Infective Endocarditis Caused by Viridans Streptococci

Infective Endocarditis Caused by Viridans Streptococci Case Study 1: Infective endocarditis caused by viridans streptococci Case Study 2: Haemorrhagic fever caused by Ebolavirus Case Study 1 Subject is a 48-year-old man with a history of mitral valve regurgitation who presents with a 10-day history of fatigue, fever and general malaise. Some reddish lesions are noted on his palm, which he has never noticed before. He denies any cough, but has mild new shortness of breath with exertion and with lying down flat at night in bed. He is generally in good health except for a root canal operation approximately 3 weeks previously. The history of mitral valve regurgitation is thought to be secondary to rheumatic fever as a child. Heart examination is notable for a loud systolic murmur best heard at the left sternal border with radiation over to the axilla. Lungs are clear and abdominal examination is normal. Skin examination is significant for several scattered reddish lesions over his palms and soles that are not painful when pressure is applied. Lab tests: Blood count shows WBC 14.8 with 86% neutrophils; blood cultures grew out gram-positive cocci in chains that are alpha haemolytic on horse blood agar. Evidence for Diagnosis Mitral valve regurgitation would account for the fatigue, and also the shortness of breath in the patient, however other symptoms are present that this alone cannot explain. The first of these is the fever suffered by the patient, which would signify an infection. The second is the presence of lesions on the palms and soles; Petechiae such as these, known as Janeway lesions, are an indicator of endocarditis (O’Connor, 2002), and the patient’s history of mitral valve regurgitation, along with a recent history of root canal work confirm that this is a likely diagnosis. The lungs and abdomen of the patient are clear, as would be expected in a case of endocarditis, however examination of the heart sounds displayed a clear murmer. The patient’s blood results showed clear signs of infection, with leukocytosis and elevated neutrophil count. The bacteria cultured from the patient’s blood can be easily identified as Streptococci, and since this is known to be a cau sative organism of endocarditis (Brooks, Butel and Morse, 2004, pp.197), it makes the diagnosis very likely. Further Testing Required While the diagnosis in this case should be straight forward due to bacteraemia and presence of peripheral stigmata, according to the Duke criteria, which is used as a tool for diagnosis of infective endocarditis, this patient would be classified as having only possible infective endocarditis. As they display some of the necessary pathologic and clinical criteria, they would need further tests to determine if it was definitely infective endocarditis (Li et al., 2000). The Duke Criteria was developed by Durack et al. (1994) as a means of better distinguishing infective endocarditis from other causes of cardiac problems; these were evaluated as being superior to previous methods for diagnosis (Bayer et al., 1994)(Cecchi et al., 1997)(Hoen et al., 1995) The criteria have been used since, though there have been studies done into improving the criteria further. According to these criteria, the patient’s diagnosis could be confirmed by carrying out other tests such as an ECG, echocar diogram, and chest x-ray, to exclude other possible cardiac problems. However, the patient would also meet two major criteria, and therefore be classified as definite infective endocarditis if two further cultures of blood grew causative bacteria. While the most likely causative organism is viridans streptococci, as Streptococcus pneumonia is more commonly associated with bacterial pneumonia or meningitis, the two can be differentiated quite simply by testing with optochin. S. pneumonia are susceptible to this microbial agent, where viridans streptococci are resistant. Suspending the bacteria in bile salts would also provide a suitable distinction, as S. pneumonia would lyse, where viridans streptococci are insoluble (Brooks, Butel and Morse, 2004, pp.197). Endocarditis as a result of streptococcal infection Microbiology Many textbooks, and in fact some journal articles refer to the group of streptococci which cause endocarditis by the name Streptococcus viridans, however this is actually a misnomer, as the viridans streptococci are actually a group of several different bacteria, and are referred to as viridans simply because they produce a green halo when grown on blood agar (Elliott et al., 1997, pp.30-1). Viridans streptococci are often found resident in abundance in the mouth, where they are usually commensal, or cause only mild infections; once in the blood stream, these usually passive bacteria can become pathogenic, and lead to endocarditis upon reaching the heart (Brooks, Butel and Morse, 2004, pp.197). The bacteria are able to proliferate in structurally abnormal valve surfaces and gradually lead to the destruction of the valves, resulting in regurgitation (O’Connor, 2002). Those valves damaged by rheumatic fever are particularly prone to infection (Heritage, Evans and Killington, 1999, p.185). Symptoms The physical symptoms suffered by the patient are a result of the body’s response to the infection; the fever and general malaise suffered by the patient would be as a result of cytokine generation from the low-grade infection, and the petechiae in the skin, known as Janeway lesions, are the result of immune complexes being deposited in small vessels there (O’Connor, 2002). Prophylaxis Any patient, such as the one here, assessed from their previous medical history to be at risk from endocarditis, should be given prophylactic treatment before undergoing invasive dental surgery. The current guidelines outlined by Ramsdale et al. (2004) recommend amoxicillin for this purpose, or clindamycin for those allergic to penicillin. This particular patient would only be considered a moderate risk according to the new guidelines, so there would be no need for gentamicin, however those considered at high risk would be given this intravenously in addition to IV amoxicillin/clindamycin. Treatment A combination of penicillin and gentamicin are used to treat streptococcal endocarditis. While studies have found that there is only a limited resistance to penicillin in sufferers at present, vancomycin can be used a viable alternative in those allergic to penicillin and those with more resistant strains (Johnson et al., 2001). For those who do not respond to antimicrobial treatment, surgery is often a viable option, replacing the infected valves. While not always successful, this offers an improved prognosis for those where other treatment is unsuccessful (Moon et al., 1997). Prognosis If left untreated, infective endocarditis is always fatal, as the destruction of a valve will prevent the heart from working. Even if treated, the disease carries a high morbidity and mortality rate. The factors which impact strongest on prognosis are uncontrolled infection and congestive heart failure. It is for this reason that early diagnosis and antimicrobial treatment is necessary. However, constant improvements in surgical procedures are leading to a better prognosis for those not responding to treatment (Karth et al., 2002). It could be reasoned that these advances in surgery will become even more important in prognosis as incidences of antimicrobial resistance increase, which is surely inevitable judging by trends in other bacterial infections such as Staphylococcus aureus. Case Study 4 A 34-year-old woman researcher studying chimpanzee behaviour in the Ivory Coast found several of the animals were dying. She dissected one several hours after it died and found that it had died of haemorrhage, and had non-clotting blood. She wore household gloves, but no mask or gown during the dissection. Eight days later she developed a fever and headache, which did not respond to malaria treatment. Five days into her illness, she developed vomiting, diarrhoea, a rash, and renal failure. Antibiotics did not improve her condition and she was transported home in isolation. The patient is lethargic but communicative. She has lymphadenopathy. Her lung exam is normal. She has a mildly tender and enlarged liver and spleen. Lab tests: She has a white blood cell count of 3.6, haematocrit of 40, and low platelets of 83. She has a low fibrinogen of 0.8. Her clotting times are normal, however. Serological tests for anthrax, dengue fever, chikungunya, yellow fever, Crimean-Congo haemorrhagic fever, Marburg virus, Rift Valley fever, Lassa fever, and Hantavirus are all negative. Evidence for Diagnosis The history of the patient suggests that she is suffering from something that has arisen from her contact with an infected chimpanzee. While a number of zoonotic diseases are known to be prevalent in the African continent, the majority of those have already been ruled out by negative test results. One which has not is the Ebolavirus, which gives rise to Ebola haemorrhagic fever. Transmission of the Ebolavirus from dead animals has been documented in the past, including in the Ivory Coast (WHO, 2004; CDC, 2005). The onset of the patient’s symptoms fits with the known timescale for the Ebolavirus of 2 to 21 days; the fever and headache which she experienced are classic symptoms. Later in the disease sufferers also usually develop diarrhoea, vomiting, and possibly a rash (CDC, 2005). It would obviously be expected that antibiotics would bring no improvement to the illness, as the infection is viral. In a physical examination, it would be expected that a patient infected with Ebolavirus would have an enlarged liver and spleen, as this is where virus replication is particularly proliferant. Sanchez et al. (2004) also specifies the lungs as also being one of the main sites of virus replication, implying that the patient should be suffering from tenderness of the lungs also, however this evidence is taken from studies into the Sudan strain of Ebolavirus, and this is much more likely to be the Ivory Coast strain, so some symptoms may differ. In the laboratory examination, it is expected to see a normal haemocrit, accompanied by leucopenia and thrombocytopenia as displayed in the patient. It would be usual for the clotting time to be shortened, however this patient has low levels of fibrinogen, possibly due to some secondary cause, which may alter the clotting time, making it higher than expected. Further Testing Required While virus isolation, transmission electron microscopy, immunohistochemistry, reverse transcription-PCR, antigen capture ELISA, and IgG or IgM antibody capture ELISA can all been used to show Ebolavirus as the causitive agent, there are conflicting reports over which techniques are preferable for use. The Centres for Disease Control and Prevention (2005) suggest that in a patient at this stage of the disease, testing should be carried out for IgM and IgG antibodies, Kurosaki et al. (2006) and Towner et al. (2004) recommend RT-PCR as the most efficient technique. Ebolavirus Aetiology Ebola belongs to the filoviruses or Filoviridae, which is divided into two genera, the Ebolavirus and the Marburgvirus. The Ebolavirus genus is split into four separate species: Ivory Coast ebolavirus, Sudan ebolavirus, Zaire ebolavirus and Reston ebolavirus (Hensley et al., 2005). While the disease is zoonotic, the natural reservoir of the disease is not non-human primates; the actual reservoir and the mode of transition into apes is so far unknown, although studies are currently being undertaken on the suggestion that bats may play a role. Transmission into humans is rare, and is often one isolated case (Peterson et al., 2004), although if the proper precautions are not taken it is possible for the disease to spread in the human population. Epidemiology The disease has appeared sporadically since its initial recognition in 1976, and has occurred only in specific geographical areas as per the names of the different strains (CDC, 2005). It is generally agreed that the virus is transmitted via direct contact with the blood or bodily secretions from another infected person (Dowell et al., 1999; WHO, 2004), due to the extensive viral involvement in the subcutaneous tissue (Peters, 2005). It is believed that this is also the case among non-human primates, such as the chimpanzees, although this is so far unconfirmed (CDC, 2005). In laboratory studies, the virus has shown the ability to be spread via aerosol between rhesus monkeys (Johnson et al., 1995), and while some authors such as Heeney (2006) list the virus as being aerosol, there have so far been no such documented cases in a real-world setting between humans (CDC, 2005; Dowell et al., 1999). Symptoms The World Health Organisation (2004) lists the main symptoms of the Ebolavirus as being a sudden onset of fever, accompanied by intense weakness and muscle pain, headaches and a sore throat. After a few days this is followed by vomiting and diarrhoea, rashes, liver and kidney dysfunction and sometimes also both internal and external bleeding. Pathogenesis The pathogenesis of Ebolavirus is currently very hard to study, due to the rarity of occurrences in humans, and also due to the dangerous nature of collecting, storing and analysing samples from those cases. The illness is severe due to the ability of the virus to supress both adaptive and innate immune responses, and the ability to cause extreme inflammatory responses and intravascular coagulation (Mahanty and Bray, 2004). At the current time it is thought that monocytes and macrophages in the body are infected during the early stages of the virus, and these then carry the virus to other areas (Sanchez et al., 2004). The infected monocytes express large amounts of tissue factor, leading to intravascular coagulation, and causing tissue damage. Infected macrophages secrete cytokines which cause apoptosis of lymphocytes in tissues that are required for the acquired immune response (Peters, 2005), hence the presence of leucopenia in blood count results. The mobile infected cells carry the viral agent to lymph nodes, where the virus further replicates and is spread through the body. Upon reaching the liver, spleen and other tissues, parenchymal cells, including hepatocytes and adrenal cortical cells will become infected (Mahanty and Bray, 2004). This is what leads to the enlarged organs, and will also result in an increase in the levels of liver enzymes in the blood. Prophylaxis and Treatment Some progress has been made in the formation of vaccines, and these have proved successful in testing on non-human primates (Hensley et al., 2005). However other sources report that all attempts so far have met with outright failure (Peters, 2005). Barrier nursing techniques appear to be effective in preventing the spread of the disease (Dowell et al., 1999; Formenty et al., 1999). Prognosis The Zaire strain of Ebolavirus is reportedly the most lethal (Mahanty and Bray, 2004); there is only one reported case of a human contracting the Ivory Coast strain, presenting similarly to the patient, and they survived (Formenty et al., 1999). It is very difficult to form an accurate prognosis however due to the limited results on which to base it. References Bayer A.S., Ward J.I., Ginzton L.E. and Shapiro S.M. (1994) Evaluation of new clinical criteria for the diagnosis of infective endocarditis. American Journal of Medicine, 96 (3), pp.220-2 Brooks G.F., Butel J.S. and Morse S.A. (2004) Medical Microbiology 23rd Edition. McGraw-Hill, p.197 CDC (2005) Centres for Disease Control and Prevention [online]- November 18, 2005.- available from: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola/qa.htm [cited February 2, 2007] Cecchi E., Parrini I., Chinaglia A., Pomari F., Brusasco G., Bobbio M., Trinchero R. and Brusca A. (1997) New diagnostic criteria for infective endocarditis. A study of sensitivity and specificity Eureopean Heart Journal, 18 (7), pp. 1149-56 Dowell S. F., Mukunu R., Ksiazek T. G., Khan A. S., Rollin P. E. and Peters C. J. (1999) Transmission of Ebola hemorrhagic fever: A study of risk factors in family members, Kikwit, Democratic Republic of the Congo, 1995. Journal of Infectious Disease, 179 Suppl. 1, pp. S87-S91 Durack D.T., Lukes A.S. and Bright D.K. (1994) New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings, American Journal of Medicine, 96 (3), pp. 200-9 Elliott M., Hastings U., Desselberger R. and Reid G. (1997) Lecture Notes on Medical Microbiology Oxford, UK: Blackwell Publishing, pp.30-1 Formenty P., Hatz C., Le Guenno B., Stoll A., Rogenmoser P. and Widmer A. (1999) Human infection due to Ebola virus, subtype Cote dIvoire: Clinical and biologic presentation. Journal of Infectious Diease, 179 Suppl. 1, pp.S48-S53 Heeney J.L. (2006) Zoonotic viral diseases and the frontier of early diagnosis, control and prevention. Journal of Internal Medicine, 260, pp. 399-408 Hensley L., Jones S., Feldmann H., Jahrling P. and Geisbert T. (2005) Ebola and Marburg viruses: Pathogenesis and development of countermeasures. Current Molecular Medicine, 5, pp. 761 772 Heritage J., Evans E.G.V. and Killington R.A. (1999) Microbiology in Action. Cambridge, UK: Cambridge University Press, p. 185 Hoen B., Selton-Suty C., Danchin N., Weber M., Villemot J.P., Mathieu P., Floquet J. and Canton P. (1995) Evaluation of the Duke criteria versus the Beth Israel criteria for the diagnosis of infective endocarditis. Clinical Infectious Disease,21 (4), pp. 905-9 Johnson A.P. [et al.] (2001) Antibiotic susceptibility of streptococci and related genera causing endocarditis: analysis of UK reference laboratory referrals, January 1996 to March 2000. BMJ, 322, p. 7283 Johnson E., Jaax N., White J. and Jahrling P. (1995) Lethal experimental infections of rhesus monkeys by aerosolized Ebola virus. International Journal of Experimental Pathology, 76 (4), pp. 227-236 Karth G.D. [et al.] (2002) Complicated infective endocarditis necessitating ICU admission clinical course and prognosis. Critical Care, 6 (2), pp. 149 154 Kurosaki Y., Takada A., Ebihara H., Grolla A., Kamo N., Feldmann H., Kawaoka Y. and Yasuda J. (2006) Rapid and simple detection of Ebola virus by reverse transcription-loop-mediated isothermal amplification. Journal of Virological Methods, doi: 10.1016. Li J.S., Sexton D.J., Mick N., Nettles R., Fowler V.G., Ryan T., Bashore T. and Corey G.R. (2000) Proposed modifications to the Duke Criteria for the diagnosis of Infective Endocarditis. Clinical Infectious Disease, 30, pp.633-638 Mahanty S. and Bray M. (2004) Pathogenesis of filoviral haemorrhagic fevers. The Lancet, 4 (8) pp. 487-498 Moon M.R., Stinson E.B. and Miller D.C. (1997) Surgical treatment of endocarditis. Progress in Cardiovascular Diease, 40 (3) pp. 239-64 OConnor D. (2002) Pathology. Elsevier Health Sciences Peters C. J. (2005) Marburg and Ebola Arming ourselves against the deadly filoviruses. New England Journal of Medicine, 325 (25), pp. 2571-2573. Peterson A.T., Bauer J.T. and Mills J.N. (2004) Ecologic and geographic distribution of filovirus disease. Emerging Infectious Dieases, 10 (1), pp. 40-7. Ramsdale D.R. et al (2004) Dental aspects of Endocarditis Prophylaxis : New Recommendations from a Working Group of the British Cardiac Society Clinical Practice Committee and Royal College of Physicians Clinical Effectiveness and Evaluation Unit [Report]: Working Group of the British Cardiac Society Clinical Practice Committee and Royal College of Physicians Clinical Effectiveness and Evaluation, 19 April 2004. Sanchez A., Lukwiya M., Bausch D., Manharty S., Sanchez A., Wagoner K. and Rollin P. (2004) Analysis of human peripheral blood samples from fatal and nonfatl cases of Ebola (Sudan) haemorrhagic fever: Cellular responses, virus oad and nitric oxide levels. Journal of Virology, 78 (19), pp.10370-10377. Towner J.S. [et al.] (2004) Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. Journal of Virology, 78 (8), pp. 4330-4341 WHO (2005) World Health Organisation Ebola Factsheet [Online]available at: http://www.who.int/mediacentre/factsheets/fs103/en/index.html [cited February 2, 2007]

Law and Ethics Case Study †Nestle Essay

Many lawful and ethical issues in Public Relations come from large corporations drive to maximise profits. An example of this is Nestles unethical conduct regarding their infant milk in the early 70’s, causing a huge scandal. Along with other aggressive marketing techniques Nestle was appointing uniformed Nurses to distribute the baby formula and leaflets for free in hospitals and maternity wards in the developing world, such as in Ethiopia and Indonesia. Nestle gave new mothers this formula long enough for their own milk to dry up, therefore leading them becoming dependent on the formula, and at the time United States Agency for International Development official Dr Stephan Joseph blamed ‘reliance on baby formula for a million infant deaths every year though malnutrition and diarrheal diseases’, showing the possible effects of Nestles unethical advertising in the developing world. http://www.businessinsider.com/nestles-infant-formula-scandal-2012-6?op=1 Nestle ga ve poor health workers gifs to promote their products as well as sponsoring hospital products such as branding newborn wrist bands and nurses prescription pads to get the brand in the forefront of people’s minds and believe it has beneficial products due to healthcare support. Nestle undermined new mothers confidence in breast feeding by the promotion of its infant milk and abused the want for westernisation in the developing world. There are many issues surrounding Nestles infant milk and its promotion. Formula is less healthy for a newborn baby and considerably more expensive than breast milk. In the developing world most could not afford this expense so gave their child weak milk to make the formula last, leading to children getting sever lack of nutrients and vitamins that they require for healthy growth. The formula also requires clean water which in many places in the developing world is not available, increasing the spread of diseases and diarrhea within infants. The infant formula also lacks basic nutrients that a newborn baby needs. This shows how Nestle took advantage of the undereducated who do not understand sanitation and nutritional needs. Labels were also not translated to the countries in which the product was been distributed, so a full understanding of the product was being withheld. Nestles promotion and widespread distribution of baby formula in the developing world led to huge damage to the brands reputation globally, especially in the developed world which in turn led to a global boycott of Nestle in the late 70’s leading to a huge fall in sales figures and lack of trust in the brand. Many made Nestles unethical behaviour public including the New Internationalists expose describing the controversial marketing practices used to get thirds world mothers ‘hooked’ on formula, published in 1973. In 1974 London’s War on Want organisation also published a booklet on Nestles behaviour called the ‘baby killer’ exposing the consequences of baby formula and unethical marketing techniques. This organisation and its translators were later sued by Nestle for its publication. * Even though Nestles behaviour was seen as extremely unethical it was not illegal as no laws were in place surrounding marketing of baby food products. However, due to public outrage and awareness of Nestles unethical marketing practices hearings were held in 1978 between the US Senate, the World Health Organisation, UNICEF and the International Baby Food Action Network which led to a new set of marketing rules for baby formula and food products and by 1981 the international codes of marketing breast milk substitutes had been created. Key points of these rules are shown below. Baby food companies may not: * promote their products in hospitals, shops or to the general public * give free samples to mothers or free or subsidised supplies to hospitals or maternity wards * give gifts to health workers or mothers * promote their products to health workers: any information provided by companies must contain only scientific and factual matters * promote foods or drinks for babies * give misleading information * There should be no contact between baby milk company sales personnel and mothers. * Labels must be in a language understood by the mother and must include a clear health warning. * The labels must not include language which idealises the use of the product. http://www.who.int/nutrition/publications/code_english.pdf Companies must also describe the costs and possible consequences of using the formula as an  alternative to breast milk and it must be made clear that breast milk is the healthiest option for a newborn baby. These guidelines are rules and are not laws so are not legally enforceable unless they have been incorporated into the legislature of a nation state. Many countries have incorporated the rules into law however this does not include the US or the UK. Therefore enforcement of these rules can sometimes be seen as being weak. In 1995 advertising on newborn formula was banned however many companies use loopholes to promote their products such as brand name and follow on formula advertising, and many social rights groups still accuse Nestle and other companies of stretching the rules. There are many ethical issues surrounding Nestles baby milk formula and its advertising and distribution, but due to lack of regulations at the time, no laws were broken. The product that was being distributed and marketed was infant formula which has been proved to hinder infant growth and contributes to unnecessary harm, suffering and death of babies, especially in developing countries where clean water, needed for the formula is rarely available. At the time the World Health Organisation found that babies on formula in developing countries had mortality rates five to ten times higher than those of breast fed babies, and Save the Children’s State of the World report says that ‘six months of exclusive breastfeeding are said to increase a child’s chance of survival by six times’. http://www.businessinsider.com/nestles-infant-formula-scandal-2012-6?op=1 Nestle is also seen to have abused the poor, taking advantage of the undereducated and illiterate as well as abusing the want for westernisation in the developing world. By doing this Nestle is also encouraging poverty by creating more costs for the poor as well as creating more health issues in poverty stricken areas. By providing lack of information Nestle also undermined mothers’ right to be properly informed. Nestle also used unethical promotion methods, undermining the benefits of breastfeeding and falsely advertising the need for and the nutritional value of its baby formula by using women dressed as nurses to distribute the product. On this UNICEF has said, ‘marketing practices that undermine breastfeeding are potentially hazardous wherever they are pursued: in the developing world WHO (The World Health Assembly) estimated that some 1.5 million children die  each year because they are not adequately breastfed. These facts are not in dispute.’ http://info.babymilkaction.org/nestlefree. These facts show that unethical behaviour and promotion methods by companies such as Nestle can cause greater infant deaths in the developing world. Codes and PR practise Nestles unethical behaviour, although at the time was not seen to be breaking any laws, was breaking many of the Public Relations Consultants Association codes of conduct. Below is listed the codes that Nestle breached during its push to sell infant milk in the developed world. – Inducement – Neither directly or indirectly give any financial or other inducement to public representatives – Influence – Neither propose nor undertake any action which would constitute an improper influence on public representatives, the media or other stakeholders – Accuracy – Take all reasonable steps to ensure the truth and accuracy of all information provided – Falsehood – Make every effort not to intentionally disseminate false or misleading information, exercise proper care to avoid doing so unintentionally and correct any such act promptly – Deception – Observance – Observe the principles of the UN Charter and the Universal Declaration of Human Rights – Conduct professional activities with proper regard to public interest – Have a positive duty at all times to respect the truth and shall not disseminate false or misleading information knowingly or recklessly, and to use proper care to avoid doing so inadvertently – Every member in healthcare public relations shall ensure that information disseminated is balanced and accurate and not likely to mislead http://www.prca.org.uk http://www.ipra.org Along with breaking these codes through deception, little regard for public interest or safety and influence, Nestle can also be seen to be breaking Human rights by not providing a balanced view on the implications and effects of infant milk, an issue which is also morally and ethically wrong. Nestles behaviour, as previously mentioned did lead to a new set of marketing rules for baby formula and food products and new codes around the  marketing of breast milk substitutes. Even though they could not be legally punished or prosecuted, the implications to Nestle from this campaign were huge and greatly damaged the company’s reputation long term. Due to the huge media coverage of the scandal, as well as the many exposes that were published Nestles sales dropped considerably due to the global boycott of the brand and trust in the company was greatly damaged long term. Only time has managed to rebuild the brand as well as the release of many healthcare related products, however this is still a widely talked about unethical campaign due to the nature of the scandal, especially at a time when poverty in the developing world was at an all time high. This case study shows how large corporations will break ethical and moral codes purely to boost sales and increase profits, and also how laws and codes will be stretched and loopholes will be found to make this behaviour possible. However it also shows how long the effects of breaching ethical codes term can be and how damaging it can be to a brand reputation long term. Even though Nestle also damaged the trust in the use of infant milk and many rules were implemented on its advertisement, baby formula and follow on milk is now an eleven and a half billion dollar market worldwide, and I believe that Nestle influenced this growth, showing how companies can also benefit from public relations scandals. Bibliography * http://www.ipra.org/secciones.php?sec=1&subsec=3 * http://www.prca.org.uk/assets/files/AboutUs/Files/PRCA_Codes_of_conduct_and_Professional_charter.pdf * Article, ‘Real world examples of bad business ethics’, 18th May 2011, N Nayab http://www.brighthub.com/office/entrepreneurs/articles/115557.aspx * Business Insider, Article, ‘Every Parent should know the scandalous history of infant formula’, Jill Krasny, 25th June 2012 http://www.businessinsider.com/nestles-infant-formula-scandal-2012-6?op=1 * Baby Milk Action Briefing, January 2009 http://www.babymilkaction.org/pdfs/nestlebriefings0109.pdf * Baby Milk Action Article and Press Releases, 2012, ‘The Nestle Boycott’ http://info.babymilkaction.org/nestlefree * World Health Organisation,

Roman Achievements and Contributions - 1571 Words

Roman Achievements Jigsaw Background: The period of great cultural achievements for the Roman Empire is referred to as the Pax Romana, or â€Å"Peace of Rome.† Beginning after the Republican Wars in 27 B.C., and lasting to about 180 A.D., this era was marked by general tranquility and unity across the empire. By this time, Rome had overtaken most of the Mediterranean world and had spread its culture. Family Religion The family was the basic unit of Roman society. Under Roman law, the male head of the household, usually the father, had absolute power in the family. He enforced strict discipline and demanded total respect for his authority. His wife was subject to his authority and was not allowed to administer her own affairs. Changing†¦show more content†¦By this time, Rome had overtaken most of the Mediterranean world and had spread its culture. Art and Architecture When the Romans conquered Greece, they shipped home thousands of Greek statues. Roman sculptors did a brisk business copying Greek works, and talented Greek artists found rich patrons in Rome. In time, however, Roman sculptors developed their own styles. Greek sculptors idealized the human form, using athletes as models of perfection. Roman artists created more realistic portraits. Roman artists produced beautiful paintings to decorate walls of homes. Although few Roman paintings have survived, landscapes and scenes based on the Iliad or Odyssey were preserved in Pompeii, a city buried by the eruption of the volcano, Mt. Vesuvius, in 79 A.D. Romans also designed magnificent mosaics, which are pictures formed of chips of colored stone. While Romans borrowed many ideas in architecture, they also made important advances. From the Etruscans (the people who first lived on the Italian peninsula) and Greeks, they learned to use columns and arches. They improved on the a rch by inventing the dome, roof formed by rounded arches. The Romans also introduced new building materials such as concrete. New building techniques allowed architectsShow MoreRelatedThe Greatest Accomplishments of the Pax Romana?1214 Words   |  5 Pagesrelative peace. The Roman empire experienced a golden age after the fall of the Roman Republic, arguably one of the greatest golden ages in history. The Pax Romana began in 27 B.C. and it reigned for 200 years before falling. The Pax Romana was a time of great prosperity with many accomplishments. The Pax Romana was not only significant because of the amount of wealth and power it wielded at the time, but it also contributed an enormous amount to society today. These contributions can be seen in manyRead MoreCivilization is Connected from the Mesopotamians to the Powerful Roman Empire836 Words   |  4 Pagesenduring influence. Society has developed many components which became foundational to Western culture from the Mesopotami an civilizations to the emergence of the Romans. The contributions of a variety of cultures shaped the course of Western history. The Mesopotamians and Egyptians are among the first civilizations to make a valuable contribution to Western Civilization. Both Babylonians and Egyptians managed to produce written systems of communicating ideas. The Babylonians created wedge-shaped cuneiformRead More Contributions of Ancient Civilizations Essay820 Words   |  4 Pageselements such as a system of writing, a development of social classes, and cities. Early civilizations such as ancient Greece, classical Rome, Mesopotamia, and classical China have made many contributions to society that still affect people in the modern world. The inventions, progress, and contributions of the people of these ancient civilizations and others have shaped the world that we all live in today. Ancient Mesopotamia was one of the first of the ancient civilizations. It formed in present-dayRead MoreEssay on The Roman and Grecian Effects on Society1261 Words   |  6 Pagesempires from early in human history. Much influence can be found from the Roman and Grecian empires, more than from any other sources. The basic forming of our own government can be traced back to the ideals that formed the Roman and Greek governments, paying attention their strengths and also to what caused the demise of those societies as well. (teachergenius.teachtci.com) Let us examine the Roman influences and facts first. Roman Governmental Influence: There was almost a caste system of sorts, anRead MoreRome: Engineering an Empire812 Words   |  4 Pagesunrivalled power of technology to make the Roman Empire span across three continents and many centuries. While the contributions of ambition, conquest and other political and militaristic factors remain important for the Roman Republic to transform into an Empire, none of this could have been possible without the immense contribution of engineering and technology. In this essay, we shall look into three engineering feats that I believe were crucial in building the Roman Empire. We shall be making use of theRead MoreFluid Mechanics and Contributions of Archimedes in the Field 773 Words   |  3 PagesFLUID MECHANICS AND CONTRIBUTIONS OF ARCHIMEDES ON THE FIELD Fluid mechanics is one of the fields of applied mechanics. It studies the behaviour of gases and liquids both in rest and in motion. â€Å"Fluids† are involved in a great portion of our daily lives even though we do not realize it. There are indeed very few aspects that we do not come across with it. Fluids are used in different fields of engineering. Leonardo Da Vinci is a notable man who had great impact on the field and gave pace to itsRead MoreCultural, Economical, Religious, And Political Contributions847 Words   |  4 PagesCultural, economical, religious, and political contributions made by both Ancient Greece, 800 B.C - 500 B.C , and Ancient Rome, 31 BCE – 476 CE, assisted in the development of western culture. Albeit Rome embraced and developed some characteristics of Greek culture, they still made prominent contributions of their own. Rome and Greece contributed Christianity, Philosophy, The Republic, and Literature. At the time, Roman religion was centered on gods and the interpretation of why things were theRead More Augustus Caesar - The First Roman Emperor Essay782 Words   |  4 Pages Augustus Caesar - The First Roman Emperor In ancient history there have been many great leaders who had saved the Roman Empire from destruction and demise. The leaders and heroes of the Roman Empire are countless, but one leader stands out from all the rest. Augustus Caesar’s contributions to Roman history helped make Rome the dominant empire we know of today. Augustus Caesar was without a question the greatest political leader in the history of the Roman Empire.   Ã‚  Ã‚  Ã‚  Ã‚  As a young adolescentRead MoreEgyptian, Islamic and Roman Architecture Essay1539 Words   |  7 PagesCivilization: I chose Egyptian civilization because it’s known as the birthplace of modern civilization. Another reason I chose Egyptian civilization is because its contributions to the world still seen, studied and absorbers. Egypt contribution has come along way and has mad an impact in on thousands of cultures worldwide. Some of Egypt’s contributions I will address are arts, literature and architecture. The Egyptians had little wood to build their buildings and monuments. The Egyptians lived in the desertRead MoreAncient Roman Civilization And Modern Times936 Words   |  4 PagesThe ancient Roman civilization had many enduring contributions to modern times. Many of the ancient structures survived the ravages of time. This leads the modern tourist to experience the ancient civilization through much of what Ancient Rome’s engineers enduring achievements, namely, temples, baths, aqueducts and roads (Temin, The economy of the early Roman Empire, 2006). Beyond the physical structures that survived the millennia, there are numerous modern cultural influences that are readily

Business Plan Coffee Circus - 8548 Words

BUSINESS PLAN COFFEE CIRCUS 3005 37th Avenue Santa Fe, AZ 68002 Coffee Circus owners are taking advantage of the coffee house rage that has been sweeping the country. Along with taking advantage of this trend, they are also planning for the future. Coffee Circus is also marketing itself as a full service restaurant to maintain stability, in case the coffee trend begins to fizzle. Page No EXECUTIVE SUMMARY 2 MISSION STATEMENT 4 PURPOSE OF BUSINESS 4 BUSINESS GOALS 4 DESCRIPTION OF BUSINESS 4-5 OPPORTUNITIES AND STRENGTHS 5 CRITICAL RISKS AND PROBLEMS 6 MARKETING 7 OPERATIONS†¦show more content†¦The total needed capital for Coffee Circus is $99,900. Owner s cash contribution is $10,000 and other investors and family members is $16,000. The amount needed in loans is $30,800 for equipment, $20,000 for remodeling, and $23,000 for operations. This is a total of $73,800. Overall management will be the responsibility of the owner. The owner brings to the business over 20 years of business experience including over five years in restaurant management and five years in directing a multifaceted non-profit housing program. The general manager will have a minimum of 10 years experience. A major emphasis of Coffee Circus will be to hire economically disadvantaged or at-risk persons and provide them with job training. The majority of these persons will be identified through the City of Santa Fe Job Training Partnership. MISSION STATEMENT To provide a friendly, comfortable atmosphere where the customer can receive quality food, service and entertainment at a reasonable price. PURPOSE OF BUSINESS PLAN This document is intended to outline the start-up of the business known as Coffee Circus. The business plan has a two-fold mission. One is to obtain financing. The other is to help define the who, what, where, when and how for the business so that the business will have a clear cut plan and operations map. BUSINESS GOALS The goals of the business are to provide a substantial income and to create aShow MoreRelatedFeasibility Study of Malungay865 Words   |  4 PagesCoffee Circus A Feasibility Study Submitted to the Faculty of the College of Tourism and Hospitality Management A Partial Fulfillment of the Requirements for the Subject Research 1 (Feasibility Study) Submitted by: Corona, Jamaica D. Coronel, Lester Ace M. Flores, Jegerose S. Figues, Mailyn E. July31, 2013 Chapter 2 Market Study Coffee Circus Product Our company is unique when it comes to drinks. Nowadays, people want some fun on the food they eat. So there is the reasonRead MorePUFFERS PASTRY And Caffe Business PLAN5289 Words   |  22 PagesContents EXECUTIVE SUMMARY 3 MISSION STATEMENT 4 DESCRIPTION OF BUSINESS 5 ADVANTAGES AND STRENGTHS 6 CRITICAL RISKS AND PROBLEMS 7 MARKETING 7 COMPETITION 9 OPERATIONS 10 MANAGEMENT 15 FINANCIAL 19 REFERENCES 20 CASE STUDY 2 21 EXECUTIVE SUMMARY This business plan is developed for opening a new patisserie and cafe in Melbourne CBD for its successful opening, growth and market share of its target audience. This rich and diverse business plan is anticipated to reach out to  pastry target market,  whichRead MoreThe Company Whole Foods Market1560 Words   |  7 PagesCompany (WFC), Wellspring Grocery, Bread Circus, Allegro Coffee, and many more. WFC was a grocery store that was about having good wholesome food and not necessarily health food like WFM. Wellspring Grocery wanted to offer high quality and great nutrition, and to encourage customers to be more connected with the food they ate (http://www.wholefoodsmarket.com/company-info/whole-foods-market-history). They joined WFM in November of 1991. Bread Circus was focused on selling natural foods and woodenRead MoreCase Analysis Essay6670 Words   |  27 Pagescovered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com. Copyright  © 2015, Richard Ivey School of Business Foundation Version: 2016-04-26 In June 2014, Darlene Traviss, owner and chief executive officer of Flip Factory Inc. (Flip Factory), stood in her fitnessRead MoreThe Importance Of The Ninth Amendment1232 Words   |  5 Pagespregnancy endangered her life (â€Å"Roe V. Wade† 1). The case of Roe V. Wade shook the nation as it battled the unpopular idea of abortion. Norma L. McCorvey was a young woman with an unwanted pregnancy. She told the police she was a part of a traveling circus and had been attacked and raped by three men, but they doubted her story (Aaseng 93). A few weeks later, she started having symptoms of nausea, and later on, food cravings. When McCorvey went to her doctor, he delivered the news that she did not wantRead MoreOrganise Business Travel Essay2754 Words   |  12 PagesOrganise Business Travel (BSBADM406B) Assessment Activity 1 Activities A, C E Organise Business Travel Table of Contents Organising Travel Itineraries ...............................................................3 Session Plan 1, Assessment Activity 1 Part A Organising Travel Itineraries ...............................................................5 Session Plan 1, Assessment Activity 1 Part C Organising Travel Itineraries Hotel Information ..........................Read MoreHotel Analysis : Hotel Inn4986 Words   |  20 PagesEastern traditions. THE GUESTS We aim to welcome an exciting blend of modern individuals with an intelligent appreciation of quality, integrity and design; captains of industry with an entrepreneurial spirit from the five pillars: ïÆ' ¼ Fashion Design ïÆ' ¼ Business Politics ïÆ' ¼ Entertainment Media ïÆ' ¼ Arts Culture ïÆ' ¼ Aristocracy Royalty 1.1.5 Products Services Property Name: Hotel Cafà © Royal Property Address: 68 Regent Street, London, W1B 4DY, United Kingdom Property Star Rating: 5 Luxury NumberRead MoreSideshow Alley - Event Management Plan2740 Words   |  11 PagesSideshow Alley – Event Management Plan Introduction: Event management involves creation and development of events such as festivals, conferences, ceremonies, formal parties, concerts or conventions. It includes identifying the target audience, planning the event concept, organising the logistics and coordinating the technical aspects prior to the event day. The process of coordinating the event is called event planning. It involves budgeting, timing, selecting the venue, obtaining necessary permissionRead MoreEnglish: Past Tense and Verb Tense Exercise7200 Words   |  29 Pagescurrently) a book about his adventures in Tibet. I hope he can find a good publisher when he is finished. 8. Jim: Do you want to come over for dinner tonight? Denise: Oh, I m sorry, I can t. I (go) to a movie tonight with some friends. 9. The business cards (be, normally ) printed by a company in New York. Their prices (be) inexpensive, yet the quality of their work is quite good. 10. This delicious chocolate (be) made by a small chocolatier in Zurich, Switzerland. Verb Tense ExerciseRead More Summary of Twelve Years a Slave Essay5063 Words   |  21 Pagesa life of industry so that he could help support him and his wife. He first was employed with others repairing the Champlain Canal. By the time the Canal was finished Northup purchased a pair of horses and other things necessarily required in the business of navigation. He hired several men to help him and he began to transport large rafts of timber from Lake Champlain to Troy. Being involved with this type of work for awhile Northup became very good with the arts and mysteries of rafting. After he