Genera: Postmodernism – after modernism, reaction to modernism, bleed into popular music.is a late 20thcentury movement in philosophy, art, and culture that questions established norms, embraces pluralism, and often rejects the idea of objective truth Pendercki – graphic scores, microtones, extended technique Cage – Conceptual art Glass – Minimalism Pop(ular)- made to sell, simple and easy. Edison invents sound recording, frank Sinatra in jazz Blues- originated among African Americans in the Deep South of the United States around the 1860s. Blues is party music, sad songs. Country- largely from the British (Irish) tradition, Appalachia called “Hillbilly” – oral tradition. Made into pop, appellation mountains. From Ireland. Rock and Roll – fast and organic, Baby Boomers R&B and Country mix Bill Hayley and the Comets Elvis Presley - debatably greatest selling artist of all time Soul- rhythm and blues with gospel singing. musical representation of the Civil Rights Movement R&B + Gospel, Ray Charles, James Brown – Cells becomes Funk, becomes Hip Hop, seeking end segregation. Folk- (music of the people) like country long unwritten tradition), social activism. Bob dylan Rock- music is a genre of popular music characterized by strong beats, electric guitar-driven sound, and a cultural emphasis on rebellion and self-expression. Disco- pop in 70’s, whole bunch of money it does go to gay club. Edm, influences pop music. Punk – united by nihilism- no value in anything, reaction corporate in the 70’s Rap- dance halls of Jamaica influenced by disco, Jamaica making up lyrics, 70’s house parties. Alternative- 90’s, alternative to modern music, to pop, rock hits. Nouns: Penderecki - Polish composer, noted for his highly individual orchestration Cage- concept composition Glass- minimalist composition Frank Sinatra- pop singer, jazz? Miles Davis- trumpet jazz composer best album Baby Boomers- born after world war 2 Elvis- selling artist of all time, started then helped James Brown- soul Bob Dylan- folk Beatles- influential group, introduces rock and roll in pop music, psychedelia involved Michael Jackson- king of pop, thriller- greatest album Public Enemy-golden age rap music, politcal Nirvana- 1990s reinvents rock, metal with punk, grunge, alternative Napster- music file-sharing computer service created by American college student Shawn Fanning in 1999. Max Martin- song writer, producer Technical: Social Activism- music for political change Concept Album- story by album, dark side of moon Psychedelia- movement of drugs, philosophy Nihilism- punk philosophy, belief that nothing matters at all Scratching- scratching records like in the video Synthesizer- electronic instruments, 80’s

📚 FULL REVIEW SHEET: Ethics & Meaning of Life 🏛️ Aristotle’s Ethics (Virtue Ethics) 🔹 The Golden Mean (Virtue = Balance) Aristotle believed that moral virtue is a balance between two extremes: Excess (too much) Deficiency (too little) 👉 Examples: Courage = between cowardice (too little bravery) and recklessness (too much) Generosity = between stinginess and wastefulness ✔ Key idea: Virtue is not one-size-fits-all—it depends on the situation and requires judgment. 🔹 Habits & Character We are not born virtuous Virtue is developed through practice and repetition “We are what we repeatedly do” 👉 If you act honestly repeatedly → you become an honest person ✔ This is why habits are central to Aristotle’s ethics 🔹 Instrumental vs Intrinsic Goods Instrumental goods = useful for achieving something else (ex: money, tools, education) Intrinsic goods = valuable in themselves (ex: happiness) 🔹 Happiness (Eudaimonia) Aristotle’s ultimate goal: eudaimonia (flourishing) Not just pleasure → a life of reason and virtue ✔ Happiness = Living morally Using reason well Achieving your full potential ⚖️ Kant’s Ethics (Deontology) 🔹 Core Idea: Duty Over Consequences Immanuel Kant believed: Morality is about doing your duty NOT about outcomes or happiness 🔹 Maxims A maxim = your personal rule for acting 👉 Example: “It’s okay to lie when it helps me” 🔹 Categorical Imperative The most important rule: 👉 Only act on maxims you would want to become universal laws Ask yourself: “What if everyone did this?” ✔ If it creates a contradiction → it’s immoral 🔹 Treat People as Ends Another version: Never treat people as means only Always treat them as ends (valuable individuals) 🔗 Free Will & Determinism 🔹 Determinism All events are caused by previous events Your actions are the result of: Biology Environment Past experiences 🔹 Hard Determinism No free will exists Everything is predetermined 🔹 Soft Determinism (Compatibilism) Free will can exist with determinism You are free if you act without coercion 🔹 Libertarianism (Free Will Theory) Humans have true freedom We are not fully determined 🔹 Beliefs, Desires & Freedom Actions come from: What you believe What you want 👉 Debate: If these are determined → are we really free? 🔹 Coercion When someone is forced by external pressure 👉 Examples: Threats (gunpoint) Blackmail ✔ Coerced actions = not fully free 🔹 Free Will & Moral Responsibility We can only be held responsible if: We had control We acted freely 🧠 Existentialism & Meaning 🔹 Jean-Paul Sartre Key Idea: 👉 “Existence precedes essence” You are NOT born with a purpose You create yourself through choices 🔹 Human Nature No fixed human nature Humans are radically free 🔹 Anguish Deep anxiety from: Total freedom Total responsibility 👉 You are responsible for everything you choose 🔹 Meaning of Life No built-in meaning You must create meaning yourself 🪨 Sisyphus 🔹 Sisyphus Punished by rolling a rock uphill forever The rock always rolls back down 👉 Represents: Meaningless or repetitive life Human struggle ✔ Often used in existentialism: Even in absurdity → we can create meaning ✝️ Arguments for the Existence of God 🔹 Ontological Argument (A Priori) Anselm of Canterbury Based on logic alone God = “greatest possible being” If God exists in the mind → must exist in reality ✔ No observation needed 🔹 Design Argument (Teleological) William Paley World is complex and ordered Like a watch → implies a watchmaker 👉 Therefore → God exists 🔹 The Problem of Evil If God is: All-powerful All-good 👉 Why does evil exist? ✔ Challenges belief in God 🔬 Scientism & Naturalism 🔹 Scientism Only science gives true knowledge 🔹 Naturalism Everything is explained by natural causes No supernatural explanations 🔹 Impact on Free Will If everything is scientific → maybe free will is an illusion 😊 John Stuart Mill & Utilitarianism 🔹 John Stuart Mill Focus: maximize happiness 🔹 Higher vs Lower Pleasures Higher Pleasures: Intellectual (reading, thinking, learning) Lower Pleasures: Physical (eating, comfort) ✔ Key idea: 👉 “Better to be a human dissatisfied than a pig satisfied”

exam notes often forget

📊 PRICING DEFINITIONS Odd-Even Pricing Pricing items slightly below whole numbers (e.g., $9.99) to make them seem cheaper. Penetration Pricing Setting a low initial price to quickly attract customers and gain market share. Skimming Price Strategy Setting a high initial price and gradually lowering it over time. Price Elasticity The degree to which demand changes when the price changes. Prestige Pricing Setting high prices to create an image of quality or luxury. Cost-Plus Pricing Determining price by adding a markup to the cost of the product. ❓ Key Concepts Best strategy for price-sensitive customers Penetration pricing—because lower prices attract them. Best strategy when you have unique advantages Skimming pricing—because customers are willing to pay more. Last step in setting initial price Finalizing the price after evaluating all factors. 💸 Costs Fixed Costs Expenses that do not change regardless of production level. Variable Costs Expenses that vary depending on production volume. ⚡ Other Pricing Concepts Dynamic (On-Demand) Pricing Adjusting prices in real time based on demand, competition, or other factors. Demand The quantity of a product consumers are willing and able to buy at a given price. Status Quo (Competitive) Pricing Setting prices based on what competitors are charging. 🎯 Pricing Objectives Maximize Sales Focus on increasing the number of units sold. Maximize Profits Focus on achieving the highest possible profit. Maximize Market Share Aim to capture the largest portion of the market. Specific Return on Investment (ROI) Set prices to achieve a targeted financial return. Bundle Pricing Offering several products together at a lower combined price than if purchased separately. 📢 PROMOTION DEFINITIONS Promotion Communication activities used to inform, persuade, and remind customers about a product. Integrated Marketing Communication (IMC) Coordinating all promotional tools to deliver a consistent message. Public Relations (PR) Managing a company’s image and relationships with the public. 🧰 Public Relations Tools News Releases Official statements given to media to share information. Public Service Announcements (PSAs) Messages promoting social good, often free of charge. ⚖️ Strengths & Weaknesses Public Relations Strengths → Credible, low cost Weaknesses → Little control over how message is presented Sales Promotion Definition Short-term incentives to encourage purchase. Strengths → Immediate results Weaknesses → Short-lived impact Advertising Definition Paid, non-personal communication through media. Strengths → Large audience, message control Weaknesses → Expensive, easily ignored Personal Selling (Professional Selling) Definition Direct interaction between a salesperson and a customer. Strengths → Personalized, builds relationships Weaknesses → Costly, time-intensive 🎯 Key Promotion Concepts Lead Element for Mass Consumer Audiences Advertising—reaches large groups efficiently. Lead Element for Business-to-Business (B2B) Personal selling—focuses on relationships. Promotion Strategy in Growth Stage Increasing advertising and sales promotions to build demand. 💵 Budgeting METHODS Objective Task Approach Setting budget based on specific goals and tasks needed to achieve them. Pros → Accurate, goal-oriented Cons → Time-consuming, complex Competitive Comparison Budgeting Setting budget based on competitors’ spending. Percentage of Sales Budgeting Allocating a fixed percentage of sales revenue to promotion. 📊 ADVERTISING TERMS Touch Points Any interaction between a customer and a brand. Reach The number of different people exposed to a message. Frequency The number of times a person sees the message. 🛍️ SALES PROMOTION TYPES Trade Promotions Incentives aimed at retailers or wholesalers to carry or promote products. Consumer Promotions Incentives aimed directly at consumers. Rebate A partial refund given after purchase. Coupons Certificates offering discounts on products. Contests Promotions where skill is required to win. Sweepstakes Promotions where winners are chosen randomly. 📞 SELLING TERMS Cold Calling Contacting potential customers without prior interaction. Lead Generation Identifying and attracting potential customers

Modulei 10: State Government module 10 banner Module Objectives Upon completion of this module, the learner will be able to: Explain how the balance of power between national and state governments shifted with the drafting and ratification of the Constitution. Identify the formal powers and responsibilities of modern-day governors. List the basic functions performed by state legislatures. Describe how state legislatures vary in size, diversity, party composition, and professionalism. State Power & Delegation When the framers met at the Constitutional Convention in 1787, they had many competing tensions to resolve. For instance, they had to consider how citizens would be represented in the national government, given population differences between the states. In addition, they had to iron out differences of opinion about where to concentrate political power. Would the legislative branch have more authority than the executive branch, and would state governments retain as many rights as they had enjoyed under the Articles of Confederation? Here we look at the manner in which power was divided between the national and state governments, first under the Articles of Confederation and then under the U.S. Constitution. As you read, observe the shifting power dynamic between the national government and subnational governments at the state and local level. State Power at the Founding Before the ratification of the Constitution, the state governments’ power far exceeded that held by the national government. This distribution of authority was the result of a conscious decision and was reflected in the structure and framework of the Articles of Confederation. The national government was limited, lacking both a president to oversee domestic and foreign policy and a system of federal courts to settle disputes between the states. Restricting power at the national level gave the states a great deal of authority over and independence from the federal government. Each state legislature appointed its own Congressional representatives, subject to recall by the states, and each state was given the authority to collect taxes from its citizens. But limiting national government power was not the delegates’ only priority. They also wanted to prevent any given state from exceeding the authority and independence of the others. The delegates ultimately worked to create a level playing field between the individual states that formed the confederation. For instance, the Articles of Confederation could not be amended without the approval of each state, and each state received one vote in Congress, regardless of population. It wasn’t long after the Articles of Confederation were established that cracks began to appear in their foundation. Congress struggled to conduct business and to ensure the financial credibility of the new country’s government. One difficulty was its inability to compel the individual states to cover their portion of Revolutionary War debt. Attempts to recoup these funds through the imposition of tariffs were vetoed by states with a vested financial interest in their failure. Given the inherent weaknesses in the system set up by the Articles, in 1787 the delegates came together once again to consider amendments to the Articles, but they ended up instead considering a new design for the government. To produce more long-term stability, they needed to establish a more effective division of power between the federal and state governments. Ultimately, the framers settled on a system in which power would be shared: The national government had its core duties, the state governments had their duties, and other duties were shared equally between them. Today this structure of power sharing is referred to as federalism. An image of an original handwritten version of the Articles of Confederation. Picture 10.1. The Articles of Confederation, written in 1777 and adopted in 1781, established the first government of the United States. The Articles were replaced by the Constitution in 1787. The Constitution allocated more power to the federal government by effectively adding two new branches: a president to head the executive branch and the Supreme Court to head the judicial branch. The specific delegated or expressed powers granted to Congress and to the president were clearly spelled out in the body of the Constitution under Article I, Section 8, and Article II, Sections 2 and 3. In addition to these expressed powers, the national government was given implied powers that, while not clearly stated, are inferred. These powers stem from the elastic clause in Article I, Section 8, of the Constitution, which provides Congress the authority “to make all Laws which shall be necessary and proper for carrying into Execution the Foregoing powers.” This statement has been used to support the federal government’s playing a role in controversial policy matters, such as the provision of healthcare, the expansion of power to levy and collect taxes, and regulation of interstate commerce. Finally, Article VI declared that the U.S. Constitution and any laws or treaties made in connection with that document were to supersede constitutions and laws made at the state level. This clause, better known as the supremacy clause, makes clear that any conflict in law between the central (or federal) government and the regional (or state) governments is typically resolved in favor of the central government. Although the U.S. Constitution clearly allocated more power to the federal government than had been the case under the Articles of Confederation, the framers still respected the important role of the states in the new government. The states were given a host of powers independent of those enjoyed by the national government. As one example, they now had the power to establish local governments and to account for the structure, function, and responsibilities of these governments within their state constitutions. This gave states sovereignty, or supreme and independent authority, over county, municipal, school and other special districts. States were also given the power to ratify amendments to the U.S. Constitution. Throughout U.S. history, all amendments to the Constitution except one have been proposed by Congress and then ratified by either three-fourths of the state legislatures or three-fourths of the state conventions called for ratification purposes. This process ensures that the states have a voice in any changes to the Constitution. The Twenty-First Amendment (repealing the Eighteenth Amendment’s prohibition on alcohol) was the only amendment ratified using the state ratifying convention method. Although this path has never been taken, the U.S. Constitution even allows for state legislatures to take a direct and very active role in the amendment proposal process. If at least two-thirds of the state legislatures apply for a national convention, constitutional amendments can be proposed at the convention. Despite the Constitution’s broad grants of state authority, one of the central goals of the Anti-Federalists, a group opposed to several components of the Constitution, was to preserve state government authority, protect the small states, and keep government power concentrated in the hands of the people. For this reason, the Tenth Amendment was included in the Bill of Rights to create a class of powers, known as reserved powers, exclusive to state governments. The amendment specifically reads, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” In essence, if the Constitution does not decree that an activity should be performed by the national government and does not restrict the state government from engaging in it, then the state is seen as having the power to perform the function. In other words, the power is reserved to the states. Besides reserved powers, the states also retained concurrent powers, or responsibilities shared with the national government. As part of this package of powers, the state and federal governments each have the right to collect income tax from their citizens and corporate tax from businesses. They also share responsibility for building and maintaining the network of interstates and highways and for making and enforcing laws. For instance, many state governments have laws regulating motorcycle and bicycle helmet use, banning texting and driving, and prohibiting driving under the influence of drugs or alcohol. table showing federal powers, concurrent powers, and state powers Figure 10.1. Examples of federal, concurrent, and state powers. On the left is an image of a sign that reads “No texting while driving”. On the right is an image of a person in the driver’s seat of a vehicle. The person is holding a phone in their hand and looking at it. Picture 10.2. State (and sometimes local) governments regulate items having to do with highway safety, such as laws against cellphone use while driving. (credit right: modification of work by “Lord Jim”/Flickr) The Evolution of State Power Throughout U.S. history, the national and state governments have battled for dominance over the implementation of public policy and the funding of important political programs. Upon taking office in 1933 during the Great Depression (1929–1939), President Franklin D. Roosevelt initiated a series of legislative proposals to boost the economy and put people back to work. The enacted programs allowed the federal government to play a broader role in revitalizing the economy while greatly expanding its power. However, this result was not without its critics. Initially, the Supreme Court overturned several key legislative proposals passed under Roosevelt, reasoning that they represented an overreach of presidential authority and were unconstitutional, such as Schechter Poultry Corp. v. United States. Eventually, however, the Supreme Court shifted direction to reflect public opinion, which was decisively behind the president and the need for government intervention in a time of economic turmoil. Just three decades later, during the 1964 presidential election campaign, incumbent President Lyndon B. Johnson declared a “War on Poverty,” instituting a package of Great Society programs designed to improve circumstances for lower-income Americans across the nation. The new programs included Medicare and Medicaid, which are health insurance programs for seniors and low-income citizens respectively, and the food stamp program, which provides food assistance to low-income families. These initiatives greatly expanded the role of the federal government in providing a social safety net. State and local governments became partners in their implementation and also came to rely on the financial support they received from the federal government in the form of program grants. As the federal government’s role in policy creation expanded, so did its level of spending. Spending by the federal government began to surpass that of state and local governments shortly after 1940. It spiked temporarily during the Great Depression and again during World War II, resuming a slow climb with the implementation of Johnson’s Great Society programs noted above. A graph titled “Federal Spending vs. State and Local Spending”. The x-axis of the graph is labeled “Year” and reads from left to right “1930”, “1940”, “1950”, “1960”, “1970”, “1980”, “1990”, “2000”, “2010”, and “2020”. The y-axis is labeled “Expenditure as percent of GDP” and reads from bottom to top “5%”, “10%”, “15%”, “20%”, “25%”, “30%”, “35%”, “40%”, and “45%”. A line labeled “Federal” starts around 4% in 1930, rises to around 10% in 1940, rises sharply to around 40% around 1945, drops sharply to around 15% in 1960, increases to around 20% in 1970, increases to around 23% in 1980, decreases to around 19% in 200, increases to around 25% in 2010, and ends at 32.5% in 2020. A line labeled “State” starts around 10% in 1930, rises to around 11% then drops back to around 10% in 1940, drops to around 5% then rises to around 8% in 1950, rises to around 10% in 1960, rises to around 13% in 1970, rises to around 14% then drops back around 13% in 1980, maintains around 13% in 1990, rises to around 14% in 2000, rises to around 16% in 2010, and ends at 14.3% in 2020. At the bottom of the graph a source is cited: “U.S. Bureau of Economic Analysis. NIPA table 1.1.5: “Gross Domestic Product.” April 29, 2021. NIPA Table 3.2: “Federal Government Current Receipts and Expenditures.” April 29, 2021. NIPA Table 3.3: “State and Local Government Current Receipts and Expenditures.” April 29, 2021. Figure 10.2. After spiking during World War II, spending by the federal government has consistently exceeded that of state and local governments. Since 2000, the gap between federal and state spending has widened considerably. An upswing is evident with the Great Recession (2008–10) and federal spending escalated as COVID-19 became the dominant policy issue in 2020. Growing financial resources gave the federal government increased power over subnational governments. This increased power was because it could use categorical grants to dictate the terms and conditions state governments had to meet to qualify for financial assistance in a specific policy area. Over time, the federal government even began to require state and local governments to comply with legislative and executive authorizations when funding was not attached. These requests from the federal government are referred to as unfunded mandates and are a source of dissatisfaction to political actors at the state and local level. To provide more transparency to state and local governments and reduce the federal government’s use of mandates, the Unfunded Mandates Reform Act was passed in 1995. This act requires the Congressional Budget Office to provide information about the cost of any proposed government mandate that exceeds a specified threshold before the bill can be considered in Congress. Despite the national government’s power to pass and fund policy that affects lower-level governments, states still have gained considerable headway since the late twentieth century. For instance, with the passage of the Personal Responsibility and Work Opportunity Reconciliation Act in 1996, known as the welfare reform bill, states were given great discretion over the provision of welfare. The federal government reduced its level of monetary support for the program and, in exchange, the states gained more authority over its implementation. States were able to set more restrictive work requirements, to place caps on the number of family members who could receive aid, and to limit the length of time someone could qualify for government assistance. Since then, states have been granted the flexibility to set policy across a number of controversial policy areas. For instance, a wide array of states require parental consent for abortions performed on minors, set waiting periods before an abortion can be performed, or require patients to undergo an ultrasound before the procedure. As another example, currently, almost half the states allow for the use of medical marijuana and sixteen more states have fully legalized it, despite the fact that this practice stands in contradiction to federal law that prohibits the use and distribution of marijuana. Today, it is not uncommon to see a patchwork of legal decisions granting states more discretion in some policy areas, such as marijuana use, while providing the federal government more authority in others, such as same-sex marriage. Decisions about which level controls policy can reflect the attitudes of government officials and the public, political ideology and the strategic advantage of setting policy on a state-by-state basis, and the necessity of setting uniform policy in the face of an economic downturn or unanticipated national security threat. What has not changed over time is the central role of the U.S. Supreme Court’s views in determining how power should be distributed in a federalist system. Governors & State Legislatures Public opinion regarding Congress has reached a dismal low, with more than 80 percent of those surveyed in 2014 saying they do not feel most members of Congress deserve to be reelected. This attitude stems from partisan rivalry, media coverage that has capitalized on the conflict, fiscal shutdowns, and the general perception that Congress is no longer engaged in lawmaking. The picture looks quite different at the subnational level, at least where lawmaking is concerned. State representatives and senators have been actively engaged in the lawmaking function, grabbing national attention at times for their controversial and highly partisan policies. Governors have been active in promoting their own policy agendas, either in cooperation with the state legislature or in opposition to it. Among the early 2016 Republican presidential contenders, nine were current or former state governors. In the Democratic field in 2020, four current or former state governors pursued the nomination.30 Increasingly, governors are using their office and the policies they have signed into law as a platform to gain national attention and to give voters a sense of their priorities should they ascend to the highest office in the country, the presidency. Governors in Charge Anyone elected to the office of governor assumes tremendous responsibility overnight. He or she becomes the spokesperson for the entire state and their political party, accepts blame or praise for handling decision-making in times of crisis, oversees the implementation of public policy, and helps shepherd legislation through the lawmaking process. These tasks require a great deal of skill and demand that governors exhibit different strengths and personality traits. Governors must learn to work well with other lawmakers, bureaucrats, cabinet officials, and with the citizens who elected them to office in the first place. The ongoing water crisis in Flint, Michigan, provides a good case in point. The COVID-19 pandemic put every governor in the hot seat as they considered decisions on masks, social distancing, and how to allocate federal funds. A photo shows Gretchen Whitmer standing outside of an urban building being briefed by a person in military uniform. Two other people in military uniforms and a plainclothed person are at the briefing. Picture 10.3. Michigan governor Gretchen Whitmer is briefed by the military on the potential to convert the TCF Center, a convention venue in downtown Detroit, into a medical site to care for persons with COVID-19. Governors have tremendous power over the legislative branch because they serve year-round and hold office alone. They also command wide press coverage by virtue of being the leading elected official in their state. Finally, while there are variations in degree across the states, most governors have more power relative to their state legislatures than does the U.S. president relative to the U.S. Congress. State executive power flows from factors such as the propensity of state legislatures to meet for only part of the year and their resulting reliance for information on the governor and his/her administration, stronger formal tools (e.g., line-item vetoes), budget-cutting discretion, and the fact that state legislators typically hold down another job besides that of legislator. Three of the governor’s chief functions are to influence the legislative process through an executive budget proposal, a policy agenda, and vetoes. Just as the president gives a State of the Union address once a year, so too do governors give an annual State of the State address before the state legislature. In this speech, they discuss economic and political achievements, cite data that supports their accomplishments, and overview the major items on their legislative agenda. This speech signals to members of the state legislature what priorities are high on the governor’s list. Those who share the governor’s party affiliation will work with the governor to see these goals achieved. Given that governors need the cooperation of state legislators to get their bills introduced and steered through the lawmaking process, they make developing good relationships with lawmakers a priority. This can entail helping lawmakers address the concerns of their constituents, inviting legislators to social events and meals, and scheduling weekly meetings with legislative leaders and committee chairs to discuss policy. An image of Nikki Haley standing behind a podium. Picture 10.4. Then-governor Nikki Haley delivers her 2015 State of the State address from the State House in Columbia, South Carolina, on January 21, 2015. In addition to providing a basic list of policy priorities, governors also initiate a budget proposal in most states. Here they indicate funding priorities and spell out the amounts that will be appropriated to various state agencies under their discretion. When the economy is strong, governors may find themselves in the enviable position of having a surplus of tax revenue. That allows them some flexibility to decide whether they want to reduce taxes, direct funds toward a new initiative or program, allocate more funds to current programs, restore funds that were cut during times of fiscal distress, or save surplus revenue in a rainy-day account. Moreover, when cuts must be made, especially when the legislature is not in session, it is typically the governor or their finance director who makes the call on what gets cut. Having introduced their priorities, the governor will work on the sidelines to steer favored bills through the legislative process. This may entail holding meetings with committee chairs or other influential lawmakers concerning their legislative priorities, working with the media to try to get favorable coverage of legislative priorities, targeting advocacy organizations to maintain pressure on resistant lawmakers, or testifying in legislative hearings about the possible impacts of the legislation. Once legislation has made its way through the lawmaking process, it comes to the governor’s desk for signature. If a governor signs the bill, it becomes law, and if the governor does not like the terms of the legislation they can veto, or reject, the entire bill. The bill can then become law only if a supermajority of legislators overrides the veto by voting in favor of the bill. Since it is difficult for two-thirds or more of state legislators to come together to override a veto (it requires many members of the governor’s own party to vote against the governor), the simple act of threatening to veto can be enough to get legislators to make concessions to the governor before the governor will pass the legislation. The ability to veto legislation is just one of the formal powers governors have at their disposal. Formal powers are powers the governor may exercise that are specifically outlined in state constitutions or state law. Unlike U.S. presidents, many governors also have additional veto powers at their disposal, which enhances their ability to check the actions of the legislative branch. For instance, most states provide governors the power of the line-item veto. The line-item veto gives governors the ability to strike out a line or individual portions of a bill while letting the remainder pass into law. In addition, approximately 30 percent of governors have the power of an amendatory veto, which allows them to send a bill back to the legislature and request a specific amendment to it. Finally, a small number of governors, including the governor of Texas, also have the power of a reduction veto, which allows them to reduce the budget proposed in a piece of legislation. Besides the formal power to prepare the budget and veto legislation, legislators also have the power to call special sessions of the legislature for a wide array of reasons. For instance, sessions may be called to address budgetary issues during an economic downturn, to put together a redistricting plan, or to focus intensively on a particular issue the governor wants rectified immediately. In some states, only the governor has the power to call a special session, while in other states this power is shared between the legislative and the executive branches. Although governors have a great deal of power in the legislative arena, this is not their only area of influence. First, as leaders in their political party, governors often work to raise money for other political figures who are up for reelection. A governor who has high public approval ratings may also make campaign appearances on behalf of candidates in tough reelection fights across the state. Governors can draw in supporters, contributions, and media attention that can be beneficial to other political aspirants, and the party will expect them to do their part to ensure the greatest possible number of victories for their candidates. Second, as the spokesperson for their state, governors make every effort to sell the state’s virtues and unique characteristics, whether to the media, to other citizens across the United States, to potential business owners, or to legislative leaders in Washington, DC. Governors want to project a positive image of their state that will encourage tourism, relocation, and economic investment within its boundaries. Collectively, governors make a mark through the National Governors Association, which is a powerful lobbying force in the nation’s capital. For example, Texas governor Greg Abbott made headlines in 2015 for writing to the CEO of General Electric (GE), urging the company to relocate its corporate headquarters from Connecticut, which had just raised its corporate tax rate, to Texas. As his state’s spokesperson, Abbott promoted Texas’s friendly corporate tax structure and investment in transportation and education funding in hopes of enticing GE to relocate there and bring economic opportunities with it. The company has since decided to relocate to Boston, after receiving incentives, worth up to $145 million, from Massachusetts officials. Another example involved Texas governor Rick Perry touring California in 2014 in order to bring prospective businesses from the Golden State to Texas. In what was arguably the biggest round of lobbying by state and local governments toward a big business, Amazon recently conducted a search for a second corporate headquarters. After months of consideration, hundreds of op-eds extolling the virtues of locating in particular communities, Amazon picked two sites—Arlington, Virginia and Long Island City, New York—where it plans to spend over $2 billion at each site. In March 2015, the governor of Virginia, Terry McAuliffe, and the mayor of Chicago, Rahm Emanuel, both sent letters to corporate heads in Indiana after controversy erupted around the passage of that state’s Religious Freedom Restoration Act. This bill is designed to restrict government intrusion into people’s religious beliefs unless there is a compelling state interest. It also provides individuals and businesses with the ability to sue if they feel their religious rights have been violated. However, opponents feared the law would be used as a means to discriminate against members of the LGBTQ community, based on business owners’ religious objections to providing services for same-sex couples. In the media firestorm that followed the Indiana law’s passage, several prominent companies announced they would consider taking their business elsewhere or cancelling event contracts in the state if the bill were not amended. This led opportunistic leaders in the surrounding area to make appeals to these companies in the hope of luring them out of Indiana. Ultimately, the bill was clarified, likely due in part to corporate pressure on the state to do so. The clarification made it clear that the law could not be used to refuse employment, housing, or service based on an individual’s sexual orientation or gender identity. Controversial legislation like the Religious Freedom Restoration Act is only one of the many environmental factors that can make or break a governor’s reputation and popularity. Other challenges and crises that may face governors include severe weather, terrorist attacks, immigration challenges, and budget shortfalls. New Jersey governor Chris Christie gained national attention in 2012 over his handling of the aftermath of Hurricane Sandy, which caused an estimated $65 billion worth of damage and cost the lives of over 150 individuals along the East Coast of the United States. Christie was famously photographed with President Obama during their joint tour of the damaged areas, and the governor subsequently praised the president for his response. Some later criticized Christie for his remarks because of the close proximity between the president’s visit and Election Day, along with the fact that the Republican governor and Democratic president were from opposite sides of the political aisle. Critics felt the governor had betrayed his party and that the publicity helped the president win reelection. Others praised the governor for cooperating with the president and reaching across the partisan divide to secure federal support for his state in a time of crisis. Image A is of Chris Christie and Barack Obama standing on a sidewalk with another person. Image B is of Chris Christie and Barack Obama in a room full of people. Picture 10.5. New Jersey governor Chris Christie (right) hosted President Obama (center) during the president’s visit to the state in October 2012 following the destruction brought by Hurricane Sandy (a). After viewing the damage along the coastline of Brigantine, New Jersey, Christie and Obama visited residents at the Brigantine Beach Community Center (b). If severe winter weather is forecasted or in the event of civil unrest, governors also have the power to call upon the National Guard to assist residents and first responders or aid in storm recovery. When governors declare a state of emergency, National Guard troops can be activated to go into local areas and assist with emergency efforts in whatever capacity they are needed. In 2015, many governors in the New England region called press conferences, worked with snow-removal crews and local government officials, set up emergency shelters, and activated travel bans or curfews in the face of crippling snowstorms. When winter storms fail to bring predicted levels of snow, however, politicians can be left to field criticism that they instigated unnecessary panic. However, it is a potential catch-22 because if storms end up worse than expected, elected leaders get hammered. For example, a lengthy freeze in south Texas, where even one winter day below freezing is highly unusual, led to a tragic disaster when electrical capacity failed, water pipes froze, and supplies of drinking water were deemed unsafe. A total of 111 people died during the episode and the Texas power grid was within minutes of a total collapse; government officials mandated blackouts, even as people experienced below freezing temperatures.55 Governors feel the weight of their decisions as they try to balance the political risks of overreacting and the human costs of letting the state be caught unprepared for these and other major natural disasters. As the chief spokesperson, they take all the blame or all the credit for their actions. With that said, it is important to note that presidents can enlist the National Guard for federal service as well. President Biden tours an emergency operations center in Houston and meets with Greg Abbott. Picture 10.6. During the record-breaking freeze of 2021, President Biden met in Houston with Texas governor Greg Abbott and other state and local leaders. Governors also have the power to spare or enhance the lives of individuals convicted of crimes in their state. Although they may choose to exercise this formal power only during the closing days of their term, if at all, most governors have the authority to grant pardons just as U.S. presidents do. A pardon absolves someone of blame for a crime and can secure their release from prison. Governors can also commute sentences, reducing the time an individual must serve, if there are doubts about the person’s guilt, concerns about mental health, or reason to feel the punishment was inappropriately harsh. In the past ten years, the governors of New Jersey and Illinois have commuted the sentences of all inmates on death row before repealing the death penalty in their states. Despite the tremendous formal powers that go with the job, being governor is still personally and professionally challenging. The demands of the job are likely to restrict time with family and require forgoing privacy. In addition, governors will often face circumstances beyond their control. For instance, the state legislature may include a majority of members who do not share the governor’s party affiliation. This can make working together more challenging and lead to less cooperation during the legislative session. Another challenge for governors is the plural executive, which refers to the fact that many state officials, such as the lieutenant governor, attorney general, and secretary of state are elected independently from the governor; hence, the governor has no direct control over them the way a president might have sway over U.S. executive officials. Governors can also face spending restrictions due to the economic climate in their state. They may have to make unpopular decisions that weaken their support among voters. The federal government can mandate that states perform some function without giving them any funds to do so. Finally, as we saw above, governors can be swept up in crises or natural disasters they did not anticipate and could not have foreseen. This can drain their energy and hamper their ability to generate good public policy. The Functions of State Legislatures State legislatures serve three primary functions. They perform a lawmaking function by researching, writing, and passing legislation. Members represent their districts and work to meet requests for help from citizens within it. Finally, legislatures perform an oversight function for the executive branch. All state representatives and senators serve on committees that examine, research, investigate, and vote on legislation that relates to the committee’s purpose, such as agriculture, transportation, or education. The number of bills introduced in any given session varies. Some state legislatures have more restrictive rules concerning the number of bills any one member can sponsor. Legislators get ideas for bills from lobbyists of various types of interest groups, ranging from corporate groups to labor unions to advocacy organizations. Ideas for bills also come from laws passed in other state legislatures, from policy that diffuses from the federal government, from constituents or citizens in the officeholder’s district who approach them with problems they would like to see addressed with new laws, and from their own personal policy agenda, which they brought to office with them. Finally, as we explored previously, legislators also work with the governor’s agenda in the course of each legislative session, and they must pass a budget for their state either every year or every two years. Most bills die in committee and never receive a second or third reading on the floor of the legislature. Lawmaking requires frequent consensus, not just among the legislators in a given house but also between the two chambers. In order for a bill to become law, it must pass through both the state house and the state senate in identical form before going to the governor’s desk for final signature. Besides generating public policy, state legislatures try to represent the interests of their constituents. Edmund Burke was a political philosopher who theorized that representatives are either delegates or trustees. A delegate legislator represents the will of those who elected the legislator to office and acts in their expressed interest, even when it goes against personal belief about what is ultimately in the constituency’s best interest. On the other hand, trustees believe they were elected to exercise their own judgment and know best because they have the time and expertise to study and understand an issue. Thus, a trustee will be willing to vote against the desire of the constituency so long as the trustee believes it is in the people’s best interest. A trustee will also be more likely to vote by conscience on issues that are personal to the trustee, such as on same-sex marriage or abortion rights. Regardless of whether representatives adopt a delegate or a trustee mentality, they will all see it as their duty to address the concerns and needs of the people they represent. Typically, this will entail helping members in the district who need assistance or have problems with the government they want addressed. For instance, a constituent may write an elected official asking for help dealing with the bureaucracy such as in a decision made by tax commission, requesting a letter of recommendation for acceptance into a military academy, or proposing a piece of legislation the member can help turn into a law. Legislators also try to bring particularized benefits back to their district. These benefits might include money that can be spent on infrastructure improvements or grants for research. Finally, members will accept requests from local government officials or other constituents to attend parades, ribbon-cutting ceremonies, or other celebratory events within their district. They will also work with teachers and faculty to visit classes or meet with students on field trips to the state capitol. An image of Mitch Landrieu standing in the middle of a group of people who are playing various instruments. A streetcar is in the background. Picture 10.7. To celebrate the opening of the new Loyola Avenue streetcar line, the mayor of New Orleans, Mitch Landrieu, marched with the St. Augustine “Marching 100” on January 28, 2013. The last primary function of state legislators is to oversee the bureaucracy’s implementation of public policy, ensuring it occurs in the manner the legislature intended. State legislatures may request that agency heads provide testimony about spending in hearings, or they may investigate particular bureaucratic agencies to ensure that funds are being disbursed as desired. Since legislators have many other responsibilities and some meet for only a few months each year, they may wait to investigate until a constituent or lobbyist brings a problem to their attention. The Composition of State Legislatures In most states, the legislative function is divided between two bodies: a state house and a state senate. The only exception is Nebraska, which has a unicameral state senate of forty-nine members. State legislatures vary a great deal in terms of the number of legislators in the house and senate, the range of diversity across the membership, the partisan composition of the chamber relative to the governor’s affiliation, and the degree of legislative professionalism. This variation can lead to differences in the type of policies passed and the amount of power legislatures wield relative to that of the governor. According to the National Conference of State Legislatures, at forty members, Alaska’s is the smallest state (or lower) house, while New Hampshire’s is the largest at four hundred. State senates range in size from twenty members in Alaska to sixty-seven members in Minnesota. The size of the institution can have consequences for the number of citizens each member represents; larger bodies have a smaller legislator-to-constituent ratio (assuming even populations). Larger institutions can also complicate legislative business because reaching consensus is more difficult with more participants. The term length in the state house is frequently two years, while in the state senate it is more commonly four years. These differences have consequences, too, because representatives in the state house, with the next election always right around the corner, will need to focus on their reelection campaigns more frequently than senators. On the other hand, state senators may have more time to focus on public policy and become policy generalists because they each must serve on multiple committees due to their smaller numbers. In 2021, according to the National Conference of State Legislatures, women made up 30.6 percent of the nation’s state legislators. However, the number varies a great deal across states. For instance, in Arizona and Vermont, women account for around 40 percent of the state legislative membership. However, they make up less than 16 percent of the legislatures in Alabama, Louisiana, Oklahoma, South Carolina, West Virginia, and Wyoming. A map of the United States titled “Percentage of Women in State Legislature, but State, 2021”. These states are 10-19%: WY, LA, MS, AL, TN, SC, WV. These states are 20-29%: UT, ND, SD, NE, KS, OK, TX, IA, MO, AR, IN, KY, PA, NC. These states are 30-39%: AK, HI, CA, ID, MT, MN, WI, IL, MI, OH, GA, FL, VA, DE, NJ, NY, CT, RI, MA, NH. These states are 40-49%: WA, OR, CO, NM, AZ, ME, VT, RI, MD. These states are 50-59%: DC. These states are 60-69%: NV. Figure 10.3. In 2021, only 31 percent of state legislators across the United States were women. However, the percentage of women in state legislature varies greatly from state to state. Data on minority representatives is more difficult to obtain, but 2019 estimates from Emory University professor Beth Reingold paired with census estimates from 2019 show that African Americans and Latinos are both underrepresented in state government relative to their percentage of the population. In 2009, African Americans made up 9.3 percent of state legislators, compared to the 13.4 percent of the population they constitute nationwide. On the other hand, Latino representatives made up 4.4 percent of state legislators, despite accounting for 18.5 percent of the total population in the United States. The proportion of Latinos in the legislature is highest in Arizona, California, New Mexico, and Texas, while the proportion of African Americans is highest in Alabama, Georgia, and Mississippi. Scholars in political science have spent a great deal of time researching the impact of women and minorities on the legislative process and on voter participation and trust. Some research demonstrates that female and minority representatives are more likely to advocate for policies that are of interest to or will benefit minorities, women, and children. Other research suggests that the presence of African American and Latino representatives increases voter turnout by these groups. Thus, increased diversity in state legislatures can have consequences for voter engagement and for the type of legislation pursued and passed within these bodies. As of early February 2021, thirty states had Republican majorities in the state house and senate, while in eighteen states Democratic majorities were the norm. In only one state, Minnesota, party control was split so that the Democratic Party maintained control of one house while the Republican Party maintained control of the other. The figure below illustrates the partisan composition across the United States. Note that states in New England and the West Coast are more likely to be unified behind the Democratic Party, while Republicans control legislatures throughout the South and in large parts of the Midwest. This alignment largely reflects differing political ideologies, with the more liberal, urban areas of the country leaning Democratic while the more conservative, rural areas are Republican. A map shows legislative control of state house and senate by state as of 2021. These states are marked “Republican”: AK, ID, MT, WY, UT, AZ, ND, SD, KS, OK, TX, IA, MO, AR, LA, WI, MI, IN, OH, PA, KY, WV, TN, NC, MS, AL, GA, FL, SC NH. These states are marked “Democrat”: WA, OR, CA, NV, CO, NM, IL, ME, VT, NY, MA, RI, CT, NJ, DE, MD, DC, VA. Minnesota is marked “split”. Nebraska is marked “Nonpartisan and Unicameral”. Figure 10.4. This map illustrates which party is in control of the house and senate within each state. When one party controls the senate and another party controls the house, the partisan composition is split. Like diversity, party composition has consequences for policymaking. Governors who are not from the same party as the one controlling the legislature can find it more difficult to achieve their agenda. This governing circumstance is popularly referred to as divided government. In a time of divided government, a governor may have to work harder to build relationships and to broker consensus. In addition, when state party control is divided between the legislative and executive branches, the governor may find that legislators are more likely to muster the numbers to overturn at least some of their vetoes. In contrast, when the governor’s own party controls the legislature—a situation known as unified government—conventional wisdom suggests that they will have a smoother and more productive relationship with the legislature. Party composition also matters for the overall legislative agenda. The party in power will elect party members to the top leadership posts in the state house and senate, and it will determine who sits on each of the committees. Committees are chaired by members of the majority party, and the composition of these committees is skewed toward members affiliated with the party in power. This gives the majority party an advantage in meeting its policy objectives and relegates the minority party to the position of obstructionists. In addition, while Republicans and Democrats are both concerned about education, health care, transportation, and other major policy areas, the two parties have different philosophies about what is in the best interest of their citizens and where funds should be allocated to meet those needs. The result is vastly different approaches to handling pressing public policy problems across the states. As a whole, state legislatures have become progressively more professional. Political scientist Peverill Squire, at several points throughout his career, has measured the degree of state legislative professionalism with a ranking across the fifty states. Legislative professionalism is assessed according to three key factors: state legislators’ salary, the length of time they are in session, and the number of staff at their disposal. Members of professional or full-time legislatures tend to consider legislative service their full-time occupation, and they are paid enough not to require a second occupation. They also have larger staffs to assist with their work, and they tend to be in session for much of the year. On the other end of the spectrum are citizen, or part-time, legislatures. Representatives and senators in these legislatures do not enjoy the same perks as their counterparts in professional legislatures. Generally, salary is much lower and so is staff assistance. Members typically need to seek outside employment to supplement their income from legislative work, and the legislature will meet for only a brief period of time during the year. Between these two extremes are hybrid legislatures. Their members are compensated at a higher rate than in citizen legislatures, but they are still likely to need outside employment to make an income equal to what they were making prior to taking office. These representatives and senators will have some staff assistance but not as much as in a professional legislature. Finally, members in hybrid legislatures will not consider their service to constitute a full-time occupation, but they will spend more than part of their time conducting legislative business. As Figure 10.4 shows, California, New York, and Pennsylvania are home to some of the most professional legislatures in the country. On the other hand, New Hampshire, North Dakota, Wyoming, and South Dakota are among the states that rank lowest on legislative professionalism. A map of the United States titled “Level of Professionalism Within State Legislatures, 2008”. California, Pennsylvania, and New York are marked “Full-time, high salary, large staff”. Alaska, Florida, Wisconsin, Illinois, Michigan, Ohio, and Massachusetts, are marked “Full-time, moderately high salary, moderately large staff”. Washington, Oregon, Arizona, Colorado, Nebraska, Oklahoma, Texas, Minnesota, Iowa, Missouri, Arkansas, Louisiana, Indiana, Kentucky, Tennessee, Alabama, South Carolina, North Carolina, Virginal, DC, Maryland, Delaware, New Jersey, Connecticut, and Hawaii are marked “Hybrid”. Idaho, Nevada, New Mexico, Kansas, Mississippi, Georgia, West Virginia, Rhode Island, Vermont, and Maine are marked “Part-time, moderately low salary, moderately small staff”. Montana, Wyoming, Utah, North Dakota, South Dakota, and New Hampshire are marked “Part-time, low salary, low staff”. Figure 10.5. This map illustrates the degree of professionalism within state legislatures. States in purple and green tend to meet full-time and have larger staff and salaries, while the opposite conditions exist in states colored in orange and red. States in blue fall somewhere in the middle of these conditions. Like the other indicators discussed above, legislative professionalism also affects the business of state legislatures. In professional legislatures, elections tend to be more competitive, and the cost of running for a seat is higher because the benefits of being elected are greater. This makes these seats more attractive, and candidates will tend not to run unless they perceive themselves as well qualified. Since the benefits are more generous, elected officials will tend to stay in office longer and develop more policy expertise as a result. This experience can give professional legislatures an edge when dealing with the governor, because they are likely to be in session for about the same amount of time per year as the governor and have the necessary staff to assist them with researching and writing public policy. Practice Question 10.1 ________ are officeholders who represent the will of those who elected them and act in constituents’ expressed interest. The Dual Court System Before the writing of the U.S. Constitution and the establishment of the permanent national judiciary under Article III, the states had courts. Each of the thirteen colonies had also had its own courts, based on the British common law model. The judiciary today continues as a dual court system, with courts at both the national and state levels. Both levels have three basic tiers consisting of trial courts, appellate courts, and finally courts of last resort, typically called supreme courts, at the top. A chart that demonstrates the structure of the dual court system. At the top of the chart is a box labeled “U.S. Supreme Court”. There are boxes below it on either side, arranged in the shape of a triangle. On the left hand side of the triangle are two boxes. From bottom to top, the boxes are labeled “U.S. District Courts” and “U.S. Federal Courts.” An arrow points from the top of the box labeled “U.S. District Courts” to the box labeled “U.S. Federal Courts”. An arrow points from the top of the box labeled “U.S. Federal Courts” to the box labeled “U.S. Supreme Court”. On the right hand side of the triangle are three boxes. From bottom to top, the boxes are labeled “State Trial Courts”, “Intermediate Appellate Courts”, and “State Supreme Courts”. An arrow points from the top of the box labeled “State Trial Courts” to the bottom of the box labeled “Intermediate Appellate Courts”. An arrow points from the top of the box labeled “Intermediate Appellate Courts” to the bottom of the box labeled “State Supreme Courts”. An arrow points from the top of the box labeled “State Supreme Courts” to the bottom of the box labeled “U.S. Supreme Court”. Figure 10.6. The U.S. judiciary features a dual court system comprising a federal court system and the courts in each of the fifty states. On both the federal and state sides, the U.S. Supreme Court is at the top and is the final court of appeal. To add to the complexity, the state and federal court systems sometimes intersect and overlap each other, and no two states are exactly alike when it comes to the organization of their courts. Since a state’s court system is created by the state itself, each one differs in structure, the number of courts, and even name and jurisdiction. Thus, the organization of state courts closely resembles but does not perfectly mirror the more clear-cut system found at the federal level. Still, we can summarize the overall three-tiered structure of the dual court model and consider the relationship that the national and state sides share with the U.S. Supreme Court, as illustrated in the figure above. Cases heard by the U.S. Supreme Court come from two primary pathways: (1) the circuit courts, or U.S. courts of appeals (after the cases have originated in the federal district courts), and (2) state supreme courts (when there is a substantive federal question in the case). In a later section of the chapter, we discuss the lower courts and the movement of cases through the dual court system to the U.S. Supreme Court. But first, to better understand how the dual court system operates, we consider the types of cases state and local courts handle and the types for which the federal system is better designed. Courts and Federalism Courts hear two different types of disputes: criminal and civil. Under criminal law, governments establish rules and punishments; laws define conduct that is prohibited because it can harm others and impose punishment for committing such an act. Crimes are usually labeled felonies or misdemeanors based on their nature and seriousness; felonies are the more serious crimes. When someone commits a criminal act, the government (state or national, depending on which law has been broken) charges that person with a crime, and the case brought to court contains the name of the charging government, as in Miranda v. Arizona discussed below. On the other hand, civil law cases involve two or more private (non-government) parties, at least one of whom alleges harm or injury committed by the other. In both criminal and civil matters, the courts decide the remedy and resolution of the case, and in all cases, the U.S. Supreme Court is the final court of appeal. Although the Supreme Court tends to draw the most public attention, it typically hears fewer than one hundred cases every year. In fact, the entire federal side—both trial and appellate—handles proportionately very few cases, with about 90 percent of all cases in the U.S. court system being heard at the state level. The several hundred thousand cases handled every year on the federal side pale in comparison to the several million handled by the states. State courts really are the core of the U.S. judicial system, and they are responsible for a huge area of law. Most crimes and criminal activity, such as robbery, rape, and murder, are violations of state laws, and cases are thus heard by state courts. State courts also handle civil matters; personal injury, malpractice, divorce, family, juvenile, probate, and contract disputes and real estate cases, to name just a few, are usually state-level cases. The federal courts, on the other hand, will hear any case that involves a foreign government, patent or copyright infringement, Native American rights, maritime law, bankruptcy, or a controversy between two or more states. Cases arising from activities across state lines (interstate commerce) are also subject to federal court jurisdiction, as are cases in which the United States is a party. A dispute between two parties not from the same state or nation and in which damages of at least $75,000 are claimed is handled at the federal level. Such a case is known as a diversity of citizenship case. However, some cases cut across the dual court system and may end up being heard in both state and federal courts. Any case has the potential to make it to the federal courts if it invokes the U.S. Constitution or federal law. It could be a criminal violation of federal law, such as assault with a gun, the illegal sale of drugs, or bank robbery. Or it could be a civil violation of federal law, such as employment discrimination or securities fraud. Also, any perceived violation of a liberty protected by the Bill of Rights, such as freedom of speech or the protection against cruel and unusual punishment, can be argued before the federal courts. A summary of the basic jurisdictions of the state and federal sides is provided in the table below. Table 10.1. Jurisdiction of the Courts: State vs. Federal State Courts Federal Courts Hear most day-to-day cases, covering 90 percent of all cases Hear cases that involve a “federal question,” involving the Constitution, federal laws or treaties, or a “federal party” in which the U.S. government is a party to the case Hear both civil and criminal matters Hear both civil and criminal matters, although many criminal cases involving federal law are tried in state courts Help the states retain their own sovereignty in judicial matters over their state laws, distinct from the national government Hear cases that involve “interstate” matters, “diversity of citizenship” involving parties of two different states, or between a U.S. citizen and a citizen of another nation (and with a damage claim of at least $75,000) While we may certainly distinguish between the two sides of a jurisdiction, looking on a case-by-case basis will sometimes complicate the seemingly clear-cut division between the state and federal sides. It is always possible that issues of federal law may start in the state courts before they make their way over to the federal side. And any case that starts out at the state and/or local level on state matters can make it into the federal system on appeal—but only on points that involve a federal law or question, and usually after all avenues of appeal in the state courts have been exhausted. Consider the case Miranda v. Arizona. Ernesto Miranda, arrested for kidnapping and rape, which are violations of state law, was easily convicted and sentenced to prison after a key piece of evidence—his own signed confession—was presented at trial in the Arizona court. On appeal first to the Arizona Supreme Court and then to the U.S. Supreme Court to exclude the confession on the grounds that its admission was a violation of his constitutional rights, Miranda won the case. By a slim 5–4 margin, the justices ruled that the confession had to be excluded from evidence because in obtaining it, the police had violated Miranda’s Fifth Amendment right against self-incrimination and his Sixth Amendment right to an attorney. In the opinion of the Court, because of the coercive nature of police interrogation, no confession can be admissible unless a suspect is made aware of his rights and then in turn waives those rights. For this reason, Miranda’s original conviction was overturned. Yet the Supreme Court considered only the violation of Miranda’s constitutional rights, but not whether he was guilty of the crimes with which he was charged. So there were still crimes committed for which Miranda had to face charges. He was therefore retried in state court in 1967, the second time without the confession as evidence, found guilty again based on witness testimony and other evidence, and sent to prison. Miranda’s story is a good example of the tandem operation of the state and federal court systems. His guilt or innocence of the crimes was a matter for the state courts, whereas the constitutional questions raised by his trial were a matter for the federal courts. Although he won his case before the Supreme Court, which established a significant precedent that criminal suspects must be read their so-called Miranda rights before police questioning, the victory did not do much for Miranda himself. After serving prison time, he was stabbed to death in a bar fight in 1976 while out on parole, and due to a lack of evidence, no one was ever convicted in his death. The Implications of a Dual Court System From an individual’s perspective, the dual court system has both benefits and drawbacks. On the plus side, each person has more than just one court system ready to protect that individual's rights. The dual court system provides alternate venues in which to appeal for assistance, as Ernesto Miranda’s case illustrates. The U.S. Supreme Court found for Miranda an extension of his Fifth Amendment protections—a constitutional right to remain silent when faced with police questioning. It was a right he could not get solely from the state courts in Arizona, but one those courts had to honor nonetheless. The fact that a minority voice like Miranda’s can be heard in court, and that grievances can be resolved in a minority voice's favor if warranted, says much about the role of the judiciary in a democratic republic. In Miranda’s case, a resolution came from the federal courts, but it can also come from the state side. In fact, the many differences among the state courts themselves may enhance an individual’s potential to be heard. State courts vary in the degree to which they take on certain types of cases or issues, give access to particular groups, or promote certain interests. If a particular issue or topic is not taken up in one place, it may be handled in another, giving rise to many different opportunities for an interest to be heard somewhere across the nation. In their research, Paul Brace and Melinda Hall found that state courts are important instruments of democracy because they provide different alternatives and varying arenas for political access. They wrote, “Regarding courts, one size does not fit all, and the republic has survived in part because federalism allows these critical variations.” But the existence of the dual court system and variations across the states and nation also mean that there are different courts in which a person could face charges for a crime or for a violation of another person’s rights. Except for the fact that the U.S. Constitution binds judges and justices in all the courts, it is state law that governs the authority of state courts, so judicial rulings about what is legal or illegal may differ from state to state. These differences are particularly pronounced when the laws across the states and the nation are not the same, as we see with marijuana laws today. Where you are physically located can affect not only what is allowable and what is not, but also how cases are judged. For decades, political scientists have confirmed that political culture affects the operation of government institutions, and when we add to that the differing political interests and cultures at work within each state, we end up with court systems that vary greatly in their judicial and decision-making processes. Each state court system operates with its own individual set of biases. People with varying interests, ideologies, behaviors, and attitudes run the disparate legal systems, so the results they produce are not always the same. Moreover, the selection method for judges at the state and local level varies. In some states, judges are elected rather than appointed, which can affect their rulings. Just as the laws vary across the states, so do judicial rulings and interpretations, and the judges who make them. That means there may not be uniform application of the law—even of the same law—nationwide. We are somewhat bound by geography and do not always have the luxury of picking and choosing the venue for our particular case. So, while having such a decentralized and varied set of judicial operations affects the kinds of cases that make it to the courts and gives citizens alternate locations to get their case heard, it may also lead to disparities in the way they are treated once they get there. Practice Question 10.2 A state case is more likely to be heard by the federal courts when ________

Exam 1 Concepts: Integumentary System: Know the importance of pressure injury prevention strategies i.e.. Q2 turns (pressure redistribution), moisture barrier cream (reduce moisture), pillows under bony prominences (limits friction/shearing), smooth and wrinkle-free linen (reduce bed irritation), adequate protein intake (improve wound healing) Normal skin findings vs abnormal findings Importance of each skin layer: epidermis (melanin, keratin), dermis (glands, vessels, nerves), hypodermis (fat, anchors skin) How to assess for early signs of pressure injury: redness, blanching, moist vs dry ​Dark skin tones: use palpation to detect tissue consistency Early signs of pressure injury: Q2 turns/repositioning= priority, never massage area, apply heat, or use alcohol Increase protein intake to help wound healing Musculoskeletal System: ROM: active vs passive. Always compare both sides of body for accurate assessment Body mechanics when transferring a patient: bend at knees, not waist, use leg muscles, avoid twisting, stand on patient’s stronger side to optimize support Cane=one point of contact for unilateral weakness; standard walker= four points of contact for bilateral weakness; crutches= three points of contact for non-weight bearing injury (crutches should be 6 inches from sides of feet to ensure stability and prevent tripping) Post-op joint replacement: cold therapy reduces swelling How to prevent contractures (splints, ROM) Osteoarthritis and Rheumatoid arthritis: encourage ROM after pain medication given, use assistive devices as needed to protect joints, apply warm compress before activity to reduce pain/stiffness, take breaks to conserve energy, perform low impact exercises to maintain mobility and strength, quit smoking Function of bone marrow Neurologic System: Correct sequence of a nerve impulse: action potential moves down axon terminal → neurotransmitter released → neurotransmitter binds to receptor → Sodium and potassium ions move to generate new action potential Cranial nerves: CN III = oculomotor, CN VII = facial, CN IX = glossopharyngeal, CNXII = hypoglossal (know what these 4 cranial nerves control) Cerebellum = coordination. Tested with finger-to-nose test Aphasia = difficulty communicating (receptive or expressive). Provide calm, slow speaking/direction, allow extra time, face patient directly, do not rush, do not ask multiple questions at once, do not talk over them Dysphagia = difficulty swallowing. High risk of aspiration. Stop oral intake and notify provider. If able, proceed with thickened liquids, sit patient up 90 degrees, observe for further signs of choking, monitor weight/hydration/nutrition Autonomic nervous system= involuntary (automatic) functions like digestion and heart rate Stroke prevention: adequate blood pressure control = priority Eye/Ear: Eye structures: cornea-bends light; lens-focuses light; retina-photoreceptors; iris-controls light entry PERRLA = pupils equal, round, reactive to light and accommodation Outer ear = pinna, canal; middle ear = ossicles, ET, tympanic membrane, amplifies sound, equalizes pressure, transmits sound; inner ear = cochlea, vestibular apparatus, converts sound to electrical nerve impulse Tympanic membrane: normal = pearly gray, shiny, translucent, visible cone of light Respiratory System: Abnormal lung sounds: Wheezes =high-pitched, often associated with asthma. Crackles = rattling sound, fluid in alveoli/bronchioles, common in pneumonia and heart failure. Ronchi = low pitched, snoring, caused by airway obstruction, common in COPD. Stridor = high pitched sound in the larynx or trachea, medical emergency, common in foreign body obstruction or anaphylaxis Diaphragm = breathing muscle Alveoli = gas exchange Pleura = serous membrane surrounding lungs and chest cavity; reduces friction, allows smooth expansion and contraction of lungs Incentive spirometry: smoking can affect results Chest Xray: patient should inhale fully and hold breath for best view Pulmonary function test (PFTs): avoid caffeine before test Bronchoscopy: post-op encourage coughing and deep breathing exercises Laryngoscopy: NPO for 8 hours prior ETCO2, capnography monitoring = measurement of CO2 being expired. Gas Exchange: Normal pH= 7.35-7.45; < 7.35 = acidosis, > 7.45 = alkalosis Normal CO2= 35-45; <35 = alkalosis, > 45 = acidosis Normal HCO3= 22-26; <22 = acidosis, >26= alkalosis CO2 = respiratory HCO3 = metabolic Dosage Calculation/Miscellaneous: Nursing process: always assess first before intervention There are 5 mL in 1 teaspoon There are 2.2 lbs per kg. ​Pounds to kilograms: divide by 2.2 ​Kilograms to pounds: multiply by 2.2 Know how to read a 24 hour clock (military time…ex. 2000 hours is 8pm) Fahrenheit to Celsius formula: F = (C x 9/5) + 32…….(9/5 = 1.8 in decimal form) ​Example: convert 38.3 C to F ​F = (38.3 x 9/5) + 32 OR (38.3 x 1.8) + 32 ​F = (68.94) + 32 ​F = 100.94 (round to nearest tenth—100

¿Qué estudia la economía? ; La economía estudia cómo se crean, distribuyen y consumen los recursos, productos y servicios que satisfacen necesidades humanas, tanto materiales como emocionales, buscando justicia social y equilibrio entre clases sociales. ¿Cuál es el principal problema de la planeación económica? ; Aunque puede estar diseñada con proyecciones matemáticas exactas, su impacto en la sociedad suele diferir de lo esperado, generando resultados distintos a los planeados. ¿Qué significa la elección en economía? ; Es la priorización que hacen los consumidores al adquirir bienes o servicios frente a la escasez de riqueza, reflejando decisiones sobre necesidades y recursos limitados. ¿Qué ocurre cuando la economía no distribuye adecuadamente la riqueza? ; Se genera polarización social, desigualdad de oportunidades y falta de justicia social, lo que profundiza las diferencias entre clases. ¿Qué analiza la microeconomía? ; Estudia relaciones en pequeñas unidades económicas como familias, empresas, clientes y proveedores, observando cómo interactúan en mercados reducidos. ¿Qué analiza la macroeconomía? ; Examina el funcionamiento global de la economía mediante indicadores nacionales e internacionales, considerando países, bloques regionales o el sistema mundial. ¿Qué papel juegan las necesidades humanas en la economía? ; Son el motor que impulsa la producción y distribución de bienes y servicios, ya que determinan qué recursos se requieren para actividades o estados emocionales. ¿Qué diferencia existe entre necesidades tangibles e intangibles? ; Las tangibles son materiales como comida o vivienda, mientras que las intangibles son emocionales o sociales, como seguridad o pertenencia. ¿Qué relación existe entre economía y justicia social? ; La economía busca distribuir riqueza y servicios; cuando falla, se rompe la igualdad de oportunidades y se debilita la cohesión social. ¿Qué porcentaje de mexicanos vivía en pobreza en 2016 según CONEVAL? ; El 43.6% (53.4 millones de personas), mientras que 7.6% (9.4 millones) estaban en pobreza extrema, mostrando una gran desigualdad estructural. ¿Cuáles son los agentes económicos? ; Son las familias, las empresas y el Estado, responsables de decidir el destino de la riqueza y de participar en el intercambio de bienes y servicios. ¿Qué es el flujo de capital en economías abiertas? ; Es el movimiento de dinero entre agentes económicos, donde el gasto de uno se convierte en ingreso de otro, permitiendo acumulación de riqueza. ¿Cómo se mide el crecimiento de un país? ; A través del Producto Interno Bruto (PIB), que refleja la riqueza generada en un periodo por productos y servicios de la economía formal. ¿Qué diferencia hay entre PIB nominal y PIB real? ; El nominal usa precios vigentes del periodo, mientras que el real ajusta por inflación, tipo de cambio y variaciones en hidrocarburos o dólar. ¿Qué es el PIB per cápita? ; Es el resultado de dividir el PIB total entre la población, mostrando el ingreso promedio por persona. ¿Cómo define Henry Pratt la pobreza? ; Como una situación relativa donde el nivel de vida está por debajo del estándar de la comunidad, generando miseria al faltar bienes y servicios básicos. ¿Qué representa la vivienda en el entorno socioeconómico? ; Más que un espacio físico, refleja estatus, capacidad económica y acceso a servicios, además de seguridad y pertenencia. ¿Qué es el trabajo formal en México? ; Una actividad remunerada con prestaciones legales como seguro social, vacaciones, aguinaldo y reparto de utilidades. ¿Qué caracteriza a la economía informal? ; Carece de contratos, prestaciones y pago de impuestos, aunque representa una gran parte del empleo en México. ¿Qué es un indicador económico? ; Es un dato que auxilia el análisis de la economía, mostrando tendencias y resultados en producción, ingreso, gasto y precios. ¿Qué mide el Índice Nacional de Precios al Consumidor (INPC)? ; La variación de precios de productos básicos en periodos determinados, reflejando inflación y poder adquisitivo. ¿Qué mide la tasa de desempleo? ; El porcentaje de la población económicamente activa sin empleo, calculado mensualmente. ¿Qué es la balanza de pagos? ; La comparación entre el dinero que un país gasta y el que recibe, reflejando su posición en comercio internacional. ¿Qué mide el Índice de Precios y Cotizaciones (IPC)? ; El rendimiento de acciones empresariales en un día bursátil, mostrando confianza y dinamismo del mercado financiero. ¿Qué es la producción en economía? ; La generación de bienes o servicios para satisfacer necesidades, buscando eficiencia y reducción de costos sin sacrificar calidad. ¿Qué es el ingreso per cápita? ; El promedio de ingresos de una población, útil para medir bienestar económico y capacidad de consumo. ¿Qué diferencia hay entre gasto corriente y gasto de inversión del Estado? ; El corriente cubre salarios y funcionamiento gubernamental, mientras que el de inversión crea infraestructura y bienes que generan otros bienes. ¿Qué es la inflación? ; El aumento sostenido de precios en un periodo, calculado comparando precios actuales con anteriores. ¿Qué mide el Índice Nacional de Precios al Productor (INPP)? ; Las variaciones en el costo de materias primas, afectadas por oferta, demanda y escasez. ¿Qué sectores componen la economía? ; Primario (materias primas), secundario (industria) y terciario (servicios), cada uno con funciones específicas. ¿Qué actividades integran el sector primario? ; Agricultura, ganadería, pesca y silvicultura, todas enfocadas en obtener recursos naturales. ¿Qué diferencia hay entre ganadería extensiva e intensiva? ; La extensiva usa grandes extensiones de tierra, mientras que la intensiva emplea espacios reducidos como corrales. ¿Qué caracteriza al sector secundario? ; Transforma recursos naturales en productos intermedios o terminados, incluyendo industrias extractivas y de transformación. ¿Qué son los bienes de capital? ; Máquinas y herramientas que permiten transformar recursos naturales en productos, fundamentales para la industria. ¿Qué actividades integran el sector terciario? ; Comercio, transporte, servicios financieros, educativos, de salud, culturales y gubernamentales, entre otros. ¿Qué relación existe entre sectores y tipos de sociedad? ; Sociedad tradicional → sector primario; sociedad industrial → sector secundario; sociedad moderna → sector terciario. ¿Qué fue el Milagro Mexicano? ; Un periodo de 1940 a 1967 con gran crecimiento económico, apoyado en sustitución de importaciones y explotación petrolera. ¿Qué fue el Modelo Estabilizador? ; Política económica de México de 1954 a 1968 que acumuló riqueza en industriales, aumentando desigualdad y provocando movimientos sociales. ¿Qué fue el Modelo de Desarrollo Compartido? ; Fue la política económica de México de 1970 a 1982, que buscó impulsar industria petrolera y agricultura, pero fracasó, aumentando inflación y déficit. ¿Cómo se mide el desarrollo de un país? ; Por el desempeño de su industria, reflejado en inversión, empleo digno y pago de impuestos. ¿Qué políticas industriales son necesarias? ; Leyes contra monopolios y abusos, infraestructura adecuada, estímulos fiscales y fomento de inversión responsable. ¿Qué fue la política industrial durante la sustitución de importaciones? ; Política que protegió productos nacionales frente a extranjeros, con fuerte intervención estatal en empresas paraestatales. ¿Qué significó el neoliberalismo en México? ; Reducir la intervención estatal, abrirse a la globalización y competir internacionalmente, iniciado en 1982 con Miguel de la Madrid. ¿Qué problemas enfrenta la política industrial mexicana? ; Bajo desarrollo científico, desigualdad en riqueza, corrupción, dependencia de tratados internacionales y falta de infraestructura. ¿Qué es la regionalización funcional de México? ; Clasificación en cinco grupos (SUR, SUBSUR, CAS, Cisbau y Cisbar) según tamaño poblacional y capacidad productiva. ¿Qué importancia tienen los tratados comerciales internacionales para México? ; Los tratados comerciales, como el TLCAN firmado en 1994, han sido fundamentales para insertar a México en la globalización. Estos acuerdos permiten competir con países más desarrollados, abrir mercados y atraer inversión extranjera, aunque también generan retos como la presión sobre la industria nacional, la necesidad de mejorar productividad y la exposición a crisis internacionales. ¿Por qué las MIPYMES son consideradas el motor de la economía mexicana? ; Porque representan la mayoría de los establecimientos (94.9%), generan empleo, sostienen la economía local y aportan valor agregado. Aunque suelen tener limitaciones en financiamiento y tecnología, su papel es crucial para la estabilidad social y económica, ya que permiten que comunidades pequeñas participen en el desarrollo económico. ¿Qué factores explican las diferencias en el desarrollo regional de México? ; Las diferencias se deben a condiciones de infraestructura, clima, suelo y densidad poblacional. Algunas regiones tienen ventajas naturales y sociales que favorecen la industria, mientras otras enfrentan rezagos históricos. Por ello, las políticas de desarrollo deben adaptarse a cada región, reconociendo que no existe un modelo único para todo el país. ¿Qué necesita una economía para crecer? ; Requiere producción y empleo, ya que las sociedades demandan bienes de consumo y la producción transforma recursos en productos aptos para satisfacer necesidades, mientras el empleo garantiza ingresos y dinamiza el mercado. ¿Qué son los factores productivos? ; Son los recursos mediante los cuales se crean bienes de consumo. Se dividen en tierra (recursos naturales), trabajo (esfuerzo físico o mental) y capital (infraestructura y conocimiento humano). ¿Qué incluye el factor tierra? ; Incluye recursos hidráulicos, agropecuarios y mineros, todos provenientes de la naturaleza y esenciales para la producción. ¿Qué es el trabajo como factor productivo? ; Es el gasto de energía física o mental que realizan las personas para producir bienes de consumo, siendo indispensable para cualquier proceso económico. ¿Qué diferencia hay entre capital físico y capital humano? ; El físico son herramientas, infraestructura e insumos; el humano es el conocimiento y organización que permite coordinar los demás factores productivos. ¿Qué es la productividad? ; Es la cantidad de productos terminados en un periodo, considerando tiempo, costos y personal. Refleja eficiencia en el uso de recursos. ¿Cómo se calcula la productividad? ; Dividiendo las piezas producidas entre el total del dinero invertido, pudiendo medirse por hora, día, semana o año. ¿Qué es el costo unitario? ; Es el resultado de dividir el total invertido entre las unidades producidas, mostrando cuánto cuesta fabricar cada producto. ¿Qué diferencia hay entre eficiencia y eficacia en empresas? ; La eficiencia es producir lo deseado, mientras que la eficacia es disponer de lo necesario para lograrlo. Ambas son claves para obtener beneficios. ¿Cómo se clasifican las empresas según su capital? ; En públicas (del Estado), privadas (de particulares), mixtas (combinadas) y de autogestión (cooperativas de trabajadores). ¿Qué caracteriza a las empresas públicas? ; Su capital pertenece al Estado y buscan satisfacer necesidades sociales, aunque a veces operen con pérdidas justificadas por su función. ¿Qué caracteriza a las empresas privadas? ; Su capital es de particulares, buscan beneficios propios y pueden recibir apoyo estatal en crisis mediante estímulos fiscales o créditos. ¿Qué caracteriza a las empresas mixtas? ; Combinan inversión pública y privada, compartiendo beneficios y riesgos entre gobierno y particulares. ¿Qué caracteriza a las empresas de autogestión? ; Son cooperativas donde capital y beneficios pertenecen a los trabajadores, fomentando participación directa. ¿Qué es la globalización? ; Es el proceso de interdependencia económica, política, cultural y social entre países, intensificado por medios de comunicación. ¿Qué fue el Estado Benefactor según Keynes? ; Una respuesta a la crisis de 1929, donde el Estado debía intervenir directamente en la economía, aumentar dinero circulante, invertir en obra pública y fijar precios y salarios. ¿Qué es el neoliberalismo? ; Modelo surgido en los años setenta que reduce la intervención estatal, deja la creación de empleos al capital privado y disminuye gasto social, generando pobreza como costo social. ¿Qué papel tienen los programas asistenciales en México? ; Buscan reducir desigualdad y brindar oportunidades, aunque con recursos limitados que no alcanzan a cubrir todas las necesidades nacionales. ¿Qué es el mercado en economía? ; No es un lugar físico, sino un mecanismo de intercambio de bienes y servicios regulado por oferta y demanda. ¿Qué es la oferta? ; Es la cantidad de productos o servicios que los productores ponen a la venta en el mercado. ¿Qué es la demanda? ; Es la cantidad de productos o servicios que los consumidores desean adquirir para satisfacer sus necesidades. ¿Qué ocurre cuando hay excedentes de oferta o demanda? ; Se generan variaciones en los precios, por lo que se busca alcanzar el equilibrio de mercado. ¿Qué es el equilibrio de mercado? ; Es el punto donde la cantidad ofrecida por productores coincide con la cantidad demandada por consumidores. ¿Qué es la competencia perfecta? ; Situación donde existen muchos proveedores de un producto, lo que tiende a disminuir los precios y beneficiar al consumidor. ¿Qué es un monopolio? ; Cuando solo existe un proveedor de un producto o servicio, lo que eleva precios y limita opciones. ¿Qué es un oligopolio? ; Cuando pocos productores dominan el mercado, limitando opciones y afectando precios. Puede ser concentrado, diferenciado o mixto. ¿Cuál es la finalidad principal de las empresas? ; Obtener ganancias mediante la venta de productos, pero también satisfacer necesidades de consumidores y generar riqueza nacional. ¿Qué beneficios sociales generan las empresas además de salarios? ; Pagan impuestos, invierten en infraestructura y servicios, y generan empleos directos e indirectos que dinamizan la economía. ¿Qué son los empleos indirectos? ; Son negocios pequeños que surgen alrededor de grandes empresas, como tiendas, talleres o puestos de comida. ¿Qué papel juega la educación en el desarrollo económico? ; A mayor preparación académica, mayores posibilidades de obtener empleos mejor pagados, aunque la educación escolarizada ya no garantiza movilidad social. ¿Qué son las empresas sustentables? ; Son aquellas que producen sin comprometer recursos humanos y naturales, buscando equilibrio entre crecimiento económico y cuidado ambiental. ¿Por qué es importante la inversión en energías limpias? ; Porque permite que empresas y población mantengan producción sin deteriorar el medio ambiente, asegurando sostenibilidad futura. ¿Qué relación existe entre inversión empresarial y bienestar social? ; La inversión genera empleos, infraestructura y servicios, aunque las ganancias suelen beneficiar más a inversionistas que a trabajadores. ¿Qué es la autarquía o auto sostenimiento? ; Es la idea de producir todo internamente, pero sin bienes de capital ni tecnología adecuada los productos resultan de mala calidad e insuficientes. ¿Qué factores impiden el crecimiento económico en México? ; Malas decisiones políticas, ausencia de leyes de distribución de riqueza, deuda externa, exceso de asistencia social, baja ética laboral, deficiencia educativa y mala inversión en infraestructura, agua y energía

If you often wake up after 3 a.m., beware of these 4 conditions (5)

medication and use Calcium + Vitamin D – Bone strength / prevent osteoporosis Ipratropium–Albuterol (Duoneb) – Opens airways for breathing (COPD/asthma) Pantoprazole (Protonix) – Reduces stomach acid / GERD Baclofen – Muscle relaxer (spasms) Senna – Stimulant laxative (constipation) Ascorbic Acid (Vitamin C) – Supplement / wound healing support Potassium Chloride – Replaces low potassiumia im m N kJqz Furosemide (Lasix) – Diuretic; removes excess fluid (heart failure/edema) Thiamine (Vitamin B1) – Prevent/treat deficiency (often in malnutrition/alcohol use) Apixaban (Eliquis) – Blood thinner (prevents clots/stroke) Folic Acid – Vitamin supplement (red blood cell production) Levothyroxine – Thyroid hormone replacement (hypothyroidism) Magnesium Oxide – Magnesium supplement / helps constipation Milk of Magnesia – Laxative / antacid Bisacodyl (Dulcolax) – Stimulant laxative Melatonin – Sleep aid Ferrous Sulfate (Iron) – Treat/prevent anemia Multivitamin – General nutritional support Acetaminophen (Tylenol) – Pain / fever relief Trelegy Ellipta – Long-term inhaler for COPD/asthma control Docusate (Colace) – Stool softener Metoprolol Tartrate – Lowers heart rate/BP; heart protection Gabapentin – Nerve pain / sometimes seizures Lactulose – Laxative; also lowers ammonia (liver disease) Tamsulosin (Flomax) – Improves urination (enlarged prostate)

12.2 Der Osten

Events/Ideas that Changed the World Notes Day 1 What is a dictatorship? Origins: Dictatura, ancient Roman term, wasn’t originally negative, it was just a title, Caesar went by it. What it meant was that the republican senate in rome determined there was a threat to the social order, they would elect a dictator. We need to give someone total power for six months to protect the country from whatever threat. They would choose two guys, and then choose a dictator from them. That dictator would establish order, then step down. The dictator was given extralegal powers, they couldn’t change laws, but they didn’t have to, because they could do whatever they wanted for six months. It did work for awhile, but what happens if someone decides not to leave? Caesar was elected dictator, but never left, until he was murdered. After that, they started to rethink the whole system. Tyrant and Despot also used to be neutral terms. They were just court titles. It was a term for someone that had power in a local area, but gained that power in an unusual way, usually through buying it. Later, they become synonymous with illegitimate rule. Day 2 Notes Dictatorship wasn’t originally considered a negative term. You were called a Despot, which was also a neutral term. Hobbes was a believer in dictatorship, using the countries around them as evidence that they needed a monarch; they couldn’t do whatever they wanted, although they basically could, because removing them was near impossible. The logic with electing a dictator temporarily was that they assumed the public would turn against them once it was time to leave, and they would fold under public pressure. Once Caesar came in, he pretended the emergency was still going on, and he swayed the public vote in favour of him. In the 18th/19th century, tyranny and despotism started to be synonymous with power being exercised illegitimately. French Revolution, revolutionary dictatorship to achieve the social equality you need. We will force you to be free. Napoleon makes himself dictator of France, temporarily, and then makes himself emperor of France. Switch definition of what public support means, such as making nonaggress the enemy. Karl Marx wanted to overthrow the capitalist system by overthrowing the dictatorship. Vladimir Lenin took power of Russia in 1917 through a violent revolution against a long standing monarchy. They openly refer to themselves as dictators at first, saying that they need to eliminate enemies, or it will allow the enemies to come back. Post WW1: positive use of dictatorship declines, even in the Soviet Union. Mussolini seized power in 1922, establishing a Fascist state. Dictatorship starts to become a negative term. Mussolini used the term Totalitarianism, he adopted the term as positive. He wanted to neutralize the masses to preserve power and social order. Day 3 Notes Cult of Personality Non necessary element of dictatorships. Legitimize the leader. Legitimize an ideology by identifying it with said leader. Establish the leader as both above normal human concerns and as the fatherly protector of the people. Manipulation of mass media. They establish the leader as above normal human concerns, but also the fatherly protector of the people. Triumph of the Will, 1935 documentary, an account of the Nazi party. It’s an example of propaganda from the nazi party. Day 4 Notes Italy was divided into various city states, kingdoms, and other empires, for centuries. Italy was mostly unified as one country by 1861. The pope was basically the head of the country at this point. They especially welded power over Rome. The vast majority of Italians then and now are Catholics. They didn’t believe the people were ready to govern themselves, or vote, they believed in a monarchy, just not a dictatorship. The Ethiopian Army destroyed the Italians in their war, which destroyed the narrative that the black people needed help to be governed, given that they destroyed the Italians. A narrative develops that the liberals were at fault for Italy losing, creating a desire for a new leader. Enter Mussolini, he was a militant socialist advocating violence (propaganda of the deed). Was arrested many times, he was influenced by Nietzsche, Filppo Marinetti. He believed violence was useful and necessary, that it purified people. Ironically, he referred to the military a lot, yet was arrested for avoiding being drafted. He said he would only fight for the working class, not the country. WW1 breaks out, he did serve there. He started a newspaper during this time, and Italy entered the war in 1915, turning on allies Germany, and joining France, Britain, and Russia. Originally, he didn’t support Italy entering the war, but eventually decided he agreed with it. He was a socialist, and socialists didn’t support capitalist centered wars, Mussolini disagreed and expected that they would finally get all the territory Italy deserves back. He’s kicked out of the socialist party for these beliefs. In his newspaper, he starts promoting pro-intervention views. He denounces socialism entirely, and says he was kicked out for promoting violence. Day 5 Notes Fascism in a couple words is fighting in action, that’s what it’s about. It’s difficult to turn into a government. The Fascists originally didn't get as many votes as the National Fascist Party in Italy. Speech in October, march on Rome, if Fascists were not given power, they would take it by force. Day 6 Notes Mussolini's goal was to reestablish the Roman Empire, and wants to go back to a Roman Empire. It’s about obliterating earlier society, replacing corrupt liberal democracy. Mussolini's party murdered a political opponent, named Giacomo Matteotti, who was a socialist and a vocal opposition. He went missing in June, found dead in August. Vatican City, which is the smallest country in the world, smaller than the university. Italy and Mussolini recognized the Pope as a sovereign of an independent nation, which is now Vatican City, it will now be a separate country from Italy, the Pope will control it. Italy will live there, if the Pope agrees to stay out of Italian politics, and be neutral on international affairs unless asked, and all bishops in Italy have to pledge loyalty to the Fascist movement. Italy also paid this new country a big sum of money, they also agreed to teach Catholicism in schools, along with Fascists. This was viewed at the time as a win for Mussolini. Most Catholics saw it as a decent win for the church as well. Mussolini gained popularity as a result. Mussolini is even painted alongside Jesus in some churches in Italy. The Pacificiation of Libya, has since been labelled a genocide. It was meant to crush local resistance to Italian ruling. They used mustard gas on civilians and rebels. Innocent LIbyan citizens died during this. They eventually arrested the resistance leader. By the end of it, the Italians labelled Libya as pacified. Italy still deals with this in today's politics, with the fallout of committing this act to Libya. It seems like there might have been a racial motivation for it. The racial motivation was viewed as Mussolini simply seeing Italians as better than everyone else, Libyans were inferior to Italians, and in their deserved territory. One of the major problems with dictatorships is that you can never get the truth, nobody is going to tell you if there is a problem, out of fear for their lives. He didn’t know how popular Fascism was, and there wasn’t a reliable way to find out. He tries to do things to earn the popular vote, like war, like conquering things. Ethiopia was very symbolic, they had lost to Ethiopia in a previous war, that embarrassed them. So, he decides to get some getback. Mussolini has to be careful, their army can’t take Britain or France, so he has to take Ethiopia without provoking the Europeans, so he bluffs. He lies and says that his troops were attacked by Ethiopian troops, unprovoked. He threatened force to measure the reactions of the other count Day 7 Notes Mussolini was concerned about the lack of enthusiasm about fascism in Italy, He even created an encyclopedia of Fascism. Now that Mussolini has indicated they have relatively similar views with Germany, they form an alliance, there is economic dependence on each other, this is not a popular move, as Italians don’t like Germany. In 1939, they signed the Pact of Steel, this is a military agreement, they agree to attack anyone that attacks them. They continued to invade other countries, for no real reason, it was cheered, but now we were seeing the natural end of Fascism. How can you stick with an ideology that is centered around violence, if you’ve won, what do you do then? Mussolini introduced racially motivated laws called the Defense of the Race in 1938, which was very similar to the laws introduced by the Nazis. It frustrated Italians that he was just doing what Hitler was doing, it’s possible he was trying to center out specific people to explain why things aren’t perfect yet, to distract from his incompetent leadership. In 1940, Italy declared war on Britain and France. Mussolini didn't join the war early on. Poland is getting destroyed by Germany, but on the Western front, it’s quiet for a while. Mussolini changes that, by swooping in to take advantage of Hitlers chaos, who quickly destroys most of Western Europe. Hitler now owns France, Mussolini thinks things look good for Hitler. So, he declares war. His justification was that the Italians were trapped, they needed living space. Sounds very similar to Hitler there. It works, at first. Mussolini tries to expand his African empire. The Italian army was not ready for this, even his war commanders who supported him told him they would lose the war. Mussolini ignored them, insisting Fascism would always win. They start to lose the war, they don’t have the military capable of doing this. It embarrassed Mussolini greatly. His only idea is to continue to expand, but that doesn’t work either. By 1943, the Italians collapsed, and Germany had to come save them. The problem is that Germany is now fighting wars on several fronts, and that proves too much. Hitler is now really angry with Mussolini that he had to come save him. The Allies were counting on Southern Italy not being as supportive of Mussolini, so they invaded there, and the Southern Italians didn’t fight the Allies, simply because they didn’t like Mussolini. That year, Mussolini was voted out by his own Fascist Grand Council as leader. They voted him out on the basis that he was no longer promoting true Fascism, most of the council were his relatives, they still voted him out. Mainland Italy is invaded, and they surrender. This leads to a civil war. Germany is still fighting the Allies in Italy, plus Northern Italy still believes in Fascism, while Southern Italy no longer does. Hitler, while angry with Mussolini, still believes he could be useful, so he decides to liberate him from a castletop prison. THey break in with a helicopter and hand gliders, they kill all the guards, and they get Mussolini. Hitler installed Mussolini as a puppet leader of the Italian Social Republic. Hitler sees him as a useful figurehead so they can claim that Italy is still independent. The Italian Social Republic is not a well run country, and is nothing but revenge plots, Mussolini gets his son in law who voted him out, and executes him in front of his daughter. That’s what Mussolini does for the last years of his life, is take revenge. Day 8 Notes Mussolini was captured in 1945, he and numerous other Fascists were executed right after being captured. Adolf Hitler The Habsburg family led Germany for many years, they controlled various German states. Around when Hitler was born, some of the other German states were controlled by other people, eventually they were unified, the differences were religious in nature. Germany is eventually unified, Austria is left out of the proceedings. In 1867, the conflict was settled, the Hungarians took over the nation, although the other nation states were not happy about this. Hitler was born into a dysfunctional family, his parents died at a young age. Hitler had two siblings, but five siblings died as infants. He was born sick, but he survived. His mother did not work. Even Hitlers name is confusing, his father was born out of wedlock, and the gossip is that Hitler might've actually been jewish. We don’t know who his grandfather was. His step siblings ditched the abuse after their parents died, so he has to raise his sister. He did not get into the Academy of Graphic Arts. He then just works odd jobs in Vienna, sells some paintings, he’s living off the little bit that his father left him, he is often homeless. Vienna is home to many different ideologies. He’s attracted to Pan Germanism, Volkisch nationalism, and antisemitism. Pan Germanism is that the Germans needed all the German states to give them living space so that they could thrive. He sees the Hasbergs as a problem. He hated Catholicism. He blamed them for Austria being left out, and he begins to identify with Germany a lot more than Austria, despite not yet being a German citizen. Day 9 Notes Hitler existed in the military in 1914, he initially refused to serve, but eventually changed his mind. He was blinded by gas in 1918. As he was recovering from this, Germany surrendered. He did have to get special permission, as he was not a citizen. Losing this war, much like with Italy, was a shock to German nationalism. He never drank, and stopped eating meat. He fights a lot, and wins awards for bravery. He really starts to internalize social Darwinism. They believed that the European countries that were winning wars was because nature had determined they were the strongest. The destiny of Germany was to win, but they didn't, they lost. The media was telling the citizens that they had been winning, so it was a shock that they lost. The king, a monarch, abdicates, so monarchy is now gone too. A myth that Germany was stabbed in the back by internal traitors starts, communists, jews, socialists, that’s why Germany lost the war. Hitler becomes a regular in what’s known as beer hall politics. Nobody knows what to do with a lot of the vets that survived the war. So, one thing they do is hire them as military intelligence, as with Hitler. They decide they need to stop political violence. Hitler gets hired to spy on a party, called the German Worker’s Party, but it’s actually a far right party, they call themselves that so they can appeal to the working class. Their goal is to get rid of the Jews so that they can fix capitalism. Hitler joins it, to spy on it. While doing it though, he looks around, and likes some of their ideas, but it’s not extreme enough, they need more. So, Hitler starts speaking on the events, and stops spying on them. Within a couple of years, he is the leader of the group, and they rebrand themselves as the Nazi party. The Nazis are far more willing to commit violence, and are more far right than other groups of that time. He believes it’s about saving not just Germany, but the world. Ernst Rohm led the Storm Troopers. His job was to beat up political rivals, and Hitler eventually got his eye. This political violence works, it scares people into voting for the Nazis. Hitler is also able to say that he is separated from the violence because someone else runs the violent part of things. Hitler is able to stop the violence, he is able to stop Rohm. Day 10 Notes The people in charge of Hitlers trial were Nazi sympathizers, and gave Hitler and Nazis light sentences, while also allowing him to speak at his trial, which gave him ample time to gain fame, it made national news. Hitler is convicted anyway, for five years, but only serves nine months, in a min security prison, and is allowed visitors, where he converts most of the prison to his worldview, and also writes Mein Kempf. Hitler now learns that he can’t use force to win the government, he needs to win them over. Paul von Hindenburg uses the emergency act to be a dictator temporarily after the depression, but uses it several times. He does not believe in democracy. His plan is to stop the left from forming a party and organizing. There are about five elections in 1931, because the left keeps getting elected, but the emergency act is being used to overrule it, though it annoys the German population. However, it was being used as an example of the fact that democracy doesn’t work. The Nazis continued to grow, there were several elections in 1932, where the Nazis got 37 % of the popular vote, the largest single party. This is one of the worst points of depression. After less than a year, Hitler became dictator. Franz von Papen convinced Hindenburg to appoint Hitle chancellor in 1933. Their popularity starts to decline, the only way to get around that is for Hindenburg to hire Hitler, they count on him being a peasant that will be too stupid to do much. Papen will be co chancellor, to watch things, we’ll be able to control him. A fire happened in 1933, historians still don’t know who started it, but it was blamed on a communist conspiracy at the time. The Nazis use this to get more power, they pass the Enabling Act, which gives Hitler a dictatorship. A couple of months later, all non Nazi political parties were removed. In 1934, Hindenburg died, he didn't replace him, he just merged his position with his own, so he gained more power. A significant amount of violence and intimidation happens in his early years. The Night of the Long Knives happens during this time, that is when Hitler killed rivals of the Nazi party, sending out goons later known as the SS, and brutally hundreds of people he believes are challenging him for power. He killed Rohm for being gay, though he had known this since he had met him. In 1939, they opened their first concentration camp. From the first party, it’s usually enemies of the Nazis, communists, the left, starts to include more Jews as it goes. This is justified by saying these people are threats to the government. Day 11 Notes You had to get a racial card, if you had more than 3 jewish relatives, you would not be considered a german citizen. If it was less than that, you would temporarily be a German citizen. This would get restricted even more as time goes on. These regulations consider who you can marry, who can drive cars, everything is regulated. Property is taken away from Jews. If you were gay, or religious, you would be regulated. They also sterilized thousands of people as well. THey gas brought 500 000 people in three years. Hundreds of jews were shot in public merely for being Jews, then the Germans blamed them for property damage, justification for restricting the jews even more. He took Germany out of the League of Nations. That’s what Nazis do, they create conditions that then they can point to and say see, you need us, we need war, it’s being forced upon us. Hitler invades Czechia, but claims he only wants the part that has mostly german speaking people, people on the Allies side don’t believe him, others say that they don’t want to fight a war. So they hammer out an agreement to give him this land, guess who they get to negotiate? Mussolini. Hitler then immediately betrays everybody, takes the land he was given, but then also invades the rest of Czechia. So Hitler is told, if he does anything else, they will go to war. Hitler then invades Poland, Britain and France soon declare war, and WW2 begins. The West is pretty quiet at this time, a different story in the East. We’re at war, even with the total destruction of Poland, the Allies do nothing, they seem to be holding out hope that maybe things can be resolved. The Germans through the 40s took Denmark, Norway, Sweden, Netherlands, France, Belgium. France was one of the strongest empires in the world at the time, and they fell in six weeks, now the Nazis have a monopoly. The Allies are losing by a lot at this point. Nobody seems to be able to stand up to Germany, Hitler is the most powerful man in the world. Some of this was revenge for WW1. Hitler has more power than anybody on earth pretty much, and portrays himself as a Messiah, but he’s not actually very good at this, it’s mostly the military taking advantage. Hitler starts to believe his own hype, and believes that he’s infallible. He starts to execute military leaders that contradict him, creating a bunch of yes-men. Hitler even allowed the Allies to escape at one point when they had him on the run because of a decision made by Hitler. This is causing the empire to crack. Hitler decided in 1941 to invade the Soviet Union. His racial version of the world centers around this, and he’s convinced that they have enough to stop the Russians. They bet it all on one giant hit on the SU, really fast, it’ll take them all out, and then they will own Russia. This was briefly successful at first, but then it’s not. The top reason is that Russia is really big, and it’s cold, the Soviets don’t just collapse, 27 million Soviets die in this war. However, they don’t fold, they retreat, burn everything so the Nazis can’t get supplies, but unlike Hitler, Stalin goes the other direction, he listens to military leaders. Htiler is doubling down on making his own decisions. To the point all the decisions are made by Hitler, which leads to inaction in several areas, they stretch out the Germans supplies and people, and then winter hits. The Germans weren’t prepared for the cold, and they slowed down significantly. The Soviets then join the Allies. So the Soviets get supplies from the Allies, and it helps them as the Germans are now isolated in Russia. America then entered the war in 1941. Japan attacks the States, and so the States have to enter the war, they are a powerhouse. They help the Allies, but the States also give supplies to the Russians against the Nazis. All of a sudden, the advantage in the war has moved to the allies. Day 12 Notes In just two days in 1941, the Nazis shot 33 thousand Jews, in another two day span, 28 thousand, in a couple weeks, 70 thousand. However, the Nazis realize that they are using too much resources, and it comes to light that some of the soldiers are showing signs of guilt, and that needs to be minimized, so they need to come up with a better way. Hitler had permission to come up with a plan, so they went back to what they had been doing to disabled: gas them. They determine they will build extermination camps, the whole point being to kill as many people as possible. They did this by putting gas in showers. It’s estimated roughly 1.1 million people that were deported into Germany were killed. The Germans couldn’t function, they were terribly disorganized. D Day, the Allies decided to attack the Nazis where they were at their strongest. They believed that they had reallocated so many resources to the Eastern front, that the area was weak enough in the West that the Allies could break through, while it was difficult, they were correct. Hitler refused to believe that the Allies could break through the West, so even though he was warned, he ignored the warnings. From this point, everyone knows the Nazis will lose eventually. In 1944, there was an assanation attempt on Hitler. A group of military elites and citizens were banded together to try and kill Hitler, a pretty diverse group of people that had different motivations for why they wanted Hitler dead. Some for moral reasons, for most of them, were afraid of what Hitler was going to do to the country, thinking he was a madman. If they got rid of them, they could surrender and get peace. Some had been active members in getting rid of Jews, they agreed with his mindset, but believe he specifically is a madman. Their plan involves a meeting that is approaching for military leaders, one of them was going to bring two bombs, and place them next to Hitler, who would blow up. They would then claim someone inside of the Nazi government had killed him, they would arrest everybody, and establish a new government. One of the bombs doesn’t work, he can only arm one. He places it next to Hitler, someone by chance moves it a little bit, and when it explodes, it explodes a table. Anyone involved, and their families, are executed. Several thousand are killed in the next few days, as he believes the hype that he’s a god even more. Hitler then orders the Battle of the Bulge, against advice, and it fails. He believed he could hit the Allies once, and they would get defeated, which of course doesn’t happen. The Western front has collapsed. The Red Army has pushed the Nazis back to Poland. They keep getting to the areas quicker and quicker, for the first time, the Russians find the concentration camps, and share the information with the world, they didn’t know this. Some believe the Russians even made it up. Hitler keeps demanding more deaths, starves thousands in the Netherlands, orders half a million deaths in Hungary, and he starts realizing that the walls are closing in on him. He’s about to lose. The Allies had debated whether they should invade Berlin, in 45, they decided that they needed to kill him, otherwise the war would never end, so they decided to go all out on Berlin, which they did. They destroy Berlin. Hitler lived the rest of his days in an underground bunker, Hitler had said that if he died, he would take the Germans with him. So, Hitler stayed in Berlin. Day 13 Notes Germany is slowly encircled, Hitler is all powerful, but he has no counter strategy. Berlin is under attack, and Hitler refuses all concessions. he then commits suicide, with a will and a last dictate left behind him. Germany surrenders a week after he dies. He appointed a heir to his dictatorship, and Hitler also married his girlfriend a few hours before they both commited suicide. The war still is going on, because Japan does not surrender. Hitler did try to make a deal to get away from the Allies, they of course refused. Joseph Stalin Under the Tsarist government, the Russian Empire was one of the major powers of Europe for centuries. The majority of the country were serfs. The dictator of the nation was called a Tsar, this idea was taken from what Caesar was called. Serfs were not technically considered slaves, though they had a similar role to one. They had no personhood, and were legally considered property. They were technically considered people, they had some rights, but very few. They were peasants, tied to the land forever. They owed their allegiance to the local princes, usually a rich family in the area that reported to the tsar. Almost none of the population went to high school, especially peasants. Stalin was a peasant, but he did go to hs for about a year. Most of the population was completely illiterate. Things started to change in the 19th century, new ideas started to come into Europe, and Alexander the second freed the serfs, technically, with a lot of qualifications. Stalin was raised poor, but in the school he was able to attend, he thrived. He rather suddenly converted to socialism in 1896. He became a professional revolutionary, one that got arrested frequently. Once he converts to socialism, he is kicked out of the seminary he was a part of, and eventually joins a Socialist Party. Day 14 Notes Stalin was arrested for trying to organize a strike in a factory in Georgia. Marxism is a pretty complicated set of ideas. Marxists believe history has a beginning, middle, and end, these stages are defined by the economic stages of the time. Marxists believe these are the laws of history, these ideas are widely criticized, especially for the idea history is predictable, it’s scientific. History will evolve until we reach the final class conflict, the ones that own the means of production, and then everyone else. Marxist believe work is essential to who we are as people, class consciousness is when people are tricked into believing that they have to work and not knowing that work should define who they are. Religion dulls the senses and makes you easier to control. The Su was a little bit different from the Nazis in that they claimed that they accidentally persecuted the Jews, not for their race specifically. Whereas the Jews were specifically targeted and that was made obvious by the Nazis. First, a Social Democratic Workers Party was started, in 1898. Russia needed to develop to be ready for revolution. Then, three years later, the Socialist Revolutionary Party was started, they needed land reform. It was labelled at the time as a party split, as the Social Democratic party was split on how to handle the situation. Russia lost the Russo-Japan war just four years later, Russia lost. This is a disaster, for obvious reasons, but it was also an embarrassment. There’s also racism involved, how could Russia lose to a non-European country? It signaled to many that Russia was collapsing. Workers started going on strike, over 100,000 workers, a couple of years later, which grinds the country's production to a halt. Then a bread march led to a czar's house, demanding food, the Russian soldiers came out, killing hundreds and wounding thousands. The czar started to break, allowing a very restricted vote, which temporarily kept people at bay. However, he reverted those policies a couple of years later. The socialist parties, all of them, pulled out of working with the czar entirely. This emboldened radicals, including Stalin. In 1912, Stalin was part of the two parties officially splitting. He was arrested for sedition in 1913, and this time, the authorities sentenced him to exile in the Arctic, this is his first real punishment. He’s stuck there when WW1 breaks out a year later. His party publicly advocates for Russia to lose the war, because that party believes it’s the inevitable result of capitalism, so if you destroy them, it would lead to communism being enforced. So, the party sabotages their own country. Russia, for more than one reason, handles the war really poorly. The Tsar says that they are getting involved to protect the Slavs peoples, which was a race. They lost the Battle of Tannenberg to the Germans badly. In 1917, the Tsar was overthrown, the family had run Russia for three centuries, but Russia is getting dominated by Germany. In his place, a provisional government takes over, there is no vote. So, a coalition of the two parties and several others are all formed to form a government in Russia. At the same time, in the major cities, groups called Soviets, or a Workers Council, are rising, and organizing the cities. They become strong locations of authority that counters the provisional government. Day 15 Notes The new party promised peace immediately, and delivered, this made them popular. They promised war would end. They threw the only real election in Russian history at this time. They lost the election really badly. They believe the election was tainted somehow. After this party signs a peace treaty with Germany, it pulls them out of the war, but they seize a significant amount of land. Giving up the land was not popular. Russia then breaks into a civil war, with three sides, the communist, the red side, very well organized. The whites, they are a loose grouping of anti communists. The greens were really effective, they were the socialist revolutionaries, the reds are afraid of the greens, they are powerful, but the whites kill them because they don’t like communists, then the reads finished them off. Russia becomes a Communist state, with Stalin being a background member of the party. They hold farce elections at this point, where there are several communist from the same party to choose from, but you pick the same party no matter what. Stalin was named General Secretary by Lenin in 1922. He parlays this position to gain further power. The leadership of the party notices that Stalin is growing more power. Vlad Lenin releases a document on his death called the Testament where he warns his party of the threat Stalin presents. He asked the party to think of a way to get rid of Stalin. His testament is debated, but Stalin stays in power. Against the wishes of Lenin and his widow, they embalm his body to hold it for display to the party. Stalin survives the vote, and decides he can outmanuever everybody. He does this by continuing a cycle of forming alliances, breaking them with another alliance, breaking that one, and so on. Stalin is part of a trio that is leading the Socialist party. They align themselves against Trotsky's ideas of permanent revolution to save the world. He was outed by the trio. The trio's idea is to let the Western powers weaken themselves, it’s inevitable with a capitalist system, in the meantime, make sure socialism is strong here in Russia first. By outing Trotsky, Stalin gains even more power and influence. Stalin then betrays his two partners of the trio right after. Stalin changes his mind on whether some members of his party, including his partners, aren’t really spies, or not dedicated enough, to what is now known as Marxism-Lenism. He fosters distrust in those members of the party. Despite it being counterintuitive, Stalin makes friends with the capitalists of the party, and uses that alliance to vote out the two members of the trio, even having them killed and/or expelled from the country. He’s now the only one left from the last era, and the undisputed leader. Day 16 Notes Stalin plans now to abolish private property. Everything is owned by the state. This is being done to provide food to other cities, and the SU starts building industrial cities. Stalin is building, or rearming Russia. They had gone through a lot, and he was getting fresh war material. They are planning on going to war with the capitalist countries eventually. They call it the five year plan. Stalin blames most of the problems on peasants who had been successful during this dark time for Russia. A key part of this period was to remove the peasants as a problem, by murdering them all. So, there are mass killings of anybody that identifies with that system. Stalin, by 1929, was a full dictator, he got rid of all challengers. It’s widely debated on whether this actually worked, within a decade, they had collectivised almost everything. Production, however, went down. This caused a massive famine that spread across the whole US, leading to millions of deaths. It’s debated over whether Stalin targeted specific people groups with the famine. Stalin's wife kills herself because of her husband being responsible for this. Stalin blames the failures of the system on the industrial production people in charge, killing them. Stalin also imprisoned millions of people in labour camps. One of the consequences of purging the people is that Stalin can make the people more dependent on him, so he appoints puppet leaders. They introduced a new Constitution in 1936, however, it made little change. All of the culture was still very traditional, criminalizing abortion, limiting divorce rights. This was called the Depression. Stalin knew SU was not ready for a WW in the 30’s. He attempted to ally with the Western powers, but that didn’t work, he tried again with Germany, but that also didn’t work. Enter the Spanish Civil War. Stalin thinks that if he waits for the capitalist countries to go to war, he can wait and then come in and wipe them all out. The Nazis offered the SU good terms for an alliance. However, they didn’ count on the Nazis trying to promote racial conquest. SU fought Finland in the Winter War in 1939, the SU didn't start off very well, despite outnumbering the Fins. The Fins start off well because they have a good strategy. Stalin actually took Finland to defend against Germany, even though they were allies. Eventually, SU overwhelmed Finland. Day 17 Notes Nazis invaded the USSR in 1941. Early disaster for the SU, German forces are halted outside of Moscow. Stalin goes into hiding, for weeks on end after the Nazis invade. Both sides wipe out whole populations, with nobody being safe. Stalin rallies, as he creates more positions for himself to fill. The difference between Stalin and Hitler was charisma, with the exception being a famous speech in 1941 to motivate his soldiers. Women fight in the Soviet Union, unique for those times. The Germans make it all the way to Moscow, then are stopped. In the West of the Soviet Union, it’s a blood bath, and the Final Solution begins. Everybody is wiped out. When territory would be invaded, you would have to decide whether you would ally with the Nazis or with the Soviet Union. The SU refuses to retreat from Moscow, and it works. stalin from this point starts to delegate and not just do all of it himself. He allows the military experts to do what they do. Gregory Zhukov leads the military effort against the Nazis and turns the tables. They also get a significant amount of money, before America gets in the war, they don’t want to get involved in the war. The Soviets, unlike the Allies, are willing to sacrifice their people to win. Stalin starts to relent on things like religion, as well as delegating. However, Stalin, due to believed disloyality, orders his daughter in law arrested and murdered, killed his brother in law, and their wife, and Stalin's son was captured as a POW, and he allowed his son to die. From this, Stalin became a world leader in the big state. They were willing to ally with the Soviets despite disagreeing with him because of the threat the Nazis faced. The Soviets held the Nazis off long enough that the other countries realized the threat the Nazis faced, and they acted. Poland is stuck between Germany and Russia. So, they are sacrificed. Stalin goes to the Allies, and says that he needs help, he’s been fighting the Nazis by himself. He believes the Allies should attack the West so weaken Germany, which eventually happens and he is correct. This adds to Stalin's credibility. Because they are capitalists, Stalin believes that the Allies will negotiate with Hitler as soon as they can sell out the Soviets. So, he pushed the Red Army to aggressively pursue Hither, the Allies were also racing there for a different reason, they didn’t want to give a lot of the land to the Russians. Stalin encouraged his soldiers to rape Germans, and to kill as many citizens as possible. It didn't matter if they were Nazis or not. They also start to liberate concentration camps. The war ends, the Soviets are now a superpower. The reason for the Cold War starting is heavily debated, who started it? Was it Americans, or Russians? Could it have been stopped? The Soviet Union was scared of being invaded again, given recent history. However, the SU are now more powerful than after WW1, they are now in the Security Council and the United Nations. Stalin says that he wants Poland to be free, but friendly to the SU. That’s not what happens. The elections that do happen are not free or fair. Stalin does not trust former allies. In 1947, the United States agreed to the Marshall Plan, this is a generous infusion of American dollars, billions, into Europe, to help it recover from the war, with almost no strings attached. Stalin doesn’t trust it. He’s suspicious of those that participated in the war coming back to the Soviet Union, he worries his people have been Westernized. Stalin is angry at the donations, he believes Communism is being destroyed. He refuses the marshall plan, and forces various countries in the East to refuse it too. He threatens invasion. Day 18 Notes The Marshall Plan was made in part to stop eastern countries from becoming communist. The tensions in the Cold war ramp up. The Soviets stop food from going into Berlin if it’s not given to them by the West. The West ignored the demands, flew over the blockade that the Soviets had set up, and delivered food. The Soviets are still somewhat in a position of weakness, not as strong as the US, so they back down. Stalin is at his most powerful, but is more suspicious than ever. He was scared of the different military leaders, as some of them were executed. He believes some of his people that had been in the war had been exposed to the western version of living. He starts having his own family members executed, his daughter escapes, and actually advocates against him Stalin's anti-semitism became stronger during this time as well. Stalin died in March 1953, they had not attended a meeting, so had been scared that he would kill them, so it took several days for anyone to realize he was dead. He had tens of millions of people killed during his reign, de stalinization began almost immediately, although the dictatorship was maintained for decades. Mao Zedong Qing Dynasty Was a Manchu family, a small minority within the massive country of China. However, they are the royal family. This was not well received by most of the country, since Manchus were considered outsiders. Most of China are peasants, Mao comes from a royal family, but his father had been a peasant, and had worked his way up to being a successful farmer, where he hired people. He was rural, but being a land owner at the time was a big deal in China. Mao is outspoken and rebellious, that doesn’t fit into society. His mother is a devout Buddhist, and is illiterate. She had bound her feet for most of her life, which was a tradition that deformed the feet of those that did it. Mao wants to be more than the farmer that his dad is. Day 19 Notes Sino Japanese war is a war that the Japanese won soundly over the Chinese, where the Chinese called it the Century of Darkness. The Chinese were unable to protect land, and were unable to modernize their military. This is when America gets involved, takes over Spain, and wages war against the Filipino population. This was seen as a good step towards China, America has interest in China for economic possibilities. However, America is late in the game, compared to the European powers. They try to negotiate, this doesn’t go well, the negotiation, rather unconvincingly saying that they should negotiate together against the Chinese, without taking them, but we’re not taking them over, just control the whole economy. The Chinese Revolution is next, moderate reforms at first, such as local elected assemblies. Don’t have much power, but the idea is you can give them a place to vent anger. Dr. Sun Yat sen founded the Revolutionary Alliance, he believed in nationalism. He founded a political party as well. Dedicated to overthrowing the monarchy. The Qing dynasty was overthrown, though Mao is not a part of the Revolution. Shikai names himself emperor, and only lasts three days. China started to enter world politics, called Warlordism. China is disintegrated into regional warlords and competing authorities. Remnants of Shikais Beiyang government. Sun Yat-sen returned from exile to the south, re-established the Guomindang, and tried to organize a rival power. May 4th Movement, student led protest against Treaty of Versailles. Left wing radicalism gained in popularity. The treaty was an agreement they had to get stuff back that had been taken from them from Germany, however, it was given to Japan. It was around here when Mao started reading Marx, anything he can get translated. So, the Chinese Communist Party came into play in 1921. To this day, they rule the government in China. Mao was converted to Communism in two years, and was a founding participant. He organizes labour and students. He is concerned about the anti-nationalism parts of it however. Is looked at as a voice of the people because he was well educated while also being a peasant at the same time. It was Guomindang and the CCP worked together to oust the Beiyang government and the warlords. Chiang Kai shek Sun Yat sen died in 1925, succeeded by Kai shek. He was a military leader in the Guomindang, leader of the right wing faction of the party. Keep the United Front, but only for convenience. Mao began to theorize more about the centrality of the peasantry for the achievement of true Chinese Communism. Mobilization of mass peasantry, radical transformation from spontaneous mass action. Day 20 Notes In 1926-28, warlordism was broken, Chiang established a government in Nanjing. Started to purge Communists and leftists in 26. Mao was unsure at this point about supporting the United Front, but stayed the course. The People would decide the revolution, not the United Front. So, the White Terror starts in 1927, Chiang betrays the Communists, slaughtering thousands. Mao and roughly 1000 communists organize the Chinese Red army. Shiang is trying to wipe out the Communist party in one fell swoop. Mao leads his faction to killing thousands of political opponents. Chiang becomes obsessed with wiping out communists, they lose a whole region of China under his rule, and they are forced to negotiate with the Japanese. Only Mao's stronghold was left, and they had to abandon it. So, what do they do? Why don’t we just leave, and walk somewhere else? We need to pick a time period where Chiang is busy, then we can try and escape. The Long March 1934-35, a 6000 mile walk, 18 mountain ranges. Roughly 70,000 people died, one of the reasons for that is that soldiers were following them, any mistakes, they die. Mao consolidated support by acting against Soviet advice. Portrayed the March as moving against Japanese imperialism. Guomindang was weak in face of foreign influence. They can’t fully wipe them out though. There are only 20,000 communists left, yet they are able to rebuild. Mao almost dies on the march. Japan invaded 1937, resulting in GMD-CCP United Front, CCP and Mao proved to be more capable at reaching out to the peasantry, crushing internal opposition and enforcing ruthless discipline centred in Mao's interpretations of Marxism. Red Army forces were often on the frontlines against Japan. Shiang is forced to constantly give concessions to the Japanese, he can’t do anything else, CCP calls him a cronie, he complains that it’s only because he has to deal with the Communists. Shiang is now told he can’t work with the Japanese anymore, they just signed a deal with the Nazis and Fascist Italy. They get tired of Shiang, so his own military kidnaps him. Shiang concedes, and says they will focus on Japan as well now. Day 21 Notes Another new wife for Mao, named Jiang Qing. For WW2, Guonmindang and CCP forces forced a stalemate on Japan. The Red Army cultivated grassroots support in occupied China. Guomindang is not in occupied China and continues in corruption and even sometimes its anti CCP actions. Mao Zedong Thought: Became the official ideology of the CCP, Rectification Movement, and self criticism to save people from error. Mao used the fact that Sheng needed help to take over. One of the reasons Japan lost is due to the violence they were inflicting, they were unable to gain allies. Part of it too is Shiang tries to force people into joining his army, his government is also super corrupt. IN this period, the SU is dealing with something else, which helps Mao. Japan and Germany had terrible communication with each other, in part because Hitler didn’t want to communicate with them, because he thought they were lesser. For Pearl Harbour, for example, Germany didn’t advise Japan on that. China was viewed as the fourth of the big three, and was underestimated. Not consulted on the plan to bomb Japan by the Allies, the Allies also didn’t trust Sheng's government. They didn’t understand the GMD CCP hatred, didn’t understand the appeal of the CCp in China, and didn’t see China as an issue in the postwar era. Mao agreed to American backed negotiations for a coalition government. Mao and Sheng are actively trying to backstab each other at this time. The United Nations were formed in October 1945, General Assembly, one nation, one vote, where most of the big stuff happens. Security Council: 5 permanent, 6 rotating members, China was one of the 5 permanent members, Chiang's Republic of China would hold this seat until 1971. Another Civil War breaks out between CCP and GMD forces. Mao ordered strategic retreat into the countryside and abandonment, which had been going on for almost 40 years at this point. Mao knew the longer the war went, it would be worse for GMD. GMD corruption, reliance on conscription, reliance on foreign money. They rely on the people's support, and have far more discipline. They outsmart Shiang's army. CCP now occupied Beijing, Nanjing, and Shanghai. Chiang fled to Taiwan, with men, civilians, and money. They are still the Republic of China. Mao declared the People's Republic of China, there are now technically two Chinas. Day 22 Notes Korean War Communist North Korea invaded Western allied South Korea, prompting a United Nations backed, US led force. Mao was pressured into involvement by North Korean weakness and US strength. China lost 500k troops, stood against the USs, who now was committed to permanently protect Taiwan. The economy was militarized. Eventually, China gets pulled in, North Korea gets pretty far, but the US forces push the North Koreans back. The US forces were told not to cross a border line so as to not provoke the Chinese, the men didn’t listen, and the Chinese entered the war. War ends in a stalemate, with little to no territory changing hands. Mao commits to building a massive bomb, and announces a five year plan. To collectivize agriculture to support the military and industrialization. Thousands were executed in a two year span. America decides that Taiwan needs to be defended, which sends a massive fleet to protect them from China, the forces are still there. Taiwan at this time was run by Shiang's government. China and Taiwan are often still considered the same, much to the chagrin of people from Taiwan. They launch the Hundred Flowers Campaign. The Chinese people are too afraid to criticize Mao because he was in power, so he’s willing to criticize himself, then they are willing to criticize him. He encourages this feedback. A few months later, he kills them all. He was trying to make the enemies of the people clear. It led to the greatest famine in human history, killing at least 34 million people. Any suffering was covered up. Mao fails to take responsibility for this famine. Mao is so determined to prove himself right he exports grain to the Soviet Union to impress them, leading to more deaths. The alternative to Stalin's communism is Mao's, which isn’t anything better. Maos has a book on how to fight imperialists, which enables people around the world to model themselves after Mao. Soviets don’t like this. The two of them finally realize that the two countries need to learn how to live together, Mao looks down upon the Soviets for backing off of Stalin's approach. Mao also believes they are trying to isolate China. They broke diplomatic relations in 1961, that was the case for about 25 years, almost going to war multiple times. Mao retreated from the public eye, and focused on developing a cult of personality. He realizes that his rule has been a disaster, but he needs a scapegoat. So, he allows two other people to clean up the mess, to enact some reforms to help the people recover. They were similar to Stalin, allowed some private property, didn't take their food, etc. He allows this so that he can blame them later for China being poorly run. A key part of this cult of personality is the little red book. It’s been printed hundreds of millions of times, it’s actually known as Quotations of Mao, literally just quotes of wisdom from Mao that spread his cult of personality. In 1964, China tested its first bomb. This changes how the West sees China, gaining them respect out of fear. Day 23 Notes Mao is being convinced that the Revolution is being corrupted from within. Starting in 1966, Chinese society was purified of bourgeois intellectualism. Empowered youth to murder authority figures. Mao thought the SU had lost its way and condemned Stalin's legacy, he believed the Communist Party didn’t care about the Revolution anymore, just staying in power. He didn’t want this to happen in China. The Chinese had really struggled, but Mao blaming himself wasn’t an option, so he advertised that the Revolution was being corrupted. May 16th, Mao announced that some people in authority were capitalists, he said that they would try to seize power. Striking fear among the people by bringing up the Soviet Union as an example. The Gang of Four stands out in Mao's camp as being especially violent and aggressive, one of them being Mao's wife, despite not having a great relationship. Young people should attack their parents, professors, and unleash a tidal wave. There was no significant challenge to him at this time. China is now in social and economic chaos. Mao disbanded the Red Guards, ordered them to be labour for peasants. The People's Liberation Army is now tasked with protecting the Revolution. In the 70’s, Mao was almost dead. He continues to purge the parties. He is concerned with what will happen when he dies. SU and China are still bickering about who the Communist Party truly is. Mao then decides to meet with the West, specifically Richard Nixon. Nixon is a strong capitalist, why is he meeting with Mao in China? The talks aren’t extensive, more symbolic, but there are some trade talks, and it ends up increasing trade between the two of them. China opens its markets up to the world eventually. He likely had Parkinsons, maybe ALS. Addicted to drugs, poor hearing, likely was blind. Multiple heart attacks as well. Died in 1976. Day 25 Notes Idi Amin is our African dictator. Uganda is divided significantly regionally, tribally, ethnically. Buganda was viewed by the British as civilized by Africans. The Bugandans were propped up by the British as sort of being trusted and capable. The Northerners were viewed as backwards and primitive. It was claimed they had no government, which wasn’t true, though it wasn’t very capable. They were called Muslims, maybe even Arabic, however, they were good fighters, it was all based on racist assumptions. Britain used these divisions to their advantage by convincing the population that they will need to oversee them. Idi Amin was a Muslim convert, his father was a police officer and in the King's Army Rifles, and his mother was a traditional healer, or witch according to the British. The British claimed they wanted to remove slavery, they just changed it to indebted servitude, which they viewed as the same thing by raising taxes to such an extent that most would have to do it. Idi was one of many that joined the military to avoid this. He enlisted in 1946, and gained a reputation as an effective soldier. He is very violent, and helps quash Black African resistance to British rule in Uganda. Through the 50’s, he helped quash the Mau Mau uprising in Kenya. He was seen as a stooge of the British, this was because he was a part of the British forces that took down African resistance, he betrayed his people. Critics of that would say that assuming that is racist in and of itself, he may not have identified with black people necessarily, he was also following orders. British forces viewed Amin as an ideal candidate if armed forces were to be Africanized, although that is not the plan that they favour. Gets to a point where he is one of two black supervisors. Amin rose quickly, Ugandan independence came in 1962 under PM Milton Obote. Amin was very important during this time under Obote, he helped to calm down mutinies and present grievances to Obote, who made concessions. He was seen as defending Ugandan rights, while also proving himself to the British. There are significant revolts during this time, where the Africans recognize and believe that the British are still running the show. Amin uses the fact he is one of them to appeal to them. Amin takes demands from the people to Obote, which show to be reasonable. It doesn’t last, but helps to prove Amin. Obote, worried for his powers, goes on the offensive, suspending the constitution. Amin is appointed head of the armed forces. He is united Uganda, whether anyone likes it or not. This created a rift between Amin and Obotoe after a while. They negotiated with the British during the Cold War, threatening to not help them if they didn't give in. Amin is promoted to commander of the army during this time as well. Amin knows at this point Obotoe will try to kill him, but nonetheless Obotoe gets convinced to go to an important meeting in Singapore. Amin overthrows his government while Obotoe is at the meeting. Amin is named temporary leader. Immediately, Amin purges the military, which is the only thing he seems to know how to do. He relies on an army from his hometown, which he gives special privileges to. Obote allied forces attacked Uganda in 1972 of people that didn't like Amin. Repression increases significantly during this time. Amin orders the expulsion of all Asians, he calls himself the Black Hitler. Thousands of people have to leave during this time. The West condemns this, but most Ugandans support it. But it devastated the Ugandan economy. Day 28 Notes The Vietnam war went poorly for the States because they weren’t willing to sacrifice their own people. Bombs were dropped on Cambodia, an innocent party, in 1973, by the Americans. It kills a lot of Vietnamese, but the Vietnamese don’t care about losing people, eventually, they realize the Americans won’t keep killing citizens like that. They reach a treaty, but the treaty is quickly broken. So the Democratic Republic of Kampuchea takes over. They are unknowns, they were not known as the people that had taken over Cambodia. In fact, the citizens think they defeated the Americans, and the war was going to stop. They had been in the rural areas through most of this area. Within weeks, the Kampuchea over evacuated everyone in the cities, everyone was an enemy of the people that needed to be eradicated or removed. Leads to significant deaths as the Kampuchea starts to purge, if they aren’t helpful to the revolution, they are killed. Sick people, old people, children. They abolish money, and all forms of religion. Money is no longer worth anything. Poi Pot is the general secretary of the Democratic party, but no one knows he’s the leader, as he lies in the background. The head of state tries to rein them in, ends up getting kidnapped and becomes a puppet leader. To the detriment of the Cambodian people, they continue to rule for years. Collectivize agriculture to gather money, even though they had gotten rid of money. They would be able to stand on their own against their enemies, primarily Vietnam. They wanted the country to be self-sufficient. Pot was very convinced it only didn’t work because people didn’t try hard enough, so he executed people as his system didn’t work. Pot arrests all the people he’s been allied with for years. Pot also abolishes education, turning high school into an interrogation complex, which is now a genocide museum. One example is over 5000 people were in the place, only 6 survived. The people from April 17th were turned into slaves, many of which died. They went to war with Vietnam in 1977. A series of border raids are carried out by the Cambodians, which in response leads to attacks. He resented Vietnam for believing that they didn’ t respect Cambodia. Su supported Vietnam, China supported Cambodia, became a proxy war between two communist nations, and supported by communist parents. It doesn’t go well with Cambodia, who had killed all of the people that could have served in the army. When Vietnam is able to liberate prisoners, Pot kills the soldiers, this method obviously has consequences. Most of the fighting takes place in Cambodia. In 1978, Vietnam invaded Cambodia fully, which they won easily and quickly. Vietnam then creates their own Communist government. They kick out Poi Pot. They publicize Poi Pot's crimes. Vietnam gives the government the same name as the previous one, basically a puppet government for Vietnam. Poi Pot and some others are able to flee to Thailand. By 1980, everyone knows what Poi Pot did, in less than four years, they had killed about 25% of the Cambodian population. However, because of Vietnam's reputation, Thailand agrees to protect Poi Pot and his people, in exchange for China not funding Vietnam. So, China sends supplies and pays for Poi Pot, and so does America, they reject the new government in Cambodia because they lost in Vietnam. America supports Poi Pot being protected and funded by Thailand and China. Pot carries out raids in Cambodia from Thailand trying to retake it. Also means they keep their seats in the United Nations for 14 years after his crimes were made public. The justification made by the US is that Pot isn’t running the party anymore, which he claims, but he’s lying. In the mid 90’s, Cambodia had an election under the supervision of the UN, which didn't last very long. This ends all the international support for Poi Pot. In 1997, he ordered the murder of his closest ally and their family. Finally, his party has enough, and they consider Poi Pot a traitor, Pot dies while on trial by heart attack. Some repetition from previous tests. Need to know authors' last names and who they wrote about. Will focus on major events, themes, people, and organizations. Won’t be testing on specific dates or stats. Guest lectures can be included. Most questions will be about a specific dictator, although some might be on themes. What were the themes or the focus of specific readings? List of Authors of Readings + Subheadings Non-Specific Dictators: Dictatorship: Modern Tyranny Between Leviathan and Behemoth by Jan C Behrends Benito Mussolini: Mussolini by Peter Neville Chapters 2,5,6,9 Sub Headings: Chapter 2: The Achievement of Power The Genesis Fascism The Red Two Years The Death of Liberal Italy The Taking of Power The March on Rome Fascism: revolution or counter-revolution? Mussolini and Parliament The Fascist Grand Council The Voluntary Militia for National Security The 1924 Elections Chapter 5: Italian society under Mussolini, 1931–39 Winning Over Italy's Youth Women Under Fascism The Media Corporativism and the Great Depression The Dopolavoro Opposition in Fascist Italy Anti-Semitism Was there a Fascist consensus? Chapter 6: The Ethiopian War, 1935–36 The end of the old diplomacy, 1932–35 The Austrian crisis Fascism in Africa The Ethiopian Question The invasion of Ethiopia’ The Hoare–Laval Pact The consequences of the war Chapter 9: The last phase, 1943–45 The foundation of the Italian Social Republic A dictator's twilight The Congress of Verona The last days Conclusion Mussolini in retrospect Adolf Hitler Hitler by Ian Kershaw Eva Braun: Life With Hitler by Heike Gortenmaker War and Genocide: A Concise History of the Holocaust by Doris Bergen Kershaw Chapter 1: Power of the Idea No subheadings Braun Chapter 9: Isolation of War The Outbreak of War The Berghof of Fuhrer Headquarters The Beginning of the End Bergen Death Throes and Killing Frenzies Attacks on the Nazi Regime The Soviet Advance Allied Bombing and Conditions in Germany D Day - Allied Invasion from the West The Plot of 20 July, 1944 The Volkssturm The Warsaw Uprising Germany's Allies and the Jews of Hungary Auschwitz and the end of war The Death Marches Final Collapse Joseph Stalin Popular Opinion in Stalin’s Russia: Terror, Propaganda, and Dissent, 1934- 1941 by Sarah Davis Stalin by Hiroaki Kuromiya Davis Chapter 9: The leader cult in official discourse The evolution of the cult The cult as official culture Chapter 10: Affirmative representations of the leader and the leader cult The leader as benefactor The traditional defender of the people The Charismatic Leader Kuromiya Chapter 7: Twilight of the god Victory Cold War Death Also, supposed to read Conclusion ig Mao Zedong From Urban Radical to Rural Revolutionary: Mao from the 1920s to 1937 by Brantly Womack War, Cosmopolitanism, and Authority: Mao from 1937-1956 by Han J

NUR 204: EXAM 1 COMPLETE STUDY GUIDE SECTION 1: CANCER PATHOPHYSIOLOGY & EPIDEMIOLOGY Cellular Characteristics • Cancer is uncontrolled cell growth caused by genetic damage. • Apoptosis: The body's natural ability to destroy abnormal or cancerous cells. Malignant cells fail to undergo apoptosis. • Angiogenesis: Malignant cells can create their own blood supply for nourishment, making them very difficult to eliminate. • Progression to Malignancy: Hyperplasia (rapid increase in normal cells) → Dysplasia (abnormal cells) → Carcinoma in situ (localized cancerous cells) → Malignancy. Tumor Types & Staging • Primary vs. Secondary: The primary tumor is where the cancer originated. Secondary tumors are the sites of metastasis (e.g., lung cancer that spreads to the liver means the liver contains secondary tumors). • TNM Staging System: o T = Tumor size. o N = Lymph Node involvement. o M = Metastasis (Spread). • Number Staging (0-4): Stage 0 (In situ, abnormal cells haven't spread) to Stage IV (Distant metastasis, spread to distant body parts). Risk Factors & Prevention (Live Lecture Focus) • Modifiable vs. Non-modifiable: Age, genetics (BRCA mutations), and gender are non-modifiable. Smoking, alcohol, obesity, and sedentary lifestyle are modifiable. • Environmental Factors: o Physical: UV light (tanning beds), radiation. o Chemical: Tobacco, alcohol, workplace pesticides/cleaners. o Biological: Viral infections (HPV causes cervical cancer, Hep B/C causes liver cancer), poor diet. • Nurse's Role in Community Screenings: Skin cancer screenings are highly effective for community health fairs because they are non-invasive. Screening Guidelines • Breast: Mammograms starting at age 40 (earlier if high risk). • Colorectal: Colonoscopy every 10 years starting at age 45. • Prostate: PSA blood screening at age 50. • Tumor Markers: PSA (Prostate) and BRCA1/BRCA2 (Breast). SECTION 2: IMPACT OF CANCER & NURSING CARE Physiological Impacts • Pain: Very common, affecting up to 80% of advanced cancer patients. • Infection/Neutropenia: Dangerously low white blood cells. Live Lecture Note: Any spike in temperature (even a low-grade fever like 100.4°F) is a massive red flag for impending sepsis and must be addressed immediately. • GI Issues: Nausea, vomiting, and mucositis (painful mouth inflammation). For mucositis: avoid spicy/acidic foods and use lidocaine rinses. Cognitive & Psychosocial Impacts • Delirium (HIGH YIELD): Acute, sudden confusion. Live Lecture Note: Delirium is reversible. The nurse must treat the underlying cause. Interventions include reorienting the patient, clustering care, avoiding interruptions, and simulating day/night to regulate circadian rhythms (lights on during the day, off at night). • Financial & Psychosocial: Cancer treatments are grueling and expensive, leading to lost employment and depression. Nurses should facilitate early referrals to social workers and case managers. Nursing Safety & Medication Administration • Extravasation Safety: Vesicant chemotherapy drugs can severely damage tissue if they leak outside the vein. Live Lecture Note: If chemo is given via a peripheral IV, the nurse MUST check for blood return every single hour to prevent extravasation. If extravasation occurs: stop the infusion immediately. • Chemotherapy PPE: The nurse must wear proper PPE (e.g., double gloves, chemo gown, face protection) and dispose of chemo materials in designated hazardous waste bins (e.g., yellow bins). • Neutropenic Precautions (Reverse Isolation): Protecting the highly vulnerable patient from the nurse/visitors. Includes strict hand hygiene, no sick visitors, and avoiding crowds. SECTION 3: ONCOLOGIC EMERGENCIES • Spinal Cord Compression: Early signs include back pain, muscle weakness, loss of sensation, and bowel/bladder incontinence. • Brain Metastasis/Increased ICP: Personality changes, seizures, altered speech/balance. • Hypercalcemia: Confusion, severe muscle weakness, arrhythmias, and ECG changes. • Superior Vena Cava (SVC) Syndrome: Tumor compresses the SVC causing facial/neck edema and dyspnea. • Tumor Lysis Syndrome (TLS): Rapid cell death causes severe electrolyte imbalances (hyperkalemia, hyperuricemia). • SIADH: Tumor triggers excessive antidiuretic hormone (ADH), leading to massive water retention, dilutional hyponatremia, and confusion. SECTION 4: SELECTED CANCERS Lymphedema What is it? A frequent cancer treatment complication where fluid builds up in an extremity (typically on one side), causing severe swelling. • Signs & Symptoms: Swelling, a feeling of heaviness, decreased range of motion, and tightness in the skin. • Common complication of: Breast cancer treatments, specifically resulting from lymph node dissection/removal, radiation therapy, or chemotherapy. • Nursing Priorities & Treatment: o Elevate the affected arm above heart level. o Use compression sleeves as prescribed. o Encourage range-of-motion exercises to prevent stiffness. o ABSOLUTE SAFETY RULE: NO blood pressures, NO IVs, and NO blood draws on the affected arm. • Breast Cancer: o Live Lecture Note: Ductal breast cancer is the most common type (originating in the milk ducts). o Signs: Hard mass, nipple retraction, "orange peel" skin (peau d'orange). o Hormone Receptors: If the tumor is estrogen-receptor positive, treatment must avoid estrogen as it will feed the tumor. o Lymphedema Care: Swelling in the arm due to lymph node removal. Rule: No blood pressures, IVs, or blood draws on the affected arm. Elevate the arm and use compression. • Lung Cancer: o Live Lecture Note: Often asymptomatic in the early stages, leading to late diagnosis. o Signs: Chronic cough, hemoptysis (rust-colored/bloody sputum), dyspnea. High risk for brain metastasis. • Colorectal Cancer: o Live Lecture Note: A hallmark sign is "ribbon-like" or pencil-thin stool, caused by a tumor pressing in the rectum and narrowing the passageway. Other signs: rectal bleeding, changes in bowel habits, anemia. • Pancreatic Cancer (HIGH MORTALITY): o Live Lecture Note: High mortality because early symptoms are incredibly vague; usually caught too late. o Whipple Procedure: Surgery that removes the head of the pancreas but leaves a portion behind so the patient retains some insulin secretion. Nursing Priority: You must strictly monitor for manifestations of diabetes (hypo/hyperglycemia) because pancreatic function is deeply impaired. • Skin Cancer: o Types: Basal cell (slow-growing, sun-exposed areas), Squamous cell (more serious), Melanoma (most deadly, highly metastatic). o Melanoma ABCDEs: Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving. • Brain Tumors: o Live Lecture Note: Primary brain tumors are typically benign. Malignant brain tumors have usually metastasized from somewhere else. SECTION 5: INFLAMMATION & IMMUNITY BASICS • Acute vs. Chronic Inflammation: Acute is short-term and protective (redness, heat, swelling, pain). Chronic is prolonged, causing tissue damage. Exam Tip: Chronic inflammation heavily increases the risk for cardiovascular disease. • Infection vs. Inflammation: Inflammation does not always mean infection (e.g., sprains, allergies). Systemic infection signs include fever, tachycardia, and confusion. Rule: Always draw a blood culture before starting antibiotics. SECTION 6: AUTOIMMUNE & INFLAMMATORY DISORDERS Detailed Osteoarthritis (OA) (Live Lecture Focus) • Pathophysiology: OA is a degenerative joint disease causing progressive cartilage breakdown. It is characterized by the friction of "bone on bone" as cartilage degenerates, which leads to the formation of bone spurs and bone cysts (fluid-filled cavities). • Key Distinction: There is NO systemic inflammation; OA is localized to the affected joints. • Risk Factors: Natural wear and tear of aging, trauma, joint overuse (e.g., repetitive work or sports), obesity, genetics, and a sedentary lifestyle. • Complications: Because OA causes a lack of mobility and a sedentary lifestyle, patients are at a highly increased risk for cardiovascular disease, diabetes, and obesity. Patients over 65 should also be screened for iron overload (hemochromatosis), which can accelerate the progression of OA. Patients are also at high risk for depression and anxiety due to loss of independence and chronic pain. • Signs & Symptoms: Joint pain, stiffness, crepitus (cracking of the joints), muscle atrophy, and limited range of motion. • Treatment: o Non-surgical first: Physical therapy, exercise (specifically swimming/water exercises to take pressure off the joints), and weight loss. o Medications: Acetaminophen (monitor for liver toxicity), NSAIDs like ibuprofen/naproxen (monitor for kidney toxicity), and cortisone injections into the joint. o Surgical: Joint replacement (e.g., hip or knee). Nursing Priority: Ambulate the patient right away after surgery to prevent complications. Detailed Rheumatoid Arthritis (RA) (Live Lecture Focus) • Pathophysiology: A chronic autoimmune disease where the body's immune system mistakenly attacks the synovial tissue and fluid in the joints. • Risk Factors: Increased age (highest onset in the 60s), genetics, females (especially those who have never given birth), obesity, smoking, and high stress. o Trigger mechanism: Someone with a genetic susceptibility who experiences an external trigger (like an infection or trauma) can kickstart the autoimmune reaction. • Signs & Symptoms: Symmetric joint swelling and pain (usually in the hands and feet), morning stiffness lasting longer than 1 hour, fever, malaise, and weakness. Patients experience flare-ups (severe symptoms) and remissions (no symptoms). • Rheumatoid Nodules: The most common visible manifestation of RA. These are detachable, movable subcutaneous knots or swellings of varying sizes, typically found in the fingers/hands. • Diagnostics: Elevated ESR and C-reactive protein (CRP) indicate inflammation. Positive Rheumatoid Factor (RF) and ANA (anti-nuclear antibody) blood tests. • Medications & Safety: o Treated with DMARDs (Disease-Modifying Antirheumatic Drugs). o Priority: DMARDs suppress the immune system, putting the patient at a severe risk for infection. o Hydroxychloroquine teaching: Long-term use can cause retinal damage and glaucoma leading to blindness; patients MUST see an optometrist regularly for eye exams. Systemic Lupus Erythematosus (SLE): • Multisystem autoimmune disease attacking self-tissues. • Symptoms: Butterfly rash on the face, photosensitivity, joint pain. • Complications: Cardiovascular disease (pericarditis) and kidney failure (lupus nephritis). • Triggers: Teach patients to avoid UV light/sun exposure, severe stress, exhaustion, and infections to prevent flare-ups. Peritonitis (LIFE THREATENING): • Inflammation of the peritoneum (abdomen). • Symptoms: Rigid, board-like abdomen, rebound tenderness. • Complication: Septic shock and death. SECTION 7: HIV / AIDS & HYPERSENSITIVITY HIV/AIDS: • A retrovirus that specifically targets and destroys CD4 T-cells. • Transmission Phase: The virus is most highly infectious during the initial phase when the viral load is the highest. • Opportunistic Infections: When CD4 drops < 200 (AIDS), the patient is at extreme risk for deadly infections like Tuberculosis, Pneumocystis pneumonia (PCP), and Kaposi sarcoma. • PrEP (Pre-Exposure Prophylaxis): Reduces risk of contracting HIV but does NOT replace safe sex practices (condoms). Risk Factors & At-Risk Populations: o Individuals with multiple sexual partners without protection, and those who share IV drug needles. o Substance use (drugs/alcohol) is a major risk factor because it lowers inhibitions, leading to unprotected sex. o Incarcerated populations or those in closed settings (due to sharing needles, self-tattooing, and sexual violence). o Pregnant or lactating women (due to the risk of perinatal transmission). Phases of HIV Progression: 1. Acute Infection Phase: Occurs 2 to 4 weeks after exposure. The risk of transmission is at its absolute highest because the viral load in the blood is massive. Patients exhibit flu-like symptoms (fever, malaise, fatigue). 2. Chronic Infection Phase: Patients are often asymptomatic, meaning they may not even realize they are infected. They can still transmit the virus if their viral load is high enough. This stage can last for a decade or longer. 3. AIDS: If left untreated, HIV progresses to AIDS. Diagnosis is confirmed when the CD4 T-cell count falls below 200. Immune system damage is severe, creating a very high risk for fatality and opportunistic infections (such as Tuberculosis, Kaposi sarcoma, and fungal infections). • PrEP vs. PEP (Crucial Difference): o PrEP (Pre-Exposure Prophylaxis): Medication taken prophylactically to prevent the transmission of HIV to an HIV-negative person. It does NOT replace safe sex practices (condoms must still be used). o PEP (Post-Exposure Prophylaxis): Medication taken after accidental exposure (e.g., a broken condom, a needle stick injury, or sexual assault). It MUST be taken within 72 hours of exposure to be effective. It is taken daily for 28 days and is not meant for regular, ongoing use. Anaphylaxis: • Severe allergic reaction triggering massive histamine release. • Patho: Causes increased capillary permeability, where blood vessels leak fluid into the tissues, leading to profound hypotension and airway edema. • Priority Treatment: Epinephrine IM. • High-Risk Factor: Patients taking Beta-blockers or Alpha-adrenergic blockers are at a high risk of death because these medications reduce the effectiveness of epinephrine, preventing the reversal of the shock. SECTION 8: INFECTIONS & SAFETY PROTOCOLS Meningitis (SAFETY RULE): • Diagnosed via Lumbar Puncture (testing CSF). • Live Lecture Safety Rule: If the patient shows signs of Increased Intracranial Pressure (ICP) (like severe headache, altered mental status), a CT scan of the head MUST be performed BEFORE a lumbar puncture. Performing a lumbar puncture when ICP is high can cause fatal brain herniation. • Risk Groups: College dorm students, unvaccinated individuals. Lumbar Puncture (Live Lecture Safety Rules) • Purpose: To draw out and test the cerebrospinal fluid (CSF) specifically to screen for and confirm a diagnosis of meningitis. • Position: The patient should be laying on their side with their knees pulled to their chest (fetal position) to help open up the spinal column for needle insertion. • Contraindication & Safety Priority: A lumbar puncture is completely contraindicated if the patient has Increased Intracranial Pressure (ICP). o Rule: A CT scan of the head MUST be performed BEFORE a lumbar puncture to rule out increased ICP. Performing a lumbar puncture on a patient with increased ICP can cause fatal brain herniation Sinusitis: • Inflammation of the sinuses causing facial pressure ("like you got punched in the face"), congestion, and post-nasal drip. • Live Lecture Rule: Treat with hydration, nasal irrigation, and steam. AVOID over-the-counter antihistamines and decongestants because they cause rebound inflammation (making symptoms worse when they wear off). Influenza: • FACTS Mnemonic: Fever, Aches, Chills, Tiredness, Sudden onset. High risk for secondary pneumonia in older adults and pregnant women. SECTION 9: MEDICATIONS HIGHLIGHTED IN LIVE LECTURE 1 Your instructor specifically highlighted these medications and their nursing implications during the recorded lectures: 1. Analgesics & Anti-inflammatories • Opioids (Cancer Pain): A major side effect is delayed gastric emptying and severe constipation. Intervention: Administer stool softeners, encourage hydration and mobility. Monitor for decreased respirations and drowsiness (which creates a fall risk). • Acetaminophen (Tylenol): Used for mild OA pain. Warning: Hepatotoxic (toxic to the liver) if too much is given. • Ibuprofen/Naproxen (NSAIDs): Used for OA/RA inflammation. Warning: Nephrotoxic (toxic to the kidneys) and can cause GI bleeding. • Corticosteroids (Cortisone): Can be injected directly into joints for OA inflammation. 2. Neurological & Emergency Medications • Mannitol: An osmotic diuretic used specifically to lower elevated Intracranial Pressure (ICP) in patients with brain tumors. • Phenytoin & Levetiracetam (Keppra): Anti-epileptic medications used to prevent seizures in patients with brain metastasis/tumors. • Epinephrine: The absolute first-line priority treatment for anaphylaxis. Works to constrict blood vessels and open the airway. • Hydroxychloroquine (DMARD): Used for RA and Lupus. Warning: Can cause retinal toxicity. Patients require regular eye exams (every 6 months) and must use photosensitivity precautions. SECTION 10: SAMPLE QUESTIONS & ANSWERS Q1: The client’s cancer is staged as T1, N2, M1 according to the TNM classification system. How would the nurse interpret this staging? A. One tumor that is nonresponsive to treatment with distant metastasis B. Leukemia indicated that is confined to the bone marrow C. A 2-cm tumor with one regional lymph node involved and no distant metastasis D. Small tumor with extension into two lymph nodes and one site of distant metastasis Answer: D. Rationale: T = small primary tumor, N = extension to regional lymph nodes, M = distant metastasis has occurred. Q2: The nurse is assessing an older client at a checkup visit. Which reported change would alert the nurse to the possibility of colon cancer? A. Pencil-thin stool B. Erectile dysfunction C. Reduced urine stream D. Persistent pain in the lower back and legs Answer: A. Rationale: Tumors growing in the colon/rectum compress the passageway, resulting in ribbon-like or pencil-thin stool. Q3: A nurse is performing a cancer screening assessment on several clients. Which of the following findings is a possible manifestation of cancer? (Select all that apply) A. Temperature 36° C (96.8° F) B. Sore that does not heal C. Difficulty swallowing D. Blood in the urine E. Rhinitis Answer: B, C, D. Rationale: Using the CAUTION mnemonic, signs include sores that do not heal, difficulty swallowing, and unusual bleeding/discharge. Q4: A nurse is caring for a client who has breast cancer. The client asks why the treatment plan contains a combination therapy of three different medications. Which of the following responses should the nurse make? (Select all that apply) A. “Combination chemotherapy decreases the risk of medication resistance.” B. “Combination chemotherapy attacks cancer cells at different stages of cell growth.” C. “Combination chemotherapy increases production of platelets.” D. “Combination chemotherapy stimulates the immune system.” Answer: A, B. Rationale: Using multiple chemo drugs reduces drug resistance and attacks the cell at various phases of the cell cycle. Q5: A nurse is caring for a burn client whose calculated 24-hour intravenous fluid requirements are determined to be 5000 mL. What is the total volume (mL) that the nurse should infuse after the first 8 hours of fluid resuscitation has infused? Answer: 2500 mL. Rationale: Standard burn fluid resuscitation protocols require half (50%) of the 24-hour total to be administered in the first 8 hours following the burn injury. Q6: The nurse is caring for a client who has a systemic infection. What is the best method to prevent infection transmission? A. Obtaining an immunization B. Implementing proper hand hygiene C. Wearing gloves D. Managing the client’s fever Answer: B. Rationale: Strict hand hygiene remains the most effective method for preventing the transmission of infectious organisms. Q7: The nurse is assessing a client with systemic lupus erythematosus (SLE). Which of the following laboratory findings should the nurse anticipate? (Select all that apply) A. Positive ANA titer B. Increased hemoglobin C. Pancytopenia D. Urine positive for protein and RBCs Answer: A, C, D. Rationale: SLE causes an autoimmune response (Positive ANA), bone marrow suppression (pancytopenia), and lupus nephritis, which damages the kidneys causing protein and blood to spill into the urine. Q8: A nurse is providing teaching to a client who is to receive a vaccination following a deep puncture wound to the foot. Which information would the nurse include? A. “You will need to receive this vaccination annually.” B. “Your passive immunity will be boosted by receiving this shot.” C. “I am administering this vaccination to help protect you against tetanus.” D. “This immunization requires three separate injections several weeks apart.” Answer: C. Rationale: Tetanus vaccination is indicated for deep puncture wounds. Q9: A nurse is assessing a client who is being treated with interferon alfa-2b for malignant melanoma. The nurse should identify that which of the following findings are adverse effects of this medication? (Select all that apply) A. Tinnitus B. Muscle aches C. Peripheral neuropathy D. Bone loss E. Depression Answer: B, C, E. Rationale: Interferon therapy causes significant flu-like symptoms (muscle aches, chills), peripheral neuropathy, and mood changes including severe depression. Q10: A nurse is reviewing the medical record of a client. Which of the following findings are risk factors for ovarian cancer? (Select all that apply) A. Previous history of endometriosis B. Family history of colon cancer C. First pregnancy at age 24 D. First period at age 14 E. Use of oral contraceptives for 10 years Answer: A, B. Rationale: Endometriosis and a family history of associated cancers (like colon or breast BRCA mutations) increase the risk for ovarian cancer. (Pregnancy and oral contraceptive use typically decrease the risk). Q11: The nurse is caring for a client whose white blood cell count is 6000/mm3. Which differential value would the nurse discuss with the health care provider? A. Eosinophils 700/mm3 (Reference range: 50–400/mm3) B. Monocytes 500/mm3 (Reference range: 100–800/mm3) C

NURS 348 — EXAM 4 STUDY GUIDE Hypertension Definition & Overview • Persistent elevation of BP ≥130/80 mmHg (systolic at/greater than 130 OR diastolic at/greater than 80) on at least 2 separate visits, 2+ weeks apart. • Primary (Essential): No identifiable cause, most common (90–95% of cases). • Secondary: Caused by another condition or adverse effects of medications. Etiology/Pathophysiology • ↑ Peripheral resistance and/or ↑ cardiac output → ↑ blood pressure → When blood vessels get narrower (increased resistance) or the heart pumps more forcefully (increased output), pressure inside the vessels rises “like squeezing a hose while water is running” → Over time, this high pressure damages the vessel walls and heart muscle, increasing the risk for atherosclerosis, heart attack (myocardial infarction), and stroke. • ↑ Increased peripheral resistance (arteriolar constriction) → ↑ afterload → left ventricular hypertrophy → heart failure → The heart pushes against more resistance (afterload), making the heart muscle thicker (hypertrophy). Over time, it becomes weaker and can lead to heart failure. • Kidneys retain sodium and water → ↑ circulating volume → The kidneys hold onto extra salt and water, adding more fluid to the blood. More fluid means higher pressure—like overfilling a water balloon. • Activation of renin–angiotensin–aldosterone system (RAAS) = vasoconstriction + fluid retention. RAAS is like the “blood pressure booster” → When this system turns on, blood vessels tighten and the kidneys save even more salt and water, both of which raise blood pressure. Risk Factors: • Primary: family history, ↑ sodium intake, Obesity (BMI >25), African-American ethnicity, smoking, hyperlipidemia, diabetes mellitus, and stress. • Secondary: kidney disease, Cushing’s, pregnancy, pheochromocytoma, medic (steroids, OCPs). Clinical Manifestations (S/S) • Often asymptomatic (“silent killer”)!!! • Headache, dizziness, fainting, vision changes • Retinal damage on exam (cotton wool spots, papilledema). • Note: if blood pressure reading is elevated then take in both arms; pt legs uncrossed, and arms above heart; correct cuff Diagnostics (Dx)/Labs • Multiple BP readings (both arms, sitting and standing) • ECG → Left-Ventricular hypertrophy. evaluates cardiac function. • Labs → ↑ BUN/creatinine (kidney disease), lipids, glucose, cortisol (Cushing’s) Nursing Care / Nursing Interventions • Monitor pt BP regularly and accurately, check both arms/correct cuff • Put on DASH diet (Dietary Approach to Stop Hypertension) Medications • ⭐️Diuretics (first-line): excess fluids, they need to remove; increase urine • Thiazides (hydrochlorothiazide) inhibits water & sodium reabsorption and increases potassium excretion • Side effects/SE: hypokalemia; monitor potassium(K⁺) levels • Loop (furosemide) decreases sodium reabsorption & increase potassium excretion– SE: hypokalemia; monitor potassium(K⁺) levels • Potassium-sparing (spironolactone) – SE: hyperkalemia; monitor potassium levels. EKG: peaked T waves • Also watch out for muscle weakness, irregular, pulse, and dehydration. • ⭐️Calcium channel blockers (verapamil, amlodipine, and diltiazem) Calcium channel blockers relax and widen blood vessels by preventing calcium from entering muscle cells, leading to lower blood pressure (vasodilation) • SE: constipation; take fiber for verapamil, and all can ↓HR • Avoid grapefruit juice ➡️ toxicity, hypotensive effects Calcium= contract • ⭐️ACE inhibitors (lisinopril, enalapril): prevents angiotensin II → vasodilation • SE: - hypotension; monitor BP and pulse HR -hyperkalemia; monitor potassium levels -erectile dysfunction -⭐️cough linked to angioedema (swollen tissue under the skin around lips, tongue, and glottis); report swelling & discontinue med • ⭐️ARBs (valsartan, losartan): for ACE-intolerant pts from cough/hyperkalemia. ARBs lower blood pressure by blocking angiotensin II from binding to its receptors, preventing vasoconstriction, and reducing fluid retention. • SE: angioedema, heart failure, hyperkalemia • Change position, slowly, report, angioedema, edema, and avoid foods that are high in potassium (bananas, potatoes, apricots, spinach, beans); monitor potassium levels • Aldosterone-receptor antagonists (eplerenone, spironolactone): blocks aldosterone action. • SE: kidney damage, hypertriglyceridemia, hyponatremia, and hyperkalemia; monitor kidney function, triglycerides, sodium, and potassium levels • Avoid Grapefruit juice and St. John’s wort, salt substitutes, and potassium rich foods • ⭐️Beta blockers (metoprolol, atenolol): blocks beta receptors (adrenaline/epinephrine) ➡️reduces heart rate, cardiac output, and blood pressure ↓HR, ↓CO; use cautiously in diabetics • SE: -⭐️erectile dysfunction, -Fatigue, weakness, depression -hypoglycemia • Monitor heart rate (hold if HR is less than 60) and do not suddenly stop taking med (cause rebound hypertension); and don’t give to pts with asthma, airway disease (cause bronchospasms) • Central Alpha-2 agonists (clonidine): calm the nerves that raise blood pressure, letting blood vessels, relax, and BP go down, ↓SNS tone • SE: sedation, orthostatic, hypotension, and sexual dysfunction/impotence • Monitor BP and pulse • Alpha-adrenergic blockers (prazosin, doxazosin): vasodilator= relaxed BP; give at night to avoid first-dose hypotension. Start with low dose. • SE: postural hypotension; make sure patient rises slowly and caution. • Monitor BP 2 hrs after initiation Complications • Hypertensive Crisis: usually when patients do not follow the medication regimen • BP >180/120 → organ damage (encephalopathy, renal failure) • S/S: severe headache, dizziness, blurred vision, confusion, epistaxis • Treat: IV antihypertensives (nitroprusside, nicardipine, labetalol); the goal is to lower BP gradually by 20-25% in first hour. Not less than 140/90. Monitor BP every 5-15 mins Patient Education • Adhere to medication regimen, don’t abruptly stop even when you feel better • Change positions slowly • Encourage DASH diet (low sodium, high fruits/veggies, low-fat dairy) ex: grilled salmon, brown rice, steamed broccoli, and low-fat milk • Avoid high-sodium foods. Consume less than 2.3 g/day • Monitor BP at home • Report signs or symptoms of electrolyte imbalances • Encourage Weight loss, exercise 3x weekly • Encourage Smoking cessation • Encourage Limit alcohol (≤2/day men, ≤1/day women) • Manage stress • Report persistent cough or swelling (ACE inhibitor red flag) Peripheral Venous Disorders(PVD) Patho: problems with veins where Deoxygenated blood can't get back to the heart Oxygenated blood pools in the extremities. The valves are preventing backflow. • Venous Thromboembolism (VTE): blood clot that starts in a vein. -Two types: deep vein thrombosis (DVT) and pulmonary embolism (PE) • Venous insufficiency: Improper functioning of the veins. Veins aren’t able to push back blood to the heart which results in swelling, venous stasis ulcers, or cellulitis. Blood can go down into the veins just fine but cannot come back up. a. VTE ex: Deep Vein Thrombosis (DVT) Pathophysiology • Thrombus (Blood clot) forms in deep veins (usually in legs) → can embolize (travel and block vessel) its way to lungs (PE). • Caused by Virchow’s triad: venous/blood flow stasis, endothelial injury, hypercoagulability. Risk Factors • Surgery (hip, knee, prostate) • Immobility • Heart failure • Pregnancy • Family hx • Oral contraceptives or hormone therapy • Cancer • COVID-19 (elevated D-dimer) • Central venous catheters Clinical Manifestations • Note that clients can be asymptomatic • Calf/groin pain (dull/achy), tenderness, warmth, edema • Unilateral swelling • Shallow, irregular shaped wounds • Too much blood, brown/yellow discoloration • Sudden SOB and sharp chest pain → suspect PE • Positioning: “Elevate Veins”, position up in “V” shape, above heart. Worsens: if dangling, sitting/dangling for long periods of time. Diagnostics • ⭐️Venous duplex ultrasonography = gold standard; it’s an ultrasound of Leg to see blood clot/blood flow through the vessel. • ⭐️D-dimer ↑ = clot breakdown evidence • Venogram/MRI if ultrasound inconclusive Nursing Interventions • Bed rest until anticoagulation started • Elevate leg slightly above heart (no knee gatch). Positioning: “EleVate Veins”, think V as veins are up, to keep the veins open. • Warm compresses • DO NOT massage leg • Compression stockings (after swelling ↓) • Encourage early ambulation when safe • SCDS Medications/Procedures (Anticoagulants) stops blood from clotting, another nurse must be with you • Unfractionated heparin (given IV): prevents clots and growth of existing clot; monitor platelets, and aPTT (how long it takes blood to clot) (1.5–2× normal). Must be given in facility. MUST MONITOR CLOSELY • Antidote: protamine sulfate • Low-molecular-weight heparin (Lovenox/enoxaparin): given SubQ, weight-based, prevention and treatment of DVT, given twice daily, can be used in home setting. Don’t need labs. Monitor for bleeding, and take bleeding precautions (Electric razor, soft toothbrush, environment safety) • Warfarin (Coumadin): oral, inhibits vitamin K clotting factors overlaps; combined with heparin 3–4 days until INR 2–3 (takes awhile to kick in; therapeutic affect) • Antidote: vitamin K • Avoid high vitamin K foods (green leafy veggies) • Monitor PT (range: 11-13.5 secs), INR (must know range: 2–3) • Factor Xa inhibitors (fondaparinux; SubQ) (rivaroxaban, apixaban; oral): Prevents development of Thromboses; transitional medication; initial labs are PT and PTT; not routinely • Direct thrombin inhibitors (dabigatran): directly prevents growth of thrombus Formation, given sub Q ; initiate initial lab values only for PT and APTT. • Antidote: idarucizumab • Thrombolytics (tPA): for massive DVT/PE, directly infused into clot, start within 24hrs- 5 days of clot formation; monitor for bleeding, neuro status, dizziness, headache. Take bleeding precautions, pt must use electric razor and, brush teeth with a soft toothbrush. • Inferior vena cava filter: prevents embolus from reaching lungs (PE), inserted in femoral vein; catches blood clot. Used when pt is unresponsive to other treatments. Monitor: bleeding, hematoma, infection, PE (dyspnea, chest pain, tachycardia). Nursing actions: assess circulation and encourage leg exercises/ambulation early, have patient not sit for too long Anticoagulant Therapy Nurse’s Role • Verify labs,;Double-check with another RN for IV heparin, Assess for bleeding (bruises, gums, stools) and Monitor vitals, mental status (signs of intracranial bleed) Reversal Agents • Heparin → protamine sulfate • Warfarin → vitamin K • Dabigatran → idarucizumab Patient Education • Avoid contact sports • Soft toothbrush, electric razor • Avoid sudden diet changes (vitamin K) Complications (anticoagulants) • ⭐️Pulmonary embolism: sudden dyspnea, chest pain, SOB, anxiety, tachypnea → emergency; sit, patient in high Fowlers, and administer oxygen and anticoagulants • ⭐️Ulcer formation(venous): often formed over the medial malleolus, chronic, hard to heal, can reoccur. Can lead to amputation/death. Neuropathic patients might not feel this. Nursing care: Dressing is left 3–7 days; wound vacuums, diet: high in zinc, protein, iron, and vitamins A and C, debride necrotic tissue so wound can heel. Patient Education(Anticoagulants) • Bleeding precautions (soft toothbrush, electric razor) • Report bruising or black stools • Avoid prolonged sitting/crossing legs • Wear compression stockings b. Venous insufficiency Pathophysiology • Valves and legs are damaged due to prolong venous HTN Our previous blood clot Risk factors: • Sitting/standing in one position for a long period of time • Obesity • Pregnancy • Thrombophlebitis Clinical manifestations: • Status dermatitis(brown discoloration along ankles) • Edema • Stasis ulcers around ankles Labs/DX • D-dimer ↑ = clot breakdown evidence, detects clot Nursing interventions: Elevate legs to increase venous return (20 mins, 4-5/day), position: legs above heart, “Elevate Veins”, Apply stockings, and monitor for cellulitis Patient education: avoid sitting/standing still for too long, change positions often, avoid crossing legs, tight clothing. Apply stockings before getting out of bed in the morning Peripheral Arterial Disease (PAD) : affects blood vessels that carry blood away from the heart; artery carries blood away from heart but has difficulty going down to extremities. Pathophysiology • Atherosclerosis in lower extremities → decreased blood flow to tissues. Risk Factors • Smoking, DM, hypertension, hyperlipidemia, obesity, age, sedentary lifestyle. Clinical Manifestations • Intermittent claudication: leg pain with exercise, relieved by rest; not enough oxygen makes the tissue suffer = pain; ischemia • Pain(sharp) that is only relieved when resting in dependent position • Cool, pale, cyanotic skin • Loss of hair on legs, thick toenails • Weak/absent pedal pulses; dorsalis pedis; Doppler(verify), +1 • Numbness, burning at night • No blood and no edema due to an adequate blood flow • Note: think “A” in PAD as Antarctica, where it’s cold! For cold, pale skin! Diagnostics • ⭐️ABI < 0.9 = PAD; ankle pressure compared to break your pressure; expected finding is 0.9–1.3; less than is PAD • ⭐️Arteriography for visualization of occlusion/decreased arterial flow with contrast injection on a x-ray. Monitor for bleeding, hemorrhage, marked, pedal pulses • Doppler studies → decreased flow in DM patients • ⭐️Exercise tolerance testing → decreased pressure in lower limbs, read the workload of the heart/circulation, and clarification during exercise. May use treadmill or meds (dipyridamole, adenosine). Finding of a BP/pulse waveform = arterial disease. Monitor vitals before, during, and after. Stop test if chest pain or symptoms are severe. Nursing Interventions • Encourage graded exercise until pain, rest, repeat • Avoid elevating legs above heart (impairs flow) • Avoid cold, caffeine, nicotine, tight clothing • Keep extremities warm (no heating pad), they can’t feel • Foot care: inspect daily, no bare feet, toenails straight Medications • Antiplatelets: (aspirin, clopidogrel) reduces blood viscosity and increases blood flow and extremities. Monitor: bleeding, abdominal pain, black, tarry stools. • Statins: (atorvastatin, simvastatin). Relieved manifestations like intermittent claudication. • Pentoxifylline: improves RBC flexibility (claudication). Monitor for bleeding, abdominal pain, black tarry stools. Procedures • Angioplasty (balloon/stent). Opens and helps, maintain the patency of the vessel, however, laser vaporizes atherosclerosis plaque. Monitor for bleeding, vital signs, pulses, cap Refill. As patients rest limbs are straight for 2-6 hrs before ambulation. Anticoagulant/Antiplatelet therapy given 1-3 months after. • Atherectomy rotation, device removes, arterial plaque. Monitor for bleeding and distal pulses. rest limbs are straight for 2-6 hrs. Anticoagulant/Antiplatelet therapy given 1-3 months after. • Arterial revascularization bypass surgery • Used for clients at risk for losing a limb, severe claudication, or limb pain at rest. It reroutes the circulation around the arterial occlusion. • Post-op: ⭐️ maintain adequate circulation in repaired artery, mark pedal/dorsalis pulses(compare both), monitor color/temp, pain, cap refill, blood pressure (HTN= risk for bleeding; Hypotension=clot risk). • Complications: for these notify provider first -graft occlusion: acute blockage of bypass graft within 24 hr(absent pulse, cold foot, increased pain) -compartment syndrome: tissue pressure restricting blood flow; causing ischemia (numbness, tingling, edema, worsening/passive pain) -infection: infection of site (warm, tenderness, elevated, WBC, purulent drainage, use sterile technique) Patient Education • Walk until pain → rest → walk more • Stop smoking • Avoid crossing legs • Diet low in cholesterol and fat Postoperative Care – Peripheral Bypass/Revascularization Priorities • Assess extremity: color, temperature, cap refill, sensation, pulses q15min ×1hr • Mark pedal pulses before surgery • Maintain adequate BP (avoid hypo or hypertension) • Do not flex hip/knee excessively • Encourage ambulation when ordered • Report sudden pain, loss of pulse, pale/cool extremity = graft occlusion Complications • Graft occlusion, Compartment syndrome, Wound infection Arterial vs. Venous Ulcers Feature Arterial Ulcer Venous Ulcer Location Toes, feet, lateral ankle Medial ankle Appearance Pale, dry, round “punched out”, no drainage Irregular, leaky/moist, brown discoloration Pain Severe, worse with elevation Achy, relieved with elevation Skin Cool, shiny Warm, thickened Treatment Improve arterial flow Compression therapy, elevate legs Valvular Heart Disease OVERVIEW Overview • Stenosis = narrowed opening/thickening and hardening • Regurgitation = backflow of blood • Causes: rheumatic fever, degenerative calcification, endocarditis Diagnostics • Chest X-ray → chamber enlargement • ⭐️ECG → hypertrophy • Echo → valve dysfunction • TEE → direct view of valves ⭐️ Medications overview • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: reduce pulmonary congestion, by removing excessive extracellular fluid. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Afterload–reducing agents [Beta-blockers (-lol); calcium channel blockers (-dipine); ACE inhibitors (-pril); angiotensin–receptor blockers (-artan); vasodilators (hydralazine]): control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Inotropic agents (digoxin): increases contractility, improves cardiac output. Hold medication if pulse rate (abnormal) is less than 60/min or greater than 100/min. Take medication same time every day, avoid combining with antacids (2hrs). Monitor: toxicity such as weakness, confusion, visual changes, low appetite. • Anticoagulants: reduces risk of thrombus. Monitor: stroke, PT, INR, bleeding/bruising. Procedures • Valvuloplasty (balloon dilation) • Valve replacement • Mechanical = lifelong anticoagulants • Tissue = replace every 7–10 years Patient Education • Prophylactic antibiotics before dental procedures • Good oral hygiene • Daily weights • Sodium restriction • Avoid caffeine/alcohol • Report HF signs (weight gain, edema, SOB) • Avoid alcohol, epinephrine, and ephedrine= can cause dysrhythmias THE 4 VALVULAR DISORDERS Mitral Stenosis Etiology/Pathophysiology: Narrowed mitral valve obstructs blood flow from left atrium (LA) → left ventricle (LV), increasing LA pressure and pulmonary congestion → right-sided heart failure. Often caused by rheumatic fever. Clinical Manifestations: Dyspnea on exertion, orthopnea, pitting edema, fatigue, palpitations, hemoptysis, apical diastolic murmur. Risk Factors: Rheumatic heart disease, aging, congenital malformations. Labs/Diagnostics: Echocardiogram (valve narrowing, pressure gradient), ECG (A-fib), chest X-ray (LA enlargement). Medications/Management: • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: reduce pulmonary congestion, by removing excessive extracellular fluid. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Afterload–reducing agents [Beta-blockers (-lol); calcium channel blockers (-dipine): control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Anticoagulants: reduces risk of thrombus; prevent emboli from A-fib. Monitor: stroke, PT, INR, bleeding/bruising. • Surgical: Balloon valvuloplasty or valve replacement. NCLEX Tip: Rheumatic fever is the most common cause. Mitral Insufficiency Etiology/Pathophysiology: Incomplete closure of mitral valve causes blood to leak back into LA during systole → LV dilation and hypertrophy. Clinical Manifestations: Fatigue, dyspnea, orthopnea, palpitations, holosystolic murmur at apex, pitting edema, S3 sounds Risk Factors: Mitral valve prolapse, rheumatic disease, MI, endocarditis. Labs/Diagnostics: Echocardiogram (regurgitant volume), ECG (A-fib), BNP (HF indicator). Medications/Management: • Beta-blockers (-lol); ACE inhibitors (-pril); ARBS/angiotensin–receptor blockers (-artan): reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: manage fluid overload. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Anticoagulants if A-fib present; reduces risk of thrombus; prevent emboli from A-fib. Monitor: stroke, PT, INR, bleeding/bruising. • Surgery for severe cases. NCLEX Tip: Afterload reduction decreases regurgitant flow. Aortic Stenosis Etiology/Pathophysiology: Narrowed aortic valve → obstructed LV outflow → ↑ LV pressure → hypertrophy → ↓ cardiac output. Clinical Manifestations: Triad: angina, syncope, dyspnea (heart failure); systolic murmur radiating to carotids. Risk Factors: Aging (calcification), congenital bicuspid valve, rheumatic fever. Labs/Diagnostics: Echocardiogram (valve area), ECG (LV hypertrophy), cardiac cath (pressure gradient). Medications/Management: • Avoid nitrates/vasodilators (can cause hypotension). • Use beta-blockers (-lol) cautiously. reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Surgical aortic valve replacement (definitive). NCLEX Tip: Do not aggressively lower preload; maintain perfusion. Aortic Insufficiency Etiology/Pathophysiology: Incomplete closure of aortic valve → backflow of blood into LV → volume overload → dilation and LV hypertrophy. Clinical Manifestations: Dyspnea, palpitations, fatigue, bounding (“water hammer”) pulse, wide pulse pressure, diastolic murmur. Risk Factors: Rheumatic fever, endocarditis, Marfan syndrome, trauma. Labs/Diagnostics: Echocardiogram (backflow volume), ECG (LV enlargement), chest X-ray (cardiomegaly). Medications/Management: • Calcium channel blockers (-dipine); ACE inhibitors (-pril); vasodilators (hydralazine]): reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Diuretics for volume management. • Surgical valve replacement when severe. NCLEX Tip: Bounding pulse and wide pulse pressure are hallmark findings. General Nursing & Exam Focus • Best diagnostic test: Echocardiogram (for all). • Monitor for A-fib in mitral disorders. • Valve replacement (mechanical): Lifelong anticoagulation. • Daily weights & fluid balance: Detect early HF. • Positioning: High-Fowler’s for dyspnea, low-sodium diet. Inflammatory Heart Disorders (Endocarditis, Pericarditis, Myocarditis, Rheumatic Carditis) Risk Factors • IV drug use, valve replacement, streptococcal infection, immunosuppression, lower socioeconomic status Pericarditis: inflammation of the pericardium (sac around heart) -RF: heart attack, lupus, rheumatoid arthriti -Clinical manifestations: Chest pain (relieved when leaning forward), coughing, Pericardial friction rub, fever, dysrhythmias, and SOB -Labs/DX: • High WBCs, EKG showing ST or T spiking, echocardiogram (inflamed heart) -Nursing care/Intervention: address pain/inflammation, and monitor for cardiac tamponade, position, patient upright, leaning forward, and monitor ECG - Medications: NSAIDs, corticosteroids, anti antibiotics for bacterial • Ibuprofen/NSAIDs for inflammation (pericarditis). Avoid if patient has peptic ulcer, monitor for G.I. bleeding, platelets, liver/kidney function. Must be taken with food, avoid alcohol. • Corticosteroids (prednisone) for autoimmune causes (pericarditis/myocarditis). Low-dose first, take with food, and patient must not stop abruptly. Monitor BP, glucose, electrolytes, wounds, infection, sudden weight gain. -Complication: cardiac tamponade → muffled heart sounds, paradoxical pulse, JVD, hypotension (Beck’s triad) Myocarditis: inflammation of the myocardium (heart muscle itself) -RF: viral (covid, Coxsackie), fungal, or bacterial infection; autoimmune disorder -Clinical Manifestations: Tachycardia, chest pain, murmur, friction rub, dysrhythmias, peripheral swelling, cardiomegaly. -Labs/Dx: ECG, echocardiogram, high troponin, CK – MB, ESR in CRP for inflammation/injury -Nursing Care/interventions: monitor for heart failure, and dysrhythmia’s, provide rest and activity restriction -Medication: • Amphotericin B for fungal infection (myocarditis/endocarditis). Monitor liver/kidney function for a G.I. upset. • Corticosteroids (prednisone) for autoimmune causes (pericarditis/myocarditis). Low-dose first, take with food, and patient must not stop abruptly. Monitor BP, glucose, electrolytes, wounds, infection, sudden weight gain. Endocarditis: bacterial infection that leaves inflammation of the endocardium (inner layer of the heart); bacterial or fungal Infection of endocardial tissues that leads to necrosis and embolization of growth -RF: congenital/valvular heart disease, prosthetic valve, IV drug use -Clinical Manifestations: janeway lesions, Fever, murmur, petechiae, splinter hemorrhages (red streaks under nail beds), Osler’s nodes -labs/dx: positive blood culture, echocardiogram -nursing interventions/care: administer IV antibiotics, antipyretics for fever, and anticoagulants, patient should use soft toothbrush, and prophylactic antibiotics before dental/invasive procedures -medication: • Penicillin for infection (rheumatic fever/endocarditis). Monitor for allergic reaction, kidney function/electrolytes. • Amphotericin B for fungal infection (myocarditis/endocarditis). Monitor liver/kidney function for a G.I. upset. Rheumatic Carditis/heart disease: infection of endocardium due to complication of rheumatic fever; GABHS triggers, rheumatic fever leading to inflammatory lesions in the heart -RF: children, Follows untreated strep infection -Clinical Manifestations: tachycardia, Fever, rash(trunk/extremities), joint pain, murmur, chest pain, muscle spasms, friction rub -Labs/Dx: throat culture (strep infection), positive ASO titer, echocardiogram -Nursing care/Interventions: administering antibiotics to stop strep infection, and promote rest, monitor for heart failure, and encourage life on prophylactic antibiotics. -Medications: antibiotics, valve replacement/repair • Penicillin for infection (rheumatic fever/endocarditis). Monitor for allergic reaction, kidney function/electrolytes. Nursing Interventions (Overview for Inflammatory disorders) • Monitor for tamponade & HF • Administer antibiotics (penicillin) • Pain relief (NSAIDs for pericarditis) • Bed rest • Emotional support • Auscultate heart sounds; murmur or friction rub • Collab with cardiologist and physical therapists Procedures (Overview for Inflammatory disorders) • Pericardiocentesis for fluid removal, then sent to laboratory; monitor for recurrence of cardiac tamponade. ( pericarditis.) • Valve surgery if damaged Complications (Overview for Inflammatory disorders) • Cardiac tamponade: medical emergency resulted from fluid accumulation in pericardial sac. S/S: dyspnea, dizziness, tightness in chest, restlessness. Administer IV fluids, notify the provider, obtain chest, x-ray or ECG Cardiac Diagnostics & Vascular Access (Ch. 28) Transesophageal Echocardiography (TEE) Provides clear heart images via probe in the esophagus to detect valve disease, thrombi, or heart failure. NPO 4–6 hr, monitor VS, ECG, and sedation; check gag reflex before eating post-procedure; keep HOB 45°. Stress Testing (Exercise or Pharmacologic) Assesses heart’s response to stress for angina, HF, MI, or dysrhythmia. NPO 2–4 hr, avoid caffeine/tobacco, wear comfortable clothes; stop test for chest pain, SOB, dizziness. Post: monitor ECG & BP until stable. Coronary Angiography (Cardiac Catheterization) Identifies coronary artery blockages using contrast dye via femoral, radial, or brachial artery. NPO 4–6 hr, assess renal function, allergies (iodine/shellfish), and hold metformin 48 hr before/after. Post: monitor VS and site for bleeding, hematoma, or thrombosis, keep limb straight, maintain bedrest. Complications: cardiac tamponade (↓BP, JVD, muffled heart sounds), embolism, hematoma, AKI—notify provider. Teach: report chest pain, bleeding, SOB, avoid lifting >10 lb, and take antiplatelets as prescribed if stent placed. Vascular Access Devices (VADs) Provide reliable central access for fluids, meds, TPN, or blood. Verify tip placement via x-ray before use. PICC: up to 12 mo use, insert in basilic/cephalic vein → SVC; no BP/venipuncture in that arm, keep dressing dry. Tunneled Catheter: long-term use, subcutaneous tunnel prevents infection; no dressing once healed. Implanted Port: long-term chemo access; access with Huber needle, flush with heparin after use. Complications: • Phlebitis: redness, pain, warmth—maintain sterile technique. • Occlusion: flush gently with 10 mL syringe; never force. • Mechanical issues: swelling or pain at port site = dislodgement → notify provider

A person who often helps others

Chapter 5 Vocabulary Quiz #1 Nouns: cura, curae, f. care, anxiety exemplum, exempli, n. example, model sapientia, sapientiae, f. wisdom terra, terrae, f. land, earth, soil; country Verbs: iacto, iactare, iactavi, iactatus to throw sum, esse, fui, futurus to be, exist Adjectives aeger, aegra, aegrum sick, weak altus, alta, altum high, deep bonus, bona, bonum good divinus, divina, divinum divine, of the gods; prophetic liber, libera, liberum free Quiz #2: longus, longa, longum long magnus, magna, magnum large, great malus, mala, malum bad meus, mea, meum my, mine multus, multa, multum much; many (pl.) noster, nostra, nostrum our, ours parvus, parva, parvum small primus, prima, primum first pulcher, pulchra, pulchrum beautiful, handsome; fine tuus, tua, tuum your, yours, your own (sg) vester, vestra, vestrum your, yours (pl) Prepositions: cum (+abl) with sub (+abl) under, beneath sub (+acc) to the foot/base of, along under (implying motion) Chapter 4 Vocabulary Please note that all long marks (macrons) must be memorized!e, ex Quiz #1 Nouns: factum, facti, n. deed, act, exploit, achievement oculus, oculi, m. eye saxum, saxi, n. rock, stone; cliff verbum, verbi, n. word via, viae, f. road; way Verbs: ambulo, ambulare, ambulavi, ambulaturus to walk erro, errare, erravi, erratus to wander; err festino, festinare, festinavi, festinatus to hurry, hasten Quiz #2: navigo, navigare, navigavi, navigatus to sail sedeo, sedēre, sēdi, sessurus to sit Adverbs: facile easily non not saepe often semper always tandem finally tum then, at that time; next Prepositions: a, ab (+abl) away from ad (+acc) to, toward e, ex (+abl) out of, from in (+abl) in, on in (+acc) into, onto, against post (+acc) behind, after pro (+abl) in front of; on behalf of; instead of trans (+acc) across Chapter 3 Vocabulary Please note that all long marks (macrons) must be memorized! Quiz #1 Nouns: arma, armorum, n. (pl) arms, weapons caelum, caeli, n. sky, heavens cena, cenae, f. dinner dea, deae, f. goddess dat. pl. and abl. pl. = deabus deus, dei, m. god nom. pl. = di; dat. pl. and abl. pl. = dis fabula, fabulae, f. story filius, filii, m. (voc. sing = fili) son imperium, imperii, n. command, (military) power liber, libri, m. book nemo, m./f. no one acc. sing. = neminem pontus, ponti, m. sea, ocean Romulus, Romuli, m. Romulus (legendary founder of Rome) Quiz #2: silva, silvae, f. forest, wood templum, templi, n. temple, shrine turba, turbae, f. crowd ventus, venti, m. wind, breeze Verbs: aedifico, aedificare, aedificavi, aedificatus to build do, dare, dedi, datus to give impleo, implēre, implevi, impletus to fill, fill up; complete monstro, monstrare, monstravi, monstratus to show, demonstrate narro, narrare, narravi, narratus to tell (a story) paro, parare, paravi, paratus to prepare porto, portare, portavi, portatus to carry, bring pugno, pugnare, pugnavi, pugnatus to fight Chapter 2 Vocabulary Please note that all long marks (macrons) must be memorized! Quiz #1 Nouns: ager, agri, m. (cultivated) field; countryside amicus, amici, m. friend animus, animi, m. mind, spirit, courage; soul bellum, belli, n. war casa, casae, f. house, hut consilium, consilii, n. plan, advice dominus, domini, m. master, lord donum, doni, n. gift, present locus, loci, m. place, position (in pl. sometimes also neuter) luna, lunae, f. moon natura, naturae, f. nature puer, pueri, m. boy Quiz #2: puella, puellae, f. girl regnum, regni, n. kingdom, royal power vir, viri, m. man; occasionally “husband” Verbs: audeo, audēre, ausus sum to dare clamo, clamare, clamavi, clamatus to shout dubito, dubitare, dubitavi, dubitatus to hesitate, doubt rideo, ridēre, risi, risus to laugh, laugh at soleo, solēre, solitus sum to be accustomed Coordinating Conjunctions: et and et...et both...and -que (translate to the left of word it’s added to) and sed but Chapter 1 Vocabulary Quiz #1 Nouns agricola, agricolae, m. farmer aqua, aquae, f. water femina, feminae, f. woman fortuna, fortunae, f. chance, luck, fortune nauta, nautae, m. sailor pecunia, pecuniae, f. money, property rosa, rosae, f. rose Verbs amo, amare, amavi, amatus to love debeo, debēre, debui, debitus “ought to, should;” to owe; to be obligated to habeo, habēre, habui, habitus to have; consider iaceo, iacēre, iacui, iaciturus to lie (e.g. on the ground) Quiz #2 iuvo, iuvare, iuvi, iutus to help; please laboro, laborare, laboravi, laboratus to work, strive laudo, laudare, laudavi, laudatus to praise moneo, monēre, monui, monitus to advise, warn, remind opto, optare, optavi, optatus to choose, desire, wishfor supero, superare, superavi, superatus to overcome, conquer, surpass taceo, tacēre, tacui, taciturus to be silent (“I am silent

Regulation of Gene Expression Lecture Outline Overview: Differential Expression of Genes • Both prokaryotes and eukaryotes alter their patterns of gene expression in response to changes in environmental conditions. • Multicellular eukaryotes also develop and maintain multiple cell types. ○ Each cell type contains the same genome but expresses a different subset of genes. ○ During development, gene expression must be carefully regulated to ensure that the right genes are expressed only at the correct time and in the correct place. • Gene expression in eukaryotes and bacteria is often regulated at the transcription stage. ○ Control of other levels of gene expression is also important. • RNA molecules play many roles in regulating eukaryotic gene expressions. • Disruptions in gene regulation may lead to cancer. Concept 18.1 Bacteria often respond to environmental change by regulating transcription • Natural selection favors bacteria that express only those genes whose products are needed by the cell. ○ A bacterium in a tryptophan-rich environment that stops producing tryptophan conserves its resources. • Metabolic control occurs on two levels. • First, cells can adjust the activity of enzymes already present. ○ This may happen by feedback inhibition, in which the activity of the first enzyme in a pathway is inhibited by the pathway’s end product. ○ Feedback inhibition, typical of anabolic (biosynthetic) pathways, allows a cell to adapt to short-term fluctuations in the supply of a needed substance. • Second, cells can vary the number of specific enzyme molecules they make by regulating gene expression. ○ The control of enzyme production occurs at the level of transcription, the synthesis of messenger RNA coding for these enzymes. ○ Genes of the bacterial genome may be switched on or off by changes in the metabolic status of the cell. • The basic mechanism for the control of gene expression in bacteria, known as the operon model, was described by Francois Jacob and Jacques Monod in 1961. The operon model controls tryptophan synthesis. • Escherichia coli synthesizes tryptophan from a precursor molecule in a series of steps, with each reaction catalyzed by a specific enzyme. • The five genes coding for the subunits of these enzymes are clustered together on the bacterial chromosome as a transcription unit, served by a single promoter. • Transcription gives rise to one long mRNA molecule that codes for all five polypeptides in the tryptophan pathway. • The mRNA is punctuated with start and stop codons that signal where the coding sequence for each polypeptide begins and ends. • A key advantage of grouping genes with related functions into one transcription unit is that a single on-off switch can control a cluster of functionally related genes. ○ In other words, these genes are coordinately controlled. • When an E. coli cell must make tryptophan for itself, all the enzymes are synthesized at one time. • The switch is a segment of DNA called an operator. • The operator, located within the promoter or between the promoter and the enzyme-coding genes, controls the access of RNA polymerase to the genes. • The operator, the promoter, and the genes they control constitute an operon. ○ The trp operon (trp for tryptophan) is one of many operons in the E. coli genome. • By itself, an operon is turned on: RNA polymerase can bind to the promoter and transcribe the genes of the operon. • The operon can be switched off by a protein called the trp repressor. ○ The repressor binds to the operator, blocks attachment of RNA polymerase to the promoter, and prevents transcription of the operon’s genes. • Each repressor protein recognizes and binds only to the operator of a particular operon. • The trp repressor is the protein product of a regulatory gene called trpR, which is located at some distance from the operon it controls and has its own promoter. • Regulatory genes are transcribed continuously at slow rates, and a few trp repressor molecules are always present in an E. coli cell. • Why is the trp operon not switched off permanently? • First, binding by the repressor to the operator is reversible. ○ An operator vacillates between two states, with and without a repressor bound to it. ○ The relative duration of each state depends on the number of active repressor molecules around. • Second, repressors contain allosteric sites that change shape depending on the binding of other molecules. ○ The trp repressor has two shapes: active and inactive. ○ The trp repressor is synthesized in an inactive form with little affinity for the trp operator. ○ Only if tryptophan binds to the trp repressor at an allosteric site does the repressor protein change to the active form that can attach to the operator, turning the operon off. • Tryptophan functions in the trp operon as a corepressor, a small molecule that cooperates with a repressor protein to switch an operon off. • When concentrations of tryptophan in the cell are high, more tryptophan molecules bind with trp repressor molecules, activating them. ○ The active repressors bind to the trp operator and turn the operon off. • At low levels of tryptophan, most of the repressors are inactive, and transcription of the operon’s genes resumes. There are two types of operons: repressible and inducible. • The trp operon is an example of a repressible operon, one that is inhibited when a specific small molecule (tryptophan) binds allosterically to a regulatory protein. • In contrast, an inducible operon is stimulated (induced) when a specific small molecule interacts with a regulatory protein. • The classic example of an inducible operon is the lac operon (lac for lactose). • Lactose (milk sugar) is available to E. coli in the human colon if the host drinks milk. ○ Lactose metabolism begins with hydrolysis of lactose into its component monosaccharides, glucose and galactose. ○ This reaction is catalyzed by the enzyme ß-galactosidase. • Only a few molecules of b-galactosidase are present in an E. coli cell grown in the absence of lactose. ○ If lactose is added to the bacterium’s environment, the number of ß-galactosidase molecules increases by a thousandfold within 15 minutes. • The gene for ß-galactosidase is part of the lac operon, which includes two other genes coding for enzymes that function in lactose metabolism. • The regulatory gene, lacI, located outside the operon, codes for an allosteric repressor protein that can switch off the lac operon by binding to the operator. • Unlike the trp operon, the lac repressor is active all by itself, binding to the operator and switching the lac operon off. ○ An inducer inactivates the repressor. ○ When lactose is present in the cell, allolactose, an isomer of lactose, binds to the repressor. ○ This inactivates the repressor, and the lac operon can be transcribed. • Repressible enzymes generally function in anabolic pathways, synthesizing end products from raw materials. ○ When the end product is present in sufficient quantities, the cell can allocate its resources to other uses. • Inducible enzymes usually function in catabolic pathways, digesting nutrients to simpler molecules. ○ By producing the appropriate enzymes only when the nutrient is available, the cell avoids making proteins that are not needed. • Both repressible and inducible operons demonstrate negative control of genes because active repressors switch off the active form of the repressor protein. ○ It may be easier to see this for the trp operon, but it is also true for the lac operon. ○ Allolactose induces enzyme synthesis not by acting directly on the genome, but by freeing the lac operon from the negative effect of the repressor. Some gene regulation is positive. • Positive gene control occurs when a protein molecule interacts directly with the genome to switch transcription on. • The lac operon is an example of positive gene regulation. • When glucose and lactose are both present, E. coli preferentially uses glucose. ○ The enzymes for glucose breakdown in glycolysis are always present in the cell. • Only when lactose is present and glucose is in short supply does E. coli use lactose as an energy source and synthesize the enzymes for lactose breakdown. • When glucose levels are low, cyclic AMP (cAMP) accumulates in the cell. • The regulatory protein catabolite activator protein (CAP) is an activator of transcription. • When cAMP is abundant, it binds to CAP, and the regulatory protein assumes its active shape and can bind to a specific site at the upstream end of the lac promoter. ○ The attachment of CAP to the promoter increases the affinity of RNA polymerase for the promoter, directly increasing the rate of transcription. ○ Thus, this mechanism qualifies as positive regulation. • If glucose levels in the cell rise, cAMP levels fall. ○ Without cAMP, CAP detaches from the operon and lac operon is transcribed only at a low level. • The lac operon is under dual control: negative control by the lac repressor and positive control by CAP. ○ The state of the lac repressor (with or without bound allolactose) determines whether or not the lac operon’s genes are transcribed. ○ The state of CAP (with or without bound cAMP) controls the rate of transcription if the operon is repressor-free. ○ The operon has both an on-off switch and a volume control. • CAP works on several operons that encode enzymes used in catabolic pathways. It affects the expression of more than 100 E. coli genes. ○ If glucose is present and CAP is inactive, then the synthesis of enzymes that catabolize other compounds is slowed. ○ If glucose levels are low and CAP is active, then the genes that produce enzymes that catabolize whichever other fuel is present are transcribed at high levels. Concept 18.2 Eukaryotic gene expression is regulated at many stages • Like unicellular organisms, the tens of thousands of genes in the cells of multicellular eukaryotes turn on and off in response to signals from their internal and external environments. • Gene expression must be controlled on a long-term basis during cellular differentiation. Differential gene expression is the expression of different genes by cells with the same genome. • A typical human cell probably expresses about 20% of its genes at any given time. ○ Highly specialized cells, such as nerves or muscles, express a tiny fraction of their genes. ○ Although all the cells in an organism contain an identical genome, the subset of genes expressed in the cells of each type is unique. • The differences between cell types are due to differential gene expression, the expression of different genes by cells with the same genome. • The function of any cell, whether a single-celled eukaryote or a particular cell type in a multicellular organism, depends on the appropriate set of genes being expressed. ○ Problems with gene expression and control can lead to imbalance and disease, including cancer. • Our understanding of the mechanisms that control gene expression in eukaryotes has been enhanced by new research methods, including advances in DNA technology. • In all organisms, a common control point for gene expression is at transcription, often in response to signals coming from outside the cell. ○ For this reason, the term gene expression is often equated with transcription. • With their greater complexity, eukaryotes have opportunities for controlling gene expression at additional stages. Chromatin modifications affect the availability of genes for transcription. • The DNA of eukaryotic cells is packaged with proteins in a complex called chromatin. ○ The basic unit of chromatin is the nucleosome. • The location of a gene’s promoter relative to nucleosomes and to the sites where the DNA attaches to the chromosome scaffold or nuclear lamina affect whether the gene is transcribed. • Genes of densely condensed heterochromatin are usually not expressed. • Chemical modifications of the histone proteins and DNA of chromatin play a key role in chromatin structure and gene expression. • The N-terminus of each histone molecule in a nucleosome protrudes outward from the nucleosome. ○ These histone tails are accessible to various modifying enzymes, which catalyze the addition or removal of specific chemical groups. • Histone acetylation (addition of an acetyl group, —COCH3) and deacetylation of lysines in histone tails appear to play a direct role in the regulation of gene transcription. • Acetylation of lysines neutralizes their positive charges and reduces the binding of histone tails to neighboring nucleosomes, easing access for transcription proteins. ○ Some of the enzymes responsible for acetylation or deacetylation are associated with or are components of transcription factors that bind to promoters. • Thus, histone acetylation enzymes may promote the initiation of transcription not only by modifying chromatin structure but also by binding to and recruiting components of the transcription machinery. • Other chemical groups, such as methyl and phosphate groups, can be reversibly attached to amino acids in histone tails. ○ The attachment of methyl groups (—CH3) to histone tails leads to condensation of chromatin. ○ The addition of a phosphate group (phosphorylation) to an amino acid next to a methylated amino acid has the opposite effect. • The recent discovery that modifications to histone tails can affect chromatin structure and gene expression has led to the histone code hypothesis. ○ This hypothesis proposes that specific combinations of modifications, as well as the order in which they have occurred, determine chromatin configuration. ○ Chromatin configuration in turn influences transcription. DNA methylation reduces gene expression. • While some enzymes methylate the tails of histone proteins, other enzymes methylate certain bases in DNA itself, usually cytosine. ○ DNA methylation occurs in most plants, animals, and fungi. • Inactive DNA is generally more highly methylated than actively transcribed regions. ○ For example, the inactivated mammalian X chromosome is heavily methylated. ○ Individual genes are usually more heavily methylated in cells where they are not expressed. Removal of extra methyl groups can turn on some of these genes. • In some species, DNA methylation is responsible for the long-term inactivation of genes during cellular differentiation. ○ Deficient DNA methylation leads to abnormal embryonic development in organisms as different as mice and the plant Arabidopsis. • Once methylated, genes usually stay that way through successive cell divisions in a given individual. • Methylation enzymes recognize sites on one strand that are already methylated and correctly methylate the daughter strand after each round of DNA replication. • This methylation pattern accounts for genomic imprinting, in which methylation turns off either the maternal or paternal alleles of certain mammalian genes at the start of development. • The chromatin modifications just discussed do not alter the DNA sequence, and yet they may be passed along to future generations of cells. • Inheritance of traits by mechanisms not directly involving the nucleotide sequence is called epigenetic inheritance. • The molecular systems for chromatin modification may well interact with each other in a regulated way. ○ In Drosophila, experiments suggest that a particular histone-modifying enzyme recruits a DNA methylation enzyme to one region and that the two enzymes collaborate to silence a particular set of genes. ○ Working in the opposite order, proteins have also been found that bind to methylated DNA and then recruit histone deacetylation enzymes. ○ Thus, a dual mechanism, involving both DNA methylation and histone deacetylation, can repress transcription. • Researchers are amassing more and more evidence for the importance of epigenetic information in the regulation of gene expression. ○ Epigenetic variations may explain why one identical twin acquires a genetically based disease, such as schizophrenia, while another does not, despite their identical genomes. ○ Alterations in normal patterns of DNA methylation are seen in some cancers, where they are associated with inappropriate gene expression. • Enzymes that modify chromatin structure are integral parts of the cell’s machinery for regulating transcription. Transcription initiation is controlled by proteins that interact with DNA and with each other. • Chromatin-modifying enzymes provide initial control of gene expression by making a region of DNA more available or less available for transcription. • A cluster of proteins called a transcription initiation complex assembles on the promoter sequence at the upstream end of the gene. ○ One component, RNA polymerase II, transcribes the gene, synthesizing a primary RNA transcript or pre-mRNA. ○ RNA processing includes enzymatic addition of a 5¢ cap and a poly-A tail, as well as splicing out of introns to yield a mature mRNA. • Multiple control elements are associated with most eukaryotic genes. ○ Control elements are noncoding DNA segments that serve as binding sites for protein transcription factors. ○ Control elements and the transcription factors they bind are critical to the precise regulation of gene expression in different cell types. • To initiate transcription, eukaryotic RNA polymerase requires the assistance of proteins called transcription factors. • General transcription factors are essential for the transcription of all protein-coding genes. ○ Only a few general transcription factors independently bind a DNA sequence such as the TATA box within the promoter. ○ Others are involved in protein-protein interactions, binding each other and RNA polymerase II. • Only when the complete initiation complex has been assembled can the polymerase begin to move along the DNA template strand to produce a complementary strand of RNA. • The interaction of general transcription factors and RNA polymerase II with a promoter usually leads to only a slow rate of initiation and the production of few RNA transcripts. • In eukaryotes, high levels of transcription of particular genes depend on the interaction of control elements with specific transcription factors. • Some control elements, named proximal control elements, are located close to the promoter. • Distal control elements, grouped as enhancers, may be thousands of nucleotides away from the promoter or even downstream of the gene or within an intron. • A given gene may have multiple enhancers, each active at a different time or in a different cell type or location in the organism. ○ Eukaryotic gene expression can be altered by the binding of specific transcription factors, either activators or repressors, to the control elements of enhancers. • Two structural elements are common to many activator proteins: a DNA-binding domain and one or more activation domains. ○ Activation domains bind other regulatory proteins or components of the transcription machinery to facilitate transcription. • Protein-mediated bending of DNA brings bound activators in contact with a group of mediator proteins that interact with proteins at the promoter. ○ These interactions help assemble and position the initiation complex on the promoter. • Eukaryotic repressors can inhibit gene expression by blocking the binding of activators to their control elements or to components of the transcription machinery. ○ Other repressors bind directly to control-element DNA, turning off transcription even in the presence of activators. • Some activators and repressors act indirectly to influence chromatin structure. ○ Some activators recruit proteins that acetylate histones near the promoters of specific genes, promoting transcription. ○ Some repressors recruit proteins that deacetylate histones, reducing transcription or silencing the gene. • Recruitment of chromatin-modifying proteins seems to be the most common mechanism of repression in eukaryotes. The control of transcription in eukaryotes depends on the binding of activators to DNA control elements. • The number of different nucleotide sequences found in control elements is surprisingly small: about a dozen. • On average, each enhancer is composed of about ten control elements, each of which can bind to only one or two specific transcription factors. ○ The particular combination of control elements in an enhancer may be more important than the presence of a unique control element in regulating transcription of the gene. • Even with only a dozen control element sequences, a large number of combinations are possible. • A particular combination of control elements is able to activate transcription only when the appropriate activator proteins are present, at a precise time during development or in a particular cell type. • The use of different combinations of control elements allows fine regulation of transcription with a small set of control elements. • In prokaryotes, coordinately controlled genes are often clustered into an operon with a single promoter and other control elements upstream. ○ The genes of the operon are transcribed into a single mRNA and translated together. • In contrast, very few eukaryotic genes are organized this way. • More commonly, co-expressed genes coding for the enzymes of a metabolic pathway are scattered over different chromosomes. ○ Coordinate gene expression depends on the association of a specific control element or combination of control elements with every gene of a dispersed group. ○ A common group of transcription factors binds to all the genes in the group, promoting simultaneous gene transcription. • For example, a steroid hormone enters a cell and binds to a specific receptor protein in the cytoplasm or nucleus, forming a hormone–receptor complex that serves as a transcription activator. ○ Every gene whose transcription is stimulated by that steroid hormone has a control element recognized by that hormone–receptor complex. • Other signal molecules control gene expression indirectly by triggering signal-transduction pathways that lead to activation of transcription. ○ The principle of coordinate regulation is the same: Genes with the same control elements are activated by the same chemical signals. • Systems for coordinating gene regulation probably arose early in evolutionary history. • The nucleus has a defined architecture and regulated movements of chromatin. • Recent techniques allow researchers to cross-link and identify regions of chromosomes that associate with each other during interphase. • Loops of chromatin extend from individual chromosomal territories into specific sites in the nucleus. ○ Different loops from the same chromosome and loops from other chromosomes congregate in such sites, some of which are rich in RNA polymerases and other transcription-associated proteins. ○ These sites are likely areas specialized for a common function or transcription factories. Post-transcriptional mechanisms play supporting roles in the control of gene expression. • Regulatory mechanisms that operate after transcription allow a cell to rapidly fine-tune gene expression in response to environmental changes, without altering its transcriptional patterns. ○ RNA processing in the nucleus and the export of mRNA to the cytoplasm provide opportunities for gene regulation that are not available in prokaryotes. • In alternative RNA splicing, different mRNA molecules are produced from the same primary transcript, depending on which RNA segments are treated as exons and which as introns. ○ Regulatory proteins specific to a cell type control intron-exon choices by binding to regulatory sequences within the primary transcript. • Alternative RNA splicing significantly expands the repertoire of a set of genes. ○ It may explain the surprisingly low number of human genes: similar to those of a soil worm, a mustard plant, or a sea anemone. ○ Between 75% and 100% of human genes that have multiple exons probably undergo alternative splicing. ○ The extent of alternative splicing increases the number of possible human proteins, likely correlated with complexity of form. • The life span of an mRNA molecule is an important factor in determining the pattern of protein synthesis. ○ Prokaryotic mRNA molecules are typically degraded after only a few minutes, while eukaryotic mRNAs typically last for hours, days, or weeks. ○ In red blood cells, mRNAs for hemoglobin polypeptides are unusually stable and are translated repeatedly. • Nucleotide sequences in the untranslated trailer region (UTR) at the 3¢ end affect mRNA stability. ○ Transferring such a sequence from a short-lived mRNA to a normally stable mRNA results in quick mRNA degradation. Translation presents an opportunity for the regulation of gene expression. • The initiation of translation of an mRNA can be blocked by regulatory proteins that bind to specific sequences within the 5¢ or 3¢ UTR of the mRNA, preventing ribosome attachment. • The mRNAs present in the eggs of many organisms lack poly-A tails of sufficient length to allow initiation of translation. ○ During embryonic development, a cytoplasmic enzyme adds more adenine nucleotides so that translation can begin at the appropriate time. • Translation of all the mRNAs in a eukaryotic cell may be regulated simultaneously by the activation or inactivation of the protein factors required to initiate translation. ○ This mechanism starts the translation of mRNAs that are stored in eggs. ○ Just after fertilization, translation is triggered by the sudden activation of translation initiation factors, resulting in a burst of protein synthesis. • Some plants and algae store mRNAs during periods of darkness. Light triggers the reactivation of the translational apparatus. The final opportunities for controlling gene expression occur after translation. • Often, eukaryotic polypeptides are processed to yield functional proteins. ○ For example, cleavage of pro-insulin forms the active hormone. • Many proteins must undergo chemical modifications before they are functional. ○ Regulatory proteins may be activated or inactivated by the reversible addition of phosphate groups. ○ Proteins destined for the surface of animal cells acquire sugars. • Regulation may occur at any of the steps involved in modifying or transporting a protein. • The length of time a protein functions before it is degraded is strictly regulated. ○ Proteins such as the cyclins that regulate the cell cycle must be relatively short-lived. • To mark a protein for destruction, the cell attaches a small protein called ubiquitin to it. ○ Giant protein complexes called proteasomes recognize and degrade the tagged proteins. • Mutations making specific cell cycle proteins impervious to proteasome degradation can lead to cancer. • The scientists worked out the regulated process of protein degradation won the 2004 Nobel Prize in Chemistry. Concept 18.3 Noncoding RNAs play multiple roles in controlling gene expression • Only 1.5% of the human genome codes for proteins. Of the remainder, only a very small fraction consists of genes for ribosomal RNA and transfer RNA. • Until recently, it was assumed that most of the rest of the DNA was untranscribed. Recent data have challenged that assumption, however. ○ Study of a region comprising 1% of the human genome found that over 90% of the region was transcribed. ○ Introns accounted for only a fraction of this transcribed, nontranslated RNA. • A significant amount of the genome may be transcribed into non–protein-coding RNAs (or noncoding RNAs or ncRNAs), including a variety of small RNAs. • A large, diverse population of RNA molecules may play crucial roles in regulating gene expression in the cell. MicroRNAs can bind to complementary sequences in mRNA molecules. • In the past few years, researchers have found small, single-stranded RNA molecules called microRNAs (miRNAs) that bind to complementary sequences in mRNA molecules. • miRNAs are formed from longer RNA precursors that fold back on themselves to form one or more short, double-stranded hairpin structures stabilized by hydrogen bonding. • An enzyme called Dicer cuts each hairpin into a short, double-stranded fragment of about 22 nucleotide pairs. • One of the two strands is degraded. The other strand (miRNA) associates with a protein complex and directs the complex to any mRNA molecules that have a complementary sequence of 7-8 nucleotides. • The miRNA–protein complex either degrades the target mRNA or blocks its translation. • Expression of up to one-half of all human genes may be regulated by miRNAs. • The phenomenon of inhibition of gene expression by RNA molecules is called RNA interference (RNAi). • Injecting double-stranded RNA molecules into a cell somehow turns off expression of a gene with the same sequence as the RNA. ○ This RNA interference is due to small interfering RNAs (siRNAs), similar in size and function to miRNAs and are generated by similar mechanisms in eukaryotic cells. • Both miRNAs and siRNAs can associate with the same proteins, with similar results. ○ The distinction between these molecules is the nature of the precursor molecules from which they are formed. ○ Each miRNA forms from a single hairpin in the precursor RNA, while multiple siRNAs form from a longer, double-stranded RNA molecule. • Cellular RNAi pathways lead to the destruction of RNAs and may have originated as a natural defense against infection by double-stranded RNA viruses. ○ The fact that the RNAi pathway can also affect the expression of nonviral cellular genes may reflect a different evolutionary origin for the RNAi pathway. • Many species, including mammals, possess long, double-stranded precursors to small RNAs that interfere with various steps in gene expression. Small RNAs can remodel chromatin and silence transcription. • Small RNAs can cause remodeling of chromatin structure. ○ In yeast, siRNAs are necessary for the formation of heterochromatin at the centromeres of chromosomes. • An RNA transcript produced from DNA in the centromeric region of the chromosome is copied into double-stranded RNA by a yeast enzyme and then processed into siRNAs. ○ The siRNAs associate with a protein complex, targeting the complex back to the RNA sequences made from the centromeric sequences of DNA. ○ The proteins in the complex recruit enzymes to modify the chromatin, turning it into the highly condensed centromeric heterochromatin. • A newly discovered class of small ncRNAs, called piwi-associated RNAs (piRNAs) also induce formation of heterochromatin, blocking expression of parasitic DNA elements in the genome known as transposons. ○ piRNAs, 24–31 nucleotides in length, are processed from single-stranded RNA precursors. ○ In germ cells of many animal species, piRNAs help re-establish appropriate methylation patterns in the genome during gamete formation. • Chromatin remodeling not only blocks expression of large regions of the chromosome; RNA-based mechanisms may also block the transcription of specific genes. ○ Some plant miRNAs have sequences that bind to gene promoters and can repress transcription; piRNAs can also block expression of specific genes. ○ In some cases, miRNAs and piRNAs activate gene expression. • Small ncRNAs regulate gene expression at multiple steps and in many ways. ○ Extra levels of gene regulation may allow evolution of a higher degree of complexity of form. ○ An increase in the number of miRNAs encoded in the genomes of species may have allowed morphological complexity to increase over evolutionary time. • A survey of species suggests that siRNAs evolved first, followed by miRNAs and later piRNAs, which are found only in animals. ○ While there are hundreds of types of miRNA, there appear to be many thousands of types of piRNAs, allowing the potential for very sophisticated gene regulation by piRNAs. • Many ncRNAs play important roles in embryonic development, the ultimate example of an elaborate program of regulated gene expression. Concept 18.4 A program of differential gene expression leads to the different cell types in a multicellular organism • In the development of most multicellular organisms, a single-celled zygote gives rise to cells of many different types. ○ Each type has a different structure and corresponding function. ○ Cells of different types are organized into tissues, tissues into organs, organs into organ systems, and organ systems into the whole organism. • Thus, the process of embryonic development must give rise not only to cells of different types but also to higher-level structures arranged in a particular way in three dimensions. A genetic program is expressed during embryonic development. • As a zygote develops into an adult organism, its transformation results from three interrelated processes: cell division, cell differentiation, and morphogenesis. • Through a succession of mitotic cell divisions, the zygote gives rise to many cells. ○ Cell division alone would produce only a great ball of identical cells. • During development, cells become specialized in structure and function, undergoing cell differentiation. • Different kinds of cells are organized into tissues and organs. • The physical processes that give an organism its shape constitute morphogenesis, the “creation of form.” • Cell division, cell differentiation, and morphogenesis have their basis in cellular behavior. ○ Morphogenesis can be traced back to changes in the shape and motility of cells in the various embryonic regions. ○ The activities of a cell depend on the genes it expresses and the proteins it produces. ○ Because almost all cells in an organism have the same genome, differential gene expression results from differential gene regulation in different cell types. • Why are different sets of activators present in different cell types? • One important source of information early in development is the egg’s cytoplasm, which contains both RNA and proteins encoded by the mother’s DNA, distributed unevenly in the unfertilized egg. • Maternal substances that influence the course of early development are called cytoplasmic determinants. ○ These substances regulate the expression of genes that affect the developmental fate of the cell. ○ After fertilization, the cell nuclei resulting from mitotic division of the zygote are exposed to different cytoplasmic environments. ○ The set of cytoplasmic determinants a particular cell receives helps determine its developmental fate by regulating expression of the cell’s genes during cell differentiation. • The other important source of developmental information is the environment around the cell, especially signals impinging on an embryonic cell from nearby cells. ○ In animals, these signals include contact with cell-surface molecules on neighboring cells and the binding of growth factors secreted by neighboring cells. • These signals cause changes in the target cells, a process called induction. ○ The molecules conveying these signals within the target cells are cell-surface receptors and other proteins expressed by the embryo’s own genes. ○ The signal molecules send a cell down a specific developmental path by causing a change in its gene expression that eventually results in observable cellular changes. Cell differentiation is due to the sequential regulation of gene expression. • During embryonic development, cells become visibly different in structure and function as they differentiate. • The earliest changes that set a cell on a path to specialization show up only at the molecular level. ○ Molecular changes in the embryo drive the process, called determination, which leads to the observable differentiation of a cell. • Once it has undergone determination, an embryonic cell is irreversibly committed to its final fate. ○ If a determined cell is experimentally placed in another location in the embryo, it will differentiate as if it were in its original position. • The outcome of determination—observable cell differentiation—is caused by the expression of genes that encode tissue-specific proteins. ○ These proteins give a cell its characteristic structure and function. • Differentiation begins with the appearance of cell-specific mRNAs and is eventually observable in the microscope as changes in cellular structure. • In most cases, the pattern of gene expression in a differentiated cell is controlled at the level of transcription. • Cells produce the proteins that allow them to carry out their specialized roles in the organism. ○ For example, liver cells specialize in making albumin, while lens cells specialize in making crystalline. ○ Skeletal muscle cells have high concentrations of proteins specific to muscle tissues, such as a muscle-specific version of the contractile proteins myosin and actin, as well as membrane receptor proteins that detect signals from nerve cells. • Muscle cells develop from embryonic precursors that have the potential to develop into a number of alternative cell types. ○ Although the committed cells are unchanged, they are now myoblasts. ○ Eventually, myoblasts begin to synthesize muscle-specific proteins and fuse to form mature, elongated, multinucleate skeletal muscle cells. • Researchers have worked out the events at the molecular level that lead to muscle cell determination by growing myoblasts in culture and analyzing them with molecular biology techniques. ○ Researchers isolated different genes, caused each to be expressed in a separate embryonic precursor cell, and looked for differentiation into myoblasts and muscle cells. ○ They identified several “master regulatory genes” that, when transcribed and translated, commit the cells to become skeletal muscle. • One of these master regulatory genes is called myoD. ○ myoD encodes MyoD protein, a transcription factor that binds to specific control elements in the enhancers of various target genes and stimulates their expression. ○ Some target genes for MyoD encode for other muscle-specific transcription factors. ○ MyoD also stimulates expression of the myoD gene itself, helping to maintain the cell’s differentiated state. • All the genes activated by MyoD have enhancer control elements recognized by MyoD and are thus coordinately controlled. • The secondary transcription factors activate the genes for proteins such as myosin and actin to confer the unique properties of skeletal muscle cells. • The MyoD protein is capable of changing fully differentiated fat and liver cells into muscle cells. • Not all cells can be transformed by MyoD, however. ○ Nontransforming cells may lack a combination of regulatory proteins in addition to MyoD. Pattern formation sets up the embryo’s body plan. • Cytoplasmic determinants and inductive signals contribute to pattern formation, the development of spatial organization in which the tissues and organs of an organism are all in their characteristic places. • Pattern formation begins in the early embryo, when the major axes of an animal are established. • Before specialized tissues and organs form, the relative positions of a bilaterally symmetrical animal’s three major body axes (anterior-posterior, dorsal-ventral, right-left) are established. • The molecular cues that control pattern formation, positional information, are provided by cytoplasmic determinants and inductive signals. ○ These signals tell a cell its location relative to the body axes and to neighboring cells and determine how the cell and its progeny will respond to future molecular signals. • Studies of pattern formation in Drosophila melanogaster have established that genes control development and have identified the key roles of specific molecules in defining position and directing differentiation. • Combining anatomical, genetic, and biochemical approaches in the study of Drosophila development, researchers have discovered developmental principles common to many other species, including humans. • Fruit flies and other arthropods have a modular construction. ○ An ordered series of segments make up the three major body parts: the head, thorax (with wings and legs), and abdomen. • Cytoplasmic determinants in the unfertilized egg provide positional information for two developmental axes (anterior-posterior and dorsal-ventral axis) before fertilization. • The Drosophila egg develops in the female’s ovary, surrounded by ovarian cells called nurse cells and follicle cells that supply the egg cell with nutrients, mRNAs, and other substances. • During fruit fly development, the egg forms a segmented larva, which goes through three larval stages. ○ The fly larva forms a pupal cocoon within which it metamorphoses into an adult fly. • In the 1940s, Edward B. Lewis used mutants to investigate Drosophila development. ○ Bizarre developmental mutations were on the fly’s genetic map, providing the first concrete evidence that genes somehow direct the developmental process. ○ These homeotic genes control pattern formation in the late embryo, larva, and adult. • In the late 1970s, Christiane Nüsslein-Volhard and Eric Weischaus set out to identify all the genes that affect segmentation in Drosophila. They faced three problems. • First, because Drosophila has about 13,700 genes, there could be either only a few genes affecting segmentation or so many that the pattern would be impossible to discern. • Second, mutations that affect segmentation are likely to be embryonic lethals, leading to death at the embryonic or larval stage. ○ Flies with embryonic lethal mutations never reproduce, and cannot be bred for study. ○ Nüsslein-Volhard and Wieschaus focused on recessive mutations that could be propagated in heterozygous flies. • Third, because of maternal effects on axis formation in the egg, the researchers also needed to study maternal genes. • After exposing flies to mutagenic chemicals, Nüsslein-Volhard and Wieschaus looked for dead embryos and larvae with abnormal segmentation. ○ Through appropriate crosses, they found heterozygotes carrying embryonic lethal mutations. • Nüsslein-Volhard and Wieschaus identified 1,200 genes essential for embryonic development. ○ About 120 of these were essential for normal segmentation. • The researchers grouped the genes by general function, mapped them, and cloned many of them. • In 1995, Nüsslein-Volhard, Wieschaus, and Lewis were awarded a Nobel Prize. Gradients of maternal molecules in the early Drosophila embryo control axis formation. • Cytoplasmic determinants produced under the direction of maternal effect genes are deposited in the unfertilized egg. • A maternal effect gene is a gene that, when mutant in the mother, results in a mutant phenotype in the offspring, regardless of the offspring’s own genotype. ○ In fruit fly development, maternal effect genes encode proteins or mRNA that are placed in the egg while it is still in the ovary. ○ When the mother has a mutation in a maternal effect gene, she makes a defective gene product (or none at all) and her eggs will not develop properly when fertilized. • Maternal effect genes are also called egg-polarity genes because they control the orientation of the egg and consequently the fly. ○ One group of genes sets up the anterior-posterior axis, while a second group establishes the dorsal-ventral axis. • One gene called bicoid affects the front half of the body. • An embryo whose mother has a mutant bicoid gene lacks the front half of its body and has duplicate posterior structures at both ends. ○ This suggests that the product of the mother’s bicoid gene is essential for setting up the anterior end of the fly and might be concentrated at the future anterior end. • This is a specific version of the morphogen gradient hypothesis, in which gradients of morphogens establish an embryo’s axes and other features. • Using DNA technology and biochemical methods, researchers were able to clone the bicoid gene and use it as a probe for bicoid mRNA in the egg. ○ As predicted, the bicoid mRNA is concentrated at the extreme anterior end of the egg cell. • After the egg is fertilized, bicoid mRNA is transcribed into protein, which diffuses from the anterior end toward the posterior, resulting in a gradient of proteins in the early embryo. ○ Injections of pure bicoid mRNA into various regions of early embryos resulted in the formation of anterior structures at the injection sites. • The bicoid research is important for three reasons. 1. It identified a specific protein required for some of the earliest steps in pattern formation. 2. It increased our understanding of the mother’s role in the development of an embryo. 3. It demonstrated a key developmental principle: a gradient of molecules can determine polarity and position in the embryo. • Maternal mRNAs are crucial during development of many species. ○ In Drosophila, gradients of specific proteins encoded by maternal mRNAs determine the posterior and anterior ends and establish the dorsal-ventral axis. • Later, positional information encoded by the embryo’s genes establishes a specific number of correctly oriented segments and triggers the formation of each segment’s characteristic structures. Concept 18.5 Cancer results from genetic changes that affect cell cycle control • Cancer is a set of diseases in which cells escape the control mechanisms that normally regulate cell growth and division. ○ The gene regulation systems that go wrong during cancer are the systems that play important roles in embryonic development and immune response. • The genes that normally regulate cell growth and division during the cell cycle include genes for growth factors, their receptors, and the intracellular molecules of signaling pathways. ○ Mutations altering any of these genes in somatic cells can lead to cancer. ○ The agent of such changes can be random spontaneous mutations or environmental influences such as chemical carcinogens, X-rays, and some viruses. Proto-oncogenes can become oncogenes, contributing to the development of cancer. • Cancer-causing genes, oncogenes, were initially discovered in viruses. ○ Close counterparts have been found in the genomes of humans and other animals.å • Normal versions of cellular genes, called proto-oncogenes, code for proteins that stimulate normal cell growth and division. • A proto-oncogene becomes an oncogene following genetic changes that lead to an increase in the proto-oncogene’s protein production or in the intrinsic activity of each protein molecule. ○ These genetic changes include movement of DNA within the genome, amplification of the proto-oncogene, and point mutations in a control element or the proto-oncogene itself. • Cancer cells frequently have chromosomes that have been broken and rejoined incorrectly. ○ A fragment may be moved to a location near an active promoter or other control element. • Amplification increases the number of copies of the proto-oncogene in the cell. • A point mutation in the promoter or enhancer of a proto-oncogene may increase its expression. • A point mutation in the coding sequence may lead to translation of a protein that is more active or longer-lived. • All of these mechanisms can lead to abnormal stimulation of the cell cycle, putting the cell on the path to malignancy. Mutations to tumor-suppressor genes may contribute to cancer. • The normal products of tumor-suppressor genes inhibit cell division. • Some tumor-suppressor proteins normally repair damaged DNA, preventing the accumulation of cancer-causing mutations. • Other tumor-suppressor proteins control the adhesion of cells to each other or to an extracellular matrix, which is crucial for normal tissues and often absent in cancers. • Still others are components of cell-signaling pathways that inhibit the cell cycle. ○ Decreases in the normal activity of a tumor-suppressor protein may contribute to cancer. • The proteins encoded by many proto-oncogenes and tumor-suppressor genes are components of cell-signaling pathways. • Mutations in the products of two key genes, the ras proto-oncogene and the p53 tumor-suppressor gene, occur in 30% and over 50% of human cancers, respectively. • The Ras protein, the product of the ras gene, is a G protein that relays a growth signal from a growth factor receptor on the plasma membrane to a cascade of protein kinases. ○ At the end of the pathway is the synthesis of a protein that stimulates the cell cycle. • Many ras oncogenes have a point mutation that leads to a hyperactive version of the Ras protein that trigger the kinase cascade in the absence of growth factor, resulting in excessive cell division. • The p53 gene, named for its 53,000-dalton protein product, is a tumor-suppressor gene. ○ The p53 protein is a specific transcription factor for the synthesis of several cell cycle-inhibiting proteins. ○ The p53 gene has been called the “guardian angel of the genome.” • Once activated by DNA damage, the p53 protein functions as an activator for several genes. ○ The p53 protein can activate the p21 gene, whose product halts the cell cycle by binding to cyclin-dependent kinases, allowing time for DNA repair. ○ p53 also activates expression of a group of miRNAs, which inhibit the cell cycle. ○ The p53 protein can also turn on genes directly involved in DNA repair. ○ When DNA damage is irreparable, the p53 protein can activate “suicide genes” whose protein products cause cell death by apoptosis. • A mutation that knocks out the p53 gene can lead to excessive cell growth and cancer. Multiple mutations underlie the development of cancer. • More than one somatic mutation is generally needed to produce the changes characteristic of a full-fledged cancer cell. • If cancer results from an accumulation of mutations, and if mutations occur throughout life, then the longer we live, the more likely we are to develop cancer. • Colorectal cancer, with 140,000 new cases and 50,000 deaths in the United States each year, illustrates a multistep cancer path. ○ The first sign is often a polyp, a small benign growth in the colon lining. ○ The cells of the polyp look normal but divide unusually frequently. ○ Through gradual accumulation of mutations that activate oncogenes and knock out tumor-suppressor genes, the polyp can develop into a malignant tumor. ○ A ras oncogene and a mutated p53 tumor-suppressor gene are usually involved. • About a half dozen DNA changes must occur for a cell to become fully cancerous. • These changes usually include the appearance of at least one active oncogene and the mutation or loss of several tumor-suppressor genes. ○ Because mutant tumor-suppressor alleles are usually recessive, mutations must knock out both alleles. ○ Most oncogenes behave like dominant alleles and require only one mutation. Cancer can run in families. • The fact that multiple genetic changes are required to produce a cancer cell helps explain the predispositions to cancer that run in families. ○ An individual inheriting an oncogene or a mutant allele of a tumor-suppressor gene is one step closer to accumulating the necessary mutations for cancer to develop. • Geneticists are devoting much effort to finding inherited cancer alleles so that a predisposition to certain cancers can be detected early in life. • About 15% of colorectal cancers involve inherited mutations. • Many of these mutations affect the tumor-suppressor gene adenomatous polyposis coli or APC. ○ Normal functions of the APC gene include regulation of cell migration and adhesion. ○ Even in patients with no family history of the disease, APC is mutated in about 60% of colorectal cancers. • Between 5% and 10% of breast cancer cases show an inherited predisposition. ○ Breast cancer is the second most common type of cancer in the United States, annually striking more than 180,000 women and leading to 40,000 deaths. • Mutations in one gene, BRCA1, increase the risk of breast and ovarian cancer. ○ Mutations in BRCA1 and the related gene BRCA2 are found in at least half of inherited breast cancers. • A woman who inherits one mutant BRCA1 allele has a 60% probability of developing breast cancer before age 50 (versus a 2% probability in an individual with two normal alleles). ○ Both BRCA1 and BRCA2 are considered tumor-suppressor genes because their wild-type alleles protect against breast cancer and their mutant alleles are recessive. • BRCA1 and BRCA2 proteins function in the cell’s DNA damage repair pathway. ○ BRCA2, in association with another protein, helps repair breaks that occur in both strands of DNA. • Because DNA breakage can contribute to cancer, the risk of cancer can be lowered by minimizing exposure to DNA-damaging agents, such as ultraviolet radiation in sunlight and the chemicals found in cigarette smoke. • In addition to mutations and other genetic alterations, a number of tumor viruses can cause cancer in various animals, including humans. ○ In 1911, Peyton Rous, an American pathologist, discovered a virus that causes cancer in chickens. ○ The Epstein-Barr virus, which causes infectious mononucleosis, has been linked to several types of cancer in humans, notably Burkitt’s lymphoma. ○ Papillomaviruses are associated with cancer of the cervix, and a virus called HTLV-1 causes a type of adult leukemia. • Worldwide, viruses seem to play a role in about 15% of the cases of human cancer. • Viruses can interfere with gene regulation in several ways if they integrate their genetic material into a cell’s DNA. ○ Viral integration may donate an oncogene to the cell, disrupt a tumor-suppressor gene, or convert a proto-oncogene to an oncogene. ○ Some viruses produce proteins that inactivate p53 and other tumor-suppressor proteins, making the cell more likely to become cancerous. Lecture Outline for Reece et al., Campbell Biology, 10th Edition, Copyright © 2014 Pearson Education, Inc

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The Concise Laws of Human Nature — Full Notes Introduction + Chapter 1: Master Your Emotional Self 📌 INTRODUCTION — What’s the Point of This Book? Core idea: Most people act on the surface — reacting emotionally without understanding why they or others behave the way they do. This book is a guide to understanding the deeper roots of human behavior. Two main problems Greene identifies: |Problem |What it looks like | |-----------------------|-----------------------------------------------------------------------------------------------| |Other people’s behavior|Someone sabotages you, manipulates you, or charms you — and you don’t see it coming | |Your own behavior |You say the wrong thing, make a bad decision, fall for the wrong person — and can’t explain why| Why does this happen? Because human behavior is mostly not consciously controlled. Deep forces — built into us over millions of years of evolution — drive what we do. Greene calls this collection of forces “human nature.” Key evolutionary points (simplified): ∙ Early humans couldn’t talk, so they evolved emotions to communicate quickly (fear, joy, anger, shame) ∙ We became highly sensitive to others’ emotions — useful back then, but today it makes us easily manipulated ∙ We still carry ancient instincts: status-seeking, tribalism (us vs. them), wearing masks to hide our dark side What the book promises: Turn you into someone who can: ∙ Read people more accurately ∙ Spot manipulation before it hits ∙ Understand your own emotional patterns ∙ Make better decisions 📌 CHAPTER 1 — The Law of Irrationality Core idea: You think you’re in control of your decisions. You’re mostly not. Emotions are quietly running the show — and you usually don’t realize it. 🧠 How the Brain Works (Simple Version) Your brain has 3 layers: 1. Reptile brain → automatic responses (breathing, reflexes) 2. Emotional/limbic brain → feelings and emotions 3. Thinking brain (neocortex) → logic, language, planning The problem: emotions are processed in a different place than thinking. So when you feel something and try to explain it, you often get it wrong. Example: you think you’re angry at someone, but the real feeling underneath is envy. Since envy is uncomfortable to admit, your brain rebrands it as anger. ⚠️ The 3-Step Path to Rationality |Step |What it means | |-----------------------------------------|-------------------------------------------------------------------------------------------------------------------------| |**1. Spot low-grade irrationality** |Your everyday moods quietly bias your thinking without you noticing | |**2. Recognize high-grade irrationality**|When emotions spike (anger, excitement, fear) you enter a reactive state — everything feels worse, decisions get terrible| |**3. Build mental habits** |Practice strategies that give your thinking brain more control | 🎯 STEP ONE: The 6 Biases — Simplified + Applied These are the main ways emotions secretly hijack your thinking: 1. Confirmation Bias You only notice information that supports what you already believe. Example: You think a teacher is unfair — suddenly every grade they give “proves” it, even if they’re actually reasonable. 2. Conviction Bias The louder and more passionate you are about an idea, the more you assume it must be true. Example: Someone argues a conspiracy theory intensely — that intensity feels like proof to them. It’s not. 3. Appearance Bias You judge people by how they seem, not who they actually are. The “halo effect” = if someone is attractive or funny, you assume they’re also trustworthy or smart. Example: A charismatic new friend seems great — you ignore early red flags because their vibe is positive. 4. Group Bias You adopt opinions because a group you belong to holds them — not because you actually thought them through. Example: Your friend group hates a certain music artist. You start hating them too without ever really listening. 5. Blame Bias When things go wrong, you blame others or circumstances rather than examining your own role. Example: You fail a test → “The teacher explained it badly” → never reflect on your study habits. 6. Superiority Bias You believe you’re more rational, ethical, and self-aware than you actually are. The trap: If you read this list and think “I don’t really do any of these” — that IS the superiority bias. 🔥 STEP TWO: The 5 Inflaming Factors Quick reminder: Low-grade irrationality = slow, quiet bias. High-grade irrationality = sudden emotional explosion that hijacks your thinking completely. 1. Childhood Trigger Points Old emotional wounds from childhood never fully disappear. A person or situation today can accidentally “poke” that old wound — and suddenly you’re reacting with way more intensity than the situation deserves. How to spot it: You or someone else is acting childish, over-the-top, or completely out of character. Example: A friend cancels on you and you feel devastated — way beyond what makes sense. Possibly touching an old feeling of being abandoned or excluded. 2. Sudden Gains or Losses Unexpected wins release chemicals that push you toward risky, addictive behavior. Unexpected losses make you feel cursed and hopeless. Example: You win $200 on a bet → feel invincible → immediately bet it all again. That’s the chemical high talking, not logic. Fix: After a big win, force pessimism. After a big loss, force optimism. Balance the spike. 3. Rising Pressure / Stress Under real stress, your primitive brain takes over and shuts down reasoning. Stress also reveals who people really are — the mask slips. Useful insight: Watch how people behave under pressure. It tells you more about their true character than how they act when everything’s fine. For yourself: When stress rises, watch for sudden paranoia, unusual sensitivity, or disproportionate fear. 4. Inflaming Individuals Some people just trigger extreme emotions in everyone around them — love, hatred, obsession, blind loyalty. Nobody stays neutral around them. Red flags: You think about them constantly. You feel unable to reason around them. They seem larger than life. Fix: Actively remind yourself they’re just a regular flawed human — same insecurities as everyone else. Deflate the myth. 5. The Group Effect Large groups create a contagious emotional current. Crowds can be manipulated into hatred and mob thinking without anyone realizing it. Fix: Enter group settings with extra skepticism. Step away physically to regain independent thinking when needed. 🛠️ STEP THREE: Strategies to Build a More Rational Self |Strategy |What it means in plain language | |----------------------------------|--------------------------------------------------------------------------------------------------| |**Know yourself** |Study how *you specifically* react under stress. Your patterns, your weaknesses. | |**Dig into your emotions** |Don’t just feel anger — ask *why*. Trace it to the real source. A journal helps. | |**Slow your reaction time** |Train yourself to pause before responding. Write the angry text — don’t send it. Wait. | |**Accept people as facts** |Stop wishing people were different. Work with reality, not the ideal version in your head. | |**Balance skepticism + curiosity**|Question everything — but don’t close your mind. Stay curious like a kid, verify like a scientist.| |**Enjoy being rational** |Mastering your emotions feels genuinely good — deeper satisfaction than acting on impulse. | 🔑 The Maker’s Mind-Set (Key Concept) Almost everyone has experienced moments of pure rationality — usually when deep in a project with a deadline. In that state, emotions that don’t help just feel like noise, your ego quiets, and you focus purely on results. That’s your rational self — it already exists. The goal of this chapter is to access it more often, not just by accident. ✏️ Full Chapter Summary You have two selves: a thinking self and an emotional self. The emotional one is older, faster, and usually winning. It distorts your thinking through 6 quiet biases (Step 1) and can completely take over through 5 inflaming triggers (Step 2). The path forward isn’t to kill your emotions — it’s to slow down, know your patterns, and build habits that give your thinking brain a fighting chance (Step 3)

Vascular Structures The circulatory system comprises blood vessels responsible for transporting blood throughout the body. The vascular structures are categorized into three types: arteries, veins, and capillaries. Understanding their functions and differences is crucial for patient care technicians. Arteries Arteries are blood vessels that carry freshly oxygenated blood from the heart to the various tissues and organs in the body. These vessels have thick walls to withstand the high pressure generated by the heart. Key Arteries to Know: * Coronary Artery: Supplies blood to the heart muscle itself. * Femoral Artery: Located in the thigh, supplying blood to the lower limbs. * Pulmonary Artery: Carries deoxygenated blood from the heart to the lungs for oxygenation. Veins Veins are blood vessels that carry deoxygenated blood from the body back to the heart. Unlike arteries, veins have thinner walls and contain valves that prevent the backflow of blood. Key Veins to Know: * Jugular Vein: Located in the neck, returns blood from the head and neck to the heart. * Saphenous Vein: A large vein running along the leg, important in procedures like varicose vein treatment. * Pulmonary Vein: Carries oxygenated blood from the lungs back to the heart. Capillaries Capillaries are the smallest blood vessels and serve as the site for nutrient, gas, and waste exchange between the blood and body cells. They are extremely permeable, allowing oxygen and nutrients to move into cells and carbon dioxide and waste products to move out. * Function: Capillaries allow the exchange of gases, nutrients, and waste products with surrounding tissues. The thin walls facilitate this process, and they play a crucial role in maintaining homeostasis. Infection Control Practices As a Patient Care Technician, it is essential to practice infection control techniques to prevent the transmission of infectious agents during patient care. This is especially critical when performing invasive procedures. Personal Protective Equipment (PPE) PPE protects both healthcare workers and patients from potential infections. Common PPE includes gloves, gowns, masks, face shields, and goggles. * Always wear appropriate PPE based on the procedure and the patient's condition. * Hand Hygiene: Wash hands thoroughly before and after patient contact and before performing procedures. Always use hand sanitizer if soap and water are unavailable. * Safe Disposal: Dispose of equipment like needles and gloves properly to prevent the spread of infection. Dispose of sharps in a sharps container immediately after use. Preventing Infection During Invasive Procedures When performing procedures such as blood draws, catheter insertions, or injections, ensure the environment is sterile. Follow these guidelines: * Sterile Technique: Ensure that all equipment is sterile before use and that the procedure area is clean. * Use of Clean Materials: Always check that materials such as gauze pads, alcohol wipes, and bandages are intact and not expired. Patient Identification and Consent Patient identification and consent are vital aspects of delivering safe care. Patient Identification To prevent errors, always verify patient identity before conducting any procedure. Use two acceptable patient identifiers (e.g., name, date of birth, medical record number). * Verification Process: 1. Confirm patient’s identity by asking for their name and date of birth. 2. Compare the patient's provided information with the information on the requisition form. Consent Before any procedure, obtain verbal or written consent from the patient. Always confirm the patient understands the procedure and consents voluntarily. Patients have the right to refuse consent for any reason, whether personal, cultural, or medical. * If a patient refuses consent, document the refusal and notify the nurse or supervising healthcare professional immediately. Handling and Safety of Medical Equipment Proper handling and safety protocols for medical equipment are critical in patient care. Always inspect equipment thoroughly to ensure its functionality and safety. Needles and Syringes * Inspection: Visually inspect needles for any burrs, bends, or defects before and after removing the cap. * Single Use Only: Needles should only be used once, even if it is for the same patient. * Deploy Safety Devices: Immediately activate the safety device after use to protect yourself and others. Place used needles in a sharps container as soon as possible. Evacuated Tubes Evacuated tubes are used for blood collection, and their integrity is crucial for obtaining accurate test results. * Expiration Dates: Always check the expiration date on the tube packaging before use. Expired tubes may not function properly. * Inspect for Cracks or Breaks: Do not use tubes with cracks, breaks, or missing labels. * Additives: Ensure that the additives in the tubes are not expired as expired additives can alter test results. * Do Not Use Without Labels: Ensure that the tubes are correctly labeled with the patient's information. Tourniquets Tourniquets are used to temporarily restrict blood flow during venipuncture. Inspect the tourniquet before use. * Inspection: Ensure the tourniquet is free of tears, rips, dirt, or contamination. * Single Use vs. Multiple Use: Some tourniquets are disposable while others are reusable. Always clean reusable tourniquets between uses. Specimen Collection and Labeling Accurate labeling and handling of specimens are crucial for diagnostic accuracy. Labeling Specimens * Label Before Leaving the Room: Always label specimens in front of the patient to ensure proper identification. * Required Information: Labels must include the patient’s full name, date of birth, date and time of collection, and the medical or facility identification number. * Placement of Labels: Place the label over the preprinted label and ensure that the stopper is not covered. Be careful to avoid creases or wrinkles on the label. * Do Not Allow Others to Label: Never allow someone else to label your specimens, and do not label for others. Handling of Requisition Forms * Verification: Always verify that the requisition form matches the patient’s information and the test ordered. * Documentation: Ensure that any discrepancies are resolved before proceeding with specimen collection. Key Points * Vascular structures: arteries (e.g., coronary, femoral, pulmonary), veins (e.g., jugular, saphenous, pulmonary), and capillaries are essential for circulatory functions. * Infection control is vital in all patient care tasks, including the use of PPE, hand hygiene, and safe disposal of contaminated materials. * Always confirm the patient’s identity and obtain consent before performing procedures. * Inspect needles, tubes, and tourniquets for defects to ensure patient safety. * Properly label and handle specimens to prevent errors and ensure accurate test results. Dermal Punctures Dermal punctures are blood collection procedures that involve the puncturing of the skin’s surface to collect a smaller amount of blood, typically for diagnostic purposes. This method is commonly used when only a small sample is required or when venous access is difficult. * Alternative Names: Dermal punctures are sometimes called heel sticks, finger sticks, or capillary puncturesdepending on the patient’s age and the area from which blood is drawn. * Comparison with Venipuncture: Dermal punctures remove smaller amounts of blood compared to venipuncture, which involves drawing blood from veins. Dermal punctures are less invasive and are typically used when only a small sample is needed for testing. Indications for Dermal Puncture Dermal punctures are useful in various clinical scenarios. It’s essential to understand when and why dermal punctures are preferred over other methods of blood collection: * Small Amounts of Blood: Dermal punctures are used when only a small amount of blood is required, such as for point-of-care tests like glucose monitoring, cholesterol checks, and hematocrit levels. * Inaccessible Veins: In cases where veins are not easily accessible, such as with infants, elderly patients, or patients with specific medical conditions, dermal punctures provide an alternative solution. * Capillary Blood Required: Some laboratory tests require capillary bloodbecause it offers a mix of arterial, venous, and capillary blood, which can provide different insights into a patient’s health. * Risk of Iatrogenic Anemia: Dermal punctures are also preferred in cases where multiple blood draws could lead to iatrogenic anemia, particularly in infants, as they have a smaller blood volume and are more at risk of developing anemia from repeated venipunctures. * Common Uses for Point-of-Care (POC) Tests: Dermal punctures are often used for point-of-care tests (POC), which are rapid tests performed at or near the site of patient care. Common POC tests include: * Glucose: Blood sugar testing for diabetes management. * Cholesterol: Monitoring cholesterol levels to assess cardiovascular health. * Hematocrit: Assessing the percentage of red blood cells in blood. Dermal Puncture in Infants and Children Dermal punctures are commonly performed on infants younger than 1 year old due to the following reasons: * Less Blood Required: Infants require much smaller blood samples, and dermal punctures provide an easy way to collect blood without the need for large quantities. * Avoiding Damage to Blood Vessels: Repeated venipuncture in infants can damage their fragile veins and blood vessels. Dermal punctures reduce this risk and provide an effective alternative. * Preferred Sites for Infants: Heel sticks are the most common method used for infants, and the preferred sites are the medial or lateral sides of the plantar surface of the heel. Blood Composition in Dermal Punctures When performing dermal punctures, it’s important to understand the composition of the blood being collected. Dermal puncture blood specimens contain three types of blood: * Arterial Blood: Blood that is rich in oxygen and comes from the arteries. * Capillary Blood: Blood that comes from the capillaries and reflects a mixture of arterial and venous blood. * Venous Blood: Blood that is deoxygenated and returns to the heart from the body. Important Note: Because dermal punctures involve a mix of these three types of blood, it’s essential to document on the requisition form that a dermal puncture was performed, as the composition differs from that of venous blood, which may affect test results. Performing Dermal Punctures on Adults and Children For adults and children older than one year, finger sticks are commonly performed. Below are detailed instructions on how to perform a finger stick correctly: Finger Stick * Preferred Site: Perform the finger stick on the third or fourth finger of the patient’s non-dominant hand. * Site Selection: Choose the fleshy, off-center side of the finger to avoid nerves and bones. * Avoid Certain Fingers: Never perform finger sticks on fingers that are: * Cold * Cyanotic (bluish discoloration) * Scarred * Swollen * Rash-covered * Wipe the First Drop: After making the puncture, wipe away the first drop of blood because it may contain tissue fluid or contaminants that could affect test results. * Collect the Second Drop: Use the second drop of blood for the collection to ensure a clean sample. * Lancet Insertion: Insert the lancet at a 90-degree angle (perpendicular to the fingerprint) to ensure the proper depth of puncture. Heel Stick (For Infants) * Preferred Site for Heel Stick: The medial or lateral sides of the plantar surface of the heel are the best sites for performing a heel stick. Avoid the back of the heel because it may damage sensitive structures. * Warm the Heel: Apply a heel warmerfor 3 to 5 minutes before performing the procedure. This helps to increase blood flow to the area and makes the blood easier to collect. * Wipe the First Drop: Similar to finger sticks, wipe away the first drop of blood to ensure accurate collection from the second drop. Key Points * Dermal punctures are ideal when a small sample of blood is needed, when venous access is difficult, or when point-of-care tests are required. * For infants and children under 1 year, dermal punctures, especially heel sticks, are the best option due to the limited blood volume and the risk of damaging their veins. * Finger sticks for adults and children over 1 year old should be performed on the third or fourth finger of the non-dominant hand. * Lancet insertion should be done at a 90-degree angle to the fingerprint. * Always wipe away the first drop of blood to avoid contamination and collect the second drop for the test. * For heel sticks, apply a heel warmer for 3 to 5 minutes to improve blood circulation in the infant’s foot. Safety and Comfort During Blood Collection * The primary goals during blood collection are to ensure patient safety, provide comfort, and obtain specimens efficiently and effectively.  Patient Positioning * Never perform venipunctures with patients standing or sitting on a high stool or the edge of an examination table. * The optimal position for venipuncture is for the arm to be fully extended with the palm facing upward. Venipuncture Site Selection * Begin by palpating the veins in the antecubital area. * First Choice: Median cubital vein (preferred due to its size and location). * Second Choice: Cephalic vein (often accessible and fatty). * Third Choice: Dorsal hand vein (smaller and less ideal). * Last Choice: Basilic vein (close to the radial nerve and brachial artery, making it riskier to puncture). * The ideal vein for venipuncture should be well anchored, feel spongy and bouncy, and should be straight and easy to access with a needle. Special Considerations * Avoid collecting blood from the arm on the affected side of a patient who has had a mastectomy. * Do not perform collections in any area with tattoos, as this can influence results. * Avoid collecting blood through a hematoma, as it can alter results and cause pain. * Steer clear of areas with edema, as collection may yield excess fluid and discomfort for the patient. * Do not collect blood from scarred areas, as access may be difficult and painful. * Avoid sclerotic veins, as blood flow may be inadequate, making collection painful. Tourniquet Application * Apply a tourniquet 3 to 4 inches above the antecubital area or above the wrist bone. * The tourniquet must be removed within one minute of application to prevent hemoconcentration. Preparation for Venipuncture * Allow the alcohol to dry completely before performing venipuncture; do not fan or blow on it to speed up the drying process. * Insert the needle until you feel a change in resistance (indicating entry into the vein). Stop insertion once this is felt. Blood Collection Techniques * The most common method for venipuncture is the evacuated tube system. * Equipment needed includes: * Gloves * Isopropyl alcohol swabs or pads * Gauze pads * Tape * Self-adhesive wrap or adhesive bandages * Tourniquet * Needles * Hub adapter or needle holder * Blood collection tubes * Always check tubes for additives, expiration dates, and the amount of blood they can hold. * Common additives are anticoagulants or clot activators. Angles for Needle Insertion * For antecubital area: Insert the needle at a 15 to 30-degree angle. * For hand collection: Insert the needle at a 10-degree angle. Special Collection Devices * Winged Infusion Devices: Used for patients with small or difficult veins, primarily on the dorsal hand vein. * Syringe Method: Utilized for patients with fragile veins that can easily collapse; this method allows for controlled and adjustable blood withdrawal, minimizing the risk of vein collapse. Importance of Urine Specimens * One of the most commonly performed diagnostic tests involves urine specimens. * Urinalysis includes examining: * Appearance * Color * Odor * pH * Specific gravity * Presence or absence of protein, glucose, or hemoglobin. Urine Culture * Urine culture tests are performed for the growth and identification of microorganisms. Types of Urine Specimen Collections: * Random Collection: * The most common urine test. * Can be done at any time without restrictions or preparations. * First Morning Urine Specimen: * Instruct the patient to urinate before going to bed. * Collect the first urination when they wake up. * Timed Urine Specimen: * Provide a rigid, light-resistant container with a capacity of about 3000 mL and a wide-mouth, leak-proof screw-on cap. * 24-Hour Collection: * The patient begins at a specific time and collects all urine until the same time the next day. * If a patient forgets or discards any urine, they must start the process over. Specialized Urine Tests: * Glucose Tolerance Test: * Requires fasting for a specific duration. * Typically collected at the same time as a blood collection and done every 1 to 2 hours. * Postprandial Test: * Patient urinated, then eats a meal. * Collect a urine sample 2 hours after eating. * Clean Catch Midstream: * Patient should urinate a little, stop, and then collect the sample before completing urination. * Important Note: Never use alcohol, hydrogen peroxide, or iodine to clean the genitals prior to collection. Reagent Strips and Urinalysis Results * Reagent strips provide information about: * pH * Specific gravity * White blood cells * Hemoglobin * Ketones * Bilirubin * Glucose. * Expected Ranges: * pH: 4.6-8.0 (ideal around 6.0). * Specific gravity: 1.005-1.030 (typically around 1.010-1.025). Other Types of Specimens: * Saliva Specimens: Used for hormone, alcohol, and drug levels. * Sputum Samples: * Mucus and secretions from the lungs and trachea. * Should be collected first thing in the morning before brushing teeth or eating/drinking. * A sample should be about 1 to 2 teaspoons. * Fecal Specimens: Used to test for bacterial infections, parasites, or occult blood. Ensure urine is not present in the fecal sample. * Semen Specimens: * Used for sperm counts, fertility assistance, and identity proof in rape cases. * Keep samples warm and protect them from light. * Throat Swabs: Culture specimens that help identify strep throat. * Wipe both tonsils, the throat, and any inflamed/infected areas. * Buccal Swab: Swabs the inside of the cheek to collect the patient’s DNA. Introduction to Blood Cultures Blood cultures are laboratory tests designed to detect bacteria or other microorganismspresent in the bloodstream. The primary goal of this test is to identify infections caused by bacteria or fungi, which can lead to serious health complications if not treated promptly. Purpose of Blood Cultures Blood cultures are used to: * Diagnose Infections: Providers request blood cultures when they suspect that a patient has a bloodstream infection, which could be caused by bacteria, fungi, or other pathogens. This helps doctors determine the exact cause of the infection so they can select the appropriate treatment (e.g., antibiotics or antifungals). * Identify the Causative Microorganisms: Blood cultures allow laboratories to grow and identify microorganisms from the patient’s blood, which can be critical in diagnosing conditions like sepsis, endocarditis, or infections originating from other parts of the body. How Blood Cultures Work 1. Specimen Collection: Blood is drawn from the patient’s vein. The sample is then placed into specialized blood culture bottles. 2. Incubation: The blood is cultured in a laboratory, meaning it is placed in dishes or bottles containing a growth medium. This medium promotes the growth of microorganisms present in the blood. 3. Observation: The blood culture bottles are observed over a period of time to see if any microorganisms begin to grow. This growth indicates the presence of an infection-causing microorganism. 4. Identification: Once growth is detected, laboratory technicians further analyze the sample to identify the specific microorganism. This allows them to determine what type of infection the patient has, which informs treatment decisions. Collection of Blood Cultures When collecting blood for culture, it is essential to follow proper procedures to ensure that the sample is accurate and uncontaminated. Site Selection and Preparation The site of collection plays a crucial role in obtaining a quality blood culture sample. Contamination can lead to inaccurate results, so it is essential to follow proper protocols for disinfecting the collection site. * Disinfection of the Collection Site: To prevent contamination from skin microorganisms, the collection site must be disinfected thoroughly before drawing blood. Follow your facility’s guidelines, but generally, the site should be cleaned for 30 to 60 seconds. * Disinfecting Procedure: 1. Use an alcohol-based antiseptic(e.g., chlorhexidine or iodine) to clean the site. 2. Scrub the area in a circular motionstarting from the center and working outward. 3. Allow the disinfectant to air dry to ensure its effectiveness. * Proper Technique: Always disinfect the site just before collecting the blood culture to avoid introducing any microorganisms that may be present on the skin. Blood Culture Bottles You will need to use two bottles for each blood culture collection: one for aerobic bacteria (which need oxygen to grow) and one for anaerobic bacteria (which grow in the absence of oxygen). * Aerobic Bottle: This bottle contains a growth medium that supports the growth of microorganisms that require oxygen. It is used for collecting blood samples that may contain aerobic bacteria. * Anaerobic Bottle: This bottle supports the growth of bacteria that thrive without oxygen. It is essential for collecting samples that may contain anaerobic bacteria. Both bottles are typically marked with color codes or labels indicating which type of microorganism they are designed to cultivate. Blood Volume and Timing * Amount of Blood: A set of blood cultures typically requires a specific volume of blood to be collected. This ensures that enough material is present for the laboratory to perform the necessary tests. Always follow the instructions from the lab or facility for the required volume. * Multiple Sets: In some cases, multiple sets of blood cultures may be needed for accurate diagnosis, especially in cases of suspected sepsis or other severe infections. * Timing: Blood cultures should be collected before starting antibiotics, as antibiotics can kill the microorganisms in the blood and interfere with the culture results. If antibiotics are already being administered, notify the laboratory, as this can affect the accuracy of the results. Guidelines for Blood Culture Collection Labeling and Documentation * Accurate Labeling: Label the blood culture bottles with patient identifiers, such as the patient’s name, date of birth, and medical record number, to avoid mix-ups. * Documenting the Collection: Always document the following information on the requisition form: * The site from which the blood was collected. * The time of collection. * The collection method (whether it was an aerobic or anaerobic sample). * Notify the Laboratory: If there are any unusual circumstances (such as suspected contamination), make sure to notify the laboratory so they can take appropriate precautions when handling the sample. Special Considerations Blood cultures are a critical diagnostic tool, and as a Patient Care Technician, it is important to understand the procedures and the potential consequences of improper collection. Infection Prevention * Always use sterile equipment and maintain a clean technique throughout the blood culture collection process. * Wear gloves and follow standard infection control protocols, including wearing appropriate PPE (personal protective equipment) to protect both yourself and the patient from cross-contamination. Handling and Transporting Blood Cultures * After collection, make sure to transportthe blood culture samples to the laboratory as soon as possible. * Avoid delays in transporting blood cultures to the lab, as prolonged exposure to room temperature can affect the growth of microorganisms. * Follow your facility’s guidelines for sample transport to ensure that the blood culture samples reach the laboratory in optimal condition. Key Points * Blood cultures are used to detect microorganisms (e.g., bacteria, fungi) in the blood and are critical in diagnosing infections such as sepsis and endocarditis. * Proper site disinfection (30-60 seconds) before collection is essential to avoid contamination and ensure accurate results. * Always collect one set of blood culture bottles per collection: one for aerobicand one for anaerobic microorganisms. * Multiple sets may be required, and blood cultures should be collected before administering antibiotics for the most accurate results. * Accurate labeling and documentationare vital to ensure proper identification and handling of specimens. * Handle and transport blood culture samples promptly and follow infection control protocols to maintain a sterile environment. Phlebotomy Overview Phlebotomy is the process of obtaining a blood sample from a patient, usually through a venipuncture (insertion of a needle into a vein). This is a common procedure performed in medical settings, and as a PCT, you may be asked to assist with or directly perform this task. The following is a breakdown of important steps and safety protocols: * Preparation: Ensure you have all necessary equipment, including gloves, gauze, alcohol swabs, bandages, and blood collection tubes. * Patient Identification: Always confirm the patient's identity to ensure correct specimen collection. * Technique: Be aware of the anatomy and correct venipuncture sites, including the antecubital fossa (area inside the elbow) and dorsal veins on the hand. Pressure on the Puncture Site After collecting the blood sample, it is criticalto apply appropriate pressure to the puncture site to stop the bleeding and prevent hematoma formation. A hematoma is a localized collection of blood under the skin, which can happen if both walls of the blood vessel are pierced during a venipuncture. * Pressure Application: Make sure to hold pressure on the puncture site for several minutes to stop the bleeding. Ensure the patient maintains the pressure to minimize the risk of bruising. * Bandage Application: Once the bleeding has stopped, a bandage should be placed on the puncture site. Observing for Complications Following a venipuncture, it is essential to monitor the patient for any complications that may arise. While most procedures are safe, complications can occur, and early identification is crucial for the patient's safety. Monitor the patient for the following complications: * Color Changes: Observe for any changes in the patient’s skin color, particularly signs of paleness or discoloration. * Diaphoresis: Excessive sweating could indicate nausea, syncope, or a panic attack. * Dyspnea or Shortness of Breath: This could signal respiratory distress and must be reported immediately. * Confusion: A change in mental status can indicate complications like shock or hypoxia. Complications of Phlebotomy It is important to understand the various complications that can arise during phlebotomy procedures. Some of these may be minor, while others could indicate more serious issues. Below is a comprehensive list of potential complications you may encounter: 1. Nerve Damage * Although rare, nerve damage can occur during venipuncture. The patient may report a sensation of numbness or a pin-and-needles feeling at the puncture site. If the patient experiences these symptoms, it is important to stop the procedure immediately and inform the nurse or supervisor. 2. Hematoma * A hematoma is a common complication, resulting from the rupture of the blood vessel wall during venipuncture. It is characterized by a localized blood collection under the skin. To minimize hematoma formation, ensure you apply adequate pressure to the puncture site after the procedure. 3. Infection * Infection is a risk with any invasive procedure, although it is rare in venipuncture. It is important to follow sterile procedures to reduce the likelihood of infection. If an infection develops, it may present as redness, swelling, or warmth around the puncture site. 4. Phlebitis * Phlebitis is inflammation of the vein, often caused by repeated use of the same vein. It may present with signs of warmth, tenderness, and redness around the puncture site. This condition is uncommon but requires attention to prevent further damage to the vein. 5. Petechiae * Petechiae are small red or purple spots on the skin. They can occur due to the rupture of small blood vessels under the skin. Though unpleasant and upsetting for the patient, petechiae are generally not dangerous and will resolve on their own. 6. Thrombus (Blood Clot) * A thrombus or blood clot can form if adequate pressure is not applied to the venipuncture site. It is essential to ensure that the patient applies sufficient pressure after the procedure to prevent clot formation. Other Reactions and Symptoms While performing venipuncture, it is important to be aware of the following minor to severe reactions that may occur: * Dizziness * A common minor physical reaction, dizziness usually resolves without treatment within a few minutes. Encourage the patient to rest and monitor for any additional symptoms. * Syncope (Fainting) * Syncope is uncommon but can occur during a venipuncture, especially in patients who are anxious. In rare cases, the patient may fall or suffer a more serious complication like an arrhythmia or stroke during the syncopal episode. * If a patient experiences syncope, lay them down and elevate their legs. Call for help immediately and stay with the patient until assistance arrives. * Nausea * If a patient feels nauseated before the blood collection, wait a few minutes before proceeding. Ensure the patient is not left alone. Use a cold compress on the patient's head or the back of their neck, provide a wet cloth to clean their mouth, and offer a glass of water if the patient vomits. Inform the nurse of the situation. * Diaphoresis (Excessive Sweating) * Excessive sweating can signal nausea, syncope, or a panic attack. Ask the patient how they are feeling, provide a tissue or towel, and ensure the patient is not left alone. Observe the patient for any further signs of complications and notify the nurse immediately. * Seizure * If the patient has a seizure during the procedure, stop the procedure immediately and seek emergency assistance. Do not attempt to restrain the patient. Remove any objects from the area that could harm the patient and stay with them, providing as much privacy as possible. * Shock * Symptoms of shock include cold, clammy, and pale skin, rapid pulse, increased shallow breathing, and a blank stare. If you suspect shock, call for help immediately. Ensure the patient has an open airway and, if they are laying down, lower their head below the body. Keep the patient warm and safe until help arrives. Key Points * As a PCT, your primary responsibility is to ensure patient safety and comfort during venipuncture. Always monitor for complications and be ready to take action if any adverse reactions occur. * Familiarize yourself with the common complications and learn how to handle them appropriately. Remember, your role may not involve diagnosing or treating these complications, but you are responsible for reporting any signs of trouble to your supervisor or healthcare provider. * Effective communication with the healthcare team is crucial. If you notice something unusual during the procedure, always report it immediately to the appropriate person. Importance of Specimen Handling, Packaging, and Communication The delivery process of laboratory specimens must be precise to ensure the accuracy of test results. Every step in the specimen handling process plays a significant role in maintaining the quality of the sample and in complying with established protocols. * Adequate Specimen Handling: Specimens should be handled with care to avoid contamination, degradation, or incorrect results. Proper techniques ensure that the samples remain intact and viable for testing. * Packaging and Communication: Proper packaging is critical to prevent spillage, contamination, or loss during transport. The communication of specimen details (e.g., patient ID, collection time, and test type) ensures that laboratory personnel can accurately process the sample. Always label specimens immediately after collection. Temperature-Specific Specimen Handling Certain tests require that specimens are maintained at specific temperatures to preserve their integrity until they reach the laboratory. * Heat Sources and Ice Slurries: Specimens that require specific temperature handling should be kept in appropriate temperature conditions immediately after collection. Common temperature controls include: * Heat Block or Heat Source for maintaining warmth. * Ice Slurry or Refrigerator/Freezer for cold storage. * Some tests require specific temperature handling as detailed below: * Ammonia and Lactic Acid: These blood samples must be placed in an ice slurry immediately after collection to maintain their stability. * Cold Agglutinins: These samples should remain at body temperature (37°C) during transport and testing to prevent interference with test results. * Bilirubin and Folate Levels: To protect blood samples from light, wrap the collection tube in foil to prevent degradation due to photosensitivity. * Blood Gas Tests: For these tests, store specimens at room temperature for 15 to 30 minutesor in an ice slurry for up to 1 hour. * Coagulation Tests: Analysis should be performed within 1 hour of specimen collection to ensure accurate results. * Photosensitive Specimens: Always protect specimens that are photosensitive, such as those for bilirubin or folate, from light to avoid changes in their composition. Timed Tests and Proper Labeling Timed Tests: Ensure the patient has fulfilled the necessary requirements for the test timing. Timed tests are critical for conditions where the concentration of the substance being tested varies over time (e.g., glucose, cortisol, etc.). * Labeling of Specimens: Label every collection container immediately after collection to prevent errors: * Patient's full name and identification number * Date and time of collection * Specimen type * Clear labeling ensures that the sample can be accurately tracked, preventing mix-ups or delays in processing. Urine Specimen Handling Urine specimens are often collected for analysis and must be handled with specific care to ensure accurate results. * Glove Use: Always wear gloves when handling patient-collected nonblood specimens to reduce the risk of contamination. Change gloves between handling each specimen to prevent cross-contamination. * Refrigeration: If a urine specimen is not going to be tested immediately, it should be refrigerated to preserve its composition and prevent bacterial growth. The specimen should be delivered to the laboratory within 1 hour of collection. * Room Temperature for Certain Tests: Some urine tests are best performed at room temperature, so verify whether immediate refrigeration is necessary. * Transferring Specimens: To transfer urine from a collection container to a transport container, use a disposable pipette or carefully pour the urine into the tube after removing the stopper. Always avoid contamination when transferring the sample. * Preserved Urine Specimens: For urine specimens that have been preserved with chemicals, keep the tubes at room temperature for no longer than 72 hours before performing a urinalysiswith chemical reagent strip testing. * Culture and Sensitivity Tests: Specimens for culture and sensitivity testing should also be kept at room temperature for up to 72 hours before analysis. Specimen Delivery Methods When specimens are ready for transport, they must be delivered to the laboratory using safe and efficient methods to prevent degradation or contamination. * Plastic Biohazard Bags: Always place specimens in biohazard bags with zipper seals to prevent spillage and to clearly communicate that the contents are biologically hazardous. Ensure that the specimen is adequately secured before transport. * Hand Delivery: In some cases, specimens may need to be delivered directly to a reference laboratory. When hand-delivering specimens: * Follow the timeliness of delivery guidelines. * Complete necessary log-in processes to track the sample's arrival. * Use proper carrying devices (e.g., coolers, bags) to prevent damage during transport. * Pneumatic Tube Systems: Commonly used in inpatient settings, pneumatic tube systems offer enhanced mechanical reliability and increased transport distance and speed. These systems also feature specific control mechanisms and shock-absorbing features to prevent hemolysis (destruction of red blood cells) during blood specimen transport. * Automated Carrier Systems: Automated transport systems use motorized containers and share many of the same features as pneumatic tube systems. These systems help streamline the transport process while maintaining the integrity of the specimens. Introduction to the Clinical Laboratory Improvement Act (CLIA) The Clinical Laboratory Improvement Act (CLIA) is a U.S. federal law that was passed in 1988. The purpose of CLIA is to regulate laboratory testing to ensure that patients receive accurate and reliable test results. CLIA sets specific standards for laboratories performing tests on specimens collected from humans, ensuring that patient care meets safety and accuracy standards. As a Patient Care Technician (PCT), you will be responsible for performing certain laboratory tests that fall under CLIA-waived procedures. These are tests that the CLIAdeems to carry a low risk for patient harm, often due to the simplicity of the procedure and the type of specimens involved. These tests are common in both medical facilities and patients' homes. CLIA-Waived Procedures CLIA-waived tests are defined as those that: * Present a minimal risk to the patient. * Involve small amounts of blood or easily collectable specimens (such as urine). * Are simple and easy to perform, which reduces the potential for error and harm. These tests include commonly performed procedures such as: * Urine dipstick tests * Glucometer tests * Pregnancy tests * Hemoglobin A1C tests Key Responsibilities in CLIA-Waived Testing When performing CLIA-waived tests, there are specific procedures you must follow to ensure the accuracy and safety of the test. Below is an outline of the key responsibilities you have when performing these tests. Confirming Written Test Requests Before performing any test, confirm that you have received a written test request from the healthcare provider. This request ensures that the test being performed is necessary and appropriate for the patient's care. Establishing Patient Identification Accurate patient identification is crucial. Always verify that the patient is the correct individual by using at least two unique identifiers, such as their full name and date of birth, before collecting any specimen. Providing Pretest Instructions Some tests require specific instructions for the patient to follow before the test. It is your responsibility to provide the patient with clear pretest instructions and ensure that the patient understands and follows them. Afterward, verify with the patient that they followed the instructions correctly. Collecting Specimens Specimens should be collected according to the package insert instructions provided with the test kit. Always make sure you are using the correct specimen collection method and tools for the test. Pay attention to the recommended procedure to avoid sample contamination. Labeling Specimens Accurately Accurate labeling of specimens is essential to prevent misidentification and errors. Label specimens immediately after collection with the patient's name, identification number, date and time of collection, and specimen type. Avoiding Expired Reagents or Test Kits Using expired reagents or test kits can lead to inaccurate results. Always check the expiration date on the test kits and reagents before use. Never use any kit or reagent that has passed its expiration date. Performing Quality Control Testing Before performing patient tests, you must perform quality control testing using the control solutions provided in the test kit. Quality control tests ensure that the testing equipment and reagents are working correctly. * Correcting Problems: If a problem is discovered during the quality control testing, resolve it before testing patient samples. If the control results are not within the acceptable range, investigate the issue, and perform corrective actions. * Frequency of Quality Control Testing: Your facility should have policies in place for the frequency of quality control testing. Follow these policies to ensure consistent accuracy in testing. Test Timing Recommendations Each test has specific timing guidelines that must be followed carefully. The timing recommendations are typically included in the package insert for the test. Follow the instructions to ensure that the test is performed accurately. Interpreting Test Results After performing the test, interpret the results by referring to the package insert information. Always be aware of the normal ranges and the specific steps to interpret the results. Recording and Reporting Test Results Once you interpret the test results, it is your responsibility to record them accurately and report them to the healthcare provider in a timely manner. Ensure that you document the results clearly and communicate any abnormal findings immediately. Follow-up or Confirmatory Testing If a test result indicates the need for follow-up or confirmatory testing, make sure to follow the package insert recommendations. You may need to communicate with the healthcare provider to discuss next steps. OSHA Regulations and Biohazardous Waste Disposal When performing any medical testing, it is essential to follow OSHA regulations for the safe disposal of biohazardous waste. This includes disposing of used test strips, gloves, and other materials in appropriate biohazard containers to minimize the risk of contamination or infection. * Biohazardous Waste Disposal: All materials that come into contact with blood, urine, or other bodily fluids should be disposed of in red biohazard bags or sharps containers as appropriate. Always follow your facility's protocol for waste disposal. Participation in Quality Assurance Programs You are responsible for participating in quality assurance and quality assessment programs for every test you perform. These programs are designed to ensure that testing is done accurately and that standards are continuously met. * Reviewing Performance: You will regularly review test results, quality control data, and procedures to assess whether improvements are needed. * Corrective Actions: If quality issues arise, corrective actions should be implemented promptly to ensure that the testing process remains reliable and safe. Glucometer Test Controls One of the most common CLIA-waived tests you will perform is blood glucose testing using a glucometer. For accurate results, you must always follow the correct procedures when performing these tests. Performing Liquid Controls * Liquid controls should be used every time you open a new package of glucometer test strips. * Use liquid controls at room temperature and ensure they are within the expiration date. Logging Test Control Results * Log the time and date of control testing, as well as the serial number of the glucometer you used. This will ensure traceability and consistency in testing. Proper Storage of Test Strips * Store glucometer test strips at room temperature and close the packageafter each use to keep the strips dry. * Ensure that test strips are not exposed to extreme temperature changes or moisture. Cleaning the Glucometer * After each use, clean the glucometerwith an alcohol wipe to remove any contamination and maintain the accuracy of the device. Preanalytical Errors Preanalytical errors are mistakes that occur before the analysis of a specimen in the laboratory. These errors can lead to inaccurate test results and affect patient care. As a PCT, your responsibility is to minimize these errors by following best practices during specimen collection and handling. Preanalytical errors can occur in several stages, including: * Specimen collection (e.g., improper technique, wrong site) * Specimen handling (e.g., incorrect transportation, improper mixing) * Specimen labeling (e.g., incorrect or missing patient information) By ensuring proper technique and avoiding common mistakes during the preanalytical phase, you can help ensure accurate and reliable test results. Factors Affecting Specimen Collection Several physiological and environmental factors can affect specimen collection. Understanding these factors helps minimize preanalytical errors: Veins and Skin Conditions * Sclerotic veins (hardened veins) and scarred skin can make venipuncture more difficult. If the veins are sclerotic or the skin is scarred, always find another site to collect the specimen. Stress * Stress can cause physiological changes, such as an elevation in white blood cells, decreased iron levels, and abnormal hormone levels, which may affect test results. Ensure the patient is relaxed before drawing blood whenever possible. Other Considerations * Menstrual cycle: Blood tests may be affected by a patient's menstrual cycle, potentially altering results such as hormone levels. * Edema: Swelling or edema in the arms can make it difficult to find veins and may affect the specimen. * Medications: Certain medications can influence test results, so it is important to know what medications the patient is taking. * Infections and vomiting: Both can impact blood chemistry and overall health, leading to unreliable results. * Pregnancy: Pregnancy can alter various lab values, including hormone levels and other metabolic markers. Preventing Hemolysis During Collection Hemolysis occurs when red blood cells are broken open, releasing hemoglobin into the plasma. This can interfere with many lab tests, leading to inaccurate results. It is essential to follow specific guidelines to avoid hemolysis. Key Practices to Prevent Hemolysis: * Tourniquet Use: Leaving a tourniquet on the patient’s arm for more than 60 seconds can cause hemolysis. Always apply the tourniquet briefly and release it before collecting the specimen. * Alcohol Application: Allow alcohol to dry completely before performing venipuncture. Alcohol can cause hemolysis if not given enough time to evaporate. * Needle Gauge: Use an appropriate gauge needle for the patient. A needle that is too small can cause hemolysis due to the force applied during blood draw. Best Practices for Collection and Handling Dermal Puncture: * Forceful squeezing or milking during a dermal puncture can lead to hemolysis and contamination of the sample. Always perform the puncture gently and avoid squeezing the puncture site. * Vigorous Mixing: Avoid vigorous mixing of collection tubes as it can also cause hemolysis. * Syringe Transfers: When transferring blood from a syringe to a tube, do not push the plunger forcefully. This can damage blood cells and lead to hemolysis. Specimen Transport: * Gently Handle Specimens: Always handle specimens gently during transport to avoid physical damage, which could lead to inaccurate results. * Avoid Freezing or Thawing: Do not allow specimens to freeze or thaw during transport, as this can alter the composition of the specimen. * Correct Order of Draw: Ensure that you follow the correct order of draw when collecting specimens from the patient to avoid cross-contamination between tubes. Mixing and Transferring Specimens: * Always mix each tube properly after removing it from the tube holder to ensure thorough mixing of the blood with the additive. * Transfer specimens promptly from syringes to evacuated tubes to prevent clotting. * Use Tubes with Valid Expiration Dates: Always check that the tubes used have not expired. Air Purging in Winged Infusion Sets: * Purge the air out of the winged infusion set by using discard tubes, especially when filling light blue top tubes, to avoid air bubbles that could interfere with test results. Removing Tubes at the Fill Level: * Remove tubes from the holder as soon as the blood reaches the fill level to avoid overfilling, which could alter the results. Proper Technique for Minimizing Clotting in Dermal Punctures Dermal punctures are typically used for capillary blood draws (such as fingerstick or heel stick samples). Proper technique is essential to minimize clotting: * Minimize Clotting: Avoid excessive pressure or manipulation at the puncture site to reduce the chance of clotting. * Correct Tube Selection: Make sure you use the correct tube for dermal puncture collections to avoid clotting or interference with the test. Understanding and Interpreting Requisitions Accurate interpretation of test requisitions is vital for collecting the correct specimen. You must: * Correctly interpret requisitions to ensure that you are collecting the correct type of specimen for the ordered tests. * Ensure correct labeling with patient details (name, identification number, time of collection, etc.) and accurate specimen information to avoid errors. Special Considerations for Light and Temperature-Sensitive Specimens Some specimens are light-sensitive or require specific temperature conditions to remain stable: * Protect light-sensitive specimens(such as bilirubin and folate) by wrapping them in foil to avoid degradation due to exposure to light. * Store temperature-sensitive specimens (such as blood gas tests) in specific temperature conditions (e.g., room temperature for 15 to 30 minutes or in an ice slurry for up to an hour). Alcohol as an Antiseptic During specimen collection, follow the manufacturer's instructions on the use of alcohol as an antiseptic. In some cases, alcohol may not be recommended, as it could affect the sample. Always ensure that you are following the correct antiseptic procedure for the specific test being performed. Labeling Specimens Accurate labeling of specimens is one of the most crucial steps in preventing errors: * Label specimens immediately after collection with the patient's name, identification number, date and time of collection, and specimen type. * Ensure that the label is legible and that all required information is present. CLSI Order of Draw The Clinical and Laboratory Standards Institute (CLSI) provides guidelines for the correct order of draw during specimen collection. The correct order of draw minimizes the risk of contamination and cross-reactivity between different additives in the tubes. The order is as follows: 1. Blood culture bottles 2. Light blue stopper 3. Red stopper serum tubes 4. Orange rapid serum tubes 5. Green stopper 6. Lavender stopper 7. Pink stopper 8. Gray stopper Chain of Custody The chain of custody refers to the process of maintaining control and accountability for every specimen from the moment it is collected until it is disposed of or reaches its final destination (e.g., testing or analysis). The chain of custody ensures that the specimen is not tampered with during transportation or storage, which is particularly crucial for legal and forensic purposes. A well-documented chain of custody prevents errors, misidentification, and the potential for legal challenges regarding the accuracy or authenticity of test results. Chain of Custody Documentation When a specimen is collected, the chain of custody form must be filled out thoroughly. The following information must be documented to ensure proper tracking and accountability: 1. Patient Information: The name and identifying information (such as the patient ID number) of the patient or individual from whom the specimen was obtained. 2. Specimen Information: The type of specimen (e.g., blood, urine, swabs, etc.), as well as the body part or object from which the specimen was obtained. 3. Collector’s Information: The name of the person who obtained and processedthe specimen. 4. Date and Location: The date and location where the specimen was collected. 5. Attestation Information: The signature of the person who is attesting that the specimen is the correct one and that it matches its documentation. 6. Signature and Date from Every Custodian: Every person who has handled the specimen (even if just for transporting) must sign and date the form. This includes every individual who has taken possession of the specimen, no matter how brief the interaction was. Transporting and Handling Specimens in Chain of Custody When transferring specimens during the chain of custody process, it is crucial that the specimen remains properly identified and protected. Steps for Transferring Specimens: * Label the Specimen: Ensure that the specimen is labeled properly with identifying information, including the patient’s name, specimen type, and any other relevant details. * Biohazard Bag: Place the specimen in a biohazard bag with a permanent sealto prevent tampering. The seal ensures that the specimen remains intact and protected during transportation. * Specimens as Legal Evidence: Specimens handled under the chain of custody are often legal evidence and must not be tampered with. Tampering with specimens can result in legal consequences and invalidate the use of the specimen in testing. Situations Requiring Chain of Custody Certain tests require strict adherence to the chain of custody because they are used as legal evidence or in sensitive situations. These situations include: Forensic Analysis: Forensic testing may involve various specimens, such as: * Vaginal swabs (after a rape or assault) * Blood and body fluids collected from crime scenes or postmortem (after death) specimens taken during autopsies. * Toxicology testing to identify substances in cases of poisoning, overdose, or drug abuse. Forensic analysis tests are used in criminal investigations, and the specimens must be handled carefully to ensure their integrity is maintained for legal proceedings. Workplace Drug Testing: Chain of custody is vital in workplace drug testing to ensure the accuracy and integrityof results. The specimens collected for drug testing are considered legal evidence in some cases, so maintaining the chain of custody helps protect against challenges to test results. Drug Testing for Professional Athletes: In professional sports, athletes may be tested for performance-enhancing drugs (PEDs). Chain of custody procedures help ensure that the specimen collected from the athlete is handled correctly and that the results are legitimate. Neonatal Drug Testing: Testing for drug use in newborns is essential in situations where the mother may have used substances during pregnancy. Neonatal drug testing must adhere to chain of custody procedures to ensure the results are valid and reliable. Specimens for neonatal drug testing are typically collected within 24 hours of birth to detect drugs used 24 to 72 hours prior to childbirth. Urine Drug Testing Urine drug tests are commonly used to detect the presence of illegal or prescription drugs in the body. These tests may be used in various scenarios, such as workplace testing, legal cases, or medical evaluations. Privacy and Accuracy: * Privacy: It is important to ensure the privacy of the patient during urine collection, as this is a sensitive process. * Accuracy: The specimen must be handled carefully to ensure that the test results are accurate and not compromised. The chain of custody form must be signed and dated by everyone involved in the specimen collection, handling, and transport. * Detection of Drugs: Urine tests can usually detect the use of certain drugs, including: * Marijuana: Can be detected for up to a week after use. * Cocaine, heroin, and other substances: Can typically be detected for 2 days following use. Sports-Related Drug Testing Sports-related drug testing is another area where the chain of custody is critical. These tests typically detect the use of substances that can enhance athletic performance, such as stimulants. Chain of custody is essential to ensure that the sample is not tampered with or contaminated. Neonatal Drug Testing and Procedures As mentioned earlier, neonatal drug testing focuses on the presence of substances used by the mother during pregnancy. Drugs that may be detected include: * Cocaine * Opiates * Amphetamines * Methamphetamines * Phencyclidine (PCP) Collection Timing: * Neonatal drug testing should be performed within 24 hours of birth and typically looks for maternal drug use 24 to 72 hours prior to childbirth

Digital business Digital business refers to digital technologies to transform tranditional business processes, operations and customer interactions. Key characteristics: • Leverage digital platforms • data-driven decision making • personalised customer experiences, products or services (Netflix, Amazon, Google) • agile and innovative business moodels and revenue streams Increasingly vital due to rapid advancements of technology and changing consumer behaviors. Digital business models often disrupt traditional industries and challenge existing players (e.g. Webjet, Uber, AirBnB) What are Digital Technologies? • Electrical equipment and devices • Applications • Infrastructure • Networks Digital Techologies store, generate, process and transport data across interconnected networks. Digitisation Is the process of converting information from a physical form into a digital one. For example: Scanning a paper document to turn it into a digital file or converting old photos into digital images. It helps store, share and use information more easily on computoers and other devices. Digitalisation Means using technology to improve how business works. Its not just about turning paper files into digital one, its about using new techonologies to make things faster, efficient, and better for customers. Companies change the way they operate, find new ways to work, and use digital tools to stay competitive in todays world. Digital Tranformation Is when businesses use technology to completely change how they work and serve customers. It is more than just using digital tools, its about improving proceeses, creating new ways to operate, and staying competitive in a fast-changing digital world. For example, a store moving from physical shops to an online business or bank using mobile apps instead of only in-person services. Digital Transformation Is about leveraging digitalisation to improve business operations and gain competitive advantage. Example: An ERP System is an ecosystem of interconnected business applications and Data. ERP helps organisations manage and automate core businesses processors across departments, such as supply chain, HR, finance and manufacturing. All aspects of business are internally intergrated. Answering Questions • Define the concept involved • Describe how the concept occurs in the case • Explain the evidance thhat supports the answer • Answer: Have you answered the question proberly? • Everything must be in your own words, anything else is plagiarism Big Data Definition "Big Data is high volume, high velocity and high variety information assets that demand cost-effective, innovaive forms of information processing that enable enhanced insight, decision making, and process automation" (Gartner, 2017) "Data is BIG, when the size of data becomes part of the problem" (Magoulas, 2019) Volume- Amount of Data, Scale Variety- Range of data types and sources Velocity- Speed of the generation of new data and... Analysis- big data requires cost-effective, innovative forms of information processing to enable insight and decision making. Charateristics of Big Data: Variety Structure data- can include: numbers, labels, formulae. Typically it fits neatly into a spreadsheet. Unstructured data- Can include: SMS, MMS, audio, video, radio waves, GPS, anything that doesnt fit neatly into a spreadsheet. Typically, big data is Semi-structured data as it is a combination of structures and unstructured. Velocity Relates to speed, data is being generated quickly and needs to be processed in real-time to useful. Real-time analytics is required, new tools, skills and methods. Late decisions means missing opportunities. E.g. Streaming data, data such as digitised maps, weather, patterns, GPS locations, customer history, reviews, and other data is being analysed using algorithms to give uber drivers real-timeinformation such as length of drive, proximity to passengers, and to calculate the fare. Volume- Data Volume is increasing exponentially Velocity- Data needs to be analysed quickly Variety- Different types of structured and unstructured data. Where does data come from? Big Data in Healthcare Benefits • Preventitive vs reactive • Reduced healthcare infrastructure costs • Reduced death, longer life expectancy • fewer cases of preentable diseases • Less strain on emergency services Challenges • Privacy issues • Digital divide: technology accessibility • Data security issues • Less responsibility for health • Increased popultion/ life expectancy • Ethical challenges • Descriptive Analytics • Explains what has happened (historic) • using data agregation and data mining to provide insight into the past. • Describe and summarise raw data to make it interpretable by humans • Decriptive analytics are useful because they allow us to learn from past behaviors and understand how they might influence future outcomes. Diagnostic Analytics • Explains why something happened (historic) • E.g. for social media marketing campaign, you can use diagnostic analytics to access sudden changes to site visitor activity. • takes the insights found from what descriptive analytics and drills down to find the causes of those outcomes. Predictive Analytics • Explains what might happen in the future • use statistical models and forcast technique to understand the future based on probabilities. • combined transactional and historical data such as ERP, CRM,HR and POS systems to identify patterns in the data and apply statistical models and algorithms to capture relationsips between various data sets. • Use predic likely outcomes Prescriptive Analytics • Recommends an action based on the forecast (future) • use optinisation and simulation algorithms to advice on possible outcomes and recommend best outcomes. • attempt to quantify the effect of the future decisions in order to advise on possible outcomes before the decisions are made. • links with autonomous decision making, artificial intelligence, automation and robotics. By allowing machines to make decisions and take actions. Defining Cloud Computing • The practice of using a network of remote servers hosted on the internet to store, manage, and process data, rather than a local server or a personal computer. • computing processing power • data storage • networking • development platforms • deployment platforms • business processors • Cloud computing is the enabling technology of all digital business. Key Features • On-demand access to recourses • scalability- easily scale up or down based on needs • Cost efficiency- pay only for what you use • Accessibility- access from anywhere with internet connection Why it matters: • Cloud computing enables businesses and individuals to be more flexible, efficient and collaborative while reducing infrastructure costs. • The basic idea is that businesses rent IT services instead of owning the hardware or software. • Key"as a service" models: • Iaas- Infrustructure as a service Rent servers, storage, networking, security (AWS, Microsoft Azure) • PaaS- Platform as a service Rent tools to build and run apps (Google App Engine) • SaaS- Software as a service Use ready-made apps deployed over the internet(Gmail, Microsoft 365) • AlaaS- Artificial Intelligence as a service Access AI tools and models (like image recognition, chatbots, or language processing) • BaaS- Blockchain as a Service Use blockchain infrastructure and development tools through cloud provider. • AaaS- Analytics as a Service Perform data analytics and visualisation in cloud, without needing your own data infrastructure • IoTaaS- Internet of Things as a Service Access IoT capabilities such as sensors and connected devices through cloud provider. What is IoT? The Internet of Things (IoT) is a network of single-task physical objects embedded with software, sensors and network connectivity that enables these objects to collect and exchange data autonomously