In a wellness attention environment there are many different imaging modes available which are used to help diagnosing, or program patient direction and intervention. Modalities within Radiology include X-Ray, Computed Tomography ( CT ) , Ultrasound, Nuclear Medicine, Fluoroscopy and Magnetic Resonance Imaging ( MRI ) . Each mode plays a specific function in replying a clinical inquiry, and each has their ain specific advantages and disadvantages.
MRI uses a big, powerful magnet and Radio Frequency ( RF ) pulses to bring forth transverse sectional images of many anatomical country of the organic structure. In recent old ages MRI has been progressively used, and its applications and capablenesss have advanced to intend that it is used widely as a diagnostic tool in many clinical state of affairss. In fact the figure of MRI scrutinies carried out in England for the NHS has more than doubled from 2003 to 2009 ( DOH, 2010 ) .
Imaging techniques have advanced quickly in about all Fieldss of medical specialty. In many instances such as neurology, these progresss have meant an addition in the quality of anatomical word picture but besides the ability to supply more functional and physiological information such as diffusion and perfusion techniques ( Evans, 2006 ) . MR has many advantages at encephalon imagination compared to other modes. MR is good at looking at anatomy and pathology utilizing high declaration, multi-planar imagination.
The chief advantage is that no radiation is used during MRI and it is besides a non-invasive scrutiny. Progresss have led to high declaration and first-class soft tissue contrast imagination which is exceptionally good for analyzing encephalon anatomy, peculiarly Grey and white affair distinction, posterior pit and analyzing blood, including its flow ( Armstrong et al 2004 ) .
In fact, a large advantage of MRI compared to CT scanning as stated by Munir ( see article 2 ) is that it ‘eliminates exposure to ionizing radiation and there is no hazard of contrast kidney disease… and MRA is associated with decreased patient morbidity and decreased hazard of complications associated with conventional contrast angiography ‘ . Other interesting applications which have made an impact in modern MRI sections include Diffusion Weighted Imaging ( DWI ) and functional MRI ( functional magnetic resonance imaging ) . DWI looks at H2O in different countries of the encephalon and their local features ( Department of Health, 2008 ) . ( nicked from caput instance survey – demand ref pg updated ) .
This sequence has proved a critical tool peculiarly in shot and TIA imagination because countries of ischaemia are readily seeable ( Latchaw, et al. , 2009 -Journal -3 ) . fMRI utilizations are still developing nevertheless, its applications are turning because it can map countries of the encephalon that are activated when patients are asked to finish a given undertaking ( Koretsky- Journal 4 ) .
On the other manus there are besides disadvantages of MRI compared to other modes when imaging the encephalon. For illustration in injury instances, CT scanning is frequently used because it is readily accessible in most infirmaries, scan times are short, and there are no contraindications sing surgery and equipment ( Bruce Journal 1 ) . In add-on, imagination of bleeding with MRI can be complex to construe because the age, size and province of hemoglobin must be taken into history ( Koretsky -Journal 4 ) .
Therefore, CT is frequently the used as first line imaging in instances of acute bleeding ( Longmore 2004 ) . Furthermore, MRI is inferior when imaging bony constructions because cortical bone contains fewer H protons and hence returns small signal ( Jackson and Thomas, 2005 ) . Another disadvantage of MRI is that it is frequently prone to artifacts which can degrade image quality, such as, metal artifact from dental fillings and gesture artifact due to long scan times ( McRobbie, et al. , 2003 ) – acquire ref from instance survey ) .
Other modes used for imaging the encephalon include, Digital minus angiography ( DSA ) , ultrasound and atomic medical specialty. DSA remains the gilded criterion signifier some cerebrovasular diseases, such as arteriovenous deformities, nevertheless it is an invasive trial and can do serious complications ( Latchaw et al 2009 Journal 3 ) .
Ultrasound is widely used for scanning the neonatal encephalon as it does non utilize radiation, and is peculiarly good at naming intellectual bleeding, developmental deformities and hydrocephaly ( Jackson and Thomas 2005 ) . Ultrasound in newborns is possible due to the acoustic window provided by the soft spot in the skull, nevertheless this closes with age and hence, the usage of ultrasound in kids is limited to the first two old ages ( Jackson and Thomas 2005 ) . Nuclear medical specialty, including SPECT and PET, has a function in diagnosing and theatrical production of patients with dementedness and other neurological diseases ( 2005 ) .
Word count -727
Spinal column
MRI – mets, tumors
CT – Injury
Nucmed – mets – whole spinal column, expression for secondary? Get hot musca volitanss on specific countries which can take to MRI scanning a specific country e.g. T-spine.
X-ray – injury, breaks, spinal column abnormalcies ( could be inborn – developmental )
MRI is the ‘gold criterion ‘ for spinal cord imagination because it is extremely sensitive and specific to pathology ( Berquist 1996 ) . This is due to good tissue and spacial declaration. Berquist, T. , 1996. MRI of the Musculoskeletal system. 3rd erectile dysfunction. Keystone state: Lippincott-Raven Publishers. MRI used to look for meniscal cryings in articulatio genuss.
MRI besides has many advantages when it comes to imaging the muscular-skeletal system. For illustration, MRI can be used to observe little cryings such as a meniscal tear within the articulatio genus and no contrast is needed for this clinical diagnosing. The synovial fluid within the joint capsule Acts of the Apostless as a natural contrast agent enabling little cryings to be visualised cleary.
Besides a rotator turnup tear would demo up as a nice bright signal within the shoulder which confirms there is a tear within this country of involvement. When scanning the shoulder for re-current disruption, an arthrogram survey is really utile.
The disadvantage of this survey is that it is invasive, clip consuming, radiation to patient, adviser handiness – operator dependent, patient tolerance for process – can be uncomfortable, patient is advised non to make any manual work over the following 24hrs after process.
CT/Nucmed used for looking at bone.
CT shoulder/knee – measuring tibial platto breaks ( articulatio genus ) . Fractures, boney lesions. CT can retrace images to see bony item and see where fragments have gone.
U/S used for looking at balls and bumps.
Ultrasound is suited for measuring hypodermic abnormalcies as it can bring forth high quality images with high spacial declaration. The same can be said for MRI imaging although Ultrasound can be the preferable mode due to this. ( Bearcroft, 2007 )
The chief disadvantage of utilizing ultrasound in any scrutiny is that the consequence is operator dependent. ( Bearcroft, 2007 )
X ray used for looking at castanetss for interruptions and boney tumors.
Complain X raies are still used on a day-to-day footing but other modes seem to be used more to reply more clinical specific inquiries. They are still used in order to corroborate chiefly bone abnormalcies. . ( Bearcroft, 2007 )
ABDO/PELVIS- In this instance, the chief disadvantage of MRI, other than safety issues, is that images of the venters and pelvic girdle are frequently degraded by gesture artifact caused by respiration, intestine vermiculation and fetal motion ( Campos, et al. , 1995 ) .
Pregnant Patient
Pregnant patients and fetal conditions can be imaged under MR counsel ( Shellock, 2001 ) . Research into MR safety during gestation and technological progresss, such as high field scanners and rapid sequences ( to cut down gesture artifacts ) has meant that MRI have several utile applications for pregnant patients. The preferable imagination mode is presently sonography, nevertheless this may non ever turn out sufficient to do a diagnosing and so MRI possibly considered ( Abbott, EL al. , 2004 ) .
MRI is besides a good option when ultrasound proves deficient as there are no radiation hazards. It clinically provides first-class cross-sectional positions that have good tissue distinction and declaration to help diagnosing for the clinician. ( Abbott, EL al. , 2004 ) . Furthermore, MRI provides the ability to measure map, for illustration MR urography to measure the nephritic system.
Wordss = 129
TIA/CVA – Mention TIA clinic is a new clinic, nexus to U/S carotids as most TIA instances originate from the cervix, acquire narrowing of carotid arteries.. MRI will demo countries where blood supply will be reduced ( caput scans ).
Birthday Party In Chinese Family Sample
The memorable event for me is about my grandfather’s mother’s 92th birthday which was in the Lantern Festival ten old ages ago. As 92 is an of import age for everyone. my parents spent three yearss fixing for this large twenty-four hours. On the twenty-four hours of her birthday. we booked a Chinese dinner in a eating house in Chengdu.
At precisely 7:30pm. all of our relations. household members and even some friends of my parents attended this party. Equally far as I can retrieve. about 40 people wished her a happy birthday. At the party. we had a rather large birthday cake with the Chinese character ” Wanshouwujiang” on it.
At the beginning of the party. we lighted the ruddy tapers and my gramps made a address on standing for the whole household. showing all our gratitude to his female parent for her hardworking and love on conveying up her kids and grandchildren. After that. some of our relations and friends presented so many gifts to grandmother. Later everyone joined us in wishing her a happy birthday in a birthday vocal around her. and we cheered each other. Then we cut and shared the birthday bar as a usage. It is said that if you portion the birthday bar of an older individual. you besides portion his or her length of service.
During this party. my grandma was excessively aroused to state any words merely with immense felicity on her face. I remember clearly that at that clip I saw the starry sky what I seldom met.
That twenty-four hours gave me a lasting memory. Even though my grandma had been decease for nine old ages. I besides miss her quite a batch forever and of all time.
Bitter Competition: The Holland Sweetener Company Versus NutraSweet Sample
In late 1986, the Holland Sweetener Company (HSC), based in Maastricht, the Netherlands, was preparing to enter the European and Canadian aspartame markets. Aspartame, a low-calorie, high-intensity sweetener, had been discovered in 1965 by G. D. Searle & Co., a US pharmaceuticals company. After securing a number of patents on its discovery, Searle had gone on to develop markets for aspartame as a food and beverage additive.
By 1986, NutraSweet, the operating entity set up by Searle to build the aspartame business, had reached sales of $711 million. Now, NutraSweet’s patents in the European and Canadian markets were due to expire as of 1987, although the US market would remain protected until December 1992.
Winfried Vermijs, president of HSC, reviewed his company’s strategy for competing in the aspartame business. Price and volume forecasts had been prepared for the European and Canadian aspartame markets. Two price scenarios were being considered: “normal competition” and “price war.” Vermijs wondered which scenario was more likely.
High-intensity sweeteners have a long history. In Roman times, grape juice was boiled down in lead pans to produce sapa, a sweet compound used for everything from a food additive to an oral preventive. Concerns over the safety of modern high-intensity sweeteners unfortunately led to neurological damage or even death from the use of sapa.
Discovered in 1879, the oldest high-intensity sweetener still in use was saccharin, an oil derivative about 300 times as sweet as sugar (sucrose) of equal weight. In the 1960s, Abbott Laboratories developed cyclamate (30 times as sweet as sugar), but following studies suggesting a link to cancer, the Food and Drug Administration (FDA) banned cyclamate in 1970.
In 1977, the FDA attempted to ban saccharin as well, but the resulting public outcry caused Congress to intervene and declare a moratorium. However, manufacturers of saccharin were required to place notices on labels warning consumers of the potential increased cancer risk. Apart from the safety issue, many people found saccharin to have a slightly bitter, metallic aftertaste.
Aspartame is a white powder consisting of L-aspartic acid and L-phenylalanine, two naturally occurring optically active amino acids, together with a small amount of methanol. Professor Adam M. Brandenburger prepared this instance as the basis for class treatment rather than to exemplify either effective or ineffective handling of an administrative situation.
The case draws on a study by Peter Wetenhall (MBA ’92). Aid from Research Associate Maryellen Costello, Rena Henderson, and Research Assistant Julia Kou is appreciatively acknowledged.
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No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the permission of Harvard Business School.
Acrimonious Competition: The Holland Sweetener Company versus NutraSweet (A)
Aspartame had the same caloric content as sugar of equal weight but was 180 times as sweet. Unlike sugar, aspartame did not promote tooth decay. The main drawbacks of aspartame were that it became unstable when exposed to high temperatures (as in baking) and that it had a limited shelf life in soft drinks.
Aspartame had been discovered by accident. In 1965, James Schlatter, a research scientist at G. D. Searle & Co., a pharmaceutical company based in Skokie, Illinois, was working on a project to develop an anti-ulcer drug. While experimenting with L-aspartic acid and L-phenylalanine, he happened to touch his finger to pick up a piece of paper and noticed a sweet taste. He later coined the term “aspartame” for the combination of amino acids.
NutraSweet/G. D. Searle & Co. was formed in 1908, although the company’s roots could be traced back to 1888. From its upper Midwest beginnings, Searle grew to become a Fortune 500 pharmaceutical company in 1968. Following its serendipitous discovery of aspartame, the company had an opportunity to strike out in a new direction. Searle secured two key patents on aspartame.
The “use” patent, obtained in 1970, covered any use of aspartame as a sweetening ingredient. The “blend” patent, obtained in 1973, covered combinations of aspartame and saccharin. Approval from the FDA for the use of aspartame as a food additive was sought the same year. After giving a green light to dry use of aspartame (tabletop sweeteners and powdered drinks) in 1974, the FDA withdrew its approval shortly afterwards, pending the results of further tests. Not until July 1981 did the FDA give the final green light for dry use of aspartame.
Wet-use blessing (soft drinks) came in July 1983, in the aftermath of regulatory holds. Searle sought extensions of its two patents and was successful in acquiring an extension of the usage patent – to 1987 in Europe, to December 14, 1992, in the United States, and to April 1993 in Australia.
An effort to widen the Canadian usage patent, which was due to run out in 1987, was unsuccessful. The blend patent was extended to November 4, 1996, in the United States.
To fabricate aspartame on a commercial scale, Searle turned to Ajinomoto, a major Japanese chemical and food company. Ajinomoto was a leading participant in amino acid research and production, dominating the monosodium glutamate (MSG) market. (For financial information on Ajinomoto, refer to Exhibit 3.)
Ajinomoto supplied a chemical yoke process for manufacturing aspartame as well as the L-phenylalanine input. (The other input, L-aspartic acid, was widely used in pharmaceutical applications and could be obtained from a number of sources.) Searle agreed to pay Ajinomoto royalties for access to the process technology, and the two parties further agreed to share information on subsequent process improvements.
A cross-licensing deal was also struck under which Ajinomoto was given sole access to the Japanese aspartame market, where it went on to sell aspartame under the trade names Pal Sweet and Pal Sweet Diet. Searle retained exclusive rights to the North American market.
Some information in this section is taken from “The NutraSweet Company: Technology to Tailor-Make Foods” (Harvard Business School Case No. 589-050) and Sweet Success: How NutraSweet Created a Billion Dollar Business, by Joseph McCann (Homewood, Ill.: Irwin, 1990).
Under FDA regulations, an applicant had to establish the “added value” of a new product. However, only the effectiveness of a new product, and not its cost, entered into the added value assessment. Thus, the standard for the approval of a high-intensity sweetening was that it be demonstrably superior to existing sweeteners as an aid to dieting.
Acrimonious Competition: The Holland Sweetener Company versus NutraSweet (A)
It took two to three years to bring aspartame production up to speed. Once operational, however, a facility had to be run at or near to planned capacity, as breaks in production were prohibitively expensive due to significant mothballing and debugging costs. Minimum efficient scale was of the order of 2,000 metric tons annual capacity, while plant construction costs exceeded $100 million.
With transportation costs for aspartame around 15-20 cents per pound, NutraSweet and Ajinomoto concentrated production in a limited number of facilities (see Table A). Table A: NutraSweet and Ajinomoto Production Facilities.
Beginning:
Annual capacity (metric tons): 2,000, 3,000, n/a, 2,000.
Chemical Marketing Reporter and Financial Times (assorted issues). Case writer estimations.
The NutraSweet-Ajinomoto method of fabricating aspartame was covered by process patents extending through the late 1990s. With a continuing plan of process improvement and capital investment in place, NutraSweet and Ajinomoto aimed to increase the efficiency of their manufacturing operations over time. By 1992, NutraSweet would be announcing that it had cut its manufacturing costs by 70% over the previous decade.
Market Development: Having spent about $80 million in start-up costs (excluding investments in plants), Searle launched its first aspartame product, the tabletop sweetener Equal, in October 1981.
At that time, the US tabletop sweetener market totaled approximately $110 million. It was dominated by one brand, Sweet ‘N Low, a saccharin-based product made by the Cumberland Packing Company of Brooklyn, New York. Although it was three times more expensive than Sweet ‘N Low, Searle’s Equal was an immediate success in the marketplace.
In December 1982, The NutraSweet Group was established as a separate operating division of Searle. Forty-year-old Robert Shapiro, Searle’s general counsel, was brought in as president. Educated at Harvard and Columbia Law School, Shapiro had served on several government advisory commissions and had then spent time in the private sector before joining Searle in 1979.
Following FDA approval for wet use of aspartame, Shapiro set in motion the now-famous “branded ingredient” strategy. Aspartame, under the trade name NutraSweet, was made available to any interested food or beverage manufacturer.
This was backed up with extensive advertising (estimated at $30 million yearly) of the brand name directly to end-users and by cooperative advertising with manufacturers. The company gave discounts of up to 40% off the list price of aspartame to manufacturers who agreed to use 100% aspartame as a sweetener (instead of blends of aspartame and saccharin, for example), to make NutraSweet their exclusive worldwide supplier, and to display the NutraSweet trademark and distinctive red-and-white “swirl” logo on their products and in their own advertising.
Acrimonious Competition: The Holland Sweetener Company versus NutraSweet (A) By 1986, the company was claiming that 98% of American consumers…
The soft drink market was NutraSweet’s primary focus in 1983. The US soft drink industry was dominated by two players, Coca-Cola and Pepsi-Cola, which, between them, accounted for something over 60% of shipments in an industry with annual sales of $26 billion at the retail level. The diet section accounted for 20% of the US soft drink market and was growing quickly. To date, saccharin had been used to sweeten diet soft drinks.
NutraSweet sold aspartame directly to major purchasers such as Coke and Pepsi via secret, negotiated, multi-year contracts. In 1983, the contracted monetary value was around $85-$90 per pound. Although this represented a significant premium over saccharin (which cost around $3 per pound) and even sugar (about 25 cents per pound), aspartame replaced virtually all the U.S. soft drink usage of saccharin within two years of its debut. Pepsi, first to use 100% aspartame in its diet drinks, used its head start over Coke to promote Diet Pepsi against Diet Coke.
The 1980s saw intense activity by Coke and Pepsi in the U.S. soft drink market. A memorable episode in the alleged Cola Wars was Coke’s 1985 reformulation of its 99-year-old Coca-Cola trade name, from which it beat a headlong retreat in the face of consumer opposition.
Pepsi responded to the reformulation with commercials proclaiming: “For 87 years Coke and Pepsi have been eyeball to eyeball. It looks like they just blinked. . . .”
Over time, NutraSweet expanded aspartame’s range of applications to include usage in powdery drink mixes, frozen sweets, masticating gum, toppings, cereals, and non-prescription pharmaceuticals, among other products.
However, diet soft drinks continued to be the main use, accounting for approximately 80% of total sales of aspartame. The tabletop market accounted for another 15% of sales, with other food and drink products the balance.
NutraSweet also looked to develop markets for aspartame outside the United States. Canada was an early target. In 1984, NutraSweet and Ajinomoto set up a 50:50 joint venture, NutraSweet AG, based in Zug, Switzerland, to market NutraSweet to European commercial purchasers and the tabletop sweetening (under the name Canderel) to European consumers.
As in the United States, the soft drink industry was the primary focus of efforts to sell aspartame internationally, and Coke and Pepsi were once again the major purchasers. Unlike the situation in the United States, however, Coke enjoyed a strong lead over Pepsi in most overseas markets. In Europe, Coke was estimated to have a 50% market share and Pepsi a 10% share.
In Asia, Coke’s share of the soft drink market stood at 40%; Pepsi again held a 10% share. In Latin America, Coke held a 55% market share and Pepsi a 20% share. Exhibit 1 depicts the growth of the worldwide aspartame market through 1986. In that year, worldwide aspartame prices were about $70 per pound.
Acquisition In the summer of 1985, Searle was acquired by Monsanto Corporation for $2.8 billion. Monsanto, headquartered in St. Louis, Missouri, was a leading U.S. manufacturer of agricultural products, plastics and specialty chemicals, performance materials (such as synthetic fibers), and industrial control equipment. (Exhibit 4 summarizes financial data on Monsanto.)
Curiously, the mission of the original Monsanto Chemical Works, formed in St. Louis in 1901, was to challenge the then German monopoly hold on the saccharin market. Now, with the purchase of Searle, NutraSweet became a wholly owned subsidiary of Monsanto.
Since the acquisition, Monsanto had been writing off the cost of the aspartame patents via a $173 million one-year charge against NutraSweet’s net income. The amortization charge would stop with the US termination of the usage patent in 1992.
The Holland Sweetener Company In April 1985, the Holland Sweetener Company (HSC) was formed in Maastricht, the Netherlands, as a joint venture between Tosoh Corporation and DSM to enter the aspartame market. Headquartered in Tokyo, Japan, Tosoh had begun business in 1935 as a manufacturer of sodium carbonate ash and acidic sodium carbonate.
The company had since grown to become a diversified maker of basic chemicals, intermediates, and downstream products, as well as scientific instruments and ceramics. Based in Heerlen, the Netherlands, DSM was a chemicals group with interests in plastics, synthetic rubber, fine chemicals, fertilizers, resins, consumer products, and oil and natural gas exploration and development.
The company had begun as “Dutch State Mines” around the turn of the century but over time had been migrating into downstream businesses. Since 1986, DSM had been publicly traded, with the Dutch government retaining a one-third interest. Exhibits 5 and 6 summarize financial data on Tosoh and DSM.
Tosoh brought to the hookup with DSM a patented process for manufacturing aspartame that employed a natural accelerator to solve the problem of achieving a precise bond between the aspartic acid and phenylalanine inputs. The Tosoh process was capable of using either L-phenylalanine or D.L-phenylalanine (a mixture of the D- and L-isomers) as base feedstock. (Exhibit 2 reports the process.)
HSC claimed that its method of producing aspartame would be less costly and more flexible than NutraSweet’s, although this was disputed. DSM’s contribution to the joint venture was raw material supply and traditional chemical processes (courtesy of its Fine Chemicals Division) and knowledge of the European market place.
Heading up HSC was Winfried Vermijs, a 50-year-old chemical engineer who had been with DSM since 1961. Vermijs had begun his career working on process development in DSM pilot plants. After a stint as a plant manager in the 1970s, he had returned to research and development activities for several years before taking on general management responsibility as president of HSC.
In February 1986, HSC began work on a 500-tonne aspartame plant in Geleen, the Netherlands, with a view to challenging NutraSweet in Europe and Canada once NutraSweet’s patents expired there in 1987. The company received a DFl. 35 million ($17 million) loan from the European Investment Bank toward the project.
In preliminary discussions with potential customers, HSC discovered that NutraSweet had signed Coke and Pepsi to exclusive, multi-year contracts. It decided to lodge a complaint with the European Commission, charging that the contracts were anti-competitive. Joining HSC in the complaint was the Irish company Angus Fine Chemicals.
New Sweeteners In addition to aspartame, saccharin, and cyclamate, several other high-intensity sweeteners were on the market or in various stages of regulatory review. Acesulfame-K had been discovered in 1967 and was now being sold in Europe. It was 200 times sweeter than sugar and was heat-stable, which gave it an advantage over aspartame in shelf-stable products and in baking.
Acrimonious Competition: The Holland Sweetener Company versus NutraSweet (A)
Acesulfame-K was manufactured by Hoechst, a major German company.
Sucralose, a heat-stable compound 500 times sweeter than sugar, was derived from sucrose by a patented chlorination procedure developed in 1976 by the British sugar company Tate & Lyle and researchers at Queen Elizabeth College in London. Johnson & Johnson, the U.S. consumer products company, had entered a licensing agreement with Tate & Lyle and, through its McNeil Forte Products division, hoped to market sucralose in the United States and Japan under the trade name Splenda.
Alitame, a heat-stable product 2,000 times sweeter than sugar, was made by the U.S. pharmaceuticals company Pfizer. A request for FDA approval was submitted in 1986. There were also several naturally derived high-intensity sweeteners. Stevioside, made from the leaves of the South American Stevia plant, was in demand in Japan.
Thaumatin, genetically engineered to replicate proteins found in berries of certain West African plants, was being used as a sweetener in Japan, Brazil, and the U.K. Neither sweetener had yet been approved in the United States.
One trend expected to strengthen if a wider range of high-intensity sweeteners became available was blending. Researchers had found that combining sweeteners could have a synergistic effect: the blend was sweeter and might have a better taste profile for certain applications than either sweetener individually. U.S. health authorities also encouraged a multiple-sweetener approach on the grounds that it reduced the health risks from any one product.