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Table of contents

1. Introduction
2. Blanche and Mitch relationship
3. Conclusion
4. References

Introduction

In the 1947 play A Streetcar Named Desire by Tennessee Williams, the relationship between Blanche and Mitch is a key subplot in the tale of Blanche’s descent into madness and isolation. Whilst Williams initially presents Mitch as the answer to all Blanche’s problems and as a viable male suitor, it soon becomes evident that Blanche and Mitch are not meant to be together. Mitch, in the broader progression of Williams' work, is merely another man who will ruin Blanche’s life. Hence, Blanche and Mitch's relationship are analyzed in this essay.

Blanche and Mitch relationship

Williams first presents Mitch as Blanche’s potential saviour, and indeed that is how Blanche also wishes to see him at the start. Not only might Mitch be able to provide for Blanch financially, but emotionally too. Blanche remarks that Mitch is “sensitive”, and they share a tragic romantic past. Furthermore, Mitch seems to fit Blanche’s ideal of the Southern Beau when compared to other men, whom she regards as “apes”. Mitch is formal and respectful, calling Blanche “Miss DuBois” and Blanche admits that she appreciates his “gallantry”. It seems that Blanche and Mitch are in a way united by their shared loss, and are brought together by mutual experience. They both need to fill a vacuum in their lives and conveniently find each other as a means for emotional (and financial) security. Mitch hits upon this, stating: “you need somebody, and I need somebody – could it be you and me Blanche?”. There is even a brief tenderness in their relationship and Blanche to find solace in Mitch; she “huddles” into him and gives “long grateful sobs” before exclaiming “sometimes, there’s God, so quickly”. We can see the closeness of the bond between the two of them as Mitch is the only character who Blanche tells the truth about “Alan”, and it is after this outburst of emotion that they are united together.

However, Blanche and Mitch’s relationship is doomed to fail by the nature of Mitch’s incomplete pseudo-masculinity. When recounting the story of Alan, Blanche reveals that she couldn’t be with him because he wasn’t “like a man” – obviously alluding to his homosexuality which was taboo and illegal at the time. Yet throughout the play we find that Mitch too isn’t “like a man”. From the very beginning we see that Mitch works in “the spare parts department”, a possible reference to his incomplete masculinity according to Kolin; he seems never to have matured, still living with his “mother”; and when he dances with Blanche, it is “awkwardly”. Similarly, his conversation is awkward and unromantic, as he remarks on how he “sweats” and how much he “weighs”. It soon becomes apparent that Mitch is therefore not the “Rosenkavalier” or “Armand” that Blanche paints him to be. This is the problem. Blanche, who “doesn’t want realism” but “magic”, makes Mitch fir the mould of the Southern Beau which she desires by means of her literary allusions despite the fact that he belongs to the new order of men in the post-World War II era. She demands that he “bows” and commands him to “dance”. Mitch becomes Blanche’s pet man whom she moulds into her ideal of masculinity which is, like Blanche, “incongruous” to contemporary ideals of masculinity which promoted strong men who were war veterans and the defenders against tyranny after World War II. Blanche, as with everything, clouds the relationship with Mitch in illusion, which Williams symbolises with the scene when Blanche invites Mitch to place a “lantern” over the light in her room. She says “I can’t stand a naked bulb”, a metaphor for her refusal to accept reality, and placing the lantern over the light is symbolic of Blanche’s masking the truth of her age and past from Mitch. Mitch’s masculinity is further questioned when compared with Stanley. Stanley is the ideal stereotypical man’s man of the time: he is highly sexed; he brings home “meat” for his wife, symbolic of the hunter-gatherer dynamic; and he plays sport. Furthermore, when it comes to Blanche, Stanley is assertive and successfully has his way with he in the implied rape of scene 10, thus asserting his sexual dominance. Mitch however is unable to do so, and in his attempted rape he “fumbles to embrace her”. It is therefore clear that, either due to Mitch’s incomplete masculinity, or the veneer of chivalrous romanticism Blanche lives under, eventually will fail. In the end, Mitch yells that is was “lies, lies, lies!” that tore them apart and the relationship ends.

Yet Williams makes greater use of the relationship between Mitch and Blanche than as a mere subplot, doomed to fail. Thematically, Mitch, like Stella, becomes a battleground for the ideology clash between Stanley and Blanche, who represent the New and the Old World respectively. Stanley: the immigrant worker, “100% American”, war veteran. Blanche: the upper class Southern Belle of the USA’s French-colonial past. When Stanley and Blanche meet it is clear that their two ideologies cannot live side by side, and a battle ensues for dominance. Stanley wins the first battle, after convincing Stela to “come back” to him after hitting her, and the field of battle shifts to Mitch. Initially, by means of her deceptive seduction and emotional appeal, Mitch falls for Blanche, yet Stanley manages to convince Mitch to seek the truth from Blanche. Indeed, he does and Mitch adopts Stanley’s speech patterns and physical movements in scene 9, a maneuver which is symbolic of Stanley having successfully exerted his influence over Mitch: he speaks monosyllabically (“Me. Mitch”) and with interrogative statements (“Why?”, “Are you out of your mind?” and “Do we have to have that fan on?”). Eventually, Mitch “rips” the “lantern” off the lamp, symbolically violating Blanche and prefiguring the subsequent rape scene by shattering her illusions and pretences. After Stanley has taken Mitch from Blanche, she has lost everything and appears in clothes which are “soiled” and “crumpled”, symbolic of her stained purity and helplessness.

Conclusion

Ultimately, Williams creates Mitch as someone who means well concerning Blanche, and who is one of the few characters to empathise with her, however he never realistically does anything to help her. His well-meaning yet powerless position is epitomised by the end stage directions as he is “sobbing” while Blanche leaves, and in his failed attempt to criticise Stanley (“You…brag…brag…brag…bull!”) This criticism may well have carried some weight and helped Blanche, yet it is castrated by Mitch’s inability to even formulate a sentence. Mitch was Blanche’s last opportunity to detach herself from the Old World of the colonial South and attach herself to the modern, post-industrialist world in the aftermath of World War II, a world in which traditional gender roles had shifted. Once this opportunity is missed, Blanche is doomed to fade away into the abyss of obscurity and her institutionalisation becomes inevitable as she is left insane, alone, unstable, and unsupported.

References

1. 1. Iftimie, N. M. (2018). The Clash of Genders in A Streetcar Named Desire. Postmodern Openings, 9(2), 70-78. (https://www.ceeol.com/search/article-detail?id=677446)
2. Jacobs, D. (2006). Blanche, Stella, Tennessee and Rose: The Sibling Relationship in A Streetcar Named Desire. The Psychoanalytic Study of the Child, 61(1), 320-333. (https://doi.org/10.1080/00797308.2006.11800777)
3. Zhao, Y. (2016, November). An analysis of the characters in a streetcar named desire. In 4th International Conference on Management Science, Education Technology, Arts, Social Science and Economics 2016 (pp. 464-467). Atlantis Press. (https://www.atlantis-press.com/proceedings/msetasse-16/25865166)
4. Hezaveh, L. R., bt Abdullah, N. F. L., & Yaapar, M. S. (2013). Fragmented Identities on the Stage a Psychoanalytical Analysis of the Characters in A Streetcar Named Desire Based on Abjection. Journal of Language and Literature, 4(2), 54-59. (https://www.academia.edu/7905305/FRAGMENTED_IDENTITIES_ON_THE_STAGE_A_PSYCHOANALYTICAL_ANALYSIS_OF_THE_CHARACTERS_IN_A_STREETCAR_NAMED_DESIRE_BASED_ON_ABJECTION)
5. Nawaz, U., & Awan, A. G. CRITICAL EVALUATION OF WILLIAM TENESSEE PLAYS “A STREETCAR NAMED DESIRE AND GLASS MENAGERIE”. Global Journal of Management, Social Sciences and Humanities, 4. (https://www.researchgate.net/publication/322356696_CRITICAL_EVALUATION_OF_WILLIAM_TENNESSEE_PLAYS_A_STREETCAR_NAMED_DESIRE_AND_GLASS_MENAGERIE)

Throughout A Streetcar Named Desire, Blanche is caught between the contradictions of her own character and the society surrounding her. She persistently fights to conceal the truth of her personality and past, failing to comprehend the changing conditions of post-WWII, post-New Deal America. In the midst of this societal conflict, Blanche retreats into her own illusion and self-deceit, and this is reflected physically through her avoidance of light. Her aversion to being seen clearly demonstrates her inability to face the truth of both her character and her lifestyle. The facade she draws around herself reflects the corruption of America’s history, the reality of the ‘epic fornications’ of the elite and the incongruity of this past to the future. Blanche is ultimately conscious of her flaws and actively works to conceal them: her promiscuity, hypocrisy and deteriorating mental state. The way her pretense disintegrates against Stanley’s brutal character is arguably an allegory for the emergence of a new America and the fading significance of the old.

Blanche is driven by a compulsion to disguise her declining beauty. She plays the part of the southern belle; a fading stereotype that adds to the tragic and pitiable aspects of her character. On her arrival to Elysian Fields, Blanche frantically asks Stella to ‘turn that over-light off!’ so that she won’t be looked at in the ‘merciless glare’. Her desperation demonstrates her self-consciousness and anxiety about her physical appearance but also reveals how she is afraid of direct scrutiny, therefore suggesting she has something to hide. The ‘merciless glare’ adds to the idea that Blanche is afraid of the repercussions for her actions, and links her physical deterioration to her declining morality. The exclamatory phrases add to her tone of panic and suggest her mental instability. Blanche’s ‘delicate beauty’ is fallible to ‘a strong light’, which shows the flaws in Blanche’s self-made illusion and demonstrates that despite her efforts to deceive herself, her reality is inescapable. Blanche also shows a wish to conceal herself through her ritualistic bathing and use of makeup. These repeated motifs of her obsession with her beautified image demonstrate Blanche’s false character whilst revealing her precarious mentality. Therefore, as the play progresses Blanche’s nervous actions become a visualization of her mental state, developing as the intensity of her affectations increases. Critic John Chapman commented that Blanche ‘shuns the reality of what she is and takes gallant and desperate refuge in a magical life she has invented for herself’. Indeed, Blanche’s actions to disguise and hide her appearance demonstrates a fear of involving herself in the real world, and instead she can only project a falsified image of herself. The darkness she finds so ‘comforting’ and the layers of makeup and clothing create physical barriers between herself and reality. In the last two scenes of the play, Blanche’s discourse is limited almost entirely to her appearance, bar her final confrontation with Stanley. Dressing up for Shep Huntleigh and parading in her gown and tiara, Blanche creates a romanticized projection of her past as the daughter of an elite and wealthy family. In this costume it’s clear Blanche longs to return to her simpler past, but its made clear to the audience by her ‘soiled and crumpled’ dress and ‘scuffed’ shoes that her retreat into her past is an artificial mask of her reality. Blanche’s obsession with disguising her appearance is shown by Williams to be an incapability to accept the truth of herself or the fact she has left the comfort of her privileged youth behind, and is now stranded in a world where she is no longer the epitome of others’ desire. As the play reaches its end, Blanche becomes increasingly less self-aware, and by the final scene she has lost all consciousness of reality, having lost herself in her own false image.

Blanche’s avoidance of light can also be read as part of her act as an innocent and pure character. Blanche believes she is undesirable as she is, and so presents a false image of a respectable and prim woman. She tells Stella she wants to ‘deceive [Mitch] long enough to make him - want [her]...’, demonstrating her anxiety and obsession over how men respond to her. Blanche gains her confidence from the attention she receives from men, as shown by Stella pressuring Stanley to compliment her appearance. In keeping with her imitation of a prudish unmarried woman, Blanche tells Mitch to ‘unhand’ her on account of her ‘old fashioned ideals’. Again, Blanche is attempting to ally herself with the southern belle of her past, who would not have any aspect of sexual freedom and would only have sexual relations with a husband, which is the opposite of Blanche’s promiscuity. Blanche’s reality of her incessant sexuality separates her further from her affected role and demonstrates her deceitful character. Her promiscuity is revealed later in the play, but already in scene 3 Williams hints at her real attitudes to sex. In the stage directions, Blanche stands ‘in her pink silk brassiere and white skirt in the light’ of the poker game next door until Stella warns her, and she moves away. By breaking her convention and standing fully visible in the light, this moment suggests at Blanche’s need to be desired. Later in the play, Blanche conflates images of love and light when she describes Allan’s death as causing ‘the searchlight which has been turned on the world’ to turn off again. This gives the symbol a secondary meaning of representing love and sexual freedom, contrasted by the discretion and loneliness of the dark Blanche appears to confine herself to. The symbol is also picked up by Stanley, who euphemistically describes sleeping with Stella as ‘having them colored lights going’. This draws a parallel between Stanley and Blanche, and indeed they share a constant sexuality and both thrive on relationships with the opposite sex. Critic Shirley Galloway suggests that Blanche’s desires ‘draw her to Stanley like a moth to a light’. Throughout the play scenes with Blanche and Stanley are portrayed as sexually charged, and parallels are drawn between their passionate and assertive personalities. Later in the play, Blanche reflects Stanley’s violence, when she ‘slams [a] mirror down with such violence that the glass cracks’. This illustrates Blanche’s obsession over her looks and how their decline links to her disintegrating sanity, but also demonstrates how she is determined to be perceived as beautiful in the same way Stanley is determined to be viewed as entitled and rightfully American. In Scene 7, he smashes a cup and rants, ‘what i am is one hundred percent American [...] so don’t ever call me a Polack’. Similarly to Blanche, Stanley is angry over how he is viewed by the rest of society. Although the images they posit are polar opposites, Stanley and Blanche’s discontent with how they are viewed reflects the fractioned American society and the jarring divide between the insignificant elite and the dominated working class. Within the relationship between Blanche and Stanley, Williams also conflates the opposing images of sexuality and mortality, with the contrast of the ‘desire’ streetcar and Elysian Fields reflected throughout the play. Indeed, the sexual tension between Stanley and Blanche results inevitably in the metaphorical ‘death’ of Blanche as she is taken away to a mental asylum once she succumbs to her insanity after she is raped by Stanley.

Finally, Blanche and her demise represent the death of ‘old America’. Blanche is incongruous to Stanley and Stella’s home, and the tensions that ensue are reflective of the conflict within America at the time. Blanche and her old-fashioned and dated attitudes harken back to antebellum era America, which is dramatically contrasted with Stanley’s character. The contrast between the characters demonstrates the change from the remnants of colonial America to modernity in the aftermath of the Second World War. Frequently, Williams explores this contrast through the imagery of light. In the poker game, the kitchen is lit with a ‘lurid nocturnal brilliance’ and the men within are dressed in block primary colours, evoking images of modernity and progression. The bedroom, where Stella and Blanche are, is ‘relatively dim’ in comparison, lit only by the streetlight and the light spilling in from the kitchen. This contrast demonstrates the waning significance of the America Blanche represents and instead promotes the idea of a new America, prompted by the enfranchisement of the working class in the wake of war and the New Deal. This would be noticeable visually for the audience, as the image of modernity would appear literally more vivid and significant. While Blanche’s snobbery brings out her sister’s privileged attitudes, her eventual submission to Stanley and her mental disintegration demonstrates the lack past’s lack of power. Descriptions of Blanche as a ‘moth’ adds to this image; she will be destroyed by modernity and change. Blanche attempts to the counter the electric symbol of modernity by romanticizing the past, favoring candles over harsh light and trying to physically block out a lamp with her Chinese paper lantern. By softening the light, Blanche can create an illusion of the past in order to soothe her fear of reality and modernity. The dimmed light allows for a self-inflicted blindness where she can reimagine the society she is ostracized by, and also try revert to being a young and beautiful woman. In Scene 7, Blanche appears conscious of her own delusion when she remarks, ‘candles aren’t safe [...] wind blows them out and after that happens, electric light bulbs go on and you see plainly’.This demonstrates that Blanche feels threatened by the new world she finds herself in because she can’t accept who she has become within it. Blanche has also realized her childhood and ancestry are irrecuperable, and perhaps this explains the breakdown of her character into childlike actions and speech by the end of the play. Williams stated that the play is about the ‘ravishment of the tender [...] by the savage and brutal forces of modern society’, and with this it is easy to see Blanche as a representation of the tender past, overwhelmed by the vigor of modernity, represented by Stanley. This fundamental conflict drives the play and turns Blanche into a tragic character, embodying the death of an era and representing the changing society Williams witnessed around him.

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Blanche repeatedly attempts to edit herself, by playing the part of a sexually innocent and yet desirable young woman who is unaffected by aging. However, she is inevitably trapped by the reality of herself and is ultimately overtaken by modernity. Williams describes her avoiding light to show her vulnerability and to demonstrate her inability to accept herself for who she is. Too ‘delicate’ for a strong light, Blanche’s facade is broken down by the future Stanley represents, and her demise at the end of the play is a reflection of the death of an outdated past.

Table of contents

1. Technology and healthcare
2. Improved Nurse satisfaction and Patient Safety
3. Improved workflow and Decision Making
4. Transforming Approach to Illness and Health
5. Eliminating Waste in the Nursing Workflow
6. Right Care at the Right Time
7. Improving care effectiveness and efficacy
8. Conclusion

Technology and healthcare

Technology is transforming the world and that is more evident in the health care arena than any other setting. Considerable progress has been made in the health care arena through the implementation of advanced technology in delivering patient care. By the year 2020, technology will transition the health care from curative to preventive where people will be treated for ailments that they are likely to develop.

Effective blending of technology and care facilitates transformation of health care across health care facilities, clinical fields of expertise and departments. Advancing technology can be a critical tool for nurses -the frontlines in the health care landscape in- order to improve patient care and safety. However, medical progress may be decelerated and can curtail patients’ access to required care due to inappropriate implementation.

Although several medical technologies have been around since decades and are in the continuous process of development, some latest technologies are changing the way medicine would be practiced in the future. These technologies would allow medical practice from anywhere, any time and from any device. These include smart phones, Tablet PCs, Touch screens, digital ink, voice recognition, Electronic Health Records (EHRs), Health Information Exchange (HIE), Nationwide Health Information Network (NwHIN), Personal Health Records (PHRs), patient portals, Nanomedicine, genome-based personalized medicine, Geographical Positioning System (GPS), Radiofrequency Identification (RFID), Telemedicine, clinical decision support (CDS), mobile home healthcare, cloud computing, and social media, to name a few significant, .

Accelerated cost savings Healthcare is just a market for technology where consumers such as hospitals are happy to pay enormous amounts of money, particularly for prestige equipment, such as PET and MRI scanners and linear accelerators. Technology automates and extends things that previously had to be done by people. Before infusion pumps, nurses had to give injections every so often; the infusion pump technology automated that. Now the nurse’s time is freed up for other activities.

In the old days a patient would go to their doctor and get a paper prescription. They would then go around to the pharmacist and get their medicines. One problem with this process was that paper prescriptions were notoriously hard to read, and there was a danger of incorrect dispensing. Today, this process has been computerized. The doctor sends the prescription electronically to the pharmacy, and the pharmacy can dispense the drugs almost immediately.

Innovative information technology tools help ensure patients get the right care at the right time. Health information technology would allow medical professionals, such as doctors, nurses, physician’s assistants, and other medical professionals easy access to a number of services, such as patient’s records, dental services, nursing services, social services, and crisis and critical care services, etc. By using the health information technology to update and maintain information in real-time, available medical, social and community resources may be allocated appropriately and efficiently by the users of the technology. This may result in decreased costs for treatment of individual patients and for the health care system as a whole. Non-invasive and minimally invasive tools for diagnostics and treatment generally result in lower patient risk and cost.

Laparoscopic surgery, a modern surgical technique, has gained popularity over conventional abdominal surgery. There are a number of advantages of laparoscopic surgery as compared to an open procedure. These include less pain than an open procedure faster recovery, smaller incisions, less risk of infection. People can typically resume normal activities within 1or 2 days after surgery resulting in decreased hospital expenditure.

Improved Nurse satisfaction and Patient Safety

The use Information and Communication Technologies (ICTs) by nurses can impact their practice, modifying the ways in which they plan, provide, document, and review clinical care. ICTs can influence nurses’ working environment and have the potential to impact on professional satisfaction, for example, the quality of care as perceived by nurses. Nursing sensitive outcomes (or patients’ outcomes), such as patient safety, comfort, and quality of life.

However, nurses are sometimes concerned that using electronic nursing documentation or the Barcode Medication Administration (BCMA) for documenting and for administering medication might take away or reduce time for patient care. Conversely, other reviews including communication systems like tele homecare, and management systems like Electronic Health Record System (EHRs) found that time spent for patient care has significantly improved and particularly, nurses using EHRs spent more time with patients in assessment, education, and communication.

Improved workflow and Decision Making

Conventional patient records are paper records in folders in cabinets. Many patients have extensive patient records, lab results and so on, and even more patients have patient records that are in many places – in hospitals they have visited, consultant’s offices, general practices, and so on. They are rarely all together where the patient is, often they get lost or duplicated, and sometimes destroyed by fire or floods. An electronic health record (EHR) is a digital version of a patient’s paper chart.

A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated. With EHRs, information is available whenever and wherever it is needed. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can: Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results. Allow access to evidence-based tools that providers can use to make decisions about a patient’s care. Automate and streamline provider workflow.

Transforming Approach to Illness and Health

There is no space here to fully explore the vast range of likely and significant technological breakthroughs. Consider Nano health, brain implants, artificial organs, networked sensors, genomics, exoskeletons, just a few of the potentially transformative developments already under way. Some of these technologies are going to transform our whole approach to illness and health – in the same way that the nineteenth century development of anesthetics changed society’s moral approach to pain. Pain and suffering used to be inevitable; now we like to think we have a right to painless procedures.

At the international level, organizations such as the European Union, the World Health Organization and the United Nations entertain high hopes and great expectations of eHealth when it comes to the major issues in global health care: ageing, curbing healthcare expenditures, consumerism, prevention and control of infectious diseases.

Eliminating Waste in the Nursing Workflow

The American Academy of Nursing’s Workforce Commission recognized the importance of effective technologies in improving the safety and efficiency of care and in helping to return time to nurses for essential care. Technology enables care and enhances safety by automating functions both simple and complex. They recognized the value of technology in eliminating waste in the nursing workflow due to inefficient work patterns, interruptions, or distractions; missing supplies; and inaccessible documentation. These findings support the business case for using technology to return more time to direct nursing care and to improve communication and implement other safeguards available through smart devices.

Right Care at the Right Time

Technologic tools can provide the right care at the right time and in the right place. For example, telehealth affords veterans the convenience of accessing primary or specialized care services either from their local Veterans Administration (VA) community clinic or from the privacy of their own home. Under the Choice program, any veterans now have the option to access community. partner health care rather than waiting for a VA appointment, or traveling to a VA facility when the geographic distance is more than 40 miles, or if the appointment in the VA is not available for 30 days.

The Choice program and telehealth are 2 very concrete examples of (Veterans’ Health Administration (VHA) transformation from a facility or provider-centric health care delivery model to a model that puts the veteran’s needs at the center and improving the veteran’s access to resources to meet their health care needs. More than 717, 000 veterans have accessed VA care through telehealth in fiscal year 14, and 45% of these veterans live in rural and highly rural areas.

In FY14, the total for veterans using telehealth represented about an 18% growth from the prior year; and the telehealth services provide access to help in more than 45 different specialty areas, including those areas where VHA has a particular expertise, especially, for example, in mental health that may not be available from the local community partner.

Improving care effectiveness and efficacy

Quality is one of the most frequently used terms in health care. However, there are no clear definitions available. In an authoritative publication of the US Institute of Medicine, the authors listed six components of quality in health care for the 21st century: safety, effectiveness, patient-centeredness, timeliness, efficacy and equity. eHealth contributes to the global issue of keeping our health systems affordable, accessible, acceptable and of good quality.

Though limited when it comes to the impact on all six components of quality health care by the Institute of Medicine these results show where eHealth stands as of now: effective in education, monitoring and self- management support. Safety, effectiveness and efficacy are manifest in lower mortality rates, lower hospital admissions rates, better lab-values and lower medication use.

Economic benefits are indicated by a reduced use of care, though the evidence is not very extensive yet. eHealth significantly supports enhancement of patients; knowledge about their diseases, their self-management capacities and their quality of life. Additionally, a well-functioning system of care delivery is hardly imaginable without the continuous support of a secondary process driven by information and communication technology such as logistics, appointments, finance, case-management, procurement, (personal) health records etc.

For example, Canada Mount Sinai Hospital (MSH) developed a comprehensive, integrated approach to improve care for hospitalized older adults and older adults at high risk of hospitalization, particularly because of functional, cognitive, social, or other problems. To improve the delivery and quality of care, patient and system outcomes in all older patients, and those older patients at especially high risk of poor outcomes.

The MSH geriatric zed order sets and care protocols to support safer evidence-based care; tracking systems to monitor flow of Acute Care for Elders (ACE) patients throughout Mount Sinai Hospital in real time and support timely transfer to ACE unit; secure e-mail notification and flagging systems to allow primary care, home care, emergency, and inpatient care providers to communicate effectively; and risk identification tools (ACE Tracker) to support early identification of high-risk patients.

Mount Sinai has maintained region’s lowest admission rate of older patients — 25 percent, 18 percent lower than regional admission rate. For those admitted to hospital, there was 28 percent decrease in mean length of stay; 13. 4 percent decline in readmissions; reduction in “alternate level of care” (“bed blocker”) days per patient of 20 percent; and increase in patients discharged directly to home. Average direct cost of care per patient reduced by 23 percent, and general inpatient medical beds reduced by 18. 2 percent.

Conclusion

Healthcare changes dramatically because of technological developments, from anesthetics and antibiotics to magnetic resonance imaging scanners and radiotherapy. Future technological innovation is going to keep transforming healthcare, yet while technologies (new drugs and treatments, new devices, new social media support for healthcare, etc. ) will drive innovation, human factors will remain one of the stable limitations of breakthroughs.

The healthcare environment will also continue to be rapidly transformed by new technology as a result of the need to provide confidentiality and security of patient data. eHealth will accelerate the much-needed transformation of our healthcare systems and sustain access, affordability and quality for all in the near future. Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery by nurses.

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A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated. A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated.

The poem “Blessing” by Imtiaz Dharker; an award-winning female British poet born in Lahore, Pakistan. The poem is an incident of a municipal pipe that bursts in the deprived slums of Mumbai and how people run with mugs and pots to collect the precious liquid. With the use many poetic techniques and literary devices, Imtiaz Dharker tries to emphasise the poverty that these people live in and how rare drinking water is for these people.

This is the first stanza of the poem “Blessing” a couplet with power. Here “The skin cracks” literally means a person’s skin that has shrivelled from the constant exposure to the sun or maybe like the dry and dusty ground that cracks during droughts but also implies pain and discomfort because the skin is one of the most important organs of the body. Describing the skin cracking like a “pod” suggests that people are “breaking” due to the lack of the main life source: water, which is the title of the poem for the people in poverty, a “Blessing.

”The second stanza of the poem which is a quatrain. As the poet introduces us to “imagine the drip of it,” the sound of the words make you feel like you are in that situation and are thirsty like a man in the desert hallucinating about that thirst-quenching drop of water. The pleasing clanging of the consonants “echoing” “tin” and “mug” deliver such a solid image of how precious water is for these people. The poet then describes this sound of water as the “voice of a kindly god” because it emphasizes that often people in this situation (where water is rare) think this is an act of god.

The penultimate stanza, the longest one which is 11 lines. “the sudden rush of fortune” like someone winning the jackpot on a slot machine and the money is pouring out of it. This is a very clever way of how the poet joins financial wealth and water in that part. You might notice how the water is “silver” which is far more expensive than something like “brass, copper, aluminium, plastic buckets, frantic hands” that scramble to capture a bit of the precious resource. The poet also uses the word “silver” to show how precious a commodity is. The fact that the “municipal pipe” broke was a mistake on the authorities side - the burst and the water got out, it makes me think of the corrupt people in the authorities that could help the poor but don’t

“The blockchain is the most consequential technology since the internet. The internet is programmable information. The blockchain is programmable scarcity.” — Balaji Srinivasan, CEO of 21.co

Blockchain is a type of data structure that’s used to create a digital ledger of transactions and share it among a distributed network of computers. The distribution network could include smart phones, tablets, cloud-based resources or on-premises compute nodes. Imagine a universal digital ledger that helps shape how you transact with other individuals or entities all in a secure and anonymous fashion. A key outgrowth of the ledger is the idea of “smart contracts”, which “provide security superior to traditional contract law and reduce other transaction costs associated with contracting”.

Technologists and health-care professionals across the globe see blockchain technology as a way to streamline the sharing of medical records in a secure way, protect sensitive data from hackers, and give patients more control over their information Blockchain has the potential to propel innovation in preventative care and community-based healthcare models. The capacity of a distributed ledger technology for ensuring data integrity while sharing between parties can ensure collaboration between rising trends in healthcare; which are vital to the improvement of health in communities worldwide.

Here are some of the other ways that blockchain could benefit health care:

• Clinical data sharing. Advance directives, genetic studies, allergies, problem lists, imaging studies, and pathology reports are just some of the data elements that could be distributed. Alternately, instead of storing actual patient data, blockchain could be used to store access controls — like whom a patient has authorized to see their health data — even if the clinical data itself is stored by the EHR.
• Public health. A shared, immutable stream of de-identified patient information could more readily identify pandemics, independent of governmental bodies currently aggregating this data — for example, an influenza reporting system.
• Research and clinical trials. Distributing patient consent or trial results could foster data sharing, audit trials, and clinical safety analyses.
• Administrative and financial information. Insurance eligibility and claims processing workflows could benefit from blockchain and have decreased transactional costs.
• Patient and provider identity. National (or international) patient or provider identities could be secured in the blockchain, providing the basis for health data portability and security.
• Patient-generated data. Personal health devices, “wearables,” “Internet of Things” (IOT) devices, and patient-reported outcomes are just some examples of patient-generated data that could leverage the blockchain for security and sharing.

Table of contents

1. Introduction
2. The Company’s Goal
3. The problems of the cargo transportation industry by the sea and their solution
4. The project team

Introduction

Today shipping is one of the most popular groups of carriers in the world, and container shipping occupies the lion's share of 60% of the total industry. Containers are popular due to their security, reliability and the ability to move dangerous cargo in themselves. But we also have a share of negativity in this area, such as: great pollution of the environment, due to higher environmental standards, problems with cargo tracking, and many more shortcomings, if you ordered goods from another country that went by sea, then you know what the price of waiting, when you can track your goods before shipment by sea and already on arrival on land, the location in the sea to track was absolutely impossible. This baffled craftsmen from Blockshipping

The Company’s Goal

To begin with, I would like to pay attention to the project itself and tell what it was created for, Blockshipping is a Scandinavian corporation situated in Copenhagen, Denmark. Blockshipping is emerging a global common container platform (GSCP), which will permit the reserves possible for the worldwide container business to total to 5.7 billion dollars. USA per year because of more rational conduct of intermodal cargo containers

The global joint container platform Blockshipping (GSCP) is intended to make key practices in global container handling much more effective and thus resolve certain of the most significant difficulties in the container shipment business today. Initially, the goal of the GSCP platform is to deliver a whole registry with compulsory to block keys (for example, the register of ships), where a whole worldwide record of containers (about 27 million units) is recorded organized with immediate places of every single container everywhere in the world. The goal for 3-4 years is to provide 60% coverage of the market with 16 million container units in the GSCP blocker register. The GSCP platform will save at least 5.7 billion potential for the world container industry US per year.

The problems of the cargo transportation industry by the sea and their solution

At the moment, many companies experience different difficulties: financial, political, lack of staff, not the effectiveness of the company itself. The sea transport industry occupies 60% of the world maritime trade, which is estimated at 12 trillion a year, but still weighing the pros and cons of the industry is far from effective due to weak security, overcapacity, poor financing, lack of digitization and large CO2 emissions into the atmosphere. Fortunately Blockshipping found a solution to all problems. These are not just loud statements, but a competently written business plan to increase the control of all containers, reduce CO2 emissions, save money and distribute work competently. So in the development of the inefficiency solution, it was suggested to reduce the number of containers by 15-20%.

Many companies do not even know where most of their containers are located due to parking in the port, improper unloading and reloading from ship to ship, the solution to this problem is quite simple: to make all the containers in a single register, so that every owner can track the position of his container.

Correct allocation of the space in the container, since now half of the containers on the ships are either empty or half full, which already breaks the logistics, for this case the registry also comes to the rescue, in which it will be possible to see the fullness of a container on the ship, as well The company will be able to compare the possibilities where they can use empty containers or use them together with others.

The term "street turn" means that empty containers are moved from importers to exporters without an intermediate stop in the port or in the inner warehouse. Currently, this is difficult to do, but with the help of registration and tracking Blockshipping, they plan to facilitate this action, simplify and save up to $ 750 million a year.

Now Blockshipping has created its own platform, which will simplify all processes and significantly reduce costs. Also, the platform will deal with the automation of processes, because the business model today is obsolete and requires a large number of documents. Thanks to automation from Blockshipping, this will significantly reduce costs.

The project team

The founder of the company has seriously approached the selection of personnel and to date, only the aces of his business work there, which we clearly see in the created perspectives and plans of the company.

The project promises to be successful due to its contribution not only to the shipping industry, but also due to its simplicity, the desire to reduce the level of pollution, streamline the structure of each company and solve many other problems related to this area. Now you can buy tokens of the company, by the way, the company gives an account of its tokens and does not hide their distribution, exactly the same as the financial portion.

Table of contents

1. Introduction
2. Discussion
3. Conclusion
4. Reference

Introduction

Phlebotomy is a method of making a cut in a vein. Phlebotomy is also called venipuncture .Venipuncture is also the method of taking intravenous access as the purpose of taking venous blood samples. Getting out the blood from the vein is a very difficult task. It requires great care. A person who takes blood from patient’s vein is called a phlebotomist.

Discussion

Why Blood Collection is Important?

There are many reasons for blood collection :

1. Taking a blood sample is very essential for the purpose of diagnosing ,examine and improving the disease and disorder.

2. Sometimes blood samples are also taken to check hemoglobin levels.

3. Taking blood sampling is also very important for checking the values and for examing the morphology of blood components including red blood cells (RBCs), White blood cells (WBCs) and Platelets.

4. Blood sampling is done before donating the blood to anyone .To see the donor blood is compatible with the patient’s blood, and to see that the donor has no disease and that the blood will not be dangerous for the patient .

5. Blood sampling is also important for examing and checking the quatity of different biochemical parameters in the body such as blood sugar level,uric acid, blood gases and colestrol level.

6. Blood sampling is also very important in every test like CBC,LFT, and RFT etc.

Sites of Blood Sampling

1.    Venous Blood Collection : the best positions for venipuncture are usually superficial veins that are in the upper limbs. Because the veins are larger here . In case if the upper limb veins are not felt or not available than other positions may be used for withdrawing blood. Mostly median cubital vein is preferred as it lies between muscles and it is most easy to puncture. Another advantage of selecting the median vein is it does not roll or move beneath the skin. In simple it’s totally safe to puncture. Basili vein runs an artery and a nerve. So puncturing here is a risk of damaging nerve and artery is more .So puncturing basilica vein is more painful. Cephalic vein interacts with the basilica vein through the median cubital vein at the elbow site .Blood moves from smaller veins and drains into cephalic vein. It is used for obese patient.
2.    Artery Blood Sample : the artery is less common position for the blood sampling. The most common cause for getting blood from the artery is arterial blood gas examination. The common puncture position is radial artery at wrist and femoral artery in groin. Blood from artery can also be pulled from arterial catheter.
3.     Capillary Blood sample: the capillary blood sample is needed where only a small amount of blood is required for as in blood glucose examination by glucometer method. The most common of capillary blood sample is finger but it also performed at heels in infants.
4.     Finger blood sampling: the best site for finger sticks is the center of finger pads of 3rd middle and 4th ring finger of non-dominant hand. The tip of the finger should not be used .The side of the finger where there less soft tissue should also be avoided .
5.     Heel blood sampling : the suggested area for collection of blood in newborn baby is heel. Heel stick is a process of collecting blood for child blood test .

Blood Bags

Carl Walter is remembered for inventing the bags for blood collection that are still used in whole the world for collecting and transporting the blood. He discovered blood bag 15 years ago by doing reasonably to finish a critical and delicate method through which the surgeons drew the blood directly from donor to patient through paraffin coated glass tube that were heated over alcohol lanterns. Blood bags are very useful for separation, collecting, storing and transporting the blood.

Conclusion

To sum up, blood collection is used in all medical labs to find out why symptoms appear in a patient. Phlebotomy is the method of getting blood samples from the patient’s vein and examination of a disease that occurs inside the body of the patient .

Reference

1. https://en.wikipedia.org/wiki/Venipuncture
2. https://medcaretips.com/blood-sampling-or-blood-collection-methods/
3. https://www.labpedia.net/anticoagulants-and-preservatives-for-blood-plasma-and-serum/

Blue eye technology is a technology which is being developed so that the machines get sensational abilities and perceptual abilities just like our human beings. These abilities make the computational machines to understand the feelings of humans and this helps to interact with them. The main aim of this technology is to analyse human brain and understand their physiological conditions.

Imagine a world where humans can communicate with their computers. This concept was first developed by a research team in IBM at Almaden Research Center (ARC) in San Jose, California since 1997.This based on the idea of Paul Ekan’s facial expression.

The etymology of the term blue eyes goes as blue stands for Bluetooth technology which is wireless and the term eyes are used because it is the only part that helps us in finding the human expressions easily.

The main aim of this technology is to provide computers all those human abilities of understanding the feelings of others by just recognizing their facial expressions, and the tone in which they speak so that these machines would interact with human beings very easily. It could understand your feelings even with the touch of the mouse.

For example, if you are really tensed and you want to call your friend; this technology automatically understands the urgency and calls your friend who is working in your office or someone who is very close to you. In short its objective is to provide sessional and perceptual powers to machines to interact with humans and help the in all situations. Hence computer could act as intimate partners to humans.

This technology works with the combination of both software and hardware components. Central system unit and the data acquisition unit act as the hardware component. Microcontroller acts as the heart for this technology. Bluetooth technology is used for connecting both hardware and those software units. We could use this type of technology in all working places to understand the emotions humans and to record them.

It generally consists of the following units

• data acquisition unit
• Central system unit
• The software unit

It is otherwise called as mobile measuring unit. The main objective is to get the physiological information from the sensors and transfer it to central system unit. This is done for processing purposes and for verification too. A Bluetooth is integrated with the DAU is used to send the data to the central system. Both CSU and DAU contains their own pin codes and id numbers for authentication purposes. The components that are used are five-key keyboard, beeper and LCD for displaying purposes. The voice is transferred by using a headset.

The next component being used is the CSU. It contains a codec and a Bluetooth module. codec refers to those voices transmitted information. This part is connected to our computers by using a USB cable or a parallel cable. The microcontroller which is present in it handles the UART transmission.

The physiological condition of the operators will be continually supervised by this blue eye technology software. The operators real time physiological condition will be respond by the software. It helps to transfer the data from manager to analyzer. The data visualization module supports the user for interface section. It will continually fetch the information from database and record audio, video and physiological parameters of the user if the visualization module is offline. The blue eyes software is mainly enables to know about the physiological condition of the operator.

To design a computational machine having sensory and perceptual abilities like human beings, we are using ‘blue eyes technology'. This technology uses most modern cameras, microphones and advanced non-obtrusive sensing techniques to interact with humans to understand the emotions of human beings. The process of making sensing and emotional capabilities by computer is called 'Affective computing'. Steps involved for designing this type of computers:

• Process of giving sensing capacity.
• Human Emotion detection or Affect Detection.
• Respond appropriately and properly.

Brain computer interface is to develop an adaptable computer system. These types include speech recognition, eye tracking, facial recognition, gesture recognition etc. Blue Eyes technology enables the machines to identify the minor emotional variations of human being by a single touch on keyboard or a mouse. According to the emotion level the machine started react with the user.

It is a substitute for usually available machine vision face or eye recognition methods. The glass senses and identifies the expressions by analyzing the facial expressions method.

The SUITOR is having the ability to maintain an intimate relationship between the human and the computer by using the revolutionary approaches towards the machine. It continuously analyze where eyes is focus on the screen.

The working environment should be very important for implementing the Artificial Intelligent Speech Recognition system in Blue Eyes technology. Some important factors that influence the features of speech recognition system they are user’s speech, grammar, noise type, noise level and position of the microphone.

This 'THE BLUE EYES' technology assures appropriate techniques. It simplifies the life in a more elegant and user friendly way in computer device. Blue Eyes will reach as your handheld mobile devices in future generations.

Table of contents

1. Body
Concluding Statement (try and link points made in paragraph back to thesis)Concluding Statement (try and link points made in paragraph back to thesis)
2. Conclusion

Time can change everything, it may even flip your world upside down in seconds.. If one makes a single wrong move, everybody tends to judge them. This can be clearly seen in Little Deaths by Emma Flint through the theme of the book. Moreover, by using makeup as a mask to hide feelings, and judging someone due to their appearance. This book portrays hardships of a single, driven mother living in a judgemental society.

Body

The theme of the book clearly showed how one wrong move can change one’s life completely. Helping one find the angel or devil inside them. Moreover,

POINT: This quote help show the true side of Ruth, how she cared about her kids. This quote helps ignore other people’s judgemental opinions.

“She stretched out a hand but Devlin was suddenly there, pulling her back. Forbidding her to touch. She opened her mouth, but the flies and the heat and the smell and the sudden awareness that this was the hair she had shampooed and combed and braided for four years made everything go dark for a moment.”

COMMENT: This is a clear example that shows how kids require time and attention of parents to survive, otherwise they disappear. This quote helps understand the theme of the book. Ruth is not just a woman that cares about her looks, lovers, and drinks. She has a very soft side for her kids.

POINT: This passage expresses the type of mindset Ruth had. She wasn’t very aware of where her kids were. She was also comfortable with the idea of strangers bringing her kids back home after they escape. This suggests that if anything ever went wrong with her kids, she wont know. Unless someone informs her.

PROOF: Ruth knew she should be proud of these kids. She should be proud of herself, bringing them up practically alone. They had toys and books, their clothes were neat and clean, they ate vegetables for dinner every night. They were safe here. It was a friendly neighbourhood: when they climbed out of their window back in the spring, an old lady brought them home before Ruth even knew they were gone.

COMMENT: Through this passage, Ruth's adoration for her children is evidently portrayed. How she provided them with everything they needed and wanted. However, it also show how careless Ruth truly was, as mentioned: when they climbed out of their window back in the spring, an old lady brought them home before Ruth even knew they were gone. Shows how careless she truly was. Unfortunately, even after providing her kids with everything, she failed to take care of them. She was a mother who guaranteed to be dedicated to her youngsters, yet she worked long shifts in a shabby bar as opposed to remaining home to deal with them, and she locked them in their room for quite a long time while she dozed late.

Concluding Statement (try and link points made in paragraph back to thesis)

Providing kids with what they need or want isn’t enough, one must spend time with their kids. As opposed to leave them alone at house. It’s not wrong to say that Ruth’s worst move was to abandon her kids for long hours. Believing that they lived in a “friendly neighborhood” and nothing could go wrong. Which eventually led people into judging her after her kids death, and believing that she was the murderer.

Topic sentence: Ruth's veil of cosmetics, her eagerness on looking right, fills in as a screen on to which social dreams are anticipated.

POINT: This passage portrays Ruth’s obsession with looking perfect. Doesn’t matter how critical a situation might be . Also proving that she, once again, cares more about how she looks than her dead children. Moreover, she also tends to use makeup to hide her true feeling that can evidently be felt in this passage.

PROOF: ‘She knew that there would be men, strangers, looking at her, asking questions. Their eyes all over her like hands. She had to be ready for them. She had to look right.’

COMMENT: As soon as ruth realizes that cops are on their way to investigate her young children's murder case. She doesn't hesitate even a bit to fix herself. Ruth's fragile cover of cosmetics and pride that also portrays her sadness, and misfortune with an extreme delicacy that is both correct and awful. She was grieving, yet she kept on dressing provocatively and to apply her substantial cover of make-up in the days following the revelation of her kids bodies.

POINT: Even during grieving for her children’s death, she couldn’t ignore the thoughts of how she expects herself to look. Again, showing her interests and first priorities. Priorities that depict the importance of her makeup mask she wears, rather than her kids.

PROOF: She wiped at it savagely and thought how she must look: smudged and blotched and swollen. Drooling. And for a while she did not care.

COMMENT: even during crying for her dead kids, she still hesitated to let out her feelings. Ruth always wanted to present herself elegantly in front of everyone. She cared way too much about her looks and reputation. To the point where her looks were always a bigger concern than anything else. This also hints how Ruth always kept her feelings to herself. As proven by the text: Finally she could weep. Even now she remembers the sweet relief of being able to let go in front of a woman who had seen the worst of her all her life. It was hard for her to express her feelings.

Concluding Statement:It was hard for her to express her feelings without being concerned about the way she looks. These insecurities and obsession with looking good destroyed Ruth completely. As people around her judged her, she kept possessing herself over make up.

Topic sentence: Society judged Ruth according to her appearance. The fact that she had lovers and drinked a lot, made her an indecent women in the eyes of her community and the police.

POINT: Since everyone around Ruth blamed her for her children’s death. Ruth also started believing that it was her fault. Showing how devastated and pitiful she had become.

PROOF: her leaking wet body that had betrayed her. It was her fault that someone had taken the children, her fault that Frankie was missing, that Cindy was . . . gone.

COMMENT: Women in the modern world are still judged and misunderstood based on their appearance and sexuality more than anything else. People blamed Ruth for her kids death. Which lead her into believing that it was her fault only.

POINT: This helps clarify the thoughts of people around Ruth. From police officer to neighbors, they all lead to the same conclusion, that Ruth was the killer. All judged by her appearance and without any evidence.

PROOF: Seen through the eyes of the cops, the empty bourbon bottles and provocative clothing which litter her apartment, the piles of letters from countless men and Ruth’s little black book of phone numbers, make her a drunk, a loose woman–and therefore a bad mother. The lead detective, a strict Catholic who believes women belong in the home, leaps to the obvious conclusion: facing divorce and a custody battle, Malone took her children’s lives. (from article)

COMMENT: The police just jumped to conclusions without proper investigation. Ruth was also involved with a lot of men, they also could've been culprit. However, because of Ruth's appearance, her drinking and other inappropriate habits. Sbe was automatically considered the murderer.

Concluding Statement (try and link points made in paragraph back to thesis)

Ruth suffered to prove herself guilty. As she feared of not looking perfect, people around her solved this puzzle, blaming Ruth for her children’s death. Without any evidence, and purely based on Ruth's outer appearance. Ruth’s wrong move here was that she still cared more about her looks at such a critical time. Which lead into the whole world pointing fingers at her.

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Conclusion

Children require time and consideration of guardians to survive, or else they vanish. If one makes a solitary wrong move, everyone tends to judge them. This can be unmistakably found in Little Deaths by Emma Flint through the epic theme of the book. Also by using cosmetics as a cover to shroud feelings, and passing judgment on somebody because of their appearance. People should start considering the fact that you can't judge a person through their appearance. We might not know what someone else is going through. Either way, no one should have the right to blame someone for such a tragic crime.

Table of contents

1. Introduction
2. Prevalence of the Disease in USA and Worldwide
Mechanisms of TransmissionDiagnosisSigns and SymptomsTreatment, Control, and Prevention
3. Summary and Conclusion

Introduction

Bluetongue virus is from the genus Orbivirus in the family Reoviridae. Bluetongue virus is a non-zoonotic disease of ruminants like sheep, cattle, and deer that is believed to have originated in South Africa as early as the 18th century. This virus was first known as the ‘epizootic catarrh’ and was later named ‘malarial catarrhal fever of sheep. ’ However, in 1905 it was renamed as ‘bluetongue’ due to its swollen, cyanotic tongue characteristic in infected animals. Bluetongue is a vector borne disease that can infect most ruminants and camelids but it is most common in white tailed deer and sheep breeds found in the United States. Bluetongue virus is closely related to hemorrhagic diseases but has different characteristics than epizootic hemorrhagic disease virus (EHD). Hemorrhagic disease is caused by two orbiviruses known as epizootic hemorrhagic disease virus and bluetongue virus.

Prevalence of the Disease in USA and Worldwide

The spread of Bluetongue Virus throughout the world corresponds with the geographical and physical distribution of vector species of Culicoides biting midges, which are the only significant natural transmitters of the virus. In the United States, prevalence is high in southern and western regions due to frequent or diverse serotype exposure. However, most infections are reported with mild or inapparent disease. The disease is most often found in sheep, sometimes in goats, and occasionally in cattle. However, the bluetongue virus is commonly seen in white-tailed deer in the Kentucky and Tennessee areas, with a few cases reported in cattle in Texas and Ohio. In places like Africa, bluetongue viruses are broadly divided into western and eastern lineages based on phylogenetic analysis of nucleotide sequences. The prevalence of blue tongue is most closely related to tropical and subtropical regions where certain climate conditions can support large amounts of the midges species that depend largely on the distribution of vector competent species and climate conditions.

Mechanisms of Transmission

Bluetongue virus is a non-contagious disease that is transmitted by insects called biting midges. Midges become infected with Bluetongue virus by ingesting blood from infected ruminants. Once midges ingest a blood meal, they transmit the infection to their next host which is how bluetongue spreads. In the United States, midges are found in the late summer and early fall months and temperatures. There are roughly 1, 400 species of these biting midges of the Culicoides genus identified, however only 30 have been proven to transmit bluetongue virus. Biting midges are commonly found in the mud around or near ponds, lakes, and other water sources for animals. When there are heavy droughts, animals do not get all the hydration they need from the forage they graze so they search for water sources more often which makes them at higher risk of infection by the biting midges. Until recently, it was thought that the disease was not spread by direct contact between animals. However, there is a possibility this might no longer be accurate. Although it is known that bluetongue virus is exclusively transmitted by the female hematophagous midges, there has been a newly identified strain that may very well be transmitted via direct contact.

Transplacental infection can occur and depending on time of gestation to when the fetus is infected it can cause stillbirths and abortions. Bluetongue virus infects endothelial cells of blood vessel walls and mononuclear phagocytic and dendritic cells. This results in vascular thrombosis, tissue infection, necrosis, and hemorrhage. Rates of infection are higher than ever before due to the recent increase in drought conditions have created the perfect environment for these insects to spread the disease.

Diagnosis

There are many different ways to diagnose bluetongue virus. Diagnostics relies heavily on laboratory techniques including isolation of BTV and demonstrations of antigens, viral nucleic acids, and antibodies. The use of blood samples, or samples taken from the spleen, lung, or lymph node tissue are a small selection. However, bluetongue is more often diagnosed based on the signs and symptoms of each species it infects. Specimens such as semen from male animals may also be used for diagnostic purposes if they were collected at the peak of viremia. Bluetongue may also be diagnosed by petechiae, ecchymoses, and hemorrhages in the wall of the base of the pulmonary artery as well necrosis of the papillary muscle of the left ventricle of the heart. Pathogenesis Bluetongue virus infects monocytes both in vivo and in vitro and can interact with target cell surface by VP2 trimers that bind to the cell surface glycoproteins. Once BTV replicates in the lymph nodes where it drains sites of inoculation, it runs to secondary sites such as the lungs and spleen. Here, it replicates into endothelium and mononuclear phagocytes. From then, Bluetongue virus can disperse into lymph and the blood where it can be found in the intracellular vesicles of erythrocytes. At this point, it does not replicate but persists in the folds of cell membranes. In sheep and cattle BTV can be detected in the blood for 35 to 60 days and viral structures for up to 160 days. It can be said that erythrocytes could be the critical mechanism of cattle to serve as a natural reservoir host of bluetongue virus because BTV RNA is remotely similar to the erythrocyte lifespan in cattle.

Signs and Symptoms

Deer infected with bluetongue virus have been known to be depressed, feverish, emaciated, and remain near water in late summer or early fall. In many instances, the hooves of the infected animals become painful, making it very difficult for the animals to move. In some cases the hooves actually slough off. Blue tongue virus may also cause swelling of the head, neck, tongue, and eyelids, respiratory distress, and internal hemorrhaging. The swelling of the tongue can cause it to turn blue due to the lack of blood supply. In sheep, vascular endothelial damage is often seen which results in capillary permeability changes and coagulation. Typical clinical signs of sheep can also include edema, congestion, inflammation, necrosis, and hemorrhage. Young lambs have a higher mortality rate and can show signs of lameness and depression. Infected sheep have been known to eat less and even hold their food in their mouth to soften it before chewing because of oral soreness. In sheep, mortality ranges from 2-30% and can occasionally reach 70%.

Clinical signs of cattle can include ocular discharge, oral mucosal congestions, conjunctivitis, necrotic lesions on in the mouth, and edema. Goats are seen with an acute drop in milk production, edema, nasal discharge, and erythema of the skin and udder. Clinical signs can vary from subclinical infections to severe death of infect animals. In general, clinical signs include pyrexia, tachypnoea, muscle necrosis, and lethargy. Animals that survive may develop chronic dermatitis as well as vesicular and erosive lesions at interdigital and mucosal surfaces. Clinical signs usually can be seen 5-20 days and typically subside within a month. Animals infected during pregnancy have been known to abort or deliver malformed offspring. These malformations can lead to ataxia and blindness at birth.

Treatment, Control, and Prevention

There are a select few protective vaccines for ruminants available that are attenuated or inactivated and their protective activities are serotype specific. However, vaccination strategies depend on serotypes that are causing the infection so using certain vaccinations may not provide any protection at all. In South Africa, there are now three pentavalent attenuated vaccines have been developed for use of protecting sheep herds. However, farmers have been advised to use good husbandry by enclosing infected sheep in smaller areas with soft food, water, and shade and let them recover from the disease on their own, from there antimicrobial and anti-inflammatory drugs can be administered if needed. Due to the fact the disease is spread by midges, implementing insect control in moist areas and removing animals from infested areas helps in controlling the spread of the disease. Unfortunately, insecticide control alone will not completely eradicate the disease and should be used alongside a vaccination program for domestic animals. Another natural occurring control is the oncoming of cold weather; frost will kill the insects, which in turn results in less deaths in the animal population.

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Summary and Conclusion

Bluetongue virus, although not spoken of often, has been known to eradicate large populations of deer species. It had not been a large issue in North America until in recent years. This virus originated in Africa and has spread to different regions of the world like North America and Europe. Bluetongue virus is transmitted by biting midges that are commonly found in the mud near water sources especially during droughts. This virus most commonly infects ruminants like sheep, deer, and cattle. Bluetongue virus is known for tissue necrosis, cyanotic mucous membranes and tongue, as well as hemorrhage. This disease is commonly diagnosed by isolation of the antigen through blood samples or tissue samples. There are a few vaccines available to use in domestic ruminants, however researchers have said to just isolate the infected and let them rest to get over the disease. Although there are different vaccinations for prevention, you have to have a serotype specific vaccine in order to protect animals from getting the disease. I chose to write my paper on Bluetongue virus because honestly, I had never heard of it until I told a friend I had to pick a virus to write a report on. My friend began to explain small details of this particular virus and it intrigued me to learn more. I’ve learn through my research that this virus is prominent in my home state of Kentucky. Since I enjoy participating in deer hunting, I will be looking more closely this year at the white tailed deer in our area. Hopefully, I won’t see any of them sticking their tongue out at me. And although research documents that it’s okay to eat a deer infected with the disease “as long as it smells okay, ” I personally will not partake in a meal from that animal.