Sepsis and Septic Shock Essay Example

Sepsis and Septic Shock Essay Sepsis refers to the uncontrolled systemic immune response to infection. It describes the condition known as systemic inflammatory response syndrome in which as infectious etiology is identified or suspected (Munford, 2001). The key element in sepsis is the overwhelming systemic inflammation as a result of the host’s reaction to microbial invasion. It involves augmented inflammatory signals in response to an infectious insult that is not controlled by local inflammatory processes. Bacteremia, which is the presence of bacteria and in blood or septicemia, which is the presence of any microbial agent in the blood can lead to sepsis. When the regulatory controls that put the inflammatory response in check are unable to contain the overwhelming reaction, unaffected organs are involved and severe sepsis ensues which is characterized by multiorgan dysfunction. As the homeostatic counterregulatory mechanism fails, sepsis progresses to septic shock, which is the presence of hypotension along with along with organ dysfunction. The hypotension, which is defined as systolic blood pressure of less than 90 mmHg or 40 mmHg less than the patient’s usual blood pressure, is unresponsive to fluid resuscitation. Unlike sepsis which is reversible, patients in septic shock have unfavorable prognosis and usually succumb despite aggressive treatment (Munford, 2001).EpidemiologyOver 10 million cases of sepsis have been reported in the United States based on a 22-year period study of discharge data from 750 million hospitalizations (Martin, Mannino, Eaton, Moss, 2003). Annually, approximately 750,000 people develop sepsis and more than 210,000 cases are fatal (Bernard, Vincent, Laterre, Larosa, Dhainaut, Lopez-Rodriguez et al 2001; Hotchkiss Karl, 2003). Despite advances in critical care management, sepsis has a mortality rate of 30 to 50 percent and is among the primary causes of death in intensive care units (Bernard et 2003; Mitchell, Cotran, 1999). It is believed th at the increasing incidence of severe sepsis is due to the growing population among the elderly as a result of increasing longevity among people with chronic diseases and the high prevalence of sepsis developing among patients with acquired immune deficiency syndrome (Munford, p.798 2001).PathophysiologyThere are a lot of factors attributable to the development of sepsis. Several studies have conflicting results on the pathologic basis of the disease and the exact mechanism involved has not been elucidated. The pathogenesis of sepsis is a series of complex interactions between offending microorganism and the host inflammatory, immune and coagulation responses. The accepted theory is that sepsis results from an uncontrolled inflammatory response in which our own defense system becomes so powerful that it causes more damage to our organs than the etiologic agent of the initial infection Hotchkiss Karl, 2003). This is based on the overstimulated immune response seen in studies of anim al models of sepsis which does not seem to correlate which the clinical picture in humans. Clinical trials involving anti-inflammatory agents have not been successful in patients with sepsis which led investigators to question if sepsis is indeed the result of uncontrolled inflammation (Hotchkiss Karl, 2003). In fact, sepsis with organ dysfunction is attributed to an inadequate immune response to primary local infection which allowed it to spill into the bloodstream and the ensuing tissue injury is primarily caused by superantigens and other virulence factors from the infecting microorganism (Russel, J.A., 2006).Approximately 70 percent of cases of septic shock are caused by gram-negative bacilli which produce endotoxin, hence the term endotoxic shock (Mitchell, Cotran, 1999). The endotoxins are the lipopolysaccharides(LPS) from the bacterial cell wall that are released after the wall is degraded during an inflammatory response. The reproduction of the hemodynamic picture of septi c shock through the injection of LPS alone shows that LPS is one of the main culprits of septic shock. The complex inflammatory cascade caused by LPS eventually leads to hypoxic injury and the multi organ failure is mostly evident in the brain, heart, kidneys, lungs, and gastrointestinal tract. The widespread hypoxia during septic shock causes the brain to develop ischemic encephalopathy while in the heart, cardiac muscles undergo coagulation necrosis and subendocardial hemorrhages. The kidneys undergo acute tubular necrosis as a result of extensive ischemic injury. This results into electrolyte disorders, oliguria and anuria which are severe complications of sepsis. Despite the high resistance of lungs tissues to hypoxic injury, diffuse alveolar damage can be seen in severe bacterial sepsis. In the gastrointestinal tract, hemorrhagic enteropathy develops which appears as patchy mucosal hemorrhages and necrosis. The liver undergoes fatty change and in severe ischemic injury, central hemorrhagic necrosis can be seen (Mitchell, Cotran, 1999).Clinical FeaturesThe clinical manifestations of sepsis are usually superimposed with the signs and symptoms of the primary infection and other underlying medical condition of the patient.However, in the course of the disease, an increasing intensity of inflammatory response to infection becomes evident although the rate varies among patients. Hyperventilation is usually one of the early signs. Manifestations of ischemic encephalopathy such as disorientation and confusion may also occur early in sepsis. They are usually seen among the elderly and in patients with preexisting neurocognitive deficits (Munford, 2001). Patients with hypotension usually presents with weak but rapid pulse accompanied by tachypnea and cold, clammy skin. However, patients in septic shock may be initially warm due to peripheral vasodilation in the skin (Mitchell, Cotran, 1999). It should be noted that some patients with sepsis are normothermic and e ven in the presence of infection, fever can be absent especially in neonates, elderly, and patients with uremia or suffering from alcoholism (Munford, p.801 2001).The occurrence of disseminated intravascular coagulation or DIC, which results from the widespread activation of the coagulation system, can predispose patients to ischemic necrosis especially to those with hypotension. This leads to skin lesions seen as pustules, cellulites, bullae or hemorrhagic lesions. Gastrointestinal involvement manifests as nausea, vomiting, diarrhea and ileus. Patients with stress ulcers may present with upper gastrointestinal bleeding. In cases of prolonged and severe hypotension, ischemic bowel necrosis may occur as well as acute hepatic injury. Elevation of serum levels of conjugated bilirubin often leads to cholestatic sepsis. Liver function test may reveal elevated blood levels of alkaline phosphatase which along with the elevated bilirubin represent an underlying hepatocellular or canalicular dysfunction (Munford, 2001).Treatment and PrognosisPatients with sepsis requires urgent management which is best accomplished in an intensive care setting by medical specialist experienced in the care of critically ill patients. The management entails immediate treatment of the focus of infection while providing adequate hemodynamic and ventilatory support.The appropriate antimicrobial therapy should be given immediately based on blood culture and sensitivity although an empiric initial treatment should be started based on known pathogens at identified sites of infection. An adequate antibiotic cover should include therapy against gram-positive and gram-negative microorganism. Pending results from blood cultures, empiric antimicrobial therapy can be based on several factors, especially in patients with no obvious source of infection. In immunocompetent adults, acceptable regimens include ceftriaxone or ticarcillin-clavulanate or piperacillin-tazobactam and imipenem-cilastin or mero penem. Gentamycin or tobramycin may be added to these regimens. If the causative agent is suspected to be methicillin-resistant staphylococcous areus, vancomycin should be added to these regimens (Munford, 2001). In patients with AIDS, ceftazidime, tircacillin-clavilanate or piperacillin-tazobactam plus tobramycin should be used. In patients with drug allergy to beta lactams, ciprofloxacin plus vancomycin and tobramycin should be used (Munford, 2001). Other factors to be considered are the presence of neutropenia or neutrophil count of less than 500 per microliter, splenectomy and history of intravenous drug abuse. These patients require appropriate antimicrobial cover based on their higher susceptibility to certain microorganisms.The immediate removal of the focus of infection is also important in the successful management of patients with sepsis. Sites of infection should be identified immediately and appropriate drainage should be done when possible. In patients with indwelling i ntravenous catheters, microbial cultures should be done and a new catheter should be placed in another site. Adequate hemodynamic and respiratory support should also be provided especially in patients with septic shock to prevent tissue injury secondary to ischemia. The pulmonary wedge pressure and central venous pressure should be monitored constantly. Metabolic support should also be provided. The urine output should be watched closely for oliguria and anuria. Diuretic therapy with furosemide may be used (Munford, 2001).Despite aggressive treatment, many patients with severe sepsis and septic shock succumb to the disease. Several new agents have been developed which should promising outcome in averting death. These are drugs that neutralize the bacterial endotoxin such as monoclonal antibodies to endotoxins and drugs that interfere with the mediators of inflammatory response such as monoclonal antibodies to tumor necrosis factor alpha. Another promising drug for severe sepsis is d rotrecogin alfa or recombinant human activated protein C which has shown antithrombotic, antiinflammatory, and profibrinolytic properties. A clinical study has shown that the drug significantly reduced the mortality in severe sepsis although due to its antithrombotic properties, the patients are at a higher risk of bleeding (Bernard, et al 2001).Further studies are necessary to better understand the pathogenesis leading to sepsis. The knowledge gained in these studies which further enhance the development of newer drugs with better safety profile. In addition, more clinical trials are important to assess the drug efficacy of existing drugs so that better management of sepsis can be formulated to improve the morbidity and mortality of the disease.

Racial Identity and Religion

Racial Identity and Religion Introduction Cultural differences can be explained using multicultural concepts that may include racial identity and religion. These two concepts can summarize the behavioral norms in both a single cultured and a multicultural society. Both concepts are important in enhancing the development of co-habitation in the contemporary fast growing world.Advertising We will write a custom research paper sample on Racial Identity and Religion specifically for you for only $16.05 $11/page Learn More Multicultural concepts do also come in handy in societal development especially when they tackle the subject in question on an interaction perspective. This is because development does not take place in single isolated variables. They take place in totality. This work gives a brief but comprehensive discussion of the two multicultural concepts which are quite significant in the understanding of cultural differences. Racial Identity It should be noted that the genesis of ra cial concepts is closely related to the classification of human beings. Many racial theories have attempted to demarcate and elevate one particular social group from others, thereby justifying the oppression and exploitation of certain ethnic groups who are presumed to be inferior. The inferiority concept here refers to the level of intelligence, degree of morality, physicality of the individuals in the social group and culture of the social group (Fedelina and Guido-Dibrito, 1999). As a result, there was the institutionalization of enslavement of Africans by the whites. Another act that is related to racialism is the terrorism committed against particular groups. Racial identity is the subjective sense of an invigorating sameness and continuity. The concept is known to interact closely with the social class, culture, gender and other biological factors. Racial identity takes on many forms. The concept begins during the early stages of childhood development and develops rapidly amon gst groups so visibly recognized by race. Such messages are conveyed through metacommunications which are subtle and often unspoken messages that are learned early in life and reinforced without the aid of spoken words. Thus, it may not emanate from the teachings of parents. This is pretty evident especially in racially integrated schools. In such schools, there are racially homogeneous eating areas in lunch rooms. The unspoken rule in these lunch rooms is that boundaries must not be violated. Thus, whites eat with whites; blacks eat with blacks, Hispanics with Hispanics and so forth. This instance explains the fact that even without parents verbal teachings on racial orientations, racialism can still be conveyed implicitly in racially segregated housing patterns and socioeconomic relationships.Advertising Looking for research paper on cultural studies? Let's see if we can help you! Get your first paper with 15% OFF Learn More As an individual matures, he or she develops a personality that is informed by social and moral attitudes, behaviors, and feelings. It should be noted that social and personality developments are strongly intertwined with racial presumptions that are learned through copying (Fedelina and Guido-Dibrito, 1999). This habit is internalized and further enhanced by the need to conform the prevailing racial norms so that the individual’s characters are socially acceptable. It is quite disheartening to understand that racial segregation still has its roots in the modern society. In places where race is still a powerful divider, sociocultural backgrounds and ethnical similarities do not matter a lot even if it is within the particular social group. The reality of sociocultural and ethnical similarities is quite irrelevant in such situations. A good example is the relationship between the Whites and the Blacks in America. Their cultural similarities are so obvious to people living outside the United States. However, racial spheres still exist and it is the major tool that obfuscates the two races. Religion Religion is the culture of a belief in a deity or a superior being that is believed to control natural phenomena among those who practice it. Religion concerns with nature and life’s purpose especially when viewed in the perspective of creation and a holy being (Culture and religion, 2010). Religion is actually a wide subject that requires extensive research concerned with the development of personalities in a multicultural society. There are so many religions at present and they include Islam, Christianity, Judaism, Shinto, Buddhism, Hinduism and Jainism among many others. The above are just the major religions. Otherwise, there are many other religions whose beliefs are practiced by fewer numbers of the population. In a multicultural society, it is quite difficult to enhance specific religious convictions. In the western society, for example, Caucasian, Afro-Caribbean, South Asian an d Chinese people jostle every street. The presence of these people comes along with different cultural and religious backgrounds. Such kinds of society are usually faced with the problems of decisions on how to adjust to make their own ways. Such people may insist upon many religious beliefs as essential tools for the satisfactory livelihood of the entire community in question. Thus, there must be a visible line that distinguishes between religion and culture is such a pluralistic society (Culture and religion, 2010).Advertising We will write a custom research paper sample on Racial Identity and Religion specifically for you for only $16.05 $11/page Learn More It is here that pluralism must take effect so as to take care of the various modes of freedom. These forms of freedoms include the freedom to believe or not to believe, and the freedom to conform or not to conform. Also in this system lies the freedom from the domination of one religious group. Religi ous beliefs are taught to children and enhanced through internalization and the need to maintain the individuality and character of the religion. Some people tend to be exclusivists by thinking that only their religion is right. Integration plays a major role in the adaptation and acceptance of different religious groups. It is through integration, adaptation and acceptance that a particular religious group may secure homes, incomes, and amenities together with other different groups. In many urban multicultural societies, religious affiliations have continued to diminish in use as a benchmark for public decision making. The act of assimilation in exclusivist societies is quite difficult taking into consideration that most of these societies come from rural backgrounds. Exposure to different religious beliefs other than ones own is a factor that plays a big role in acceptance of the other religions. However, it should be noted that integration of particular religious groups is quite different from assimilation. Assimilation is not easy when dealing with enhancement and maintenance of a particular religion. However, integration is quite easy because it comes along with acceptance that means trust. As it is well known, trust is not a threat to the society as a whole. Conclusion Many racial theories have attempted to demarcate and elevate one particular social group from others, thereby justifying the oppression and exploitation of certain ethnic groups who are presumed to be inferior. Racial identity is the subjective sense of an invariant sameness and continuity. The concept is known to interact closely with the social class, culture, gender and other biological factors. On the other hand, religion is the culture of a belief in a deity or a superior being that is believed to control natural phenomena among those who practice it. In a multicultural society, religion requires integration to develop the culture of acceptance and adaptability.Advertising Looking for research paper on cultural studies? Let's see if we can help you! Get your first paper with 15% OFF Learn More Reference List Culture and religion, (2010). Culture and Religion: Thoughts on Religion. Retrieved from cultureandreligion.com/html/thoughts_on_religion.html Fedelina, A., Guido-Dibrito, F. (1999). Racial and Ethnic Identity and Development. New Directions For Adult And Continuing Education. No. 84. Web.

Systems And Operations Management At Atokowa Essay

Systems And Operations Management At Atokowa - Essay Example Each organization has certain business objectives which are pursued through the operations of the organization. The success of an organization depends upon the efficiency of its decision making process and the execution of its operations. The systems and operations management in the organization helps the organization in achieving its objectives (Kolli 2000). The information system of the organization helps the organization collect and manage the information that is required for effective decision making and the operations management of the organization helps the organization conduct its operations in an effective and efficient manner (Slack & Johnston 2004). If the operations of an organization are performed effectively and efficiently, the organization would acquire its business objectives more easily. In order to make the operations of an organization efficient, the organization shall give high importance to the operations management (Greasley, 1999). ... There are numerous retail outlets being run by the company. The company also offers a facility to deliver stationery and office supplier directly to the organizations. The company also offers customized printing for organizations. The business of the company was initially established as photocopying business which later extended towards printing. The company prints; brochures, flyers, letterheads, business cards, compliments slips, memo slips, fax headers and NCR pads. The products by Atokowa are marketed to two distinct types of customers; the individual customers and the business customers. The retail outlets by the company offer products to both the individual customers and the businesses at the same time. The businesses make a significant proportion of the overall customer base of the organization. SYSTEMS AND OPERATIONS MANAGEMENT AT ATOKOWA From the study done on Atokowa, it can be inferred that the current systems management of the company does not provide sufficient and accur ate information regarding the type of market that generates most revenue. In order to make effective decisions, it is highly important for any organization to have complete and accurate information regarding its operations. The operations being conducted at Atokowa are also very complex. Invoices are generated after a complex formal procedure and the discounts are offered after significantly extensive paper work. In order to make the operations management at Atokowa more effective and efficient, the company may need to modify its existing information system that is called ASIS. The information system is outdated and with the introduction of new technology, the company may need to apply new information system in its organizational structure.

Implementing Lean Approach to Eliminate Non-value-added Activity Essay

Implementing Lean Approach to Eliminate Non-value-added Activity - Essay Example With regard to the second question, it was determined that the JIT significantly decreases the total NVA in the WSS when the huge stock level is declined. This causes the obvious reduction in the variable costs; for example, opportunity costs and warehousing costs. By contrast, the TPM results in better productivity and product quality due to the higher effectiveness of the machine, which is caused by better maintenance systems and practices. Concerning the third question, both external and internal factors are the obstacles and limitations of the Lean application. Ultimately, this pilot research study functions as a guidepost for manager’s of paperboard companies, as well as other continuous operation companies lacking adequate sufficient models, that are seeking means of applying Lean production mechanisms to their firm’s supply chain system. The term, ‘Lean Production’ or ‘Lean Manufacturing’, was first introduced in the seminal book, The Machine that Changed the World by Womack et al. (1990) in order to represent the evolutionary approach against traditional thinking from the 1920s, ‘Mass Production System (MPS)’. This method intends to add values on products or services from the customers’ perspective and enhance efficiency by eliminating wastes or non-value-added activities (NVAs) in the production or supply chain. It requires all people, both management and operational level, in the organization to take part in the improvement (Womack and Jones, 2003; Liker, 2004). The Lean was previously known as ‘Toyota Production System (TPS)’ after the company that developed it in the 1940s. This approach was behind the successful growth of Toyota and other Japanese manufacturers, especially in the 1980s (Ohno 1988; Shingo 1989; Liker, 2004).

Employment Business Law Coursework Example | Topics and Well Written Essays - 250 words

Employment Business Law - Coursework Example w their workers should spend their off hours from duty, the fact that the airline did not act from the previous cases of sexual harassment proves their liability in this case. Other New York torts of negligent hiring, retention and supervision of employees find the employer liable. Though the hotel rooms were not a property of the airline, the fact that they rent the hotel rooms for their employees proves their liability (England, 2012). It is evident that the woman was discriminated against because of her faith. Everyone has a right to worship in a religion of his or her wish and this should not be resulted into discrimination by others who do not believe in that religion. Thus, the court should decide that the company compensates the woman and gives her the job back. The reason is the manager and assistant manager of the store discriminated against her due to her Wiccan faith. They violated the law of religious discrimination and work situations in the title VII of the civil rights act of 1964. It states that under no circumstances should a worker be discriminated against in any aspects of hiring, pay, firing and any other aspects of employment. The manager terminated her job that inconvenienced the woman in question. It is important for an employer to give their employees a reasonable notice of termination. The fact that the store manager never formally disciplined the woman for her wearing the Wiccan medallion s howed that there was nothing wrong with it. However, they had to terminate her for allegedly missing a scheduled day at work that she was not aware of. The action was a way of eliminating the woman from the store due to her Wiccan

Todays Fashion Ltd.

Todays Fashion Ltd. Q1: Job analysis conducted by Mary for Todays Fashion ltd is inefficient. This is because a typical analysis of any job requires a combination of more than one method and/or approach in analyzing tasks to arrive at quality outcome. Employing a sngle method in analyzing any given tasks requirements in most instances brings inaccurate results owing to the perceived weaknesses of such a method. Such weaknesses have a dire impact on task and skills analysis procedures. Additionally, job analysis should be carried out by a professional with relevant specialization in hiring/recruitment procedures in order to ensure credible results of the entire analysis. As evidenced from the case study, Mary who is the pacific region sale manager has no formal education on job analysis or in particular personnel management training. Any job analysis carried by individuals with no formal training is likely to be inefficient. Training is paramount to the quality of output for any given task and/or activit y. Therefore, Marys experience alone does not qualify her to institute effective job analysis schedule. The method used by Mary is appropriate. However, the weakness of the overall analysis is brought by relying on one method to come up with the analysis. Additionally, relying on experience may be subjective and thus may not actually reflect the task requirements. Nevertheless, there are various strengths of the sales manager efforts. First, during the interviews, the interviewer can effectively describe himself to the people he is interviewing compared to other methods like questionnaires. Proper description of the task requirements will enable the interviewer to come up with proper conclusions regarding the job analysis. Interviews will help the interviewers to clarify issues which are not clear to the people being interviewed. Clarification of issues will enable the people being interviewed to give reliable answers to the interviewer. Also, interviews allow immediate response and interaction environment between the recruit and the employer, as compared to other methods like questionnaires. This boosts firms effort in driving needed conclusions for job analysis Just-in-Time. Interviews are also useful for complex questions that require intensive discussion which could not have otherwise be achieved through other method of job analysis. Interviews may also be modified to gather extra information needed to make conclusions as compared to other methods such as online recruiting which are static. However, Marys efforts have various weaknesses. First, interviews may lead to biased conclusions as the outcome of the entire procedure is pegged on subjective opinions such first-impression effects of the interviewer. Biased conclusion may affect the companys efficiency in selection and recruitment of human resources if the selection is based on the biased job analysis. Additionally, interviewing as well as employee skill scrutiny requires an interviewer with relevant skills and relevance for quality results, which Mary is devoid of. Therefore, the efforts employed by the sales manager may not yield the desired results. Moreover, interviews are time consuming and expensive. Also due to the large size of Todays fashions, interview carried out on the sample outlet may not represent the views of the 35 outlets that Mary is managing. Q2: Some of the factors that Mary ought to considered with more weight to improve her job analysis includes the frequency of specific tasks, skills, complexity and efforts exerted in performing various falling the assistant managers position, so as to effectively evaluate the competence and skills to sought during hiring. Also, in order to improver the quality of her analysis, Mary should consider the environment and job market dynamics in which the business is operating. Environment in most instances has a major impact on requirements in carrying out a given task. Work environment may include such as aggressive and hostile customers and extreme temperaments, among others. Consideration of work environment by the sales manager in job analysis for Todays fashion is crucial as it will help select store managers with good customer relations skills. Valuable customer relation is necessary for todays fashion ltd because some customers are aggressive and hostile, and therefore dealing with these types of customers requires high level of customer relations capacity. To improve the quality of analysis, Mary should also consider the equipment and tools needed to perform various tasks. For instance, if the stores records are to be maintained using a computerized system, the selection should include a manager with relevant information technology skills. Additionally, the sales manager should consider organization culture and strategy to improve her quality of analysis. An analysis that is consistent with the culture and laid down procedures usually yields positive returns for any given firm. Q3: Job description and specification prepared by Mary does not appear to be thorough. This is because the description fails to substantively spell out the role of the assistant manager in a given store department. An assistant manager has a significant degree of authority in making strategic decisions on store departmental issues under delegated authority from general stores manager. Additionally, under job specification, to effectively manage human capital in a given store Mary ought to posses some level of management skills. This is because the efficiency of management is directly proportional to the companys profitability and/or performance. In my opinion, the job specification and description criterion outlined by Mary does not form a substantive ground to form a basis of new selection criteria. This is because of the loopholes noted in the specification and job description schedule. For instance, the qualifications desired for the assistant store manager are inadequate, and no consideration has been made to include authority issues and duties scope. The documents prepared by Mary will work against firms goal attainment standards if sued for discrimination in recruitment of employees. This is because she restricts appointment to the people who have previously worked with the Todays fashion to some degree.

Managing COnflicts :: essays research papers

Scenario: Agency Issues in Negotiations Al and Bob entered the third meeting with some confidence. As the representatives for Symbiot Services (SS), they had hammered out some detailed language with the Department of Natural Resources (DNR) that would meet all of the prior objections raised during negotiations by the agency, and would still assure SS a reasonable profit for the services that SS would provide. Al had been the primary negotiator for SS. Bob was now entering the negotiations to provide the final legal fine points to the agreement in principle, and to thereafter give the legal department ¡Ã‚ ¦s blessing to the agreement. On the other side of the table, Rhonda and Sarah unpacked their notes meticulously. Rhonda, DNR ¡Ã‚ ¦s primary negotiator, had worked with Al to identify all the issues raised by the respective organizations and craft an agreement that weaved together all the parts into an effective agreement. Sarah had joined Rhonda for this meeting to sign off for the States Attorney Office, putting the legal seal of approval on what had been written. While Sarah and Bob unloaded their papers and books, Al and Rhonda chatted about how difficult it had been to identify all the issues raised at their respective home offices, then figure out how things could be addressed in a way agreeable to both sides, and then reduce the entire wall of post-it notes, taped copies of e-mails, and highlighted letters to a readable document. Because they are the talking links between their organizations, Al and Rhonda had to almost personally bridge the gaps between the organizations, and often it seemed they were a team of their own, arguing with the two  ¡Ã‚ §home teams. ¡Ã‚ ¨ The last sticking point had been the issue of how much SS would discount its regular charges for services. DNR was a very big customer and expected to get the bulk discount for services. The DNR had wanted a 50% reduction from the regular rate; SS had offered 10%, and they had finally settled on a 25% rate reduction for this contract, in the interest of providing a break to taxpayers. Both Al and Rhonda were careful to obtain e-mailed or hard copy approval of the 25% rate reduction from their bosses, because neither had the authority to set unique rates unilaterally. Sarah, representing DNR, brought the meeting to focus by reciting the issues that had been resolved, and asked SS if it had any final issues to resolve before declaring the final document completed.