Post Traumatic Stress Disorder (PTSD) Essay Example | Topics and Well Written Essays - 750 words - 1

Post Traumatic Stress Disorder (PTSD) - Essay Example Studies allover the globe cites PTSD as a common mental disorder among veterans of war. Moreover, these studies indicate that this disorder has a lifetime prevalence rate of 7% to 12%. In addition, there have been several studies carried out in vulnerable populations. These vulnerable populations include â€Å"peacekeepers, combat veterans, Aboriginal populations and terrorist attack survivors.† In the studies of all these populations, there were higher rates of the disorder compared to the rest of the population who are not susceptible. Moreover, many of the people with a diagnosis of PTSD have a comorbid diagnosis with an additional lifetime mental condition (Sareen et al, 2007). Despite the prevalence of the disorder being high among at-risk populations, these rates vary according to the circumstances surrounding the susceptibility. For example, studies carried out among Vietnam battle veterans demonstrate higher prevalence of PTSD than is found in noncombat veterans or sim ilar nonveterans. Moreover, other studies indicate that the Posttraumatic stress disorder experienced by most of the U.S. veterans, is at least because of battle-related PTSD (Boscarino, 2006). The development of diagnosis of veterans with combat-related mental disorder dates back in the 1800. During this time, the United States military doctors diagnose soldiers with a condition they called â€Å"exhaustion†. ... Other signs include being bad-tempered or angry, flashbacks, trying not to bear in mind the incidents that occurred, nightmares and feeling emotionally frozen or isolated from others (Paolillo, 2008). Effects of Posttraumatic stress disorder in the Military In addition, PTSD-positive veterans may be more vulnerable to autoimmune diseases. Although there could be inconsistency, investigations have found that individuals who developed PTSD, especially men exposed to war, have shown to have lower plasma concurrent with higher catecholamine levels. In addition, studies have clearly shown that Vietnam veterans with current PTSD had clinically raised leukocyte and T-cell counts. In addition, it is evident that there is a relationship between the PTSD development and alterations in immune system functions (Boscarino, 2006). Because of nighttime PTSD symptoms, the patient is likely to experience suicidal ideation, alcohol and drug abuse, and can precipitate completed suicide. According to cl inical studies, the enhanced postsynaptic adrenergic receptor responsiveness to central nervous system (CNS) leads to the pathophysiology of PTSD, especially at night. This on the other hand, interrupts sleep physiology increasing sleep stage phenomena linked with emergence of trauma nightmares and increasing emergence of primitive alarm-related cognitive processing (Raskind et al, 2007). Implications of Posttraumatic stress disorder in the Military There is rising proof that exposure to sensitively shocking incidents among combat veterans’ leads to increased medical morbidity. In addition, it is evident that there is a direct connection between prolonged exposure to harsh psychological suffering and the commencement of disease. The experience with battle veterans suffering

Investigation into the Sovereign Debt Credit Ratings of Five EU Member Literature review

Investigation into the Sovereign Debt Credit Ratings of Five EU Member States and China over the Period 2005-2012 - Literature review Example Caprio and Klingebiel (2003), McKinsey (2010), Mihalakas (2012) find that common problems existing in crisis countries are financial imbalances, government debt over the country's debt paying ability, huge public spending, which eventually lead to the occurrence of crisis. Calvo (1998), Eichengreen et al. (2005) and De Grauwe (2011) and Wolf (2011) all think that monetary union is one of the important factors. Detlef (2012) argues that large-scale sovereign debt is due to the endogenous structural problems. Leigh (2010) through the statistical methods to find low growth is another incentive to crisis. The financial crisis accompanied by the enormous public debt in the Euro zone particularly the Greece that occurred in 2009 resulted in a great confusion in the vast world financial market, this even became of in the year 2010 (Buckley & Arner, 2011). Despite this the International Monetary Fund (IMF) and the European Union (EU) have acted so fast to handle the crisis and restore the co nfidence of the market participants :( Portes, 1986). It did this through restoring the fiscal economies such as Greece, Ireland, and Portugal among others. However, the Euro zone crisis extended even in the first half of the 2011 through vigorously shaking the financial markets both internally and externally of the monetary union. This extended the thought that other countries would be rescued from the crisis later on. Although the countries mentioned so far are small economically, there was an exposure of through financial contagion and therefore the possibility of the scourge spreading to other countries of the EU like Spain and Italy, this has made handling of the crisis more complicated and serious. On the other hand, a variety of questions has been raised over whether the institutions conferred with the obligations of handling the issues will be up to the task (Buckley & Arner, 2011). The proponents of the advocacy that the monetary unions escaped national monetary and economi c sovereignty are right though they lacked central fiscal authority :( Portes, 1986). It is quite evident that without such conferred authority; the organizations are toothless hence preventing the monetary union from effective action by the constituents. This therefore has made the recovery of the mentioned countries out of the debt crisis hence more muted than it would have been expected (Canuto & Giugale, 2010). For decades, the financial positions of the countries in the euro zone exhibited the strengths that have never been witnessed in the year 2007 (Canuto & Giugale, 2010). This had largely been attributed majorly due to the economic environments that facilitated the strongest view. The onset of the 2008-2009 financial crunches witnessed a longer and lasting impact in the economic environments of the countries in the EU (Buckley & Arner, 2011). This penetrated the economic environment in three major transmission channels, which entail: - the nature that the financial system i s highly contagious and connected, the effects and impacts that demand had on wealth and confidence and lastly, the global trade

Interco Case Essay Example for Free

Interco Case Essay Interco On August 8, 1988, Interco’s board of directors met to discuss, among other matters, a merger proposal from City Capital Associates Limited Partnership. City Capital had offered $64 per common share of Interco on July 28, 1988, and had raised that offer to $70 per share on the morning of August 8. At this board meeting Interco’s financial advisors, Wasserstein, Perella Co., established a valuation range of $68-$80 per common share of Interco and presented their evaluation of the offer. Given their valuation, Wasserstein Perella advised the Interco board (see Exhibit 1) that the $70 per share offer was inadequate and not in the best interests of the company and its shareholders. The board of directors voted to reject the City Capital offer. The Company Founded in December 1911, the International Shoe Company was established as a footwear manufacturing concern and remained so until the early 1960s. In 1966, the company was renamed Interco to reflect the changing character of its business. It had grown, into a major manufacturer and retailer of a wide variety of consumer products and services. Among the most well-known of the brands Interco made were Converse and Florsheim shoes, Ethan Allen furniture, and London Fog rain gear. Interco’s various operations were substantially autonomous and were supported by a corporate management staff in St. Louis, Missouri. The company’s philosophy had historically been to acquire companies in related fields and to provide their existing management teams with the incentives to expand their businesses while relieving them of such routine support functions as financial and legal requirements. Nearly half of Interco’s growth had come through acquisition. The company continually sought entities that would complement the existing Interco companies. Additional criteria used in  screening and selecting acquisition candidates included the presence of highly skilled managers and products that had established leadership positions in their respective markets. Equity analysts viewed Interco as a conservative company that was financially â€Å"overcapitalized.† With a current ratio of 3.6 to 1 and a debt-to-capitalization ratio, including capitalized leases, of 19.3% on February 29, 1988, Interco had ample financial flexibility. This flexibility had allowed the company to repurchase its common shares and make acquisitions as opportunities arose. Research Associate Susan L. Roth prepared this case under the supervision of Professor Scott P. Mason as the basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Copyright  © 1991 by the President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685 or write Harvard Business School Publishing, Boston, MA 02163. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the permission of Harvard Business School. Within these four operating divisions were numerous independent companies as listed in Exhibit 2. Apparel Manufacturing This group consisted of 11 apparel companies that designed, manufactured, and distributed a full range of branded and private-label sportswear, casual apparel, outer garments, and headwear for men and women. Apparel brands included Le Tigre, Sergio Valente, and Abe Schrader. Distribution was national in scope to department stores, specialty shops, and other retail units, including discount chains. General Retail Merchandising This group operated 201 retail locations in 15 states. General retailing included large do-it-yourself home improvement centers, general merchandise discount stores, men’s specialty apparel shops, and specialty department stores. Over the prior few years, general retail had been greatly scaled back and was now dominated largely by Central Hardware, a do-it-yourself home improvement chain that emphasized customer service and a broad selection of products. Footwear Manufacturing and Retailing This division designed, manufactured, and distributed men’s and women’s footwear principally in the United States, Australia, Canada, and Mexico. The group operated 778 retail shoe stores and leased shoe departments in 42 states and in Australia. Interco’s two major footwear operations, Converse Inc. and the Florsheim Shoe Co., commanded leading positions in their respective markets: athletic shoes and men’s traditional footwear. Furniture and Home Furnishings This group manufactured, distributed, and retailed quality wood and upholstered furniture and home furnishings. Furniture brands included Broyhill, Lane, Ethan Allen, and Hickory Chair. In recent years, furniture had expanded through acquisitions and increasing profitability to dominate Interco’s net income. At the end of fiscal year 1988, Interco was the largest furniture manufacturer in the world. Strategic Repositioning Program Interco’s goals included long-term sales and earnings growth, increased  return on corporate assets, and most important, improved return on shareholders’ equity. To achieve these goals, Interco took a four-pronged approach that included improving the profitability of existing operations and divesting underperforming assets, making acquisitions that had the potential for better than average returns and growth, and employing opportunistic financial strategies such as share repurchases and the prudent use of borrowing capacity. With these goals established, Interco, in 1984, began a strategic repositioning program aimed at improving overall corporate performance. As part of this initiative, Interco accelerated its efforts to divest underperforming assets and reposition itself in markets offering superior growth opportunities and profitability. The program resulted in a substantial change in Interco’s mix of sales as shown in Table A below. In fiscal 1988 the furniture and footwear groups together accounted for 60% of corporate sales, with apparel and general retail accounting for the rest. This was a reversal of the sales distribution in fiscal 1984.

Sepsis Systemic Immune Response Health And Social Care Essay

Sepsis Systemic Immune Response Health And Social Care Essay Sepsis is defined by the clinical signs and symptoms of a systemic immune response to infection. (1-2) Currently, sepsis on a worldwide level creates a significant level of mortality; and results in approximately one third of all Intensive Care admissions. (3-5) In Victoria alone there are approximately 8500 admissions to Emergency Departments with patients suffering from sepsis (3) and this number is increasing. Sepsis treatment can be initiated with a broad spectrum antibiotic, and then transferred onto a specific antibiotic regimen. Currently the level of pre hospital data available on the management of sepsis is very limited and the most advanced model has been initiated in the United Kingdom; including a pre hospital screening tool and then the hospital management known as the Sepsis six. (6) Pre hospital management can be utilised to the full potential of paramedics training and knowledge with the administration of pre hospital antibiotics; however this is not without risk. Per haps the resistance to hand over the authority to paramedics in the United States is the notion of creating a super bug; similar to Methicillin-resistant Staphylococcus aures. This paper proposes that the administration of antibiotics in the pre hospital field does carry some risk, but the research suggest that the benefits clearly outweigh these risks. A new pre hospital guideline must be created due to the sheer number of Emergency Department admissions. The potential to make a significant difference to a patients outcome is imperative. Epidemiology It has been highly researched and reported across the world that sepsis is a major cause of morbidity, mortality and places an enormous financial burden on the respective health system. (2, 5, 7) Statistics from Australia, United States and the United Kingdom are similar in nature and provide a wealth of information regarding the epidemiology of sepsis. Sepsis in the United States has been recognised as a public health issue, (8) with studies reporting that there are 300 reported cases per 100,000 with approximately 40% mortality. (5, 7-9) Severe sepsis in the United kingdom accounts for 27% of Intensive Care Unit admissions (4) and this is comparable with 23.8% of Intensive Care admissions in Victoria, Australia. (3) However it may be noted that this data is not very recent and that in the time of study the incidence was increasing by approximately 9% per year; whilst also reporting a decrease in the number of deaths associated with sepsis from approximately 45% to 37.7%. (5, 7, 9) Whilst many studies report the number of admissions, few report the age distribution of patients presenting with sepsis. Sundararajan et. al. highlight that the age distribution within their study was bimodal which identified that the age brackets at the extremes of the spectrum were over represented; with children less than 1 and adults in the 70-79 age bracket. (3) Upon further investigation into the types of causative pathology causing sepsis in these patients; gram positive organisms account for 28%, gram negative for 20%, fungal infections 2% and other organisms for 49%. (3) These figures are comparable with a study conducted by MacArthur et. al. of approximately 2634 patients with approximately 30% identified as gram positive and 26% gram negative bacteria. (10) Pathophysiology and clinical features What is Sepsis? Sepsis is an infection induced syndrome and the clinical appearance in nature is the consequences of cellular interactions between the host and invading pathogen. (2, 11-12) Sepsis may be initialised by prolonged local inflammation to eliminate and clear the invading pathogen. The second line of defence against invading pathogens involves the production and activation of leukocytes at the local site of infection. (13-14) Throughout this phase, immune cells identify the pathogen through pattern recognition protein receptors on the cells. (15) An example of one of these receptors are toll like receptors and these are among the recognition receptors which have the ability to activate immune cells, inducing the production of pro-inflammatory cytokines and chemokines by the stimulation with bacteria and viral proteins (depending on the infection). (15-16) The invading pathogen may initiate the complement pathway of the immune system, allowing leukocytes to phagocytose [digest] the pathoge n. If the host fails to limit the invading pathogen to a local area, the pathogen may invade the bloodstream. (16) If phagocytosis continues in the blood stream, toxic substances released by the pathogen may leak directly into the bloodstream; these include endotoxins released by gram negative bacteria (17) and lipoteichoic acid and peptidoglycan released by gram positive bacteria. (18) These by-products of phagocytosis and death of the cell may trigger a systemic activation of the complement system and stimulate the production of inflammatory cytokines. (19) Subsequently leading to an increased excessive and prolonged inflammatory response. (20) The result of this prolonged response leads to Systemic Inflammatory Response Syndrome (SIRS) which is the result of either direct or indirectly through the production and activation of nitrous oxide, oxidants and proteolytic enzymes which is known to have the potential to lead to inflammation induced organ injury. An example of this would be Acute Respiratory Distress Syndrome. (16, 20) SIRS is characterised by two or more of the following: body temperature >38Â °C or 90 beats per minute, respiratory rate >20 per minute or arterial CO2 >32mmhg or a need for artificial ventilation, and white blood count greater than 12,000/mm3 or 10% immature forms. (21) SIRS can be also initiated not only by infection, it may also develop as a result of trauma, ischemic injury or sterile inflammation. (22) What is severe sepsis? If SIRS is left untreated, this response then cascades into what is known as severe sepsis. Severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion or hypotension responsive to fluid resuscitation. (23) This can progress to septic shock, which involves persistent hypotension unresponsive to fluid administration. (23) An example of severe sepsis is called Multiple Organ Dysfunction Syndrome (MODS). This occurs when the infection of the bloodstream leads to progressive failure of two or more organ systems which result from a prolonged and uncontrolled inflammatory response. This organ dysfunction can lead to potential organ failure and death. (19) Analyse evidence relating to the prehospital management of sepsis to identify risks and benefits of paramedic-initiated antibiotic therapy; Sibley and Sibley (23) suggest that if Emergency Medical Services (EMS) or Paramedics have a patient suffering from suspected sepsis, that they must be managed with oxygen therapy, well documented vital signs and IV access to initiate fluid resuscitation. (24) The goal for EMS is to maintain systolic blood pressure just above 90mm Hg, with a Mean arterial pressure of 65mm Hg as any higher has the potential to worsen cardiac output, with adverse reactions. (24-26) Other studies support the notion of maintaining Mean arterial pressure at 65mm Hg as there is no clinical benefit to increasing this value higher. (27-28) Sibley and Sibley (23) contradict many other studies which suggest that early empiric antibiotic treatment of patients suspected of having sepsis is a standard practice; and the earlier treatment is initiated, the more positive the outcome. (2, 6, 8, 10, 16, 25, 29-30) Empirical antibiotic treatment is the use of a broad spectrum antibiotic whilst therapeutic treatment with antibiotics is the initiation of antibiotic treatment after blood cultures are taken and the specific pathogen is identified. (31) Whilst empirical antibiotic treatment in the management of sepsis may be the initial drug of choice, it is in the patients best interest that appropriate antibiotic therapy is continued within the hospital. Appropriate antibiotic therapy is defined as the use of an antimicrobial agent that is correct on the basis of all available clinical, pharmacological and microbiological evidence. (32) With respect to the pre-hospital administration of antibiotic therapy, a recent study concluded that, if a patient is suffering septic shock, with each hour of delay in antibiotic administration after the onset of hypotension was associated with an average decrease in survival of approximately 8%. (33) However, a potential problem with empirical antibiotic treatmen t is that because sepsis is not the result of a single pathogen, the use of empirical antibiotics may not cover the pathogen causing the disease or illness. Broad spectrum antibiotics may bide time until blood cultures and appropriate testing can be done within a hospital setting. The current research suggests that the antibiotic selection used to treat conditions such as sepsis has a profound impact on patient outcomes (34) and this is also the case with inadequate antibiotic therapy, where the invading pathogen is not being effectively treated. (31) With regard to the empirical treatment, there are many different forms of pathogens that can cause sepsis, including Staphylococcus aures, Streptococcus pneumoniae, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. (10) With this in mind, the aforementioned figures that roughly 28% of septic patients are caused by a gram stain positive, and 20% of patients are gram stain negative, and the rest being approximately 52% (3, 10), the notion is that broad spectrum antibiotics may not cover these specific pathogens, therefore rendering treatment useless. Potentially this could l ead to a negative or adverse outcome. An International Initiative, the Surviving Sepsis Campaign (30, 35) and the Critical Care Community in the United Kingdom (6) initially concentrated on educating emergency department staff to promote the introduction of management of sepsis known as Early Goal Directed Therapy. Upon review, poor implementation of this initiative and resuscitation lead the education staff involved to a move to target the staff working in areas outside of the emergency department, including the implementation of an operationalised resuscitation management plan referred to as the Sepsis Six. The Sepsis Six involves the administration of high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measure serum lactate and haemoglobin and the insertion of a urinary catheter to measure urine output. The Sepsis Six can be implemented by hospital staff with different skill sets in the first hour following the diagnosis of sepsis and can make a significant contribution to decreasing mortality. (6) With respect to the rationale of the Sepsis Six Robson et. al. proposes that components of this treatment can be initiated pre hospital, and interestingly, the authors also highlight that pre hospital sepsis care is unusual, but pre hospital cardiac care is common. The question remains as to why that is. Given that all the literature available suggests that there is a significant decrease in morbidity and mortality associated with early antibiotic treatment. Within Ambulance Victoria, the current management for the treatment of severe sepsis has not been established. Only a guideline is specifically written for meningococcal septicaemia which allows paramedics to administer Ceftriaxone in the pre hospital field in the suspected case of meningococcal septicaemia. (36) Walker (37) proposes that in the year 2003, meningococcal disease affected approximately 500 Australians with approximately 100 of these cases presenting in Victoria. It would seem logical that an appropriate guideline is established for sepsis and severe sepsis based on the available data from Sundararajan et. al. (3) which suggest within a 4 year time frame, approximately 34,000 admissions to hospital were identified as suffering from sepsis. However, it must be recognised that this only accounts for 1.1% of the total number of admissions to Victorian emergency departments. (3) This is considerably more hospital admissions when compared with meningococcal septicaemia, with similar, if not more deadly consequences. Perhaps the thought of utilising empirical antibiotic therapy causing a super bug with sepsis is debateable. Whilst many studies report that Methicillin-resistant Staphylococcus aures is developed within the hospital system (38) rather than the community based setting; this attitude is changing with larger numbers of community acquired Methicillin-resistant Staphylococcus aures being reported, (39) with an estimated 50% of the population being a carrier of the bacteria. (40) The concern of doctors and other health professionals to the thought of initiating treatment with an empirical antibiotic may be a result of previous dealings with Methicillin-resistant Staphylococcus aures. Methicillin-resistant Staphylococcus aures has evolved and mutated to be come resistant over generations with different strains of antibiotic that were initially effective at eliminating the bacterial pathogen. (41) The thought that exposing such a broad spectrum antibiotic; for example ceftriaxone, (a cephal osporin antibiotic) is that the exposure of a drug like this may potentially initiate a genetic mutation in potentially a wide spread of different strains of pathogens. Many studies have investigated the use of empirical antibiotics and also the possibility of not only one pathogen causing disease, therefore developing an appropriate antibiotic regime. This makes logical sense however, with consideration to the potential to cause a genetic mutation, exposing a pathogen to several antibiotics may have the potential to produce a resistant strain to not only one antibiotic, but several. The surprising news is that these studies have proven to have little or no extra effect in reducing mortality. (42-43) Walker (37) proposes that the administration of pre hospital antibiotics by paramedics does have the potential for complications, including adverse reactions such as anaphylaxis and vasomotor collapse. However, the risk of antibiotic administration is no different to the administration of any other drug, with potential side effects and adverse reactions specific to individual patients. Synthesise recommendations for paramedic management of sepsis based on available evidence. Pre hospital data available on the treatment and management of septic patients are scarce. It is evident that more research needs to be undertaken in order to correctly identify septic patients and initiate early treatment. However the question remains as to whether data will ever be available due to the potential adverse reactions and the ethical dilemmas surrounding the prospective withholding of treatment to patients. The data that is available suggest that paramedics can make a difference in the potential outcomes of these patients. A mortality rate of close to 40% is unacceptable. It is proposed that paramedics undertake a similar model to the Sepsis Six with an available pre hospital screening tool; similar to what the United Kingdom propose. This involves the identification of systemic involvement of the immune system by utilising the classification for SIRS; whilst using this in conjunction with history of a new infection. Taking both of these into consideration, persistent h ypotension, low oxygen saturation and lack of urine output classifies pre hospital patients as suffering from severe sepsis. (6) Paramedics are an integral part of the health care team and within the United States they are being overlooked and potential skills are being disregarded and this is still not understood when the literature suggest that early treatment does make a difference in outcomes. With regard to the early administration of antibiotics, not all patients will call at the onset of symptoms. Many will wait until the condition is unbearable or they feel like they are deteriorating, therefore it is important that empirical antibiotic therapy is undertaken at the earliest opportunity. From the available literature; the United Kingdoms model is the gold standard in terms of pre hospital screening and management of sepsis. Paramedics are highly trained health professionals and are able to manage septic patients accordingly, and as previously mentioned, the sepsis six involves high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measured serum lactate and haemoglobin and urinary catheter and measure urine output. This paper does not propose that paramedics undertake all of the treatment outlined, but instead have the ability to initiate oxygen therapy, deliver intravenous fluid and antibiotics; and potentially have the ability to take blood cultures to hand over to the hospital. However, it must be emphasised that extra on scene time to complete these assessments and treatment must be taken into consideration as well as how long till the nearest hospital. Also important to note that paramedics must notify a receiving hospital so that the hospital ca n appropriately triage (44) and utilise the pre hospital taking of blood in the commencement of faster treatment and provide the ability to initiate an appropriate antibiotic regime. Perhaps a review of the current guideline in Victoria is needed to extend the scope of paramedic practice to screen for potential septic patients, as the literature suggest that this current proportion of patients are exponentionally increasing. However; it may be easy to speculate changes that need to be made to the system, and this will take time and money. Walker (37) proposes from a management perspective there are significant costs associated with the antibiotics, training and assessment and ongoing replacement of antibiotics on all vehicles. Therefore it is imperative to continue research and therefore implement a new guideline into ambulance practice; which will benefit the health of all invested parties. The early recognition and management of sepsis has implications on potential patient outcome. Sepsis has an extremely high mortality associated with it and as mentioned previously the sooner antibiotics can be administered; the rapid decrease in patient morbidity and mortality. With respect to the high numbers of presentations to Victorian emergency departments and intensive care admissions; this is mirrored throughout the world. One of the important points to understand that the admissions to intensive care can be avoided if sepsis is recognised earlier and paramedics may have a significant impact on the recognition and administration of antibiotics, as septic patients have the potential to be very unwell. The financial burden on the health system is enormous with one study speculating that the United States approximate spend on sepsis alone to be sixteen billion dollars. (2, 7) Data is unavailable from Victoria and Australia; however the costs associated with providing antibiotics for the management of sepsis will cost less than treating in an Intensive Care Unit. Conclusion One of the main recurring themes throughout this paper is that sepsis and severe sepsis have a high association with morbidity and mortality, even though the number of presentations have increased. The point needs to be emphasised that current management is not good enough. The research within hospitals is evident, that early antibiotic treatment of patients suffering from sepsis has profound effects on survival and recovery. Paramedics are potentially the first line of health care workers exposed to patients suffering severe sepsis and have the ability to act with broad spectrum antibiotics. Within Victoria, ambulances already carry Ceftriaxone; an example of a broad spectrum antibiotic. A guideline specific to sepsis needs to be developed and implemented in the pre hospital field, potentially on the basis of the United Kingdoms model of recognising severe sepsis. The cost benefit analysis of implementing a new guideline, with the possible administration of antibiotics to more patie nts would severely outweigh the costs associated with an admission to an intensive care facility. The notion of taking pre hospital blood and notifying a receiving hospital of the potential septic patient may initiate appropriate treatment faster. Paramedics have the ability to make a difference with this time critical patient.

Spinal Stenosis Essays -- Disease/Disorders

The spine is made up of bones known as the vertebrae which are each separated by discs that serve to reduce the impact that movement may have on the spinal column thus acting as a movable support structure. The spine is made up of seven vertebrae in the neck known as the cervical spine, twelve vertebrae in the mid-back known as the thoracic spine and 5 vertebrae in the low back known as the lumbar spine. There is a hollow space that runs down the middle of each vertebra that contains the spinal cord known as the spinal canal. The spinal nerves exit the spinal canal via the intervertebral foramen. It is imperative that these canals maintain enough room to support the spinal cord and spinal nerves. Spinal stenosis occurs when the canals narrow causing irritation or pressure on the spinal cord or the spinal nerves, depending on which area of the spine is affected. As the canals narrow, there is less space for the spinal cord and nerves to move without restraint. Spinal stenosis is a de generative condition that can occur in any area of the spine, although it is most prevalent in the lumbar area. Lumbar spinal stenosis is a reduction in the dimension of the central or lateral lumbar spinal canal that occurs most frequently as a result of chronic degenerative changes (Celik et al., 2012). The narrowing may be caused by either congenital or acquired etiologies, or in some rare cases, both. Congenital stenosis is also known as primary stenosis which occurs during postnatal development meaning it is seen at birth. Acquired stenosis or secondary stenosis occurs after the normal development of the spine in which the narrowing occurs due to an acquired condition such as degenerative stenosis, spinal instability or trauma. As the aged po... ...udy of a clinical diagnosis support tool for lumbar spinal stenosis. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association 14, 711-718. Landi, A., Tarantino, R., Marotta, N., Ruggeri, A.G., Domenicucci, M., Giudice, L., Martini, S., Rastelli, M., Ferrazza, G., De Luca, N., et al. (2011). The use of platelet gel in postero-lateral fusion: preliminary results in a series of 14 cases. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 20 Suppl 1, S61-67. Miyakoshi, N., Hongo, M., Kasukawa, Y., Ishikawa, Y., and Shimada, Y. (2011). Prevalence, Spinal Alignment, and Mobility of Lumbar Spinal Stenosis with or without Chronic Low Back Pain: A Community-Dwelling Study. Pain research and treatment 2011, 340629.

Ukraine: Population crisis Essay -- essays research papers fc

Purcell Consulting Company is world’s foremost independent consulting company regarding policy issues for governments, and we are glad that you have chosen us in helping with your policies. As addressed in your personal statement, you are extremely concerned about your country’s population decline, and the years to come. This problem, distressing to say, is notably related to the way your government is governed, as well as other factors including health issues, and economics that puts a strain on the your population. In this assessment I will brief on specific reasons for your countries declining population, as well as sufficient solutions in solving this apprehensive problem.   Ã‚  Ã‚  Ã‚  Ã‚  First I would first like to address health issues surrounding this problem. Ukraine, like many other Eastern European states generally have poor health conditions. Most Ukrainian citizens drink more alcohol, have bad nutrition, and visit doctors less frequently. As a result death comes quick, along with diseases, and lowered fertility rates (Jamestown). According to the 2001 Census, Ukraine registered a 6.1 percent decline in population. Dr. Oleh Wolowyna, a professor at the Harvard Ukrainian Research Institute, also reports mortality rates in infants and adults have risen due to a poor health care system. The main reason behind an increase in infant death rates is due to an increase in â€Å"perinatal complications,† that arise from birth---low birth weight, poor-prenatal nutrition, birth/pregnancy problems, and pre mature birth---- of which are all related to a poor health care system. Adult mortality rates has also risen almost 60% due to a â€Å"circul atory diseases† --- stroke, heart attack, and high blood pressure (Jarosewich). Moreover, AIDS has contributed generously to Ukraine’s declining population. According to the UN, AIDS is growing faster in Ukraine than any other post-communist European country and is also growing faster then anywhere else outside Africa (Jamestown). The UN predicts that about 400,000 people are affected by AIDS of which almost to none will survive (FHI). Nevertheless, we must not be quick to blame your citizens for a poor health care system, or a declining population. We must concentrate on economics, and how it contributes heavily on your declining population. .  Ã‚  Ã‚  Ã‚  Ã‚  Economics is a theory of business science... ...xample, women should know about the risks of malnutrition when carrying a child. She should know about the dangers, and risks of other substances that may harm the baby or herself; while men should learn about the health risks of high blood pressure, diabetes and other diseases. In addition, education about the HIV virus should be taught at schools and in the community, in terms of how to prevent from getting the virus, and how to treat it. By emphasizing proper nutrition and health care amongst men, women and children, Ukraine’s birth rate will exceed death rates, ensuring a steady increase in population.   Ã‚  Ã‚  Ã‚  Ã‚  In conclusion, you, the Ukrainian government, must create jobs, and educate your citizens about proper health care in order to increase your country’s population. If your government follows these simple guidelines, Purcell Consulting will guarantee your population to increase, and continue to grow for the ages to come. Works Cited Kuzio, Taras. The Jamestown Foundation. 4 Feb. 2003. 30 Mar. 2005 . Jarosewich, Irene. Ukraine's Population Suffers Dramatic Decline In Health. 24 Aug. 1997. 30 Mar. 2005 . Family Health International. 30 Mar. 2005 .

Basic Concepts in the Law of Contracts

LGST 612 Prof. Kevin Werbach BASIC CONCEPTS IN THE LAW OF CONTRACTS Contracts are essential to business. They are a legal mechanism used in every industry and every part of the world to structure relationships among firms, and with customers, partners, and suppliers. Over several centuries, the law governing contracts has developed a large number of doctrines. Most are consistent with common sense, but unless you know what the rules are, you can easily make a mistake. This document introduces the fundamentals of contract law most relevant to businesspeople.Important legal terms are italicized. What is a Contract? And what is Contract Law? Legally, a contract is a set of promises that the law will enforce. We make promises all the time. Only some of them – the ones that meet the contract formation requirements listed below – are legally enforceable. That means the legal system, in the form of courts, can step in to order some action or payment for violation of the contra ct. Contracts are therefore private deals with the possibility of public (governmental) enforcement.Of course, there are many reasons to fulfill promises other than legal obligations. Reneging on promises may be unethical, or may result in a loss of goodwill or reputation as costly or more so than anything a court can impose. The general principles of contract law are fairly universal around the world. However, specific rules vary from country to country. In common law countries such as the United States and Great Britain, most of the legal doctrines governing contracts have been developed by courts over the centuries.In civil law countries such as those in Continental Europe, most of the terms of contract law are specified through comprehensive legislative codes. Even in the U. S. , some aspects of contract law are regulated by legislation. Certain classes of contracts involving employment, securities transactions, health care, and consumer financial transactions are subject to reg ulations that supersede the general principles of common law. Commercial contracts for the sale of goods (as opposed to services like consulting) are covered in virtually every state in the U. S. y the Uniform Commercial Code, which imposes specific statutory requirements. And certain contracts are made unenforceable by the Constitution: for example, a provision that a house may not be sold to a certain racial or ethnic group. Parties negotiating a contract each believe they will benefit from the agreement. For example, a corporation purchasing a license for enterprise software believes the benefit from the software will exceed the price it pays, and the software vendor believes the price will exceed sum of expected costs for providing access to its product.When parties enter into a contract, therefore, they generally do not expect it to be breached (violated), or to resort to the legal system. However, they recognize that sometimes a partner may make a promise with good intentions, and later fail to fulfill it, or that circumstances may chance in some way. When evaluating contracts, courts will generally not consider whether the deal was a good one for either side. The standard view is that no one forced the parties to enter into the contract; they should be held to the bargain they struck.Another way to think of a contract is as a legal hedge against uncertainty or risk. The contract gives each party confidence that if the other fails to perform, they can receive compensation through the courts. It also allows parties to specify how specific situations in the future may be addressed. For example, in the software license described above, what happens if the buyer decides to modify some of the software code and resell it? Rather than wait for the confusion if that happens, the parties can specify ahead of time how the situation will be handled, by adding provisions to the contract.LGST 612 (Prof. Werbach) Page 2 Contemporary legal systems focus on two things i n contracts cases: intent and reliance. If the evidence shows that all parties acted as though they intended to be legally bound to a contract, and the plaintiff (the one filing the lawsuit) reasonably relied on the defendant to follow through with the contract, the courts will generally enforce it. To do otherwise would be unfair to the party that was harmed by honoring their commitments. In modern contract law, intent and reasonable reliance often trump formalities.A contract may generally be enforced even if it not signed, written, or even expressly made. For example, if a fishmonger delivers fresh fish to a restaurant every Monday for a year and receives the same payment each time, there may be an implied contract even if the parties never explicitly spoke about it. The plaintiff still needs to convince the judge or jury in court, which is much harder to do based on oral testimony than documentary evidence. Unwritten contracts also leave significant gaps for courts to fill in.Th e implied contract between the restaurant and the fishmonger, for example, could be terminated at any time by the parties, because there is no explicit term guaranteeing how long it will last. Remedies What a court awards to a successful plaintiff for breach of contract is known as the remedy. In contract law, the sole purpose of the remedy is to adequately compensate for the breach. You cannot receive additional â€Å"punitive† damages to punish someone for breach of contract, as you might under a tort claim such as products liability. The same facts, however, might give rise to both kinds of claims, as when a party deliberately breaks a contract in order to harm the other party’s business. ) In most contracts cases, the remedy is a payment of money, known as damages. There are three main ways that courts may calculate the level of damages: †¢ Expectation is the preferred formula. Whenever possible, this is what courts will use. Expectation means that the plainti ff (who did not breach the contract) gets the â€Å"benefit of the bargain. † In other words, they receive compensation to put them in the position they would have been in, had the contract been performed.For example, if an airline enters into a futures contract to purchase jet fuel in one year at $4/gallon, and at the time of performance the fuel company breaches because the spot market price is now $7/gallon, the expectation remedy would be $3/gallon times the number of gallons. In other words, it is the difference between the market and contract price. That way, the airline can buy the fuel from someone else at the market price, and still get the benefit of the contract. Reliance is used when expectation damages cannot be calculated because the amounts are too uncertain, or there is some other reason not to give expectation damages.Under this formula, the plaintiff gets back any costs he or she has expected by relying on the contract, so they are no worse off than before t he agreement. Generally, this will be a smaller amount than the expectation remedy. Restitution is used in rare situations where even reliance damages are not feasible to determine. Under this formula, the defendant (who breached the contract) must give back whatever benefit he or she received from the plaintiff, even if this does not fully cover the plaintiff’s reliance.For example, if the plaintiff paid money to the defendant for some services, the defendant must give it back. †¢ †¢ Courts may also consider awarding incidental and consequential damages. These are other costs the plaintiff can demonstrate, which go beyond his or her expectation under the contract. For example, imagine a factory owner contracts for a $50,000 piece of machinery to power a production line, and LGST 612 (Prof. Werbach) Page 3 the supplier breaches the contract. It takes a month before the factory can obtain an equivalent machine from another supplier (also for $50,000).As a result, the factory loses one month of production, which produces financial losses of $500,000 and causes its customers to terminate future orders worth several million dollars. All those costs are considered consequential damages. Whether they can be recovered depends on how foreseeable they were, and on the terms of the contract itself. On the one hand, those are actual losses the plaintiff suffered; on the other hand, was it reasonable to think the defendant took on millions of dollars of potential liability when it sold a $50,000 machine?In limited situations, monetary damages are not sufficient to give the plaintiff an adequate remedy. In such cases, a court may order an injunction (forbidding the defendant from some course of action) or specific performance (affirmatively ordering the defendant to go through with the transaction). Specific performance is only available for unique objects, where the money to purchase a similar object is not considered sufficient. This includes things such as works of art and real estate. Breach Failing to follow through on the legal obligations of a contract is called a breach.A breach might mean one party totally ignored its contractual obligations, or that it failed to perform some of them (such as completing the contracted-for services within a specified time), or that it did so in an inadequate manner. Whether something constitutes a breach is a factual decision for the court. The decision may be easier if the contract itself specifies conditions for breach, or whether a failure to perform specific responsibilities constitutes a breach of the whole agreement.As mentioned above, breaching a contract is not the same thing as breaking a promise, because law and ethics are not identical. In particular, sometimes a breach is, economically at least, a good thing. Imagine that an architect contracts with a cabinetmaker for custom-designed built-in furniture in a renovated house. However, the owner of the house changes her mind before f inalizing her contract with the architect, and he loses the commission. The cabinetmaker has not yet started to manufacture the furniture.It would be wasteful to force the architect to go through with the contract, when he knows the cabinets will be useless. It is more efficient for the architect to breach the agreement. So long as the architect pays sufficient compensation to the cabinetmaker (voluntarily or in the form of monetary damages or a voluntary payment), there is nothing unethical in his breach. Contract Formation There are five required elements for a legally binding contract. In other words, a plaintiff suing for breach of contract must first show that all five were met. Then they must show the contract was breached, and they are entitled to a remedy. ) 1. 2. 3. 4. 5. Offer Acceptance Consideration Legality Capacity The first two requirements, offer and acceptance, are sometimes lumped together and called â€Å"mutual assent. † They are typically the most difficu lt and important elements to establish. LGST 612 (Prof. Werbach) Offer Page 4 An offer is a proposal that manifests intent to enter into a contract. It is distinguished from an invitation, which is merely a proposal to enter into negotiations and therefore not legally binding.The party that makes an offer is called the offeror and the party that receives it is called the offeree. For the offer to be valid, the offeror must: 1. Manifest the intent to enter into a contract 2. Be definite and certain regarding the essential terms of the proposed contract 3. Communicate the offer to the offeree Suppose you are at a used-car dealer's lot. You see a care you like with the price listed as $9,995. You ask the salesperson what he’d take for the car; he doesn't answer you, but responds by asking you what you would offer.If you then say, â€Å"I wouldn't pay the list price, but I might pay $8,000 if I could finance it,† have you made an offer? In considering questions of this typ e, courts will look to â€Å"objective† manifestations of intent. Would a reasonable (ordinary, average) person, listening to your conversation in context, think that you intended to bound into a contract if the salesperson accepted? Again, reasonable reliance is what the courts look to protect, so your subjective mental state, even if it could be reliably determined, is irrelevant. Courts do, however, consider the context.You might offer to purchase a candy bar simply by holding out a dollar bill to a cashier, but an offer to enter into a multi-million dollar merger agreement might require significantly greater formalities. Similarly, if it would be clear to a reasonable observer that a statement was made as a joke, or in a social setting that does not involve contractual obligations, such as a wedding invitation, there is no binding offer. All these, however, are factual questions that courts might assess by hearing witnesses, looking at evidence, and listening to experts.A cceptance An acceptance is the mirror of an offer. If the offeree (the one receiving the offer) objectively manifests intent to be bound, the other elements below are met, and the offer is still valid, a contract comes into being at that moment. Intent is evaluated the same way for acceptance as for the offer. For the acceptance, however, courts are more sensitive to situations where someone takes actions that indicate acceptance (such as signing a document), but does not in fact understand the obligations they are undertaking.In such cases, courts generally look to whether this is the sort of contract that is typically accepted in that manner, and whether the offeree had a reasonable opportunity to analyze the contract but chose not to. Many business-to-consumer agreements are so-called contracts of adhesion or form contracts, where the consumer has no real opportunity to negotiate the specific terms – think of a rental-car agreement – but acceptance is still generall y considered valid because there are other means to protect the consumers and the alternative would be extremely inefficient and cumbersome.There are four ways that an offer may no longer be valid: 1. The offeror may generally revoke the offer by communicating that to the other party at any moment before acceptance. 2. If the one receiving the offer rejects it, which includes making a counter-offer, the original offer is considered no longer binding. 3. After some reasonable period of time, determined by the court based on the context, offers lapse. You cannot walk into a used-car dealer and say you are accepting the list price of a car advertised two years before. 4. Death or incapacitation of an offeror generally cancels an offer.One exception to the rule about revocation of offers is the option contract. This is essentially a contract that binds only one party. For example, a property owner might grant a real estate investor LGST 612 (Prof. Werbach) Page 5 an option to purchase a building for $15 million within a period of 90 days. If the investor comes forward with the $15 million, the owner must sell the building. The investor, however, is under no obligation to do anything. (Options on stocks operate the same way; the price for the put or call is the payment for the option. ) Under U. S. aw, there must be a separate payment for holding open the option, even if it is specified in the same document as the purchase terms. In other words, in the real estate example, if the building owner promised to keep the offer open for 90 days, but received no compensation for that promise, it would technically be free to sell to someone else. In many other countries, a party that promises an option must keep it open for a reasonable period of time, even without payment. The acceptance must mirror the offer. That means the offeree must comply with any conditions the offeror placed on the offer.If, for example, the offer states that payment must be made in cash, or that t hose wishing to accept the offer must show up in person at a certain location, those conditions must be met for a valid acceptance. If the offeror does not specify, the offeree may use any reasonable means. This may even include actions rather than words. If I ask a friend to bring me a sandwich from the cafe downstairs, which I’ll pay for, and she immediately goes to purchase it without saying a word, her actions would likely be a sufficient manifestation of intent.As always, context matters. In a complex commercial negotiation, it may be reasonable to exchange numerous very specific drafts, which are not formally accepted until the final version is signed off on by senior executives. Consideration Consideration means that each party has committed to giving up something of value to induce the promise or action of the other party. It is the way the law distinguishes an enforceable contractual bargain from a gift. If someone promises to give you a gift, and then reneges on the promise, you cannot sue them for breach of contract.There was no contract to begin with, because you did not have to give anything up in return for the gift. In most contracts, consideration will be money in exchange for some goods or services. However, it can be anything of legal value, including property or voluntarily giving up a legal right to act in a certain way. In a famous case, a court held that an uncle’s promise to pay money to his nephew if the nephew gave up smoking and drinking was enforceable, because the nephew stopped doing something he was legally entitled to do. The consideration must, however, be needed to induce the promise.If your action or inaction wasn’t what motivated the other party, there is no consideration. The amount of consideration need not match the value of what the party receives in return. A contract to pay $100 for a computer worth $1,000 may be a bad deal, but it has sufficient consideration. The main question is whether there is something of value exchanged to demonstrate the agreement is not a gift. In business agreements, this sometimes means a recital (a contractual provision that simply states a fact) along the lines of, â€Å"in exchange for good and valuable onsideration of one dollar†¦Ã¢â‚¬  to ensure consideration is found. Legality Contracts that are made for an illegal purpose will not be enforceable in a court of law. An agreement with a hit man to kill a disfavored relative may meet all of the formalities of a contract, but it should be obvious that you could not sue him for failing to go through with it. More realistically, an agreement to engage in bribery or to restrain market competition in violation of antitrust laws would be unenforceable.Capacity All parties to a contract must have the legal capacity to enter into a binding agreement. In other words, they must have what the law considers sufficient mental fortitude to understand and commit to LGST 612 (Prof. Werbach) Page 6 the obl igations involved. Two main classes of people who do not have capacity are children and those under significant mental disability or impairment. Children are generally not allowed to become legally bound by contracts. (The specific age cutoff and other considerations vary from jurisdiction to jurisdiction. If an adult contracts with a child, the child can void the contract at will, but the adult is still bound if the child wishes to enforce the agreement. The other situations in which capacity becomes an issue are when a party either has a significant disability that prevents them from understanding contractual obligations, or they are too severely impaired by drugs, alcohol, or another factor. Capacity is judged objectively: would a reasonable observer think the party was in a state that made it impossible to express intent to contract?If so, the party at that moment lacks the legal capacity. It is important to note that capacity is not the same thing as capability or authority. A bank may not actually have the financial wherewithal to provide the financing that it contracts for, but this does not mean it is incapable of entering into any contract. If it fails to provide the financing that the other party reasonably relied on, it is in breach of contract, whether or not it actually has the resources needed to perform. Similarly, an agent may or may not have the legal authority to speak for a firm.If a sales representative (or someone claiming to be a sales representative) commits a company to an agreement with a customer that the company does not in fact wish to honor, that has no bearing on the legal capacity to contract. In that situation, the court must determine whether it is appropriate to bind the company. If the salesperson did not in fact have actual authority to sign off on such contracts, courts would look to whether it was reasonable for the customer to think that they did, especially without communicating with corporate headquarters.Whether a Cont ract Must be in Writing (â€Å"Statute of Frauds†) As mentioned above, there is no general requirement that contracts be in writing. It is generally a good idea to write contracts down, because that provides clear evidence of their existence and terms if they are ever breached. Fundamentally, though, an oral agreement, or an unsigned written agreement, is a valid contract, except in two broad cases. The first is when there is a statutory or regulatory requirement to put a certain agreement in writing. This is often the case, for example, with financial and healthcare agreements.The second is if the contract is under the statute of frauds. The Statute of Frauds was a 17th century English law that required some contracts to be in writing, because otherwise there would be too much risk of witnesses lying (the â€Å"fraud†) in their oral testimony in court. Today, the term refers mostly to common law principles that impose a writing requirement, plus provisions of certain modern statutes (such as the Uniform Commercial Code) that impose similar obligations. Saying that a contract is â€Å"under the statute of frauds† means that it has to be in writing.There are several categories of contracts that fall under the statute of frauds, including suretyship (promising to pay someone else’s debts) and contracts in consideration of marriage (such as prenuptial agreements). The three categories most likely to arise in a business context are: †¢ †¢ Sale of land. This also includes interests in land, such as a mortgage. Sales of goods worth $500 or more. Note that contracts for services, such as consulting or financial advice, are not covered under this provision. The $500 figure comes from the Uniform Commercial Code, and is an arbitrary figure, not pegged to inflation.LGST 612 (Prof. Werbach) Page 7 †¢ Promises not performable in one year. In other words, there is no way the contract could be successfully performed within a year. If the contract does not specify a term of longer than a year, and there is come conceivable scenario in which both parties would discharge their responsibilities before the end of the year, it need not be in writing. If a contract falls under the statute of frauds, a sufficient â€Å"writing† is a document that identifies the parties, describes the basic obligations of the contract, and is signed by the party to be charged.As with any written contract, if there are specific details not set out in the document, the court can interpret the language or fill in reasonable terms as necessary to enforce it. If, however, the writing is missing a material term – for example, the price in most sales contracts – it is not enforceable. Basically, the court needs enough information to determine a remedy. If the contract is not under the statute of frauds, the courts can look to other written evidence or oral testimony to find a material term. However, if the parties simply failed to agree on such an essential point, the contract is unenforceable.Note that when the statute of frauds applies, only one party is required to sign the agreement: the party who is being sued to enforce it (the defendant). The signature of the other party may still be useful to prove there was intent to enter into a binding agreement. Excuses to Performance In some circumstances, a party will not be held to an agreement, even when it met all the legal requirements for a valid contract. The most common excuses to performance are: Fraud. If one party induces a contract by lying to the other party, it is not enforceable even when the form of the contract is perfectly good.Duress. If a party felt it was forced to enter into a contract against its will, it can claim the contract is unenforceable due to duress. This means something more than a difficult situation or a tough negotiating partner on the other side. For example, if there is only one supplier for an important input with sufficient production capacity, buying from that supplier is not duress. There must generally be some misconduct, involving threats to engage in illegal conduct or breach other obligations, which convinces the other party it has no choice. Unconscionability.As noted above, a contract will not be considered unenforceable because it is unfair, or because there is unequal bargaining power (as is typically the case in business-to-consumer interactions). However, if one party has no reasonable opportunity to understand the obligations they are undertaking, or there are terms in the agreement so manifestly unfair that they â€Å"shock the conscience,† courts can declare specific provisions or whole contracts as unconscionable. This doctrine is successfully invoked infrequently, and then typically when there is unfairness in the process, rather than the substantive terms.Mutual mistake. If both parties were mistaken about the fundamental subject matter of the contract, such that th ey never truly had an agreement, the contract can be declared unenforceable. If the mistake is simply a bad business decision, such as an assumption that the price of a good will not increase substantially, it will not excuse performance. Impossibility/frustration of purpose. If circumstances change so dramatically that either a contract is effectively impossible to perform, or it would be pointless to complete it, courts can excuse performance.As with the other doctrines, courts will not release parties from their obligations if performance is merely more difficult or costly than they expected. – – – – LGST 612 (Prof. Werbach) Page 8 These excuses are considered by courts after the fact. In such situations, there is a contract, but there is no legal remedy for a breach. Sometimes, the result is merely to sever a problematic provision of the contract. For example, a contract may be enforceable minus the specific term the court considered unconscionable.Re covery Outside of Contract (â€Å"Promissory Estoppel†) Modern contract law makes it relatively easy for parties to enter into contracts, to specify the terms of those contracts, and to be excused from contractual obligations when fundamental fairness dictates. Consequently, the legal system generally focuses on whether the procedural obligations of contract law described above have been met, rather than on whether the outcome is just. After all, the parties were free to act differently, yet chose to structure their agreement in a certain way.Why should the courts interfere with their decisions? In a host of cases, this freedom-based view of contracts fails to account for reality. Inequalities in access to information or bargaining power may so warp the relationship between parties that the formal structure of an agreement may not actually reflect the intent of at least one of them. Or there may be significant public policy concerns, such as avoiding mistreatment of patients or retail investors, which counsel for heightened obligations beyond those of common-law contract doctrines.Another category cuts in the opposite direction. Sometimes the un-enforceability of an agreement is unfair. If one party reasonably relies on the other party, yet has no remedy because the agreement is unenforceable, it can create a situation in which the courts view themselves as parties to an injustice. The legal doctrine known as promissory estoppel arose to allow for recovery of damages in court, even when there is no enforceable contract between the parties.The Restatement (Second) of Contracts, a collection of â€Å"best practices† in contract law written by leading legal experts in the field, describes promissory estoppel as follows: â€Å"A promise which the promisor should reasonably expect to induce action or forbearance on the part of the promisee or a third person and which does induce such action or forbearance is binding if injustice can be avoided only b y enforcement of the promise. The remedy granted for breach may be limited as justice requires. † Most commonly this doctrine is invoked for charitable gifts.For example, imagine that a donor to Wharton promises the school $100 million for a new building bearing her name, the school builds the building in reliance on the gift, and the donor then reneges on the promise. There is no enforceable contract, because there is no consideration. (The school’s expenditure in building the building was a response to the promised gift; it is not what induced the promise, as required for consideration. ) In such a situation, if a court feels it would be an â€Å"injustice† that Wharton receives no compensation, it can award damages on a promissory estoppel theory.Courts have applied promissory estoppel in other situations where, because of some legal quirk, a party reasonably relies on a contract and yet has no adequate remedy. Note that promissory estoppel is a distinct legal claim, not a lawsuit based on a valid contract. One consequence is that damages are generally limited to reliance. In the donation example in the previous paragraph, this means that Wharton might recover the amount it spent on constructing the building, but not the full $100 million that was promised. And remember that the court can decline to award anything if it does not feel that an injustice has occurred.