Entrepreneurs Book Report Making Their Own American Dream - 550 Words

Entrepreneurs Book Report: Making Their Own American Dream (Book Report Sample) Content: Entrepreneurs: Making their own American DreamStudents NameInstitutional AffiliationIntroductionThe United States signed a law to control the number of immigrants who joined the country in 1986. Whereas, the Business formation is a key factor to help in the success of any enterprise, taking note of the basic factors involved is important. Valdez examines certain factors such as race, gender as well as a social class and the role they play in developing successful enterprises. The book gives detailed information about the role of structural inequality and how it relates to gender, race, and ethnicity to determine the ability of a minority entrepreneur to bring together resources that can be used in improving an enterprise. The book is based on theory and extensive research by the author based on factual findings and theoretical assumptions that help in explaining the role of race, ethnicity, and class in the success of business. The main point is how the diverse factor s affect the entrepreneur's ability to achieve the American Dream. The dream that is about the availability of equal opportunities for any American citizen to achieve a successful life by working hard in whatever they set their minds to and having the drive and determination to achieve financial independence and prosperity.Chapter 1: IntroductionBusiness formation is a key factor to help in the success of any enterprise. Taking note of the basic factors involved is important. Valdez in the first chapter examines certain factors such as race that are very important in developing successful enterprises in an attempt to achieve the American dream. She gives an example of Dona Tona and Mr. Alfaro who are all Latino Immigrants hoping to make it in the States. As Valdez (2011) states, "ethnicity has a role in facilitating business ownership through social capital, and economic resources. She continues to add that "the resources are generated by ethnic and social networks", (Valdez, 2011). The chapter aims at introducing the different factors discussed in the book relating to immigrants achieving the American dream.Chapter 2: The embedded market: race, class, and gender in American enterpriseThe issues encompassing race, class and sexual orientation in the United States have for some time been full of contention. The chapter investigates the theoretical approaches relating to embedded market. It aims to understand the structural oppression experienced by immigrants as well as the traditional ethnic paradigm in the United States relating to entrepreneurship. According to Valdez (2011), the embedded market approach maintains that the American social structure is comprised of racial grouping hierarchies." The section gives the reader a systemic view on the issues of race, class, and gender. Through the readings in this book, the author gives the reader the materials to decide for themselves and plan their particular conclusion on the issues race, class, and sexual orien tation and how it influences them in contemporary society. According to Valdez, (2011), "social capital stemming from multiple dimensions may offset structural disadvantage." These readings open the reader's eyes to the frameworks of abuse that remain and how people can be a specialist of progress to destroy unreasonable and unequal treatment towards achieving the American dream.Chapter 3: Entrepreneurial Dreams in an Intersectional ContextThe idea of 'social business enterprise' has been quickly developing in the private, open and non-benefit areas throughout the most recent couple of years, and enthusiasm for social business enterprise keeps on developing. Intersections are very influential in shaping entrepreneurial dreams for the immigrants. The entrepreneurial dreams, according to Valdez (2011), "he states that they include their motivations for and expectations of business ownership. The chapter also analyzes racial as well as group differences that influence entrepreneurship. According to Valdez, (2011), "entrepreneurs are sometimes but not always motivated by the prospect of making money." The chapter concludes by restating the ethnic entrepreneurship approach and the combination of factors that may lead ethnic minorities to engage in business activities.Chapter 4: Intersectionality market capacity and Latino enterpriseIntersectionality is characterized as the connections among different measurements of personalities and modalities of social relations. The chapter endeavors to uncover the diverse sorts of segregation and burdens that happen as an outcome of the blend of natural, economic and social characters. Intersectionality, as stated by the author could help in creating and running successful enterprises in America. Valdez, (2011) "access to social capital may help in alleviating the detrimental impact of discrimination." The chapter also examines the difficulties that lower class individual's face in their attempt to pursue the American dream. Ac cording to Valdez, (2011), "negative societal reception contexts intensify the immigrant's class disadvantage." She also examines the market concept in the embedded market and concludes by noting that an economy is normally embedded in its social relationships.Chapter 5: By what measure success? The economic and social value of Latino enterpriseThe Latino's and other immigrants have experienced a couple of challenges in their quest to succeed in business. In this chapter, Valdez explores their achievements, objectives and motivations. Moreover, the chapter also examines the meaning of success according to the immigrants. Valde's (2011), the Latino entrepreneurs define success using non-economic indicators as other things than money motivate some." Moreover, the author explores economic mobility as a measure of success for the immigrants. It also uses an entrepreneurship approach to determine the success of establishments. According to Valdez, (2011), she states that "ethnic entrepre neurship tends to minimize the social costs associated with the enterprise." Lastly, the chapter examines the economic as well as the social value for success.Chapter 6: Ethnic and racial identity formation among American entrepreneursThe exercises of ethnic personality business leaders which are regularly at first inspired by the longing to open up choices and to encourage decision among individuals instigate congruity and capacities as an instrument of social control. The section accentuates a specific subset of ethnic personality business visionaries. The chapter begins by Valdez acknowledging the existence of racial segregation in America, especially in business establishments. The oppression of minority groups such as Latinos began long ago before the beginning of modern developments. According to Valdez, (2011), "aggressive recruitment of minority during the industrial revolution and the exclusionary immigration policies such as Chinese exclusion act resembled minority segrega tion." The chapter continues to examine the deep rooting of the racial segregation of diverse communities among the American immigrants who had a dream of achieving a better life. Valdez (2011) indicates that "the racial hierarchy in the United States has a structural foundation that develops out of a racialized social system". She also notes that until now, ethnic minorities in the United States require having a racial classification to acquire a chance that may help them achieve their dreams. In this chapter, the author also acknowledges the supremacy of the white ethnic majority groups. He offers examples of immigrants such ...

Throughout The Course Of Society, Political Leaders And

Throughout the course of society, political leaders and individuals with authority have either led their followers to great success, or towards misery and tyranny. In society, great leaders have been able to not only change the landscape of the region they abide in, but ultimately change the viewpoints and understandings of individuals across the globe for the better. On the other hand, leaders with ill intentions have led their followers towards mischief and suppression of not only their physical being, but also of their mental state. In William Shakespeare’s world-renowned play Julius Caesar, Shakespeare illustrates the political, power struggle between the prodigious leader of Rome, Julius Caesar, and Brutus and his conspirators.†¦show more content†¦Through the genderbending of the UH play, the vital theme of self-exploration and equality of both genders is discovered. From the outset of the play, the audience can see that Julius Caesar is a powerful figurehead th at has gained respect from the entirety of the Roman people. This is evident when Julius denies the crown of Rome from his people three times during the Feast of Lupercal. The Roman people admire Julius to such a great extent to where they offer him leadership and control not once, or twice, but three times. By Becker portraying Julius Caesar as a female character in the coronation scene it reveals many things about gender equality. First and foremost, it shows that men and women can be equally as successful. Even though Julius Caesar was cast as a young and short woman, the charisma and supremacy exuded by the actor exceeded that of any male actor. From how she conversed with the other powerful male characters, Brutus, Antony and Cassius, to the way she carried out her mannerisms and strong will upon others, it proved that she was no individual to underestimate. In a way, both the male and female audience members felt empowered by spectating a female actor play one of the strongest male roles in Theatre history with extreme confidence and precision. Overall, the reversal of gender roles and the theme of gender empowerment helped me understand one of the play’s central messages of how the death of a respected leaderShow MoreRelatedThe Political Influence of Women676 Words   |  3 PagesWomen Exert Significant Political Influence Women have never been able to exert any significant political influence: discuss with reference to any one period of History that you have studied. Throughout history women are often seen as subservient to men. This has led to the belief that they do not have any kind of significant political influence. Based upon historical information, it is clear that these views are simply untrue. 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Classification Of Permanent Magnet Synchronous Motors Essay

This chapter focuses on classification of Permanent Magnet Synchronous Motors (PMSM) and its main advantages. It also discusses automotive applications of PMSM Drive System, description of software hardware implementation of PMSM drive, Aims Objective of research work. It also describe the organization of thesis. In this proposition, a field arranged controlled PM engine drive framework is portrayed and investigated because of its significance in Automotive applications. A shut circle control framework with a PI controller in the rate circle has been composed. A relative investigation of PWM,SV-PWM CB-SVPWM control plans connected with current controllers has been made. At that point, the recreation of a field situated controlled PM engine drive framework is created utilizing Simulink. The reenactment circuits for PM synchronous engine, multilevel inverter, velocity and current controllers incorporate every practical part of the drive framework. Reenactment consequences of PWM,SV-PWM CB-SVPWM control plans connected with current controllers are given for three velocities of operation. 1.1 classification of Permanent Magnet Synchronous Motors (PMSM) Synchronous motors with an electrically stimulated rotor winding have a conventional three stage stator winding (called armature) and an electrically empowered field curving on the rotor, which passes on a DC current. The armature winding is similar to the stator of actuation motor. The electrically stimulated fieldShow MoreRelatedDirect Current (Dc) Motors . Student’S Name. University.1027 Words   |  5 Pages(DC) Motors Student’s Name University Course Code Date of Submission Direct Current (DC) Motors 1.0 Overview of DC Motors A Direct Current (DC) motor is a broad classification of electric motors that operate from a direct current (DC). Nearly all mechanical devices used in electric applications are powered by electric motors. Motors transform electrical energy to mechanical energy. Thus, they are essential for energy conversion in electrical machines. All types of electrical motors compriseRead MoreTypes of Dc Motors and Dc Generator2262 Words   |  10 PagesTypes of DC Motors and DC Generators MOTORS – convert electrical energy to mechanical energy Motors and generators are the most frequent used electrical machines. ⠝â€" Generators action can take place when and only when, there is a relative motion between conducting wires and magnetic lines of force. ⠝â€" Electric motor is in operation when it is supplied with electrical energy and develops torque, that is, a tendency to produce rotation. ⠝â€" In DC generator, the armature winding is mechanicallyRead MoreRenewable Resources Wind Energy Is An Important Factor For The New Era Of Power Quality1568 Words   |  7 Pageshave fast response time and controllability, they are relatively common for combination with WECS (wind energy conversion systems). So a wind diesel system is considered in this project. Recent technology, â€Å"permanent magnet type† have advantages and disadvantages. They are also discussed here. To convert the energy generated by wind generation, induction generator as it have many advantage over the other types of generators. Connection with the strong grids duringRead MoreDifferent Types Of Electric Motors Essay1535 Words   |  7 Pagesenergy, applications of electric motors are expanding widely in motor industry, and different types of electric motors are used in all kinds of applications, such as, the public transportation, electric vehicles, and mechanical fans. Because of the variety of working conditions in distinct application usages, engineers are developing various control theories to meet specific requirements based on different types of power system and motor. Generally, an electric motor is a machine which can transformRead MoreA Semi Physical Simulation Experimental Platform For The Signal Wheel Sensor1827 Words   |  8 PagesChina) Abstract The signal wheel sensor in an engine is quite important for achieving engine timing, enhancing the performances, and reducing emission. In this study, we designed a simulation teaching platform, in which the engine was replaced by a motor to realize the signal wheel sensor ’s operation according to the practical operating conditions; in addition, an engine analyzer was employed for the acquisition of output signals. The experimental results reveal that the motor’s rotational speed wasRead MoreJntuk 2-1 and 2-2 Mech Syllabus R105047 Words   |  21 Pagestypes – DC motor types – torque equation – applications – three point starter. UNIT - III TRANSFORMERS : Principle of operation of single phase transformers – emf equation – losses – efficiency and regulation UNIT - IV AC MACHINES : Principle of operation of alternators – regulation by synchronous impedance method – Principle of operation of inducti on motor – slip – torque characteristics – applications. UNIT - V INSTRUMENTS : Basic Principle of indicating instruments – permanent magnet moving coil

The Big Five Personality Theory - 1186 Words

Psychology refers to the study of the human mind, behaviors associated with it and the humanistic behavior of man in any given context. The primary goal of psychology is to gain a true knowledge and understanding of how and why individuals of all ages and genders behave the way they do. A popular worldwide theory is called The Big Five Personality Theory. This world-renowned theory of understanding ones personality traits has been revolutionary towards understanding the minds of people all over the world and from all backgrounds. The Big Five Personality Theory is based on five main traits which include neuroticism, agreeableness, extroversion, openness and conscientiousness. These five traits are necessary as they make up ones personality composition. These five â€Å"big† personality traits are often referred to using the acronym â€Å"OCEAN†. (Measuring, 2015) For decades, people have tried to determine how many personality traits actually exist and can be recorded. No matter the speculation, the big five (neuroticism, agreeableness, extroversion, openness and conscientiousness) remain concrete. Extroversion is a trait that has broad scope due to its predominantly social aspect. Individuals, who are categorized as extroverts, often are viewed as being very talkative and more concerned with the environment around them rather than with their own thoughts, feelings, and personal environment. People who fall low on the extroversion scale are considered introverts, the counterpart toShow MoreRelatedBig Five Theory Of Personality Traits955 Words   |  4 PagesAmong the many established trait theories, the most widely known and used is the Big Five Theory of Personality Traits. It is a five-factor model composed of the broad personality traits of openness to experience, conscientiousness, extraversion, agreeableness and neuroticism. There are a variety of ways to assess one’s broad dimensions of personality in these five categories. 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According to each team member the results of the test wouldRead MoreDispositional Vs Biological Theory Essay990 Words   |  4 Pagesï » ¿ Dispositional vs. Biological Theory Sarah Quincey PSY 405 September 15, 2014 Leslie Binnix Dispositional vs. Biological Theory Dispositional personality theories are quite different from biological personality theories. The two will be compared and dissected in this article. The Big Five Personality Test will also be analyzed and how it is used to study personality will be examined. Dispositional personality theories contend that each person per certain stable, long lasting dispositions.Read MoreEssay on Cattells Big Five Factors997 Words   |  4 PagesCattells Big Five Factors Cattell’s Big Five Factors of Personality, Behavioral Genetics, and Evolutionary Personality Theory. Current Research Raymond Cattell (1905-present) designed the â€Å"Big five Factors of Personality†, in which five classifications are revealed. Big Five factors: #1 extraversion vs. introversion, #2 agreeableness vs. antagonism, #3 conscientiousness vs. undirected ness, #4 neuroticism vs. emotional stability, and #5 openness to experience vs. not open to experience

Real Future Accounting, By Michael Kummer - 945 Words

Real Future Accounting, founded by Michael Kummer April 2014, is a new accounting firm located at 5268 Canal Drive in Kennewick Washington. We are Open Monday thru Friday, 8am-8pm. Our professional accountants are standing by, ready to answer any questions that you may have, or to perform any services that you may require. You may also contact us at +1 (509) 555-2525/5252 or through our web page, www.RealFutureAccounting.com. Our mission statement is to ensure that our clients prosper while receiving professional services. We strive to keep our clients informed on any new advances in technology in regards to their finances, such as new apps, or finance software that they can use from their home computers. We, at Real Future Accounting, are here to provide our clients with the most professional accountants, and the most accurate accounting services. All of our accountants are CPA certified, well experienced and can answer any questions that you have. We have many specialized accountan ts, dealing with matters such as taxes and bookkeeping. Furthermore, we provide consulting services for businesses or for individuals. Filling your own taxes can be a nightmare, and hiring an accountant can be difficult and costly. However, our tax accountants can prepare your federal, state, and local tax returns quickly, and at an affordable cost. Also, they will ensure that your taxes get done right, allowing them to maximize your return. Apart from filing your taxes, we can also help you

SNP/CGH Microarray Based Genomic Testing in Myelodysplastic Syndrome

Question: Describe about the SNP/CGH Microarray Based Genomic Testing in Myelodysplastic Syndrome. Answer: Introduction: Myelodysplastic syndrome (MDS) is a progressive disease characterised by ineffective haematopoiesis, peripheral blood cytopenias, abnormal cellular morphology and variable risk of progression to acute leukaemia. Myelodysplastic syndromes (MDS) are the clonal disorders of an immature hematopoietic progenitor cell. MDS hematopoiesis is categorised by irregular progenitor proliferation and impaired cellular differentiation and maturation. As a result, the bulk of MDS patients have a plodding evolution in the direction of progressive bone marrow failure and leukemic transformation. The hard work made by numerous research assemblies during past few years have assisted to unknot the complex that forms the fundamentals of the pathogenesis of MDS. In this review, we will focus on the major molecular abnormalities and cytogenetic involved in MDS beginning and disease development. Moreover, we will deliberate the impact of the marrow microenvironment on proliferation and survival of hematopoie tic progenitors in MDS. It is one of the commonest haematological disorders worldwide accounting for 1.3% of all cancers in New Zealand [31]. Approximately 86-87% cases of MDS in Australia and New Zealand were reported to be diagnosed in individuals of above 60 years of age [31]. The MDS pathogenesis is not understood very well but as being a neoplasm, it involves the accumulative acquisition of oncogenic driver mutations. MDS is generally considered a clonal process that is thought to develop from a single transformed hematopoietic progenitor cell [47]. The recent improvement in the detection of recurring chromosomal abnormalities and mutations has provided better understanding of the pathogenesis of MDS. The investigation gone through the Three decades into the pathophysiology of the myelodysplastic syndromes (MDS) have established the heterogenicity of MDS and emphasised the intricacy in disease biology. Recent improvements in technology have yielded stimulating observations. The aim and objective of this review is to assimilate laboratory and clinical findings into a functioning hypothesis for the advancement of idiopathic MDS, distinguish idiopathic MDS from SAA, and propose latest therapeutic strategies. Understanding of data from MDS studies still remains challenging. Without a dependable disease marker, here can be a questions about the exactness of an MDS analysis. Supplementary problems ascend the minute patients with incongruent biologies are made compared. Patients who are possessing MDS may have noticeable single or multiple clonal chromosomal variations at the time of analysis or gain them later through the course of the disease which may pave the way of transformation into acute myeloid leukaemia (AML). Simple chromosome changes may involve a numerical change which may be monosomy or trisomy, a structural abnormality like inversion and interstitial deletion that involve only one chromosome and very rarely a balanced translocation which involve two chromosomes. Complex karyotyping with multiple abnormalities approximately more three can also be detected in advanced cases [29]. A large MDS series of 1029 patients was studied by Pozdnyakova and his colleagues, found 44% of cases with MDS to have clonal cytogenetic abnormalities evident by standard metaphase karyotyping at diagnosis [33] [29]. Del(5q) was the most common and seen in 18% of cases followed by complex karyotype in 6% of cases. Trisomy 8 and Del(20q) were present in 4%, and 3%, respectively [29]. Trisomy 8 increases the risk of leukemic transformation which is predominant in male and causes oral ulceration. Loss of the Y chromosome is known to be one of the good prognostic markers in MDS, however, it is generally thought to be an age related phenomenon [46]. The analysis of MDS relies mainly on the detection of clonal genetic abnormalities in the appropriate clinical context as well as the identification of significant morphological dysplasia on peripheral blood film and/or bone marrow. There are certain cytogenetic abnormalities considered as a presumptive evidence of MDS even in the absence of morphological dysplasia. The presence of these specific cytogenetic abnormalities confirms the MDS diagnosis in cases with absent or very little morphologic dysplasia. Similarly, the diagnosis of AML can sometimes be established in the presence of certain cytogenetic abnormalities regardless of blast count. An amazing development in the understanding of the leukemogenesisis made conceivable by the methodological improvements in the cytogenetic field. The cytogenetic irregularities that have usually provided the molecular basis for the finding of the genes that are engaged into the mechanism of the leukemogenesis. Numerous study illustrates that t he cytogenetic turned out is one of the most significant prognostic factor and so it was integrated into the statistical model which aims for the improvement of the forecast the procedures of the individual prognosis. The identification of clonal chromosomal abnormalities is not only important in establishing the MDS diagnosis but also aids in the classification of MDS, prognostic stratification and treatment planning [33], [14]. The impact of cytogenetics is clearly demonstrated in its role in determining the International Prognostic Scoring System (IPSS). The conventional metaphase cytogenetics is the standard genetic test routinely performed in evaluating MDS cases in most laboratories. Sometime the traditional cytogenetic analysis and routine chromosome analysis is mentioned to as karyotyping. These kinds of studies are used to identify numerical and structural chromosome irregularities in metaphase cells. Routine chromosome analyses involves sterile viable tissue samples. The removal of the long arm of the chromosome 5, del (5q) is the most frequently occurring chromosomal abnormalities found in the patient diagnosed with MDS. The lenalidomide developed as the effective targeted therapy for the little and intermediate risk of MDS with a del 5(q) has increased the importance of karyotyping in disease management. This test has a number of limitations including the low resolution and the need for high quality metaphases and cell division within the abnormal cells. In view of those limitations, new methodology with much higher resoluti on such as Single nucleotide polymorphism (SNP) and comparative genomic hybridization (CGH) microarray analysis were incorporated in the evaluation of MDS cases. Genomic Micro-Array Studies: The main principle present behind the microarrays is the hybridization between two strands of DNA , the property by which complementary sequences of the nucleic acid exactly pairs with complementary nucleotide bases by forming hydrogen bonds among each other. A large number of complementary base pairs in a nucleotide sequence means more tight non-covalent bonding among the two strands. Subsequently washing off non-specific bonding sequences, only toughly paired strands will remain hybridized. Fluorescently labeled target sequences which bind to a probe sequence will help to produce a signal which is dependent on the hybridization circumstances (such as temperature), and perform washing after the hybridization. The total strong point of the signal, from a spot (feature), rest on the quantity of target sample binded to the probes that are present on the spot. The Microarrays uses comparative quantitation in which the intensity of a feature is compared to the intensity of the same featu re under several different condition, and the distinctiveness of the feature is recognised by its situation. Both SNP and CGH array are basically high resolution DNA microarray tools that can detect genomic gains or deletions associated with copy number changes down to a level of 5 KB of DNA [28], [30]. SNP arrays however have the additional advantage of its ability to detect copy-neutral loss of heterozygosity (LOH) or uniparental disomy (UPD). The basic components of SNP and CGH arrays include: DNA hybridization of immobilized allele -specific oligonucleotide (ASO) probes with target DNA sequences labelled with florescent dyes [7]. ASO probes are generally designed and selected from a representative pool of healthy individuals [7]. The use of fluorescence microscopy and a solid surface DNA capture system that picks up and interprets hybridization signals [35] [7]. The differences in the fluorescence intensities reflects copy numbers changes in DNA sequences. This indicates the presence of either loss or a gain mutation. Despite of the high resolution of SNP/CGH microarray analysis, it has important limitations. Those limitations are: Inability to detect genomic abnormalities that do not result in copy number changes such as balanced translocations. Inability to detect genomic abnormalities in the settings of small clone sizes. Microarray analysis in MDS: Mohamedali study showed that the use of SNP microarray analysis in MDS cases resulted in a much higher detection rate of genomic abnormalities up to 75% compared to 50% using conventional metaphase cytogenetics alone. Some of these detected cryptic genomic lesions were shown to have prognostic implications [22]. Essentially similar results were demonstrated in Tius study of 430 patients with MDS disorders. It concluded that combining both the metaphase cytogenetics and SNP array together led to a higher diagnostic yield of chromosomal defects (74% vs 44%, P .0001), compared metaphase cytogenetics alone [40, 41 42]. It also demonstrated that some of the newly detected SNP array defects contributed to poorer prognosis. Some of these new SNP array detected chromosomal lesions were independent predictors of overall and event-free survival [41]. Both Heinrichs and Volkert studies evaluated the use of SNP/CGH microarray on MDS cases with normal metaphase cytogenetics [16, 43]. In both studies the SNP/CGH microarray detected cryptic genomic lesions in 11-15% of cases respectively [16, 43]. Heinrichs study showed that most of these genetic lesions resulted from segmental uniparental disomies (UPD). The study also showed that UPD affecting chromosome 7q are associated with a progressive course and worse outcome regardless of their low-risk International Prognostic Scoring System score [16]. In Volkert study, the majority of CGH array identified genetic lesions were sub-microscopic copy number changes (4% gains and 7% losses) [43]. Compared to sub-microscopic gains, more than half of the sub-microscopic deletions were recurrent and involved the genes TET2, DNMT3A, ETV6, NF1, RUNX1 and STAG2 [43]. The presence of sub-microscopic deletions was associated with lower overall survival rates compared to those without deletions [43]. SNP/ CGH microarray analysis with its superb resolution in detecting genomic abnormalities resulting from copy number changes, is expected to be particularly useful in MDS. This is supported by two factors; firstly, the fact that the vast majority of cytogenetic abnormalities in MDS are characterised by copy number changes and secondly, because balanced translocations are not common in MDS. Overall SNP/CGH microarray analysis appears to be a good complementary method to conventional metaphase cytogenetics analysis in MDS cases, with its own unique prognostic information The use of SNP/CGH microarray analysis in MDS related disorders has been evaluated in this study by comparing its results with standard metaphase cytogenetics. AIM: The overall objective of this study is to demonstrate the ability of SNP/CGH microarray in 1- Improving the diagnostic yield of suspected MDS cases by detecting clonal genetic lesions in cases with either normal or non-informative conventional metaphase cytogenetics. 2- Providing higher resolution genetic testing capable of accurately guiding both prognostic stratification scoring system and therapy. 3- Providing early detection of micro genetic abnormalities that can potentially be associated with a progressive course and hence prioritising early bone marrow transplant therapy in transplant eligible patients. 4- Effectively replacing or complementing the conventional metaphase cytogenetic testing in our local practice in evaluating MDS cases. Methodology: We hypothesized that the combination of standard metaphase cytogenetics and SNP/CGH microarray could potentially enhance both the diagnosis and prognostic stratification of MDS related disorders. We also evaluated the possibility that MDS cases with either normal or non-informative metaphase cytogenetics could potentially harbour cryptic chromosomal lesions with possible prognostic implications that can only be detected by SNP/CGH microarray analysis. A total of 28 cases (14 women and 14 men) with a mean age of 68.4 years (range 2287 years) were included in the study. Out of those 28 cases, A total 17/28 cases including 15 cases with normal metaphase cytogenetics and 2 cases with failed metaphase cytogenetics were randomly selected for the study (Table 1a). A total of 11/28 cases with previously detected genetic abnormalities by metaphase cytogenetics were preselected for the study. Those 11 cases have wide range of chromosomal abnormalities ranging from simple numerical changes (ie, monosomy or trisomy), structural chromosomal abnormalities such as interstitial deletion, translocation involving two chromosomes and complex karyotypes with multiple abnormalities. The 28 cases included in the study are 18 cases of confirmed MDS, five suspected cases of MDS with borderline morphologic dysplasia, three cases of AML with myelodysplasia related changes, one case of Chronic myelomonocytic leukaemia (CMML) and one case of Myelodysplastic syndrome / Myeloproliferative neoplasm overlap unclassifiable (MDS/MPN u) (Table 1b). According to the bone marrow morphological assessment and the WHO classification, the cohort comprised of the following MDS subtypes: refractory cytopenia with multilineage dysplasia (RCMD, n=7), refractory cytopenia with multilineage dysplasia with ring sideroblasts (RCMD-RS, n=3), refractory anaemia with ring sideroblasts (RARS, n=4), refractory anaemia (RA, n=1), refractory anaemia with excess blasts ( RAEB-1, n=1; RAEB-2:n=1). All cases had their bone marrow samples submitted to our regional laboratory within the period from March 2014 to April 2016 for evaluation of cytopenias and/or clinical suspicion of MDS related disorders. The cytomorphological examination and assessment was performed in Auckland regional laboratory and MDS diagnosis reported according the world health organisation (WHO) Classification criteria 2008. Samples were also referred to IGENZ laboratory for further cytogenetic testing. These laboratories are IANZ accredited. Metaphase cytogenetic analysis was carried out on marrow samples according to standard methods. Chromosome preparations were G-banded using trypsin and Giemsa (GTG) and karyotypes were reported according to the International System for Human Cytogenetic Nomenclature (ISCN). SNP/CGH microarray analysis was performed using an Agilent 8 x 60K SUREPRINT G3 custom CGH/SNP array platform according to the manufacturer instructions and with a practical resolution of ~180kb. Data was analysed using Agilent Cytogenomic Software v3.0 using human genomic build 19. The sample was hybridised against a commercially produced reference DNA obtained from Agilent. The research project has been registered and approved by the local Middlemore hospital research office and adhered to the national HDEC guidelines where formal ethics approval was deemed not required. The study cohort was subdivided in to two main groups (Group A Group B) and one small group (Group C). Group A included the randomly selected 15 cases with normal karyotype by conventional metaphase cytogenetics analysis. Group B included the preselected eleven cases with wide range of chromosomal abnormalities detected by metaphase cytogenetics. Group C however is comprised of two cases with failed conventional metaphase cytogenetics. The detection rate of genomic abnormalities was compared between metaphase cytogenetics analysis and SNP/CGH microarray analysis across the three groups. Further analysis including IPSS scores, survival data and disease outcome was performed on the 18 cases with confirmed MDS diagnosis. The standard metaphase cytogenetics based IPSS scores were compared to the SNP/CGH microarray based IPSS scores. (Table 2). Table 1a. Result showing the Standard metaphase cytogenetic and SNP/CGH microarray analysis of 28 patients Case # AGE Gender Diagnosis Metaphase cytogenetics SNP/CGH microarray 1 70 Male AML-with-MDS-related-changes Normal Normal 2 73 Male AML-with-MDS-related-changes Normal Normal 3 78 Female RARS Normal Normal 4 80 Female RCMD -20 dic (17;20) 5 72 Male RAEB-2 -7 -7 6 52 Female MDS/MPN-unclassifiable Complex Complex 7 76 Male RCMD-RS Del(20q)+t(4;7) Del(20q) 8 78 Female RCMD Del(20q) Del(20q) 9 82 Male Possible MDS -y -y 10 58 Female RCMD+RS Normal Normal 11 67 Female Possible MDS Normal Normal 12 83 Female RCMD Normal Normal 13 87 Female RCMD and Myeloma Normal Del(20q) 14 73 Female RARS Normal Normal 15 22 Male RCMD Normal Normal 16 53 Female Hypoplastic MDS and Myeloma Normal Del(13q) 17 71 Male Possible MDS +20 Normal 18 72 Male AML-with-MDS-related-changes Complex Complex 19 72 Male RARS karyotype-failed -y 20 34 Female Possible MDS karyotype-failed Normal 21 74 Male RAEB-1 Complex Complex+additional 22 77 Male RARS Normal Complex 23 78 Female RCMD Del(20q) Del(20q) 24 56 Female RA Normal Normal 25 79 Male Possible MDS Normal Del(5q13.2) 26 75 Male CMML2 Normal Del(17q11.2) 27 65 Male RCMD+RS Normal Normal 28 57 Female RCMD Del(7q) Complex (including Del(7q) RCMD = refractory cytopenia with multilineage dysplasia, RCMD-RS = refractory cytopenia with multilineage dysplasia with ring sideroblasts. RARS = refractory anaemia with ring sideroblasts, RA = refractory anaemia, RAEB-1 or 2 = refractory anaemia with excess blasts 1 or 2. Results: The SNP/CGH microarray analysis results were compared with metaphase cytogenetics in the three groups. Table1a(i). Results which are considered in Group A Case # AGE Gender Diagnosis Metaphase cytogenetics SNP/CGH microarray 1 70 Male AML-with-MDS-related-changes Normal Normal 2 73 Male AML-with-MDS-related-changes Normal Normal 3 78 Female RARS Normal Normal 10 58 Female RCMD+RS Normal Normal 11 67 Female Possible MDS Normal Normal 12 83 Female RCMD Normal Normal 13 87 Female RCMD and Myeloma Normal Del(20q) 14 73 Female RARS Normal Normal 15 22 Male RCMD Normal Normal 16 53 Female Hypoplastic MDS and Myeloma Normal Del(13q) 22 77 Male RARS Normal Complex 24 56 Female RA Normal Normal 25 79 Male Possible MDS Normal Del(5q13.2) 26 75 Male CMML2 Normal Del(17q11.2) 27 65 Male RCMD+RS Normal Normal In group A there are 15 cases with normal metaphase cytogenetics but SNP/CGH microarray analysis was able to detect a wide spectrum of cryptic genomic abnormalities in 5 cases out of 15 cases that I one third of cases. Among those five cases, there is only one case with a very little morphological dysplasia and the rest of the four cases had a confirmed MDS diagnosis with significant morphological dysplasia. Those five cases with only positive SNP/CGH microarray findings are: 1) CMML case where SNP/CGH microarray analysis detected a 521 kb loss in the long arm of chromosome 17 [Del(17q11.2)]. 2) A case of suspected MDS with borderline dysplasia. The SNP/CGH microarray detected Del(5q13.2) characterised by a 2.2 Mb deletion in the long arm of chromosome 5. 3) A case of confirmed MDS diagnosis WHO subtype RARS, the SNP/CGH microarray detected complex cytogenetics abnormalities (5p+, 19q+, 21q+) in the form of three small chromosomal gains in 5p13.3-p15.1, 19q13.2-q13.3 and 21q21.1-q21.2. 4) A case of Hypoplastic MDS and myeloma, the SNP/CGH microarray detected Del(13q) characterised by 30Mb deletion in the long arm of chromosome 13 at band q21.31 - q31.3. 5) A case with established MDS and RCMD WHO subtype, the SNP/CGH array identified the presence of Del(20q). Table1a(ii). Results which are considered in Group B Case # AGE Gender Diagnosis Metaphase cytogenetics SNP/CGH microarray 4 80 Female RCMD -20 dic (17;20) 5 72 Male RAEB-2 -7 -7 6 52 Female MDS/MPN-unclassifiable Complex Complex 7 76 Male RCMD-RS Del(20q)+t(4;7) Del(20q) 8 78 Female RCMD Del(20q) Del(20q) 9 82 Male Possible MDS -y -y 17 71 Male Possible MDS +20 Normal 18 72 Male AML-with-MDS-related-changes Complex Complex 21 74 Male RAEB-1 Complex Complex+additional 23 78 Female RCMD Del(20q) Del(20q) 28 57 Female RCMD Del(7q) Complex (including Del(7q) In group B there were 11 cases with already established chromosomal abnormalities by metaphase cytogenetics. However, the SNP/CGH microarray showed a wide spectrum of findings that correlated quite well with most of the already established metaphase cytogenetics results. However, the microarray managed to reveal additional significant cryptic genomic abnormalities in three out of the eleven cases (27.2%) that were not apparent by metaphase cytogenetics. Some of those additional SNP/CGH array abnormalities have shown significant prognostic implication. On the other hand, metaphase cytogenetics were superior to SNP/CGH microarray in two out of the eleven cases (18.2%), where the SNP/CGH microarray failed to detect some of the already established chromosomal abnormalities by metaphase cytogenetics. The three cases where the SNP/CGH microarray detected additional genetic abnormalities are: 80-year-old female with confirmed diagnosis of MDS WHO subtype refractory cytopenia with multiline age dysplasia (RCMD) and presented with moderate anaemia and thrombocytopenia. Conventional metaphase cytogenetics identified -20 as a sole cytogenetic abnormality. The SNP/CGH microarray analysis however revealed a serious cryptic genomic abnormality, dic(17;20) with both 17p and 20q deletions. 74-year-old male with a confirmed diagnosis of MDS WHO subtype refractory anaemia with excess blast -1 (RAEB-1). Metaphase cytogenetics analysis established a complex karyotype (+19, Del(20q), +21). The SNP/CGH microarray however confirmed the complex abnormalities with an additional abnormality of +8. A 57-year-old female with established diagnosis of MDS, WHO subtype RCMD. She presented with moderate anaemia and neutropenia. Metaphase cytogenetics analysis revealed Del (7q) only. The SNP/CGH microarray analysis however confirmed the presence of Del(7q) and showed two additional cryptic genomic lesions; Del(7p) and gain of 21. This confirmed the presence of complex cytogenetics. The two cases with higher detection of chromosomal lesions by metaphase cytogenetics than SNP/CGH microarray analysis are: 71-year-old male with suspected diagnosis of MDS and borderline dysplasia. Initial conventional metaphase cytogenetic revealed the presence of trisomy 20. The SNP/CGH microarray analysis failed to detect the trisomy 20. 76-Year-old male with confirmed diagnosis of MDS WHO subtype refractory cytopenia with multilineage dysplasia and ring sideroblast (RCMD+RS). Conventional metaphase cytogenetics identified the presence of two clonal abnormalities; t(4;7) and Del(20q). The SNP+CGH microarray analysis was able to accurately detect the presence of Del(20q) but failed to identify the presence of t(4;7). Table1a(iii). Results which are considered in Group C Case # AGE Gender Diagnosis Metaphase cytogenetics SNP/CGH microarray 19 72 Male RARS karyotype-failed -y 20 34 Female Possible MDS karyotype-failed Normal The group C consist of two cases with failed metaphase cytogenetics analysis and the SNP/CGH microarray detected Y chromosome in the first case of 72-year-old male with established morphologic diagnosis of MDS and RARS subtype. The second case is a suspected MDS case and the SNP/CGH microarray did not reveal any genomic abnormality. Table 1b. Frequency and Percentage of diseases Frequency Percent AML-with-MDS-related-changes 3 10.7 CMML2 1 3.6 Hypoplastic MDS 1 3.6 MDS/MPN-unclassifiable 1 3.6 Possible MDS 5 17.9 RA 1 3.6 RAEB-1 1 3.6 RAEB-2 1 3.6 RARS 4 14.3 RCMD 7 25.0 RCMD+RS 3 10.7 Total 28 100.0 AML= acute myeloid leukaemia, CMML2 = chronic myelomonocytic leukaemia2, MDS, MDS = myelodysplastic syndrome, RCMD = refractory cytopenia with multilineage dysplasia, RCMD-RS = refractory cytopenia with multilineage dysplasia with ring sideroblasts. RARS = refractory anaemia with ring sideroblasts, RA = refractory anaemia, RAEB-1 or 2 = refractory anaemia with excess blasts 1 or 2. Table 2. Result showing IPSS score analysis of 18 cases Diagnosis (MDS subtype) Metaphase cytogenetics Microarray Metaphase cytogenetics based IPSS score Microarray based IPSS score Patient outcome. Survival in months Time to transformation to AML. RARS Normal Normal 0.0 (Low) 0.0 (Low) Alive 23M No transformation RCMD -20 Dic(17;20) 0.5 (INT-1) 0.5 (INT-1) Dead 14M 11 M RAEB-2 -7 -7 2.5 (High) 2.5 (High) Dead 28M 2M RCMD+rs Del(20q), t(4;7) Del(20q) 0.5 (INT-1) 0.0 (Low) Alive 29M No transformation RCMD Del(20q) Del(20q) 0.0 (Low) 0.0 (low) Alive 20M No Transformation RCMD+rs Normal Normal 0.0 (Low) 0.0 (Low) Alive 5M No Transformation RCMD Normal Normal 0.0 (Low) 0.0 (Low) Alive 22M No Transformation RCMD Normal Del(20q) 0.0 (Low) 0.0 (Low) Alive 34M No Transformation RARS Normal Normal 0.0 (Low) 0.0 (Low) Alive 15M No Transformation RCMD Normal Normal 0.0 (Low) 0.0 (Low) Alive 24M No Transformation Hypoplastic MDS Normal Del(13q) 0.0 (Low) 0.0 (Low) Alive 24M No Transformation RARS Failed -Y - 0.0 (Low) Alive 9M No Transformation RAEB-1 Complex Complex + Additional 1.5 (INT-2) 1.5 (INT-2) Alive 31M No Transformation RARS Normal Complex (undetermined clinical significance) 0.0 (Low) 0.0 (Low) Alive 29M No Transformation RCMD Del(20q) Del(20q) 0.0 (Low) 0.0 (Low) Alive 20M No Transformation RA Normal Normal 0.0 (Low) 0.0 (Low) Alive 276M No Transformation RCMD+rs Normal Normal 0.0 (Low) 0.0 (Low) Alive 3M No Transformation RCMD Del(7q) Complex 1.5 (INT-2) 1.5 (INT-2) Alive 2M No Transformation. AML= acute myeloid leukaemia, MDS = myelodysplastic syndrome, RCMD = refractory cytopenia with multilineage dysplasia, RCMD-RS = refractory cytopenia with multilineage dysplasia with ring sideroblasts. RARS = refractory anaemia with ring sideroblasts, RA = refractory anaemia, RAEB-1 or 2 = refractory anaemia with excess blasts 1 or 2. M= month, IPSS= international prognostic scoring system, INT-1 or 2 Intermediate 1 or 2. The IPSS score analysis on the 18 cases with confirmed MDS cases diagnosis showed that the microarray based IPSS scores correlated quite well with conventional metaphase cytogenetics based IPSS scores. In a total of 7/18 cases, the SNP/CGH microarray detected more genomic abnormalities than metaphase cytogenetics. In all of these 7/18 cases with newly microarray detected additional genomic abnormalities, there has been no change in the IPSS score following the microarray compared to the conventional metaphase cytogenetics based IPSS score. On the other hand the metaphase cytogenetics was superior to microarray in one case with confirmed MDS diagnosis (1/18), where the Array failed to identify the balanced translocation t(4;7). This resulted in the case being inappropriately categorised into a lower risk category with the microarray based IPSS score of 0.0, compared to standard metaphase cytogenetics based IPSS score of 0.5 consistent with Intermediate-1 risk category. The 18 cases with confirmed MDS diagnosis have a median survival 22.5 months from time of diagnosis (range 2-276 months). Two cases progressed into AML and died, while the rest of the 16 cases are still alive with no transformation to AML . Discussion: The application of SNP/CGH microarray analysis has the potential to greatly enhance the diagnostic and prognostic stratification processes for MDS cases especially when conventional metaphase cytogenetics is not informative. In group A 15 cases were found with normal metaphase cytogenetics, the SNP/CGH microarray analysis was able to detect cryptic chromosomal lesions in 5 cases put of 15 that means 33.3% of cases were having normal standard metaphase cytogenetics. This can be attributed to the higher resolution of SNP/CGH microarray analysis and the ability to reliably detect sub-microscopic chromosomal lesions. Relatively similar results have been demonstrated in other studies such as in Volkert study where the microarray identified copy number changes in 11% of total 520 MDS cases with confirmed normal karyotyping by metaphase cytogenetics [43]. Similarly, Mohamedali showed SNP array detected 10% cytogenetically cryptic deletions and 8% gains in low-risk MDS cases [22]. Our result of 33.3% is slightly higher than those studies, this can be attributed to sample size differences and also to patient selection. Those microarray identified chromosomal abnormalities are; Del(20q), Del(5q13.2), Del(17q11.2), complex (5p+, 19q+, 21q+) and Del(13q). Some of them helped determining the exact underlying gene mutation as Del(17q11.2) in the CMML-2 case where a 521 kb loss was identified in the long arm of chromosome 17. This abnormality had been previously described by Kolquist and thought to be encompassing NF1 tumour suppressor gene which has a possible role as a negative regulator of the RAS pathway [18]. This gene has also been shown to have some prognostic implications as per Franks study showing relatively increased incidence of NF1 mutation as the MDS disease progresses to acute leukaemia [34]. This was particularly relevant in our case as the patient had a relatively high risk CMML-2 with high blast count. The detection of Del(5q13.2) in a suspected case of MDS with borderline dysplasia also supports the hypothesis of enhanced diagnostic yield of SNP/CGH microarray analysis in suspected MDS cases with normal metaphase cytogenetics. This chromosomal lesion is different from the common 5q- and has been reported to be related to the gene RAD17 which have been previously identified in MDS by Starczynowski and others [36]. This clonal abnormality however will support the diagnosis of either MDS or clonal cytopenia of undetermined significance in the right clinical context. The detection of Del(20q) by the microarray in the case with established MDS diagnosis, will help in supporting the MDS diagnosis, given that it is very well known to be MDS related. The new identified microarray complex cytogenetics abnormalities; (5p+, 19q+, 21q+) and Del(13q) are not known to be specifically MDS related lesion. However, they may well indicate clonality and further support the MDS diagnosis in the right clinical context. Overall, it is worth highlighting the diagnostic yield of the SNP/CGH microarray as it helped in supporting the diagnosis of either MDS or Clonal Cytopenia of Undetermined Significance (CCUS) in 5/15 cases (33.3%) by detecting either known MDS cytogenetic abnormalities or clonal lesions. In group C (the two cases with failed metaphase cytogenetics analysis), SNP/CGH microarray however was normal in the case with inconclusive MDS diagnosis and only detected Y in the other established case of MDS. Given that Y may not be considered as a clonal abnormality in the elderly the utility of SNP/CGH array has not been accurately analysed in this context. A study by Arenillas showed that SNP array was able to detect cytogenetic abnormalities in 50% patients with failed metaphase cytogenetics. It also demonstrated some prognostic implications related to copy number alterations detected by the array [2]. In the Group B results it was found that 11 cases with already established chromosomal abnormalities by metaphase cytogenetics. The SNP/CGH microarray analysis showed good correlation characterised by the detection of majority of chromosomal abnormalities identified by standard metaphase cytogenetics. It also managed to reveal additional cryptic genomic lesion in 3 cases out of 11 cases which is 27.2% of the total cases. Some of those novel SNP/CGH array additionally identified genomic lesions s were noted to have major prognostic implications. This has been demonstrated clearly in the case of the 80-year-old lady with an established diagnosis of MDS RCMD subtype. Her conventional metaphase cytogenetics identified monosomy 20 as a sole cytogenetic abnormality and as a result of that her case had been categorised into the intermediate-1 risk category according to standard IPSS scoring system. Subsequent the SNP/CGH microarray analysis however revealed a seriously hidden cryptic genomic abnormality characterised by unbalanced dicentric (17;20), resulting in loss of 17p (including TP53) and 20q. Although dic(17;20) is a rare abnormality it has been reported in MDS cases by Tirado and Campbell and has been shown to be associated with disease progression and worse outcome [39]. Moreover, the SNP/CGH microarray in this case has also suggested the presence of TP53 mutation which is one of the known mutations associated with MDS and AML. The presence of this mutation has been shown to be of great clinical significance and associated with poor survival even after bone marrow transplant [4,5,6 11]. Some studies also showed that TP53 mutations have a major and unique prognostic value independent of the current IPSS score system for patients with MDS. [4,6 17]. This was consistent with our patients progressive course with early transformation to acute leukaemia in 11 months time. The Array results however did not lead to change in the IPSS score for this patient. This will support the hypothesis that large-scale genetic and molecular profiling is needed for further sub-classification and prognostic stratification in MDS patients [15]. The other two cases with the SNP/CGH microarray showing additional clonal chromosomal lesions, have already confirmed MDS diagnosis at the high risk category based on the metaphase cytogenetics based IPSS score. The additional clonal abnormalities identified by the SNP/CGH microarray however in those cases did not indicate significant change in the disease outcome or prognostic risk stratification. The combined SNP+CGH microarray analysis however did not identify a couple of chromosomal lesions previously detected by metaphase cytogenetics analysis in 2/11 (18%) of cases with abnormal karyotype. In one case due to low level of the abnormal clone of 10%, the SNP/CGH microarray was unable to detect the presence of trisomy 20. This is one of the known limitation of SNP/CGH microarray analysis in detecting low clone size less than 30%. Given that microarray was reported as normal in this particular case, this could potentially lead to a reduction on its diagnostic yield. The array result in this case did not result in change in the IPSS score, given that trisomy 20 is one of the low risk clonal genetic abnormality. In the second case the SNP/CGH microarray analysis failed to detect the presence of a likely balanced translocation t(4;7), however it managed to detect the presence of Del(20q). This can be explained by the known limitation of the SNP/CGH microarray analysis in detectin g balanced translocations. This could potentially lead to inappropriately stratifying the patient into a lower risk group, if karyotyping has not been performed. The IPSS score analysis on the 18 cases with confirmed MDS cases showed that the Array based IPSS scores correlated quite well with the conventional karyotyping based IPSS score (Table 3). There has been no significant change in IPSS score following the SNP/CGH microarray in the 7/18 cases with higher detection of genomic abnormalities by the SNP/CGH microarray compared to conventional metaphase cytogenetics. This could possibly be explained by three factors: 1) The fact that some of these SNP/CGH microarray detected genomic lesions were of not known to be MDS related such as Del(13q) and (5p+, 19q+, 21q+). As a result of that those newly detected genomic lesions are not included in the standard IPSS score assessment. 2) Despite of the SNP/CGH microarray ability to detect certain poor prognostic genetic mutations, most of these mutations act as an independent risk factor regardless of the IPSS score. 3) Those Array identified good prognostic chromosomal abnormalities (e.g. Del(20q) and -Y) were mostly detected in the low risk group with already established low standard metaphase cytogenetics based IPSS score. On the other hand, the SNP/CGH microarray identified poor prognostic genomic abnormalities were also mostly detected in high risk group with already high IPSS score based on conventional metaphase cytogenetics. This has resulted in the IPSS score to essentially remain unchanged following the SNP/CGH microarray analysis results. Overall in this small study the conventional metaphase cytogenetic appears to be slightly better than the microarray analysis in guiding the IPSS scoring system. This was particularly demonstrated in the case with the balanced translocation t(4;7) missed by the SNP/CGH microarray. There is no enough follow up period to reliably assess the presence of survival differences among the group with new or additional microarray identified genomic abnormalities. However, only one case with unique cryptic genomic abnormalities detected only by the array demonstrated progressive course with early transformation to AML and death. This case showed that certain genomic abnormalities (Del(17p) /TP53 gene mutation) have extremely poor prognosis independent of the IPSS score. This is consistent with other studies by Bejar and Horiike [4,5, 6 17]. Conclusion: This pilot study has demonstrated that the combination of SNP/CGH microarray and conventional G banding analysis enhances the diagnostic yield and provides additional prognostic information in the assessment of MDS cases. The SNP/CGH microarray analysis was able to detect some cryptic genomic lesions which are of utmost clinical and prognostic significance. It was also able to identify the presence of some of the common genetic mutations with some of these lesions acting as an independent risk factor regardless of the IPSS /IPSS-R scoring system. This will open the door for the creation of a new risk stratification system that includes all these relevant clonal genomic abnormalities. The SNP/CGH microarray analysis is relatively more expensive and costs $750 NZD pert test compared to $560 NZD for conventional metaphase cytogenetics. While our data showed that microarray analysis has a higher detection rate of genomic abnormalities with relatively good correlation with metaphase cytogenetics, however in view of its inherent limitation to detect small clone size and balanced translocation, it is recommended to be used in combination with standard metaphase karyotyping. We conclude that SNP/CGH microarray is relevant option that can be easily performed in routine diagnostics in MDS in combination with standard G banding analysis. However given the significant cost implications associated with that, this option could be of particular relevance in certain cases such as: Diagnostically uncertain cases with normal standard metaphase cytogenetics. Transplant eligible patients where it is important to confirm the diagnosis and accurately determine the disease prognosis in order to make appropriate recommendations about the merits of a proceeding to stem cell transplant. Research situations. 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WIT Film Analysis on Effective Communication-Samples for Students

Question: Discuss about the WIT Film on Effective Communication. Answer: WIT Film Analysis on Effective Communication Effective communication is an important aspect for establishing therapeutic relationships. Effective communication enables nurses to provide ethical, safe, quality, and person-centered nursing care (Farrington and Townsend, 2014). Effective communication refers to a verbal or nonverbal methods that relay information in a clear and simple term (Matusitz and Spear, 2014). Communication is essential to nursing as nurses are used as communication hub and relay or interpret information between family members, physicians, caregivers and the patients (Jolles, Clark and Braam, 2012). The following essay discusses effective and ineffective communication when providing nursing care as watched from a WIT Movie 2001 directed by Mike Nichols. The essay will also contain my reflection on knowledge or skills gaps and a plan for improving communication effectiveness when providing nursing care. The WIT Movie was shot in a hospital setting where the main character Vivian Bearing is diagnosed with Stage (IV) Ovaries Cancer. The patient is convinced by Harvey Kelekian to agree and undertake an experimental eight months treatment that was to help contribute knowledge towards cancer treatment. Harvey Kelekian is a prominent physician and leads a team of researchers who include a former Vivians student Jason Posner and a primary nurse Susie Monahan (WIT, 2001). The physicians are involved in several ineffective communications that are insensitive and amuses the patient causing more pain that the real illness. The phrase how are you feeling today? is frequently as a form of greetings or inquiring her condition. Vivian narrates how she was asked how she was feeling today after a four hours operation. She remembers how she used to be asked the same question while growing up and contrasts with the current situation. Vivian remarks that when she dies she will not be able to hear the q uestion. For instance, Doctor Posner together with other researchers asks Vivian what she was feeling today and she replies she was fine. Doctor Posner then leads the physicians on experimental briefing. Vivian feels that after teaching she was used to a specimen to learn and contribute to existing knowledge. In another account, Jason Posner in an isolation room after taking an assessment asks Vivian how she was feeling on that day. Vivian replied that she was fine and was just taking sometime from the chills. Vivian thereafter expresses her feelings and attitudes towards her condition in isolation room when the Doctor leaves the room. Jason Posner also asks Vivian how she was feeling that day after she had several treatments and now she was back to her room. Vivian has expressed distress about the series of treatments that she had undergone before doctor Posner assessment. The phrase how you are feeling today? has an automatic spontaneous response fine (Ha and Longnecker, 2010). Th e other party is obliged to answer in a certain way not to disappoint. This applies to patients too as they are obliged to give a positive response despite their ill condition not to disappoint (Bramhall, 2014). The phrase said to patients also becomes more of a greeting rather than an inquiry. This leads to the patients responding with a short answer or in an expected manner that does not reveal the patients emotions, attitudes, or feelings. The physicians are thereby not able to get an inquiry because the phrase does not encourage patients to give a detailed feedback. On the other side, the movie contains effective communication scenery. Nurse Susie shows good therapeutic relationship and communicates effectively with Vivian. Susie answers Vivian call early in the morning where they engage in a conversation. Susie starts the conversation with Vivian by inquiring if there is a problem since she was awake at 4am. Susie combines tone and body language to communicate with Vivian. The nurse tries to find out why the patient doesnt sleep. Vivian explains that she is not able to sleep as she kept on thinking. The nurse changes her body posture and looks directly to the patient. Vivian expresses her doubts and that she was scared. Vivian becomes emotional and Susie responds by a body contact and showing care to the patient. The nurse also provides Vivian with popsicles and sits alongside her. The nurse and Vivian engaged in an honest discussion was targeted to providing the patient with knowledge (Ha and Longnecker, 2010). A nurse offering a touch is a po werful means of communicating with a patient. Touching a patients hands conveys that the nurse is concerned and shows empathy (Shannon, 2012). Maintaining eye contact with patient expresses confidence that offer encouragement to their condition (Garrett, 2016). The body posture is also an important part of effective communication. It helps a nurse communicate better by showing relation that reduces anxiety to patients. Therefore, Susie was effective in communicating with Vivian by finding a balance between empathy and honest discussion. Reflection The WIT Movie has several scenes that are educative to health professionals or students learning to practice the profession. I have learnt about effective therapeutic and professional communication that has enabled me to indentify the knowledge and skills gaps that can impact my capacity for effective communication when practicing nursing. First, I have learnt that nonverbal language is an important tool to effective communication. Nurses should combine verbal and nonverbal communication to enhance the effectiveness of communication in health centers. Nonverbal communication to be used includes eye contact, body posture, and touch. Nonverbal communication enhances the delivery of the information by establishing confidence, trust, and empathy. Secondly, I have learnt that some phrases are inappropriate when establishing a therapeutic relationship. For instance, using the phrase how are you feeling today? frequently is mechanical and patients are obliged to answer fine accompanied by a short or no comment. The phrase does not allow patients to express themselves as expected in an assessment session. The phrase is also taken as greetings and therefore cannot be used to inquire information from a patient. Thirdly, I have learnt that effective professional and therapeutic communication require a humanistic approach. A humanistic approach enables nurses to take a holistic approach of care to a patient that foster emotional and mental health in addition to the physical illness. This can be enhanced by finding a balance between professional practice and research to avoid undermining the patients interests. I have also learnt on the need for using simple vocabularies and providing information for effective communication. Use of medical jargons is a barrier to effective communication as patient is not able to understanding their conditions. Nurses should therefore communicate in simplest language that patients can understand and make decisions about their health. Providi ng patient with information empowers the patient to make decisions. Therefore, effective therapeutic and professional communication is essential for providing quality and safe nursing care. From the film, I noticed a knowledge gap and skills in establishing effective professional communication and therapeutic relationships. I noticed that I lack alternative phrases that I can use to inquire information from a patient. The how are you feeling today? phrase is common but inappropriate in establishing therapeutic relationship with patients. The phrase has a spontaneous answer and cannot be used for professional inquiry. Secondly, I have noticed that I did not pay attention to my nonverbal communication. I have a weakness when it comes to aligning my verbal communication with body language. The body language is important in delivering effective communication to a patient and therefore an important that I should addressed before I start practicing nursing. The plan to improve my knowledge and skills gap will involve learning new things that are essential for effective communication. First, I will research on alternative phrases that can be used to inquire information from a patient. This will involve reviewing past research work on effective communication for inquiring patient information. This will increase my opening conversation phrases that are appropriate and effective for therapeutic and professional communication. The plan to improve my body language will involve learning by practice. I will learn how to align my verbal communication with facial expressions, touch, eye contact, and body posture. This will increase the effectiveness of my communication when establishing therapeutic relationship as a health care professional. In conclusion, patients health care delivery is impacted by the effectiveness of the health care provider communication skills. Therapeutic and professional communication is important to delivering a safe and quality health care. Health care professionals should be careful when choosing words as opening statement or when inquiring information from patients. They should use nonverbal communication to compliment their verbal communication. Health professionals should also take a humanistic approach when providing health care to hospitalized patients. This will enable physicians to balance between research and professional practice interests when handling an experimental condition. Therefore, it requires effective communication in establishing appropriate therapeutic relationships for safe and quality health care. References Bramhall, E. (2014) Effective communication skills in nursing practice, Nursing Standard, 29(14), pp. 5359. doi: 10.7748/ns.29.14.53.e9355. Farrington, N. and Townsend, K. (2014) Enhancing nurse-patient communication: a critical reflection, British Journal of Nursing, 23(14), pp. 771775. doi: 10.12968/bjon.2014.23.14.771. Garrett, J. H. (2016) Effective Perioperative Communication to Enhance Patient Care, AORN Journal, 104(2), pp. 111120. doi: 10.1016/j.aorn.2016.06.001. Ha, J. F. and Longnecker, N. 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