An audit looking at how many patients are with thyroid dysfunction

An audit looking at how many patients are with thyroid dysfunction What is the function of thyroid gland and thyroid hormones The thyroid gland is located in the anterior part of the neck, attached to the thyroid cartilage. It consists of two lobes, approximately 5 cm each, that lie either side of the trachea joined in the middle by an isthmus. The thyroid gland is responsible for the production of three thyroid hormones: Calcitonin (involved with calcium homeostasis), Thyroxine (T4) and Triiodothyronine (T3). Everyday, approximately 100  ¿Ã‚ ½g of T3 and T4 are secreted 90% of which are in the form T4. Most of T4 is later converted to T3 in the liver and Kidneys. T3 is 10 times more active than T4. [1] The thyroid hormones are responsible for the control of basal metabolic rate. Expand? How is Thyroid hormone regulated The functional unit of the thyroid is the follicle. A spherical arrangement of secretory epithelial cells around a protein rich colloid. It is at this cell-colloid boundary that thyroid hormones are formed by iodination of thyroglobulin formed from tyrosine.[1] The follicular cells are involved in active absorption of iodine from the plasma which is required for thyroglobulin synthesis. The formed thyroid hormone is stored in the colloid until its secretion is triggered by thyroid stimulating hormone from the anterior pituitary which triggers the degradation of thyroglobulin in the follicular cells to release thyroid hormone. Thyroid hormone secretion is under the control of the hypothalamic-pituitary axis. The hypothalamus releases Thyrotrophin Releasing Hormone (TRH) which stimulates the anterior pituitary to secrete Thyroid Stimulating Hormone (TSH). The TSH reaches the thyroid where it binds to the TSH receptors on the surface of the follicular cell, stimulating it to produce and release thyroid hormones. The homeostasis of thyroid hormone concentration is maintained by a negative feedback loop whereby increased concentration of thyroid hormone inhibits Thyroid Stimulating Hormone release from the anterior pituitary by decreasing the affinity for TRH. This leads to a decrease in TSH causing reduced amount of thyroid hormone to be released by the thyroid gland. This feedback loop enables us to monitor patients on thyroid hormone replacement therapy (such as Levothyroxine) by measuring TSH levels. If for instance the prescribed dose is insufficient, it would lead to inadequate inhibition of the pituitar y gland and a raised serum TSH level. The reverse would occur with levothyroxine excess. () This cannot be done in patients with secondary hypothyroidism. So what do we do then? Common pathologies Thyroid disease is the second most common endocrine disorder after diabetes.  ¿Ã‚ ½ Hypothyroidism Hypothyroidism is defined as an underactive thyroid gland leading to decreased levels of T3 and T4. The annual incidence of hypothyroidism in the UK is 4 per 1000 in women and 0.6 per 1000 in men.[3] Symptomatic hypothyroidism is known as myxodema. Hypothyroidism is categorised into primary and secondary. Primary hypothyroidism results from disease processes affecting the thyroid gland itself, slowly decreasing thyroid function and thyroid hormone production. Onset of symptoms is therefore gradual, developing over months or even years. Secondary hypothyroidism is relatively uncommon. Secondary hypothyroidism develops when the pituitary is unable to produce enough TSH to induce enough T3 and T4 production from the thyroid gland. The causes of secondary hypothyroidism can include a pituitary tumour. Patients with hypothyroidism could present with a number of signs and symptoms including:  ¿Ã‚ ½ Tiredness  ¿Ã‚ ½ Somnolence  ¿Ã‚ ½ Slow cognition  ¿Ã‚ ½ Cold Intolerance  ¿Ã‚ ½ Depression  ¿Ã‚ ½ Bradycardia  ¿Ã‚ ½ Weight gain  ¿Ã‚ ½ Calf stiffness  ¿Ã‚ ½ Menstrual disturbance  ¿Ã‚ ½ Carpal tunnel syndrome  ¿Ã‚ ½ Hearing impairment  ¿Ã‚ ½ Dry, thin and pale skin  ¿Ã‚ ½ Puffiness below the eyes  ¿Ã‚ ½ Bradycardia The most common cause of primary hypothyroidism in the UK is autoimmune thyroiditis. In Hashimoto ¿Ã‚ ½s thyroiditis autoantibodies are produced against thyroglobulin. This leads to inflammation of the thyroid gland as it is infiltrated by lymphocytes causing goitre formation. Hashimoto ¿Ã‚ ½s thyroiditis is remarkable in this respect that it initially causes hyperthyroidism as inflammation of the thyroid gland releases stored thyroxine. Once this released thyroid hormone is metabolised the patient progresses to normal and then a hypothyroid state. [1] Other notable causes of hypothyroidism include:[4]  ¿Ã‚ ½ Iatrogenic: Radioiodine ablation or thyroidectomy as a treatment for hyperthyroidism  ¿Ã‚ ½ Thyroiditis: Subacute (de Quervain ¿Ã‚ ½s) thyroiditis  ¿Ã‚ ½ Drugs: Lithium, Amiodarone, thalidomide, rifampicin and sutinib as well as drugs used in the treatment of hyperthyroidism  ¿Ã‚ ½ Iodine deficiency: common in some developing countries but very rare in the western world At the opposite end of the spectrum lies Hyperthyroidism where there is increased Free T4 and a reduced level of TSH and has the opposite effect on the body than the one noticed in hypothyroidism e.g. tachycardia, heat intolerance etc. Hyperthyroidism is not covered further as this audit focuses on hypothyroidism. Diagnosis and treatment Symptoms of hypothyroidism are quite non-specific and can commonly occur with other medical conditions not related to the thyroid. Diagnosis of hypothyroidism therefore should not be made on clinical symptoms alone and it is essential to test thyroid function biochemically. This is done by measuring Thyroid Stimulating Hormone and Free Thyroxine (T4) in blood. The normal reference range for TSH is 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4] A TSH level within the normal reference range has over a 99% predicted value to rule out primary hypothyroidism or hyperthyroidism.[5] In hypothyroidism the patient would have a high Thyroid Stimulating Hormone level, with or without a low Thyroxine level. Depending on thyroid function tests hypothyroidism is further divided into: a) Overt hypothyroidism: patients with a high Thyroid Stimulating hormone level and a Low serum free Thyroxine (T4) b) Subclinical hypothyroidism: Patients with a high Thyroid Stimulating Hormone but a normal Thyroxine (T4) level Treatment depends on whether the patient has overt or subclinical hypothyroidism. Patients with overt hypothyroidism should be treated with Levothyroxine to render them  ¿Ã‚ ½euthyroid ¿Ã‚ ½.[5] According to NHS statistics 12 million Levothyroxine prescriptions were issued during 2006.[6] The goal of the treatment is to reduce the TSH back to within the reference range. The dose of Levothyroxine is usually titrated up from 25-50  ¿Ã‚ ½g daily however a recent trial has shown that this is unnecessary for most patients.[7] The study recommended that patients with no cardiac symptoms should be started on the full dose of 1.6  ¿Ã‚ ½g/kg. The following figure illustrates the algorithm for treatment of -pregnant adults with primary hypothyroidism:[4] Algorithm for management of non-pregnant adults with primary hypothyroidism [4] It is very important to monitor levothyroxine therapy as over or under prescription can be dangerous. Thyroid Stimulating Hormone (TSH) is the key method of monitoring levothyroxine therapy in patients with primary hypothyroidism. Unlike the thyroid function tests used to diagnose thyroid disease, free T3 and T4 levels are not very useful in monitoring treatment as their levels are influenced by the prescribed dosage of thyroid replacement hormone and are not accurate indicators of the individual ¿Ã‚ ½s requirement. TSH without T3 and T4 is also a cheaper test to carry out in General Practice. Current guidelines state that patients should have their Thyroid Stimulating Hormone level tested eight to twelve weeks after starting levothyroxine.[4] The dose can later be fine tuned accordingly to get the TSH level in the lower half of the reference range.[5] Besides monitoring TSH levels, an assessment of the patient ¿Ã‚ ½s symptoms should also be made as some younger patients may need higher doses to relieve their symptoms in which case it is acceptable to have the TSH between 0.1-0.4 mU/Litre. The Quality and Outomes Framework (QOF) guidance suggests that all Patients on long term thyroid hormone replacement therapy should have their TSH levels tested yearly to make sure their replacement dose remains optimal.[8] Audit 1. Reason for audit move it to the top to include the rest of the study Despite the yearly TSH tests, studies have shown that a considerable number of hypothyroid patients managed in primary care have TSH levels outside of the reference range. Okosieme et al reported that in 2009 data collected from 11 GP practices showed that 37.2% of the 1037 patients on the hypothyroidism register were inadequately managed.[9] When we take into account the high prevalence of hypothyroidism (9.3% in women and 1.3% in men)[3] the results of the Okosieme et al study suggests that the total number of patients with suboptimal thyroid hormone replacement is significantly large. Imperfect thyroid hormone replacement could have damaging repercussions for health. It may adversely affect blood pressure, body weight and lipid profile. Since the basal metabolic rate of the body is controlled by thyroid hormones it is perhaps not surprising that a decrease in thyroid hormone levels leads to a decrease in metabolic rate and thus can cause weight gain. Even in euthyroid subjects there is a negative correlation between free T4 and Body Mass Index (BMI).[10] This suggests that even a small under-prescription of thyroid hormones could, over a period of time, lead to obesity. Reduced Thyroxine levels also cause a dyslipidemia characterised by increased Low Density Lipoproteins (LDL) and a decrease in High Density Lipoproteins (HDL) with normal or slightly raised cholesterol levels.[11] Such a lipid profile is associated with a higher risk of atherosclerosis. The thyroid hormones also seem to have a role in blood pressure homeostasis as hypothyroid patients recorded a higher systolic and diastolic blood pressure after stopping thyroid replacement therapy.[12] Thus inadequate replacement may cause hypertension which, together with the dyslipidemia described above adds to the risk of atherosclerosis and its subsequent cardiovascular complications. Conversely, excessive thyroid hormone replacement has its own perils, having enhanced risk of atrial fibrillation, osteoporosis and fractures linked to it. Excessive thyroid hormone increases the risk of developing atrial fibrillation especially in older patients. Studies have shown that a low TSH level in patients over 60 years old have a threefold higher risk of developing atrial fibrillation.[13] Patients over treated with levothyroxine also show increased loss of bone mineral putting them at increased risk of osteoporosis.[14] Subsequent studies have shown that patients with a suppressed TSH i.e. = 0.03 mU/Litre also had an increased risk of fractures however this was not observed in patients with low but unsuppressed TSH (0.04  ¿Ã‚ ½ 0.4 mU/Litre).[15] This highlights the need for maintaining optimal thyroid hormone replacement in primary hypothyroid patients in the General Practice setting to reduce the above mentioned risk factors. The 11 GP practices used by Okosieme et al showed that there is significant room for improvement as one third of the patient population on levothyroxine had TSH levels outside the reference range.[0.11] Thus this is a worthwhile area for audit to establish current standards of care in our practice, Dr Dean Partners, Heald Green Health Centre. Since this audit has not been carried out before in the practice it would give an idea of how well the practice manages patients on thyroid hormone replacement therapy. The suggestions for improvement would be beneficial to the patients of the practice and might also help with obtaining QOF points. This audit would also be beneficial to me personally introducing me to the concept of audit cycles and giving me the opportunity to conduct my very first audit. It would also help me get a better understanding of management of hypothyroid patients which is the second most common endocrine disease in the UK after diabetes mellitus. 2. Criteria to be measured Serum Thyroid Stimulating Hormone is used as the gold standard for biochemically diagnosing hypothyroidism and monitoring thyroid hormone replacement therapy.[4] The reference range indicating adequate replacement is usually around 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4, 9] However this figure slightly varies according to local guidelines. For this I have chosen to use TSH between 0.1  ¿Ã‚ ½ 4.0 mU/Litre as a reference range for adequate thyroid hormone replacement as this is the reference range used by the local Primary Care Trust (Stepping Hill Hospital) and the practice. Patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 3. Setting standards For setting the standard I have found that there are no specific guidelines stating what proportion of patients should be achieving the above mentioned criteria. There are no NICE guidelines for the treatment of hypothyroidism. The QOF guidance states that patients should have their TSH levels tested yearly but it does not state the standard of care required. Having discussed this with GP at the practice I have decided that a theoretically ideal standard i.e. 100% of patients meeting the above criteria would be very impractical in theory from a resources perspective. Given the fact that suboptimal thyroid hormone replacement could be harmful, it is nonetheless important to achieve a high standard of care. Therefore I have decided on an optimum standard: 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 4. Preparation planning Before starting the audit I had a discussion with the GP tutor about worthwhile areas for audit. As I had never conducted an audit before he explained the audit cycle. As thyroid dysfunction was an area of interest for me I suggested undertaking this audit. The GP tutor agreed that this would be a useful area for audit and advised to me to review the literature to find out if it would be an appropriate audit from a clinical point of view and was an area where practice could be improved. After preliminary reading clinical reviews I formulated a step by step template of the things I felt should be covered and got the GP tutor ¿Ã‚ ½s approval to go ahead. The data was collected with the help of the GP tutor. As the practice keeps electronic records of all patients, EMIS Population manger search function. Using the search function we identified all patients who had been prescribed thyroid hormone replacement medication for the past 12 months. We then identified patients who in the past 12 months had had their TSH levels tested. We then selected patients who had a TSH =0.1 mU/Litre and TSH =4. Subtracting the number of patients which meet the TSH search parameters from the total number of patients on thyroid hormone replacement would give us the number of patients who were outside the reference range of TSH. 5. Initial data collection Criterion Number of Patients taking thyroid hormone replacement medication (n) Number of Patients with TSH levels within reference range Standard (%) Patients with primary hypothyroidism on thyroid replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 206 167/206 (81%) 90% Discussion Results: what they are. How close to the standard. Are they good enough? (no, didn ¿Ã‚ ½t meet the standards). Why didn ¿Ã‚ ½t they meet the standard? Merge results discussion with limitations discussion The data collected shows that the current practice is 9% below the standard set. The standard required i.e. 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. However this was the case with only 167 patients (81%). This means that 39 patients (19%) did not meet the standard set. There could be several reasons why the results did not meet the standards set. One factor influencing TSH levels is the use of medicines which interact with thyroid function. Due to the limitations of the software used in data collection (as discussed below) we were unable to exclude patients who were on medication known to interact with thyroid function such as Amiodarone, Lithium, etc. Amiodarone, a fairly commonly prescribed drug to prevent arrhythmias, can cause deranged thyroid function as it contains iodine (37mg of iodine in 100mg of Amiodarone). This can cause a severe iodine overload and can lead to hypothyroidism as well as thyrotoxicosis.[0.16] Inclusion of such patients would bring the percentage down unfairly because management of such patients is a lot more complex and the TSH levels are not always a good indication of the adequacy of their thyroid hormone dosage. Patients with hypothyroidism due to Amiodarone are monitored by their Free T4 levels instead of TSH. [0.16] Another factor which could have contributed to the high number of patients with TSH levels outside those defined in the criteria is the possibility that patients with abnormal TSH levels often don ¿Ã‚ ½t get their levothyroxine dose optimised. A study published in 1995 reported that at one GP practice in Suffolk 71% of patients with abnormal TSH levels did not have their medication dosage change as a result.[17] If patients do not have their thyroid hormone replacement optimised as a result of abnormal TSH not only does it defeat the purpose of carrying out yearly TSH tests, it also means that these patients would continue to have an abnormal TSH when tested again. Currently we do not have the data to find out how many of the patients in our practice with abnormal TSH had not had their dose changed after a previous abnormal TSH in an attempt to bring it within the reference range specified in the criteria. Ranging from poor patient compliance to the way the data has been collected Lack of dose adjustment after abnormal TSH The way results were collected. Limitations of software used. Limitations of the results collected ie things missed: how many patients actually had test done in the last 12 months (QOF points). How many were over and how many were under prescribed. This audit has limitations. The data was collected from electronic records using the EMIS Population Manager. The limited search algorithms of the software meant that we couldn ¿Ã‚ ½t distinguish patients with a TSH below the reference range from those above it. All we were able to obtain was a single figure of how many people were within the reference range. Due to the limitations of the EMIS Population Manager software we were also unable to test how many patients with hypothyroidism had actually had their TSH levels tested in the past 12 months as stated in the QOF guidance  ¿Ã‚ ½ 2004.[8] Thyroid Function Tests are done for a large number of patients whose symptoms are actually caused by a non-thyroid illness. Due to this reason we could not search for people who had their thyroid function tested in the past 12 months as that data would have included a lot of non-hypothyroid patients. Instead we had to search for patients who had been prescribed levothyroxine therapy in the past 12 months. And then further narrow the search parameters TSH levels in the past 12 months to obtain the data. This meant that the people who have not had their thyroid functions tested in the past 12 months were excluded from our data. The positive aspect of only testing people within the last 12 months is that the data reflects current level of care. The data collection software shows patients as being within the normal TSH range if they have had at least one TSH test within the normal range during the last 12 months. If the patient has been started on levothyroxine therapy recently their TSH levels wouldn ¿Ã‚ ½t have had enough time to return to normal. However this is likely to be statistically insignificant. The way to get round these limitations of the EMIS Population Manager would have been to study the clinical notes of all patients who were prescribed levothyroxine in the past year. By looking at the notes we would be able to exclude patients who are unsuitable for the purpose of this audit i.e. those patients in whom the TSH level is not a valid indicator of thyroid hormone requirement e.g. those on Amiodarone or lithium or patients with secondary hypothyroidism. Looking at the notes would also allow us to check the number of patients who had not had their TSH levels tested in the past year. Reading through the notes would also allow us to obtain more information such as age gender etc which might be helpful in indentifying some of the factors responsible for suboptimal thyroid hormone replacement. However reading the notes of over 206 patients would have taken a considerable amount of time. Since this was my first audit I decided to avoid gathering qualitative data and decided that the using electronic records would be sufficient for the purposes of this audit. Changes to practice to hit the target. Tietable to implement that change and when to re-audit? Practicality, why change? Positives and negatives of changing. There are a few approaches which could potentially be taken to improve the standard of care. In order to improve the standard of care to meet the goal of 90% all patients on the hypothyroidism register should have yearly or six monthly blood tests to measure their TSH levels. all patients with abnormal TSH levels should be invited for an appointment with the GP and should be considered for a change in their current dosage. This would be a good opportunity to assess why their TSH levels are abnormal and check that the patient is adhering to the prescribed treatment regimen. If the dose remains unchanged the reason should be recorded in the notes so that the information is available for the second cycle of the audit. Doing this will allow us to make sure that patients are kept at the optimum dose of levothyroxine to reduce the risks associated with under or over prescription. Seeing patients like this would however increase the workload placed on the surgery and its resources. However by talking the patients as and when they have their TSH levels tested the strain on the resources would be spread out over a year. Since the current audit identified 39 patients with abnormal TSH levels, this would mean an extra 3-4 patient appointments per month over the period of a 12 months. This should be discussed at the doctors ¿Ã‚ ½ meeting. Twelve months after the implementation of the change of practice a second data collection should be done to complete the audit cycle and evaluate the impact, if any, the change in practice has had on the management of hypothyroid patients. Write to the patients to invite them to come in for a dose adjustment? Consider collecting better data by reading the notes. That would take too long. Consider specialist referral if symptoms persist. What have I learned: 1 about the condition, 2 about auditing. Conducting this audit has given me the chance to take an in-depth look at all aspects of hypothyroidism which has been an area of interest for me for some time. In the course of researching for the audit I have been able to review various guidelines, clinical reviews and other journal articles. Not only has that improved my understanding of the management of thyroid disease in primary care immensely. It has given me a sense of how a condition is followed through in general practice from first presentation to treatment to long term management. I have also realised that management of chronic conditions such as hypothyroidism is an ongoing process as the patients ¿Ã‚ ½ condition and requirements change continuously for instance if their body mass index changes significantly their thyroid hormone requirements would also change and the dose would have to be altered. Also if a patient is planning on or has become pregnant they would need to be referred to specialist endocrinologists. I have been able to review the evidence which forms the basis of current practice. Researching this topic by reading clinical reviews has made me realise the advantages of using original literature and how much beneficial it can be in achieving a comprehensive understanding of a topic. Being involved in a general practice standard-based audit has enabled me to learn about the role and significance of audits in healthcare. I have become familiar with the audit cycle and its different steps. Having conducted an audit myself, I can see the important role audits have in measuring and improving practice. It is a systematic way of monitoring standards of care and is very useful in facilitating change of practice through an evidence based approach. It has also allowed me to learn how to quickly and efficiently find relevant papers using such resources as ISI Web of science and medline. Conclusion and summary Timetable change re-audit 6. Description of change 7. Data collection (2) 8. conclusions be almost impossible to achieve due to variables like poor patient compliance or use of interactive medications e.g. Amiodarone and Lithium. It would also be vastly impractical from a reasources point of view to aim for a 100% standard.

Being Charlie Kaufman: A Glimpse into the Mind of a Genius :: Essays Papers

Being Charlie Kaufman: A Glimpse into the Mind of a Genius Movies suck these days. All Hollywood seems to care about anymore is making profitable movies, not thinking twice about what the movie might actually be about. Whether it’s another special effects-ridden clunker, a giddy romantic comedy, or another lame-plotted action flick, they just don’t seem to get it. Although a small handful of films over a year’s time are occasionally worth seeing, for the most part it’s all about making money and not about the true art that filmmaking can be. Charlie Kaufman is exactly the kind of anomaly that the film industry needs. Kaufman was born in November 1958 in Massapequa, Long Island and spent his childhood there. Later his family moved to West Hartford, Connecticut, where he went to high school. After graduating, he attended Boston University for a short time, but soon transferred to New York University to study filmmaking. Kaufman got his start in writing for television for sitcoms such as Ned and Stacey and The Dana Carvey Show (Couzens). After his work with sitcoms, however, he began writing some of the oddest scripts that have ever been conceived. It was just over four years ago when Kaufman presented his very first film, Being John Malkovich, which was nominated for both Oscar and Golden Globe awards, as well as winning many others, such as the Independent Spirit Award for Best First Screenplay and Best Screenplay from the National Society of Film Critics. That is not something every screenwriter is able to do with their first script. His fortune of being nominated came again with his third film, the genre-bending Adaptation, which was a fictional movie about him working on writing the screenplay for a movie adaptation of a book that was based on a true story. His work on this won him the Golden Satellite Award for Best Adapted Screenplay. His latest work, Eternal Sunshine of the Spotless Mind, is being hailed as â€Å"remarkable† with â€Å"groundbreaking performances,† which gives it a very likely chance of being nominated for awards (Travers, 2004). Although his reputation is already respectable, Kaufman didn’t easily get to where he is now. His struggles of becoming a film screenwriter were not without boundaries, but every time he tripped, he got back up and kept going. Being Charlie Kaufman: A Glimpse into the Mind of a Genius :: Essays Papers Being Charlie Kaufman: A Glimpse into the Mind of a Genius Movies suck these days. All Hollywood seems to care about anymore is making profitable movies, not thinking twice about what the movie might actually be about. Whether it’s another special effects-ridden clunker, a giddy romantic comedy, or another lame-plotted action flick, they just don’t seem to get it. Although a small handful of films over a year’s time are occasionally worth seeing, for the most part it’s all about making money and not about the true art that filmmaking can be. Charlie Kaufman is exactly the kind of anomaly that the film industry needs. Kaufman was born in November 1958 in Massapequa, Long Island and spent his childhood there. Later his family moved to West Hartford, Connecticut, where he went to high school. After graduating, he attended Boston University for a short time, but soon transferred to New York University to study filmmaking. Kaufman got his start in writing for television for sitcoms such as Ned and Stacey and The Dana Carvey Show (Couzens). After his work with sitcoms, however, he began writing some of the oddest scripts that have ever been conceived. It was just over four years ago when Kaufman presented his very first film, Being John Malkovich, which was nominated for both Oscar and Golden Globe awards, as well as winning many others, such as the Independent Spirit Award for Best First Screenplay and Best Screenplay from the National Society of Film Critics. That is not something every screenwriter is able to do with their first script. His fortune of being nominated came again with his third film, the genre-bending Adaptation, which was a fictional movie about him working on writing the screenplay for a movie adaptation of a book that was based on a true story. His work on this won him the Golden Satellite Award for Best Adapted Screenplay. His latest work, Eternal Sunshine of the Spotless Mind, is being hailed as â€Å"remarkable† with â€Å"groundbreaking performances,† which gives it a very likely chance of being nominated for awards (Travers, 2004). Although his reputation is already respectable, Kaufman didn’t easily get to where he is now. His struggles of becoming a film screenwriter were not without boundaries, but every time he tripped, he got back up and kept going.

Beximco Pharmaceuticals Ltd

BEXIMCO PHARMACEUTICAL COMPANY LTD Here is the management report, which you asked me to prepare.. In the process of formulating this project report I selected a PHARMACEUTICAL company,â€Å"BEXIMCO PHARMACEUTICALS† which produces world class live saving medicines in our country. I gained knowledge about managing the product & the structure from online articles and reports.Along with it, I employed the management concepts developed throughout the course to construct an effective management project to demonstrate the mentioned firm’s entire management strategies in Bangladesh. This plan is formulated with the idea of managing the all managerial activities of a large firm like BEXIMCO PHARMACEUTICALS LIMITED. A special note of acknowledgement is to our course instructor Mr Shahid Hossain for letting me do this project on Beximco Pharmaceuticals .He was very generous and productive toward mewhile conducting the course and he was the person who has guided methroughout prepar ing the report. The way he taught was really interesting and effective. All of these activities have been conducted within a very short time and we think it became possible only for  his dynamism. Taking the course with him was a great fortune for me. Finally, I would like to thank myr family and friends whose support I needed to complete my project. TABLE OF CONTENTSCONTENTS PAGE NO Mission Statement 1 Executive Summary 2-3 Organogram 4 Organizational Chart 5 Situation Analysis 6-16 Swot Analysis 17-20 Matrix of Swot Analysis 21 Objectives 22 Management Issues 23 Conclusion 24 Appendix 25 BIBLIOGRAPHY 1. Company Website : http://www. beximcopharmaceuticals. com 2. Books : Kotler Philip (2010), Principles of Marketing (12th edition). Prentice Hall, New Jersey, USA. * Kritner Robert (2009). Management (11th edition). Houghton Mifflin Harcount Publishing Company. (Boston – New York). * H. Donelly (2008), Fundamental Management (10th edition). Mcgraw, Hill Irwin * William J. Nickels (2009) Understanding Business (9th edition) Mcgraw, Hill Irwin. 3. Newspaper * The Ittefaq * The Independent. * Finanacial Express 4. Personal Interview Mr. Hashem Awal Chowdhury, Senior Executive Officer,Planning 5. ANNUAL REPORT OF BPL 2011 Ltd, BPL Annual Report 2011 6. Advertisement Shantinagar billboard DOHS, Mohakhali billboard 7. Magazines Indian Times Magazine MISSION STATEMENTBeximco Pharmaceuticals Ltd (BPL) is a leading manufacturer of pharmaceutical formulations and Active Pharmaceutical Ingredients (APIs) in Bangladesh. With decades of contract manufacturing experience with global MNCs, skilled manpower and proven formulation capabilities, the company has been building a visible and growing presence across the continents offering high quality generics at the most affordable cost. The company is committed to enhancing human health and well- being by providing contemporary and affordable medicines, manufactured in full compliance with global standards. The compan y continually strive to improve their core capabilities Strengthening research and development capabilities, creating partnerships and building presence across the globe.To address the unmet medical needs of patients and to deliver outstanding results for our shareholders. Our vision is to be one of the most trusted, admired and successful pharmaceutical companies in the region with a focus on. EXECUTIVE SUMMARY Beximco Pharmaceuticals Ltd. belongs to Beximco Group, the largest private sector business conglomerate in Bangladesh. It was incorporated in the late 70s, Beximco Pharma began as a distributor, importing products from global MNCs like Bayer, Germany and Upjohn Inc. , USA and selling them in the local market, which were later manufactured and distributed under licensing arrangements. The Company introduced its own branded generic products in 1983.Since then, the journey continued, and today, Beximco Pharma is a leading manufacturer and exporter of pharmaceuticals in the coun try, winning National Export Trophy (Gold), a record four times. Beximco Pharma’s manufacturing facilities have been accredited by major Global regulatory bodies and it has expanded its geographic footprint across four continents. Having a broad portfolio of more than 500 products and a dedicated team of around 2,700 employees, Beximco Pharma is committed to provide access to medicines which are affordable and manufactured in strict compliance with global standards. During the year 2011 we have successfully registered 48 products in overseas markets.In 2011, we introduced 40 new generics in 55 presentations, five of which were launched for the first time in Bangladesh. The 55 new products include the sectors given below: * Analgesic * Anti-effective * Cardiovascular * CNS * Endocrine & Met Disorders * GI System * IV Fluid * Muscular Skeletal * Ophthalmic * Respiratory * Skin * Vitamins and Minerals * Others We maintained our record of uninterrupted growth, achieving a 21. 6% increase in sales to Tk. 7,890. 24 million (2010: Tk. 6,490. 85 million). In 2011 we significantly enhanced our prescription share in sales of the formulation products and maintained, as expected, growth in all our key therapeutic segments. Sales of our Active Pharmaceutical Ingredients (APIs) also recorded a significant 37. % growth to reach Tk. 486. 91 million (2010: Tk. 355. 24 million). However, its impact on the overall profitability of the company is currently low because of a low gross margin predominantly due to the high cost of import of intermediate materials to manufacture these APIs. In 2011 export sales grew by 18. 1% to Tk. 390. 32 million (2010: Tk. 330. 54 million). Along with sales growth, Beximco Pharma also achieved a marked growth in profit in 2011. Our pre-tax profit increased 23. 2% to Tk. 1,677. 85 million (2010: Tk. 1,361. 53 million). Gross margin as percentage of sales however, slightly declined to 48% as against 48. 9% for the prior period.As the company c ontinue to evolve into a stronger company, their strategy for growth is to build a strong and diverse product portfolio; to expand our geographic reach; and to develop and leverage our generic drug capabilities. All these will drive them to build a future for our employees, to create value for shareholders and to focus on the reason for being in this business – to enhance the health and wellbeing of people. They are confident that their Company will continue to deliver strong financial results and achieve sustained growth in the coming days. Organogram Organisational Chart * Member’s name| * Designation| BOARD of DIRECTORS| |A S F Rahman| Chairman| Salman F Rahman | Vice Chairman| Nazmul Hassan MP| MD| Iqbal Ahmed| Director| Md. Abul Qasem| Director| Osman Kaiser Chowdhury| Director| A B Siddiqur Rahman| Director| Ad. Ahsanul Karim| Director| Dr. Abdul Alam Khan| Independent Director| | | Management Committee| | Nazmul Hassan MP| MD| Osman Kaiser Chowdhury| Director| R abbur Reza| Chief Operating officer| Ali Newaz| Chief financial officer| Afsar uddin Ahmed| Director, commercial| Lutfur Rahman| Director, manufacturing| Zakaria Seraj Chowdhury| Director, international marketing| A R M Zahidur Rahman| Executive Director, production| Shamim Momtaz| Executive Director, manufacturing| Md.Tahir Siddiqui| Executive Director, Quality| Jamal Ahmed Chowdhury| Executive Director, Finance and Accounting| | | Executive Committee| | Osman Kaiser Chowdhury| Director| Nazmul Hassan MP| MD| Rabbur Reza| Chief Operating officer| Ali Nawaz| Chief financial officer| Afsar Uddin Ahmed| Director, commercial| SITUATION ANALYSIS Situation analysis is a method managers use to analyze both the internal and external environments of an organization in order to understand the firm’s own capabilities, customers and business environment. INTERNAL FACTORS: Refers to the environment inside the organization within which a manager works. LEVELS OF MANAGEMENT: Strategic leve l:The Board of Directors A S F Rahman Chairman Salman F Rahman Vice Chairman Nazmul Hassan MP Managing Director Iqbal Ahme Director Mohammad Abul Qasem Director Osman Kaiser Chowdhury Director Abu Bakar Siddiqur Rahman Director Advocate Ahsanul Karim Director Dr. Abdul Alim Khan Independent Director The strategic level must make sure the technical level operates within the bounds of the society.Thus the strategic level determines the long range objectives and directions for the organization- in other words, how the organization interacts with its environment. (Textbook) Technical level: Middle floor managers, Branch Managers, Factory Managers work like a connector and works in the middle. At this level, the managerial task is twofold: 1. Managing the operations functions. 1. Serving as a liaison between those who produce the product or service and those who use output. In other words, for the operations level to do its work, managers at the technical level must make sure they have t he correct materials and see that the output gets used or sold. (Textbook) Operational level:Rabbur Reza Chief Operating Officer Ali Nawaz Chief Financial Officer Afsar Uddin Ahmed Director, Commercial Lutfur Rahman Director, Manufacturing Zakaria Seraj Chowdhury Director, International Marketing A R M Zahidur Rahman Executive Director, Production Shamim Momtaz Executive Director, Manufacturing Mohd. Tahir Siddique Executive Director, Quality Jamal Ahmed Choudhury Executive Director, Accounts & Finance. In any organisations, the operations level focuses on effectively performing whatever the organization produces or does.In Beximco pharmaceuticals, the operations fuction is at the core of their business. The managerial task here is to develop the best allocation of resources that produces the desired output. (Textbook). Research & development R&D is the key to success for any pharmaceutical company. We have given it top priority and have made substantial investment in upgrading our generic drug capabilities as we firmly believe R&D plays the most important role in spurring innovation and helps a company go up the value chain. Our research and development activities are closely focused on market needs and driven by technological progress in order to create product differentiation.Our team comprising top class formulation scientists with extensive experience of working in leading pharmaceutical companies in the world continuously strives to integrate the advanced technological changes to create competitive edge and match international standards. There has been a series of positive developments in the year and our team successfully introduced 40 new generic formulations in 55 different presentations and expanded our dosage delivery portfolio with technology driven products like prefilled syringes, total parenteral nutrition, dry powder inhalers, etc. Beximco Pharma’s well defined organizational structure, policy guidelines and internal controls ensure effi ciency of operations, and compliance with applicable regulations. The Company continuously upgrades these systems in line with the best practices in the industry.Other initiatives to keep our team updated with the recent advances in analytical methodology, platform technology, and regulatory affairs include frequent in-house and overseas workshops and training programs. The benefits we derive as a result of these initiatives will only increase in the coming years. Beximco Pharma’s R&D team works meticulously towards creating generic formulations that are comparable to innovators’ formulations. Their dedication can be witnessed in their successful development of challenging formulations such as multi-layer tablets, sustained release formulations, dispersible tablets, melt-in mouth tablets, and chewable vitamins; to name just a few.To add to that, Beximco Pharma was the pioneering local generic company to produce anti-retroviral drugs and to proactively launch CFC œfree metered dose inhaler formulation. In addition, we are also developing a number of APIs to ensure availability of raw materials across the range of therapeutic classes. Our capability to produce hi-tech, specialized niche products as well as drug delivery systems has been our core strength to transform BPL into an innovation-driven generic drug company. Human Resource We recognize it is our people’s unwavering values that molded us into who we are today. It is their tireless contributions that have propelled us to greater heights over the years. They are indeed our greatest assets in the way they create meaningful difference.Every product, every experience, and every breakthrough we ever presented for the betterment of human health and well-being have been made possible by our people. We are prouder than ever of the collective intentions and determination we have witnessed time and time again. The shared vision and values, reflected in our leadership and execution, help us attract the very best. Currently, the Company employs almost 2,700 people including around 400 white-collar professionals such as Pharmacists, MBAs, Doctors, Chemists, Engineers, Microbiologists etc. In 2011, we welcomed into the Beximco Pharma family highly experienced expatriates in key positions to deliver a fresh take on strategic direction as we steadily progress towards our aspirations of becoming a global pharmaceutical company.We are strong advocates of the notion that learning never really ends simply with the completion of formal education. One of the best perks of being a part of the Beximco Pharma family is that the people undergo continuous training and development programs to further develop their skills. In 2011 alone, over 30 such workshops and training, covering various departments, were conducted. Within Beximco Pharma, we support employees interested in reaching out to others. In 2011, we launched our very own internal Knowledge Center as a platform for continu ous learning and interconnectivity; an initiative that is stills quite a novel concept in Bangladesh.However, we know that competence alone is not enough; it is them intricate threads of connectivity, binding us as one family, which makes our organizational culture truly coveted and one of a kind. We have also undertaken a major corporate branding initiative as a reflection of our rejuvenated drive and aspirations. Financial Position We maintained our record of uninterrupted growth, achieving a 21. 6% increase in sales to Tk. 7,890. 24 million (2010: Tk. 6,490. 85 million). In 2011 we significantly enhanced our prescription share in sales of the formulation products and maintained, as expected, growth in all our key therapeutic segments. Sales of our Active Pharmaceutical Ingredients (APIs) also recorded a significant 37. % growth to reach Tk. 486. 91 million (2010: Tk. 355. 24 million). However, its impact on the overall profitability of the company is currently low because of a lo w gross margin predominantly due to the high cost of import of intermediate materials to manufacture these APIs. In 2011 export sales grew by 18. 1% to Tk. 390. 32 million (2010: Tk. 330. 54 million). Along with sales growth, Beximco Pharma also achieved a marked growth in profit in 2011. Our pre-tax profit increased 23. 2% to Tk. 1,677. 85 million (2010: Tk. 1,361. 53 million). Gross margin as percentage of sales however, slightly declined to 48% as against 48. 9% for the prior period.This was due principally to depreciation in the value of the Taka against the Dollar and the high level of domestic inflation. However, with our constant drive to contain costs and effective profit optimization strategies, the negative impact of rising cost on profit has been kept to the practicable minimum. The Board of Directors has recommended 21% stock dividend for approval of the shareholders for the year ended 31 December, 2011. Technological Advancement Beximco Pharma has always been a pioneer in adopting innovative technologies. This brings both sophistication and the potential to sustain growth to our business. Over the past couple of years we have made considerable nvestments in facilities and processes to improve productivity, drive growth and achieve excellence in operations. Situated near Dhaka, the capital city of Bangladesh, our manufacturing site extends over an area of 23 acres. The site houses manufacturing facilities for producing various drug formulae in different strengths and delivery systems such as capsules, tablets, intravenous fluids, metered dose inhalers, ophthalmic drops, injectables and nebulizer solutions. The site has its own utility infrastructure to ensure adequate generation and distribution of electricity with an installed capacity of 10 MW, in addition to water purifying and liquid nitrogen generation facilities.The bulk drug unit for producing paracetamol is also located within this site. The Company’s penicillin API and formulation u nits are situated at Kaliakoir, a few kms from the main site. The company has diversified into innovative delivery systems such as dry powder inhalers, total parenteral nutrition, prefilled syringes and lyophilized products. * Oral Solid Dosage * Metered Dose Inhaler * Intravenous Fluid * Inject able, Ophthalmic and Nebulizer * Liquid, Cream and Ointment Val EXTERNAL FACTORS These are the forces that act on the organization from outside. DIRECT FORCESThese are the forces that have direct and immediate influence on the organization. CUSTOMERSWe offer our customers a comprehensive and high-quality product portfolio encompassing all major therapeutic categories, available in various dosage forms including tablets, capsules, syrup, suspension, sterile eye drops, injectables, nasal sprays, creams, ointments, suppositories, IV fluids, metered dose inhalers, dry powder inhalers, prefilled syringes etc. Over the years, we have nurtured and developed a special bondage with the medical commun ity. We stand by healthcare providers and appreciate their valiant services to the community at large. COMPETITOTORS Square Pharma Reneta GlaxoSmith Klein’ ACI Limited Eskayef Bangladesh Limited The ACME Laboratories Limited EDCL Aristropharma Limited Orion Pharmaceuticals limited Indirect Forces * Political Analysis: Political analysis creates a great impact on business growth.The Beximco Pharmaceuticals is an established company, it gets many positive support of Bangladesh government, which enables it to advance its product. In addition it suffers many political unexpected conditions, like- political instability, and high risk investment, high rate of tax, high barriers of rules and regulation and so on. Because of strikes, obstruction and any other political issues, it noses a lot. But now they adopt with rules of exporting, producing, importing and so on. They use BCP (Business Continuation Plan) to fight against any critical political issues. [ Documentary,Newspaper] * E conomic Analysis: In economy, the biggest threat for â€Å" Beximco Pharmaceuticals† would be economic recession.During the recession, the Beximco’s growth will be adversely affected. Because of the high interest rate, inflation rate and economic downturn it’s growth is not just affected by the local economy but also in the international economy. * * Social Analysis:†Beximco Pharmaceuticals â€Å" has performed many social activities, to improve the company image. To reach the goal, the group implements the local job creation program as well as health and education program Corporate Social Responsibility: Our vision is to make significant contribution to humanity by improving health. This vision guides our Company’s operations, including its commitment to corporate responsibility.We work together with non-profit organizations who work to improve people's lives through research, information, and advocacy. As the Company writes its success story as a n emerging leader in the pharmaceutical industry, we also realize that responsibility towards all our stakeholders increases in tandem. We remain committed to being a good corporate citizen. Prevention is the best cure and the first step is to create awareness. Every year, we launch campaigns touching on different forms of heath impediments ranging from asthma, diabetes, hypertension and many more. Campaign activities include rallies in addition to organizing and sponsoring scientific seminars and conferences for various associations and societies in medical disciplines. ANNUAL REPORT CultureCulture is a very complex environmental influence, encompassing knowledge, beliefs, values, laws, morals, customs and other habits and capabilities an individual acquires as a member of society. As BEXIMCO is a global MNC, management must adapt its managerial practices to the specific and unique aspects of culture. Most of the time they follow formal ways to control the employees, and get their full potentiality. They also follow the profit oriented by doing more customer service and social responsibilities. SWOT ANALYSIS: Strength: Diversification The strength of Beximco Pharmaceuticals Ltd. lies in its diversified products and dosage forms.BPL has been producing solid products like tablets and capsules and liquid products like syrup, suspension and solution, as well as semisolid products like cream and ointment. It is   the pioneer company to manufacture and market nasal sprays, inhalation aerosols and suppositories in Bangladesh. In 2001, Beximco Pharmaceuticals Ltd. stepped into a new path–bringing SmallVolume Parenteral(SVP) or injectable dosage form. Arixon is it’s first small volume injectable product It is a preparation of Ceftriaxone, which is considered as a breakthrough antibiotic in the history of medicine, . In 2002, Arixon is predicted to be one of our leading brands interms of sales revenue.The company has lot of diversified products like, Na pa: Neoceptin R: Neofloxin: Tycil : Aristovit M etc. Achivement of National Export Trophy First export market operation with finished pharmaceutical products1994-95 : Achievement of National Export Trophy (Gold) as the first pharmaceutical company of the country. R ; D B P L is a company that is continuously searching for the next treatment advancements. BPL’s portfolio features a range of high-quality, effective products. This product portfolio, combined with the steady stream of promising new products in development, is one of the many reasons BPL is among the nation's leading pharmaceutical companies. We have introduced 26 new products in 2001.Around 70 new products are in our development pipeline. They will obviously enrich our portfolio to employment of the employees so that they can cope with the rapidly changing business environment. Innovation is a major priority that we want to promote. Accordingly, training programs are regularly undertaken for the staff to seek opp ortunities for skills improvement. Weakness: Too many departments There are too many departments under the supervision of the gm which can cause low productivity due to large span of supervision. Diseconomy of scale: If the company exceeds the optimum size there would be diseconomies of sale. Availability of substitutes Availability of very close substitute goods.For example: medicine produced by other pharmaceutical companies Opportunities: Adding new products BPL always tried to add new products of different therapeutic classes in its portfolio and these products are highly appreciated by the health professionals. Most important of them are Triocim, Arixon, Prosan, Recox, Atova etc. Introduction of these new products enriched it’s product portfolio and is contributing to enhance it’s sales. Apart from all these, we have intensified and consolidated our marketing efforts another overseas markets, like Myanmar, Kenya, Yemen and Vietnam. To capitalize immense opportunit ies in these overseas markets, we are bringing in more new and exciting brands in these markets.Last year, BP donated one ‘Medical Information K i o s k’ to the Myanmar Medical Association of Mandalay which gained enormous attention and acceptance in the minds of the medical community of Mayanmar. In Kenya, number of salespeople has been increased to best exploit its huge market potentials. All these efforts are already bringing in desired results. Entering into new horizons and establishing new overseas markets will remain our top most priority in 2002 also. Russia, Ukraine, Sri Lanka, Cambodia, Nepal will be on the list. We are confident that our process of globalization will continue with a more and more accelerated speed in the coming days. TechnologyTechnology carries the promise of tomorrow. The benefits of technology belong to all of us benefits that create new opportunities and open doors toa better life. For example, the new inhaler plant of BPL has been design in a way to ensure highest-possible quality at every stage of manufacturing and quality control. World-class facilities are being employed in each and every step including mixing, filling, testing, labeling, batch printing and other procedures to ensure manufacturing of world class products. Threats: Supply cost effective materiaals BPL has a commitment to the society to supply world class Active Pharmaceutical Ingredients (APIs).Therefore, BPL is not only engaged in formulations but also in fine chemicals business with a view to supplying cost effective quality materials to other local companies as well as for captive consumption. Competition Beximco Pharmaceuticals Ltd. has been preparing itself for the post-WTO open market competition. It has all the courage to compete with world leaders in pharmaceuticals business when the tariff and non-tariff barriers will be withdrawn The new USFDA standard plant is planned to be operational in early 2003. Once completed, this will be one of the finest facilities available anywhere in the globe. OBJECTIVES Increase rate of purchase by existing customers by 10 percent by the year end. Strategy Such a strategy may involve devising a marketing plan to encourage customers to purchase more of a product.Tactics used to carry out the strategy could include price reductions, advertising stressing the many benefits of the product, packaging the product in different sized packages or making the product available at more locations. Design additional features into product that will induce new uses by existing buyers Strategy This strategy include much more than simply getting the product to the new market. Before considering sales techniques such as packaging and promotion. Company often find they must establish a foothold. MANAGEMENT ISSUES Centralization Centralization refers to the location of decision making authority in the hierarchy of the organization.The upper level managers in the organization make all the significant dec ision and managers at all levels can command their subordinates to undertake legitimate work related activities. The idea of centralization can be difficult to grasp in a particular organization for several reasons. People in the in an organization can have different decision making authority. Moreover, all decisions are not of equal importance in organization. Thus subjectively they do not have authority but objectively they have authority. Matrix Organization The matrix organization structure attempts to maximize the strengths and minimize the weakness of both functional and product bases.Matrix organization structure achieved the desired balance by superimposing or overlaying a horizontal structure of authority, influence and communication on the vertical structure. Matrix organization facilitates the utilization of highly specialized staff and equipment. CONCLUSION This is Beximco Pharmaceutical’s firm as a whole. I have discussed the mission, executive summary, organizat ional structure, situation analysis, swot analysis, objectives and management issues of the company. I have also given some important data regarding this company. I hope you can have the clear picture of Beximco Pharmaceuticals company at a glance. APPENDIX Appendix are given after this page

The Biggest Loser Are They Really - 1586 Words

Fae Rose Kobernik Mrs. Phillip English 3 H 6 January 2014 (but actually 17 December 2014) The Biggest Loser: Are They Really? In a world where â€Å"graphic t-shirts with the words â€Å"eat less† [are sold]† (Mulliniks) in popular stores marketed for teenagers, where â€Å"children as young as 5 years old have been treated in hospitals for anorexia† (Touhy), and where studies have found â€Å"that the fashion industry is a significant influence on a woman s identity† (Monitor s Editorial Board). It is clear that we live in a society that corresponds it’s definition of beauty to the definitions of weight, body type, and body image. This problem of beauty and body is magnified through the medias excessive use of altered images that depict a false sense of†¦show more content†¦In some cases this is from genetic or unknown reasons but in many cases it has to do with the pressure our society and specifically our media puts on woman. Therefore women who aren t as exposed to mainstream media are less likely to develop an eating disord er. A study done in â€Å"a region of Fiji where only one case of an eating disorder had been reported, [and there was] no exposure to westernized television until 1995† (Mulliniks) produced shocking results. â€Å"Within three years of television being introduced to the region, the amount of girls who induced vomiting to control their weight increased by 11 percent and the amount of girls scoring highly on a test for eating disorder risks increased by 16 percent† (Mulliniks). These results show a link in media and eating disorders. Only after being exposed to media for 3 years did a regions eating disorder stats go up by 11 percent, a region that prior to the introduction of television and mainstream media had only â€Å"one reported case of an eating disorder† (Mulliniks). â€Å"Additionally, [this study showed that] girls who watched TV three or more nights a week were 50 percent more likely to describe themselves as being ‘too fat’ (Mulliniks) . This result from the study bridges the problem of body image to mainstream media because the numbers show that the girls who are more exposed to the mainstream media, are also the girls who are more likely to have a negative image of their