Infections in Hb SD Disease

Infections in Hb SD Disease Case Report HBSD Disease, a compound heterozygote condition presentation with stroke Dr. Hasnain Afzal 1 Dr. Syed Farrukh Umair 2 Abstract Haemoglobin SD ÃŽ ²S/ÃŽ ²D is a rare compound heterozygous Haemoglobinopathy which presents as severe disease similar to homozygous sickle cell anemia(1). The patient being reported is a 8 yr old girl, Kiran who is a resident of Larkana, presented with complains of fever and headache for 15 days which progressed to generalized tonic clonic seizures and acute loss of consciousness while being treated in Larkana. After the child was stabilized, a thorough history, physical examination was done; initial laboratory tests, lumbar puncture, and MRI were performed. Treatment was started on the lines of acute meningoencephalitis on clinical suspicion. On peripheral blood film, sickle shaped cells, target cells, poikilocytosis, anisocytosis were noted and Hb Electrophoresis was sent which showed compound heterozygous state for Hb S/ Hb D. The lumbar puncture was negative for CSF infection and an alternate diagnosis was sought Introduction The adult hemoglobin HbA molecule consists of two ÃŽ ± chains coded by 4 genes on chromosome 16 and two beta chains coded by 2 genes in the ÃŽ ² gene cluster on chromosome 11(2). Sickle Hemoglobulin Hb S is a beta chain variant which occurs when valine is substituted for glutamic acid on the surface of the Hb S molecule in the sixth codon of the beta globin chain whereas the most common subtype of HbD i.e HbD Punjab also known as Haemoglobulin D Los Angeles (after the city where it was first discovered) is also a beta chain variant caused by a glutamic acid to glutamine substitution at codon 121 of the beta globin gene. HbS is associated with a number of compound heterozygous syndromes with other mutant beta globin which include Hemoglobin SC disease, Sickle beta+thalassemia, Sickle beta0thalassemia, Sickle alpha thalassemia, Sickle hereditary persistence of HbF (sickle HPFH), Other less common sickle cell syndrome variants (eg, delta beta0thalassemia, Hb Lepore, HbD, HbO Arab, HbE). HbSD presents as mild to moderate hemolytic anemia unlike HbD homogyzous and simple hetrozygotes which are usually asymptomatic.(3) Discussion A study done on abnormal hemoglobin variants among the major ethnic groups of Karachi in 2002 showed that 60% had iron-deficiency anemia and 40% had hemolytic anemia, of which 20.6 % was due to thalassemia major, 13% thalassemia trait, 5.1% sickle cell disease, 0.76% hemoglobin D Punjab (HbD Punjab), 0.32% hemoglobin C (HbC), and 0.22% hereditary persistence of fetal hemoglobin (HPFH) (4).Hb S is the most common Hb variant, its clinical outcome is severe in homozygous or when associated with other hemoglobinopathies, such as beta-thalassemia, Hb C or Hb D. (5). A number of studies have been done on Hb S and Hb C but Hb D is still poorly studied especially in Pakistan. Hemoglobin D has several varients such as HbD Punjab (Los Angeles), Hb D Iran, Hb D Ibadan and Hb D Bushman but the most common variant is HbD-Los Angeles (also called HbD-Punjab). High performance liquid chromatography (HPLC) can be used to separate hemoglobin polypeptide chains in the laboratory. High performance liqu id chromatography (HPLC) employs ion exchange method to identify and exchange various fractions of Hb.Hb D can be also distinguished from Hb S by acid electrophoresis or isoelectric focusing (IEF) (separation according to isoelectric points). On alkali electrophoresis (cellulose acetate) Hb D Punjab migrates slower than Hb A which is similar to HbS but its migration under acid electrophoresis (agarose gel) is similar to Hb A (6) In HbSD disease, HbD does not take part in the sickling process, as patients homozygous for HbD do not sickle but mild hemolytic anemia, mild to moderate splenomegaly may occur (7,8). Studies has indicated that although HbD itself does not polymerize, it increases the hydrophobic interaction between Hb S molecules and facilitates the polymerization of HbS thus enhancing the severity of the disease. (9) HbD heterozygotes with normal HbA have no clinical or hematologic alterations. (6) Table 1.1: Hb Electrophoresis : Test Done on high performance liquid chroma tography (HPLC) Haemoglobin Test Percentage Normal Percentage Haemoglobin A 20.7% (98-100) Haemoglobin A2 2.6% (1.5-3.5) Haemoglobin F 13% (1-2) Haemoglobin D 37.9% (0.0-0.0) Haemoglobin S 25.8% (0.0-0.0) Interpretation A+F+D+S+A2 Case Report 8 yr old, 16 kg, Kiran resident of Larkana district, presented to us on 7th April, 2015 with acute loss of consciousness and recurrent episodes of seizures for 3 days. Patient’s father reported that she was in a usual state of health 15 days back when she developed high grade intermittent fever and constant severe headache associated nausea, vomiting and neck stiffness. She was taken to a primary care hospital in Larkana and treated on the lines of viral/bacterial meningoencephalitis. During her hospital stay in Larkana she developed recurrent episodes of generalized tonic clonic seizures which were controlled by multiple antiepileptic agents. First Lumbar pucture was done on 31ST March, 2015 and CSF DR showed 21mg/dl Protein, 68 mg/dl Glucose, CSF TLC 17 and 2-3 RBC/HPF. CT was done on 31st March, 2015 showed generalized brain edema. Upon arrival in ICU Patel Hospital the patient was in a comatose condition with GCS 5/10, bilateral upgoing planters and flexor response to pain (decorticate) Patient was febrile 103F, other vitals were BP 130/90, Pulse 100, RR 28. After the child was stabilized, a thorough history, physical examination was done; initial laboratory tests, lumbar puncture, and MRI were performed. CBC showed normocytic anemia and peripheral film showed target cells, sickle cells, anisocystosis, poikilocytosis, polychromasia diamorphic picture. Hb Electrophoresis was sent on hematologist advice. Patient was started on mannitol to decrease intracranial pressure and multiple antiepileptic agents for seizure prevention. ATT, bacterial and viral meningitis cover was given and CSF DR was sent on 9th April, 2015 which showed 27 mg/dl Protein, 71 mg/dl Glucose, Chloride 123 mg/dl, TLC 04 and 17 RBC/HPF. CSF fluid gram stain, culture were initially negative. AFB Culture report to follow in 6 weeks. MRI done on 8th April, 2015 showed widespread abnormal signal intensity area involving bilateral frontal and parietal lobes. Few focal hyperintense signals were identified on bilateral occipital region which may represent areas of ischemic infarction. An alternate diagnosis such as cerebral ischemia due to small infarcts/ vasculitis involving bilateral frontal and parietal lobes was sought secondary to Hb SD disease. Patient had significant improvement in GCS 10/15 with spontaneous eye opening, withdrawal on pain and few incomprehensible sounds and was shifted out of the ICU due to financial constraints. Graph 1.1 High Performance Liquid Chromatography Conclusion The case demonstrates increase susceptibility to infections in Hb SD disease. Studies are seldom on Hb D in Pakistan. Genetic counceling is of pivotal role in hereditary hemoglobinopathies and hospitals should consider it as an important management strategy and employ in hospital genetic counceling facilities. Hydroxyurea used to increase Hb F levels in Homozygous Sickle Cell Disease Hb SS disease has shown efficacy by reducing the complications, frequency of transfusions and hospitalization but its role in Hb SD Punjab is not well established. A recent study in India showed reduction in incidence of vaso-occlution and frequency blood transfusions in Hb SD Punjab disease which is encouraging and more studies should be done on the management of Hb SC compound heterozygous disease. (10) References Rahimah A, Syahira Lazira O, Siti Hida HM, Faidatul Syazlin AH, Nur Aisyah A, Nik Hafidzah NM, Zubaidah Z. Haemoglobin sickle d punjab: a case report. Med J Malaysia. 2014 Feb;69(1):42-3. Birol G, Abdullah C, Cagatay U4, Sule MY, Ferda TT, Sevcan TB. ÃŽ ²-Globin chain abnormalities with coexisting ÃŽ ±-thalassemia mutations. Arch Med Sci 2012; 8, 4: 644-649. El-Kalla S, Mathews A R. HbD Punjab in the United Arab Emirates. Hemoglobin 1997;21:369-75. Ghani R,Manji MA,Ahmed N. Hemoglobinopathies among five major ethnic groups in Karachi, Pakistan. Southeast Asian J Trop Med Public Health.2002 Dec;33(4):855-61. Thom CS, Dickson CF, Gell DA, Weiss MJ. Hemoglobin variants: biochemical properties and clinical correlates. ColdSpring Harb Perspect Med. 2013;3(3):a011858.4. Torres Lde S,Okumura JV,Silva DG,Bonini-Domingos CR. Hemoglobin D-Punjab:origin,distributionand laboratory diagnosis. Rev Bras Hematol Hemoter.2015 Mar-Apr;37(2):120-6. doi: 10.1016/j.bjhh.2015.02.007. Epub 2015 Feb 23. Adekile A, Muah-AlI A, Akar NA. Does elevated hemoglobin Fmodulate the phenotype in Hb SD-Los Angeles? ActaHaematol. 2010;123(3):135–9. Taghavi Basmanj M, Karimipoor M, Amirian A, Jafarinejad M,Katouzian L, Valaei A, et al. Co-inheritance of hemoglobin D and thalassemia traits in three families: clinical relevance.Arch Iran Med. 2011;14(1):61–3. Winford CW, John NL. Wintrobes Clinical Hematology, 11th edn. Philadephia; 2004. pp. 1347-81. Patel S, Purohit P, Ranjeet SM, Dehury S, Meher S, Sahoo S,et al. The effect of hydroxyurea on compound heterozygotesfor sickle cell-hemoglobin D-Punjab—a single centreexperience in eastern India. Pediatr Blood Cancer.2014;61(8):1341–6.32.

The Battle of Shiloh

The Battle of Shiloh (also known as the Battle of Pittsburgh Landing), was known to be a major battle in the American Civil War. It was fought on April 6 and April 7, 1862 in southwestern Tennessee, where forces under Confederate Generals Albert Sidney Johnston and P. G. T. Beauregard staged a surprise attack against the Union Army troops of Major General Ulysses S. Grant and almost defeated his military units. The Battle of Shiloh was also regarded as the costliest military engagement within the American Civil War.The American Civil War stemmed from the convoluted issues of slavery and clashing perspectives on federalism, party politics, expansionism, sectionalism, economics and modernization during the Antebellum Period, or the turbulent years prior to the American Civil War. The Antebellum Period saw the emergence of the Industrial Revolution in America. Much of the nation's growth was brought about by technological advancements, a large British demand for cotton and a wave of Mid western settlement that created opportunities for regional specialization and trade.However, the Industrial Revolution in America also institutionalized black slavery. Large cotton plantations were labor-intensive, creating a huge need for slave workers. At the height of cotton production in the United States, about 40% of the Southern population consisted of black slaves. The percentage of slaves rose as high as 64% in South Carolina in 1720 and 55% in Mississippi in 1810 and 1860. All in all, more than 36% of all the New World slaves in 1825 were in the southern United States.These slaves were subjected to abysmal working and living conditions such as starvation, poor housing inadequate clothing allowances, overwork and physical and sexual abuse from their masters. Many Northerners, especially the leaders of the Republican Party (established in 1854), considered slavery a grave social ill and believed that owners of large Southern plantations were responsible for its promotion. Bu t Southerners were instead worried about the relative political decline of their region because the North was more progressive in terms of population and industrial output.As the North and the South's societies diverged, so did their regional identities. The North enjoyed a rapidly growing economy brought about by family farms, industry, mining, commerce and transportation, with a fast-growing urban population (fed by a high birth rate and large numbers of European immigrants) and no slavery outside the Border States. Meanwhile, the South was dominated by the settled plantation system operated through slavery, with a rapid population growth based on high birth rates and low immigration from Europe.Overall, the Northern population grew much more quickly than the Southern population, which made it increasingly difficult for the South to continue its dominance of the national government. Although slave owners controlled the region's politics and economics, two-thirds of the Southern wh ites who were elected into public office did not own slaves and were usually engaged in subsistence agriculture. Hence, it was unclear if they would support the plantation owners in perpetuating slavery.Both the North and the South were influenced by the ideas of Thomas Jefferson, the third President of the United States and the principal author of the Declaration of Independence. The South emphasized the states' rights (from the Kentucky and Virginia Resolutions) and the right of revolution (from the Declaration of Independence), while the North emphasized Jefferson's declaration that all men are created equal. However, the coexistence of a slave-owning South with an increasingly anti-slavery North made conflict unavoidable.The Compromise of 1850 was enacted as an attempt to resolve the territorial and slavery controversies arising from the Mexican-American War (1846-1848). Although the Compromise of 1850 admitted California as a free state (a state in the antebellum United States where slavery was either prohibited or eliminated over time) due to the California Gold Rush of 1849, it ruled that the status of the rest of the territories acquired from the Mexican-American War (Utah, Nevada, Texas and parts of Wyoming, Colorado, New Mexico and Arizona) will be determined through popular sovereignty.Hence, debates over sectionalism and the Fugitive Slave Laws (at set of laws passed by the United States Congress in 1793 and 1850 to provide for the return of slaves who escaped from one state into another or into a public territory) became prevalent. In 1845, the Kansas-Nebraska Act dictated that each new state of the Union will decide its stance on slavery. This proved to be disastrous for Kansas, as it was home to both pro- and anti-slavery factions, with the former emerging victorious on the slavery debate.The tension between the two parties had already escalated to the point that the admission of Kansas into the Union in 1861 led to the surfacing of numerous ant i-abolitionist movements that espouse racist sentiments that are still prevalent up to this day. Abraham Lincoln, an outspoken opponent of slavery in the United States, was elected president in 1860. After he assumed the presidency, 11 Southern states seceded from the Union between late 1860 and 1861 and established a rebel government, the Confederate States of America, on February 9, 1861.On April 12, 1861, Confederate General P. G. T. Beauregard opened fire upon Fort Sumter in South Carolina, marking the start of the American Civil War. However, with the loss of Forts Henry and Donelson in February 1862, Johnston disengaged his demoralized Confederate forces into west Tennessee, northern Mississippi and Alabama to reorganize. As a response, Grant transported his 58,000-strong Army of West Tennessee into southwest Tennessee from March 1 to April 5, 1862. He then settled at Pittsburgh Landing and waited for Major General Don Carlos Buell's Army of the Ohio from Nashville.According t o instructions from Union Major General Henry W. Halleck, Grant and Buell’s forces will merge in a joint offensive to seize the Memphis-Charleston Railroad. It was the Confederacy’s most reliable supply route, linking the lower Mississippi Valley to cities on the Confederacy's east coast. In order to defend the Memphis-Charleston Railroad, Johnston and Beauregard transported 55,000 Confederates to Corinth as early as March 1, 1862. Corinth was the western Confederacy's most important rail junction, as it was strategically located where the Memphis-Charleston crossed the Mobile-Ohio Railroad.Realizing that Buell would soon reinforce Grant, Johnston advanced towards Pittsburg Landing on April 3, 1862 with his newly-christened Army of the Mississippi. However, rain and bad roads delayed his advance. Johnston launched a surprise attack on the Federals on the dawn of April 6, 1862. Being unfortified, the Federals were easily surrounded. By mid-morning, the Confederates mana ged to overrun one frontline Union division and capture its camp. But Johnston's brigade met stiff resistance from the Federal right, which resulted in a savage fight around Shiloh Church.Johnston's army battered the Federal right all throughout the day. Although the Federal right did not give in, numerous casualties ensued. Johnston died at mid-afternoon after he was struck down by a stray bullet while directing the action on the Confederate right. Meanwhile, Johnston's contiguous assault was mired in front of Sarah Bell's peach orchard and the dense oak thicket the Confederates labeled as the â€Å"Hornet's Nest. † For seven crucial hours, Grant's left border endured Confederate attacks before being forced to yield ground later in the afternoon.The Confederates only drove Grant towards the river, instead of away from it, despite inflicting heavy casualties and seizing ground. By dusk, the Federal survivors have established a solid front before Pittsburgh Landing and revolte d the last Confederate charge. The Union finally got the upper hand on April 7, 1862. The night before, General Buell's Federal Army of the Ohio reached Pittsburgh Landing and positioned itself on the Union left. The Federal Army of Ohio joined forces with a reserve division from Grant's army, led by Major General Lewis Wallace. This merger added over 22,500 reinforcements into the Union lines.Despite being caught unprepared, Beauregard still managed to rally 30,000 of his badly-disorganized Confederates and stage an obstinate defense. Although Beauregard's troops temporarily halted the determined Union advance, strength in numbers provided Grant with a decisive advantage. As waves of fresh Federal troops swept forward by mid-afternoon, the exhausted Confederates were pressed back to Shiloh Church. Realizing the peril his army was facing, Beauregard ordered a retreat. The greatly disorganized Confederates withdrew to their fortified stronghold at Corinth. But the Federals still succ eeded in conquering Corinth.The Battle of Shiloh led to the defeat of the Confederate Army and the failure of Johnston's plans to prevent the joining of the two Union armies in Tennessee. Union casualties were estimated to have reached 13,047 (1,754 killed, 8,408 wounded, and 2,885 missing); Grant's army alone led to 1,513 killed, 6,601 wounded, and 2,830 missing or captured soldiers. On the Confederates' side, casualties reached up to 10,699 (1,728 killed, 8,012 wounded, and 959 missing or captured). This total of 23,746 fatalities was estimated to be greater than those of the American Revolution, the War of 1812, and the Mexican-American War combined.The Battle of Shiloh was very crucial to the American Civil War in the sense that it secured the Unionists' position on the Western front. After winning the Battle of Shiloh, Grant was able to continue his drive towards Corinth and take control of the Memphis-Charleston Railroad. The Union takeover of the Memphis-Charleston Railroad p aved the way for their victory in the American Civil War. However, this victory came after three more years of bloodshed and eight larger and bloodier battles. The Battle of Shiloh also influenced the Civil War and the way it was fought in the years to come.It imparted that weighing the accomplishments of the victors equally with the lost opportunities of the defeated was an important part of any criteria for military decisiveness. Simply put, what makes a battle decisive is not only what historically happened, but also what became historically unfeasible as a result of the event. For instance, the Battle of Antietam (fought on September 17, 1862, near Sharpsburg, Maryland, and Antietam Creek, as part of the Maryland Campaign) was significant not only because it led to Lincoln's Emancipation Proclamation.Rather, it was also because Confederate General Robert E. Lee's forces did not remain outside Virginia long enough to affect the elections in the North or to relieve the draining ma npower reserves there. Furthermore, the outcome of the 1862 Maryland Campaign failed to elicit support for an independent Southern Confederacy from politically-conscious countries such as Britain and France. In the succeeding campaigns, the Unionist soldiers applied a tactic that was very useful in the Battle of Shiloh – the seizure of locations that are indispensable to the Confederates.In the Siege of Vicksburg (May 18 – July 4, 1863), Grant and his Army of the Tennessee attacked souther forces at Jackson, where Vicksburg's reinforcements were located. As a result, the Confederacy gave the Union total control of the Mississippi River, except for the western states (Arkansas, Los Angeles and Texas). In the Atlanta Campaign (May 1864 – September 1864), Grant and Major General William Tecumseh Sherman defeated the Confederates by destroying their strategic, economic, and psychological capacity for warfare.They then ordered the Union troops to burn crops, kill liv estock, consume supplies, and destroy civilian infrastructure along their path. The Atlanta Campaign eventually led to the hastening of the end of the American Civil War in 1864. What is saddening about the Battle of Shiloh is that it is a war that could have been prevented in the first place. In fact, the entire American Civil War was a war that could have been prevented in the first place. But then, they both happened due to oppression, or the philosophy that a person can subjugate another because of race, creed or social status.Out of profit and a misplaced sense of racial supremacy, the whites enslaved the blacks. The end result was the American Civil War, a hostility that claimed millions of innocent lives at its wake. But what is more saddening is that people never seem to learn the mistakes of the past. Nowadays, despite advances in education and reason, discrimination and racism are still very rampant. People are still persecuted due to their beliefs, the color of their skin or their religion. Those who promote the status quo are called â€Å"freedom fighters,† while those who deviate from it are labeled â€Å"terrorists.†But they just end up waging senseless wars that kill millions of innocent people and turn the oppressed of today into the tyrants of tomorrow. Indeed, those who do not study the past are bound to repeat it.Works Citedâ€Å"Slavery. † 2007. Encyclopedia Britannica's Guide to Black History. 20 December 2007 .â€Å"The Battle of Shiloh, 1862. † 2004. EyeWitness to History. 20 December 2007 .† The Battle of Shiloh Official Records and Battle Description. 20 December 2003 . â€Å"Timeline of the Battle of Shiloh (Pittsburg Landing).† The Battle of Shiloh Official Records and Battle Description. 20 December 2003 .Beason, W. Keith. â€Å"Understanding Shiloh: The Death Knell of the Confederacy (Part 3). † 1999. KeithStuff Homepage. 20 December 2007 .

The Ritz-Carlton: A Snapshot

The Ritz-Carlton Hotel Company is a management company that develops and operates luxury hotels for W. B. Johnson Properties, also based in Atlanta. In 1983, W. B. Johnson acquired exclusive U. S. rights to the Ritz-Carlton trademark, a name associated with luxury hotels for 100 years. The Ritz-Carlton Hotel Company operates 23 business and resort hotels in the United States and two hotels in Australia. It also has nine international sales offices and employs 11,500 people. Two subsidiary products, restaurants and banquets, are marketed heavily to local residents.The company claims distinctive facilities and environments, highly personalized services, and exceptional food and beverages. â€Å"Gold Standards† Quality planning begins with President and Chief Operating Officer Horst Schulze and the other 13 senior executives who make up the corporate steering committee. This group, which doubles as the senior quality management team, meets weekly to review the quality of products and services, guest satisfaction, market growth and development, organizational indicators, profits, and competitive status.Each year, executives devote about one-fourth of their time to quality-related matters. The company's business plan demonstrates the value it places on goals for quality products and services. Quality goals draw heavily on consumer requirements derived from extensive research by the travel industry and the company's customer reaction data, focus groups, and surveys. The plan relies upon a management system designed to avoid the variability of service delivery traditionally associated with hotels.Uniform processes are well defined and documented at all levels of the company. Key product and service requirements of the travel consumer have been translated into Ritz-Carlton Gold Standards, which include a credo, motto, three steps of service, and 20 â€Å"Ritz-Carlton Basics. † Each employee is expected to understand and adhere to these standards, which de scribe processes for solving problems guests may have as well as detailed grooming, housekeeping, and safety and efficiency standards.Company studies prove that this emphasis is on the mark, paying dividends to customers and, ultimately, to Ritz-Carlton. The corporate motto is â€Å"ladies and gentlemen serving ladies and gentlemen. † To provide superior service, Ritz-Carlton trains employees with a thorough orientation, followed by on-the-job training, then job certification. Ritz-Carlton values are reinforced continuously by daily â€Å"line ups,† frequent recognition for extraordinary achievement, and a performance appraisal based on expectations explained during the orientation, training, and certification processes.To ensure problems are resolved quickly, workers are required to act at first notice — regardless of the type of problem or customer complaint. All employees are empowered to do whatever it takes to provide â€Å"instant pacification. † No matter what their normal duties are, other employees must assist if aid is requested by a fellow worker who is responding to a guest's complaint or wish. Much of the responsibility for ensuring high-quality guest services and accommodations rests with employees.Surveyed annually to ascertain their levels of satisfaction and understanding of quality standards, workers are keenly aware that excellence in guest services is a top hotel and personal priority. A full 96 percent of all employees surveyed in 1991 singled out this priority — even though the company had added 3,000 new employees in the previous 3 years. Detailed Planning At each level of the company — from corporate leaders to managers and employees in individual work areas — teams are charged with setting objectives and devising action plans, which are reviewed by the corporate steering committee.In addition, each hotel has a â€Å"quality leader,† who serves as a resource and advocate as teams a nd workers develop and implement their quality plans. Teams and other mechanisms cultivate employee commitment. For example, each work area is covered by three teams responsible for setting quality-certification standards for each position, problem solving, and strategic planning. The benefits of detailed planning and the hands-on involvement of executives are evident during the 7 days leading up to the opening of a new hotel.Rather than opening a hotel in phases, as is the practice in the industry, Ritz-Carlton aims to have everything right when the door opens to the first customer. A â€Å"7-day countdown control plan† synchronizes all steps leading to the opening. The company president and other senior leaders personally instruct new employees on the â€Å"Gold Standards† and quality management during a 2-day orientation, and a specially selected start-up team composed of staff from other hotels around the country ensures all work areas, processes, and equipment are ready.Quality Data Daily quality production reports, derived from data submitted from each of the 720 work areas in the hotel system, serve as an early warning system for identifying problems that can impede progress toward meeting quality and customer-satisfaction goals. Coupled with quarterly summaries of guest and meeting planner reactions. the combined data are compared with predetermined customer expectations to improve services.Among the data gathered and tracked over time are guest room preventive maintenance cycles per year, percentage of check-ins with no queuing, time spent to achieve industry-best clean room appearance, and time to service an occupied guest room. From automated building and safety systems to computerized reservation systems, Ritz-Carlton uses advanced technology to full advantage. For example, each employee is trained to note guest likes and dislikes. These data are entered in a computerized guest history profile that provides information on the preferen ces of 240,000 repeat Ritz-Carlton guests, resulting in more personalized service.The aim of these and other customer-focused measures is not simply to meet the expectations of guests but to provide them with a â€Å"memorable visit. † According to surveys conducted for Ritz-Carlton by an independent research firm, 92 to 97 percent of the company's guests leave with that impression. Evidence of the effectiveness of the company's efforts also includes the 121 quality-related awards received in 1991 and industry-best rankings by all three major hotel-rating organizations.

Effects Of Smoking On The United States - 1311 Words

Have you ever smoked before? What makes an individual want to smoke often? There are so many cigarettes being sold around the world, which increases the amount of smokers. It is common to smoke in social situations or gatherings. People are more likely to smoke if they have more friends and family who are smokers, because they can all smoke together. Also, they like to smoke when they are not working, because they have more free time to do so. According to the Center for Disease Control and Prevention (CDC), I noticed that the percentage of cigarette smoking is higher in the United States and kills more than 480,000 Americans each year (2015). In fact, cigarettes are harmful to smokers and nonsmoker, and the number of smokers rises day by day. Moreover, there are many harmful effects smoking has on an individual, such as heart disease, cancer, and the effect on nonsmoker and women, while it may cause an individual to feel relaxed, spend a lot of money and not be informed, it is harmf ul in the United States. The consequences of smoking are harmful on the body, such as the heart because it can cause heart disease. Smokers can also be diagnosed with diabetes or high blood pressure as well. According to WebMD, people who smoke has higher blood pressure, which increases their heart rate. Having higher blood pressure can lead to future heart attacks (2016). In addition, smoking effects on diabetes because of smoking is one of the risk factors that increase the likelihood ofShow MoreRelatedEffects Of Smoking On The United States1570 Words   |  7 PagesWorld-wide efforts have increased to alarm people of the danger in consuming tobacco products, both first hand and second hand. In recent years, reports have proven a decline in smoking. However, there are still millions of people that smoke in the United State of America. As a result, the effect of smoking has become a major health risk. According to the Centers for Disease Control and Prevention (CDC), tobacco use is the leading preventa ble cause of death, disease, and disability in the USRead MoreEffects Of Smoking On The United States976 Words   |  4 PagesSmoking Smoking, the drug killer number one is everywhere at this time, even government and enough information, which we can get almost everywhere cannot stop some young people. What forces young people to smoke? Why they risk their health just for cigarettes. Is it the addiction what make them smoke, or it is a societal pressure, or it is something else ? The second important question is that, what is the major and minor effect of smoking. I have many experiences with smoking, because using of thisRead MoreEffects Of Smoking On The United States905 Words   |  4 PagesPrevention (CDC), smoking kills more than 480,000 in the U.S. each year. In order to reduce this statistic, numerous controlling strategies are adopted by the government, which includes a limitation of tobacco advertising, and the prohibition of smoking in public areas. Meanwhile, several people are suffering from health issues caused by consumption of cigarette. It increases the risk of cancer, heart disease and stroke. The se three diseases are the leading causes of death in the United States (Taylor 8)Read MoreEffects Of Smoking On The United States1841 Words   |  8 PagesIn the United States, tobacco use is the number one cause of preventable death. Chronic cigarette smoking is associated with many adverse health effects and 70% of adult smokers started smoking when they were adolescents. The World Health Organization’s definition of adolescence is a period of development that corresponds to the period between the ages of 10 and 19 years. This age group is vulnerable to initiate risky behaviors such as cigarette smoking. According to the Surgeon General’s reportRead MoreEffects Of Smoking On The United States2439 Words   |  10 PagesIn the United States, tobacco smoking is by far the leading cause of lung cancer, which includes non-small cell lung cancer. About 80% of lung cancer deaths are caused by smoking, and many others are caused by exposure to secondhand smoke. Smoking is clearly the strongest risk factor for non-small cell lung cancer, but it often interacts with other factors. Smokers exposed to other known risk factors such as radon and asbestos are at even higher risk. However, not everyone who smokes gets lung cancerRead MoreEffects Of Smoking On The United States871 Words   |  4 PagesPathogenic role of smoking has been proved by many researchers in the world and in our country. Smoking 01 cigarettes himself losing 5.5 minutes of life. The average life expectancy of people who smoke less than non-smokers from 05 to 08 years. Smoking increases the mortality rate from 30 to 80%, mainly because of cancer (lung cancer), chronic obstructive pulmonary disease, cardiovascular disease.... The degree of increased risk depends on the age of starting smoking (smoking as soon as the higherRead MoreEffects Of Smoking On The United States1026 Words   |  5 Pagescigarettes have has declined from 20.9% in 2005 to 16.8% in 2014. The evidence also suggests that smoking was noticeably ln 2014 than in 2013. Sources reported that tobacco is the leading cause of preventable disease and death. Another essential point is that it kills 28,000 people every year in New York and afflicts nearly 600,000 residents with serious injuries directed to their smoking. In addition, smoking kills half a million Americans every year and costs about $300 billion dollars a year. ConsideringRead MoreThe Effects Of Smoking On The United States1639 Words   |  7 PagesSmoking is established as a recognized cause of cancer, lung disease, coronary heart disease, and stroke(US Public Health Service,1964,Doll R 1976,1994, US Department of Health and Human Services,1989).it is considered to be the single most important avoidable cause of premature morbidity and mortality in the world. WHO has estimated that there are about 1100 million smokers worldwide; this represents about one-third of the global population aged over 15 years (WHO,1997). About 73% of these sm okersRead MoreEffects Of Smoking On The United States2197 Words   |  9 Pagesproducts for example cigarettes while ant-smoking campaigns are the activities and rally that the tobacco industries and other institutions or organization employ to oppose or curb smoking globally, example public education. The rate of smoking globally is on the rise if the current data is to go by the youths will be the most affected compared to adults, this trend is worrying and leaves us with many questions than answers concerning the future of the nations. Smoking has been identified as one of theRead MoreEffects Of Cigarette Smoking On The United States961 Words   |  4 PagesThe facts are right there on the box; â€Å"Cigarette smoking causes lung cancer, heart disease, and emphysema and may complicate pregnancy.† Almost all teen smokers say they regret beginning to smoke. Most smokers attribute the habit of smoking to the glamorization of smoking in the media, peer pressure, self-image, and easy access to tobacco; from stealing cigarettes from parents or having someone who is 18 buy the cigarettes for them. Teen smoking is on the rise and it is a problem. Cigarette smoke