, is male whore. In the scene where the Dude gets back in the wake of being captured in Malibu, he wind up participating in sex in line with Mod Lebowski. After they finish, Mod discloses to the Dude that she was utilizing him to yield a kid. We will compose a custom article on The Big Lebowski explicitly for you for just $16.38 $13.9/page Request now Clearly he was not given cash in return for sexual favors at the same time, the Dude, much like genuine whores was utilized for sex. The Dude is consistently utilized by his companions and business relates all through the entire film. In spite of the fact that introduced as a laidback cool character, the Dudes title is illustrative of how he is seen by everybody around him. In the film, Bowling is viewed as a keeps an eye on movement, a place where go to contend and escape from the world. In the bowling alley there will never be a female present in the shot inside any scene. This theme is strengthened during the scene entitled Gutter Balls. In the Dudes trip-out it begins as a bowling parody explicit film, which can likewise be viewed as a male thing. It has shots of coasting bowling pins and balls improved in various sexual positions, where the pins speak to the male genitalia. Further on in the fantasy, Mod, who is a solid free character, is spoken to by Viking ensemble she is wearing. In opposition to this, she despite everything required assistance from the Dude when bowling. In the Big Lebowski bowling is viewed as a male ruled movement. During the scene where the Dude and Mod Lebowski participate in sex, the Dude pores himself a White Russian. The Dude clarifies that the liquor and maryjane encourages him think. Im keeping on a severe medication regiment to ahh, keep my ahh, mind nimble. This is demonstrated when very quickly after he smokes his maryjane and pours his White Russian he makes sense of where enormous Lebowskis cash is. As opposed to this, the medications and liquor can likewise be viewed as an obstruction in the Dudes exertion to tackle the case. At a certain point the Dude crashes his vehicle in the wake of spilling his beverage and dropping a lit joint onto his lap. In another scene the Dude is captured in light of the fact that his White Russian was sedated. Medications and liquor become a Catch 22 of the Dudes achievement. In light of these themes we can see that the Coen siblings utilized various themes show any number of various things about the film. They can work together subjects of manliness to societys perspectives on the powerless. With this, the Big Lebowski has a subject which must be called varied.
Saturday, August 22, 2020
Biography of King Abdullah, Ruler of Saudi Arabia
Account of King Abdullah, Ruler of Saudi Arabia Abdullah receptacle Abdulaziz Al Saud (August 1, 1924ââ¬January 23, 2015) was the lord of Saudia Arabia from 2005 to 2015. During his rule, strains expanded between traditionalist Salafi (Wahhabi) powers and liberal reformers. While the lord situated himself as a relative moderate, he didn't advance numerous meaningful changes; indeed, during Abdullahs residency, Sauda Arabia was blamed for various human rights infringement. Quick Facts: King Abdullah Known For: King Abdullah was the ruler of Saudi Arabia from 2005 to 2015.Also Known As: Abdullah receptacle Abdulaziz Al SaudBorn: August 1, 1924 in Riyadh, Saudi ArabiaParents: King Abdulaziz andà Fahda bint Asi Al ShuraimDied: January 23, 2015 in Riyadh, Saudi ArabiaSpouse(s): 30Children: 35 Early Life Little is thought about King Abdullahs adolescence. He was conceived in Riyadh on August 1, 1924, the fifth child of Saudi Arabias establishing ruler, Abdulaziz canister Abdulrahman Al Saud (otherwise called Ibn Saud). Abdullahs mother, Fahda bint Asi Al Shuraim, was Ibn Sauds eighth spouse of 12. Abdullah had somewhere in the range of 50 and 60 kin. At the hour of Abdullahs birth, his dad Amir Abdulazizs domain included just the northern and eastern segments of Arabia. The Amir crushed Sharif Hussein of Mecca in 1928 and pronounced himself ruler. The imperial family was very poor until about 1940,â at which point Saudi oil incomes started to increment. Training Subtleties of Abdullahs training are inadequate, however the official Saudi Information Directory expresses that he had conventional strict instruction. As indicated by the Directory, Abdullah enhanced his conventional tutoring with broad perusing. He likewise spent a long spell living with the desert Bedouin individuals so as to learn conventional Arab esteems. Vocation In August 1962, Prince Abdullah was designated to lead the Saudi Arabian National Guard. The National Guards obligations incorporate giving security to the illustrious family, forestalling overthrows, and guarding the Muslim Holy Cities of Mecca and Medina. The power incorporates a standing armed force of 125,000 men, in addition to an inborn civilian army of 25,000. In March 1975, Abdullahs stepbrother Khalid prevailing to the seat upon the death of another relative, King Faisal. Ruler Khalid named Prince Abdullah second agent leader. In 1982, the seat went to King Fahd after Khalids demise and Prince Abdullah was advanced again, this opportunity to agent PM. In this job, he managed gatherings of the lords bureau. Lord Fahd likewise formally named Abdullah the Crown Prince, which means he was next in line for the seat. Official In December 1995, King Fahd had a progression of strokes that left him pretty much crippled and incapable to satisfy his political obligations. For the following nine years, Crown Prince Abdullah went about as official for his sibling, in spite of the fact that Fahd and his associates despite everything employed impressive impact over open arrangement. Ruler of Saudi Arabia Lord Fahd kicked the bucket on August 1, 2005, and Crown Prince Abdullah became ruler, accepting force in name just as practically speaking. He acquired a country conflicted between fundamentalist Islamists and modernizing reformers. The fundamentalists once in a while utilized psychological militant acts, (for example, shelling and abducting) to communicate their indignation regarding issues like the positioning of American soldiers on Saudi soil. The modernizers progressively utilized sites and weight from global gatherings to call for expanded womens rights, change of Sharia-based laws, and more prominent press and strict opportunities. Lord Abdullah got serious about the Islamistsâ but didnt make the huge changes for which numerous onlookers both inside and outside of Saudi Arabia had trusted. International strategy Lord Abdullahâ was referred to all through his vocation as a firm Arab patriot, yet he connected with different nations too. In 2002, for instance, the ruler set forth a Middle East Peace Plan. It got recharged consideration in 2005, yet has moped from that point forward and presently can't seem to be actualized. The arrangement requires an arrival to the pre-1967 fringes and a privilege of return for Palestinian evacuees. Consequently, Israel would control the Western Wall and the absolute West Bank, and get acknowledgment from Arab states. To assuage Saudi Islamists, the lord prohibited U.S. Iraq War powers to utilize bases in Saudi Arabia. Individual Life Ruler Abdullah had more than 30 wivesâ and fathered in any event 35 kids. As indicated by the Saudi Embassys Official Biography of the King, he reared Arabian horsesâ and established the Riyadh Equestrian Club. He additionally wanted to peruse, and set up libraries in Riyadh and Casablanca, Morocco. American ham radio administrators additionally delighted in talking broadcasting in real time with the Saudi ruler. At the hour of his passing, the ruler had an individual fortune assessed at $18 billion, making him among the main five most extravagant royals on the planet. Demise Lord Abdullah turned out to be sick and was taken to the medical clinic toward the start of 2015. He kicked the bucket on January 23 at 90 years old. Inheritance In the wake of King Abdullahs demise, his relative Salman container Abdulaziz Al Saud turned into the ruler of Saudi Arabia. Abdullahs inheritance is a questionable one. In 2012, the United Nations granted him an UNESCO Gold Medal for his endeavors to advance exchange and harmony in the Middle East. Different gatherings including Human Rights Watch-censured the lord for his supposed human rights infringement, including the abuse of detainees. Abdullah was additionally censured for his approaches on strict opportunity. In 2012, for instance, the Saudi writer Hamza Kashgari was captured for making a few Twitter posts that purportedly stigmatized the Islamic prophet Muhammed; he was detained for about two years. People rights gatherings, for example, Amnesty International were exceptionally disparaging of Saudi Arabias treatment of the case. Sources Keyes, David. ââ¬Å"Saudi Writer Hamza Kashgari Faces Charge of Blasphemy after Tweets about Muhammad.â⬠The Washington Post, WP Company, 9 Feb. 2012.Knickmeyer, Ellen, and Ahmed Al Omran. ââ¬Å"Saudi Arabias King Abdullah Dies.â⬠The Wall Street Journal, Dow Jones Company, 23 Jan. 2015.Rasheed, Madawi al-. Salmans Legacy: the Dilemmas of a New Era in Saudi Arabia. Hurst Company, 2018.
Friday, July 31, 2020
SIPA Love Stories Love is a poem COLUMBIA UNIVERSITY - SIPA Admissions Blog
SIPA Love Stories Love is a poem COLUMBIA UNIVERSITY - SIPA Admissions Blog Heres our sixth and last story were sharing in this mini series. This final story is actually a poem someone wrote for their classmate. A SIPA love poem: I dont have any pic left but only a poem written in 2006 for my SIPA classmate : Poem for Sarah Autumn of 2005. Resistance, struggle, hesitation Jostle in the bosom of the newcomer. Yet still a flicker of expectation Upon arrival in New York, The city dreamed of. Then Columbia, SIPA. Weight of study: Meetings assignments papers reports; No interruption to the flurry of work As precious life is left to waste. No one to turn to among these cold connections And in the sudden sickness That pushes me to deathâs rim. New home, New York Frigid as the ice of winter. Then⦠Seemed it couldnât be true: Sarah, The loveliest girl my life had ever seen Came to my heart. In the nights of swirling snowflakes And the freeze of subzero mornings, You were ever shining with your sunlight, Giving me warmth that lasted all day. And with the heat of a fire on a summerâs afternoon You lit the dull classroom discussions, Making me forget all concerns. Among the things Of that year in New York, What I will treasure most Is not the great charm of the Big Apple, Not the beautiful grounds of an IVY League school. It is a girl called Sarah. She fills my memory, Occupies my thoughts. And if I yearn to return to New York And relive being a student at SIPA, It is only because I wish to Replay the time that we shared, And hold on tightly to moments Of beauty ineffable, Praying for time to leave me there. Alinson I hope youve enjoyed them all as much as I have. And dont forget to return to the blog tomorrow, Valentines Day, to discover some new connections Seeple submitted to us this week! And a big thank you to Columbia Alumni Association for coordinating the series. Find the entire Love Stories collection in Columbia Alumni Associations Facebook album.
Friday, May 22, 2020
A Comparison of Online Shopping at JCPenney and Kohls Essay
JCPenney Dominates Over Kohlââ¬â¢s in Online Shopping Being a multi-billion dollar retailer comes with its perks. JCPenneyââ¬â¢s dominance over catalog merchandising has now extended into the cyber world at www.jcpenney.com. This website is multi-functional and easy to navigate, but how would JCPenneyââ¬â¢s new e-commerce site stack up against its toughest competitor, Kohlââ¬â¢s, on the web? The answer may surprise you. This is an intriguing look at how varied retail comparisons can be. While JCPenney is struggling with sales on the retail floor, Kohlââ¬â¢s continues to exceed expectations in their stores. Online though, it is a completely different story. Kohlââ¬â¢s has a fledgling site located at www.kohls.com. The homepage for this site looks veryâ⬠¦show more contentâ⬠¦Kohlââ¬â¢s homepage is simple and bare unlike JCPenneyââ¬â¢s cluttered doorstep; however, JCPenney lists all links on the homepage, which makes online shopping easier overall. The major difference between these two sites is the shop-ability of each. Kohlââ¬â¢s has yet to expand their website to an e-commerce base. It was dramatically easier for JCPenney to expand online because of their established warehousing ability for the catalog consumer. JCPenney has the ability to receive an online order and ship the merchandise within 48 hours, a feat unsurpassed by any online retailer. Kohlââ¬â¢s would need to contract their suppliers to ââ¬Å"drop shipâ⬠(the process of shipping merchandise to fill open orders with no warehousing needed) all merchandise to fill Internet orders. JCPenneyââ¬â¢s site includes color pictures of every catalog item, and the customer can shop online by using a catalog number. This amenity is something Kohlââ¬â¢s can not pursue because their lack of catalog merchandising. JCPenney also has the advantage of offering direct customer service online. Any online customer can quickly contact JCPenney by completing an online questionnaire detailing precisely what the customer needs. On the Kohlââ¬â¢s website, a customer may scroll through several screens of customer service information before they are given the email address to contact their customer service department. On www.jcpenney.com a customer can click the ââ¬Å"Customer Serviceâ⬠Show MoreRelatedCase Analysis: Macys3825 Words à |à 16 Pageshaggling and bargaining was most popular. Macyââ¬â¢s employed the first in store Santa Claus and brought the Christmas spirit into the retail business (Rowland). Today Macyââ¬â¢s is known for creating excitement with an assortment of top retail brands, ordinary shopping experiences, as well as special events most people know to include the Macyââ¬â¢s Thanksgiving Day Parade (Macyââ¬â¢s). History. Rowland Hussey Macy opened his first store in Massachusetts in 1851. In 1858, he established a new store after moving to NewRead MoreJcpenney Industry Analysis17889 Words à |à 72 PagesDegree Course: MGMT 6800 MAY 9th, 2012 TABLE OF CONTENTS EXECUTIVE SUMMARY 2 COMPANY PROFILES 4 1. JC Penney 4 Strategy initiative 4 Missionâ⬠¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦.. 5 2.KOHLââ¬â¢Sâ⬠¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦..â⬠¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦ â⬠¦Ã¢â¬ ¦Ã¢â¬ ¦..â⬠¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦Ã¢â¬ ¦5 Strategy initiative 5 Mission 6 3. Macyââ¬â¢s 6 Strategy initiative 6 Mission 7 4. Sears 7 Strategy initiative 7 Mission 8 INTRODUCTION 8Read MoreJc Penney Marketing Analysis4341 Words à |à 18 Pageswant to be treated. That strategy worked well for them over the years as indicated by several financial milestones, including their first $1 billion sales year in 1951, their first $1 billion catalog sales year in 1979, and their first $1 billion online sales year in 2005. JC Penney weathered the storm through many major crises, including World Wars I and II and the Great Depression. They benefited from the enormous population growth and spending power of the American middle class, their core customersRead MoreMacys Strategy6474 Words à |à 26 Pagesmerchandise offering and superior shopping experience. Organization has been following that principal for over a decade and today Macyââ¬â¢s targeting consumers through dynamic department stores and online sites. Main issue Advancing e-commerce and internet technologies cause recent declines in sales in the entire industry. Online retailers offer more convenient and fast shopping on the internet directly from your personal computer or smartphone. Along with efficiency online retailers striking departmentRead Morecostco company analysis4171 Words à |à 17 Pages20% savings than the leading national brand. The average markup on the companyââ¬â¢s merchandise is much lower compared to 20%-25% at supermarkets, 30%-35% at home improvement retailers and 50%-100% at traditional mall retailers. Furthermore, over the online retail channel, the company s markup is even lower. Offering attractive value proposition to the customers acts as a competitive advantage for the company. Value price positioning enables Costco to drive customer traffic and generate strong membershipRead MoreSears Marketing Plan5417 Words à |à 22 Pagesyoung adults. Sears will also offer deals to include markdowns and rebates througho ut the year to promote many of its retail lines and market to the thrifty shopper. The retailer will continue to see aggressive competition from Target, Wal-Mart, JCPenney, Kohlââ¬â¢s, Macyââ¬â¢s, Home Depot and Lowes. These companies are some of the national retailers that Sears will have to contend with in order to survive. According to Sears Holding 2011, annual 10K Report with the Securities and Exchange Commission, Home Depot
Sunday, May 10, 2020
See Why the Sky Is Blue and Sunset Is Red - Easy Experiment
The sky is blue on a sunny day, yet red or orange at sunrise and sunset. The different colors are caused by scattering of light in the Earths atmosphere. Here is a simple experiment you can do to see how this works: Blue Sky - Red Sunset Materials You only need a few simple materials for this weather project: WaterMilkTransparent container with flat parallel sidesFlashlight or cell phone light A small rectangular aquarium works well for this experiment. Try a 2-1/2-gallon or 5-gallon tank. Any other square or rectangular clear glass or plastic container will work. Conduct the Experiment Fill the container withà about 3/4 full of water. Turn on the flashlight and hold it flat against the side of the container. You probably wont be able to see the beam of the flashlight, although you may see bright sparkles where the light strikes dust, air bubbles, or other small particles in the water. This is much like how sunlight travels through space.Add about 1/4 cup of milk (for a 2-1/2 gallon containerââ¬âincrease the amount of milk for a larger container). Stir the milk into the container to mix it with water. Now, if you shine the flashlight against the side of the tank, you can see the beam of light in the water. Particles from the milk are scattering light. Examine the container from all sides. Notice if you look at the container from the side, the flashlight beam looks slightly blue, while the end of the flashlight appears slightly yellow.Stir more milk into the water. As you increase the number of particles in the water, the light from the flashlight is more stron gly scattered. The beam appears even bluer, while the path of the beam furthest from the flashlight goes from yellow to orange. If you look into the flashlight from across the tank, it looks like it is orange or red, rather than white. The beam also appears to spread out as it crosses the container. The blue end, where there are some particles scattering light, is like the sky on a clear day. The orange end is like the sky near sunrise or sunset. How It Works Light travels in a straight line until it encounters particles, which deflect or scatter it. In pure air or water, you cant see a beam of light and it travels along a straight path. When there are particles in the air or water, like dust, ash, ice, or water droplets, light is scattered by the edges of the particles. Milk is a colloid, which contains tiny particles of fat and protein. Mixed with water, the particles scatter light much as dust scatters light in the atmosphere. Light is scattered differently, depending on its color or wavelength. Blue light is scattered the most, while the orange and red light is scattered the least. Looking at the daytime sky is like viewing a flashlight beam from the side -- you see the scattered blue light. Looking at sunrise or sunset is like looking directly into the beam of the flashlight -- you see the light that isnt scattered, which is orange and red. What makes sunrise and sunset different from the daytime sky? Its the amount of atmosphere the sunlight has to cross before it reaches your eyes. If you think of the atmosphere as a coating covering the Earth, sunlight at noon passes through the thinnest part of the coating (which has the least number of particles). Sunlight at sunrise and sunset has to take a sideways path to the same point, through a lot more coating, which means there are a lot more particles that can scatter light. While multiple types of scattering occur in the Earths atmosphere, Rayleigh scattering is primarily responsible for the blue of the daytime sky and reddish hue of the rising and setting sun. The Tyndall effect also comes into play, but it is not the cause of blue sky color because molecules in air are smaller than the wavelengths of visible light. Sources Smith, Glenn S. (2005). Human color vision and the unsaturated blue color of the daytime sky. American Journal of Physics. 73 (7): 590ââ¬â97. doi:10.1119/1.1858479Young, Andrew T. (1981). Rayleigh scattering. Applied Optics. 20 (4): 533ââ¬â5. doi:10.1364/AO.20.000533
Wednesday, May 6, 2020
Zara Market Share Free Essays
Three generations of Data Management in Decision Support 1. Early 1970s ââ¬â required a repository of data : sourced from operational system + other data (e. g. We will write a custom essay sample on Zara Market Share or any similar topic only for you Order Now external data) ââ¬â Data was customized for the specific DSS ââ¬â Application-centric approach : data support a single or a few related applications used to help make the business case for the warahouse ââ¬â Sprague provided the Data-Dialog-Models (DDM) paradigm 2. Late 1980s Telecommunications, retailing and financial services industries built warehouses to store vast amounts of customer and sales-related data ââ¬â These industries remain leaders in terms of the size of the warehouses and how the warehouses are used ââ¬â Data-centric approach : support a variety of applications 3. In 2000 ââ¬â the movement to real-time data warehousing ââ¬â changes in the way that warehouse data is used ââ¬â different : Previous : data aims to understand what had already happened and to predict what would happen in the future * limit to influence real-time decisions and current operations * Now : real-time data (current decisions and critical business process) such as customer-facing and supply chain applications can be significantly enhanced Real or Right Time ? ââ¬â Incorrect concept applied to warehousing : real-time = instantaneous ââ¬â Reason : much of warehouse data cannot be captured and entered into the warehouse in seconds or minutes. * expensive difficult to make real-time * may not be a business need for real-time data ââ¬â Example : Some source systems, e. g. a legacy COBOL program, is undated once a month Continental Airlines ââ¬â a leader in real-time business intelligence ââ¬â won The Data Warehousing Instituteââ¬â¢s prestigious Best Practices and Leadership Awards ââ¬â Real-time data warehouse : provide the data that is required to implement real-time BI ââ¬â Firms can use BI to affect current decision making and business processes by usine real-time ââ¬â Importance : especially for customer-facing applications, e. g. hose found in call centers and check-in processes, help firms become more customer-centric ââ¬â Terms describe firms use real-time BI : ââ¬Å"real-time enterpriseâ⬠, ââ¬Å"zero latency organizationâ⬠ââ¬â Purpose of real-time BI : * increase revenues and decrease costs =gt; improve profitability ââ¬â e. g. Continental Airlines * taken a $30M investment in hardware, software and personnel to generate over $500M in revenue, resulting in a ROI of over 1,000% ââ¬â Firms must overcome both organizational and technical challenges for real-time BI successful ââ¬â Organizational must be executive : * sponsorship and support * initial and on-going financial support governance processes put in place * BI and data warehousing personnel with the requisite personnel ââ¬â Technical : * acquire and implement new hardware and software * establish processes and procedures for supporting and managing real-time data feeds from source systems * data must be quickly transformed and loaded into the warehouse * data must be analyzed and made available to operational s ystems and personnel ââ¬â briefly discuss an application that illustrates Continentalââ¬â¢s use of real-time BI ââ¬â focus on the technical issues associated with Continentalââ¬â¢s implementation of real-time BI How to cite Zara Market Share, Papers
Wednesday, April 29, 2020
Never Put Off Till Tomorrow What You Can Do Today Essay Example
Never Put Off Till Tomorrow What You Can Do Today Essay More than 30 years ago the hypothesis of an interventional approach in patients with unstable angina or nonââ¬âST-segment elevation myocardial infarction (NSTEMI) was considered only after a cooling-off period. This negative attitude was in part justified by the lack of effective antithrombotic adjunctive therapies and devices in the management of lesion containing thrombus and the subsequent early hazard of percutaneous coronary intervention (PCI). The delayââ¬âmany days or weeks after hospital admissionââ¬âto interventional treatment could result in an apparent stabilization of the acute coronary syndrome (ACS) with a high incidence of early recurrent ischemia or nonfatal myocardial infarction (MI) in the more favorable cases or in a definitive cooling of the patients. During this long period many trials comparing an early invasive strategy with a conservative strategy in patients with unstable angina or NSTEMI have produced conflicting results that have delayed the current general consensus regarding the benefit of an early invasive strategy, which is more evident in high-risk patients and mainly driven by the decrease in MI and the need for percutaneous or surgical coronary revascularization. This troubled history might be explained at least in part by the design of most studies that randomized patients before cardiac catheterization and the use of a wide temporal windowsââ¬âfrom 24 to 48 h to 5 daysââ¬âfor the definition of early intervention. We will write a custom essay sample on Never Put Off Till Tomorrow What You Can Do Today specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Never Put Off Till Tomorrow What You Can Do Today specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Never Put Off Till Tomorrow What You Can Do Today specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Randomization before cardiac catheterization resulted in the enrolment of a high percentage (30%) of patients who did not receive coronary revascularization, because of mild or absent atherosclerotic coronary artery disease in most of them, making the comparison of an early invasive strategy versus a conservative or a delayed invasive strategy in selected patients distorted by the high number of patients at low risk of events whatever the strategy adopted. The use of temporal windows as long as 24 to 48 h to several days for the definition of an early treatment hides the potential benefit of a true early treatment (within 24 h of patient presentation) and contributes to maintaining considerable uncertainty about the optimal timing of cardiac catheterization and revascularization for patients with unstable angina or NSTEMI. The study by Sorajja et al. 1) in this issue of the Journal overcame these 2 critical points and provides important data on the impact of delay to PCI on clinical outcome in the large cohort of patients with ACS enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial who underwent PCI (2). Patients who underwent PCI (7,749 patients) were stratified by time from hospital presentation to PCI into 3 groups: 24 h. A delay to PCI 24 h after clinical presentation was associated with 50% increase in 30-day and 1-year mortality as compared with patients who were treated earlier. Moreover, true early PCI was associated with a decreased rate of nonfatal MI. The incremental risk of death attributable to PCI delay 24 h was greatest in high-risk patients. The study results are consistent with those of the ISAR-COOL (Intracoronary Stenting With Antithrombotic Regimen Cooling-Off) trial (3). This elegant study is the only randomized trial comparing early intervention (delay to PCI 24 h after clinical presentation than among patients who had earlier PCI: no deaths at 1 year in the Thrombolysis In Myocardial Infarction (TIMI) risk score 1 to 2 subgroup with a time-to-PCI 2% in the subgroup with a time-to-PCI 24 h. This point is really important, because it outlines a major limitation of risk-scoring before cardiac catheterization in the individual patient and at the same time weakens a strategy of deferring for expedited cardiac catheterization only patients with a high risk score. A low TIMI risk score might correspond to a very-high-risk angiographic profile. This event is frequent and confirmed also by early coronary angiography in the PCI-ACUITY patient cohort (1). Nearly one-half of patients who underwent coronary angiography within 24 h of presentation had a baseline target vessel TIMI flow grade 2. A strategy of plaque passivation before PCI could be effective in decreasing PCI complications in the portion of patients who spontaneously or with an intensive antithrombotic treatment may experience improved coronary flow. Also in this subset of patients with an initial favorable course, the incidence of recurrent refractory ischemia is highââ¬âas is MI even after successful emergency PCIââ¬âwhereas a remarkable portion of patients will not respond to antithrombotic therapy: in the ACUITY PCI study, 38% of patients who underwent coronary angiography with a delay 24 h still had a baseline target vessel TIMI flow grade 36 h after randomization). The difference between groups in the primary study end point (6-month death, MI, stroke) rate was not significant (9. % of patients in the early-intervention group, and 11. 3% in the delayed intervention group) (hazard ratio [HR]: 0. 85; 95% confidence interval [CI]: 0. 68 to 1. 06, p = 0. 15). As in previous trials with similar results, the lack of significant difference in outcome between the 2 strategies might be explained by the fact that the study could be underpowered for the primary end point (the study was stopped prematurely because of recruitmen t challenges), involved mainly low-intermediate-risk patients with a subsequent low rate of PCI (
Subscribe to:
Posts (Atom)