The risk factors and pathophysiology

o The risk factors and pathophysiology that have led to John Grants presentation are as followed: it is shown that osteoarthritis
o
Discusses the risk factors and pathophysiology that have led to the presenting patient condition.
o Diabetes https://www.medicographia.com/2013/10/osteoarthritis-and-comorbidities/
o Hyperlipidemia
o Depression
o Hypertension
o Angina ?
o Relux?
? Discusses TWO (2) comprehensive post-operative assessments that an RN would undertake for the patient. (10) ? Provides a rationale for each assessment relating to the patient condition (5) and justifies why the assessment is necessary with current evidence-based literature. (5)
Vascular Observations
Dressing exudate- wound assessment
? Discusses ONE (1) potential complication (either pulmonary embolism OR post-operative wound infection), including the development and risk factors of the complication itself (10) and ONE (1) nursing assessment used to identify the complication. (5)
? Develops a plan of care addressing how to reduce the chosen potential complication (either pulmonary embolism OR post-operative wound infection). (10)
? Uses current evidence-based literature to justify why the plan is appropriate for this patient. (5)
Post op wound infection- diabetic, wound assessment, wound nurse,

key principles and theories underlying strategic people management and how their application enhances organisational and individual performance.

Length Up to 3000 words
Learning Outcomes a) Critically assess the key principles and theories underlying strategic people management and explain how their application enhances organisational and individual performance.
b) Critically evaluate the effectiveness of different approaches and the relationships between effective people management and organisational performance.
c) Demonstrate effective communication and practical problem-solving skills to effectively manage people in a range of organisational contexts
d) Critically reflect on the roles and functions that managers perform in the context of the challenges and risks they have to address in the changing environment.
Submission By 11:55pm AEST/AEDT Friday Module 4.2 (week 8)
Weighting 40%
Total Marks 40 marks
Context:
Though challenging, group assignments are designed to reflect the reality of the workplace. In this instance, people coming together to contribute knowledge, experience and skills to produce a desired outcome.
This assessment encourages students to develop their knowledge in relation to the key topics of attracting, developing and retaining employees, teamwork, performance management, team development and change management.
Students will be allocated into groups by the learning facilitator. The group will work together to analyse the given company and provide recommendations to improve on attracting, developing and retaining employees, teamwork, performance management and team development.
Instructions:
Your group is from a well-regarded consultancy firm and has been engaged by your client, ComSyst Technologies (CST) to provide advice on addressing a variety of challenges.
CST is a multi-national communications software and systems developer serving the defence and emergency services industries. CST has offices in Australia, New Zealand, the United States, Philippines, India and South Korea.
CST has recently lost three major tenders to competitors and their market share has declined substantially in the last two years. This has been attributed to some significant people related issues including poor employee performance, low employee engagement, a decline in staff retention and resignations of some key specialists. Technological advancements elsewhere have highlighted a gap in CST’s technical skills and capabilities.
Your brief from the client is to prepare a report with recommendations to achieve the following objectives over the next two years:
1. Ensure CST is well positioned for the future by attracting and retaining the best talent possible
2. Create a team based high performance culture
3. Build employee capability and performance
To address these objectives your consulting team will need to draw on content from modules two, three and four. Some consideration may need to be given to other module content if deemed relevant. It is also expected that groups conduct research beyond the resources provided on the subject site
For each of the objectives mentioned above, you must include at least one real world example / case study from the literature of how other organisations have successfully achieved the same or similar.
Your group must prepare a business style report for the Chief Executive and Board of ComSyst Technologies. Whilst the format may vary, it must include the following:
• Cover page
• Executive Summary
• Table of Contents
• Introduction
• Background
• Main Discussion
• Recommendations
• Conclusion
• Appendices
You may make any necessary assumptions; however, any significant assumptions should be detailed in your report.
Groups will be assessed against the learning rubric below.
Teamwork and group participation will constitute 20% of the mark for the assignment for each member of the group.
Group participation will be determined as follows:
• Each participant in the team will evaluate the other member’s contribution using a participation score matrix (see Appendix 1 Team Participation Score Matrix)
• Each participant is to assess their peers according to the Peer Evaluation Grading Scheme (see Appendix 2)
• Each participant is also required to complete a self-review using the score/rate found in the Team Participation Score matrix.
• The score matrix will be individually submitted to the Facilitator at the same time as the group (collective) report submission.
• The Facilitator will take into consideration the average “team participation score” for each member to determine the weighted ‘Teamwork’ criterion rows in the final marking rubric for this assessment (see below).
• All peer evaluations are confidential and individual rankings will not be released to other members of the group.
• Failure to submit a self-review and peer review correctly, or at all, will result is zero grading for this assessment criteria.
• Groups should refer to the marking rubric to ensure all the assessment criteria are addressed.
Referencing:
You must recognise all sources of information; including images that you can include in your work. Reference your work according to the APA 6th edition guidelines. Please see more information on referencing here http://library.laureate.net.au/research_skills/referencing
Submission Instructions:
o Each group is to submit one final Case Study submission into Assessment 2 submission link in the Assessment section found in the main navigation menu of the subject Blackboard site. A rubric will be attached to the assessment.
o Each student is to submit a completed team participation score matrix document in Assessment 2 review submission link.
The Assessment 2 Case Study assignment and individual Team Participation Score documents are to be submitted at the same time for the facilitator to finalise grading for this assessment. The Learning Facilitator will provide feedback via the Grade Centre in the LMS portal. Feedback can be viewed in My Grades.
Appendix 1:
Team Participation Score Matrix
a) Individually, each team member will assign a “teamwork” score (from 1-5) for other members of the team/group using a participation score matrix attached to the marking rubric.
b) You will need to assign yourself a participation score.
c) The score matrix will be individually submitted to the Facilitator at the same time as the group (collective) report submission.
d) The Facilitator will use the average “teamwork” score for each member in considering the weighted teamwork or group participation contribution to their final mark.
Grading Matrix
Member Name/ID Maximum Teamwork Mark (%) Average Participation Score (1-5)2 10
1
20
2
20
3
20
4
20
5
20
Appendix 2:
Peer Evaluation Grading Scheme
Rating Description
5 Builds team’s identity and commitment
Leads team
Evaluates teams’ outcomes
Implements strategies for enhancing team effectiveness
4 Understands group dynamics and team roles
Facilitates team development
Renegotiates responsibilities, tasks and schedules to meet needed change
3 Contributes to small group discussions to reach agreement on issues
Works together with others towards shared goals
Renegotiates responsibilities to meet needed change
2 Participates effectively in teams
Identifies team and individual goals, tasks, responsibilities and schedules
Contributes to group processes
Supports the team
1 Does not participate effectively in a team environment
Places individual goals ahead of the group responsibility Hinders the group process and upsets the schedule
Learning Rubric: Assessment 2 Case Study
Assessment Attributes Fail (Unacceptable) 0-49% Pass
(Functional)
50-64% Credit
(Proficient) 65-74% Distinction
(Advanced)
75 -84% High Distinction
(Exceptional)
85-100%
Knowledge and understanding (technical and
theoretical knowledge)
Understands theoretical
models and concepts
Percentage for this
criterion
25%
Limited understanding of required concepts
and knowledge
Key components of the assignment are not addressed.
Knowledge or understanding of the field or discipline.
Resembles a recall or summary of key ideas.
Often confuses assertion of personal opinion with information substantiated by evidence from the research/course materials.
Thorough knowledge or understanding of the field or discipline/s. Supports personal opinion and information substantiated by evidence from the research/course materials.
Demonstrates a capacity to explain and apply relevant concepts.
Highly developed understanding of the field or discipline/s.
Discriminates between assertion of personal opinion and information substantiated by robust evidence from the research/course materials and extended reading.
Well demonstrated capacity to explain and apply relevant concepts.
A sophisticated understanding of the field or discipline/s.
Systematically and critically discriminates between assertion of personal opinion and information substantiated by robust evidence from the research/course materials and extended reading.
Mastery of concepts and application to new situations/further learning.
Application of
knowledge to practise
Shows a clear understanding of the practical application and Limited understanding of the internal and external business environment.
Uses a limited range of information as the basis Understands the internal and external business environment including commercial context and market forces.
Accesses relevant information. Understands the impact of financial, social, political, environmental issues on the business.
Understands the business.
Evaluates the impact of financial, social, political, environmental issues on the business; and where relevant, as they relate to different countries where the business may operate. Demonstrates cultural sensitivity.
Analyses the impact of financial, social, political, environmental issues on the business; and where relevant, as they relate to
implications of key
concepts and principles
Percentage for this
criterion
25%
of recommended practice.
Adequately utilises information from a variety of sources.
Can prepare and presents business cases/proposals. Understands the business and its risks.
Can prepare and presents business cases/proposals.
different countries where the business may operate.
Holistic understanding of business and its risks.
Assesses the impact of information and communication systems on the operations of the business.
Effective
Communication
Well-structured report
with clear flow of ideas
Percentage for this
criterion
20% Difficult to understand for audience, no logical/clear structure, poor flow of ideas, argument lacks supporting evidence.
Audience cannot follow the line of reasoning.
Information, arguments and evidence are presented in a way that is not always clear and logical.
Line of reasoning is often difficult to follow.
Information, arguments and evidence are well presented, mostly clear flow of ideas and arguments.
Line of reasoning is easy to follow.
Information, arguments and evidence are very well presented; the presentation is logical, clear and well supported by evidence.
Demonstrates cultural sensitivity.
Expertly presented; the presentation is logical, persuasive, and well supported by evidence, demonstrating a clear flow of ideas and arguments.
Engages and sustains audience’s interest in the topic, demonstrates high levels of cultural
sensitivity
Effective use of diverse presentation aids, including graphics and multi-media.
Team Work
Contributes effectively to the team by meeting
responsibilities, encouraging and
supporting others
Percentage for this
criterion
20% Does not participate effectively in a team environment.
Places individual goals ahead of the group responsibility.
Hinders the group process and upsets the schedule.
Participates effectively in teams.
Identifies team and individual goals, tasks, responsibilities and schedules.
Contributes to group processes.
Supports the team.
Contributes to small group discussions to reach agreement on issues.
Works together with others towards shared goals.
Renegotiates responsibilities to meet needed change.
Understands group dynamics and team roles.
Facilitates team development.
Renegotiates
responsibilities, tasks and schedules to meet needed change.
Builds team’s identity and commitment.
Leads teams.
Evaluates teams’ outcomes.
Implements strategies for enhancing team effectiveness.
Correct citation of key
resources and evidence
Professional presentation, well written and meeting APA guidelines for referencing
Percentage for this
criterion
10% Demonstrates inconsistent use of good quality, credible and relevant resources to support and develop ideas.
Demonstrates use of credible and relevant resources to support and develop ideas, but these are not always explicit or well developed.
Demonstrates use of high quality, credible and relevant resources to support and develop ideas.
Demonstrates use of good quality, credible and relevant resources to support and develop arguments and statements. Shows evidence of wide scope within the organisation
for sourcing evidence
Demonstrates use of high-quality, credible and relevant resources to support and develop arguments and position statements. Shows evidence of wide scope within and without the organisation for sourcing
evidence

The work of Department of Spatial Information (DSI) and its Online Spatial Delivery System (OSDS).

The Department of Spatial Information (DSI) is a State Government department. The major function of DSI is to provide accurate and timely spatial information to other Government departments, but also to make some of this spatial information available to the public. In order to provide both the government and public services, DSI has developed a number of web services that deliver this information through a number of internally developed services and applications. This suite of web services and applications is referred to as the DSI Online Spatial Delivery System (OSDS).
The OSDS is considered essential by DSI and their users, so these services must be:
Readily available and accessible at all times,
Capable of handling heavy loads in times of peak demand,
Capable of serving downloads to users as required,
Secure from attacks,
Capable of providing detailed reports on usage.
DSI have a number of new projects being developed that are expected to increase the demand for its spatial data dramatically. The Executive Management of DSI have looked at a number of proposals to support these new programs. The two alternatives they are investigating are:
Increasing the internal DSI Data Centre capacity to host and support the new projects in the OSDS. This would probably need a 50% increase in web infrastructure and support services within the Department. This would necessitate an increase in data centre infrastructure, server numbers as well as a major increase in the bandwidth available to DSI.
Migrating the OSDS to a Cloud provider. This would allow DSI to continue to develop and refine the data in its internal Maintenance systems and then move a copy of the completed data to the cloud-based Delivery system for publication.
DSI Management would like to adopt Proposal 2, in order to meet their budget restrictions, but have asked you to prepare a report for the DSI Board that looks at the following aspects of the proposal:
The possible delivery and deployment models that DSI should adopt for a cloud-based OSDS. This should include:
The advantages and disadvantages of using either an IaaS or PaaS approach for the OSDS, (20 marks) and
The possible architecture(s) that could be used to deploy the OSDS (20 marks).
Should the Board consider the use of an Cloud Edge solution for the OSDS? What advantages and disadvantages would the Edge give to the OSDS? (20 marks)
The OSDS software architecture uses a monolithic approach to design, while a move to use the Edge will require many applications and web services to be redesigned as microservices.
Explain the differences between monolithic and microservice architectures to the DSI Board using an example (20 marks).
Describe the advantages and disadvantages of these two styles of software architecture (20 marks)
Your recommended approach for delivery and deployment of the OSDS, including the reasoning for your recommendation (20 marks).
Your report should not exceed 10 pages, excluding references.

Firewall Setup and Configuration (performing a security testing on the network to identify the threats)

Firewall Setup and Configuration
Task Details: This Assignment requires you to perform a security testing on the network to identify the threats, prepare a Risk Mitigation report and configure some of the firewall settings using Kali Linux to secure the network and the distributed applications.
The assignment consists of two parts:
Part A: Use Nmap – a security testing in Kali Linux to perform penetration testing on the network (features of Nmap listed below). Prepare a short Risk Mitigation plan to identify the threats for the assets. This plan will guide you to proceed with the firewall settings required for the organization as you focus on the second part of the assignment.
Part B: Configure a few settings on the firewall for the network using Kali Linux commands to achieve a required level of security. The initial set of commands are given to you to start with. You may need to perform online search to complete the rest of the requirements for the firewall settings.
Case Study for the Assignment: Canadian Cafe is a small business enterprise comprising franchise at different geographical locations with appropriate network facilities to reach their business requirements. A secure network across their geographical locations is one of the objectives of a business organization. The System and Network administrator of the organization realizes that the security of the network has to be vulnerabilities that the network may pose. After risk analysis, designing a set of security policies is very important to provide high level of security.
The executive management of Canadian Cafe urges you to design the necessary security requirements. Looking into the requirements of the security and adhering to information security policy as a security team decides to configure firewall to secure the network from different types of possible threats and attacks that can harm the business network.
Part A: Perform the following task.
1. Use Nmap from Kali on your Virtual Box
2. Write an introduction to include the description of the tool
Features of Nmap:
• Host discovery: useful for identifying hosts in any network
• Port scanning: lets you enumerate open ports on the local or remote host
• OS detection: useful for fetching operating system and hardware information about any connected device
• App version detection: allows you to determine application name and version number
• Scriptable interaction: extends Nmap default capabilities by using Nmap Scripting Engine (NSE)
3. Demonstrate four tasks Nmap can perform. Discuss on how this tool can be used for mitigating differ types of threats. The discussion should include the name and bnef description of the threat and must be supported by screenshots.
4. Discuss the performance of the tools based on the following:
a. Security features and
b. Time taken to detect any threat
5. Perform the firewall testing using Nmap
6. From the report generated from the above tasks write a short Risk Mitigation Plan to identity the type of threats on the organisation’s assets.
Part B: Configure the following setting on the firewall using the appropriate commands in Kali Linux. The list of commands is provided below:
Command Description
Ufw status To check firewall status
Ufw enable Enable f rewall
Ufw allow Allow services, port range and network
Ufw deny Blocking a service
1. Check the firewall status
2. Enable or disable the firewall accordingly
3. Allow services such as TCP. SSH and samba using their port number or name
4. Verify the firewall rules after adding the above services
5. Secure a web server by blocking HTTP service and allowing HTTPS service only
6. Allow a range of ports from 20 to 80 and deny a range of ports from 100 to 500
7. Verify the firewall rules
8. Allow HTTP from a specific subnet to access your web services
9. Block connections to a network interface
Submission Guidelines:
The assignment should be submitted on Moodle on or before the deadline as a word document that includes all the details of the task completed in Part A and Part B. The report should address the requirements mentioned in the Marking Criteria section of the assignment.
Marking Criteria:
Sections Descnpton of the section Marks
Executive Summary Summary on what the report is address, ng 2
Outline Outline of the whole report inducing tool descr ption 2
Risk Mitigation Plan DetaJs of the threats n the mitigaton report 2
Analysis Critical analysis of the scenario 2
Firewall setup Details of the firewall settngs wth screenshots 6
Conclusion Informaton on what has been addressed in the report – discuss on of the findings is important 2
Demonstration Details of the tests performed wth screenshots 4

Developing a survey that will gauge the views of the Australian public regarding “Climate Change”.

Scenario
You have been commissioned by the Australian Government to develop a survey that will gauge the views of the Australian public regarding “Climate Change”. The Government intends to use the results of your survey to assist in the formulation of government policy for the next 30 years. The survey should contain 20 questions which should take a respondent no more than about 5 minutes to complete. Accordingly, for this survey, there should be no open ended questions (For more information, see Guideline Two – Variable Category Definition).
Requirements
In this assignment, your tasks will be split into two (2) distinct Parts. The Part A relates to the Survey Questions and Part B to the Collection of the Survey Data (i.e. the methodology; and, determination of the target audience). For this assignment, you do not undertake the collection of any survey data/responses.
Part A – Survey Questions
• Task 1: write/create twenty (20) survey questions that are specifically aligned to the surveys purpose, i.e.
gauging the views of the Australian public regarding “Climate Change”.
• Task 2: justify/state the purpose/reason for asking each question.
• Task 3: indicate the type of variable that is most appropriate to your question (For more information, see Guideline Three – Variable Type)
• Task 4: indicate the Level (Scale) of Measurement that is applicable to each question (For more information, see Guideline Four – Level (Scale) of Measurement)
• Task 5: indicate, in detail, the type of visualisation (i.e. Chart/Table/Graph) you would use to visually represent the data for each question.
Part B – Collection of Survey Data
• Task 6: indicate the methodology you would adopt to conduct the survey (i.e. how do you intend to collect the data).
• Task 7: determine the target audience (i.e. what is your Survey Sampling Method) in order to ensure that your data is representative of the population and then describe your sampling frame.
Survey Question Hints
An example of an appropriate Survey Question:
Which of the following age groups is appropriate for your age?
Note: If you wish, you may use this question as one of your twenty (20) but you would, of course, need to establish the ranges for these age groups.
An example of an unacceptable Survey Question:
What is your name?
This example fails on multiple counts:
o There can be “no purpose” in asking this question (see Task 2).
o It’s likely the interviewee will decline to answer any further questions (for privacy reasons) or they will deliberately answer the remaining questions untruthfully.
o It would not be possible to represent the data gathered in any meaningful manner (see Task 5).
Guidelines
Guideline One – Word Count
The following word counts are a guide: Part A – Survey Questions
• Task 1: each survey question you create should be approximately 10 to 20 words (i.e. 200 to 400 words).
• Task 2: when you explain the purpose of your question, you should allow approximately 30 to 40 words per question (i.e. 600 to 800 words).
• Task 3: when you indicate the type of variable for each question, you will use a minimal number words.
• Task 4: when you indicate the Level (Scale) of Measurement for each question, you will use a minimal number words.
• Task 5: when you explain the type of visualisation for your question, you should allow approximately 25 to 35 words per question (i.e. 500 to 700 words).
Part B – Collection of Survey Data
• Task 6: when you explain your methodology, use approximately 100 to 200 words.
• Task 7: when you explain your Survey Sampling Method, use approximately 200 to 300 words.
Therefore, based on the above guidelines, your assignment should be no less than 1600 words and no more than 2400 words overall (i.e. 2000 words plus or minus 20%).
Guideline Two – Variable Category Definition
Ensure your questions are constructed such that any possible answer is both:
a. Mutually Exclusive, and
b. Collectively Exhaustive.
Guideline Three – Variable Type
When you design your twenty (20) questions, not only do you need to indicate the type of variable that is most appropriate to your question, but you must also adhere to the following minimum counts for these variables: a. 5 Categorical questions.
b. 5 Numeric questions, of which at least:
i. 2 need to be Discrete, and ii. 2 need to be Continuous.
Guideline Four – Level (Scale) of Measurement
For each question, you must nominate which of the following Level (Scale) of Measurement applies: a. Nominal.
b. Ordinal.
c. Interval.
d. Ratio.
Submission
Your completed work should be a single Word document divided into two sections:
Part A. Survey Questions
Your results should be listed question by question (e.g. under question 1, incorporate Tasks 1 to 5).
Part B. Collection of Survey Data
There is no need to have a Table of Contents; an Executive Summary; an Introduction; or, a Conclusion. You must, however, include a section containing your references (this section not included in the word count).
The assignment is to be submitted to the MIS770 assignment drop box in CloudDeakin before 11:59pm on Thursday 9th April, 2020. Please ensure you include your name and student details in your Word document as well as naming the file in the following format: yourstudentid_A1.docx. Failure to follow this naming convention may lead to a delay in receiving feedback and marks.
Note: CloudDeakin is the only method of submission acceptable.
Referencing
In this assignment, you must reference all sources used in your assignment, including words and ideas, facts, images, videos, audio, websites, statistics, diagrams and data. There are many different types and styles of referencing and we recommend that you use the Harvard method. To assist you, the University has provided this guideline Deakin guide to referencing as well as an individual guide to the Harvard method. There is also a thirty (30) page pdf document called “Deakin Guide to Harvard” in the Unit’s “Assessments Resources” folder in CloudDeakin.
Faculty of Business and Law Assignment Extension Procedures
Information for students seeking an extension BEFORE the due date
If you wish to seek an extension for this assignment prior to the due date, you need to apply directly to the Unit Chair by completing the Assignment and Online Test Extension Application Form (PDF, 188.6KB) and sending the completed form as well as your supporting documentation and a draft of your assignment, to our generic email address (T12020MIS770@deakin.edu.au).
This needs to occur as soon as you become aware that you will have difficulty in meeting the due date.
Please note: Unit Chairs can only grant extensions up to two weeks beyond the original due date. If you require more than two weeks, or have already been provided an extension by the Unit Chair and require additional time, you must apply for Special Consideration via StudentConnect within 3 business days of the due date.
Conditions under which an extension will normally be considered include:
• Medical – to cover medical conditions of a serious nature, e.g. hospitalisation, serious injury or chronic illness.
Note: temporary minor ailments such as headaches, colds and minor gastric upsets are not serious medical conditions and are unlikely to be accepted. However serious cases of these may be considered.
• Compassionate – e.g. death of a close family member, significant family and relationship problems.
• Hardship/Trauma – e.g. sudden loss or gain of employment, severe disruption to domestic arrangements, victim of crime.
Note: misreading the due date, assignment anxiety or returning home will not be accepted as grounds for consideration.
Information for students seeking an extension AFTER the due date
If the due date has passed; you require more than two weeks extension, or you have already been provided with an extension and require additional time, you must apply for Special Consideration via StudentConnect. Please be aware that applications are governed by University procedures and must be submitted within three business days of the due date or extension due date.
Please be aware that in most instances the maximum amount of time that can be granted for an assignment extension is three weeks after the due date, as Unit Chairs are required to have all assignment submitted before results/feedback can be released back to students.
Penalties for late submission
The following marking penalties will apply if you submit an assessment task after the due date without an approved extension:
• 5% will be deducted from available marks for each day, or part thereof, up to five days.
• Work that is submitted more than five days after the due date will not be marked; you will receive 0% for the task.
Note: ‘Day’ means calendar day.
The Unit Chair may refuse to accept a late submission where it is unreasonable or impracticable to assess the task after the due date.
Additional information: For advice regarding academic misconduct, special consideration, extensions, and assessment feedback, please refer to the document “Rights and responsibilities as a student” in the “Unit Guide and Information” folder under the “Resources” section in the MIS770 CloudDeakin site.

My topic is requesting the Coca-Cola brand to donate 1% of their sales towards providing clean water in India

My topic is requesting the Coca-Cola brand to donate 1% of their sales towards providing clean water in India

Create a 5 to 10 slide PowerPoint presentation to deliver your message to the agency/ entity of your choice about the health related issue you want help with.
Your slides should:
first slide (after title slide) should explain at least three (3) objectives of your request.
clearly state purpose of request to agency/ entity.
show relevant and up to date statistic on the problem you are trying to advocate for. (include references)
use references according to the APA Style Guide.

The Case: The sleepy woman with anxiety

PATIENT FILE

The Case: The sleepy woman with anxiety

The Question: How can you be anxious and narcoleptic at the same time?

The Dilemma: Finding an effective regimen for recurrent, treatment resistant anxious depression while juggling complex treatments for sleep disorders

Pretest Self Assessment Question (answer at the end of the case) Which of the following are approved treatments for treatment resistant depression?

A. Deep brain stimulation B. Transcranial magnetic stimulation C. Vagal nerve stimulation D. Aripiprazole (Abilify) E. Quetiapine (Seroquel) F. MAO inhibitors

Patient Intake • 44-year-old woman with a chief complaint of anxiety

Psychiatric History • The patient had onset of anxiety and depression at about age 15, which

she began self-medicating with alcohol • After graduating from high school, she began college and was about to

leave for study abroad when she experienced a panic attack for which she was treated in the emergency room

• She was then hospitalized and treated for alcohol abuse at age 18, and has remained sober ever since, although she does admit to some possible alprazolam (Xanax) abuse in 1999 as well as one overdose with alprazolam

• Her history also includes multiple hospitalizations for major depression – Age 19 (approximately one year after her release from the hospital

for alcohol abuse) because she became suicidal – Age 24 due to recurrence of depression – Age 26 with an overdose following a divorce and recurrence of

depression – Age 27 due to recurrence of depression – Age 29 after two miscarriages, with a possible postpartum element

and some discontinuation of her medications at that time to try to get pregnant

– Age 30 when she received electroconvulsive therapy (ECT): 7 sessions as an inpatient and 23 as an outpatient

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48

PATIENT FILE

• Details of medication history unclear from available information and from patient’s memory, but has received numerous psychotropic drugs including antidepressants, antipsychotics, and mood stabilizers, all with poor results

• She was much better for several years following her ECT treatment, but had severe memory impairment

• She had a recurrence of her depression one year ago severe enough to become totally disabled, necessitating resignation from a job as an offi ce worker that she had enjoyed

• She continues to be disabled from depression and has a great deal of anxiety, subjectively more disturbed by her anxiety than by her depression

Social and Personal History • Married since 1996 (second marriage); no children from either

marriage • Non smoker • Husband an architect, supportive • Little contact with her family of origin • Few friends or outside interests

Medical History • Narcolepsy • Restless legs syndrome • Nighttime urinary incontinence possibly related to highly sedating

medications • BMI 26 • BP 120/78 • Normal fasting glucose and triglycerides

Family History • Grandmother: depression and who has received ECT with good

results

Current Medications • Bupropion (Wellbutrin XL) 450 mg/day (thinks it is helpful as she

worsens if she tries to taper) • Ziprasidone (Geodon, Zeldox) 60 mg in the morning and 180 mg at

night (unsure if this is helpful) • Lamotrigine (Lamictal) 200 mg in the morning and 150 mg at night

(thinks it is helpful for her mood)

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49

PATIENT FILE

• Gabapentin (Neurontin) 300 mg in the morning, 600 mg at noon, and 900 mg at night; occasional 100 mg as needed for breakthrough anxiety (experiences intolerable return of anxiety at much lower doses)

• Pramipexole (Mirapex) 1 mg/night for restless legs syndrome (unclear whether helpful)

• Methylphenidate extended-release (Concerta) 54 mg/day for daytime sleepiness (thinks it is helpful)

• Sodium oxybate (Xyrem) 9 mg in one dose at night for narcolepsy and daytime sleepiness (not taken in recommended split dose)

• DDAVP (the peptide Desmopressin) 0.4 mg/night for bedwetting

Based on just what you have been told so far about this patient’s history and current symptoms, would you consider her to fall within the bipolar spectrum? • Yes • No

Would you continue her “mood stabilizing” medications? • Yes, continue both ziprasidone (Geodon) and lamotrigine (Lamictal) • Continue ziprasidone but discontinue lamotrigine • Continue lamotrigine (Lamictal) but discontinue ziprasidone (Geodon) • No, discontinue both ziprasidone (Geodon) and lamotrigine (Lamictal)

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation • Nothing unexpected on mental status examination which showed

depression and anxiety • Because she has had numerous recurrences, this makes her illness

appear to be somewhat unstable; however, she has not shown any overt signs of bipolarity

• The best diagnosis for this patient may be severe generalized anxiety with major depressive recurrent unipolar disorder

• Nevertheless, tactics that are useful for bipolar mood disorders may be useful in this patient

• Continuing ziprasidone (Geodon) and lamotrigine (Lamictal) may help mitigate the risk of a future relapse

• Thus, these medications were continued at the time of the initial evaluation

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Further Investigation: Is there anything else you would especially like to know about this patient? • What about details concerning the diagnosis of narcolepsy and of

restless legs syndrome, the treatments given and the responses to those treatments?

– During the past year as her depression has recurred and worsened, she has developed excessive daytime sleepiness

– She had an overnight sleep polysomnogram done in another city that supposedly showed sleep onset REM (rapid eye movement) periods, but you do not have a copy of the report and do not know if it was done while taking any medications, or after the withdrawal of any medications

– During the past year she has also complained of restless legs worse in the evening when trying to fall asleep

– Because of her diagnosis of narcolepsy, she was prescribed methyphenidate extended release (Concerta) which helps a bit for her daytime sleepiness, but because she was still sleepy, sodium oxybate (Xyrem) was added without further improvement of daytime alertness although she gets to sleep right away and also sleeps well through the night now

– In fact, she sleeps too well through the night now, and has bed wetting, for which she has been prescribed DDAVP (Desmopressin), but it is not very helpful

– Because of her diagnosis of restless legs syndrome, she is prescribed pramipexole (Mirapex), with equivocal results

Based on what you know so far about this patient’s history, current. symptoms, and treatment responses, are you convinced her daytime sleepiness and nighttime restlessness are adequately diagnosed and treated? • Yes • No

Would you continue her 4 sleep disorder medications? • Yes, continue all 4 (methylphenidate (Concerta), sodium oxybate

(Xyrem), DDAVP (Desmopressin) and pramipexole (Mirapex)) • No, stop one or more of these

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Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued • The patient’s complaint of excessive daytime sleepiness can be

diffi cult to assess given all the medications she is taking, especially sodium oxybate (Xyrem) and gabapentin (Neurontin), which can cause excessive daytime sleepiness

• It can also be diffi cult to determine whether her sleepiness represents narcolepsy or really represents “hypersomnia” as an associated symptom of depression

• It can be similarly diffi cult to determine whether her restless legs represent restless legs syndrome or really represent psychomotor agitation as an associated symptom of anxiety or whether restless legs represent a side effect of bupropion (Wellbutrin) rather than restless legs syndrome

• It is even possible that her sleep disorder treatments are interfering with her treatments for depression and anxiety

• Thus, her sodium oxybate (Xyrem) was tapered, and then her DDAVP (Desmopressin) discontinued, and her pramipexole (Mirapex) was also tapered over the next month following her initial assessment

Case Outcome: First and Second Interim Followup Visits, Weeks 2 and 4 • The patient experienced some initial insomnia and restless sleep

as sodium oxybate (Xyrem) was withdrawn, but this resolved in several days, as did her incontinence; her daytime sleepiness actually improved somewhat but she continued to have problems falling asleep some nights

• Next, her pramipexole (Mirapex) was tapered without worsening of restless legs, or of insomnia, or mood

• Finally, her daytime gabapentin (Neurontin) was tapered to half dose with improvement in daytime sleepiness, but this was only intermittently tolerated, because of re-emergence of anxiety; however, higher gabapentin (Neurontin) doses caused daytime sleepiness

• She continued to have depression; also, her anxiety continued to wax and wane day and night, with some relief by additional doses of gabapentin (Neurontin), but, unsatisfactory overall results; if anxiety and agitation occur at night, she also has insomnia

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Considering her former response and side effects with ECT treatment, would you consider using an alternative non-drug treatment method for her refractory symptoms? • Yes, consider ECT • Yes, consider VNS • Yes, consider TMS • Yes, consider DBS

Attending Physician’s Mental Notes: Second Interim Followup, Week 4 • The patient’s prior response to ECT suggests that it, or a similar

treatment, may be benefi cial • She is hesitant to try ECT again because of the memory loss she

sustained, but may benefi t from another alternative treatment strategy • Vagal nerve stimulation (VNS) (approved for treatment-resistant

depression and available at the time of this evaluation) – VNS involves surgical implant of a stimulation device in the upper

left side of the chest (intended as a permanent implant, though it can be removed)

– The pulse generator can be programmed to deliver electrical impulses to the vagus nerve at various durations, frequencies, and currents

– Stimulation typically lasts 30 seconds and occurs every fi ve minutes

– After an initial wave of enthusiasm for this treatment, use of VNS for depression has waned due to disappointing results, high costs and some complications, include the hassle of having the stimulator and electrode removed

• Transcranial magnetic stimulation (TMS) (approved for treatment- resistant depression) – Generally done on an outpatient basis – Electromagnetic coil is placed against the scalp near the forehead

and turned off and on repeatedly for 30 to 50 minutes per treatment – Typical treatment duration is fi ve daily treatments a week for four to

six weeks – Insurance coverage is variable for a course of this treatment which

costs several thousand dollars – TMS has been best studied in patients who have failed a single

antidepressant, and not for more complicated cases, or in cases with prior good or bad responses to ECT, so it is diffi cult to predict the chances of success for this patient

• Deep brain stimulation (DBS) (in trials for treatment-resistant depression)

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PATIENT FILE

– Involves two surgical procedures, one to implant electrodes in the brain and a second to implant a neurostimulator in the chest

– Stimulation is generally constant but can be temporarily turned off by holding a magnetic device over the area of the chest where the neurostimulator is located

– DBS is an experimental procedure available at only a few medical centers with research protocols that may cover some or all of the costs

– Risks and benefi ts of DBS remain unknown in treatment resistant depression, so DBS is reserved for patients who have failed many treatments, such as this patient

• After discussion of these options, the patient asked to defer action on them so she could research VNS, TMS and DBS, and in the meantime, she asked to try some other medications

Would you continue her methylphenidate extended release (Concerta) for daytime sleepiness? • Yes • No

Attending Physician’s Mental Notes: Second Interim Followup, Week 4, Continued • On one hand, methylphenidate extended release (Concerta) seems

to be helpful for her daytime sleepiness and one could even consider raising the dose to try to alleviate her depression

• On the other hand, this could risk making her anxiety worse and, to the extent that daytime sleepiness is related to sedating medications’ side effects, it may be better to adjust those

• For now, the patient is not willing to stop the stimulant, and after a discussion of risks and benefi ts, methylphenidate was continued

• Spoke with husband who is supportive and denies any marital confl ict

Would you consider adding any of the following medications to her regimen? • Lithium (to boost mood and mitigate risk of cycling) • Monoamine oxidase inhibitor (MAOI) (to boost mood) • Mirtazapine (Remeron) (to boost mood and possibly treat anxiety) • Quetiapine (Seroquel) (to boost mood and possibly treat anxiety) • Aripiprazole (Abilify) (to boost mood) • None of these

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Attending Physician’s Mental Notes: Second Interim Followup, Week 4, Continued • Lithium – Could help to boost her mood and mitigate risk of future relapse – If added it may not be necessary to give her a full dose as she is

already on other mood stabilizing medications • MAOI – May help boost mood, as this has been effective for patients with

anxious depression – However, this could also be activating for some patients and cause

problems with sleep and anxiety – If added, an MAOI would require discontinuation of bupropion – Transdermal selegiline (Emsam) does not require dietary restriction

and may be a preferable formulation • Mirtazapine (Remeron) – May boost mood and also potentially treat anxiety • Quetiapine (Seroquel) – May boost mood (approved for depressed phase of bipolar disorder

and as adjunct for unipolar depression) – May also be helpful for anxiety (anecdotal reports as adjunct) – If added, it may require careful dosing to avoid daytime sedation • Aripiprazole (Abilify) – May boost mood (approved as adjunct for unipolar depression) – Can be activating and cause problems with anxiety • The patient was encouraged to switch from bupropion (Wellbutrin)

to mirtazapine (Remeron), but instead opted for aripiprazole (Abilify) augmentation of her current medications (bupropion, lamotrigine, gabapentin, methylphenidate), while discontinuing ziprasidone.

Case Outcome: Multiple Interim Followups to Week 24 • Aripiprazole (Abilify) titration from 2 mg to 5 mg while ziprasidone

(Geodon) was discontinued showed no real changes good or bad for the fi rst month (week 12)

• Aripiprazole was then increased to 10 mg, with slight improvement (week 16)

• After a second month at 10 mg of aripiprazole, no further improvement in depression and anxiety and overall results not satisfactory (week 20)

• The patient was switched from aripiprazole to quetiapine (Seroquel), which was not associated with improvement of mood or anxiety, and made her sleepiness worse (by week 24)

• The patient was offered a trial of mirtazapine (Remeron) again, and

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due to the results with quetiapine, was not willing to take it (at week 24)

• She was offered an MAOI, but said she would rather consider VNS, TMS or another round of ECT (at week 24)

• Insurance approved VNS, and the patient became essentially asymptomatic for more than 4 years

Case Debrief • The patient has a 25-year history of recurrent anxiety and depression

that appears unipolar in nature and has been somewhat responsive to antidepressants and very responsive to ECT in the past

• Her current relapse is causing her disability and is not fully responsive to the 8 medications she was taking on initial referral (bupropion, lamotrigine, ziprasidone, gabapentin, sodium oxybate, DDAVP, methylphenidate and pramipexole)

• It seems possible that her sleep symptoms are more related to her anxious depression rather than to additional diagnoses of narcolepsy and restless legs syndrome and, in any event, her treatments for these sleep disorders did not improve her symptoms; discontinuation of several sleep medications (sodium oxybate, pramipaxole and DDAVP) if anything improved her symptoms; other clinicians may have opted to continue these medications

• Following simplifi cation of her medication regimen from 8 medications to 5, she failed to respond to augmentation with aripiprazole or with quetiapine

• Possibly because of her prior response to ECT (and a fi rst degree relative also responded to ECT), she was an excellent candidate for VNS

Take-Home Points • It can be diffi cult to determine whether insomnia with anxiety

and psychomotor agitation at night, with simultaneous excessive sleepiness during the day while having poor sleep at night in a patient taking sedating medications, are due to a sleep disorder, to an anxiety disorder, to a depressive disorder or to side effects of medications

• Simplifying medication regimen from 8 medications to 5 may help determine whether some of the symptoms are due to medications and whether all medications are necessary

• The ultimate proof that her symptoms of daytime sleepiness and night time agitation are linked to her anxiety/mood disorder rather than to sleep disorders was that these symptoms abated when her depression and anxiety abated with effective treatment by VNS

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Performance in Practice: Confessions of a Psychopharmacologist • What could have been done better here? – Did it take too long to get to the VNS recommendation? – Should she have been pushed harder to try mirtazapine or an

MAOI rather than augmentation with two additional, three total, atypical antipsychotics?

– Did it take too long to clarify the sleep issues? – Should we have tried harder to get a copy of the written results of

the polysomnogram? • Possible actions for improvement in practice – Make sure that augmentation with atypical antipsychotics is not

the only option offered, or the only option offered early, since these drugs are expensive and can have notable side effects

– Despite less robust comparative data, agents such as mirtazapine and MAOIs, and also VNS and ECT, can be considered earlier in the treatment algorithm

– Get husband more involved as patient is at high risk for long term depression, and he is her major support system

– Consider psychotherapy earlier rather than after VNS and assess whether the patient is a good candidate for interpersonal or cognitive behavioral approaches

Tips and Pearls • Treatment with pregabalin (Lyrica), approved for anxiety in Europe

but not in the US, rather than gabapentin (Neurontin), not approved anywhere for anxiety, may be less sedating if more expensive

• If the patient requires an MAO inhibitor, best to stop the bupropion and the methylphenidate, but lamotrigrine and gabapentin can be continued. For heroic cases unresponsive to an MAO inhibitor, stimulants such as methylphenidate can sometimes be cautiously added to an MAO inhibitor by experts monitoring cardiovascular status who are sophisticated about weighing risks and benefi ts

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PATIENT FILE

Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case – Classifi cation and testing for narcolepsy, hypersomnia and

restless legs syndrome – Overlap of symptoms in sleep disorders with psychiatric

disorders

International Classifi cation Of Sleep Disorders Diagnostic Criteria Of Narcolepsy • Patient complains of excessive sleepiness or sudden muscle

weakness

• Recurrent daytime naps or lapses into sleep almost daily for at least 3 months

• Possible sleep-onset REM (rapid eye movement) periods, hypnagogic hallucinations, and sleep paralysis

• With cataplexy

• Sudden bilateral loss of postural muscle tone in association with intense emotion

• Hypersomnia not better explained by another disorder

• Should be confi rmed by PSG (polysomnogram) followed by MSLT (multiple sleep latency test, see below) which should show a mean sleep latency of 8 minutes and two more sleep-onset REM periods (SOREMPs) following normal sleep

• May be confi rmed by orexin levels in the cerebrospinal fl uid (CSF) <110 pg/ml or, 1/3 of mean normal control levels Narcolepsy is estimated to occur in 0.03–0.16% of the general population, with its development mostly beginning in the teens. Narcoleptic sleep attacks usually occur for 10–20 minutes and, on awakening, the patient can be refreshed for 2–3 hours before feeling the need to sleep again. Although sleep attacks occur most often in a monotonous situation, they can also occur when a person is actively conversing or eating. Symptoms of narcolepsy may include frightening hypnogogic hallucinations and sleep paralysis, which are usually coincident with SOREMPs. Not everyone with narcolepsy will have cataplexy but it is a unique feature of this disorder. An attack normally lasts a few seconds to minutes, during which the person is conscious. Some people have only minimal muscle involvement, while others can have “full-body” attacks; however, the respiratory and ocular muscles are never involved. Excessive sleepiness is the main symptom to continue with age, and it may worsen alongside the development of periodic limb movements and obstructive sleep apnea. In addition, sleep may be disrupted and include frequent awakenings (International Classifi cation of Sleep Disorders, revised, 2001). Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 58 PATIENT FILE Multiple Sleep Latency Test (MSLT) • Dark comfortable room at an ambient temperature • Smoking, stimulants and vigorous physical activity avoided during the day, only light breakfast and lunch given • Instructions are to – “Lie quietly in comfy position, keep eyes closed, try to fall asleep” • Five nap opportunities as 2 hour intervals – initial nap opportunity 1.5–3 hours after termination of usual sleep • Between naps patient out of bed and awake • Sleep onset determined by time from “lights out” to fi rst epoch of any sleep stage • To assess occurrence of REM sleep the test continues for 15 minutes from fi rst sleep epoch • Session terminated if sleep does not occur after 20 minutes The Multiple Sleep Latency Test is carried out in sleep laboratories often after a night of PSG and a week fi lling in a sleep diary. Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 59 PATIENT FILE The Epworth Sleepiness Scale (ESS) is a self-rating tool to enable patients and physicians to easily investigate problems with excessive sleepiness. For the most part it can be used both for looking at a day as a whole or for various times throughout a person’s wake time to chart their circadian changes. As a self-rating tool, it is of course subjective and may not correlate well with objective test measures. For the general population the average score on the ESS may be approximately 9 where as scores over 11 indicate excessive sleepiness. Interestingly those with insomnia may have scores lower than the general population, lending further weight to the theory that insomnia is a disorder of the arousal mechanisms that, as well as keeping someone awake at night, can leave someone in a state of hyperarousal during the day. Likelihood of falling asleep or dozing off when: Sitting and reading 0 1 2 3 Watching television 0 1 2 3 Sitting inactive in a public place – theater, meeting 0 1 2 3 As a car passenger for an hour without a break 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 Stopped for a few minutes while driving a car 0 1 2 3 Total Score Chance of Dozing: The Epworth Sleepiness Scale (ESS) Likelihood scale – rate each from 0–3 and total score 0 – would never doze 2 – moderate chance of dozing 1 – slight chance of dozing 3 – high chance of dozing Score over 11 indicates abnormal sleepiness Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 60 PATIENT FILE Cardinal diagnostic features of RLS (restless legs syndrome) 1 Urge to move limbs usually associated with paresthesias or dysesthesias 2 Symptoms start or become worse with rest 3 At least partial relief with physical activity 4 Worsening of symptoms in the evening or at night Patients with RLS experience an urge to move their legs to rid themselves of unpleasant sensations (prickling, tingling, burning or tickling; numbness; “pins and needles’’ or cramp-like sensations). This movement typically relieves the sensations, which can occur at any time but are most disruptive when one is trying to fall asleep. Primary hypersomnia Differential Diagnosis • Substance-induced hypersomnia Drug of abuse Medication use Exposure to a toxin • Psychiatric disorder Major depressive disorder Depressed phase of bipolar disorder • Sleep deprivation Symptoms reversed with increased sleep • Post-traumatic hypersomnia Head trauma CNS injury • Delay- or advance-phase sleep syndrome Circadian rhythm is shifted Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 61 PATIENT FILE Differential diagnosis in patients with hypersomnia disorders can be diffi cult, but is important in choosing the best treatment. The diagnosis of primary hypersomnia is reserved for those patients in whom no other factor can be considered causal to the symptom of sleepiness. Diagnostic measures in narcolepsy and hypersomnia (data from Bassetti et al 2003) ESS = Epworth Sleepiness Scale MSLT = Multiple Sleep Latency Test Lat = latency SOREMP = Sleep onset REM Periods CSF = Cerebrospinal Fluid ESS MSLT Lat. (min) MSLT # SOREMP CSF Hypocretin pg/ml Narcolepsy with Cataplexy 18 3.38 3.5 96.5 Narcolepsy without Cataplexy 19 2.75 2.5 277.3 Primary Hypersomnia 17 6 0 226.8 Hypersomnia in Psychiatric Disorders 18 7.83 0 278 Major Depressive Disorder Attention Defi cit Hyperactivity Disorder Narcolepsy Obstructive Sleep Apnea Shift-Work Sleep Disorder Mood +++ – – + – Sleepiness + + +++ +++ +++ Fatigue ++ + ++ ++ ++ Concentration ++ +++ ++ ++ ++ Overlap of symptoms in sleep and psychiatric disorders Many of the symptoms seen in sleep disorders are common in psychiatric disorders and vice versa. This chart compares the frequency of different symptoms among common sleep and psychiatric disorders, which is useful in making a differential diagnosis. The degree of symptom overlap among many disorders emphasizes the need to be able to recognize and treat a patient’s individual symptoms, rather than use a single treatment strategy for all symptoms of a disorder. Disorder Symptom +++ Most Common ++ Common + Average – None Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 62 PATIENT FILE Posttest Self Assessment Question: Answer Which of the following are approved treatments for treatment resistant depression? A. Deep brain stimulation (in trials for treatment-resistant depression but not approved) – Involves two surgical procedures, one to implant electrodes in the brain and a second to implant a neurostimulator in the chest – Stimulation is generally constant but can be temporarily turned off by holding a magnetic device over the area of the chest where the neurostimulator is located – This is an experimental procedure available at only a few medical centers with research protocols that may cover some or all of the costs – Risks and benefi ts remain unknown so this is reserved for patients who have failed many treatments B. Transcranial magnetic stimulation (approved for treatment-resistant depression) – Generally done on an outpatient basis – Electromagnetic coil is placed against the scalp near the forehead and turned off and on repeatedly for 30 to 50 minutes per treatment – Typical treatment duration is fi ve daily treatments a week for four to six weeks – Insurance coverage is variable for a course of this treatment which costs several thousand dollars – TMS has been best studied in patients who have failed a single antidepressant, and not necessarily indicated for more complicated cases, or for cases with multiple antidepressant failures or failure of ECT C. Vagal nerve stimulation (approved for treatment-resistant depression) – Involves surgical implant of a stimulation device in the upper left side of the chest (intended as a permanent implant, though it can be removed) – The pulse generator can be programmed to deliver electrical impulses to the vagus nerve at various durations, frequencies, and currents – Stimulation typically lasts 30 seconds and occurs every fi ve minutes – Studied in patients with more treatment failures than those patients studied with TMS, aripiprazole, or quetiapine – After an initial wave of enthusiasm for this treatment, use of VNS for depression has waned due to disappointing results, high Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 63 PATIENT FILE costs and some complications, include the hassle of having the stimulator and electrode removed D. Aripiprazole (Abilify)(approved for treatment resistant depression) – Studied in patients with major depression who did not have an adequate response to one SSRI (Serotonin Selective Reuptake inhibitor) or one SNRI (Serotonin Norepinephrine Reuptake Inhibitor) antidepressant – Not known how well it works in patients with failures to more antidepressant treatments E. Quetiapine (Seroquel)(approved for treatment resistant depression) – Also studied in patients with major depression who did not have an adequate response to one antidepressant – Also not known how well it works in patients with failures to more antidepressants F. MAO inhibitors (not approved for treatment resistant depression) – Although almost always used for treatment resistant depression and almost never used fi rst line, is currently only approved for fi rst line use and not for treatment resistant depression • Clinical practice and numerous anecdotes suggest that some patients who do not respond to one or more antidepressants, including ECT, may respond to MAO inhibitors, but no controlled studies. Activating for some patients and may cause problems with sleep and anxiety Answer: B, C, D and E References 1. Stahl SM, Antidepressants, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 511–666 2. Stahl SM, Disorders of Sleep and Wakefulness and their Treatment, in Stahl’s Essential Psychopharmacology, Cambridge University Press, New York, 2008, pp 815–862 3. Stahl SM, Aripiprazole, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 45–50 4. Stahl SM, Quetiapine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 459–64 5. Stahl SM, Gabapentin, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 221–225 6. Silberstein S, Marmura M, Stahl SM (Ed), Pramipexole, in Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 64 PATIENT FILE Neuropharmacology: The Prescriber’s Guide, Cambridge University Press 2010, pp 262–265 7. Stahl SM, Diagnosis and Treatment of Sleep Wake Disorders, NEI Press, Carlsbad, California, 2007 8. Stahl SM, Sleep: Excessive Sleepiness, NEI Press, Carlsbad, California, 2005 9. Marangell LB, Martinez M, Jurdi RA et al. Neurostimulation Therapies. Acta Psychiatrica Scandinavica 2007; 116: 174–181 10. Bassetti C, Gugger M, Bischof M et al. The narcoleptic borderland: a multimodal diagnostic approach including cerebrospinal fl uid levels of hypocretin-1 (orexinA). Sleep Medicine 2003; 4: 7–12 Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Wed Apr 08 00:14:46 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

Term Paper: Each student will be required to complete the term project, which is an 8-12 page APA Style paper. Your paper should have at least 8-12 pages of substance not counting the cover and reference pages. Please be sure that your paper is a Word Document (.doc) uploaded to the assignment section as an attachment. Students will be required to use at least three scholarly – (peer-reviewed)- sources. Students have access to peer-reviewed sources through the APUS library. Students are required to follow APA Style guidelines.

Term Paper
DUE: Apr 19, 2020 11:55 PM

Term Paper:
Each student will be required to complete the term project, which is an 8-12 page APA Style paper. Your paper should have at least 8-12 pages of substance not counting the cover and reference pages. Please be sure that your paper is a Word Document (.doc) uploaded to the assignment section as an attachment. Students will be required to use at least three scholarly – (peer-reviewed)- sources. Students have access to peer-reviewed sources through the APUS library.
Students are required to follow APA Style guidelines.
I will be using the writing rubric to grade all written work during the class. Please make sure that you are using the writing rubric to use as a checklist for all your academic writing in this class and throughout your educational experience at AMU. Research Paper Grading Rubric ~ Click Here
Students must choose from one of the following topics for their paper:
Ethics vs. Morals

ITS 630 – Residency Project

ITS 630 – Residency Project

Circuit City was an American consumer electronics company founded by Samuel Wurtzel

in 1949. By 1990s, Circuit City became the second largest consumer electronics store in the

United States with annual sales of $12 billion. On March 8 2009, Circuit City shutdown all its

stores.

On January 8th at the 2018 Consumer Electronics Show in Las Vegas, Circuit City CEO

announced a comeback and relaunch of Circuit City into “a dynamic, a social-focused e-

commerce site” and a new business strategy for its retail stores12.

In this case study, assume that Circuit City hired you as the new chief information officer (CIO)

to help relaunch the company into a global e-commerce multinational company. Create a

PowerPoint presentation containing the IT strategic plan that will address Circuit City e-

commerce initiatives.

The following information should be covered in the presentation.

1. History of Circuit City

2. What were the issues and challenges that caused the collapse of Circuit City in 2009?

3. What are the issues and challenges with Circuit City 2018 latest e-commerce initiative?

1 http://circuitcitycorporation.com/circuit-city-to-announce-official-company-relaunch-at-the-2018-consumer- electronics-show-on-january-8th/ 2 http://fortune.com/2018/01/09/circuit-city-relaunch-website/

Circuit City to Announce Official Company Relaunch at the 2018 Consumer Electronics Show on January 8th

Circuit City to Announce Official Company Relaunch at the 2018 Consumer Electronics Show on January 8th


http://fortune.com/2018/01/09/circuit-city-relaunch-website/
4. Discuss the major competitors in global e-commerce.

5. How would IT deliver value to the business?

6. Proposed the IT infrastructure required to support global e-commerce

7. Proposed the IT budget for the e-commerce initiative

8. Discuss the IT based risks associated with global e-commerce

9. Discuss how IT can leverage innovative technologies such as social media, big data and

business intelligence to provide value to the business

10. Discuss the future or emerging technologies that would be leveraged to give Circuit City

a competitive advantage.

When communicating, we constantly make decisions regarding what information to include and what information to exclude from our messages. Communication decisions have legal and ethical dimensions. Business communicators must consider the impact of their messages to ensure that receivers are not deceived.

When communicating, we constantly make decisions regarding what information to include and what information to exclude from our messages. Communication decisions have legal and ethical dimensions. Business communicators must consider the impact of their messages to ensure that receivers are not deceived.

In this assignment, students will write about news or articles that focus on the subject of business ethics in communication. Students will demonstrate and reflect the impact and importance of ethics in communication. This assignment is worth 150 points and due by the end of Module 5.

Students are required to write 6 pages of content, then include a cover page, table of contents, and reference page. The paper must follow APA format and include appropriate headings and sub-headings and at least five scholarly citations (e.g., peer-reviewed articles, textbook, etc.). Your own textbook does not count towards the scholarly reference minimum. See the rubric for grading criteria. Suggested headings are listed below:

Abstract
Overview, Introduction, or Background
Summary of news or articles
Impact of Ethics in Communication
The relevance of the content toward ethics and communication
Consequences or impact on the subject, organization, and/or society
Importance of Ethics in Business
Discussion or Reflection
The implication of the lesson learned
Conclusion
References

A few points about the paper:

The minimum requirement for length of this research paper is six pages EXCLUSIVE of the cover page, abstract, reference page, etc.

Also, be sure at least five of your sources are SCHOLARLY. Scholarly sources are from academic sources (ie journals) not web pages. You can find scholarly sources in the online library databases.