Strategic planning Essay Example for Free

Strategic planning Essay Strategic planning refers to a course of action for outlining organizational objectives, carrying out planning to achieve those objectives, and measuring the usefulness of those strategies (Kovner Knickman, 2011). How will the organizational performance at Montefiore be measured? Performance measures are important for it improves communication internally among their employees and externally between the organization, customers, and stakeholders. After all, Montefiore effective communication for their strategic planning activities is explained in their mission statement, which is to heal, to teach, to discover, and to advance the health of the community that they serve (Kovner Knickman, 2011). Montefiore organizational performance should be measured to justify programs and their costs that should include a measure of supply and demand. For instance, patient appointments, which supply is the total of clinician hours and non-appointments (refills and messages) and for demands, the total number of request for appointments received on any given day from both internal and external sources. Montefiore organizational performance should be measured by showing accountability of stewardship of the tax payer’s dollars to show that they are addressing the needs of the society by making progress towards goals (Kovner Knickman, 2011). The vision is that all organizations within the department have performance measurement systems to reinforce their planning and evaluation activities (Kovner Knickman, 2011). Planning and evaluating activities is the responsibility of every individual within that department working together to develop valid and useful measures. Why don’t all HCOs have strategic goals like Montefiore’s? Unfortunately, not all health care organizations agree with strategic planning. Questions about its importance and successfulness have continued. The reason for this is that after decades of research the outcome of strategic planning on an organization’s performance is still not clear. Significant benefits from planning have been found in some studies while others have found no connection and some unfavorable outcomes (Kovner Knickman, 2011). What contributions should the management team make? Management teams contribute to clarifying common goals and purposes of the  organization to their employees. All employees contribute to the organization’s success. Organizing people, dollars, services, equipment to accomplish the work required by the employees is another contributing factor the management teams plays a role in (Kovner Knickman, 2011). Above all, management team contributions are about teamwork, collaboration and being responsible of resources entrusted to them. References Kovner, A. R., Knickman, J. R. (2011). Jonas Kovners Health Care Delivery in the United States (10th ed.). New York, NY: Springer.

Survey on Sanitary Conditions and Hygiene

Survey on Sanitary Conditions and Hygiene ABSTRACT Mauritius is known as a paradise island, attracting thousands of tourists each year. During the last two decades this sector has undergone a rapid development making it one of the most important pillars of our economy. Nowadays our country relies a lot on this industry as it is a source of revenue for foreign currency. Our hotels accommodate the majority of this population. Hotels provide them with basic accommodation such as lodging and food facilities. Therefore any wrong management in this sector can make drastic changes to our economy. The Government did a lot to promote this sector, by amending laws protecting the environment while other authorities are working hard to avoid propagation and controlling communicable diseases. Therefore hotels have an important role in maintaining a good hygienic level and also in the fight of controlling any diseases or infections by reporting them to the authorities concerned. Thus a study was carried out to study the general sanitary practices of medium size hotels of Mauritius. Fifty hotels were selected at random throughout the island. Two survey questionnaires were designed. Questionnaire 1 was designed for my personal view to assess the hygienic conditions of food preparation area, rooms and other facilities available whereas questionnaire 2 was designed to assess the knowledge of the food handlers concerning various issues. After carrying out the surveys, it was found that simple hygienic practices were lacking among the food handlers. Moreover some hotels sanitary conditions were not satisfactory concerning certain issues, thus not complying with the recommended laws. Good sanitary facilities were not provided by the hotels management. CHAPTER 1 INTRODUCTION Overview A hotel is an establishment providing paid lodgement on short time basis. It provides basic accommodation consisting of room with bed, toilet and bathroom and water facility. It also provides food for room service daily and has its own restaurant (Wikipedia, 2010). Therefore it must have a high level of hygiene. Hotels accommodate adults, children and old persons. People coming from all parts of the world. These people are strangers with different life styles and different personal hygiene levels. A good degree of hygiene in the hotel establishment is therefore necessary to counteract any hygienic problems that may arise. Therefore hotels must provide services of good quality with trained personnel. The level of hygiene of staffs must be considered as priority. The workers must cope with all sanitary regulations for themselves to be clean and not to be the cause of any infection spread. Hotels are regulated because of cleanliness reason and sanitary practices which help to prevent the spread of diseases and parasites. Inspections are made to ensure they operate safely complying with all regulations such as Public Health Act, Safety and Health Act or the Food Act. (FAQ, 2010). From a research carried out by Environmental Health Division in the United States, inspections carried out by the inspectors were mainly to have a visual examination for overall cleanliness and soundness of building construction. Moreover simple inspections were done concerning proper washing of dishes like cups and glasses, proper laundering of bed and bath linens. Other inspections performed were to look in the maintenance of other room furnishings and for the absence of rodents and insects that are of great importance in preventing diseases. These inspections are effected according to the Tourist Accommodation Regulation (Environmental Health, 2010). Hotels are inspected at least once per year and sometimes much more depending on complaints arising from the public. In United States, Fire Marshal approval is an important factor else no permit is delivered (Environmental Health,2010). . In Mauritius hotels license are issued after approval of an EIA and compliance of all health codes. Food hygiene training is an important factor in hotels. Adopting a safe food handling practice is an important factor for effective management of food safety. A study carried out by the International Journal of Environmental Health Research on food hygiene training practices by interviewing managers and food handlers. It showed that most of the food handlers had undertaken formal food hygiene training courses but many others did not and still were preparing food, including high risk foods. Pre-training support and on-going supervision was absent, thus limiting its effectiveness. It is believed that food handlers are in many cases causes of food contamination (Taylor and Francis, 2008). Researches effected in Wales, showed many that hotels were criticised for a number of failures. Numerous high risk foods were kept past their use by dates. Chopping boards were in a state that could no longer be disinfected properly due to their worn state while mouldy plastic bread containers were also spotted. Other hotels were criticised for inadequate level of food hygiene awareness among its staff while another had a leaking cellar roof (Woodrow, 2009). Other researches reported that in United States, there were cases where rooms were causes of sickness where housekeeping staff was not properly doing their job (Conrad,2008). In New York, during an inspection it was observed that a hotel room was infested by bed bugs, mice and other vermin (Riverside Studio, 2009). Studies carried out in other parts of the world have demonstrated that hotels often lack a good hygiene level. Carelessness of workers lead to food contamination and other infections. However our country is not the best compared to them. This study is being carried out to investigate the level of hygiene in our medium size hotels of Mauritius. AIMS AND OBJECTIVES Aims of the study The aim of the study is to assess the level of hygiene present in medium size hotels of Mauritius. Food handlers are to be assessed concerning food hygiene practices in food processing area. Housekeeping staffs are to be assessed about the importance of hygiene in rooms and also evaluating the level the knowledge of workers concerning communicable diseases. Recommendations were also made for improvements. Objectives of the study The objectives of the study are to: Taking a sample size of at least 50 hotels around Mauritius to have an overview evaluation of the level of hygiene over the whole island. Carry out a survey for my personal view of hygiene in hotels. Carry out a second survey to assess the knowledge of workers about hygienic importance in their working place Compare the sanitary facilities available in these hotels to the law requirements. Analyse the data and to make propose recommendations for improving the level of hygiene and the sanitary facilities available. CHAPTER 2 LITERATURE REVIEW Hygiene Hygiene is described as the science of preserving health in connection to cleanliness. It compromises all those measures necessary to detect and prevent infection and intoxication which may be harmful to health. The aim of a good hygiene is to provide consumers with both a good service and safe food. It involves all measures directed to ensure a safe and good quality product and service. Hygiene is an important factor in a business as it helps to protect and also promote ones reputation. In order to have all these, it is a must to comply with all Acts Regulations made in the law (schurmann,2008). Food poisoning Food poisoning is one result of poor hygienic practices. We are surrounded by tiny living organisms that cannot be seen without a microscope. These organisms are called microorganisms. Some are harmless whereas those which are harmful are called pathogens. They are found everywhere. An example is Staphylococcus aureus living on the skin as a normal flora. The same bacteria if in contact with food, can cause food poisoning. This is one of the most common food poisoning bacteria. Another example is E.Coli living naturally in our intestines for breaking down of food, but when in the urinary tract, it causes serious infections (Frazier W, 1995). Contamination can be made by different bacteria such as Bacillus cereus, Clostridium perfringens and Clostridium botulinum. The symptoms arising when consuming food harboring these harmful bacteria are familiar to most people. They are namely vomiting, headache, abdominal pain and diarrhea. There is loss of fluid through vomiting and diarrhea in most severe cases. Those who are more prone to such risk are youngs and elderly or already ill people. Therefore sanitary conditions play an important role in preventing such disease to happen. Necessary precautions must be taken at all stages in food preparation and most important when this concerns bulk production of food as in hotels (JFraser,Microbiology Book). To prevent food poisoning there are three main things that can be done: stop the bacteria from multiplying by : Bacteria reproduce very if they get suitable conditions: moisture, food, warmth, and time Therefore it is important to prevent such conditions by using proper storage. stop bacteria getting onto the food Keeping food covered Handling food as little as possible Keeping raw and cooked foods separate Keeping animals and pests out of the kitchen Disposing of rubbish in covered bins destroy the bacteria in the food only a few bacteria are able to survive temperatures higher than 70o C. This is why it is important to cook food thoroughly. Food such as meat and vegetables should be chopped into small pieces to ensure cooking. Food that is reheated, should be used only once. The left overs should be discarded. Frozen food should be well defrosted before cooking as it may happen that inner part remain uncooked. Food borne diseases Food-borne disease arises when contaminated food is ingested containing a pathogen. This pathogen causes problems only because of the fact that it reproduces inside the human body which provides all necessary factors for its development. Poor food handling and bad sanitation practices are commonly the cause of food-borne diseases in food establishments. One example is the gut bacteria Escherichia coli causing food-borne disease. It may be present through faecal or other source of contamination. E.coli caused 20 deaths and 200 other cases in Lanarkshire, Scotland in 1996 which needed to be treated during the outbreak. This bacteria is particularly dangerous because few bacterial cells, possibly 20 minimum need be ingested by a person to cause severe symptoms( Maff, 2000). A study carried out in Mekelle Town in Ethiopia to determine the sanitary conditions in 420 establishments including small hotels showed that latrines, hand washing basins, proper type of solid waste disposal and tap water were available at 96.9% , 57.1 % , 39.2% and 93.6% respectively. Proper dish washing and food storage practices were observed at 46% and 52% respectively. But poor personal hygiene among the workers and food handlers were observed. Staphylococcus aureus and E.Coli were found in utensils at a high level which can only result from poor hygienic practices of the workers. (Ethiop.J.Health Dev. 2007). It was observed that sanitary conditions were maintained but however there were conditions where there was non adherence in workers. Our country is not an exception to such food-borne outbreaks. The sanitary inspectors of the Ministry of Health are here to give support to avoid such problems. Water borne diseases Water contamination is common worldwide. The category affected is mainly young people and elders having a poor immune system. A study was carried out in India about the water hygiene behaviours in hotels and restaurants few years ago. It showed that contamination in drinking water is made by man and usually due to improper storage, handling and serving which leads to serious water borne diseases. It has been noticed that in a drinking water sample of 340, 69.1% were non-potable water and 73.2 % had presence of E.Coli due to human faecal matter. Causes to this outbreak were poor hygiene behaviours, storage and handling practices which was known to deteriorate the water quality. This could have been improved by educating the workers and food handlers in these hotels and restaurants. This can result to illness of mainly diarrhoea and vomiting, whereas other symptoms include fever, abdominal pain, headache and giddiness (Pubmed,2003). General sanitary requirements in hotels People normally visit a hotel for short-term basis. There is a continuous flow of incoming and outgoing people. Different people from different countries stay in same room. Therefore rooms must be well sanitized and disinfected after each visit. Aeration and ventilation is important. Cleanliness and sanitary practices play an important role in maintaining this balance. It helps to prevent the spread of diseases and parasites not only to tourists but also our general population. Hotels are therefore inspected to make sure that it copes with the law and that they operate safely following the Health Codes (Lockyer,2003). Points that are inspected and controlled for aiming a good cleanliness and soundness of building facility are : Absence of pests such as rodents and insects Proper handling and storage of trash Proper laundering of bed linens and bed Proper washing of utensils such as plates ,cups and glasses No hazards due to infrastructure of building facility Cloakroom accommodation for staffs Proper services such as power, heat, water General maintainance of area to eliminate potential breeding places for mosquitoes or other vectors No domestic animals in area Fire safety and emergency exits Good hygiene rules Consumer satisfaction is prior to all. Thus a good service and hygienic food and water are important. Rooms should be well maintained. Housekeeping department plays an important role. It is the backbone of any good hotel. Employees of housekeeping department are made responsible for maintenance, as they have to visit each room every day to set the room for same the guest or the next guest. During their routine visit, they check all the possible electric point, water points, gadgets, while replacing linen, soap, shampoo, towel, etc other important factors are listed below. Sanitary design premises should be assessed and designed in such a way to reduce health hazards. Personal Hygiene and Food handlers One must be educated about hygiene and to start oneself should be hygienic in all aspects and should possess a food handlers certificate. Cleanliness Working environment should be maintained clean. There should be a high standard of cleanliness, most important for those handling food stuffs. Awareness knowledge of hygiene practices in work place, communicable diseases awareness. Hands Skin Hand is the main route for contamination. Therefore to avoid food poisoning bacteria to get in contact with food, water and soap must be used for washing time to time. Mouth, nose ear it is the route for staphylococcus bacteria to enter food through coughing, sneezing and scratching. Therefore necessary precautions should be taken be avoid these during food preparation. Sanitary conditions in restaurants A good hygiene is required in food premises to make sure food is safe. It prevents food poisoning and prevent spreading of any communicable diseases resulting from careless personnel or caterers handling food stuffs. Rules such as Cleanliness, Cooking, Chilling and Cross Contamination should be well observed while handling food. Food safety and hygiene practice using Hazard Analysis Critical Control Points (HACCP) is recommended by WHO and FAO to maintain a good quality of food and services (Silva, 2001). Trained personnel should preferably be employed. Facilities such as proper dustbins, wash hand basins and toilets should be made available for the workers. Points that should be observed in aiming a good and safe food hygiene are: ood handlers Certificate Floors (smooth clean) Ceilings / Walls maintained properly Utensils properly washed sterilized Proper sanitary design of kitchen Fly proof and rodent proof Storage accommodation of foods Disposal of waste (Solid and Liquid) Drainage system Wash hand easily available Good aeration / temperature /Humidity Work area spacious enough for workers Showers facility for workers(Working Day / Night) Hygiene in kitchen All employees working in food premises either in the task of preparation, handling or serving food should possess a food handler certificate after having followed a medical inspection by a doctor. They should have a satisfactory knowledge of hygiene and cleanliness and be aware of possible problems caused of improper food handling. Health education plays an important role in promoting food and personal hygiene. All staffs should be given appropriate training. Health inspectors have an important work in providing health education by promoting awareness of dangers of food poisoning and poor hygiene practices Medical certificate The law states that every food handler involved in food business should be in possession of a valid medical certificate. This food handler certificate is issued by a G.M.O and is valid for only 3 years and has to be renewed each year. This certifies that its owner is in good health and is not suffering from any communicable diseases (Food Regulation, 1999) (refer to Appendix 2). Obtention of medical certificate The person has to call at the Health Office of the Ministry Of Health of his region with his national identity card and with two photo passport. An appointment is given for a session of talk on hygienic practices and after due accomplishment, the latter is examined by a Regional Public Health Superintendent (RPHS). Thereafter if the person is observed to be in good health, the certificate is obtained(Food Regulation,1999) Working environment The standard of cleanliness of factory and its workers is a reflection of the standard of efficiency of management and the morale of the working population. Provision has been made in the Occupational Safety and Health Act 2005 concerning welfare of workers and overcrowding in place of work. It says that a place of work shall not be overcrowded as it can cause risks of health injury of the employees. It is mentioned that the space allowed shall not be less than 11 cubic metres per workers (OSHA, 2005, Appendix 3). Kitchen is an example where there is often overcrowding of workers in hotels. Smoking The personnel should be well educated and trained about hygiene in a workplace. Employees should not smoke during work, mainly during preparation of food or while handling any food stuffs or utensils. Smoking is prohibited by law in any public places and moreover smoking in a food preparation area can pass diseases from an individual to another. Customers also can be contaminated. Smokers can transfer harmful bacteria from their mouth to food and thereafter, consumers of these foods may ingest these bacteria in turn. These bacteria can be harmless on the carrier but harmful to another person. Communicable diseases Any person suffering from a communicable disease, boils, sores, acute respiratory infection or bleeding wounds should not be allowed to work in any food premises. A list of these diseases is listed in (Appendix 4). All communicable diseases should also be reported to the Health Offices for treatment. Therefore all employees should possess their food handler certificate and renew it every year by a doctor to ensure that safe food and services are provided to customers. The law has made provisions concerning infectious or communicable diseases. It is said that the occupier of any premises in which a patient resides shall give notice to Sanitary Authority or if visited by a medical practitioner and it is confirmed that the patient is suffering from an infectious disease, health inspector of the region shall made aware of the existence of the disease , name of the patient, the situation of the premises and name of the occupier. (Public Health Act,Appendix 5). Preventing food contamination We should not forget the motto PREVENTION IS BETTER THAN CURE . Prevention of food contaminations is a must. Appropriate preventive measures should be taken. Employees should give attention to personal hygiene and the working habits in a hotel kitchen. Body should be kept clean by washing and bathing. Hands should be washed at least on every occasion when entering food preparation zone. Hands and arms should he washed thoroughly using soap and water after each visit to the toilet. Avoid use of common towel (use paper that are disposable). Wear clean and washable overall preferably white Keep hands away from mouth, nose ,hair ,ear while working Do not eat while handling food/ preparation Do not wipe hands on overall Use spoons, forks , tongs instead of hands in preparation Avoid useless blabbering while working Smoking, spitting should e avoided in working area Obey food safety signs Keep work area clean Staff facilities maintained in good hygienic conditions A research carried out in 2004 in a popular hotel of Egypt after a major outbreak of Hepatitis A where 351 tourists was contaminated showed that there was poor sanitation, no proper health education and medical examination. An infected worker with imperfect hand hygiene and who was in contact with sewage-contaminated water was the source of this huge outbreak. (Eurosurveillance, 2006) Concerning food safety, the WHO has initiatives for surveillance programme with objectives of a development of an international food safety network, application of HACCP and development of a safety information system. (WHO, 2004). Storage of food Food storage is important industrially. Hotels prepare food for hundreds of persons daily. Therefore a good storage system is necessary. Area should be pest proof, warm, clean and not humid. There are three main categories of food requiring different storage methods. Dry food should be kept in a warm place and not humid to avoid spoilage by microorganisms growth. Chilled food should be stored at an appropriate low temperature, and precautions should be taken in case of electricity cut. Canned food should be verified before using. Stock rotation is important concerning canned products. It is important that you rotate and use your food storage (Caldwell M, 2006). Storage of water An ample supply of water should be provided with adequate facilities for its storage and adequate protection against contamination. Water is used both in food preparation and rooms for toilets and bathrooms. Many aquatic microorganisms can survive and flourish in water with minimal nutrients and can be transferred to people with poor immune system. A study conducted in United States described how gastroenteritis is a common outbreak in hotels. Unsteady state flow and stagnation in distribution systems affect the biological stability of drinking water which promotes bacterial accumulation (Dippold L et al, 2000). Therefore it is important that tanks are fitted tightly with lids and that they are regularly cleaned and sampled for chemical and bacteriological analysis. Cleaning frequency is an important factor. The tanks should be verified in case of rusting of any parts and dates should be noted at each cleaning done. (Logan G, 2008). Tanks should be cleaned at least once every trimester for proper maintainance to avoid microorganism proliferation. Waste disposal A hotel can be considered as a microcosm in itself having the potential of producing all kinds of waste that is hazardous. Hazardous waste comes in many different shapes and forms: it can be liquid, solid, gas or sludge, and more often it is poured down sinks directly or discharged to regular waste stream (Patel A, 2008). The types of waste generated in hotels and their sources are listed below. However there are two main types of hotel waste, solid(dry),known to be non-biodegradable and liquid(wet),biodegradable wastes. The risk and problem that arises are odour, unaesthetic and it acts as breeding place for vector of diseases (flies, rats, rodents), thus a nuisance to health (Wagh V, 2005). Solid waste Solid waste is described as materials of no longer value and which is not meant to be discharged through pipe. These dry wastes comprise of plastic bottles, papers, plastic wrappers, HDPE bags etc. These wastes should not be mixed with the wet waste which may produce bad odor and dirty look. They should be disposed in dry places for storage until collection is done (Wagh V, 2005). Liquid waste Liquid waste is simply discharged in sinks. Wet waste comprises of food and vegetable. Most hotels kitchen sinks are fitted with a garbage disposer (garburator) which is a device installed under the kitchen sink between drain and pipe which shred waste into pieces enough to pass them through plumbing. Grease traps are also fitted to prevent drains to be blocked from fats, oil and grease. Some hotels also provide septic tanks to avoid potential problems that may occur in case there is blockage of main sewage pipes provided by the Government. Elimination of mosquito breeding places The hotels management does the necessary to avoid spreading of diseases. Potential breeding places for vectors are eliminated by draining all roofs water accumulation at least twice a week and insecticides are sprayed. All ponds and garden water are regularly checked and all bottles or containers are removed and bushes like the grass are well maintained. The Ministry Of Health also provide services for spraying insecticides on a regular basis (MOH, 2009 Health surveillance of tourists Tourist can be responsible for spreading of diseases. One recent case notified was in 2009 where the first case of H1N1 flu virus was detected in a French tourist. The Ministry Of Health has provided officers for this specific duty. Health surveillance Officers are responsible to contact every incoming passengers in order to know their health condition on arrival to Mauritius. The hotel management plays an important role as they need to report any kind of communicable diseases occuring in their residence (MOH Health, 2009). The Ministry Of Health has a list of infectious and communicable diseases that are controlled closely as shown in (Appendix 4). CHAPTER 3 : METHODOLOGY Methodology A survey was carried out and two questionnaires were designed where one was for personal view and opinion about the working place and food handlers and the second, to assess the workers and their knowledge to food hygiene.50 hotel in all were chosen throughout Mauritius. Random selection will give a broader view of hygiene in hotels around the island. List of hotel was obtained from the Tourism Authority at Port-Louis and some details obtained at the Municipality and Health offices. The Questionnaires Questionnaire for Personal View of Foodhandlers, Checklist for Kitchen and environment (room, garden, Swimming pool). (Appendix 6) Questionnaire for personal hygiene for the workers (Appendix 7) The questionnaire (Appendix 6) is a checklist concerning the number of workers, personal hygiene at sight, state of preparation area and toilet in the hotel kitchen. The workers who were pointed were mainly cooks, waiters and maids who work in hotel restaurant. A walkthrough was done where access was granted by the management in the kitchen to assess the level of hygiene of the workers and to inspect if they practice personal hygiene. The toilets were also seen and mess rooms. The second part of the questionnaire was dedicated for rooms and the environment such as garden. Points that were observed during the walkthrough inspection were: No of Personnel Sanitary conditions Water availability Lighting Ventilation Refuse disposal Toilets and bathrooms The second questionnaire was designed for food handlers to assess their knowledge about hygienic practices and food poisoning. CHAPTER 4: RESULTS Results and Findings Possession of food handlers certificate among workers General personal hygiene among workers The below bar chart shows the general personal hygiene maintained among workers at work and it can be concluded that 98% of them keep their hands clean, 94% keep their fingernails clean, 75% have their hair covered, 100% keep their body clean. But it could also be observed that only 25% of them keep their overall clean and 13% of them had nail varnish. Wall conditions of kitchens The wall conditions of the kitchens were surveyed and was found to have the following structures ; 82% of them are waterproof, 88% can be observed to be clean, 93% are washable, 82% are without crevices, 94% are painted white and 86% of them are tiled up to 2 meters from floor. Ventilation From figure 6, it can be seen that 83% of the hotels had adopted a good ventilation system using air conditioner for ease of workers while 17% of them did not have appropriate ventilation system. Lighting Figure 7 describes the lighting condition in the preparation area. 78% of the hotels were seen to provide a good lighting system for the workers and 22% had lighting system not satisfactory. Provision for refuse disposal Refuse disposal availability was surveyed and was found that 50% had foot operated pedal bins,70% of the garbage bins were cleaned and disinfected regularly,75% had their bins covered while 95% removed them daily. Room management Room conditions were observed to be at 72% satisfactory. 28% was seen to have a bad room management. Frequency of changing Blanket on bed From Fig 10. it can be observed that 80% of hotels changes bed blanket regularly,5% on a weekly basis and 15% when it seems necessary to do so that is when seen dirty. Bathroom and toilets sanitary conditions From the result obtained during the survey, it has been found that toilets and bathrooms in rooms are at 70% and 75% clean respectively. . Detergents Distribution The figure below gives detail of the type of detergents commonly used in hotels for sanitizing and cleaning purposes and their percentage used. Knowledge of food poisoning During the survey it was observed that only 40% of workers interviewed had a satisfactory knowledge of food poisoning and answered yes to the question whereas the other part could not give explanation food poisoning. Validity of food handlers certificate Professional training by employer From the survey carried out among workers, it was found that among the 70% of workers who were in possession of a food handlers certificate, only 55% of them were valid while 15% of them were

Hypokalemia After Acute Acetaminophen Overdose

Hypokalemia After Acute Acetaminophen Overdose Objectives: This study intended to determine the prevalence of hypokalemia and its clinical correlates in acute psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdose. Methods: This is a retrospective cohort study of hospital admissions for acute acetaminophen overdose conducted over a period of 5 years from January 1, 2004 to December 31, 2008. Demographic data and different types of psychiatric illness were compared between hypokalemic and normokalemic patients. Hypokalemia was predefined by a serum concentration < 3.5 mmol/ L. SPSS 15 was used for data analysis. Results: Two hundred and eighty patients out of 305 admissions were studied. Hypokalemia was found in 63.6% of patients with a higher prevalence in the presence of psychiatric illness (67.7%). Hypokalemic patients were significantly associated with the presence of major depression (P = 0.04), adjustment disorder (P < 0.001), anxiety (P = 0.01), and suicidal attempts (P = 0.04). Conclusion: Hypokalemia was common among patients with psychiatric illness and acute acetaminophen overdose. Key Words: Acetaminophen; Hypokalemia; Overdose; Potassium; Psychiatric illness. Introduction Deliberate self-poisoning (DSP) is recognized as a major cause of suicide around the world.1 Acetaminophen (Paracetamol) is the most common drug employed in DSP in many countries, 2, 3 including Malaysia.4 Despite excellent safety in therapeutic doses of acetaminophen; it is also one of the leading causes of severe hepatic necrosis.5 Acetaminophen overdose may be accompanied by electrolyte disturbances including hypokalemia, and these appear to be independent of the hepatotoxic effects.6 These electrolyte changes appear to be due to the increase in fractional renal excretion of potassium, but the underlying cellular mechanisms by which acetaminophen might alter electrolyte transport are still unknown.6-9 In some cases, hypokalemia may be severe, reaching a level of 2.3 mmol/ L after reported ingestion of 48 g of acetaminophen.8 Hypokalemia, an easily identifiable and clinically important condition in clinical settings, has received little attention from researchers worldwide. Not only is hypokalemia associated with frequent cardiac and neuromuscular complications, but its effect on mental function may also exacerbate psychiatric disturbances.10, 11 Both anxiety12 and intense exercise13 increase circulating epinephrine, which induces a ÃŽ ²2 receptor-mediated influx of potassium into skeletal muscle.14 As this condition may be similar to the acute psychotic state, it was hypothesized that the decline in serum potassium concentration could be associated with the presence of psychiatric illness during acetaminophen overdose. To improve our knowledge of hypokalemia after acute acetaminophen overdose, we carried out a five-year, hospital-based study with the following objectives: 1) to determine the prevalence of hypokalemia in patients presenting to hospital after acetaminophen overdose, and 2) to investigate the clinical correlates in acute psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdose. Methods Settings and Study Design This is an observational retrospective case review of all patients with acute acetaminophen overdose admitted to a 1200-bed hospital located in the Northern region of Malaysia. The hospital provides health care and emergency treatment for all illnesses and accidents. All aspects of the study protocol, including access to and use of the patients clinical information, were authorized by the local health authorities before initiation of this study. Participants and Data Collection Data were collected from January 1, 2004 to December 31, 2008. A computer generated list was obtained from the Hospital Record Office. We identified our cases according to the T-codes of the International Classification of Diseases-Tenth revision (ICD-10). All patients with diagnostic codes T 39.1 (acetaminophen overdose) were included in the study. Specially designed data-collection forms were used to collect data concerning age, gender, circumstances of overdose (accidental or suicidal), stated date and time of poisoning to calculate the latency time (the time of ingestion to the time the patient was presented at the hospital), quantity of acetaminophen ingested, GI decontamination such as stomach wash, laboratory tests including serum acetaminophen concentration, and serum potassium concentrations during the first day of admission and after a minimum of 4 hours of ingestion. Data on serum acetaminophen concentration measurements were obtained from the hospitals therapeutic drug monitoring laboratory service. In addition, data related to the presence of psychiatric illness were obtained. psychiatric illness was defined as the presence of any disturbance of emotional equilibrium, as manifested in maladaptive behavior and impaired functioning, caused by genetic, physical, chemical, biological, psychological, or social and cultur al factors such as depression, anxiety, adjustment disorders, impulsive behaviors and stress reactions, either emotional or behavioral; these causes were noted by the hospital psychiatric specialist report. Hypokalemia was defined as a serum potassium level of less than 3.5 mmol/ L.11 Patients with hypokalemia were classified into three groups based on potassium levels: (1) mild/ grade 1 (3.0 3.4 mmol/ L), (2) moderate/grade 2 (2.5 2.9 mmol/ L) and, (3) severe/grade 3 (< 2.5 mmol/ L).15 The charts of all patients identified through the search were reviewed and the data collected. Charts were excluded from analysis for the following reasons: (1) baseline potassium concentrations were not measured, (2) if patients had taken acetaminophen but the cause of ingestion was unknown or undetermined, (3) the time of ingestion was not known or (4) the patients were on regular prescribed drugs that lead to hypokalemia, such as furosemide, and (5) the patients were children under 13 years of age. Charts of patients who had laboratory tests at or more than 4 hours post-ingestion were extracted for further analysis. Statistical analysis Data were entered and analyzed using the Statistical Package for Social Sciences program version 15 (SPSS). Data were expressed as mean  ± SD for continuous variables and as frequency for categorical variables. The Chi square or Fischers exact test, as appropriate, was used to test the significance between categorical variables. The independent samples t-test was used to compare means of continuous variables. Variables were tested for normality using the Kolmogorov-Smirnov test. Variables that were not normally distributed were expressed as a median (lower upper quartiles). Statistical significance was considered at P < 0.05. Results Three hundred and five cases of acetaminophen overdose were identified. Of these, 25 patients (8.2%) were excluded. Baseline potassium concentrations were not measured in eight patients, one patient was given furosemide at admission, five patients were less than 13 years old, the cause of ingestion was unknown or undetermined in 11 patients, and therefore, the study population consisted of 280 patients (45 male and 235 female patients with a mean age of 23.4  ± 7.1, giving a female: male ratio of 5.22: 1). The majority (72.1%) of cases of acetaminophen ingestion were presented within eight hours. The median (interquartile range) quantity of acetaminophen ingested was 10 g (6 15 g). Initial management included stomach wash, which was performed in 181 (64.6%) cases. Activated charcoal was given while patients were in the Accident and Emergency department; it was given as single or multiple doses in 173 cases (61.8%). Intravenous N-acetylcysteine (NAC) was given to 140 patients (50%) after acetaminophen levels were estimated. The median (interquartile range) serum acetaminophen concentration was 55.6 mg/ L (14 120 mg/ L). During the study period, 63.6% (178 patients; 33 males and 145 females) had potassium levels of less than 3.5 mmol/ L. For the hypokalemic patients, the mean potassium level was 3.1  ± 0.26 mmol/ L, while that for the normokalemic patients was 3.76  ± 0.35 mmol/ L. Most of the patients (129) were in mild stage hypokalemia and 45 patients were in moderate stage hypokalemia. Few patients (4) were in severe stage hypokalemia. Psychiatrically ill subjects were found to have hypokalemia, and the prevalence was higher than that in non-psychiatrically ill subjects (67.7% versus 43.8%; respectively, P = 0.002) (Figure 1). The most common clinical diagnosis among medically treated suicide attempters was adjustment disorder (45.7%) followed by impulsive behavior (24.3%), major depression (10.7%), and anxiety (2.1%). Hypokalemia was significantly associated with the presence of major depression (P = 0.04), adjustment disorder (P < 0.001), anxiety (P = 0.01), and suicidal attempts (P = 0.04). However, normokalemia was significantly associated with impulsive behavior (P < 0.001), the absence of psychiatric illness (P = 0.002), and the presence of accidental overdose (P = 0.04) (Table 1). One hundred and twelve patients with adjustment disorder and six patients with anxiety were found to have hypokalemia, and the prevalence of hypokalemia among these patients was higher than that in the overall study population and in patients with other psychiatric disorders (100% and 87.5%, respectively). Similarly, their mean potassium level was lower than that of the overall study population (3.16  ± 0.41 and 3.2  ± 0.21 mmol/ L, respectively) (Table 2). Eight hypokalemic patients (4.5%) were supplemented with oral potassium medication, and 85 hypokalemic patients (47.8%) were treated with intravenous potassium chloride, and their potassium levels were normalized in the next blood test. Additionally, most of the treated patients (59) were in mild stage hypokalemia and 32 patients were in moderate stage hypokalemia. Few patients (2) were in severe stage hypokalemia. Discussion This study is the first of its kind in Malaysia and has been carried out to determine the prevalence of hypokalemia in patients presenting to hospital after acute acetaminophen overdose, and to investigate the clinical correlates in acute psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdose in 280 patients with acute acetaminophen overdose collected retrospectively from a records registry. In this study hypokalemia was identified in 178 patients, and the prevalence of hypokalemia among hospitalized patients with acetaminophen overdose was 63.6%. A previous study found that hypokalemia was common in medical inpatient settings.16 About 20% of stroke, 10% of myocardial infarction patients,17 21.2% of psychiatric disorders,18 and about one third of acute acetaminophen overdose patients suffered from hypokalemia.9 The high prevalence of hypokalemia after acetaminophen overdose might be due to multiple risk factors. The etiology of hypokalemia is complex. The level of serum potassium depends on the balance between oral intake, renal and gastrointestinal losses as well as the balance and movement between extra and intra-cellular compartments.11 A previous study found that 7.6% of psychiatric patients had nutritional problems;19 inadequate dietary potassium intake was relatively rare unless daily potassium intake was less than 25 mmol.20 This study found that it was the psychiatrically ill patients, rather than those patients with no psychiatric illness, who were more likely to develop hypokalemia. This finding is consistent with other published studies that showed that hypokalemia was common among acute psychiatric inpatients.18, 21, 22 Adjustment disorders are often precipitated by stress reactions.23 For most people, stress is associated with higher cortisol levels.24, 25 Previous studies have suggested that high cortisol levels may be the principal cause of hypokalemia.26-28 In this study, patients with anxiety were suffering from a low mean potassium concentration and a high prevalence of hypokalemia. The exact mechanism was uncertain. This finding is in agreement with another published study that has shown small decreases in serum potassium among 200 pre-operative patients who had an increase in anxiety.12 The explanation of this finding is that anxiety increases the circulating epinephrine, 12 which induces a ÃŽ ²2 receptor-mediated influx of potassium into skeletal muscle.14 In the present study, patients with major depression were suffering from a high prevalence of hypokalemia. This finding is similar to a previous work that has shown patients with major depression had lower mean serum potassium values and a higher incidence of hypokalemia than other disorders such as dysthymic disorder and schizophrenic psychosis.18 This finding may be due to changes in adrenergic drive or in sensitivity or density of the ÃŽ ²2-receptor. 18 Expected findings in our study were the low incidence of hypokalemia in the patients with impulsive behavior. These patients differed significantly from the other types of psychiatric illness and considered as a part of the normal behavior.29 This is supported by findings that impulsivity is a type of human behavior characterized by the inclination of an individual to act on impulse rather than thought.30 It has been concluded in previous study that the decreased peripheral epinephrine levels may be involved in pathophysiology of impulsive and hyperactive behaviors.31 This mechanism results in a decreased uptake of potassium by cells. In addition, this study found that it was the suicidal patients, rather than those with accidental overdose, who were more likely to develop hypokalemia. Attempted suicide is assumed to be a hyper-adrenergic state.18 A retrospective study carried out on patients with psychiatric disorders concluded that significant differences existed among the attempted suicide group with regard to hypokalemia.18 ÃŽ ²-adrenergic receptor stimulation causes hypokalemia in experimental animals and humans.32 There is little doubt that one of the mechanisms of hypokalemia is a beta 2-receptor-mediated influx of potassium into skeletal muscle, induced by circulating epinephrine.18, 33, 34 It has been demonstrated that epinephrine causes excessive activation of the sodium/potassium-ATPase pump as a result of ÃŽ ²2-adrenergic receptor stimulation.14, 33 This mechanism results in an increased uptake of potassium by cells, leading to a decrease in serum potassium levels. As the influence of the adrenergic sy stem on serum potassium is found in many psychiatric situations, 18, 21, 22, 35 it may explain why a high prevalence of the patients included in our study were presented with hypokalemia. A high percentage of patients (47.7%) were still not being treated for low potassium levels, putting their health in jeopardy. The common occurrence of hypokalemia in patients with acute acetaminophen overdose should alert all clinicians to the importance of correcting potassium loss, since most of the patients with an acetaminophen overdose might have received intravenous fluids or N-acetylcysteine in serum dextrose 5%. However, this may have altered serum potassium concentrations through endogenous insulin production induced by 5% dextrose, resulting in movement of potassium into the intracellular compartment. Nonetheless, the extensive use of dextrose may expose the patients to higher risks. This study is the first one of its type in Malaysia to investigate the clinical correlates in acute psychiatric illness among hypokalemic and normokalemic patients after acetaminophen overdose. It is also the first study suggested that hypokalemia is related to psychiatric status after acetaminophen overdose rather than the previous studious that showed a dose-dependent relationship between fall in serum potassium and serum acetaminophen at presentation.6, 9 Our study suffers from a few limitations. Firstly, further risk factors for hypokalemia were not taken into account in the analysis. A second limitation is its retrospective nature and the lack of structured interview assessment of the subjects. Thirdly, we can only suggest, rather than prove, that the psychiatric state is responsible for the high occurrence of hypokalemia diagnosed in our population. Conclusions and recommendations In conclusion, hypokalemia is highly prevalent among psychiatrically ill patients and after acute acetaminophen overdose. Therefore, monitoring of serum potassium concentration may be clinically important on emergency admission for all cases of acute acetaminophen overdoses to prevent the consequences of hypokalemia. Supplemental potassium administration should be commenced as soon as possible. Acknowledgments: The authors would like to thank the Universiti Sains Malaysia (USM) for the financial support provided for their research. The assistance of the medical and record office staff is gratefully acknowledged. Conflict of interests: We would like to declare that there was no conflict of interests in conducting this research.

New Way To Spend A Holiday :: essays research papers

An experience in life that forces you to grow up and to take on responsibility, can only be rewarding and uplifting in the future. When you look back at all you came thru and the courage that possesed you at that most trying time. I only have one moment that really sticks out in my mind. Christmas on 1997 my family and I went to The Banquet which is a local food provider for the less fortunate in Sioux Falls. Being thrilled about this certain project my mom decided we should do was not quiet my attitude. I didn't want to spend Christmas in a dusty old high school serving food to people. Why could we just be normal and stay home with family. But despite all my protest it was set and we were going. For volunteers your day starts rather early we were to report to Thomas Jefferson Middle school by 10:00 A.M. sharp. As the thoughts ran thru my mind of what to expect when we got there. I started to make up the crazy ideas that we would get there and all around us would be these drugged out, filthy, and uncivilized people. People who choose not to try or to make a difference with there lives. People who were happy taking handouts and living on the street not wanting to change anything. We pulled up into the parking lot and the first thing i saw was 3 other guys my age. Not all that bad looking either. So I'm beginning to think maybe the day won't be so bad after all. A tall, broad, and boisterous woman walked up and introduced herself to my family and told us how happy she was to have us here. I quickly began to feel a little more at ease when i saw the rest of the volunteers. We walked into the building and into the gym. My mouth dropped there must have been 50 long cafeteria tables in their if not more. We quickly were each given a different set of jobs to do. My mom helped with the decorating of the tables. My little brother well I'm not sure exactly what he did but there was a lot of hammering. I went with two other ladies onto the stage of the gym where there were hundreds and hundreds of toys. Our job was to sort them out into gender and age groups.

Malcolm X vs. Dr. King: Passive vs; Aggressive Essay -- essays researc

Africans were brought to America by Europeans, not of their own volition, but in chains, without the knowledge that over the next several hundred years, generations and generations of our people would be brutally and unjustly treated as nothing more than property or animals. The era during which slavery flourished, Africans were bred, overworked, beaten, lynched, and stripped of any positive identity or self respect. When slavery was abolished in 1865, Africans, or former slaves, were left without a â€Å"place† in America. Where did they fit in? What was the role that they were to play as, so called, American citizens? Some, undertook the role of â€Å"leader†, and preached and taught what they felt was the best process by which, blacks could achieve equality. From the beginning, however, there were conflicts concerning the nature of how this was to be accomplished. This discrepancy over passive and aggressive attitude concerning the advancement of blacks in America h as permeated, and at times, divided the black community from the time that Africans were brought here in chains, until the present. Malcolm X’s philosophies, which centered more on blacks accepting themselves, and loving themselves, and creating their own sense of pride, was deemed racist by the media and he was portrayed as militant/violent by the Civil Rights Activists, when in fact Malcolm X’s teachings contain the exact remedy that we â€Å"victims of America† (Malcolm X uses this term to distinguish the fact that blacks were not brought to America out of their own volition) need in order to live the best lives in the conditions that we have been forced into by whites.   Ã‚  Ã‚  Ã‚  Ã‚  Booker T. Washington, born in 1856, was a prominent leader of the black community during the years following the abolishment of slavery, who believed that equality and respect for blacks would be gained over time. Washington preached to his followers that they should work on bettering themselves, not through liberal education, but by learning a trade or vocation which could be of service to either the black or white community, and that in time, whites would allow blacks to assimilate into their society. William Edward Burghardt Dubois, born in 1868 and more commonly known as W. E. B Dubois, was Washington’s adversary. Dubois preached that blacks should demand their rights, both human and civil, and that this w... ...proach of the Civil Rights Movement, led by Dr. King and financed by whites, would lead to the loss of black pride because it would encourage blacks to â€Å"try to be white† in order to â€Å"fit in† the white society. Today, blacks have the same legal rights as whites, but there is still blatant racism in America. Blacks have integrated into the white society, and the loss that Malcolm feared has become a reality. We straighten our hair in order to make it look like theirs, wear their clothes, and learn a school curriculum that centers around their history. There are more black men in prison than in college, and the percentage of black owned businesses is considerably disproportionate to the black population. The Civil Rights Movement was successful, and the Black Power Movement has been forgotten, but have blacks found their â€Å"place†? SOURCES: Haley, Alex; The Autobiography of Malcolm X; Ballantine Publishing Group; 1964 Malcolm X; â€Å"Message to the Grass Roots,† speech, Nov. 1963, Detroit (Published in Malcolm X Speaks, ch. 1, 1965) Malcolm X; speech, Dec 12, 1964, New York, NY Marable, Manning; â€Å"By Any Means Necessary: The Life and Legacy of Malcolm X†, speech; New York, NY

Pros and cons death penalty Essay

Corporal punishment can be defined as physical punishment that is meted out to someone because they have done something wrong. More often than not corporal punishment involves the use of canes to beat someone. Corporal punishment is normally meted out to children in schools by teachers and at homes by parents or guardians. The advantages of corporal punishment It helps to serve as a deterrent. When children see that someone has been whipped for misbehaving, they try not to do similar things in order to avoid getting whipped. With corporal punishment, parents are able to bring their children under control. There are certain children who can only be controlled through the use of the cane. Corporal punishment helps make children obedient, respectful, polite, etc. In the absence of corporal punishment, children likely go wild. Corporal punishment in school makes students take their studies seriously and also helps keep the students under control. Authorities are able to instill discipline in children through the use of corporal punishment in schools. It makes very recalcitrant and stubborn children submit to authority because they fear that if they don’t do the right thing they just might be whipped. The disadvantages of corporal punishment It can be very counterproductive in the sense that it can sometimes make children hardened and no longer afraid. It is very hurtful and can cause severe injuries to a child. This is the reason why in so many places it has been banned in schools. Corporal punishment strikes severe fear in the hearts and minds of students and can easily make them to drop out of school. Here, they are so afraid that they would be whipped for the least mistake they do. And this constant fear can make the students to drop out of school. Corporal punishment is very painful and is inhumane or cruel to use whips or canes to lash someone. Simply put, it is a barbaric practice. Human rights organizations and advocates all over the world consider corporal punishment on children to be a form of child abuse. When corporal punishment is used excessively in schools and at homes, it has the tendency of making children very hostile to their teachers or parents. This can lead to some children  fighting back – especially when the pain gets too much to take. Corporal punishment can scar children or disfigure them for life – both physically and mentally. Another disadvantage of corporal punishment is the fact that it can land the one meting out the physical punishment in big trouble. For example, if in the course of beating the child, the child suddenly gets severely injured or dies from the beating, then the teacher, parent, or guardian meting out the punishment will face the wrath of the law. Should corporal punishment be abolished? Having taken a look at the advantages and disadvantages of corporal punishment, I personally think that the disadvantages of corporal punishment far outweigh the advantages and for that reason I really think it should be abolished everywhere. Capital punishment or death penalty is a very common topic for writing a pros and cons essay, and many students choose it as a really great issue which opens plenty of room for discussion. The controversy of death penalty has been one of the most debatable issues for the last decade, and it is possible to find plenty of materials and plenty of ideas to support both sides of the issue. There are a great number of experts who support death penalty and believe that it is the only good punishment for mass murderers, rapists, killers, and other similar kind of criminals. At the same time, there are plenty of enthusiasts and promoters of death-penalty-free world, who underline that taking a human life is something a government has no right to do. If y ou have got an assignment to write a death penalty essay, continue reading this small article to get some interesting ideas and tips as to writing this kind of academic paper. First of all, let’s focus on the arguments of those people who are against death penalty as a punishment for heavy type of criminals. In addition to their main argument that humans have no right to take lives of other humans, even as a retaliation (since killers and murderers do take lives of other human beings), they very often address to religious issues and say that it is only God who can take our lives. He sends us to this world, and only He can decide when it is time for us to go from this world. They are convinced that death penalty is nothing else but an act of violence which has extremely negative effects on modern society. It violates the main right  that we all have, the right to live, and executing capital punishment is nothing else but a cruel and brutal way to kill a human being. Finally, they underline that practicing death penalty is not something that can stop violence and brutal killings, thus it will not work for increasing safety of our society. When speaking about the arguments of those who are supporting death penalty, those people are usually talking about using capital punishment as an instrument of fair justice. They are convinced that death penalty can serve very effectively as a tool to provide social safety. They are sure that death penalty can play a very powerful role as a deterrent and this way make criminals understand what price they are going to pay for doing such heavy criminal acts as murders, rapes, torturing their victims, etc. etc. Capital punishment proponents believe that death penalty can also serve as a threat to those who are planning acts of terrorism and other serious criminal acts. Finally, there is also an idea that exchanging capital punishment with life-long imprisonment is not a solution, and executing criminals is better and cheaper that supporting them in prison all their life long. They say that putting bad people to death is an expression of a true justice. I think the above mentioned arguments can be useful to those students who need to write death penalty pros and cons essay. Regardless of what side you are at and what viewpoint you’re going to support in your essay, you should mention both pro and con arguments. Start your work on your death penalty pros and cons essay with thinking about the way you’re going to present your arguments and creating a small outline of your essay. You can use several strategies for your presentation. After giving your thesis statement in the introduction of your essay (stating your viewpoint as to the issue, or saying if you are an opponent or a proponent of capital punishment), you can briefly mention the argument of the opponent side (in 2-3 paragraphs), and then bring your arguments to support your point of view. Another strategy is bringing the arguments of the opponent side one by one, and then responding to those with the argument supporting your own point of view. Good luck in your work!

Stefan’s Diaries: The Craving Chapter 16

November 12, 1864 Life with Damon is like playing chess with a mad person. I can think of a thousand different possibilities to defend against, a thousand different moves he could make, and then he goes and changes the rules of the game. It's just his newfound predilection for casual violence that makes him so incalculable, but the way he revels in it. Though blood is our diet, we as vampires at least have a modicum of self-will. Damon doesn't have to let his dark side win, and yet he embraces it. I view this change in him with horror and guilt, as I was the one who set him down the path of the vampire. Katherine was the one who changed him, but I force-fed him his first human. After seeing his message to me I can't consider leaving the Sutherlands until I have figured out a way to keep them all safe. What my brother did to Callie†¦ it obviously isn't beyond him to just dispose of the entire family once they serve their purpose. But when will he take action? At the wedding? After the wedding? After the honeymoon? Next year? Could I spirit the girls away somewhere? Could I convince them to hide? Could I compel them to? Damon managed to find me here, could he find me – or them – anywhere? I have to come up with a plan, in case Damon doesn't just leave town with his newfound fortune. Of course, the simplest solution would be to kill Damon. Voil – one maniacal, insane, unpredictable, murderous vampire gone, the world, and myself, a thousand times safer. That's assuming I could do it. I am so much weaker than he is, it would have to be done by surprise or guile or something equally underhanded, like a knife in the back. Like he killed Callie. There isn't any point in thinking that way. I will not stoop to his level. He is my brother. And as awful as he is, he is the only relative left to me. The next day, time flew by as if it had nothing better to do than gallop me toward matrimony. Before I knew it, I'd been stuffed into my suit, force-fed pancakes, and spirited over one hundred blocks north to the altar, where I stood awaiting my fate, as the Sutherlands unknowingly awaited their own. Damon and I stood side by side in Woodcliff Manor's great hall – the pretty family chapel nearby was far too small for Bridget's tastes. The Richards were kind enough to let her use their home at the tip of Manhattan Island. It was really more of a castle than a home, with gray towers, parapets, and decorative portcullises, all made from the gray rock that jutted seamlessly out of the rocky promontory on which it sat. Not so far from there, outside the arched gothic windows, were the remains of Fort Tryon, the site of a sad defeat of Continental forces under George Washington by the British. My thoughts drifted as I imagined redcoats and scrappy American soldiers and puffs of gunpowder†¦ and then something occurred to me. Katherine could have witnessed such a battle. I never asked how old she was – perhaps Damon did – but she was far older than her appearance suggested. She had probably witnessed events I only read about in history books. I shivered at the thought, but the chill was instantly dispelled by the incredible heat in the room. Damon and I stood in front of a crowd of more than two hundred of New York's finest socialites, all sitting uncomfortably in hastily pulled together pews. They had no idea how dangerous it was for them to be there. I pulled at my collar and tie, which suddenly felt too tight, my vision blurring. The room shifted and morphed, and for just a second, the finery and skin of every wedding attendee melted off as though they'd been caught up in a blaze. Skin flaked off like corn husks, leaving behind pure-white bone and twisted tendons. â€Å"Stefan!† Damon hissed, elbowing me. I realized then that I was clutching his arm. â€Å"Do I need to call a medic for you?† he asked sarcastically. I shook my head, wondering what illness had overcome me. The crowd came back into focus, alive, happy, laughing, and fanning themselves discreetly. Even I had to admit that Mrs. Sutherland had done a fantastic job working with Mrs. Richards and her housekeepers. A rich red carpet had been laid out, and it was scattered with so many rose petals you could scarcely see the fabric beneath. Pink, white, and deep, deep red, it looked like a beautiful trail through a magnificent rose garden. Garlands of expensive and exotic flowers hung along the pews, and the scent of orange and lemon was heavy in the air. Overhead hung giant balls of flowers like fireworks in petals. Vases in every gothic arched nook and cranny held elegant arrangements of grasses and blooming branches of quince, enhancing the woodland effect. Everyone wore full formal regalia, tailcoats for the men, some with diplomatic sashes. Heavy moire silks for the older women, lighter for the young women, yards and yards of fabric swirled around their feet like more rose petals. Hats were decked out in plumes and gems and sometimes entire birds. And the real heirloom jewelry had been pulled out for this occasion, pearls and diamonds and rubies on every neck and wrist, some gems the size of my thumb. All the women had fans, of course, made from silk and painted in Japan or England, and they tried to flutter them delicately, but most wound up just flapping them as fast as they could. The ladies' countenances remained stubbornly rosy despite their efforts to keep pale. Everyone whispered and talked excitedly, and of course I could tune in to any conversation I felt like listening to with my enhanced hearing. I almost didn't mean to, because it was the same in every seat: â€Å"†¦ so quick. Only met a month ago. Did you hear the story? He was so chivalrous†¦.† â€Å"†¦ lucky girl. I hope my Lucretia marries as well†¦.† â€Å"Apparently, the youngest Beaumont threw herself at DeSangue, but he only had eyes for Lydia†¦.† â€Å"†¦ such a handsome man! And a count!†¦Ã¢â‚¬  â€Å"†¦ yes, but who's that other one again? Marrying Bridget?† I closed my eyes, wishing I could close my ears. How I longed to be back in my grotto in the park. â€Å"Seems like old times, doesn't it, brother?† Damon sighed, adjusting one of his cuffs. â€Å"In another life, you and Rosalyn would be married already.† â€Å"Shut up,† I said. He was right, though. If Katherine hadn't killed my childhood playmate, I would have married her. Back then, I thought a forced marriage with someone I didn't love was the worst fate imaginable. How innocent I was†¦. I continued smiling, although it must have looked forced by that point. My eyes darted over the crowd, seeking out anyone in a badly matched scarf. That morning I had managed to grab and drain a pair of white doves, initially intended to be released as a romantic gesture after the wedding ceremony. But when was the last time Damon had fed? Or did he have a big, bloody feast planned? â€Å"Look at us, together,† Damon whispered, nodding at someone in the crowd and smiling. â€Å"We make quite a handsome pair.† â€Å"I'm doing this,† I whispered, â€Å"to save lives. Now be quiet.† Damon rolled his eyes. â€Å"You're no fun, brother. I hope you develop a sense of humor soon, or it's going to be a loooooong eternity.† The wedding march began, saving me from having to respond. Margaret's husband and Bram, ushers, came down the aisle first. The remaining ushers were callow youths who flirted outrageously with the bridesmaids they escorted. The girls wore pretty matching peach gowns and absolutely giant hats†¦ but I noticed that one had a slightly different accessory from the rest. Hilda wore a hastily tied kerchief around her neck. I glared at Damon. He shrugged. â€Å"I got a little peckish waiting around.† In truth, I was a little relieved – it meant he wasn't starving himself in anticipation of something later. Finally came Winfield, proudly striding down the aisle with a daughter on each arm. Lydia walked regally and easily. She wore a simple white gown of heavy material whose folds rustled with her movements. It went to the top of her neck and the bottom of her wrists, and its only ornamentation was a line of pearl buttons down the front. A net veil hung behind her, floating down her back. She looked like a fairy-tale queen, and smiled with a secretive look that only added to her beauty. On Winfield's left arm was Bridget, wearing her brocade and satin. She actually looked quite beautiful, if a bit overdone. An enormous lace veil perched on top of her head like a crown. It was hard to imagine, now, that I'd ever seen anything of Callie in her. Where Bridget was frilly and immature, Callie had been independent and practical. Thinking of Callie now was a bad idea. Time slowed down. Bridget's foot rose and fell, bringing her a few inches closer to me. Her skirts drew forward, as if of their own accord. Her mouth opened and closed in a giggle that sounded far-off and distorted. And then came the distinctive scent of lemon and ginger. Everything blurred – Katherine? Suddenly, instead of Bridget coming toward me dressed as a bride was the woman who had brought me to this place. Her thick black hair was caught up in a lace veil, revealing her perfect shoulders and neck. The blue cameo gleamed on her neck. She lowered her head demurely, but beneath her long lashes her eyes danced mischievously in my direction. She pursed her lips and I felt my knees weaken. Did Damon see her, too? I looked askance at my brother, to see if he was thinking or seeing the same thing I was. Whatever compelled me to feel the way I did about Katherine, true love or a vampire's Power, I was still under her spell, haunted by her. But Damon's face was a perfect mask of happiness and love. Time started back up again. Bridget resumed her place in my sight, smiling excitedly up at me. And then the girls were before us, and the priest was there, and rings were in our hands. It was, thankfully, a fairly short ceremony. The priest gave a speech about love and read several nice passages from the Bible that I would have liked in any other circumstance. I wasn't sure whether to pray that the priest go on, and on, and on, and give me as much time as possible before the inevitable, or if he should just hurry up and get it over with. â€Å"If anyone here knows of any impediment why these two couples may not be lawfully joined together in matrimony, you do now confess it.† I looked around the room, hoping someone would stand up and object. Maybe Margaret would speak out, with some sort of proof that Damon DeSangue wasn't who he said he was, or that I was some sort of Confederate spy, or†¦ The oldest sister shook her head and gritted her teeth, but kept silent. I may have imagined it, but I think her mother's hand had an iron grip on her knee. Damon went first, marrying the elder bride. I wasn't listening; there seemed to be a dull roar in my ears that was so loud I was surprised no one else could hear it. What was going to happen when it was over? Would the Sutherlands make it through this night? Would I be forced, on my wedding day, to fight my own brother to the death? â€Å"Repeat after me,† the priest finally said. I did as I was told. â€Å"I, Stefan Salvatore, take thee, Bridget Lynn Cupbert Sutherland, to be my wedded wife, to have and to hold, from this day forward, for better, for worse, for richer, for poorer, in sickness and in health, to love and to cherish, till†¦ death us do part.† I almost choked, and could only hope that the audience thought I was overwhelmed with emotion. â€Å"I, Bridget Lynn Cupbert Sutherland, take thee, Stefan, to be my wedded husband, to have and to hold, from this day forward, for better, for worse, for richer, for poorer, in sickness and in health, to love and to cherish, till death us do part.† She forgot my surname, and from the look in her eyes it was because she was thinking about the night before. And then there was a ring in my hand. A simple gold band with my and Bridget's initials inscribed on the inside. Precious metal binding me to my fate. I took Bridget's hand. My voice came out surprisingly clear and calm. â€Å"With this ring, I thee wed, and with my worldly goods I thee endow, in the name of the Father, and of the Son, and of the Holy Ghost.† I slipped it on her finger. She squealed in joy. I kissed her. It was hard and quick, hopefully long enough for the audience to appreciate. Bridget clung to me, trying to make the moment last. She tasted of mint. I felt terrible. And just like that, I was a married vampire.