Audit Knapp Answer - 3219 Words

CASE 8.1 LIVENT, INC. Synopsis Similar to most financial frauds, the Livent, Inc. fraud was masterminded by a few individuals, primarily Garth Drabinsky and Myron Gottlieb. However, numerous individuals were eventually drawn into Livent’s fraudulent schemes by its principal architects, including Maria Messina, the company’s chief financial officer (CFO). Messina, a former partner with Deloitte Touche’s Canadian affiliate, had previously served as Livent’s audit engagement partner. The fraud unraveled following Livent’s takeover by an investment group led by Hollywood mogul Michael Ovitz. The new management team installed by Ovitz soon found that â€Å"massive, systematic irregularities† permeated the company’s accounting†¦show more content†¦10. The â€Å"accounting manipulations† used by Livent officials included simply erasing expenses and liabilities from the company’s accounting records, improper deferrals of major production cos ts, and capitalizing common operating expenses. 11. In August 1998, Messina and four of her subordinates revealed the fraud to a Livent executive who had been appointed by Michael Ovitz. 12. In June 2001, a U.S. federal judge ruled that a class-action lawsuit filed against Deloitte for its failure to uncover the Livent fraud could proceed since there was a reasonable likelihood the audit firm had been reckless in auditing the company. Instructional Objectives 1. To emphasize the need for auditors to identify the key inherent risk factors posed by an audit client. 2. To illustrate the lengths to which client management will sometimes go to misrepresent its company’s operating results and financial position. 3. To examine the issues raised when independent auditors accept key accounting positions with former clients. 4. To illustrate the difficulty of uncovering sophisticated financial frauds masterminded by top client executives. 5. To emphasize the need for auditors to thoroughly investigate suspicious circumstances and transactions discovered during an audit engagement. Suggestions for Use In responding to Question #1, students are required to identify theShow MoreRelatedCase Study : Navistar International Corporation1148 Words   |  5 Pagesyears NIC changed and one of the most dramatic changes was the relationship with its longtime auditor Deloitte. (Knapp, 2015) In 2005, NIC was dissatisfied with a decision the independent audit firm made to replace an engagement Partner. Although, nearly complete with the Audit, the new Partner was not willing to rely on the finding of the previous Partner, which prolonged the audit (Weirich). Deloitte had been NIC auditor since 1908 and the business community was shocked to learn of the terminationRead MoreQuestions And Questions On Audit915 Words   |  4 Pagesdevelop a better understanding of a couple of the elements presented. I added those elements to my critique of this case. Questions and Answers 1. What factors likely contributed to the oversights made by Ernst Young auditors during the 2004 AA Capital engagement? Identify measures that audit firms can implement to minimize the likelihood of such oversights on audit engagements. The fact that Oprins and McNeely were unfamiliar with the company likely contributed to the oversights that were made byRead MoreGeneral Motors Company : The Automotive Industry1103 Words   |  5 PagesCorporation after merging other automobile manufactures. General Motors was known as the largest automobile maker throughout the world. However, by the 21st century the automotive industry was facing some tough competition from several competitors (Knapp, 2015). After 77 years, proud and dominant General Motors was no longer known as the number one automotive manufacture worldwide. One significant contributor to GM decline was the company’s pension and postretirement benefit expenses that drove upRead MoreCase Summary : Lehman Brother Holdings, Inc. Essay1662 Words   |  7 Pagesfinancial statements. He found no evidence that this was a business decision, rather accounting-driven. The examiner also noted that these numbers were only included in the MDA section and the financial highlights of Lehman’s annual report. The audit engagement partner for EY, during the Lehman Brother debacle was William Schlich. Schlich defends the accounting treatment for the repos and insisted the â€Å"off-balance sheet treatment† of the Repo 105s was purely a â€Å"consequence of the accounting rules†Read MoreThe Securities And Exchange Commission s Rationale For Charging Cardillo1750 Words   |  7 Pageswho was in violation or compliance with the AICPA’s Code of Professional Conduct and the reasons they were or were not complying. This paper will also analyze the actions taken by Cardillo’s outside auditors, evaluate the level of efficiency of the audit risk management, determine whether or not the five components of internal controls were being properly followed and argue for or against whether auditors have a responsibility to assess the judgment of the decisions made by Cardillo’s management. Read MoreWhy Is It Important for External Auditors to Be Independent? Relate Your Answer to the Primary Role of External Auditors. Give Examples of Specific Ways the Lack of Auditor Independence May Impact Adversely on an Audit.1648 Words   |  7 Pageswords AcF 100 Introduction to Accounting and Finance Lent Term: Individual Coursework Essay Topic: Why is it important for external auditors to be independent? Relate your answer to the primary role of external auditors. Give examples of specific ways the lack of auditor independence may impact adversely on an audit. In 2001, there was an event that had shaken the whole business world. The crash of Enron in US, followed by worldwide collapse of its auditor, Arthur Andersen.Read MoreWhy Is It Important for External Auditors to Be Independent? Relate Your Answer to the Primary Role of External Auditors. Give Examples of Specific Ways the Lack of Auditor Independence May Impact Adversely on an Audit.1638 Words   |  7 PagesAcF 100 Introduction to Accounting and Finance Lent Term: Individual Coursework Essay Topic: Why is it important for external auditors to be independent? Relate your answer to the primary role of external auditors. Give examples of specific ways the lack of auditor independence may impact adversely on an audit. In 2001, there was an event that had shaken the whole business world. The crash of Enron in US, followed by worldwide collapse of its auditor,Read MoreThe Willie Lomax Engagement Essay739 Words   |  3 Pagesreport all of your time worked on the Willie Lomax audit? Why or why not? Do you believe that Lauren Hutchinson behaved unethically by underreporting the time she worked on that engagement? Defend your answer. Ans. It is unfortunate that independent audit teams have to perform in a broken system where underreported hours are rewarded. Being labeled as â€Å"fast-track superstars† for underreporting hours was a common theme at Wong’s organization (Knapp, 2015, p. 414). However, underreporting hours or eatingRead MoreAccounts Receivable and Internal Control1470 Words   |  6 PagesAssignment Please note you have three assignments for this week. The case study, the weekly assignment and continue working on the final draft for the individual research project. Case Study (Knapp book): Dollar General Stores Questions 1-4 Weekly Assignment: Textbook (Boynton book): Complete and submit the following questions for grading: 14-26 14-28 15-23 15-27 16-24 16-33 14-26 (Analytical procedures) the following data was taken from the production and accounting records for Casuccio ManufacturingRead MoreNorth Face2062 Words   |  9 Pagescompounded with additional misstatements. North Face was the perpetrator of the intentional misstatements but they were concealed by the Deloitte audit advisor, Richard Fiedelman. Fiedelman allowed additional non-recognizable revenue to be posted and altered/replaced the original working papers that reported the original material misstatement. (Knapp, Rittenberg, Johnstone, Gramling, 2012) Several generally accepted accounting principles (GAAP) and generally accepted auditing standards (GAAS)

Analysis of The Competition of Traditional Chinese Causine In Singapor

Question: Describe about the Analysis of The Competition of Traditional Chinese Causine In Singapore. Answer: Introduction Singapore is located at the tip of Malaysia and borders China, India and Peninsula. Its population is composed of different ethnic and cultural groups who mainly include the Chinese, Eurasians and Indians. Chinese Cuisine is one of the most popular kind of food known by the Singaporeans. The Singapore Nutrition and Dietetics Association (SNDA), Health Promotion Board (HPB) and Ministry of Health, Singapore, takes the mandate to advise and educate its people on the best healthy and nutritious foods that they are supposed to feed on. The restaurants that serve cuisine in Singapore (specialized or not) face a lot of competition from other servers like hawker centers, coffee shops and food courts. These centers are preferred because they are cheap, easily accessible and are many. The fact that there is a lot of competition in the food business in Singapore, a potential business person must be ready to find the best way to be the best Chinese cuisine server in order to get profit. The following are the most competitive restaurants in Singapore that serve traditional Chinese cuisine: Asia Grand Restaurant- This is listed by Burpple as the number one best specialized Chinese cuisine restaurant in Singapore. Location- It is located at 331 North Bridge Road, Odeon Towers in Singapore. Staffs- Considering the fact that this restaurant specializes at Chinese cuisine, it means that its staff i.e the chef, managers, cleaners, waiter, waitresses and others are all professionals. They are people professionally trained and have the ability to work and give full customer satisfaction Services- The services offered in this hotel are of great excellent in quality. These services are some of the best that one can find in Singapore since they are offered by professionals. Apart from service of cuisine, the restaurant offers other food services, Financial Resources- The board of directors of this restaurant include four qualified senior accountants specialized in the corporate accounting sector who give professional advice to the management concerning financial and investment matters. The restaurants has also attracted very many investors from all over the world who buy shares and in turn get profits in terms of dividends. The restaurant managers ensure that its revenue and expenses records are safely kept. They include statement of financial analysis, income statement, statement of profit and loss and other comprehensive income statements, statements of changes in equity, statement of cash flow. Market shares- With Asia Grand Restaurant being ranked as top five best in Chinese cuisine serving restaurant, it has got a very large market share in food service industry. Products- The restaurant serves very delicious Chines cuisine that makes its customers go back to feast there. Its different kinds of food have attracted so many from all over including tourists and visitors of Singapore. Blue Lotus Chinese Eating House- Listed by Burpple as the second best cuisine restaurant in Singapore. Location- It is located at the Idryllic Quayside Isle at Sentosa cove Staff- Its staff are specialized in their fields and are professional too. They must have the training that is needed in the field they are working in. Products- Apart from serving the Chinese cuisine food, Blue lotus offers other kinds of foods like sea foods, roasted meat and noodles. The foods served here are cheap, of excellent quality and quantity which makes it one of the best restaurants in Singapore (listed as number 2 by Burpple) Services- The restaurant offers good quality services that every customers finds worth their payment. The services re done by the professional employees who give it their best. Market shares- The restaurant is popular and very well known by people in Singapore. It is preferred by many tourists who visit Singapore and the Singaporeans too making it have a large market share in the food service industry. Financial resources- The restaurants financial resources are derived from the profits gets and investments from investors. The restaurant is managed by very qualified professionals who get advice from specialized financial advisers. NB: There is a lot of competition also from the centers that I mentioned earlier i.e food courts, hawker centers and coffee shops. References: Stokes, D., Wilson, N., Mador, M. (2010). Entrepreneurship. Hampshire, UK, South-Western/Cengage Learning EMEA. Bygrave, W. D., Zacharakis, A. (2010). The portable MBA in entrepreneurship. Hoboken, N.J., Wiley. Hisrich, R. D., Peters, M. P., Shepherd, D. A. (2011). Entrepreneurship. New Delhi, Tata McGraw Hill. Carsrud, A. L., BraÃÅ'ˆnnback, M. E. (2007). Entrepreneurship. Westport, Conn. [u.a.: Greenwood Press.

Macduff vs. Macbeth a True Case of Good vs. Evil free essay sample

A True Instance of Good vs. Evil? At the end of the play Macbeth, Macduff kills Macbeth in a scene easily read as the victory of good over evil, but is this accurate? Is Macbeth completely evil? Is Macduff completely good? Or is there an in between? I believe that Macduff is good, but there is definitely an in-between with Macbeth. I see Macduff as being a good person. He does everything he can to improve the state that Scotland is in. When he flees to England and leaves his family behind, some people may interpret it as him doing bad since his family is slaughtered in his absence. I do not see it this way. I believe Macduff is doing what he thinks is best for Scotland when he flees to England. That is to get Malcolm to come back and take his rightful place as king of Scotland. This is evident when Macduff is in England talking to Malcolm. We will write a custom essay sample on Macduff vs. Macbeth: a True Case of Good vs. Evil? or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Malcolm says â€Å"let us seek out some desolate shade, and there/weep our sad bosoms empty† (4. 3:1-2, Page 70). Basically, he is feels sorry for the state into which Scotland has fallen since Macbeth has become king. To this Macduff replies â€Å"Let us rather hold fast the mortal sword, and like good men bestride our down-fall’n birthdom† (4. :3-4, Page 71). This translates to â€Å"let us rather hold fast the deadly sword, and like good men protectively stand over our native land. † Basically what Macduff is trying to say is that instead of crying for Scotland, they should fight for their land to bring her back to the state they knew and loved. Further on into this same conversation, there is further proof that Macduff was seen as good. He tells Malcolm â€Å"I am not treacherous† to which Malcolm replies â€Å"but Macbeth is† 4. 3:18-19, Page 71). This also goes toward the argument of Macbeth being evil. He is seen as treacherous and a tyrant. He brings sadness to Scotland. Macduff says that â€Å"each new morn/New widows howl, new orphans cry, new sorrow/Strike heaven on the face† (4. 3: 4-6, Page 71). This is just a hint of how bad the state of Scotland has gotten. Macbeth is also evil in that he murdered and framed people to become king of Scotland. He murdered the current king, Duncan, and made it appear that the guards in his chambers of the crime. He was told by the Weird Sisters that he would be king. He was just too impatient to wait his turn and turned to murder instead. Although he did do a lot of things that could be considered evil, I do not believe that Macbeth was wholly evil. He was brave and seen as a hero in the war against Norway. This heroism even got him the title of Thane of Cawdor. Banquo didn’t seem displeased at the prophecies of Macbeth becoming Thane of Cawdor and King. If Macbeth was evil, Banquo would have been displeased with this. He can also be seen as not wholly evil because he is hesitant in his plot to kill the king. Lady Macbeth has to help to convince him to do it. If he was wholly evil, he would have had no hesitation in murdering someone for his own gain. Due to the mix of good and evil in the character of Macbeth, there is definitely some gray area to the play. I think this gray area adds depth to the play. Not everyone is interested in straight good and evil. Some prefer a round, conflicted character such as provided by the character of Macbeth.

ART essays

ART essays ART 2D TERM PAPER German Expressionism was a movement that rebelled against the tradition of Realism, both in subject matter and style. It applied to an artistic movement that lead German Avant-Garde painting of the early 20th Century rule. Expressionist painting, which developed in reaction to the dormant academic standards of the previous century, discarded refined pictorial naturalism in favor of direct emotional expression characterized by bold distortions of form and violent color. Surrealism is a term coined by The French poet Guillaume Apollinaire in 1917 in reference to his own writings, as well as the work of certain painters, such as Picasso and Marc Chagall. In 1924, one of the founders, Andre Breton, revived the term in his Manifesto of Surrealism, where he describes a super-reality connecting the dream The movement is mostly concerned with the different aspects of the unconscious mind and representations of the dream state. Max Pechstein, an expressionist painter, born December 31, 1881, died June 29, 1955, was a member of DIE BRUECKE (the bridge) A group of German expressionist painters, active just before WWI, who reacted against the impressionism of the Secession movement. Pechstein shared the bold color and expressionist distortion of the Bruecke artists but in a less extreme and more decorative form than that practiced by the groups His painting called Zwiesprache (Two Voices) painted in 1920 is of two nude females conversing in a landscape. Its condition is unusually fine, with strong, boldly-printed colors. The sheet has only some soft creasing in the margins. The subject matter is most probably sexuality and it incorporates the angular forms of Oceanic and African art. The colors he has used in his woodcut are green, black, brown-beige and white. Color becomes largely autonomous ...

All Peptide Hormones after Cell Function by Phosphorylation, while Essay

All Peptide Hormones after Cell Function by Phosphorylation, while Steroid Act by Alerting Gene Expression - Essay Example For instance, endocrine signaling involves the secretion of specific hormonal signals in the blood stream which are then distributed to other parts of the body. The first messenger molecule cannot pass through the target cell membrane, but instead are bound by specific receptors. Intracellular communication takes place when receptors activate secondary messengers or signaling proteins which convey those signals through chemical reaction to the nucleus of the cell (Marks, 2008). Proteins are the key signal processors in a cell. The incredible structural flexibility and chemical reactivity offers characteristic signal transduction property i.e., signals movement inside from outside of the cell, to all proteins. The input signals allow conformational changes in the structure altering the specific protein functions and cellular activity. Proteins capable of binding to a phosphate molecule are called phospho-proteins, and play a central role in the signaling pathway regulating various cel lular processes. Protein phosphorylation or phosphoregulation is a reversible process which regulates the protein function by covalent modification. To switch between phosphorylized and dephosphorylized states, specific kinase (tyrosine, serine/threonine) and phosphatase enzymes act respectively. Phosphorylation may either increase or decrease activity depending on specific type of enzyme. The affinity towards interacting cohort protein, enzymatic action, and subcellular localization and other functional changes are altered by protein phosphorylation (Goto, Kiyono and Inagaki, 2007). As a signaling molecule, proteins have a receiver and a transmitter module. In order to recognize and decode a specific signal, the receiver requires prior information for that signal which has to be either obtained or is genetically fixed. To coordinate signal and its exact implication, differentiation occurs exclusively in the receptor cells or target proteins. For instance, adrenaline hormonal signal has different meanings for different target tissues or target proteins control various functional consequences of phosphorylation. The intercellular signaling molecules including peptides, amino acids, amines and proteins cannot enter cell membrane and thus interact with receptors on the surface. The output signal transduction in receptor proteins results in a conformational alterations which are then differentiated by other signal transducing proteins along the pathway such as G-proteins. The chemical interactions taking place as a result of signal reception are not definite sequences, but rather diffused and complex excitation patterns (King, 2012). The hormones secreted by endocrine tissues get attached to particular plasma carrier proteins and composites are then distributed to distant parts. The receptors in the responding tissues have very high affinity for hormones and regulate metabolism of target through a coupled process. The receptors for amino acid and peptide hormones are mostly present on the cell membrane. Signal transducing receptors are classified into receptors with ability to enter cell membrane such as tyrosine kinases, tyrosine phosphatases and serine/threonine kinases, serpentine receptors which are coupled such as adrenergic and odorant receptors, and nuclear or intracellular receptors such as steroid

Reasons why illegal immigranst who are already living in this country Research Paper

Reasons why illegal immigranst who are already living in this country should be given citiznship - Research Paper Example Recently, debates on immigration have focused on the American South due to its border with Mexico where Latino immigrants get a passage into America. The political division has not helped to bridge the political opinions of opposition sides. In this assignment, I argue that despite the ongoing heated political debates, illegal immigration ought to be granted American citizenship. Historically, the American nation has been known to be a haven for immigrants to the extent that it is now a European descendant’s majority. Prior to the September 11, 2011 attacks on America by foreign nationals, there was little talk of racial profiling at airports. Entry to America became difficult for all immigrants with additional security checks instituted for fear of attacks, therefore, the ensuing debate on illegal immigration (Wise 26). Security is paramount for the stability of the American nation. Nevertheless, racial profiling is an infringement on the civil rights of human beings since it focuses on certain ethnic groups. The impact of European descended Americans in shaping America’s course cannot be disputed. However, the argument that America ought to be identified with regards to being â€Å"white† is flawed (Wise 32). America is a melting pot with people from diverse cultures, religion and ethnic backgrounds. The contribution of the multiplicity of people cannot be ignored. Granting of citizenship to illegal immigrants would be a humane act devoid of racial overtones. National security depends less on the number of illegal immigrants. This is because foreign nationals and terrorists do not have to be American residents to commit crimes. The rigorous security checks instituted mean that it is harder for foreign terrorists to gain citizenship. With proper checks in place, illegal immigrants are granted citizenship if there is reasonable belief that they pose

Effects of Living With A Pacemaker

Effects of Living With A Pacemaker Mackenzie Crowe Millions of people live with the help of a pacemaker on a day to day basis. An enormous 600,000 pacemakers are implanted each year and a total of 3 million people worldwide are living with a pacemaker.1 Like most scenarios, health hazards do not really affect someone until a family member or close friend is diagnosed. We usually do not become curious until someone we truly care about requires some sort of help. That’s just what my family member’s heart needed. My family member lived with a pacemaker quite a few years before he passed. Along with his age, he had other health complications that lead to arrhythmias, or irregular heartbeats, and his body became too weak to keep up with the demand of pumping blood to all parts of the body; so they implanted a pacemaker. A pacemaker, also known as an implantable cardioverter defibrillator (ICD), is a miniaturized computer that sends electrical stimulation to the heart whenever it senses that the heart is not beating or is beating too slowly.2 The pacemaker is about the size of two stacked silver dollars and weighs approximately 17-25 grams.2 This device’s main purpose is to help the heart maintain its repetitive rhythm, but it can also store information for a doctor to retrieve which will allow the best possible therapy per individual.2 Newer pacemakers can also treat heart failure by resynchronizing the electrical impulses in the heart’s four chambers- therefore improving the hear t’s ability to pump blood.2 From the time my family member had one implanted to the time that he passed, he had gone through two pacemakers. Like anything else, pacemakers can malfunction. In my family member’s case, his pacemaker just wasn’t working properly and so they just simply implanted a new one. From then on, everything pertaining to his pacemaker went rather smoothly. When I was young my cousins and I always asked him questions as to why he had it, what it did for him, and sometimes he would even open his shirt and let us feel where the pacemaker was in his chest. Although I didn’t live with my grandparents I did spend a lot of time at their house and the fact that my family member had a pacemaker rather bothered me. I wanted to know everything about it. I wanted to know what to do if something were to go wrong. I wanted to know if there could be complications that others needed to be aware of. I wanted to know that having a pacemaker wasn’t going to prohibit him from doing normal daily activities. As I spent more time with him and did some research of my own, I learned a lot more about pacemakers. I learned what it’s like to live with someone who has one compared how an individual’s life can change from getting a pacemaker implanted. This paper aims to help the reader understand exactly what a pacemaker is, and what it does for someone. The reader will also learn about problems associated with having a pacemaker, latest trends and treatments, and trends in nutrition, which will include medication(s). I also hope to see the reader understand how a family can be affected by living with someone who has a pacemaker, and how caring and monitoring a person with a pacemaker can be difficult at times. In a medical aspect, this paper will connect pacemakers and dentistry together. The reader will learn of risks associated to pacemakers in a dental office, dental implications, dental complications, and how to educate a patient of good oral hygiene with the use of pacemaker in place. I have also attempted to identify important questions for the patient and what to do in the instance of an emergency. Due to the vast amount of pacemakers used throughout the United States, researching and learning about pacemakers will help me be prepared for the evaluation of a patient with this medical history. I know that as a dental hygiene student it is my responsibility to be prepared for patients that present items that could interfere with the dental practice and be ready to make modifications as needed. As a health professional it is also my job to put the health of that patient at the forefront of my care plan when preparing for treatment. A pacemaker is not to be confused with the heart’s natural pacemaker. This artificial medical device uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beat of the heart.3 Its primary purpose is to keep the heart beating adequately, either because the natural heart is not fast enough, or there is a block in the electrical conduction system. Some pacemakers are combined with a defibrillator in a single device, while others have multiple electrodes stimulating different positions within the heart to help improve irregularity of the lower chambers of the heart.3 Pacemakers are a necessity for many people. Millions of people wouldn’t be able to participate in day to day activities if not for their pacemaker. Pacemakers give a sense of normality to those who would otherwise be struggling to complete an activity that seems so easy to someone whose heart functions fine without assistance. Some complications with pacemakers during or after implantation (acute) could be bleeding, infection at implantation site, allergic reaction, swelling, or a collapsed lung, all of which are uncommon and can be treated easily and effectively.4 Later complications (chronic) can be generator failure and lead failure, both of which are extremely rare.5 If patients follow a precise routine of physician care appointments, most complication can be detected before becoming serious. Patients should be aware of symptoms such as weakness, being easily fatigued, lightheadedness, dizziness, and loss of consciousness.5 If these symptoms appear after implantation, the patient’s doctor should be notified immediately so that the pacemaker can be checked in correspondence with these symptoms. Patients with pacemakers should try to adhere to a heart healthy diet after the implantation process in order to have a successful and quick recovery. This type of diet includes low fat and low simple sugars and high fiber contents.6 The patient’s diet should also be based on height, weight, current diet pattern, medical history, and level of physical activity. Family members who are in the role of caretaking for post-surgery patients should encourage the patient to try and maintain their current weight or lose weight is the patient is considered overweight by a physician. They should emphasize eating whole foods such as whole cereals, grains, beans, and fresh fruits and vegetables.6 Proteins such as eggs, milk, fish high in omega-3 fatty acids, and poultry should also be included.6 Fatty foods, fried and salty foods, sweets, or bakery items like cookies and cakes, along with carbonated beverages should be avoided.6 The patient should also try to avoid any kind of stress wheth er is it physical or psychological, and they should take further measures to quit smoking.6 If the patient drinks alcoholic beverages, it can be continued but should be done in moderation such as limiting it to one per day or as otherwise discussed with the physician.6 Most pacemakers now allow for patients to get engaged in physical activities which is an important aspect in congruence with a healthy diet. Exercise will not only help maintain body weight, but it will also help improve the patient’s cholesterol.6 Before beginning any physical activity, exercise should be discussed with the patient’s specialist or dietician. Family members are the best advocate to help keep the patient on track and in line with multiple aspects of their diet, stress levels, smoking, and physical activity. As of now, no drugs are used along with a pacemaker because treatment consist of upgrading or reprogramming the pacemaker. Sometimes medications are given to the patient when the implantation process begins so that they patient is able to relax but still be aware of their surroundings.7 They will still be able to hear and talk to the medical team throughout the process. The patient will also receive anesthetic (numbing) medication at the site of the incision.7 Certain patients with atrial flutter/fibrillation or venous problems may be on medications such as Coumadin or patients that have had previous stent replacement may be on Plavix to reduce the chances of blockage.8 These medications are not normally prescribed after implantation but if the patient is already taking them before implantation they are normally switched over to a Heparin IV drip for surgery and then slowly moved back over to their medications afterward.8 Caring for patients with pacemakers can be difficult if the patient does not value their health as much as they should. It can be hard to take care of someone who would rather let the caretaker do all the work. Patients should be motivated to stay healthy. While most know that this is easier said than done, family members should try to emphasize a healthy diet and how it can really make a difference in their daily living. Elderly patients will need more recuperation time and won’t be able to participate in strenuous activity like a middle aged patient. It is imperative that the caregiver try to get the patient to be self-sufficient so that when the time comes for them to take care of themselves, they will know where to take off from what their caregiver was doing for them. The implantation of a pacemaker can affect the patient’s ability to undergo various medical procedures. Dental procedures, X-rays, MRI’s, CAT scans, bone density tests, mammograms, and ultrasounds can all affect pacemakers because of the reactions of the energy waves involved in the tests and the electronic component of the pacemaker.9 If the pacemaker is not programmed to resists these types of interferences, complications can arise. Dental care, like any specialized treatment, is a necessary and routine healthcare issue. Most dental care visits include x-rays, ultrasonic scaling, drilling, and other procedures that might produce high electromagnetic energy. To avoid malfunctions to the pacemaker and possible harm to the patient, it is extremely important to tell the clinician about the pacemaker in advance. The oral cavity is a likely source of bacteria that may elicit infections on pacemaker and ICD devices after systemic transmission.10 According to the American Dental Association, studies show that dental patients with a pacemaker are particularly at risk for developing endocarditis.11 This infection or inflammation of the heart occurs as a result of bacteria that enters the bloodstream from the mouth.11 Under certain conditions, patients with heart problems will be given antibiotic medications before procedures to help prevent bacteria from spreading to the bloodstream.11 This is a proactive approach that protects the patient and the dentist. Certain dental procedures often involve the use of electrical equipment that may come into close proximity to an implanted pacemaker. There is a possibility that exposure to some of this equipment may temporarily affect the function of the pacemaker. Some potential interactions that might take place are: inhibition of pacing: pacing not provided when needed, asynchronous pacing: pacing provided at a fixed rate whether needed or not, and inappropriate shocks: shock therapy provided when not needed.12 Some manufacturers contraindicate product use in patients with pacemakers, but there are also other things that can be done to avoid complications.12 The clinician should seat patients away from power sources or adjust equipment to the lowest possible setting and should also avoid draping cables over the implantation site.12 If the patient begins to feel lightheaded, have increased heart rate, experiences a shock, or hears beeping from their device they should move away from the source of interference or the clinician should power down the device.12 This will allow for the pacemaker to return to normal. According to the Boston Scientific Analysis of Dental Equipment, drills and cleaning equipment, dental x-rays, and apex locators all showed no signs of interference.12 Ultrasonic scalers can cause disturbances but are very unlikely unless notified by the manufacturer.12 To be on the safe side, the majority of dentists would not use an ultrasonic scaler to perform a scale in a patient fitted with a pacemaker or an implantable cardiac defibrillator (ICD).13 Other dental office equipment that may cause interferences are dental chairs with magnetic headrests and electrocautery.12 Both are temporary affects although if patient’s pacemaker is programmed not to respond to magnetic headrests then patients may sit in these chairs.12 Patients considered to be at risk from external interference can have a magnet placed over the pacemaker to switch the pacemaker to fixed-rate mode making it immune to external signals.14 Use of mini magnets in prosthetic dental procedures is safe for patie nts with implanted pacemakers.15 Clinicians should be prepared to make accommodations for patients that have pacemakers. The use of hand instruments will be critical if a patient shows signs of being sensitive to electrical devices. It is the job of the clinician to be able to adapt to that patients’ needs rather than making the patient adapt to the office; this includes helping the patient make changes at home as well. Some patients with pacemakers may need assistance when it comes to good home care. The patient will most likely need accommodations to be made shortly after surgical implantation. It may be hard for the upper chest and dominant hand to move a toothbrush around the oral cavity. Clinicians should be aware of this need and should be ready to make suggestions based on the individual. Some ideas that may be beneficial are having another person brush for the patient for the first few days after the surgery. If the patients then feels better suited to take over they could begin brushing once a day along with a mouth rinse and slowly move up to brushing twice a day and flossing when they feel fit to do so. This may be easier for the patient and at the same time they are still accomplishing good oral health care. Before beginning treatment in a dental office the patient should make sure that their clinician knows of their personal health status with their pacemaker included and that their clinician is prepared if an emergency would arise. It’s best to have a clinician certified in CPR and that is knowledgeable on how to use an automated external defibrillator (AED) if necessary. CPR chest compressions can be done as usual on a patient with an implanted pacemaker.16 Implantable pacemakers are also designed to withstand the shock of an external defibrillator but the pads should not be placed over the device or the pacemaker can sustain damage.16 If the patient has an implanted medical device, an alternative AED pad position is advised, such as the anterior-posterior position.17 It is best to place the pads as far from the source of the pulse as possible and to use the lowest power clinically acceptable to try and deliver a shock that will not damage the device but will restart the patien t’s heart.16 Pacemakers are a vital source of life for many Americans. They enable people to keep living a normal lifestyle. Although there will always be aspects that patients can do to sustain better care for themselves, having a pacemaker is really quite easy. Monitoring the device is important and routine doctor visits are necessary for upkeep and general health. My family member was able to go on living his life as he normally would’ve because he had the help of his pacemaker. Without that, I may not have had as much time with him as I was able to have, and for that I am truly grateful. Modern technology is continually growing and the pacemaker system is developing with it. I hope that this paper gives you a general knowledge about pacemakers, health importance at home and with family members, and their connection to the dental office. Sources Available at: http://circ.ahajournals.org/content/105/18/2136.full. Accessed November 9, 2013. Available at: http://health.sjm.com/arrhythmia-answers/treatment-options/implantable-devices/pacemaker. Accessed October 9, 2013. Available at: http://en.m.wikipedia.org/wiki/Artificial_pacemaker. Accessed March 14, 2014. Available at: http://www.mayoclinic.com/health/pacemaker/MY00276/DSECTION=risks. Accessed October 9, 2013. Available at: http://cdn.intechopen.com/pdfs/13786/InTech-Common_pacemaker_problems_lead_and_pocket_complications.pdf. Accessed March 14, 2014. Pat. A Heart Healthy Diet for Pacemaker Implant Recovery. November 10, 2008. Available at: http://www.diethealthclub.com/blog/diet-tips/a-heart-healthy-diet-for-pacemaker-implant.html. Accessed October 9, 2013. Available at: http://health.sjm.com/arrhythmia-answers/treatment-options/implantable-devices/pacemaker. Accessed October 9, 2013. Available at: http://www.pacemakerclub.com/public/jpage/1/p/story/a/storypage/sid/13421/content.do. Accessed March 25, 2014. Available at: http://www.ehow.com/way_5601960_implanted-pacemaker-dental-precautions.html. Accessed October 9, 2013. Eberhard, J., Stumpp, N., Ismail, F., Schnaidt, U., Heuer, W., Pichlmaier, M., . . . Stiesch, M. (2013). The oral cavity is not a primary source for implantable pacemaker or cardioverter defibrillator infections. Journal of Cardiothoracic Surgery, 8, 73. doi:http://dx.doi.org/10.1186/1749-8090-8-73 Available at: http://www.ehow.com/way_5601960_implanted-pacemaker-dental-precautions.html. Accessed October 9, 2013. Available at: http://www.bostonscientific.com/lifebeat-online/assets/pdfs/resources/ACL/ACL_Dental_Equipment_020209. Accessed October 9, 2013. Thompson, S. A., Davies, J., Allen, M., Hunter, M. L., Oliver, S. J., Bryant, S. T., Uzun, O. (2007). Cardiac risk factors for dental procedures: Knowledge among dental practitioners in wales. British Dental Journal, 203(10), E21; discussion 590-1. doi:http://dx.doi.org/10.1038/bdj.2007.889 Jowett, N., Cabot, L. (2000). Patients with cardiac disease: Considerations for the dental practitioner. British Dental Journal, 189(6), 297-302. doi:http://dx.doi.org/10.1038/sj.bdj.4800750a Schulmeister, L. (1999). Pacemaker interference. Nursing Management, 30(3), 14. Retrieved from http://search.proquest.com/docview/231428997?accountid=14752 Available at: http://www.bostonscientific.com/templatedata/imports/HTML/CRM/A_Closer_Look/pdfs/ACL_CPR_and_External_Defibrillation_063008.pdf. Accessed March 18, 2014. Jevon, P. (2012). Defibrillation in the dental practice. British Dental Journal, 213(5), 233-5. doi:http://dx.doi.org/10.1038/sj.bdj.2012.778