Postmenopausal Hormone Replacement Therapy Health And Social Care Essay

In the United Kingdom, about one million post-menopausal adult females use oestrogen entirely or in combination with progestogen, as portion of endocrine replacing therapy ( HRT ) , to handle the symptoms of the climacteric ( WHC, 2010 ) . HRT first became available to adult females in the United Kingdom in 1965 ( Patient UK, 2010 ) , and was traditionally prescribed for its ability to cut down vasomotor symptoms, and its preventive effects against the development of postmenopausal osteoporosis and cardiovascular bosom disease ( WHC, 2010 ) . During 2002 and 2003, two of the biggest epidemiological surveies on HRT, Million Women Study ( an experimental questionnaire ) in the UK and Women ‘s Health Initiative survey ( a clinical randomised test ) in the USA were published. Their consequences presented concerns sing the safety of traditional HRT ; peculiarly in respects to its associated hazards to the cardiovascular system and chest malignant neoplastic disease as a consequence of drawn-out use ( WHI, 2002 ; MWS, 2003 ) . The complicated image presented of the hazards and benefits of HRT has received a considerable sum of scientific and public attending, fuelling wellness anxiousness amongst medical professionals and HRT users likewise. During the period of 2003 and 2007 the figure of adult females utilizing HRT fell by 66 % ( WHC, 2010 ) . This paper presents a reappraisal of scientific literature on the efficaciousness of HRT in the direction of menopausal symptoms and assesses the proficiency of its non-hormonal options.Why a Menopause?At birth, the human ovary contains 1 to 3 – 106 Graafian follicles, with no new gametes formed after this clip ( Kim et al, 1997 ) . This figure regresses to less than 1 – 104 at the clip of climacteric ( physiology text book ) . Menopause is described as a province of oestrogen lack that is brought approximately by the loss of aboriginal follicles in the ovaries doing a failure in oestrogenic end product ( Greendale and Sowers, 1997 ) . Throughout the generative lifetime, ovarian follicles become bit by bit desensitized to gonadtrophin exposure ( physiology text book ) . This leads to the loss of progestin production and a pronounced diminution in endogenous oestrogen degrees ( Greendale and Sowers, 1997 ) .EpidemiologyHarmonizing to the office of National Statistics 2009 figures, there are about 37.8 million adult females in the UK, of whom 13.6 million are aged 45 or over ( ONS, 2010a ) . Statistics indicates that 52 is the mean age of menopausal onset ( NHS Choices, 2010 ) , and so most of these adult females will be in or shortly come ining the post-menopausal province. The current life-expectancy for a new-born miss is 81.9 old ages ( ONS, 2010b ) . Womans can therefore anticipate to populate a 3rd of their lives in a possible oestrogen deficient province ( Howard et al, 1981 ) . Womans are considered to hold reached the climacteric, after a 12 month period of amenorrhoea ( Green dale and Sowers, 1997 ) . The concluding menstruations is so retrospectively designated as the clip of climacteric ; the clip predating this is post-maturity ( Greendale and Sowers, 1997 ) . The climacteric is associated with a assortment of physical and psychological symptoms ( Porter et al, 1996 ) , where vasomotor instability and urogenital wasting are the most normally documented short-run post-menopausal symptoms. Approximately, 75 % to 80 % of all adult females normally experience their first symptoms of the climacteric during the peri-menopausal period ( Bachmann, 1999 ) ; of whom 45 % of adult females will happen the symptoms straitening ( RCPE, 2003 ) .The climacteric in the long-run increases the hazard for the development of cardiovascular diseases and osteoporosis ( Iqbal and Zaidi ) ; this is due to the physiological effects caused by the worsening degrees of estrogens in the bosom, liver, encephalon and bone ( Katzenellenbogen, 1996 ) .Vasomotor SymptomsThe vasomotor s ymptoms of the climacteric, ( for illustration hot flowers, dark workout suits, insomnia and palpitations ) ( Howard et al, 1981 ) are the most common ground why menopausal adult females seek medical aid ( Howard et al, 1981 ) . Three quarters of peri-menopausal adult females will see hot flowers ( Howard et al, 1981 ) , where symptoms are normally observed within the first twelvemonth after the concluding menstruations ( Rees and Purdie, 2006 ) . Hot flushes characteristically last between 0.5 and 5.0 old ages after natural climacteric ( Bachmann, 1999 ) , but in 25 % to 50 % of instances can last longer than 5 old ages ( Howard et al, 1981 ) . The frequence of hot flash happenings and its continuance can change from less than daily to several per hr with continuances between a few seconds to 10 proceedingss long ; nevertheless on mean hot flower episodes lasts for around four proceedingss ( Patient UK, 2010 ) . The etiology behind vasomotor symptoms is ill-defined, but it is thoug ht to be due to a combination of hormonal, metabolic, and psychogenetic factors which occur as a consequence of oestrogen backdown ( Bachmann, 1999 ) . In 1986, Sliva et al conducted a survey on rats and established the action of oestrogen in the preoptic country of the hypothalamus, here it was found to modulate the firing rate of thermosensitive nerve cells in response to stimulation. Surveies have shown that oestrogen appears to heighten ?2-adrenergic inhibitory activity ( Bachmann, 1999 ) .Women with hot flowers have higher arteriole sensitiveness to catecholamines ( Bachmann, 1999 ) .The decrease in ?2-adrenergic receptor activity leads to sudden, transient and fickle peripheral vasodilatation in the tegument blood vass, which produces the hot flower ( Bachmann, 1999 ) . Night workout suits ( sleep hyperidrosis ) , is a common job accompaniment with day-time hot flowers ( Porter et al, 1996 ) . Hot flowers and sleep hyperhidrosus can hold a Domino consequence on a patient ‘s overall quality of life ( Bachmann, 1999 ) , as a consequence of weariness, crossness, hapless concentration, and impaired memory ( Porter et al, 1996 ) .Vasomotor TherapyNumerous surveies have documented the effectivity of short-run oestrogen therapy in handling the frequence and badness of hot flowers and dark workout suits caused by climacteric. For illustration, Haas et Al ‘s 2003 double-blinded, randomized, placebo-controlled survey on 18 menopausal adult females reported that there was no immediate decrease in vasomotor symptoms after induction of oestrogen therapy ( Figure 2 ) . At first both placebo and oestradiol reduced the figure of hot flowers by 27 % and 35 % , severally. The initial placebo consequence, nevertheless, was non sustained throughout the surv ey. In contrast, those patients treated with oestradiol continued to detect a lessening in the figure of hot flowers per hebdomad, until a 74 % maximum decrease was reached after 4 hebdomads of therapy. The frequence of hot flowers fluctuated somewhat at that degree until the terminal 2 hebdomads when the placebo-only period was initiated ( see figure 2 ) . These findings were reiterated in MacLennan at Al ‘s 2004 scientific reappraisal of 24 double-blinded, randomized, placebo-controlled tests, which assessed unwritten HRT therapy. Consequences demonstrated in nine RCTs, showed a average per centum decrease of about 75 % comparative to placebo in hebdomadal hot flower frequence ( p & A ; lt ; 0.0001 ) correlating to Hass at al earlier 74 % decrease for hebdomadal hot flower episodes for HRT. In adult females randomised to have placebo intervention, a 57.7 % decrease in hot flush frequence was observed by the terminal of the survey. Eight RCTs, found that symptom badness of th ose treated with HRT was besides significantly reduced compared to placebo ( P & A ; lt ; 0.0001 ) . A direct comparing of the effectivity of combined HRT versus oestrogen merely HRT was attempted but did non make statistical significance ( p value = 0.085 ) . There is a little sum of dependable grounds available to rede the continuance of usage for the intervention of vasomotor symptoms. Clinical Knowledge Summaries ( 2010 ) recommend the prescription of uninterrupted combined unwritten or transdermic HRT, for the direction of hot flowers. Treatment for vasomotor symptoms should be continued for at least one twelvemonth ; otherwise, symptoms may repeat ( Rees and Purdie, 2006 ) . This was observed in Haas et Al survey where, during the 2 hebdomad placebo merely period ; the frequence of hot flowers began to return to baseline degrees in the group having oestradiol ( see figure 1 ) . A progressive backdown from intervention therefore is advisable. This is achieved by bit by bit cut downing uninterrupted combined HRT dosage to the lowest strength of tablets or spots, whereby half a tablet day-to-day or half a spot should be used for a farther 1-2 months ( Rees and Purdie, 2006 ) . Menopausal symptoms normally decide within 2-5 old ages ( RC PE, 2003 ) ; the consequence of uninterrupted combined HRT can be sustained for up to three old ages during disposal where, apart from shed blooding, side-effects are non normally reported ( Maclennan et al, 2004 ; Henriksson et Al, 1996 ) . Current research has confirmed the efficaciousness of oestrogen, combined or entirely, in bettering hot flowers and dark workout suits, as its effects are strong. However, farther research is required to distinguish whether combinations of low dose oestrogen and progestin may accomplish the tantamount consequence of a higher dosage of oestrogen when used entirely.Figure 1: Summarises the entire figure of Hot flowers recorded by patients on transdermic estradiol ( N = 10 ) and placebo ( N = 8, foremost seven hebdomad ; N=7, last five hebdomads ) each hebdomad ( adapted from Haas et Al, 1988 ; Bachmann, 1999 )Pre-treatment stage: A 4-week pre-treatment period during which capable eligibility of menopausal position was confirmed. Treatment stage: An active 6 hebdomad survey stage, during which the happenings of Hot flowers between 0.05 mg/ dm3 transdermic estradiol was compared against placebo. Estradiol showed to be well more effectual than placebo in cut downing vasomotor flowers during hebdomads 6 to 10. Placebo stage: Two hebdomad period where patients continued to supervise symptoms while single-blindedly utilizing a placebo spot. An addition in vasomotor flushing towards baseline was observed in estradiol-treated patients.Urogenital AtrophyThe surcease of the catamenial rhythm, consequences non merely in the conventional hot flowers observed in diagnostic menopausal adult females but besides causes alterations to the functional capacity of the urogenital piece of land ( Samsioe, 1995 ) . Urinary incontinency, recurrent lower piece of land infections, vaginal uncomfortableness, dyspareunia, and shed blooding are all symptoms of atrophic vaginitis ( Howard et al, 1981 ; Bachmann and Nevadunsky, 2000 ) . These symptoms occur as a consequence of atrophic alterations caused as a effect of a gradual diminution in go arounding estrogens ( See figure 3a ) . Once degrees fall below the threshold where endometrial proliferation is possible, the vaginal canal begins shortening and there is a loss of rugae in the vaginal wall ( DeMasters J, 2000 ) . The urinary piece of land symptoms observed is a consequence of the urethra and vagina sharing the same embryologic beginning ( Howard et al, 1981 ) . Vaginal symptoms, unlike hot flowers often persist and can worsen with age ( Grady, 2006 ) . In a 2006 survey of the Management of menopausal symptoms, Grady reported up to 30 % prevalence of atrophic vaginitis symptoms amongst adult females during the early postmenopausal period with an in addition to 47 % prevalence during the ulterior postmenopausal period ( Grady, 2006 ) . During the climacteric, the vaginal wall musculuss deteriorate to bring forth a thin, unsmooth, inflamed mucous membrane susceptible both to bacterial infections and petechial hemorrhage caused by mechanical emphasis ( Samsioe, 1995 ) . The destructive effects caused by the diminution in oestrogen degrees are most outstanding in the fundal part of the vagina ( Samsioe, 1995 ) . Hormonal alterations induced by the climacteric, actuate metabolism in the bacterial vegetation and pH of the vagina ( Samsioe, 1995 ) . Before the climacteric the vagina is colonized by lactobacilli which maintain a low vaginal pH, by and large 4.5 or less ( Brizzolara et al, 1999 ) , bring forthing a protective environment aga inst the colonisation of the vagina and urethral tissue by Gram-negative bacteriums ( Samsioe, 1995 ) . After the climacteric lactobilli becomes replaced by faecal-type vegetations which cause postmenopausal adult females to go prone to urinary piece of land infection ( see figure 3b ) . The symptoms of urogenital degeneracy can be categorised into two groups: 1 ) Lower urinary piece of land – for symptoms affecting the urethra and bladder 2 ) Vaginal – for those confined to the vagina and the vulva such as vaginal waterlessness, combustion and itchiness ( Samsioe, 1995 ) . The prevalence of urologic symptoms ‘ ( including urgency, frequence, dysuria, and incontinency ) is a job which increases in badness with age ( Grady, 2006 ) ; this nevertheless can be farther insinuated by the wasting of the urethral mucous membrane caused during the menopausal passage ( Molander, 1990 ) . In postmenopausal adult females, the control of urination becomes progressively reliant on the support of the urogential musculuss to urethrovesical junction, due to widening of the urethra ( Samsioe, 1995 ) . The decrease in oestrogen degrees consequences in the deficient blood supply to the urogenital tissues and hence impedes full muscular functionality ( Molander, 1990 ) . Poor anatomical support to the urethra consequences in the uneffective control of urination ; which consequences in pelvic laxness and emphasis incontinency ( Samsioe, 1995 ) . The diminution in go arounding blood in urogential tissues means there will besides be an damage in the immune system antibod y response to foreign organic structures ( Molander, 1990 ) ; this in add-on to the broadening of the urethra, facilitates the migration of bacteriums into the lower urinary piece of land ( Samsioe, 1995 ) .Pre-menopauseFigure 3a and 3b: Summaries the alterations in the vaginal and urethra observed as the influence of oestrogen lessenings ( adapted from Samsioe, 2005 ; Brizzolara et Al, 1999 )Figure 3a: The diminution in serum oestrogen degree causes a lessening in vaginal blood flow and secernments. As a consequence, lactic acid degrees and animal starch content of the vaginal wall decreases, this causes the hyalinisation of collagen and the impairment of elastic tissue. Atrophy of the vaginal tissues nevertheless, does non get down until endogenously produced estrogens have fallen below the threshold required for endometrial proliferative activity. Therefore the clip period between the start of climacteric and the start of wasting opens a curative window. This has allowed the poss ibility for drugs to be able to aim urogenital wasting without put on the lining endometrial proliferation which can ensue in malignant neoplastic disease, extinguishing the demand for progestin co-medicationFigure 3b: The conventional drawings represent the pre and post-menopausal urethral opening and vaginal wall. The pH of vaginal fluid in postmenopausal adult females elevates to between 6 and 7 ; this facilitates the replacing of lactobacillae with gram negative source vegetations associated with urinary piece of land infection. In healthy vaginal epithelial tissue, parabasal cells are rare and normally represent less than 5 % of the epithelial cell population, this per centum increases to around 20 % after the climacteric.Post-maturityUrogential TreatmentSurveies have shown that estrogens, administered as systemic ( unwritten or transdermic ) or intravaginal estrogens, are extremely effectual at handling vaginal wasting. It is recommended that estrogens, when prescribed with th e purpose of pull offing urogenital symptoms, are given as low-dose readyings to assist understate systemic soaking up ( Grady, 2006 ) : this prevents the additions in oestrogen endogenous degrees that could potentially do estrogenic side effects. When HRT is used at the recommended low-dose and frequence, the add-on of a progestogen for endometrial protection is non necessary ( Figure 3a ) . The physiological alterations that consequences in the decrease of urogenital symptoms observed in oestrogen therapy, suggest that oestrogen lack may lend to this pathogenesis ( Samsioe, 1995 ) . The clinical efficaciousness of low-dose HRT readyings have been demonstrated in a figure of clinical tests. Barnabei et Al followed the menopausal symptoms and the effects of oestrogen and progestogen in the postmenopausal adult females, involved in the Women ‘s Health Initiative for a mean of 5.6 old ages. The consequences from the survey showed a 74 % decrease in vaginal wasting in adult femal es who had received oestrogen plus progestin and 55 % in those who had received placebo entirely. Intravaginal estrogens are besides extremely effectual at handling vaginal wasting ; Suckling et al Cochrane reappraisal found that all intravaginal readyings ( that were administered as picks, diaphragms, intravaginal tablets or the estradiol-releasing vaginal ring ) were every bit effectual and significantly reduced the symptoms of vaginal wasting. It is for this ground and that they by and large have small consequence on the serum oestrogen degrees that intravaginal oestrogens readyings are preferred to systemic oestrogen ( Suckling et al, 2006 ) . Surveies have besides shown that HRT is effectual in forestalling urinary piece of land infections. Cardozo et Al ‘s 1998 survey found that there was a important decrease in the incidences of urinary piece of land infection in adult females who had been treated with systemic oestrogen than those given placebo. Although several positi ons have compared many of the interventions for vaginal wasting, the long-run effects of intervention have non yet been expeditiously examined. Recommendations by regulative governments will hence be more accurate if intervention was assessed over a drawn-out period, such as one to five old ages, so that the unwanted responses to intervention can be farther examined.Menopause induced OsteoporosisOsteoporosis, the most damaging side-effect to wellness associated with the climacteric ( Samsioe, 1995 ) , is a skeletal disease characterised by a lessening in bone denseness and mass ( Howard et al, 1981 ) . The skeleton comprises compact and trabeculate bone ( Kanis, 1996 ) . In the healthy grownup, bone mass is comparatively changeless, this is despite there being considerable bone turnover, of which about 95 % of this is accounted for by the remodelling of bone ( Kanis, 1996 ) . This procedure is altered after the climacteric, where there is a period of rapid bone loss that lasts betwe en 5 to 10 old ages ( Kanis, 1996 ) . This consequences in a negative remodelling instability ( Kanis, 1996 ) . Bone mass reaches its extremum between the ages 30 and 35, after this extremum, bone mass declines at a rate of 1 % per twelvemonth ( Samsioe, 1995 ) . The rate of diminution can lift up to 6 % at the climacteric and history for a loss of a 3rd of bone mass ( Samsioe, 1995 ) , after the perimenopausal period the one-year rate of bone loss returns to the 1 % ( Samsioe, 1995 ) . There is besides grounds that there is an addition in osteoclastic activity ( Kanis, 1996 ) , where high circulating FSH induces increases osteoclast-mediated bone reabsorption which exceeds the formation of new bone ( Samsioe, 1995 ) . Both of these factors in concurrence consequences in the addition bone turnover and porousness that causes the loss of the trabeculate bone model and the cutting of the cerebral mantles ( Kanis, 1996 ; Samsioe, 1995 ) . This pathological procedure finally concludes wi th the break in the bone micro-architecture, which leads to the brickle castanetss that are more susceptible to break ( Kanis, 1996 ) . Womans have a higher cumulative life-time hazard for enduring from osteoporotic breaks about three times greater than in work forces ( Kanis, 1996 ) ; with 50 % of adult females and 20 % of work forces, over the age of 50, enduring from a break. The three most common sites of osteoporotic breaks are the distal radius, the vertebral organic structure and the upper thighbone ( Howard et al, 1981 ; Samsioe, 1995 ) . Hip break is a important cause of mortality and morbidity, where one in four adult females will non last the first twelvemonth following this break ( Samsioe, 1995 ) . Several surveies indicate that early oestrogen therapy intercession can detain or forestall bone loss at the climacteric, nevertheless, grounds back uping the continuation of the good effects after discontinuance remain debatable. A reappraisal by Bagger et Al in 2004, found there was a 4-fold increased hazard of breaks in adult females having placebo than HRT. From this consequence it was concluded that short-run oestrogen replacing therapy initiated in the early postmenopausal phases, can accomplish durable benefits to the skeletal system, in footings of the saving of bone mass and important decreases in the hazard osteoporotic breaks. However another survey by Yates et Al, found grounds that postmenopausal adult females who have discontinued HRT within the past 5 old ages have a hazard for hip break that was similar to adult females who have ne'er used HRT. The latter survey nevertheless has restrictions and is hence non conclusive. Womans who responded to the study tended to be y ounger and better educated about the importance of good wellness than the non-responders ( WHC, 2010 ) . Furthermore, it must besides be taken into consideration that the hazard of osteoporosis additions with increasing age and weight. HRT as a consequence would hold a greater decrease potency in the incidences of hip break in older adult females than in younger adult females. Therefore future surveies will necessitate to be adjusted to take into history these act uponing factors.The findings from the WHI and MWSThe possible relationship between the loss of ovarian map and development of Cardiovascular Disease ( CVD ) has been substantiated by legion case-controlled and laboratory surveies carried out since the 1980s ( Iqbal and Zaidi 2009 ) . These surveies demonstrated the protective effects of estrogens on the cardiovascular system ( Mendelsohn and Karas, 2002 ) ; which encourage the production of lipid profiles that cause vascular distension, prevents coronary artery disease and augmentation of endothelial fix after harm ( Mendelsohn and Karas, 2002 ) . After the oncoming of climacteric, degrees of estrogens begin to equilibrate to that of age-matched work forces ( Iqbal and Zaidi 2009 ) . Up until 2002, HRT was established as the most effectual signifier of intervention when bettering menopausal symptoms. However this was challenged by the publication of the preliminary findings of the WHI and MWS survey, which found the benefits of HRT on CVD to no longer be important when the other possible wellness jeopardies were taken into consideration ( WHI, 2002 ; MWS, 2003 ) . For illustration that the usage of oestrogen, with or without Lipo-Lutin, was found to be associated with an increased hazard for the development of certain signifiers of malignant neoplastic disease ( such as chest, ovarian and uterine malignant neoplastic disease ) ; this hazard was substantiated farther by drawn-out use ( WHI, 2002 ; MWS, 2003 ) . Findingss from the WHI, oestrogen plus p rogestin, test besides indicated that HRT could increase the hazard of CVD, which can take to shots and venous thromboemoblism ( WHI, 2002 ) . The WHI, oestrogen plus progestin, test published in 2002 monitored and compared the HRT related consequence on CVD and other facets of adult females ‘s wellness to that of placebo, in 16, 608 adult females in the United States aged 50 to 79 from 1993 to 2002. Around 50 % of the take parting adult females were randomised to take combined oestrogen and 50 % to take a placebo. The survey ended three old ages premature after the antecedently specified bound for chest malignant neoplastic disease instances, set by the WHI Data and Safety Monitoring Board was exceeded and overall hazards were considered to outweigh benefits. The preliminary findings showed a decreased in the hazard of osteoporotic breaks and colorectal malignant neoplastic disease ( Nelson et al, 2002 ; WHI, 2002 ) , but besides found a little addition in the incidences of coronary events, shot, chest malignant neoplastic disease and venous thromboembolism ( Nelson et al, 2002 ; WHI, 2002 ) . A subsequent reappraisa l of the findings from the WHI Study in 2004, adjusted for other act uponing factors, found different consequences where the apparent higher hazard for chest malignant neoplastic disease appear to be caused by natural factors instead than to HRT ( WHC, 2010 ) . When age was taken into history analysis showed that younger adult females get downing HRT may really be protected in some wellness facets ( WHC, 2010 ) . However those get downing on HRT over 70 did non hold the same benefits and alternatively were vulnerable to certain wellness hazards, nevertheless, this may be due to the associated hazard factors increasing with age.The Million Women Study was conducted from 1996 to 2001, analysed the hazard of chest malignant neoplastic disease and other adult females wellness issues in one million adult females taking HRT in the UK, and compared findings with that received from a sum of 828,923 adult females who were non-users: All take parting adult females were over 50 old ages old. F indingss published in 2003 found a little addition in the hazard of chest, endometrial and ovarian malignant neoplastic disease when oestrogen-only HRT was used. Combined HRT was found to hold a greater addition in the hazard of chest malignant neoplastic disease but was able to cut down the hazard of endometrial malignant neoplastic disease, when compared with oestrogen-only HRT. It was besides established that the hazard of chest malignant neoplastic disease is increased the longer HRT is used ; where the extra hazard for chest malignant neoplastic disease declined to that of ne'er users when intervention ended.Restriction of the surveiesWomen ‘s Health InitiativeThe WHI survey, merely considered the dosage of 0.625 milligram of conjugated equid estrogens and 2.5 milligram Provera acetate each twenty-four hours ; whilst this dose was appropriate for younger menopausal adult females get downing HRT, it was considered by many experts to transcend the sum required for older adu lt females ( Howard et al, 1981 ) . The specification for the adult females in the WHI survey differs from adult females in the MWS. Women in the WHI survey tended to be older ( mean age 63.2 ) than the adult females in MWS ( mean age 56 ) ( MWS, 2003 ) . Therefore two-thirds of adult females in WHI were over the age of 60 and hence had a higher absolute hazard of bosom disease, shot and chest malignant neoplastic disease ( all of which increases with age ) . The mean BMI for adult females in the survey is 28.5, therefore a big proportion of adult females in the survey are overweight and were hence predisposed to bosom disease and certain malignant neoplastic diseases.Million Women StudyThe methodological analysis of MWS has been criticised: Unlike the survey by the WHI, the MWS was non a randomised controlled test. The consequences were based on a self-reporting study where adult females chose whether or non to take HRT. Furthermore the adult females in the MWS were already holding a mammogram so may already hold been at a higher hazard for malignant neoplastic disease e.g. they may hold already suspected a ball. The adult females were followed-up by studies from national malignant neoplastic disease registers, non by subsequent questionnaires, so alternations in HRT usage after initial enrollment were non recorded. Both the surveies analysed the hazard of ovarian malignant neoplastic disease in the long-run surveies and were non meant to turn to the shorter-term usage of HT. Thus, the information from these surveies should be used by adult females sing usage of HT for longer than 3 or 4 old ages.Options to HRTTibolone is a selective oestrogen receptor modulator ( SERM ) , which possesses oestrogenic, progestogenic and androgenic features ( Nelson, 2008 ) . Tibolone is effectual at handling vasomotor symptoms and bettering sexual operation and may be used as an option to combined HRT in post-menopausal adult females ( Nelson, 2008 ; Roberts, 2007 ) . In adult females under 60, the hazards of taking tibolone are tantamount to that of combined HRT ( NHS Choices, 2009 ) . For adult females over 60, the associated hazards begin to outweigh the benefits, due to the increased hazard of chest malignant neoplastic disease, shot and endometrial malignant neoplastic disease ( NHS Choices, 2009 ) . Morris et Al ( 2006 ) conducted a clinical grounds reappraisal of seven RCTs, on the effects of tibolone on vasomotor and urogential symptoms. One test found that after 16 hebdomads of intervention, tibolone reduced vasomotor symptoms by 39 % compared with placebo ( p = 0.001 ) . However, two RCTs produced questionable consequences in respects to its efficaciousness when compared against traditional combined HRT. One test ( n=437 ) found that combined HRT when compared with tibolone, well reduced the frequence of hot flowers over 48 hebdomads ( p = 0.01 ) . However contradictory findings were found in another test of a smaller population ( n=235 ) , whe re no important difference in vasomotor symptoms between combined HRT and Tibolone was established at 52 hebdomads. Due to the rawness of findings another larger adjusted RCT should be conducted to clear up the effectivity of tibolone against combined HRT. Three tests were used to measure the efficaciousness of tibolone in the direction of urogenital symptoms. All of which concluded, with the understanding that tibolone significantly improved vaginal waterlessness, sexual desire and copulatory frequence compared to both placebo and combined HRT interventions. There is besides limited grounds to back up the usage of Catapres, Neurontin, paroxetine, Prozac, citalopram, and venlafaxine as effectual interventions hot flowers ( Nelson et al, 2006 ; Anderson and Redman, 2010 ) . The latest analysis of the hazards based on the findings from the MWS and WHI survey, has concluded with the following revised hazard estimations to help health care professionals appraisal of the hazards and benefits associated with HRT for single adult females:Cardiovascular Disease hazard:There is no addition in the hazard for CHD in adult females less than 10 old ages postmenopausal when given combined HRT ( Currie and Guttinger, 2007 ; Roberts, 2007 ) . Hysterectomised adult females taking oestrogen merely HRT besides showed no increased CHD hazard during the WHI test, alternatively the hazard for both appeared to worsen ( Currie and Guttinger, 2007 ) . However there us a little addition in hazard for adult females who were more than 10 old ages postmenopausal ( Currie and Guttinger, 2007 ) . The grounds to propose a cardiovascular benefit with oestrogen-only or combined HRT is hence weak ( CSM, 2004 ; MHRA and CHM, 2007 ) .Stroke hazardWHI found oestrogen-only and combined HRT increase the hazard of shot compared with placebo ( CSM, 200 ; MHRA and CHM, 2007 ) .Breast Cancer hazard:MWS indicated that a higher hazard of chest malignant neoplastic disease is associated with drawn-out usage ( CSM, 2004 ; MHRA and CHM, 2007 ) . For oestrogen entirely, the hazard is lower than combined HRT ( MHRA and CHM, 2007 ) . Some surveies on the other manus have non shown increased hazard when compared to those who had ne'er antecedently taken HRT ( MHRA and CHM, 2007 ) .Endometrial malignant neoplastic disease hazard:There is a little addition in the hazard of endometrial hyperplasia and carcinoma with oestrogen-only HRT ; due proliferated effects of oestrogen ( Howard et al, 1981 ) . Oestrogen-only HRT is hence merely recommended for usage by adult females with a womb ( MHRA and CHM, 2007 ) . The add-on of a progestin every twenty-four hours significantly reduces the hazard ( CSM, 2004 ; MHRA and CHM, 2007 ) ; due to its endothelial protective belongings. So when used i n combination with oestrogen it can cut down the hazard of this malignant neoplastic disease to the baseline ( MHRA and CHM, 2007 ) .Ovarian malignant neoplastic disease hazard:Experimental surveies indicate that extended usage of HRT may correlate with a little increased hazard of ovarian malignant neoplastic disease ( CSM, 2004 ) , which returns to baseline a few old ages after halting intervention ( MHRA and CHM, 2007 ) .DecisionDespite the legion contraindications for HRT, they are still by and large regarded as the most effectual short-run intervention for patients enduring from menopausal symptoms, and are recognised for their preventive effects in the development of osteoporosis. The benefits nevertheless from long-run use remain debatable ; research suggests that the potency for inauspicious effects happening additions with age and drawn-out use. Clinical reappraisals hence recommend that HRT should be given cyclically ; utilizing the lowest effectual dosage for its indicate d symptom for the shortest possible clip. A reappraisal and appraisal of any alteration in the balance of hazards and benefits should be done yearly. Womans with moderate hot flowers, particularly those with contraindications or concerns about HRT may take to seek alternate therapies. Tibolone has proven good in the intervention of menopausal symptoms in younger adult females, although its usage in older adult females remains questionable due to the increased hazards to wellness. Surveies of climacteric are vast in figure, but deficient in what they discover. Nevertheless, their consequences inform the recommendations of medical professional administrations and influence criterions of pattern. Therefore an improved apprehension of the menopausal passage, its symptoms, and therapies is needed in order to unknot this epidemiological quandary and license a better conformity from patients towards intervention. This can be achieved by the reevaluating the hazards and benefits of HRT in d ouble blinded tests against a placebo or a validated therapy because of the ample placebo consequence observed in randomized controlled tests.

El-Al Marketing Analysis

El-Al Marketing Analysis El-Al Marketing Analysis Table Of Content Chapter 1: Introduction Executive summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦4 Bibliography†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 5 Chapter 2: An overview of the company Overview of the company†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦6 History†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦7 Definition of the business†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 8 Chapter 3: An analysis of the company’s business environment Firms industry and macro environment†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 The PEST Model†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 10-12 The industries competitive situation using Porter’s 5 Forces†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦. †¦Ã¢â‚¬ ¦. †¦Ã¢â‚¬ ¦. 13-15 Market segmentation†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. †¦. †¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦16-17 ELAL’s Attractiveness †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦. †¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦17 Chapter 4: The Company’s Marketing Overview Mission Statement, Objectives and Values†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 18 Marketing Mix (Four P’s)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 19 SWOT Analysis†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 0 ELAL’s main problems†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 21 Chapter 5: Recommendations and Summary Is the Company’s Marketing Mix in – tune with its markets and its objectives?†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 22 Solutions to ELAL’s main problems†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦. 22 Summary and Conclusions †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 23 Appendix 1 – Boeing†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 24 Appendix 2 – Code Sharing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 25 Chapter 1: Introduction Executive Summary 1. ELAL is the leading airline in Israel. In the past it was a government owned company until privatization commenced on 2003. 2. ELAL owned several dozen aircrafts, which are used for international and lately national flights as well. 3. ELAL hires thousands of employees and has several subsidiaries as well. 4. ELAL's narrative is defined by the ideal of being the number one airline for passengers from and to Israel. ELAL is constantly walking the thin line regarding the political status quo. ELAL maintains its religious crowd by keeping the Shabbat on one hand, and losing potential revenues by doing so. This narrative is implemented in the outline of ELAL's marketing agenda, ever claiming that it is Israel's national company and by launching numerous patriotic campaigns. As part of this agenda, ELAL serves kosher food as default. 5. ELAL is in a satisfying financial situation. ELAL is growing constantly; revenues, stock value, ROE and net value are growing in a healthy manner. The company survived impressively the latest financial crises. 6. ELAL prices its flights relatively expensive, offering the passengers non-compromising security, safety and service standards. As part of this agenda, ELAL keeps its technology in a state of the art level, using new and improved American planes. 7. ELAL offers transparent and non-transparent services, such as constant flyer benefits on one hand and code-share agreements on the other. ELAL could â€Å"hide† its disadvantages by exploiting the benefits that globalization offers, with emphasis on international collaboration and offering combined services to its clients such as hotels, car rentals and others. 8. ELAL's current and future challenges will be defined and influenced by the constant entrance of national and international competitors. ELAL will have to emphasize its advantages, maintain its technological and marketing images. Bibliography http://en. wikipedia. org/wiki/El_Al http://www. bizportal. co. il/shukhahon/bizcompbaalsump. shtml? p_id=1087824&am p;c_id=1152 http://www. elal. co. il/ELAL/Heasbrew/States/General/ . http://www. elal. co. il/NR/rdonlyres/2D943294-0735-4E30-9C7C-9FCDA40B23E7/0/FactSheet20092final. pdf http://www. youtube. com/watch? v=8nPXttPmNE0 Chapter 2: An overview of the company Overview of the company EL-Al (hereinafter â€Å"the company†) is one of the greatest Israeli symbols. It was one of the most famous trademarks of the small state. The company's story intertwined with Israel's origins. The company is operating in a â€Å"national† state of mind, aiming towards patriotic emotions based on the Israeli narrative of pride, safety and security. The company markets and considers itself as a national service provider, submitting itself to the whims and needs of the country. Not once the company has been involved in security or social operations (the joint confidential operation of bringing Ethiopian Jews to Israel), even in the price of losing money (i. e. not flying on the Shabbat), all in order of keeping the image of the national company. The company traditionally operated international flights alone, but lately it operates domestic ones as well. The company's headquarters and mother- airport are located in Israel's international airport â€Å"Ben-Gurion†. The company has evolved and changed throughout the years, and has varied its basic definition from a government organization to a private company. The privatization has been complete mid-2000's (that is less than 50% of company shares are kept in by the government). The 2nd decade of the 21st century will colored by security issues, ever growing competition and the continuation of the privatization process. It will be the first decade in the company's history that it will have to deal with strong competition over the Israeli customers, since the monopoly is finally over. EL-Al will have to adapt, and has already started, to a ruthless competitive market. This paper will deal with the company's strategies and marketing agenda and status. History â€Å"EL-AL Israel airways LTD. † was incorporated and became Israel's official airline company on November 1948. The company was incorporated as a national company fully owned by the government. The company's fleet was based on second hand American manufactured airplanes. In the first couple of years the company made only commercial passenger flights, and since 1950 it commenced cargo flights as well. The D. N. A of the company was heavily influenced by the political scene in Israel, creating an ongoing non-Sabbath flying and kosher food serving. One more influence that helped to position the company's image in Israeli society was â€Å"patriotic† and historical flights: bringing Jewish communities to the new states, from Arab countries and India. One memorable flight was the one bringing Nazi war criminal Adolf Eichmann. In the mid 50's EL-Al conducted two several actions: transatlantic flights and the purchasing of British airplanes. Later on a purchase of Boeing 707 was made. On 1960, for the first time, EL-Al became profitable. The 60's were a successful decade for the company, growing from year to year and demonstrating respectable financial figures. The good fortune of the company commenced at the end of the 60's. Security issues were magnified due to several terrorist attacks. EL-Al took some adventurous decisions, starting with the purchasing of expensive Boeing 747 aircrafts. The latter purchase was too expensive for the short run, as expenses exceeded revenues in a large magnitude. On top of things, due to inner political reasons EL-Al suffered strikes and some other political influences (see chapter). The most outlined event of the 80's was the collapse of the iron screen, revealing a wide spread bundle of new flight destinations. The 1990's were a decade of coming changes, as privatization voices started to be heard. These voices were boosted thanks to the uprising charter flights and decreasing numbers of tourists in Israel. Another major negative effect was the 25% increase in fuel prices. The uprising competition and environmental changes forced the company to tend towards the inevitable step of privatization. The privatization of EL-AL commenced in 2003. 15% of the company was offered to buy in the Tel Aviv Stock Exchange. This process continues as more and more shares held by the government were sold to the public. Definition of the business EL-AL is a publicly traded airline company. It is traded on the Tel Aviv Stock Exchange (â€Å"TASE†). EL-AL provides international and domestic flights. It also provides shipping services and touristic ones as well. General Details The company owns a 37 aircraft fleet, all manufactured by Boeing (737,747,757,767,777). The company flies to 38 non-stop service destinations worldwide and has 440 weekly departures. The company employs 5,847 workers and is one of the biggest in Israel in that factor. The company has business relationships in the form of code-share agreements () and domestic service tourism providers. The company has a frequent flyer club. The company conducts its financial reports by IAS 34, and has adopted the IFRS international code. The company is owned by several owners besides the public, and some of its owners are investment houses. The full control list is as follows: The company has increased its equity from 2010 q2 to q3 by 51. 65%, its revenues by 12. 57%, ROE by 81. 81% and net income by 186%. Chapter 3: An analysis of the company’s business environment Firms industry and its macro environment The business environment in which ELAL is performing is the civil international aviation arena from and to Israel. Political Environment – The company competes with other 103 flight companies that work within the Israeli territory. ELAL, which started as a governmental company, worked and still working according to the government decision since 1977, this decision, determined that ELAL will not work or fly neither on Shabbat nor on Jewish holidays and therefore it does not fulfill its maximum revenues potential. ELAL is the leading aviation company that works within the Israeli territory flying in and out of Israel. Social Environment – ELAL owns several subsidiary companies, which deal with a variety of complementary goods and services for the aviation world. One its main fields is cheap flight to Europe operated by the subsidiary company – San d’Or, which in 2009 increased its revenues by 2%, comparing to the previous year. Another major field is the food industry provided by the subsidiary company â€Å"Tama†m & Burenstein Catering†. This company deals with producing and supplying food to airplanes – controlled by ELAL’s management. ELAL has many more subsidiary companies in the following areas: renting flight supplies, transportation of cargo and maintenance, selling duty free products and converting currencies during its flights. Seasonal changes in this area and the fact that the world is becoming a global village forces ELAL to adjust itself to a hostile and competitive business environment. It obligates ELAL to recognize new niches in the market, following persistency in finding new company skills, improvement in existing ones, and adjusting human resource. These factors can bring ELAL to be a leading company with a competitive advantage that will keep it ahead of its competitors. The PEST Model Political * ELAL, as a governmental company that was privatized (2005) still relies on political decisions affecting its business choices. One of the best examples is that the company was anchored in the Government Companies Law. As a result, there is a consistent political intervention when referring to taking business actions. A few years ago, ELAL had to decide whether to stick with one airplane supplier – the American Boeing (Appendix1) – and to renounce the European airplane supplier – Airbus. After examining the business aspect, it decided to equip itself with the Airbus airplanes due to their more attractive price and cheaper maintenance costs. However, in 2004 the U. S. overnment pressured the Israeli government (ELAL’s owner back then) into working exclusively with Boeing and therefore ELAL did not have any other choice but to do just that. * Until 1992, ELAL flew seven days a week until a political decision was made – to prohibit flying during Shabbat and Jewish holidays. As a consequence, ELAL’s operational time decreased by 15%. In fact, after 2005 when the company w as privatized, it was decided that even though they were no obligated to do so, ELAL would keep the Status-Quo by respecting the Shabbat law (a strategic way to gain religious public adherence). Israel is geographically located in one of the problematic areas in the world, surrounded by hostile Arab countries. As a consequence, ELAL is forced to extend its flying course to its different destinations. The fact that Israel does not have good relations with many countries in the world, limits ELAL’s destinations. Moreover, the delicate security situation in Israel forces ELAL to make excessive security examinations within Israel and overseas. This security policy creates a massive cost to the company. As a result, today ELAL is well-known for its security achievements. Economical * The Global Village – the world is becoming a big global village. People are flying more and more, from and to many places. As a consequence of improvement in financial opportunities and shorter flight duration, they divide their vacations into many small vacations during the year. This economical factor brings to abundance in the financial situation in general and in the flying industry in particular. Nowadays ELAL is focusing on international destinations being affected by the world wide economical changes, such as last financial crisis in 2007. The competition with many other flight companies is growing intensively. ELAL must take action in order not to fail in the competition, usually this means either to lower prices drastically or reducing operating expenses. * There is an ongoing decrease in the incoming tourism for the last decade. Due to security and political situation in Israel, many tourists prefer either to fly with foreign companies or not to fly to I srael at all. According to statistics, in 2009 2M tourists visited Israel, a decrease of 6% from 2008. * Increase in gasoline prices had raised ELAL’s flight tickets prices by 5% to 10%. Social The financial recession was supposed to decrease the financial options to the public and so decrease the amount of Israelis traveling abroad. Nevertheless, there has been a large increase in Israelis travelers overseas at about 10% a year. This fact shows the change in Israeli consumption habits. It seems the Israeli, men and women, have more free time than ever which allows them to plan their leisure time. * The climate in Israel enables worldwide tourism to come to Israel in all seasons. The night life is longer and safer than many other places in the world – tourists who visit Israel enjoy this social freedom. The value of life and death is quite different in Israel due to struggle for survivor. Security and safety are very important and are overvalued by the customers and EL AL has a reputation regarding these issues. * Environmental awareness – *** Today’s social trend is to be green and clean. ELAL collaborates and support many green organizations and encourages youth into creating new green-tech. This promotes ELAL as an environmental friendly company while increasing public’s adherence. * Kosher food – one of ELAL’s largest audiences is the Jewish religious people. Their demand is for kosher food and ELAL is one of the only companies which provide such an option. ELAL is very tolerant to this public and therefore it gives a competitive advantage. Technology * ELAL’s airplane equipment is more sophisticated, its activation is cheaper than ever, expenses are lower and the personal service within the plane technologically wise is a step ahead from many other companies. The race over the heart and pocket of the average customers brings ELAL into a major efficiency while decreasing the market price. ELAL’s website – in the era of internet ELAL began to sell tickets through its website and its entire marketing propaganda took few steps further. In the long run, the website exposes the audience to very important and relevant details that are handier. This obviously minimized the number of flight agents while transforming them into tourist advisors. The revolution of the customer service is relying now on the innovation in technolo gy. This improves the commercial interaction between company and the customer. The industries competitive situation using Porter’s 5 Forces The threat of the entry of new competitors ELAL owns the largest market segment in the Israeli aviation field and therefore it has to create many barriers to eliminate new competitors. The company accomplished that by having full control over a variety of goods and services such as transporting passengers and baggage, a variety of destinations and high security level. There are many factors that make it difficult for other competitors to enter the market: * Initial investment – in order to found a new aviation company, it is necessary to have sufficient capital for buying airplane navy and technological infrastructures. Moreover, there is a large depreciation over the equipment this field. The maintenance of an airplane company can sometimes appear to be luxurious one but not necessarily a profitable one. * Fuel costs – jet fuel costs are 50% out of the operational cost. * Legal barrier – flight companies are responsible for licensing and employees’ training in order to keep the pilots and technicians qualified. * Economic factor- the aviation industry is one of the first to be affected from financial crises and can easily be exposed to bankruptcy. For instance, the last financial crisis in 2007 made major decrease in the tourism industry and therefore the demand for flying decreased and many aviation companies went bankrupted over the world. * Aviation Clubs – in the last decade, aviation companies have created clubs in which encouraged passengers to fly with certain companies by gaining points and getting free tickets to fly within specific companies. This created a huge barrier for new companies which wanted to enter the market. The competition in this field is very intense and competes on passengers’ benefits, flight courses, and variety of destinations and level of service. ELAL’s strategy for combating this competition is: 1. Flexibility in scheduling flights according to different seasons and international events (holidays, Olympic Games, sport events, high season-low season, etc. ) 2. Increasing flight frequencies to popular destinations by increasing the number of co-sharing flights (cooperation with other companies). 3. A consistent improvement of services within the flight, especially the comfort of the seats, quality of food and entertainment during flights. Most of the focus goes to First Class. 4. Frequent flyer club – ELAL has found a club in which it compensates its member with highly valued benefits like seat-upgrading, flight tickets discounts, etc. 5. Promoting them through worldwide advertisement. The bargaining power of customers (buyers) The customer thrives to push prices down and quality of services up. The power of the customer depends on the added value he gives to the company. The option to choose from a large variety flight companies is a threat to ELAL. A constant recession can decrease the loyalty of one customer to a certain aviation company because some other companies will offer lower prices. In this case, he will obviously choose the cheaper company to fly with. The bargaining power of suppliers The bargaining power of suppliers is different from the bargaining power of the customers. The suppliers push prices up while decreasing quality of their products and services. ELAL is very much affected from the competition existing in the field and depending on its suppliers that would make it difficult for ELAL to maintain the level of their service quality and competitive prices. Many of ELAL’s suppliers have exclusivity in their field and the knowledge that they have, made them powerful against ELAL. The fact that many of ELAL’s suppliers are also it subsidiaries, increases its profitability and neutralizes the bargaining power of these suppliers. However, the aviation field has two main suppliers (that are not subsidiaries to ELAL): jet fuel suppliers and airplanes suppliers. In Israel there are only a few jet fuel suppliers whereas abroad the suppliers are many, and the decision of buying fuel from one supplier depends on price and not on an exclusive supplier. Aviation companies in Israel have a weak bargaining power against fuel suppliers as a consequence of political issues that affect the price of fuel. There are two main airplane suppliers in the world – the American Boeing and the European Airbus. ELAL has on its behalf airplanes made by Boeing only, as we mentioned before due to American pressure over the Israelis in the days when the company was owned by the government. This kind of relationships between governments created a dependency on one supplier with a high level of bargaining power in a market which is limited in the first place. The threat of substitute products or services ELAL offers its customers a variety of permanent destinations all over the world. Moreover, through its subsidiary San D’or, ELAL offers a variety of flights to seasonal destinations flying on weekends and holidays. Goods and services given in parallel fields are called substitute products. These products have a major power influencing management decisions due to the possibility the customer will decide to put his money in another company (in another substitute product). A substitute can demolish a company. A substitute product for Aviation Company like ELAL is the low cost aviation companies as EasyJet, Arkia Express, etc. These companies reduce flight ticket’s prices (30-50 Euro) by charging only for the flight itself and any other service is being paid extra (luggage, food, drinks, etc. ). ELAL invests millions of dollars in a good and full service that will bring its customers to their destiny. The price factor sometimes defeats the comfort and the quality of service and leads to harming ELAL profitability. The intensity of competitive rivalry The aviation industry has many leading companies all over the world, where each one strives to have a significant differentiation which will attract customers’ hearts and pockets and enlarge their market segment. Barriers to exit – ELAL have â€Å"code sharing† with many foreign airlines (Appendix2). As a result, it has full access to internal information of these companies, which enables it to know about the activity of its competitors. Similarly, ELAL’s delicate information is accessible for its competitors. If ELAL decides to breach the code-sharing with the other companies, its future is doomed (ELAL may decide the barriers to exit are too significant and will be forced to continue the code-sharing). As previously mentioned, ELAL has many share-codes with foreign airline which its customers and employees can fly with (with same conditions they would have got from ELAL). This corporation provides full accessible information of flight and price on-line. This accessibility improves ELAL profitability. Target Market Potential Market Addressable Market Target Market Potential Market Addressable Market Total Market Total Market Market segmentation Macro segmentation Total Market – A group of people sharing the same characteristics that cause them to have similar needs – to fly from one place to another. Potential Market – Men and women, all ages, with no prohibition to fly (pregnancy, heart patients, etc. ), who want to fly from one place to another. Addressable Market – Men and women, all ages, with no prohibition to fly (pregnancy, heart patients, etc. ), who want to fly from and to Israel. Target Market – Men and women, all ages, with no prohibition to fly (pregnancy, heart patients, etc. ), who want to fly from and to Israel and can afford it. People who live geographically close to ELAL’s destinations. Micro segmentation – potential audience Business * Age: 30-70 years old. Occupation: Business men and women who have international businesses. * Lifestyle: Usually â€Å"Frequent Flyer† members who fly on behalf of their companies. A population who usually flies in Business and First Class. Pleasure * Age: 13to 18: family trips; 21 to 30: backpacking, vacations and trips. * Occupation: Students and families. * Lifestyle: Due to the variet y of ages in this segment, there are all kinds of lifestyles (with average+ income). Religion The Jewish religious businessmenfamily members from all over the world choose to fly ELAL due to its policies regarding kosher food and respecting Shabbat. This is a very dominant sector among ELAL customers and therefore ELAL treats this segment with delicacy and tries to be as religious oriented as possible. ELAL strives to be as least mass marketed as possible by approaching its different segments that we mentioned separately. Nevertheless, its last commercial advertisement with Omri Casspi, approaches all three segments by arousing the sense of Zionism among all. This is an emotional commercial which emphasizes that ELAL is the leading national airline in Israel. ELAL’s Attractiveness ELAL is in the business of civil international aviation arena from and to Israel. It is quite straight forward that the overall industry attractiveness does not apply that every firm in the field will return the same profitability. Firms are able to apply their core competence, businesses model to achieve a profit above the industry average. After examining Porter’s five forces, we analyzed ELAL’s attractiveness within its industry. Backward vertical integration: dealing with supplier bargaining power ELAL acted wisely when buying most of its suppliers and neutralizing their power. However, when considering the industry, most of the money is in the jet fuel industry and airplane suppliers. If ELAL could buy these suppliers, it would have a huge competitive advantage among its competitors. Nowadays, ELAL does not have the means to buy such companies (like Boeing) and we would not suggest doing so. Forwards vertical integration: Nowadays, ELAL does not â€Å"control† its customers but rather the customers choose ELAL. ELAL has the option of buying tourists companies (such as Ista), online purchasing flying tickets companies (such as netravel. com). By doing so, ELAL can increase its profitability and customer flow. The fact that tourist-agencies are becoming old-fashioned, more and more people are buying flight ticket via websites, ELAL could create a significant competitive advantage by buying these sites. This would obviously make ELAL more attractive above the industry average. Horizontal integration: As we mentioned in the threat of substitute products or services, ELAL main threat is the low-cost companies that offer cheaper prices by offering only the flight itself with no additional services. This â€Å"product† is targeted to a segment which ELAL has not addressed yet. These clients seek for short flights within Europe or the U. S. with the most attractive price. Nowadays ELAL does not offer such product and by merging with such low-cost company, they would probably increase its profitability and addressed a new unutilized market segment. Chapter 4: The Company’s Marketing Overview Mission Statement, Objectives and Values ELAL has set many targets, which the main one is to operate as an integral part in the global aviation competitive world, while keeping its uniqueness as an international airline company of Israel. In addition, ELAL is defining the following goals: 1. Uncompromising level of service 2. First priority – safety and security of the passengers 3. Investing in its employees – high level of training, focus on their welfare in order to promote the company’s success. Happy employees = successful company. 4. Promoting profitability by innovation and initiative, maximizing shareholders’ wealth. 5. Be an integral and significant company in the international aviation world, while keeping it uniqueness as the Israeli national leading airline. 6. Prioritizing the destinations according to profitably and customer demand. 7. Maintaining only new airplanes. . Efficiency and saving – retirement plans, reducing the number of offices overseas. ELAL defined the aforementioned goals as part of â€Å"ELAL’s 2010 project† and is going to achieve these goals by implementing its vision. ELAL’s vision * To lead the aviation market in Israel and to be the first choice for all customers traveling to and from Israel. * To be a winning, profitable and successful commercial company that excels in all areas of activity. * To provide the highest level of uncompromised quality service, for the benefit of its customers, employees and share holders. Marketing Mix (Four P’s) The marketing mix is the combination of several techniques that are bring used in order to achieve marketing strategy and goals. Product * Products – ELAL offers the service of national and international flights. * Variety of products – Different levels of services – Economy class, Business class and First. * Services – ELAL is very service oriented. It offers its client a high level of service starting even before flight: purchasing tickets online, express online check in, luggage pick up, duty free on board, lounge and Frequent Flyer Club. Pricing ELAL does not attempt to be a low cost company and therefore its prices cannot compete with such companies but rather with full service flying companies. It is known that ELAL’s tickets are not cheap but whoever chooses to fly with ELAL knows he will get a return on his money. * Frequent Flyer members receive free upgrades and free ticket according to their mileage. * ELAL â€Å"spontany† – a new service ELAL offers is the last minutes flights with lower prices. This is oriented for spontaneous people who don’t want to settle for service but do not want to spend much on the ticket. Promotion * ELAL promoted itself via a various media means – TV commercials, outdoor adds, Newsletters for its club members, collaboration with credit card companies which offer ELAL’s points * ELAL promotes itself as the national Israeli airline by being the official transporting airline to public organizations (like the Israeli football delegation) and well known personalities (like the President). Place * ELAL’s destinations are wisely chosen according to demand. It operates in international and principal airports accessible to many other destinations. SWOT Analysis Strength * A variety of services and goods (â€Å"Fun Day†, â€Å"ELAL Spontany†) that enables to attract many segments in the market. * ELAL is an international brand in the field of security and safety. * Kosher food and respecting Shabbat. * Many corporations with other international airlines. * Only one airplane supplier. | Weaknesses: * Does not operate on Shabbat and on holidays. * Unstable security situation in Israel reduces number of customers. * High prices relatively to the market. * ELAL does not maintain constant collaboration with agencies abroad and loses potential market. Geographically Israel is located between hostile countries which extends the flight courses and enlarge the duration of the flights, increase fuel expenses, etc. | Opportunities * ELAL e-ticket purchased online saves time and money and enlarges potential clients. * ELAL’s high reputation reduces advertisement expenses. * ELAL’s website is a commercial platform which reduce s advertisement expenses. | Threats * Low cost companies offering cheap flying tickets. * As the Israeli national airline, ELAL is exposed to terror attacks on its airplanes. * The increasing prices of fuel| ELAL’s main problems Keeping the Status Quo – ELAL does not operate on Shabbat and holidays. The company loses 15% of operational time due to its commitment to the status quo which allows other companies to enjoy ELALs customers. Expending variety of services – ELAL is exposed to a severe competition with low-cost companies. Such companies offer flights with no other extra services, airplane as an transporting mean and no more than that. Chapter 5: Recommendations and Summary Is the Company’s Marketing Mix in – tune with its markets and its objectives? We find the company's marketing mix in tune. The company provides its products in relatively high prices. Following the latter, the prices are a derivative of security and social aspects as described. The company pays relatively high salaries in order to obtain the level of service. Although privatized, the company maintains its objective to be the â€Å"national company† of Israel, first by slogans and continued by ads and commercials: i. e. the latest commercial staring NBA player Omri Casspi, who is, as ELAL wants to be, a national pride and patriotic icon. ELAL has a much focused hub-oriented hub airport destinations, which are by definition very attractive ones. Solutions to ELAL’s main problems Keeping the Status Quo Solution: On the one hand, if ELAL decides to break the status quo, it can realize its potential market and become equal to its competitors and even create an additional competitive advantage. On the other hand, this delicate issue can create antagonism among religious passengers who are a dominant factor to ELAL. This is a problematic situation which still should be considered in order to maximize ELAL’s profitability. Expending variety of services Solution: ELAL should examine the option of offering this kind of service in order to provide its customers a larger variety of services. For example, ELAL can operate a weekly flight to various destinations according to the low cost policy. By entering such a market, ELAL could enlarge its segment markets. This kind of decision could have a positive effect but also damage ELAL’s reputation. Summary and Conclusions As a small state, Israel does not have many commercial or social icons. Maccabi Tel Aviv, high tech and the Dead Sea are few that could be mentioned. ELAL is another one. As part of the Israeli pathos, ELAL played an important role in Israel's short history. ELAL has evolved from a national owned company with all that entails (unions, heavy politics, non-profit environment etc. ) to a profitable and role model airline. ELAL determined a strategy based on the evolving and more competitive environment around it and thrives for profit maximization as well as keeping its image as the national airline in Israel. To do the latter, ELAL determined prices, strategic agenda and image by the aforementioned guidelines. The future will tell whether ELAL would be able to deal with the challenges of tightened security, growing competition and ever changing political environment; up to now, it seems to be on the right track. Appendix1 – Boeing | | *Boeing 737 – 700 ; 800| Total in service:  11 ; 2 Range:  4870  km Engines:  C. F. M. Cruising speed:  873kph/Mach 0. 8 Length:  110ft (33. 6m) ; 129ft (39. 5m) Wingspan:  112ft,(34. 5m)  | |   | | Boeing 747 – 200  | Total in service:  1 Cargo Range:  10000 km Engines:  Four Pratt ; Whitney Cruising speed:  917kph/Mach 0. 84 Length:  231ft 11ins,(70. 7m) Wingspan:  195ft 9in,(59. 6m)| | | *Boeing 777 – 200| Total in service:  6 Range:  12670 km Engines:  Rolls Royce Cruising speed:  864kph/Mach 0. 83 Length:  209ft 1ins(63. 7m) Wingspan:  199ft 11ins,(60. 9m)  Ã‚  | |   | | *  Boeing 747 – 400| Total in service:  6 Range:  11860  km Engines:  Four Pratt ; Whitney Cruising speed:  927kph/Mach 0. 85 Length:  231ft 11ins,(70. 7m) Wingspan:  213ft,(64. 9m)  | | | *Boeing 767| Total in service:  8 Range:  10000 km Engines:  Two Pratt ; Whitney Cruising speed:  873kph/Mach 0. 8 Length:  159ft 2ins,(48. 5m) Wingspan:  156ft,(47. 6m)  | |   | | *  Boeing 757  | Total in service:  5 Range:  6100  km Engines:  Two Rolls Royce Cruising speed:  873kph/Mach 0. 8 Length:  155ft 3ins,(47. 3m) Wingspan:  124ft, 10ins,(37. 9m)  | | Appendix2 – Code Sharing Airlines| Destination| | American Airlines – Code Share flights operated by AA from Europe to the USA and flights operated by AA within the USA. To view the list of destinations. |   | Iberia – Flights between Tel-Aviv and Barcelona or

An Analysis of Huntington’s disease

An Analysis of Huntington’s disease The disease that I have chosen for my research essay is most commonly known as ‘Huntington’s Disease or the scientific name for it which is ‘Huntingtons chorea’. Huntington’s disease is a Neurodegenerative disease that progresses over time, causing the death of brain cells usually in Your 30’s to 40’s. Huntington’s disease is hereditary and dominant, so if one parent has Huntington’s disease may inherit it. Huntington’s disease is named after George Huntington, who discovered it in East Hampton, Long Island in 1872. In those days, people that had Huntington’s disease were often thought of As devils due to the lack of understanding of the disease. In 1993, a group of investigators Discovered the gene that revealed the causes of Huntington’s disease. Huntington’s disease can start to show symptoms at any age, but usually later in life. It varies Greatly from person to person. Usually, the symptoms start out as very subtle changes, such as Changes in coordination, fidgety movements, trouble thinking through problems, and depression/irritability. It then progresses to move obvious and intense symptoms over time, only. To result in the inability to walk and speak, and intense fidgety movements People who are at most risk for this disease are people who have a parent or parents with Huntington’s disease. An offspring of an affected parent has a 50% chance of inheriting the disease. There is no way to prevent Huntington’s when you inherit it, so only the potential parents can avoid passing it on to their future children. This can be done by doing genetic testing prior to conceiving, or doing vitro fertilization. Someone is diagnosed with Huntington’s disease is mainly diagnosed through basic medical questions and questions about your family history, and tests which will show your motor skills, like reflexes, muscle strength, muscle tone, and coordination. A neurologist will also test your sense of touch, hearing, mental status, memory, mental agility, and language function as so on. Huntington’s disease is mainly treated by simply controlling the symptoms using medications, speech or language therapy, nutritional support, exercise, and physical therapy. Using blood samples, genetic testing, and prenatal testing are technological tests involved with diagnosing Huntington’s. These are usually the best methods of discovering the disease.

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Safety and Risk of Nitrous Dioxide during Labor Literature review

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Rape in War Essay Example | Topics and Well Written Essays - 1500 words

Rape in War - Essay Example The major victims of rape during wars are females of all ages, including young girls and adult women. However, it should be understood that males can also be victims of rape during war. Regardless of the nature of the rape incident, it has long been established that the effects of rape on an individual is of a wide spectrum. Rape general physical harm to an individual, as this action is an intentional violation of the body of the victim. In addition, rape also generates a sense of severe devastation in the victim, resulting in the deterioration of their mental health and their quality of life (Lonar et al., 2006). The damage associated with rape not only affects the victim, but also his or her family. The relatives of the victim often feel bitterness, anger and fear towards to the incident and the perpetrators of the crime, while they feel pity and sadness for their victim. Rape also affects the rest of the social environment of the victim, as they would be fearful of having to exper ience the same violation at any given moment. Rape during wars has recently been considered as a feature of recent clashes between groups and it has been observed that this action can be further classified as either isolated or systematic. In the case of isolated rape cases, its incidence is often equated as to be a less planned incident that could have been performed by a few members of a group that is engaged in a war. The more complex rape cases are considered to be systematic in implementation, as this often involves the intrusion of a group of fighters into a community and preventing any members from escaping the area. Systematic rape during war thus includes the separation of the males from the females and subsequently performing the heinous crime. There are several reasons why rape is now being considered as a weapon of war. Firstly, it should be understood that women are considered as an essential component of every group of individuals. Women are considered as the caretakers of both the homes and the family, thus this gender plays an important role in the upkeep of society. In most cultures, every woman is considered as a partner of a man and thus this individual represents the private life of every man. Performing rape during a war would thus instill a sense of helplessness and failure in the part of the men of opposing group. One of the more serious actions of rape during war is involving performing the action in the sight of captive men. The knowledge of having women and young girls raped is generally hurtful to the men of the community, yet watching this act being performed is even more painful. In some barbaric war incidents, the captive men are usually tied up to render them incapable of moving and the women and girls are raped right in front of these people. Rape is thus used as a weapon of war because this heinous action can inflict pain on individuals, probably equal or even worse than the impact of physical harm. Another possible reason of using rape as a weapon of war is that this action can serve as an instrument in prolonging the suffering of the victims. Wars are often associated with anger of one group against the other. The basis of this disagreement is commonly based on principles of culture, politics or religion. When two groups are at war, the main aim of each party is to inflict harm and pain on

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Critical Process - Term Paper Example Due to this analysis the most truthful opinion is that videogames inspire and cultivate aggressive behaviour not any more or less than other forms of media like television or internet. This statement was a basis on which video games already received a First Amendment protection during the attempt of state government of California to forbid selling violent videogames to minors. Nevertheless despite the victory of videogames in that battle, though it gave them equal rights with other media, the main war is still raging on. Doctors, researchers and most of all immoderately and excessively careful and anxious parents seek to find right tactics to blame videogames in the wrong behaviour of their children. Such scenario slowly moves but still parents themselves are more responsible for any problems that they have with their children and videogames have nothing to do about it. As for the other types of media they are more independent and not so young as videogames. For those who don’t know it may be interesting that nowadays there is a serious discussion on the matter of giving videogames a status of art. This requires more significant and attentive look from the government, producers of videogames and customers. Books, movies and films are strictly categorized by the level of age and also a lot of other restrictions and requirements (for example aspersion and slander towards other person must not take place in any media). Therefore, by connecting with the world of real media and art videogames must be of a high level. The rate of the game is not similar to the rate of violence in it. Violence is just an extra option because a majority of all games need one player or a team of players to conquer, smash, beat or simply make lose the other player or team of players. Most of the games follow the jungle rule of the survival of the fittest (eat or be ea ten). Such parents` concern about the

Economic Impact of the national adoption of Electric and hybrid cars Essay Example for Free

Economic Impact of the national adoption of Electric and hybrid cars Essay The Unites States consumes 25 % of the oil produced in the world and roughly 70% of this is consumed by the demand for transportation. The demand for crude oil in US is primarily driven by the demand for transport fuels with the price elasticity ranging between -0. 12 and -0. 3, as calculated for short-run and long-run elasticity respectively for 2008. Faced with higher fuel prices and the associated environmental hazards, the consumers and the government’s focus is shifting towards development and adoption of technology for hybrid cars. The use of hybrid electric vehicles (HEVs) and Plug-in hybrid electric vehicles (PHEVs) would reduce the green house gas (GHG) emissions and improve the economics of electrical industry by reducing the US dependency on foreign oil (Scot, Kintner-Meyer, Elliott, Warwick, 2007). The hybrid electric cars are cost effective compared to the conventional vehicles when run on gasoline and are absolutely emission-free in electric-only mode, when their batteries are recharged just by regenerative braking (afdc. energy. gov. ). The potential customer base which is identified as ‘early majority group’, are motivated to buy electric cars by a desire to reduce oil imports and help protect the environment (LaMonica, 2010). A comprehensive environmental assessment of the key air quality parameters, conducted by Electric Power Research Institute (EPRI, 2007), considering the adoption of hybrid electric vehicles outlines the following societal benefits of electrifying transportation include the following: †¢ Reduction in petroleum consumption, leading to reduced dependence on imported oil †¢ Net reduction in GHG emissions †¢ Potential to improve air quality Investing in electric vehicles has been a central tenet of the US. The government plans to invest $2. 4 billion to spur the production of 50,000 batteries a year for plug-in hybrids by 2011. This initiative will not only reduce the US oil imports, it will also reduce the pollution while boosting the economy by generating thousands of jobs for the Americans (AP, 2010). The adoption of Hybrid Electric Vehicles by a larger customer base will be a boon for the environment as well as the economy of the nation. With higher demand for the hybrid vehicles in future, it is expected that the cost of production of such vehicles will also come down due to economies of scale. This would further make the hybrid vehicles popular and thus expand the benefits. .? References AP. (2010, July 15). Obama to Promote Electric Vehicles in Michigan. Cnbc. com. Retrieved from http://www. cnbc. com/id/38259732 Environmental Assessment of Plug-In Hybrid Vehicles. (July 2007). Electric Power Research Institute. Retrieved from http://mydocs. epri. com/docs/public/000000000001015325. pdf Hybrid Electric Vehicles. Alternative and Advanced Vehicles. US Department of Energy. Retrieved from http://www. afdc. energy. gov/afdc/vehicles/hybrid_electric_benefits. html Scott, M. J. ,Kintner-Meyer, M. , Elliott, D. B. , Warwick, W. M. (November, 2007). Impacts Assessment of Plug-in Hybrid vehicles on electric utilities and regional U. S power grids: Part2: Economic Assessment. Retrieved from http://energytech. pnl. gov/publications/pdf/PHEV_Economic_Analysis_Part2_Final. pdf

Hamburger and Tropical Hut Essay Example for Free

Hamburger and Tropical Hut Essay This pie chart shows the market shares of a fast food industry that the McDonald’s corporation has 13% share, Yum! Brand’s Inc. 10%, Doctor’s Association Inc. 9%, and Wendy’s have 4% of shares. While the other’s has 64% of share, including the share of a Tropical Hut. I. Introduction Tropical Hut is one, if not the oldest, fast food joint in the Philippines. It started in 1962 when the Que family had this idea of putting up a coffee shop within the confines of their supermarket, thus, Tropical Hut Hamburger was born. Now, it has more than 50 branches nationwide and still growing, proving that it can hold its stance in the fast food arena. Tropical Hut Food Market, Inc. (THFMI) started its operation as a small sari-sari store and is owned by the Que family. In 1962, the business has grown into a grocery store and expanded rapidly into a Supermarket. It was also in this year that the concept of a Coffee Shop within the Supermarket was launched with the introduction of Tropical Hut Hamburger: The Company was incorporated in February 1965. In 1972, Mercury group of Companies, Inc. acquired the Company with the introduction of a Drugstore within the Supermarket. II. Market SituationÃ'Ž Before Jollibee, before McDonalds, before Burger King, before anyone else, it seems, there is Tropical Hut Hamburger. And hamburger it is, indeed the best it could ever be. But that was long ago. Now, Tropical is just a vestige of its former self. Everyone suspects that their hamburger is where Jollibees came from They almost have the same taste. Their fried chicken is also just like Jollibees, but this time it was Tropical who copied it. Tropical has other food selections, like Bistek (a local version of beef steak er strips) and other sandwiches. However, the place is not world class. It is not as clean nor as well kempt as McDonalds or Jollibee. And they have a very poor image. Although food is good, you wouldnt want to be seen there.

Microorganisms in Waste Water Treatment Process

Microorganisms in Waste Water Treatment Process When people think of microorganisms, they tend to think of unsafe pathogens. While this may be of concern there are beneficial microorganisms living ubiquitously around us as well. Microorganisms that live in air, soil, and groundwater live in a symbiotic cycle, consuming harmful chemicals and masses of organic materials. Therefore, it is only natural that scientists would harness the natural biodegradation of these in the field of Wastewater Management. Biotechnologists prefer to call this process bioremediation. They have been using bioremediation on wastewater for many years and have discovered a plethora of usable microorganisms. Due to the vast amounts of microorganisms capable of bioremediation, this paper is focusing on bacterium capable of breaking down organic material useful in treating wastewater. Wastewater treatment is performed on a variety of waste sources such as agricultural, residential, and industrial waste. Many bacteria such as Nitrsomonas, nitrobacter and paracoccus are important players in the treatment of industrial and sewage waste. The use of microbes in wastewater treatment plants is an integral piece of the wastewater treatment process due to the fact that microbial population in a facility can become depleted resulting in system back-ups, organic material build-up and overall reduction in system efficiency. It is at this point when supplementation of a microbial product becomes necessary. There are three stages of wastewater treatment: primary, secondary, and tertiary where microorganisms can be added or encouraged to grow in wastewater . The first two stages are concerned with large debris and organic matter removal by the use of a variety of filtration and sedimentation processes. Microbial organisms are stimulated in the second and third stages and the goa l is to degrade excessive amounts of contaminants such as nitrogen, phosphates, oils, chemicals and heavy metals by the third stage. One common practice used in residential wastewater in the second stage, is using activated sludge techniques, which aerates the waste to stimulate denitrifying and nitrifying microorganisms to biodegrade the waste. Most large sewage treatment plants use a two-phase digestion system in which organics are metabolized by  bacteria,  anaerobically. In the first stage, the sludge is heated and mixed in a closed tank for about 15 days, while digestion takes place. The sludge then flows into a second tank, which serves primarily for storage and settling. Sludge digestion is a biological process in which organic solids are decomposed into stable substances. Nitrifying and denitrifying organisms, both aerobic and anaerobic are added to convert about half of the organic sludge solids to liquids and gases (Siezen Galardini, 2008). Nitrosomonas europae was isolated in 1892 by Russian microbiologist Sergio Winogradsky. It has been a useful bacterium in wastewater treatment, usually added in the secondary treatment process due to its ability to breakdown organic material. If given an aerobic environment, ammonia is oxidized first to nitrite by ammonia-oxidizing bacteria, then nitrite is oxidized to nitrate by nitrite-oxidizing bacteria which makes N. europaea primarily important in the nitrification cycle (Arp and Bottomley, 2006). Nitrosomonas. europaea  is a bacillus shaped, gram-negative obligate chemolithoautotroph; which is an autotroph that gets its energy from oxidation of inorganic substances in the absence of light. It is a mobile bacteria with flagella located in its polar region. It commonly inhabits places rich in ammonia and inorganic salt, such as in soils, freshwaters, stone monuments, and sewage. It obtains most of its energy from its ammonia-oxidizing capabilites, an unusual process for most ba cteria.  Cell division may take several days due to its need for large amounts of ammonia consuming about 25 moles of ammonia per mole of carbon dioxide assimilated into cellular biomass (Arp and Bottomley, 2006).   Due to its long delay in cell division, scientists tend to avoid studying Nitrosomona. N. eurpoaea gains carbon from the atmosphere by converting carbon in a gaseous form into carbon bound up in organic molecules. Its genome consists of a single circular chromosome with 2,812,094 bases. Its gene structure denotes that it must take in Fe and suggests it can take in other metals such as Cu, Cd, Zn, and Co as well (Chain, Lamerdin, Larimer, Ragala, Lao, 2003). N. europea functions best at a basic ph but can tolerate a ph between 6.0-9.0 and it prefers temperatures between 20-30 degrees Celsius. Nitrobacter hamburgensis got its name because it was isolated in soil of the Old Botanic Garden in Hamburg. It is a gram-negative bacteria that lives mainly in soil, building sandstone, and sewage sludge. It is pear-shaped and has one sub-polar flagellum. There is one circular DNA chromosome and three circular DNA plasmids with 4,406,967 base pairs on the chromosome. (Kaipa, et al, 2010). N. hamburgensis  gains energy from oxidation of nitrite to nitrate and has the ability of metabolizing nitrogen in nitrite from its environment. It is found mainly in soil and freshwater. (Arp Bottomley, 2006). The bacteria has provided a solution to removing high levels of nitrogen from municipal effluents of wastewater treatment plants. Biofilms with different nitrifying bacteria including  N. hamburgensis  have been constructed. Before the invention of these biofilms very large and expensive reactors were used for this purpose. Paracoccus denitrificans, an organism that removes high levels of nitrogen in wastewater when paired with Nitrosomonas europaea, a nitrifying organism which reduces ammonia to nitrate. P. denitrifican  is a spherical coccus shaped gram-negative bacteria having a double membrane cell wall. It inhabit soils in either aerobic or anaerobic environments. First isolated in 1910 by Martinus Beijerinck, a Dutch microbiologist gave the organism the name  Micrococcus denitrificans, only later to be changed by Diana.H. Davis in 1969 to the current name Paracoccus denitrificans after the discovery that the bacteria contained many features known to be in mitochondria, possibly an ancestor to the eukaryotic mitochondria. (Davis, et al, 1969). The genome of  P. denitrificans  consists of two circular chromosomes and one plasmid. The first chromosome has 2,852,282 base pairs and the second chromosome has 1,730,097 base pairs. The plasmid has 653,815 base pairs (Swiss Inst., 2007). Many of th e proteins transcribed and translated from the plasmid is what gives  P. denitrificans  its unique features of the ability to metabolize ammonium to nitrogen gas. Due to P. denitrificans  ability to produce more than 5000 proteins it is useful in biotechnological applications (Uemoto Saiki, 2007). Another process commonly used in wastewater treatment is the use of biofilms, various trickling rock filters that encourage biofilms. (Sillankorva, Neubauer, Azeredo, 2008) These biofilms build microorganism communites enclosed in a matrix of extracellular polymeric substances separated by water channels. Within these colonies are a variety of bacteria, fungi and algae which biodegrade waste. Psuedomonas fluorescens, P. syringae and P. putida are a few of the bacterias found in biofilms. As well as fungus like Mycelium and algaes. The biofilm community is an optimal environment for cell-cell interactions, including the cellular exchange of genetic material, and nutrient exchange within the community. The matrix protects the microorganisms from UV exposure, metal toxicity, acid exposure, dehydration and salinity, phagocytosis, antibiotics, and antimicrobial agents (Hall-Stoodley, et al 2004). Pseudomonas fluorescens makes a great contribution to the turnover of organic matter and while present in soil, is abundant on the surfaces of plant roots and leaves. P. fluorescens grows at an optimum temperature of 25 ° Celsius but can also survive in temperatures as low as 0 ° degrees Celsius make it a rare pathogenic in humans. The bacterias degrading ability has been applied to pollutants such as styrene, TNT and, polycyclic aromatic hydrocarbons (Sillankorva, Neubauer, Azeredo, 2008). Notable is P. putida possessing a high biodegrading metabolism. It can breakdown styrene which is a highly polluting synthetic chemical, used to make plastics (Park, et al, 2005)). Pseudomonas putida is a gram-negative shaped bacteria, similar to  Pseudomonas aeruginosa, an known pathogen to humans, however it is missing key gene segments that P. aeruginosa possess making it nonpathogenic. The biochemistry of P. putida makes it an aerobic, gram negative, flourescent colored, rod-shaped bacteria. It a motile organism with one or more polar flagella. They are usually found in moist soil and water environments and grow optimally at room temperature. Certain strains have the ability to grow on and break down many dangerous pollutants and aromatic  hydrocarbons  such as toluene,  benzene, and ethylbenzene.  P. putida  can also be used in petroleum plants to purify fuel. P. putida  is also closely related to  Pseudomonas syringae, an abundant plant pathogen, but again it la cks the gene that causes such disease (DOE, 1998). The first isolation of Psuedomonas syringae occurred in 1902 by van Hall from a diseased lilac. Psuedomonas syringae are aerobic rod-shaped gram negative bacteria that are motile with the use of several polar flagella. Psuedomonas syringae secretes a plant toxin making it a known plant pathogen. Therefore, it is easy to see its use in the biodegradation of organic waste. Each strain of this bacteria has a specific plant it targets and is often found on plant leaves. Any interesting quality is its ability to form ice crystals, P. syringae  is responsible for causing frost injury to frost-sensitive plants. (Feil, et al, 2005) This discovery led to its production of artificial snow.