Rebound Tenderness in Diagnosis of Appendicitis in Children

Rebound Tenderness in Diagnosis of Appendicitis in Children Abdominal pain is a common presentation within the accident and emergency department [A+E] and specialist nurses working in this environment need to be familiar and confident in dealing with this presentation (Hibberts and Bushell 2007, Pines, Pines, Hall, Hunter, Srinivasan and Ghaemmaghami 2005). Abdominal pain can be associated with a wide variety of surgical and nonsurgical conditions, with the most prevalent cause being acute appendicitis (Lin, Chen, Chung, Ho, and Lin, 2009). The diagnosis of appendicitis is formulated from subjective and objective data including a patients history, abdominal examination, laboratory investigations and signs and symptoms. This assignment will critically analyse the clinical skill of testing for rebound tenderness and its relevance to diagnosing appendicitis in children. The clinical diagnosis of acute appendicitis in children is difficult for many practitioners (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Between the years 2008 and 2009 the number of patients presenting to A+E within the UK who were diagnosed with appendicitis was 44,244 (NHS Information Centre, 2009). This equates to almost 0.3% of all presentations in A+E over one year. Approximately 9,300 of this population were between the ages of 0 and 14 years old (NHS Information Centre, 2009). However up to 25% of these 9,300 children with suspected appendicitis have a normal appendix at operation (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor, and Fishman, 2004). Furthermore, the 25% of paediatric negative appendectomies now result in considerable clinical and economic costs to the NHS (Koepsell, 2002). These substantial figures are one of the primary reasons for specifying this assignment on children. In addition, the scope of practice within A+E covers paediatrics for many adult q ualified nurses and adult trained nurse practitioners. It is therefore imperative that the knowledge base for all A+E staff encompasses paediatrics at an advanced level as well (Cleaver, 2003). The overall accuracy for the clinical examination in diagnosing acute appendicitis has been reported to be between 54% and 70% in children (Birkhahn, Briggs, Datillo, Van Deusen and Gaeta, 2006). In addition Whisker, Luke, Hendrickse, Bowley and Lander (2009) suggest that only 4% of children have a miss-diagnosis of appendicitis in specialist paediatric centres, compared to 20% in district general hospitals. Despite the uncertainty of the diagnosis and the cost of miss-diagnosis to the NHS, appendicitis requires urgent treatment (Williams, et al., 2009). This is due to the risk of perforation, which occurs in approximately one third of cases in children (Neilson, et al., 1990). Therefore the need for a good clinical assessment at first contact in A+E is needed to provide a correct management plan and reduce on costs for the NHS. An abdominal examination should be performed where possible in a warm, well lit room with the patient well-draped and relaxed (Bickley, 2009). Initially the practitioner should undertake inspection, auscultation and percussion of the whole nine sections of the abdomen (Lippincott Williams and Wilkins, 2008). The final aspect of the abdominal examination should be palpation as this has the potential to be the most painful (Allan, 2008). Palpation is a process which should always be commenced away from the site of pain, as this will allow the patient to gain some reassurance from the practitioner and help them to relax (Bickley, 2009, Hibberts and Bushell, 2007). The practitioner should utilise the palmer surfaces of the fingers to identify any abnormal signs (Bickley, 2009). More specific palpation techniques can help to diagnose appendicitis, such as rebound tenderness (Bickley, 2009). This is performed by pressing slowly and firmly to a specific area and then withdrawing them quickly (Bickley, 2009). Practitioners should observe the patient and ask if pain was worse on pressing or letting go (Hibberts and Bushell, 2007). However, Bickley (2009) suggests that if any of the previous examinations such as light or deep palpation are positive then this should not be undertaken as it will cause undue pain for the patient. The whole process of abdominal examination in children follows the same system as in adults. However, the causes of abdominal pain in children are often different, encompassing a broad range of acute and chronic diseases (Bickley, 2009). Therefore it maybe pertinent to suggest that more emphasis should be placed special techniques such as checking for rebound tenderness rather than abdominal palpation and testing for rebound. The initial discovery and accreditation of rebound tenderness (also known as Blumbergs sign) is credited to a German surgeon called Jacob Moritz Blumberg (1873 1955). Many articles make reference to Blumbergs sign; however there appears to be no relevant literature, research or evidence base to support this surgeon was the gentleman who discovered this sign (Mantzaris, Anastassopoulos, Adamopoulos and Gardikis, 2008). A study undertaken by (Williams, et al., 2009) showed that out of 98 children who had acute appendicitis 91% had right lower quadrant tenderness on palpation however only 30% had rebound tenderness. Another study by Lin, Chen, Chung, Ho, and Lin (2009) also suggested that 43.4% of the 53 children examined with appendicitis had rebound tenderness. So both these studies suggest that positive rebound tenderness is an indication of an acute appendicitis in children and therefore cannot be ruled out of an initial differential diagnosis. Golledge, Toms, Franklin, Scriven and Galland (1996) specifically evaluated the â€Å"cats eye symptom† (pain going over a bump in the road), the cough sign, right lower quadrant pain to percussion, rebound tenderness and guarding. The data from this evaluation suggested that rebound tenderness had a likelihood ratio of 7.4 compared to the other signs which had likelihood ratios of between 1.1 and 4.1. This data therefore suggests that rebound tenderness is a very useful sign in the diagnosis of acute appendicitis, but that the other signs and symptoms are not (Moyer, et al., 2001). Overall rebound tenderness is useful sign for diagnosing appendicitis when there is a high suspicion of appendicitis and is accompanied with other diagnostic indicators (Moyer, et al., 2001). Another presentation to be considered in relation to abdominal pain and rebound tenderness is the duration of the pain experienced by the child. A study undertaken by Oshea, Bishop, Alario and Cooper (1988) involved 246 children from 13 to 18 years old who presented to the emergency department with a history of less than one week of abdominal pain. Results showed that the likelihood ratio of pain was greater when the child had the pain for more than 12 hours (Likelihood ratio: 1.3) compared to less than 12 hours (Likelihood ratio: 0.64). Later in the study pain duration was evaluated at less than 24 hours and more than 24 hours, with their likelihood ratios being 0.83 and 1.2 respectively. When compared to Andersson, et al. (1999) study of 502 patients aged 10 to 86 the greatest likelihood ratio was 1.7 at 7-12 hours after onset of pain. Based on both studies it is very difficult to see how duration of pain can lead to the diagnosis of appendicitis. Therefore, practitioners must not allow the duration of pain to prevent any further investigation into the diagnosis (Moyer, et al., 2001). Another symptom which could possibly indicate the diagnosis of appendicitis is fever (Gwynn, 2001). Cardall, Glasser and Gusss (2004) study evaluated two hundred and ninety three people aged between 7 and 75 who presented to the emergency department with suspected appendicitis. Temperatures were classed at greater than 99oF or less than 99oF. The study showed that 27% of patients whos temperature was 99oF. When the results were analysed in terms of specific temperature intervals, the highest likelihood ratio (3.18) was found in patients with temperatures greater than 102  °F. However, Bergerons (2006) study on clinical judgement suggests there is no clinical value with temperature as there is minimal sensitivity and specificity in the diagnosis of appendicitis. Therefore, as with duration of pain duration and levels of WBCC, temperature as a single entity has little diagnostic utility in the diagnosis of appendicitis unless it is combined with other signs and symptoms such as rebou nd tenderness (Cardall, Glasser and Guss, 2004). For many years laboratory tests such as white blood cell count (WBCC) leukocytes and C-reactive protein (CRP) have been used to support a diagnosis, but the considerable overlap with other inflammatory conditions accounts for the low specificity and positive predictive value of these tests (Stefanutti, Ghirardo and Gamba, 2007). Recent studies on adult patients who present with clinical signs and symptoms indicating acute appendicitis, show that appendicitis can be excluded if both leukocyte count and C-reactive protein value are normal (Gronroos, 2001). However, Stefanutti, Ghirardo and Gamba, (2007) suggest that only a few studies have been reported in paediatric patients and the role of WBCC and CRP in excluding acute appendicitis in children has not been confirmed. According to Andersson et al. (1999) children who present with signs and symptoms of appendicitis such as rebound tenderness and have a WBCC of 15000 only moderately increases the estimated risk of appendicitis. This t herefore shows that only at the extremes of the WBCC does this diagnostic indicator appear useful (Moyer, et al., 2001). Therefore, contrary to adult patients, normal leukocyte count, WBCC and CRP value cannot effectively exclude acute appendicitis in children. Another usual predictor of appendicitis is vomiting (Bergeron, Richer, Gharib and Giard, 1999). The study by Andersson et al. (1999) calculated the likelihood ratio for appendicitis in a patient with vomiting compared to one with no vomiting to be 1.8. In addition Reynolds and Jaffe (1992) study suggests that a combination of four predictors including; vomiting right lower quadrant pain, abdominal tenderness, and abdominal guarding. More specifically 97% of the 377 children studied who were diagnosed with appendicitis had two or more of these predictors. Therefore, a patient who presents to A+E with less than two of the above predictors is quite unlikely to have appendicitis. Alvarado (1986) conducted a retrospective study of 305 patients hospitalised with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analysed for specificity, sensitivity, predictive value, and joint probability.Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain (Alvarado, 1986). This scoring system shown below is deemed by many surgeons as an easy aid for supporting the diagnosis of acute appendicitis (Khan and Rehman, 2005). A study undertaken by Baidya, Rodrigues, Rao and Khan (2007) investigated the diagnostic accuracy of Alvarado scoring system. The results showed that a score of >7 for an appendicitis was 88.2% correct in diagnosis. However, the diagnostic accuracy of an Alvarado score Despite recent advances in knowledge and diagnostic investigations, a population-based analysis in the United States found that the incidence of unnecessary appendectomy has not changed (Flum, Morris and Koepsell, 2001). Therefore to increase diagnostic accuracy, new modalities such as ultrasound scans have been introduced (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Kaneko and Tsuda (2004) conducted a 10-year study using ultrasound scans to diagnose appendicitis in children and are convinced that ultrasound scans can identify inflamed appendices with 100% sensitivity and can also determine the severity as well. However Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman (2004) suggest that the use of ultrasound has not decreased negative appendectomies as similar negative rates were present over a decade ago. Therefore on the basis of the available evidence, patients presenting to A+E with a strong clinical case of appendicitis should be referred direct to the surgeon without an ultrasound. In addition to the use of ultrasound scanning the use of computed tomography (CT) has been recently studied and evaluated. There are currently two perspectives in the literature regarding the use of CT scan for the diagnosis of acute appendicitis: one supporting its routine use due to the decreased incidence of negative appendectomies, and the other one against its routine use due to the increased cost and delay in surgical management (Ceydel, Lavotshkin, Yu and Wise, 2006). In addition the benefits of imaging eliminating inpatient observation and unnecessary surgery must be weighed against the malignancy risk from radiation, as well as discomfort of rectal contrast administration (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman, 2004). Ceydel, Lavotshkin, Yu and Wises (2006) retrospective study showed that the negative appendectomy rate was much less in patients who had CT scans (7.6%) compared to the non CT scan group (24%). Therefore clinicians within A+E use their cl inical judgement and place emphasis on the importance of routine history and an accurate physical examination utilising CT scans for atypical cases of acute appendicitis (Gwynn, 2001). Currently within the A+E department there is no specific pathway or tool for ruling in acute appendicitis in paediatrics. In addition Birkhahn, Briggs, Datillo, Van Deusen and Gaeta (2006) suggest that no major medical association or professional organisation currently endorses a standardised pathway for the evaluation of patients with suspected appendicitis. With up to 25 % of children having negative appendectomies it is therefore of clinical and financial value to consider the use of a scoring system to admit or discharge children who present with a possible acute appendicitis. Current systems are in place for other potential conditions such as myocardial infarctions, pancreatitis and pneumonia. These other systems have been audited locally and nationally and are currently working well within the trust, therefore the plans to introduce the Alvarado scoring system will be put forward in the next review of clinical practice meeting between nursing and medical staff. To conclude, this assignment demonstrates that for an emergency department practitioner in a fast paced A+E setting, the accurate diagnosis of acute appendicitis remains a challenge for the paediatric age group. An accurate history and physical examination, which as highlighted can be challenge in younger patients plays an important role in the diagnosis of early acute appendicitis (Mallick, 2008). Physical clinical signs elicited upon examination provide the practitioner with a good insight to expected diagnosis. However, the usefulness of rebound tenderness as a single examination has minimal clinical value. The whole patient picture which encompasses an accurate history, clinical examination, laboratory investigations and possible diagnostic imaging is therefore vital to providing a correct diagnosis. The use of clinical scoring systems like the Alvarado score can be a cheap and quick tool to apply in emergency departments to rule in acute appendicitis. This scoring system includes many aspects such as clinical history, rebound tenderness and laboratory investigations. This allows for observation and critical re-evaluation of the evolving clinical picture. Its application improves the overall diagnostic accuracy and consequently reduces negative appendectomies (Khan and Rehman, 2005). In clinical cases where the practitioner is unsure if the actual diagnosis is acute appendicitis other diagnostic imaging studies such as ultrasound and CT may be undertaken. This must only then be considered once a thorough clinical examination has not provided any indication for acute appendicitis and the benefits out way the risks. References NHS Information Centre. (2009). Primary diagnosis: summary. Retrieved November 21, 2009, from Hospital Episode Online: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937categoryID=202 Allan, B. (2008). History and examination (3rd ed.). Philadelphia: Mosby. Alvarado, A. (1986). A practical score for the early diagnosis of acute appendicitis. Annals of Emergency Medicine, 15 (5), 557-564. Andersson, R., Hugander, A., Ghazi, S., Ravn, H., Offenbartl, S., Nystrà ¶m, P., et al. (1999). Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World Journal of Surgery, 23 (2), 133-40. Baidya, N., Rodrigues, G., Rao, A., Khan, S. (2007). Internet Scientific Publications. Retrieved December 22, 2009, from The Internet Journal of Surgery: http://www.ispub.com/journal/the_internet_journal_of_surgery/volume_9_number_1/article_printable/evaluation_of_alvarado_score_in_acute_appendicitis_a_prospective_study.html Bergeron, E. (2006). Clinical judgment remains of great value in the diagnosis of acute appendicitis. Canadian Journal of Surgery, 49 (2), 96-100. Bergeron, E., Richer, B., Gharib, R., Giard, A. (1999). Appendicitis is a place for clinical judgment. American Journal of Surgery, 177, 460 462. Bickley, L. (2009). Bates Guide to Physical Examination and History Taking (10th ed.). Philadelphia: Wolters Kluwer Health / Lippincott Williams and Wilkins. Birkhahn, R., Briggs, M., Datillo, P., Van Deusen, S., Gaeta, T. (2006). Classifying patients suspected of appendicitis with regard to likelihood. The American Journal of Surgery, 191, 497-502. Broek, W., Ende, E., Bijnen, A., Breslau, P., Alkmaar, D. (2004). Which children could benefit from additional diagnostic tools in cases of suspected appendicitis? Journal of Paediatric Surgery, 39 (4), 570-574. Cardall, T., Glasser, J., Guss, D. (2004). Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Academic Emergency Medicine, 11 (10), 1021-1027. Ceydel, A., Lavotshkin, S., Yu, J., Wise, L. (2006). When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis? Current Surgery, 63 (6), 464-468. Cleaver, K. (2003). Developing expertise the contribution of paediatric accident and emergency nurses to the care of children, and the implications for their continuing professional development. Accident and Emergency Nursing, 11, 96 102. Flum, D., Morris, A., Koepsell, T. (2001). Has misdiagnosis of appendicitis decreased over time? A population-based analysis. Journal of the American Medical Association, 286, 1748-1753. Golledge, J., Toms, A., Franklin, I., Scriven, M., Galland, R. (1996). Assessment of peritonism in appendicitis. Annals of the Royal College of Surgeons England, 78, 11-14. Gronroos, J. (2001). Do normal leukocyte count and C-reactive protein value exclude acute appendicitis in children? Acute Paediatrics, 90, 649- 651. Gwynn, L. (2001). The diagnosis of acute appendicitis: Clinical assessment versus computed tomography evaluation. The Journal of Emergency Medicine, 21 (2), 119-123. Hibberts, F., Bushell, C. (2007). Physical assessment in gastroenterology abdominal examination. Gastrointestinal Nursing, 5 (7), 24 30. Kalan, M., Talbot, D., Cunliffe, W., Rich, A. (1994). Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Annals of the Royal College of Surgeons, 76, 418-419. Kaneko, K., Tsuda, M. (2004). Ultrasound-based decision making in the treatment of acute appendicitis in children. Journal of Paediatric Surgery, 39 (9), 1316-1320. Khan, I., Rehman, A. (2005). Application of Alvarado scoring system in diagnosis of acute appendicitis. Journal of Ayub Medical College Abbottabad Pakistan, 17 (3), 17-21. Koepsell, F. (2002). The clinical and economic correlates of misdiagnosed appendicitis: Nationwide analysis. Archives of Surgery, 137, 799-804. Lin, C., Chen, J., Chung, T., Ho, Y., Lin, W. (2009). Children presenting at the emergency department with right lower quadrant pain. Journal of Medical Science, 25, 1-9. Lippincott Williams and Wilkins. (2008). Assessment made incredibly easy Philadelphia: Wolters Kluwer Health / Lippincott Williams Wilkins. Malik, K., Khan, A., Waheed, I. (2000). Evaluation of the Alvarado score in diagnosis of acute appendicitis. Journal of College of Physicians and Surgeons Pakistan, 10, 392-394. Mallick, M. (2008). Appendicitis in pre-school children: A continuing clinical challenge: A retrospective study. International Journal of Surgery, 6, 371-373. Mantzaris, D., Anastassopoulos, G., Adamopoulos, A., Gardikis, S. (2008). A non-symbolic implementation of abdominal pain estimation in childhood. Information Sciences, 178, 3860-3866. Moyer, V., Elliott, E., Davis, R., Gilbert, R., Klassen, T., Logan, S., et al. (2001). Evidence Based Paediatrics and Child Health. London: BMJ Books. Neilson, I., Laberge, J., Nguyen, L., Moir, C., Doody, D., Sonnino, R., et al. (1990). Appendicitis in children: Current therapeutic recommendations. Journal of Paediatric Surgery, 25 (11), 1113-1116. Oshea, J., Bishop, M., Alario, A., Cooper, J. (1988). Diagnosing appendicitis in children with acute abdominal pain. Paediatric Emergency Care, 4, 172-176. Owe, T., Williams, H., Stiff, G., Jenkinson, L., Rees, B. (1992). Evaluation of the Alvarado score in acute appendicitis. Journal of the Royal Society of Medicine, 85, 87-88. Pines, J., Pines, L., Hall, A., Hunter, J., Srinivasan, R., Ghaemmaghami, C. (2005). The interrater variation of ED abdominal examination findings in patients with acute abdominal pain. American Journal of Emergency Medicine (23), 483-487. Rehman, I., Burki, T. (2003). Alvarado scoring system in the diagnosis of acute appendicitis in children. Journal of Medical Sciences, 11, 37-41. Reynolds, S., Jaffe, D. (1992). Diagnosing abdominal pain in a paediatric emergency department. Paediatric emergency care, 8, 126-128. Smink, D., Finkelstein, J., Garcia-Pena, B., Shannon, M., Taylor, G., Fishman, S. (2004). Diagnosis of acute appendicitis in children using a clinical practice guideline. Journal of Paediatric surgery, 39, 458-463. Stefanutti, G., Ghirardo, V., Gamba, P. (2007). Inflammatory markers for acute appendicitis in children: are they helpful? Journal of Paediatric Surgery, 42, 773-776. Whisker, L., Luke, D., Hendrickse, C., Bowley, D., Lander, A. (2009). Appendicitis in children: A comparative study between a specialist paediatric centre and a district general hospital. Journal of Paediatric Surgery, 44, 362-367. Williams, R., Blakely, M., Fischer, P., Streck, C., Dassinger, M., Gupta, H., et al. (2009). Diagnosing ruptured appendicitis preoperatively in paediatric patients. Journal of American College of Surgeons, 208 (5), 819 825.

Particular social system Essay

Ethics is the discipline that deals with the good and the bad as well as with the moral duty and responsibility of an individual. It can also be defined as the study of the choices made by individuals as regards right and wrong (Marie, 2005). Ethics is mainly concerned with the philosophy that results in a particular behavior. Ethics are of different types, and they differ in terms of their application in different contexts. Ethics state the working of a particular social system. They point towards the utilization of morality. At birth, as indicated by Be The Dream (2009), everyone is practically a blank slate. The period of infancy is characterized by total emptiness. The only skill an infant is equipped with is crying in order to attract the attention of the other people. Infants are contented with just lying watching the world revolve around them until they need something. However, as life progresses, individuals develop values in accordance with what they have previously learned or gone through (Be The Dream, 2009). The main intent of developing ethics is to set up the capacity to come up with rational judgment and ethical decisions. The whole process of personal ethics development is continuous and goes on through out life (Marie, 2005). Personal ethics, morals and values go hand in hand. Values are beneficial aspects learned from childhood, either as a result of interaction with the environment or from parents. Morals are the inherent beliefs that develop from the values system of the way an individual should react in a particular situation (Fairleigh Dickinson University, 2010). Ethics, on the other hand, are characterized by an individual’s reaction to difficult situations. Ethics play a major role of testing the morals of an individual. Personal ethics are instilled by the culture, environment as well as the background in which an individual is brought up (Fairleigh Dickinson University, 2010). Family values in addition to traditional values are very important in the upbringing of a child. These values play a major role in assisting an individual develop personal ethics at a very tender age. Various personal ethics include: honesty, loyalty, punctuality, open-mindedness, self respect as well as respect for others and fairness (Marie, 2005). Hatcher (2007) states that the expression of one’s ethics is not always comprehended in the global context at large, immediate surrounding, or even among the closest family members. This is mainly as a result of the difference in the development of personal ethics. Personal ethics develop early in life through interaction with family, church, school, and other members of the general community. All these people play part in helping one mold his/her beliefs (Hatcher, 2007). Personal ethics are established through unconscious observations as well as experiences of childhood. Personal ethics narrate values that help an individual make sense of his/her life. They enable one to make moral decisions that are not inclined towards the good of an individual but to all people. An ethical person undergoes extensive internal battles, trying to figure out whether his or her actions will negatively impact on others. Personal ethics enable individuals to make decisions that are meant for the benefit of all. They act as an innate factor that enable individuals make rational and morally correct decisions (Hatcher, 2007).

Competitive Analysis

Competitive Analysis One of the few advantages Japed has over its competitors is that they are t he most welkin hot dog stand in Vancouver. As they were awarded â€Å"Best of Vance feed' 3 years consecutively. Shops located at the YVES airport, Robinson Street, and Richmond d has proven to be very successful towards the company. These locations provide easy ace usability for potential consumers. The airport provides people from all over the world to g Arab a quick bite before their next flight. What better thing to grab than a cultural fusion hot do g a customer has never tried before?The convenience of Japed makes it easier for busy pep el, and hence why the restaurant location is on Robinson . While providing convenience for cue stokers, Japed also brings a unique taste to the market. This unique taste can be thou ought of as an advantage over other hot dog vendors/ restaurants. This differential advantage in culture can attract many consumers roaming around the area. The North Am erican culture e for comfort food usually consists of hamburgers, fries, and most importantly for Japed; hot dogs.This is one of the main reasons why Japed was able to gain its popularity; an teeth nice, distinct, flavors fusion of one of the most loved snacks in North America. The difference between Japed and other hot dog stands are the unique vary ties that they offer. Such as Spading signature hot dog topped with Tertiary sauce e, mayo and seaweed, these are the kinds of ingredients that makes their products unique . The price range of Japed starts from $5 for a simple hot dog $12 for a full meal inch duding its specialty hot dog, fries and a drink.Japed faces numerous competitors in d owe Anton Vancouver and many other food trucks, but with the increase of Japanese rest rants in the area, Sapwood's business has grown significantly. Japed has become very pop alular as the people of Vancouver have grown a love for Japanese cuisine. Other food trucks provide cuisines such as Mexic an cuisine are slightly more pricey than Japed. The price varies around $7 $14, despite the price, although the quantity that is given is also fulfilling, we have found the reputation, value and the taste oft he product Japed offers is on par with or surpasses other food stand competitors.Alone g with the product, Japed has the highest number of food stands in Vancouver, thus gig vying them a location advantage and easy accessibility over its competitors. The countless mount of flavors is also a major advantage that Japed possess. Currently with 13 SP Cecilia and 7 traditional hot dogs, as well as a separate category of fries, Spading menu pr vides customers an abundance of choices compared to other competitors. The main competitors of Japed are the other neighboring street vendors a ND obviously, other hot dog stands.Other vendors that have their own cultural TA set such as Mexican, Greek, Chinese or Persian are also a threat towards them. Fast food restaurants such as McDonald's, Church's Chicken and Wendy are also great threats to Jaw padded. The rice range for a burger in McDonald's is around 5 dollars and the meal is ABA UT 8 dollars and this is one of the reason why Japed is making less profit comparing to chain deed fast food restaurants. Fasted chains such as McDonald's and Wend's have been established for a longer time. They are very welkin to society and that's the greatest competitive a advantage they have.Established competitors usually take advantage of using television com Americas to advertise their new product or even a special package deal. Since Japed is q tie new compared to bigger fast food chains such as McDonald's, their locations are r stricter to only downtown Vancouver and Richmond Birdhouse strain station. They are no t as exposed as other fast food chains that have been around for a longer time. Spading AC accessibility is strictly towards the people roaming around downtown and Richmond Bright use strain station.Even with the excepti onal taste and popularity of Japed, there will be a few downsides. One of the few is that not all people like hot dogs. This difference I n taste may cause slower sales compared to competitors who do not only have hotdogs, but burgers, wraps, or salads. However, during the Winter Olympics that was held in Vance ever, Japed has experienced their busiest time with nearly 1 00 people lining up at one Tim e for the Japanese style hotdogs everyday, showing how they can provide sales with eve n only the menu selection of hotdogs, fries or drinks.In conclusion, after analyzing Spading competitive advantage we can see that t they are continually a very successful local food vendor comparing to other local of odd vendors, but must take further steps in order to grow internationally. Although there are n onerous factors that they must take carefully into consideration in order to further progress t heir business successfully.

Chemical Physical Changes

Chemical and physical changes are related to chemical and physical properties. Chemical Changes Chemical changes take place at the molecular level. A chemical change produces a new substance.  Another way to think of it is that a chemical change accompanies a chemical reaction.  Examples of chemical changes include combustion (burning), cooking an egg, rusting of an iron pan, and mixing hydrochloric acid and sodium hydroxide to make salt and water. Physical Changes Physical changes are concerned with energy and states of matter. A physical change does not produce a new substance, although the starting and ending materials may look very different from each other. Changes in state or phase (melting, freezing, vaporization, condensation, sublimation) are physical changes. Examples of physical changes include crushing a can, melting an ice cube, and breaking a bottle. How to Tell Chemical Physical Changes Apart A chemical change makes a substance that wasnt there before. There may be clues that a chemical reaction took places, such as light, heat, color change, gas production, odor, or sound. The starting and ending materials of a physical change are the same, even though they may look different.