IBM Essay Example | Topics and Well Written Essays - 1000 words

IBM - Essay Example The company and employees welcome change as the main driver of success and profitability. IBM has 32 leaders responsible for certain organizational activities and performance. Customers and technology are the primary driving factors in this arena. Customers want products that satisfy their needs or improve their productivity. IBM looks for ways to deliver these benefits at a lower cost, smaller size, and higher speed. Operating within an industry with this kind of rapid change presents several challenges for personal computer and notebooks, namely production costs, intellectual property owners, and monopolies. In general, IBM is one of the profitable Corporations today and, as predicted, in future (Bellis, 2001). Strengths of IBM Corporation include knowledge, relationships, selling and history. The challenges of the company are based on high quality of products and services. Direct sales force maintains a relationship. Among the weaknesses are high competition and rapidly changing technology market. The innovative PC technology is not cheap and that is why not all the potential customers can afford it today. IBM, in contrast to Dell Corporation, tries to maintain high standards of service proposing and selling (the most important) to its customers high quality products. Taking into account his vision of the company, it is possible to say that central planning and negotiating inputs from might have gone, but there remained the assumption that some other agency would solve the problems: an assumption the CEO himself appeared to share. All of this was taking place within a structure which remained hierarchical, with little involvement of junior management or the workforce, who believed that their product could only sell locally and clung to the assumption that they could sell everything they could produce. All of the IBM leaders participate in the change

The Marketing Plan (optional company your pick) Research Paper

The Marketing Plan (optional company your pick) - Research Paper Example 1- 6). McDonalds primarily targets children and young adults for its products. This as a result identifies three major categories of the company’s audience. The first category is parents who take their children to restaurants. Another category consists of grown up children and youths who visit the stores on their own. Adults on tight work arrangements also form part of the company’s target population (McDonalds, p. 3). McDonalds’ pricing strategy is based on continuous research that identifies customers’ perceived value of its products. The company, as a result, builds its image and develops loyalty and utility among its customers. This is then used to determine prices at which customers are willing to pay for the products. Though the food industry is competitive, the company does not adopt pure price reduction because of it has marketing disadvantages (McDonalds, p. 5). The company is majorly a retail enterprise and focuses its distribution channels to its outlets. Strategic location of its outlets is therefore the main element of its product distribution (McDonalds, p. 1). McDonalds adopts a diversified approach to promoting its products. Its promotional initiatives include advertisements, â€Å"sales promotions, point of sales display, merchandising, direct mail, telemarketing and loyalty schemes† among others (McDonalds, p. 5). Advertising also employs different media forms that include print media in posters and magazines, audio media such as radio stations, and audiovisual media (McDonalds, p. 5). McDonalds major marketing strengths include its brand imaging and research based marketing strategies. Its major weakness is lack of innovation that leads to monotony in its product mix (McDonalds, p. 3). Wallace and Forte explains that a good market plan is economical, precise, â€Å"simple and easily understood, informative and customer oriented†

Reflection papers Essay Example | Topics and Well Written Essays - 250 words

Reflection papers - Essay Example Many local musicians continually win international fame in the music arena owing to their sensational music that hits the global audience. For instance, the up-tempo Arabic tune of Princess Diana remains acclaimed piece of art that has influenced the nature of the Western music especially in San Francisco (Tomasino 2005). Music pervades the limits of the artistes region and receives global attention depending on the ability of the singer to coin the message of the songs in a manner that suits the diverse audience. Recent progress in the music industry however gives the impression that music artistry has become more audience-demand motivated than self-manipulative. Despite the remarkable progress made in the music industry, music piracy remains a public concern for the American music (Tomasino, 2005). Piracy takes the form of sales of illegally recorded music and general illegal acquisition of music segments without the consent of the songwriter. Furthermore, reception of global music threatens to scuttle the dominance of local music in various regions, though music domination has to be responsive to the changing audience base that has the access to a variety of international music. It is undeniable that piracy threatens the progress in the music industry yet its progress is dependent on the rewards that the artistes gain from their music. The music industry is obliged to remain manipulative and more responsive to changes in the global audience expectations in order to retain

Controversy Japanese Internment Camps Research Paper

Controversy Japanese Internment Camps - Research Paper Example were not included in these camps (Joy, p104). The President of United Stated Franklin D. Roosevelt declared war with Japan on December 7, 1941 after the Japan’s attack on the Pearl Harbour. After this declaration situation became worst for the Japanese living in the United Stated and most of them had to go through extremely tough time that they had never thought about. The President allowed the removal of all the Japanese from their homes to the guarded camps established in the interior part of the country. In this way the Japanese living in United States had to pay very heavy cost of Japanese attack on Pearl Harbour and getting United States involved in the war (Karen, p183). During this process, over 120,000 Japanese were taken out from their homes in United States and they were forces to leave their houses, work places, businesses and lives they were living in US. They were moved to the camps that were mostly set up in the desert areas with little facilities of life. There was no running water around the camps and the imprisoners were all time surrounded by barbed wires and guards. The establishment of these camps and moving the Japanese descents in these camps was a highly controversial step taken by the government of United States and the action started up heated and prolonged debate about the justification of the action taken by the U.S government. The government of United States put forward their stance that they had the fear of further attacks from Japan on their territory and they see the danger of presence of Japanese descent spying for Japan. They justified the establishment of camps that the step was taken to avoid the possible support provided by the Japanese American to their homeland by providing information to the Japanese or though different assets and cooperation (Nash et al, p92). Despite this justification the experts and people widely opposed the act of United Stated to detain the Japanese American in these camps and the justificatio n given by the U.S. government was also rejected. It was argues from the other side that almost two third of the interned were American citizens and half of the people kept in the camps were children. There were no evidences to prove the involvement of these people in the spying activity neither there were sign of disloyalty for America shown by these people. These camps were also criticised for providing poor living conditions to the detainees. It was reported that the people had problems in getting access to fresh water. The weather was extremely harsh and the environment of the camps was also very hostile and antagonistic. The members of the families were separated from each other and they were kept in different camps from where they found it impossible to contact their family members and reunite with them. Throughout the war there were just ten people found accused to spying for Japan and over 120,000 people were kept in the camps just because of doubt of spying and disloyalty ( Daniels et al, p54). The government of United States clarified that the step was necessary to strengthen the position of America in the war by eliminating the possibilities of spying and internal support to Japan from America but it is widely believe that it was just a cover used to justify the action and in real the step was led by racism and biasness for the Japanese Americans. The detention of Japanese Americans also became matter of

Questions to answer on Management Essay Example | Topics and Well Written Essays - 3250 words

Questions to answer on Management - Essay Example The patent right enables an individual to own the idea or invention for substantial period of time so that it can be developed sufficiently into a real invention or business. Patent rights provide protection for the idea or invention from being copied or reproduced by others. Firstly, the idea or invention has to be explained in brief through an application made to the Government Patent Office by an agent or lawyer. This will be reviewed and approved if original and new. Once the first application is approved, a date will be given to the application during which he/she can work on the idea; this date is referred to as the ‘priority date.’ Once approved, a plan for its development must be prepared and produced to the patent office for further approval within 12 months. During this period, the inventor can advertise or publish the idea. After one year, the inventor needs to produce a detailed plan for its development, which is referred to as the ‘Final Specification. ’ If this idea is completely new and does not match with any of the other patents, then it is approved. If it finds any similarities with others, it is rejected. Rejection is accompanied with sufficient explanation. The applicant can also modify it in case it resembles any other idea. If the inventor fails to abide by the confidentiality of the idea or leaks the idea in some way, the patent will be subject to cancellation. Hence, confidentiality is very important during the period when first application is sent for approval. Secondly, if the idea or invention resembles or already exists in the market, then patent rights may be rejected. Patents applied in the United Kingdom are valid only within that country. To obtain patent protection in different countries, separate patents must be filed according to the respective country’s regulations. Obtaining international patents are very expensive. However, the International Convention on Patents provides a common priority da te for all patents during which ideation and development in different countries can be prepared. One common committee governing European patents is the European Patent Office (EPO), which provides patent protection in all European countries at the same time. Hence, patents issued by the EPO are enforceable by individual nations within the European Union and few other countries that come in the purview of EPO. Moreover, the patents issued by the EPO are governed by laws related to various international committees. Patents are divided mainly into 3 categories namely utility patents, design patents, and plant patents depending upon the idea or invention. In the engineering sector, utility and design patents are more common ones. National patents issued within European countries are governed by national legislation and could include aspects related to filing the patents, examination, scope of grants, invalidation, breach and revocation. Patents obtained on methods or ideas related to pr ocedures and certain products are not same in all countries. For instance, patents approved in the United States for certain products or procedures may not be approved in the United Kingdom and other countries. Under an employment agreement, ideally all inventions that are made during the employment and related to the job during working hours and with the use of official resources are owned by the employer. Therefore, if an employee invents something related to his/her job, then the rights to that invention are with the

Private School vs Public School Essay Example for Free

Private School vs Public School Essay Many public school facilities are impressive others are mediocre. The same is true of private schools. In the public school system, the twin engines of political support and economic revenue base are critical. In private schools the ability to attract endowments and other forms of financial support are just as critical. Private school facilities reflect the success of the schools development team and that of the school to continue to generate alumni support. Some private K-12 schools have facilities and amenities which surpass those found at many colleges and universities. Hotchkiss and Andover, for example, have libraries and athletic facilities on a par with those at Brown and Cornell. They also offer academic and sports programs which make full use of all those resources. It is hard to find comparable facilities in the public sector. They are few and far between. Public schools also reflect the economic realities of their location. Wealthy suburban schools will have more amenities than inner city schools as a rule. Think Greenwich, Connecticut versus Detroit, Michigan, for example. So, who has the edge? Lets call it a draw, all things considered. Class Size: According to the NCES report Private Schools: A Brief Portrait private schools win out on this issue. Why? Most private schools have small class sizes. One of the key points of private education is individual attention. You need student to teacher ratios of 15:1 or better to achieve that goal of individual attention. On the other hand a public system has to take almost anyone who lives within its boundaries. In public schools you will generally find much larger class sizes, sometimes exceeding 35-40 students in some inner city schools. At that point teaching rapidly degenerates into babysitting. Teaching: Public sector teachers are generally better paid. Naturally compensation varies widely depending on the local economic situation. Put another way, its cheaper living in Duluth, Minnesota than it is in San Francisco. Unfortunately low starting salaries and small annual salary increases result in low teacher retention in many public school districts. Public sector benefits have historically been excellent; however, health and pension costs have risen so dramatically since 2000 that public educators will be forced to pay or pay more for their benefits. Private school compensation tends to be somewhat lower than public. Again, much depends on the school and its financial resources. One private school benefit found especially in boarding schools is housing and meals. Private school pension schemes vary widely. Many schools use major pension providers such as TIAA-CREF Both public and private schools require their teachers to be credentialed. This usually means a degree and a teaching certificate. Private schools tend to hire teachers with advanced degrees in their subject over teachers who have an education degree. Put another way, a private school hiring a Spanish teacher will want that teacher to have a degree in Spanish language and literature as opposed to an education degree with a minor in Spanish. Budgets: Since local property taxes support the bulk of public education, the annual school budget exercise is a serious fiscal and political business. In poor communities or communities which have many voters living on fixed incomes, there is precious little room to respond to budget requests within the framework of projected tax revenue. Grants from foundations and the business community are essential to creative funding. Private schools on the other hand can raise tuition, and they also can raise significant amounts of money from a variety of development activities, including annual appeals, cultivation of alumni and alumnae, and solicitation of grants from foundations and corporations. The strong allegiance to private schools by their alumni makes the chances of fund-raising success a real possibility in most cases. Administrative Support: The bigger the bureaucracy, the harder it is to get decisions made at all, much less get them made quickly. The public education system is notorious for having antiquated work rules and bloated bureaucracies. This is as a result of union contracts and host of political considerations. Private schools on the other hand generally have a lean management structure. Every dollar spent has to come from operating income and endowment income. Those resources are finite. The other difference is that private schools rarely have teacher unions to deal with. Advantages and disadvantages: There are many advantages and disadvantages to both public and private schools. As a parent, both options must be explored and the choice must be based on what is right for each particular child. Public schools often have a larger variety of subjects available, especially when it comes to electives. However, what is learned is somewhat decided by the state because public schools need to do well on standardized testing. Private schools, on the other hand, whether parochial or private have much more freedom of choice in curriculum and can choose to make their own assessments. Because of the individualized instruction, private schools tend to do generally better on standardized testing, that is, if they choose to use it. Private schools, many times, have more demanding curricula and have a higher rate of students who go on to attend college. Public schools are larger and also have larger class sizes. Public schools also have larger student-teacher ratios. According to a web site called Public School Review, Private schools average 13 students per teacher, compared with an average of 16 students per teacher in public schools (public school review). However, public schools have certified teachers. Private schools typically have teachers who are not state-certified and who may not have expertise in their subject matter. The biggest difference between public and private schools probably is that public schools are required to educate all students. They cannot deny any student admission. On the other hand, private schools have complete control about which they accept and can kick students out much more easily. Public schools are funded by tax revenue whereas private schools are funded privately. That means private schools cost money to attend called tuition. Taxpayers pay for public schools so the payment is included in what people pay. However in private schools, the payment is upfront for students to attend. Overall, there is no one right answer for which kind of school a student attends-public or private. The decision must be made for each individual student as there are advantages and disadvantages of both. Comparisons: Private school can be more beneficial than going to a public school. Private schools focus on preparing students for the next level of education; public schools are focused on test preparations sessions. Choosing the right school system for your child has a repercussion towards their future education. In the public school system the classrooms are overcrowded with students. Each class has an average of 27 to 30 students to it, which can limit the ability of one on one interaction with the teacher. A lot of the bullying issues come from the unstructured dress codes. This can create social divide to the less fortunate kids that can’t afford all the name brand items. In public school teachers are quick to say your child needs to be on medication if they are high strung, without knowing what other forms of issues might be occurring in the home. When parents try to discipline their child at home the school seems to always try to step in. Some things should be up to the parents to handle without haven to worry about the school stepping in. In the private school system when a child enters the school for the first time he or she will start out with a minimal class size with no more than 20 students. This allows more one on one time with the teacher, it also opens up more time for activities. The private school has a very strictly enforced dress code to eliminate animosity between the students. The schools are very family oriented with parents and students being involved with school activities. Teachers and parents are held to higher standards from the private schools. Teachers are expected to continue to grow and parents are obligated to maintain discipline of their children even in their absence. The testing that takes place at private schools is called Terra Nova, and kids are tested two or three times a year. Conclusion So, who comes out on top? Public schools or private schools As you can see, there are no clear-cut answers or conclusions. Public schools have their advantages and disadvantages. Private schools offer an alternative. Which works best for you? Thats the real question which you have to answer.

Rebound Tenderness in Diagnosis of Appendicitis in Children

Rebound Tenderness in Diagnosis of Appendicitis in Children Abdominal pain is a common presentation within the accident and emergency department [A+E] and specialist nurses working in this environment need to be familiar and confident in dealing with this presentation (Hibberts and Bushell 2007, Pines, Pines, Hall, Hunter, Srinivasan and Ghaemmaghami 2005). Abdominal pain can be associated with a wide variety of surgical and nonsurgical conditions, with the most prevalent cause being acute appendicitis (Lin, Chen, Chung, Ho, and Lin, 2009). The diagnosis of appendicitis is formulated from subjective and objective data including a patients history, abdominal examination, laboratory investigations and signs and symptoms. This assignment will critically analyse the clinical skill of testing for rebound tenderness and its relevance to diagnosing appendicitis in children. The clinical diagnosis of acute appendicitis in children is difficult for many practitioners (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Between the years 2008 and 2009 the number of patients presenting to A+E within the UK who were diagnosed with appendicitis was 44,244 (NHS Information Centre, 2009). This equates to almost 0.3% of all presentations in A+E over one year. Approximately 9,300 of this population were between the ages of 0 and 14 years old (NHS Information Centre, 2009). However up to 25% of these 9,300 children with suspected appendicitis have a normal appendix at operation (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor, and Fishman, 2004). Furthermore, the 25% of paediatric negative appendectomies now result in considerable clinical and economic costs to the NHS (Koepsell, 2002). These substantial figures are one of the primary reasons for specifying this assignment on children. In addition, the scope of practice within A+E covers paediatrics for many adult q ualified nurses and adult trained nurse practitioners. It is therefore imperative that the knowledge base for all A+E staff encompasses paediatrics at an advanced level as well (Cleaver, 2003). The overall accuracy for the clinical examination in diagnosing acute appendicitis has been reported to be between 54% and 70% in children (Birkhahn, Briggs, Datillo, Van Deusen and Gaeta, 2006). In addition Whisker, Luke, Hendrickse, Bowley and Lander (2009) suggest that only 4% of children have a miss-diagnosis of appendicitis in specialist paediatric centres, compared to 20% in district general hospitals. Despite the uncertainty of the diagnosis and the cost of miss-diagnosis to the NHS, appendicitis requires urgent treatment (Williams, et al., 2009). This is due to the risk of perforation, which occurs in approximately one third of cases in children (Neilson, et al., 1990). Therefore the need for a good clinical assessment at first contact in A+E is needed to provide a correct management plan and reduce on costs for the NHS. An abdominal examination should be performed where possible in a warm, well lit room with the patient well-draped and relaxed (Bickley, 2009). Initially the practitioner should undertake inspection, auscultation and percussion of the whole nine sections of the abdomen (Lippincott Williams and Wilkins, 2008). The final aspect of the abdominal examination should be palpation as this has the potential to be the most painful (Allan, 2008). Palpation is a process which should always be commenced away from the site of pain, as this will allow the patient to gain some reassurance from the practitioner and help them to relax (Bickley, 2009, Hibberts and Bushell, 2007). The practitioner should utilise the palmer surfaces of the fingers to identify any abnormal signs (Bickley, 2009). More specific palpation techniques can help to diagnose appendicitis, such as rebound tenderness (Bickley, 2009). This is performed by pressing slowly and firmly to a specific area and then withdrawing them quickly (Bickley, 2009). Practitioners should observe the patient and ask if pain was worse on pressing or letting go (Hibberts and Bushell, 2007). However, Bickley (2009) suggests that if any of the previous examinations such as light or deep palpation are positive then this should not be undertaken as it will cause undue pain for the patient. The whole process of abdominal examination in children follows the same system as in adults. However, the causes of abdominal pain in children are often different, encompassing a broad range of acute and chronic diseases (Bickley, 2009). Therefore it maybe pertinent to suggest that more emphasis should be placed special techniques such as checking for rebound tenderness rather than abdominal palpation and testing for rebound. The initial discovery and accreditation of rebound tenderness (also known as Blumbergs sign) is credited to a German surgeon called Jacob Moritz Blumberg (1873 1955). Many articles make reference to Blumbergs sign; however there appears to be no relevant literature, research or evidence base to support this surgeon was the gentleman who discovered this sign (Mantzaris, Anastassopoulos, Adamopoulos and Gardikis, 2008). A study undertaken by (Williams, et al., 2009) showed that out of 98 children who had acute appendicitis 91% had right lower quadrant tenderness on palpation however only 30% had rebound tenderness. Another study by Lin, Chen, Chung, Ho, and Lin (2009) also suggested that 43.4% of the 53 children examined with appendicitis had rebound tenderness. So both these studies suggest that positive rebound tenderness is an indication of an acute appendicitis in children and therefore cannot be ruled out of an initial differential diagnosis. Golledge, Toms, Franklin, Scriven and Galland (1996) specifically evaluated the â€Å"cats eye symptom† (pain going over a bump in the road), the cough sign, right lower quadrant pain to percussion, rebound tenderness and guarding. The data from this evaluation suggested that rebound tenderness had a likelihood ratio of 7.4 compared to the other signs which had likelihood ratios of between 1.1 and 4.1. This data therefore suggests that rebound tenderness is a very useful sign in the diagnosis of acute appendicitis, but that the other signs and symptoms are not (Moyer, et al., 2001). Overall rebound tenderness is useful sign for diagnosing appendicitis when there is a high suspicion of appendicitis and is accompanied with other diagnostic indicators (Moyer, et al., 2001). Another presentation to be considered in relation to abdominal pain and rebound tenderness is the duration of the pain experienced by the child. A study undertaken by Oshea, Bishop, Alario and Cooper (1988) involved 246 children from 13 to 18 years old who presented to the emergency department with a history of less than one week of abdominal pain. Results showed that the likelihood ratio of pain was greater when the child had the pain for more than 12 hours (Likelihood ratio: 1.3) compared to less than 12 hours (Likelihood ratio: 0.64). Later in the study pain duration was evaluated at less than 24 hours and more than 24 hours, with their likelihood ratios being 0.83 and 1.2 respectively. When compared to Andersson, et al. (1999) study of 502 patients aged 10 to 86 the greatest likelihood ratio was 1.7 at 7-12 hours after onset of pain. Based on both studies it is very difficult to see how duration of pain can lead to the diagnosis of appendicitis. Therefore, practitioners must not allow the duration of pain to prevent any further investigation into the diagnosis (Moyer, et al., 2001). Another symptom which could possibly indicate the diagnosis of appendicitis is fever (Gwynn, 2001). Cardall, Glasser and Gusss (2004) study evaluated two hundred and ninety three people aged between 7 and 75 who presented to the emergency department with suspected appendicitis. Temperatures were classed at greater than 99oF or less than 99oF. The study showed that 27% of patients whos temperature was 99oF. When the results were analysed in terms of specific temperature intervals, the highest likelihood ratio (3.18) was found in patients with temperatures greater than 102  °F. However, Bergerons (2006) study on clinical judgement suggests there is no clinical value with temperature as there is minimal sensitivity and specificity in the diagnosis of appendicitis. Therefore, as with duration of pain duration and levels of WBCC, temperature as a single entity has little diagnostic utility in the diagnosis of appendicitis unless it is combined with other signs and symptoms such as rebou nd tenderness (Cardall, Glasser and Guss, 2004). For many years laboratory tests such as white blood cell count (WBCC) leukocytes and C-reactive protein (CRP) have been used to support a diagnosis, but the considerable overlap with other inflammatory conditions accounts for the low specificity and positive predictive value of these tests (Stefanutti, Ghirardo and Gamba, 2007). Recent studies on adult patients who present with clinical signs and symptoms indicating acute appendicitis, show that appendicitis can be excluded if both leukocyte count and C-reactive protein value are normal (Gronroos, 2001). However, Stefanutti, Ghirardo and Gamba, (2007) suggest that only a few studies have been reported in paediatric patients and the role of WBCC and CRP in excluding acute appendicitis in children has not been confirmed. According to Andersson et al. (1999) children who present with signs and symptoms of appendicitis such as rebound tenderness and have a WBCC of 15000 only moderately increases the estimated risk of appendicitis. This t herefore shows that only at the extremes of the WBCC does this diagnostic indicator appear useful (Moyer, et al., 2001). Therefore, contrary to adult patients, normal leukocyte count, WBCC and CRP value cannot effectively exclude acute appendicitis in children. Another usual predictor of appendicitis is vomiting (Bergeron, Richer, Gharib and Giard, 1999). The study by Andersson et al. (1999) calculated the likelihood ratio for appendicitis in a patient with vomiting compared to one with no vomiting to be 1.8. In addition Reynolds and Jaffe (1992) study suggests that a combination of four predictors including; vomiting right lower quadrant pain, abdominal tenderness, and abdominal guarding. More specifically 97% of the 377 children studied who were diagnosed with appendicitis had two or more of these predictors. Therefore, a patient who presents to A+E with less than two of the above predictors is quite unlikely to have appendicitis. Alvarado (1986) conducted a retrospective study of 305 patients hospitalised with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analysed for specificity, sensitivity, predictive value, and joint probability.Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain (Alvarado, 1986). This scoring system shown below is deemed by many surgeons as an easy aid for supporting the diagnosis of acute appendicitis (Khan and Rehman, 2005). A study undertaken by Baidya, Rodrigues, Rao and Khan (2007) investigated the diagnostic accuracy of Alvarado scoring system. The results showed that a score of >7 for an appendicitis was 88.2% correct in diagnosis. However, the diagnostic accuracy of an Alvarado score Despite recent advances in knowledge and diagnostic investigations, a population-based analysis in the United States found that the incidence of unnecessary appendectomy has not changed (Flum, Morris and Koepsell, 2001). Therefore to increase diagnostic accuracy, new modalities such as ultrasound scans have been introduced (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Kaneko and Tsuda (2004) conducted a 10-year study using ultrasound scans to diagnose appendicitis in children and are convinced that ultrasound scans can identify inflamed appendices with 100% sensitivity and can also determine the severity as well. However Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman (2004) suggest that the use of ultrasound has not decreased negative appendectomies as similar negative rates were present over a decade ago. Therefore on the basis of the available evidence, patients presenting to A+E with a strong clinical case of appendicitis should be referred direct to the surgeon without an ultrasound. In addition to the use of ultrasound scanning the use of computed tomography (CT) has been recently studied and evaluated. There are currently two perspectives in the literature regarding the use of CT scan for the diagnosis of acute appendicitis: one supporting its routine use due to the decreased incidence of negative appendectomies, and the other one against its routine use due to the increased cost and delay in surgical management (Ceydel, Lavotshkin, Yu and Wise, 2006). In addition the benefits of imaging eliminating inpatient observation and unnecessary surgery must be weighed against the malignancy risk from radiation, as well as discomfort of rectal contrast administration (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman, 2004). Ceydel, Lavotshkin, Yu and Wises (2006) retrospective study showed that the negative appendectomy rate was much less in patients who had CT scans (7.6%) compared to the non CT scan group (24%). Therefore clinicians within A+E use their cl inical judgement and place emphasis on the importance of routine history and an accurate physical examination utilising CT scans for atypical cases of acute appendicitis (Gwynn, 2001). Currently within the A+E department there is no specific pathway or tool for ruling in acute appendicitis in paediatrics. In addition Birkhahn, Briggs, Datillo, Van Deusen and Gaeta (2006) suggest that no major medical association or professional organisation currently endorses a standardised pathway for the evaluation of patients with suspected appendicitis. With up to 25 % of children having negative appendectomies it is therefore of clinical and financial value to consider the use of a scoring system to admit or discharge children who present with a possible acute appendicitis. Current systems are in place for other potential conditions such as myocardial infarctions, pancreatitis and pneumonia. These other systems have been audited locally and nationally and are currently working well within the trust, therefore the plans to introduce the Alvarado scoring system will be put forward in the next review of clinical practice meeting between nursing and medical staff. To conclude, this assignment demonstrates that for an emergency department practitioner in a fast paced A+E setting, the accurate diagnosis of acute appendicitis remains a challenge for the paediatric age group. An accurate history and physical examination, which as highlighted can be challenge in younger patients plays an important role in the diagnosis of early acute appendicitis (Mallick, 2008). Physical clinical signs elicited upon examination provide the practitioner with a good insight to expected diagnosis. However, the usefulness of rebound tenderness as a single examination has minimal clinical value. The whole patient picture which encompasses an accurate history, clinical examination, laboratory investigations and possible diagnostic imaging is therefore vital to providing a correct diagnosis. The use of clinical scoring systems like the Alvarado score can be a cheap and quick tool to apply in emergency departments to rule in acute appendicitis. This scoring system includes many aspects such as clinical history, rebound tenderness and laboratory investigations. This allows for observation and critical re-evaluation of the evolving clinical picture. Its application improves the overall diagnostic accuracy and consequently reduces negative appendectomies (Khan and Rehman, 2005). In clinical cases where the practitioner is unsure if the actual diagnosis is acute appendicitis other diagnostic imaging studies such as ultrasound and CT may be undertaken. 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