Laryngeal Mask Airway Placement Methods in Pediatric Care

Laryngeal Mask Airway Placement Methods in Pediatric Care Laryngeal Mask Airway Placement: Comparison Between a Traditional and Alternative Methods in Pediatric Practice ============================================================ Emil Batarseh , MD , JBA* Zahi Majali , MD , JBA Basel D.Makhamreh , MD , JBA Abstract Objective To compare the quality of laryngeal mask airway placement between an alternative and a traditional methods in children. Methods Our prospective ,double-blind investigation enrolled 105 children subjects , aged 3months-15 years,of both genders,ASA I(American society of anesthesiologists), and assigned for different elective minor superficial operations under general halothane inhalational spontaneous laryngeal mask airway anesthesia at Princess Haya hospital-Aqaba-Jordan,during the period July 2007-July 2008. Subjects were randomized into two groups.Group I subjects (n=50) received laryngeal mask airway (LMA) through an alternative method,and group II subjects (n=55) received laryngeal mask airway via the traditional method. The number of placement attempts and duration required for success to attain a patent airway in both groups were recorded. Results Placement method made no difference in terems of first trial success (P>0.05).First trial successful placement was 85.5% and 90% in groups II and I respectively. Conclusion The alternative placement method is an acceptable solution to the traditional method. Key words:Anesthesia:general,spontaneous;LMA:traditional,alternative;children. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ *Corresponding author: Department of anesthesia , intensive care and pain management , KHMC , AMMAN , JORDAN. E-mail: [emailprotected]yahoo.com 1 Introduction Use of laryngeasl mask airway permits the maintenance of a patent airway with successful insertion rates of the LMA on the first attempt , varying between 67-92% in pediatric practice (1).Since its introduction in 1983 by Brain,the LMA has achieved increasing popularity (2). The laryngeal mask airway has achieved a great popularity also in pediatric anesthesia practice.The laryngeal mask airway is a novel device that fills the gap in airway management between endotracheal intubatio and the use of face mask.The laryngeal mask airway is inserted blindly into the pharynx,forming a low pressure seal aroud the laryngeal inlet. Because the insertion of the laryngeal mask airway by the standard technique is not always easy in children due to the posterior pharyngeal curvature,some different maneuvers have been described to minimize this problem(3):Innserting the LMA laterally,applying the mask firmly against the hard palate,pulling the tongue forward,repositioning the head,adding or removing air to the cuff,applying continuous positive airway pressure,usig a laryngoscope and inserting the LMA like a Guedel oropharyngeal airway. The ability to maintain a patent airway and provide effective ventilation is the main objective of pediatric anesthesiological procedures.This is achieved mainly with the use of a face mask or an endotracheal tube.Both of these devices have major limitations from a strictly anatomical point of view and require adequate operator skills.The aim of LMA was of producing an airway device that would be more practical than the face mask and less invasive than the tracheal tubes.The functional ehegance of the LMA is that it forms a low pressure airtight seal against the glottis rather than plugging the pharynx,thus combining ease of insertion and adequaqte airway patency (4). Airway management is more successful with LMA technique.This is because transoral passage of instrumentation into the hypopharynx is easier than into the glottic inlet.There are four reasons:Firstly,the hypopharynx is a posterior structure and is easier to locate.Secondly,it is wider providing a bigger target.Thirdly,it is funnel-rather than tubular –shaped ,so that imprecisely positioned instrumentation will be redirected to the target and fourthly,it is better aligned with the oropharyngeal axis,making instrumentation less likely to get snagged (3). The objective of our invewstigation was to asses the effectiveness of the modified procedure in comparison to the standard procedure regarding LMA insertion. 2 Methods Our prospective,double blind investigation included 105 children patients,aged 3months-15 years,ASA I,of both sexes and scheduled for various elective minor superficial surgical procedures under general halothane inhalational spontaneous laryngeal mask airway anesthesia at Princess Haya hospital-Aqaba-Jordan,during the period July 2007-July2008,after obtaining approval from the local ethics committee of the Jordanian royal medical service directorate and written informed consent from the parents..Subjects were randomly divided into two groups using sealed envelopes.Group I children (n=50) received LMA using the modified method and group II children (n=55) received LMA via the standard method.The size of the LMA used was indicated using the patients body weight;size 1,1.5,2,2.5 ad 3 masks for 30 kgof body w2eight ,respectively. The LMA was lubricated with saline before insertion.Induction of inhalational anesthesia was performed with 3-5%halothane mixed with70% nitrous oxidein 30%oxygen.Before insertion of the LMA ,anesthesia was maintained using 2-3%halothanne in oxygen.No muscle relaxants were used.An anesthesia technician opened the patients mouth by pulling down the jaw.Intravenous cannulation was done after child is anesthetized,if The standard insertion procedure was illustrated by Brain(5).The LMA was inserted with the cuff fully deflated and against the palate,then the cuff was inflated after insertion.In the modified insertion procedure,a two-thirds moderately inflated LMA (using 2,4,6,8 and 12 ml air for size 1,1.5,2,2.5 and 3 masks respectively) was inserted with its lumen facing laterally left.While rotated clockwise 90 D,it was passed downward into position behind the larynx.Then the cuff was fully inflated.Successful insertion was clinically called for if manual ventilation with the reservoir bag was easy and the chest wall movement was smooth. The number of trials on LMA onnsertion and the duration to achieve good airway were recorded.Vital signs including heart rate and pulse oximeter readings were recorded.In case of failed LMA insertion,endotracheal intubation was achieved.An observer blinded to the insertion procedure evaluated the two procedures. Statistics Parametric data were analyzed using Students t test.P-value 3 Results There were no significant differences in terms of gender,age,weight,duration of anesthesia and size of the LMA.Table 1.Overall study group was 110 children patients,but 5 were excluded from the investigation ,who were ASA II and III physical status classified. Successful insertion was attained in 85.5% of subjects in group II and in 90% of patients in group I,at first trial.The two groups were comparable regarding the successful insertion rate,the number of trials at insertion(Second trial;GII,4 and GI,3.P>0.05.Third trial;GII,3 and GI,2,P>0.05) and the duration required for insertion (GII,0.4 minutes and GI,0.37 minutes,P>0.05). Endotracheal intubation was achieved in 1 case in GII and in no case in GI,P>0.05.In the present study,the LMA standard approach success rate was 85.5% at first trial ,increasing to 92.7% at second trial and 98.2% at third trial.In the modified approach,the success rate was 90% at first trial but was 96% at second trial and 100% at third trial. 4 Table 1. Patients characteristics. 5 Table 2. LMA insertion comparison. 6 Discussion The LMA has become popular in pediatric aesthesia practice.Nagai S,et al showed the potency of the modifiedmethod of LMA insertion (6).LMA advantages over conventional laryngoscope guided tracheal intubation are more rapid insertion and increased success rate.The modified method can be used in this investigation as an alternative procedure to the standard method of insertion.Brimacombe and Berry (7) stated that if the standard approach is used correctly,the first time success rate should be >98% in less than 20 seconds. Wakeling et al(8) demonstrated that deflating the cuff first would allow more difficult insertion due to the presentation of a softer edge to the posterior pharyngeal wall.Lopez-Gil,et al(9) used a lubricant ,whereas we moistened the LMA with saline only.He demonstrated that there was a rapid improvement in LMA skills in pediatric anesthesia practice when the standard technique was used.Gaining more experience may decrease the rate of unsuccessful insertion.Airway trauma was less frequent with the LMA than with ETI.This is not surprising as more force is required to see the glottic inlet than the hypopharynx.Perhaps the pharyngeal/esophageal mucosa is stronger than the laryngeal/tracheal mucosa as it has evolved to accommodate solid bodies and not just passaqge of gas. This modified technique I which a two –thirds inflated LMA is inserted with its lumen facing laterally forces the patients mouth to open wider and keeps the tongue from being pushed back into the air passage.These technical features result in easy insertion through the pharynx for inexperienced anesthesiologists.In addition,the softer edge of the partially inflated LMA protects the pharyngeal mucosae from trauma during insertion.Causes of difficulty with LMA onsertion include choice of wrong LMA size and difficulty in maneuvering through the posterior curvature of the pharynx (10).Differences in the airway anatomy and the frequent presence of tonsillar hypertrophy can complicate LMA insertion in children.Maneuvers to overcome this difficulty include increased head extension,jaw thrust maneuvers puuling the tongue forward,firm pressure on the LMA and using the index finger to guide the mask(10). Oneil et al (11) have reported an alternative method of insertion with the LMA partially inflated in children.They described improved ease of insertion and explained that the softness of the inflated cuff allows for easier adaptation to the differing pharyngeal characteristics of the pediatric airway. Nevertheless,Braincompared insertion techniques concerning the mechanisms of deglutition and recommended the standard technique. Although both methods of insertion were satisfactory,partial inflation of the LMA improved the ease of insertion in children as assessed by time to insertion and success rate on the first attempt.Inflation of the cuff at the smaller sized LMA after insertion often displaces the LMA and alters its position while the inflated LMA tends to insert to the proper depth and requires no further adjustment.In the standard technique,however,insertion of the LMA is not always easy.Therefore,it is reasonable that anesthesiologists devise other insertion techniques.We believe that this technique is to be recommended in certain situations. 7 Trevisanuto et al (12) found that the occurrence of first time failure decreased overtime in their study and they thought that the change represented an element of familiarization with the LMA insertion technique.The relatively small but statistically significant difference is meaningful,sice problems associated with insertion can be attributed to inadequate depth of anesthesia which may occur with prolonged placement.Our 1.8% incidence of problems that resulted in abandonment of the LMA is comparable to that reported in similar study evaluating uses of the LMA in pediatric practice(1). In Conclusion This modified techniqueia an acceptable alternativeto the standard technique I children.Thie techniqueis likelyto allow easy insertion of the LMA for unskilled anesthesiologists.Insertion of the LMA with the cuff inflated is equallysuccessfulto the standard uninflated techiquein experienced anesthesiologists.This implies that the modified inflated approach would be accepted to the general population of LMA users. 8 References 1.Shahin NJ , Mehtab A , Hammad U , et al. A study of the use of laryngeal mask airway (LMA) in children and its comparison with endotracheal intubation.Indian journal of anaesthesia 2009;53(2):174-8. 2.Pennant JH , White PF. The laryngeal mask airway.Its uses in anesthesiology. Anesthesiology 1993;79:144-63. 3.Benumof JL. Laryngeal mask airway.Indications and contraindications.Anesthesiology 1992;77(5):843-6. 4.Ghai B , Wig J . Comparison of different techniques oh laryngeal mask placement in children. Curr opin Anesthesiol 2009;22(3):400-4 5.Patel B, Bingham R.Laryngeal mask airway and other supraglottic airway devices in pediatric practice.BJA 2009;9(1):6-9 6.Nagai S , Inagaki Y , Hirosawa J , et al. Modified insertion technique of the laryngeal mask airway in children:a comparison with standard technique. Anaesthesia 2003:59-61. 7.Brimacombe J , Berry A. The laryngeal mask airway :anatomical and physiological implications. Acta Anesthesiol scand 1996;40(2):201-9. 8.Wakeling HG , Butler PJ , Baxter PJC.The laryngeal mask airway:a comparison between two insertion techniques.Anesth Analg 1997;85:687-90. 9.Lopez GM , Brimacombe J , Cebrian J , et al.Larygeal mask airway in pediatric practice. Anesthesiology 1996;84(4):807-11. 10.Ghai B , Makkar JK , Bhardwai N, et al.Larygeal mask airway insertion in children:comparison between rotational,lateral and standard techniques. Pediatric anesthesia 2008;18(4):308-12 11.Oneill B , Templeton JJ , Caramico L, et al.The laryngeal mask airway in pediatric patients:factors affecting ease of use during insertion and emergence. Anesth Analg 1994;78:659-62. 12.Trevisanuto D , Micaglio M , Ferrarese P , et al.The laryngeal mask airway:potential applications in neonates. Fn.bmj.com 2008.www.archdischild.com. 9

Pharmaceutical Companies Stand in the Way of Treatment Essay -- Drug I

Pharmaceutical Companies Stand in the Way of Treatment Abstract This casebook concentrates on the negative effects that the pharmaceutical industry’s trade and production policies have on third world nations suffering from disease epidemics. My position is that pharmaceutical companies are not concerned with the health benefits of their drugs, but rather with the market that their drugs generate. I illustrate this notion by describing the trade policies that pharmaceutical companies influence and the pharmaceutical companies’ production policies which concentrate on producing life-style drugs rather than drugs that cure life-threatening diseases. Multinational pharmaceutical giants are occupied with producing drugs that yield the most profits rather than with producing drugs to cure life-threatening diseases. Though many people in third world countries suffer from curable or treatable infectious diseases such as malaria and tuberculosis, many of them go without treatment because the vaccines that cure these diseases are either too expensive for them to afford or they are not produced in sufficient quantities. To illustrate the down-production of necessary life-sustaining drugs is the fact that â€Å"between 1975 and 1999, 1,393 new drugs were marketed, out of which only 16 were for neglected diseases that accounted for over 10% of the diseases in the World† (Mà ©decins Sans Frontià ¨res). The Mà ©decins Sans Frontià ¨res (also known as Doctors Without Borders or MSF) is a non-profit organization that has contributed much aid and effort in alleviating populations suffering from endemic diseases and neglect. Beca use it is a non-profit organization and its goals are purely objective and humanitarian, the Mà ©decins Sans Frontià ¨res org... ... Times. 16 November 2001. 28 January 2004. - Ford, Nathan. Drug Development for Neglected Diseases: A Deficient Market and Public Health Policy. The Lancet. 359 (2002): 2188-94 - Martorell, Jordi. Drugs companies putting profits before millions of people's lives. Youth for International Socialism. 26 March 2001. - Silverside, Ann. No Turning Back on Cheap Drugs for Poor Nations. Canadian Medical Journal. 169 (2003): 1067. - Silverstein, Ken. Millions for Viagra, Pennies for the Poor. The Nation. 7 July 1999. 10 February 2004. - WTO Takes First Step. The Lancet. 362 (2003): 753 Pharmaceutical Companies Stand in the Way of Treatment Essay -- Drug I Pharmaceutical Companies Stand in the Way of Treatment Abstract This casebook concentrates on the negative effects that the pharmaceutical industry’s trade and production policies have on third world nations suffering from disease epidemics. My position is that pharmaceutical companies are not concerned with the health benefits of their drugs, but rather with the market that their drugs generate. I illustrate this notion by describing the trade policies that pharmaceutical companies influence and the pharmaceutical companies’ production policies which concentrate on producing life-style drugs rather than drugs that cure life-threatening diseases. Multinational pharmaceutical giants are occupied with producing drugs that yield the most profits rather than with producing drugs to cure life-threatening diseases. Though many people in third world countries suffer from curable or treatable infectious diseases such as malaria and tuberculosis, many of them go without treatment because the vaccines that cure these diseases are either too expensive for them to afford or they are not produced in sufficient quantities. To illustrate the down-production of necessary life-sustaining drugs is the fact that â€Å"between 1975 and 1999, 1,393 new drugs were marketed, out of which only 16 were for neglected diseases that accounted for over 10% of the diseases in the World† (Mà ©decins Sans Frontià ¨res). The Mà ©decins Sans Frontià ¨res (also known as Doctors Without Borders or MSF) is a non-profit organization that has contributed much aid and effort in alleviating populations suffering from endemic diseases and neglect. Beca use it is a non-profit organization and its goals are purely objective and humanitarian, the Mà ©decins Sans Frontià ¨res org... ... Times. 16 November 2001. 28 January 2004. - Ford, Nathan. Drug Development for Neglected Diseases: A Deficient Market and Public Health Policy. The Lancet. 359 (2002): 2188-94 - Martorell, Jordi. Drugs companies putting profits before millions of people's lives. Youth for International Socialism. 26 March 2001. - Silverside, Ann. No Turning Back on Cheap Drugs for Poor Nations. Canadian Medical Journal. 169 (2003): 1067. - Silverstein, Ken. Millions for Viagra, Pennies for the Poor. The Nation. 7 July 1999. 10 February 2004. - WTO Takes First Step. The Lancet. 362 (2003): 753

Oscar Hammerstein II †Lyricist, Writer, Producer, Director Essay

Oscar Hammerstein II was born July 12, 1895 in New York, New York. He died August 23, 1960 in Doylestown, Pennsylvania of stomach cancer. His given name was Oscar Greeley Clendenning Hammerstein. When he entered the theatre profession, he dropped his middle names and adopted the â€Å"II† from the grandfather for which he was named. His grandfather was a theatre builder and opera company producer. By titling himself â€Å"II† he capitalized on his grandfather’s success; the name recognition alone was a career builder. Hammerstein was always interested in the theatre. His father, although a theatrical producer himself, did not want his son to go into the â€Å"family business†. He made him promise â€Å"never to do anything as foolish as to consider making the theatre your livelihood. Become a lawyer. You’d be great at it and it’s also one of the more secure professions I know of.† â€Å"Getting to Know Him – Biography of Oscar Hammerstein II† Hugh Fordin As per his father’s wish, Hammerstein entered Columbia University as an English major. He was an honor student and was involved in many extra-curricular activities; one of which was the Varsity Show. This was where Hammerstein met Larry Hart and the man with whom he would later collaborate, Richard Rodgers. At the time of the initial meeting, Rodgers was only a fourteen year old boy whose older brother Morty was a member of Hammerstein’s fraternity. Although his father had passed away, Hammerstein felt compelled to honor his father’s wishes and entered Columbia law school. He finished his Bachelor’s degree during his first year of law school. During his second year of law school, Hammerstein was so disenchanted with the law he asked his uncle Arthur, a successful producer of musical comedies, for a job. He was hired as an assistant stage manager. After witnessing his nephew’s theatrical ability, Uncle Arthur hired him as a permanent member of the staff. Soon after having been hired by his uncle, he began an apprenticeship with Otto Harbach. What began as an apprenticeship turned into a twenty year collaboration and produced Hammerstein’s first Broadway success Always You. Over the course of his career Hammerstein would collaborate with many different composers notably, Jerome Kern, Vincent Youmans, Rudolf Friml and Sigmund Romberg. Hammerstein’s most successful collaboration would be with the man he had met during his varsity show days at Columbia University, Richard Rodgers. The collaboration with Richard Rodgers began in the early 1940’s with their adaptation of the play Green Grow the Lilacs. This became Oklahoma! and changed Broadway forever. Oklahoma! revolutionized the Broadway theater by integrating the music and book. Previously only Show Boat and Pal Joey, respectively a Hammerstein and a Rodgers production, had used songs to further the story along. Oklahoma! not only used the songs as an integral part of the story but it also incorporated American ballet. The opening was different – only one person on stage with an offstage voice singing as the curtain opened. The female chorus didn’t appear until 45 minutes into the play. The â€Å"chorus† girls where covered in period dress. There were no â€Å"star vehicle† numbers. No song in this musical play was written to become a popular hit. Oklahoma! changed the American musical theatre and gave Hammerstein, who had been battling a career slump, a new burst of energy for the most successful period of his career.

How does Priestley present the theme of responsibility in “An Inspector Calls” Essay

The play ‘An Inspector Calls’ is a political satire written by a devoted socialist, J.B Priestley – an ex-soldier who fought in World War I. The play was set in 1912, 2 years prior to World War I; however it was written and published in 1945 – just after world war II. Priestley uses this time difference effectively to emphasise the British society of 1912, where there were firm class and gender barriers; Priestly detested this and was passionate towards the need of collective responsibility – he believed that if there was no change, the consequence would be ‘blood, fire and anguish’. Nonetheless most of these barriers were violated by 1945; Priestly wanted to make the most of these changes. Throughout his play, he influences his audience of 1945 to take advantage of the opportunity the end of the war had set them to reform an enhanced, more compassionate society. J.B Priestly portrays Mr. Arthur Birling as an arrogant, hard-headed, selfi sh capitalist who is only concerned about his reputation. Priestley intentionally exaggerates this character to corroborate his own political agenda. Birling’s thoughts towards socialist ideologies about the significance of community is ‘nonsense’ and that â€Å"a man has to make his own way†. This indicates that he has no interest whatsoever in social responsibility – through his business or his family. In Act One, Mr Birling dictates his predictions for what he thinks is going to happen in the future. He states that â€Å"The world’s developing so fast it’ll make war impossible.† the readers already know that World War I and II have already taken place. Furthermore, he says that the Titanic is ‘absolutely unsinkable’; the audience already know that t he Titanic has sunk. Moreover, he believes that there will be ‘peace and prosperity and rapid progress everywhere’. To the audience of 1945, this character would have been viewed as laughably optimistic and short -sighted; however these were common assumptions of those living in 1912. Priestley does this to show the lack of responsibility Capitalists had for predicting what will happen in the future and causes the audience to doubt whatever Mr Birling says because he could be wrong once more.

Robin Hood-Prince of theives essays

Robin Hood-Prince of theives essays A brief summary of the film: Robin of Locksley (Kevin Costner) returns from the crusades with Azeem (Morgan Freeman). Robin Fights Guy of Gisbornes soon after his return. Later, he learns that his father has been killed by the Sheriff (Alan Rickman) and Guy of Gisborne (Michael Wincott), and swears to avenge him. He goes to see Marian (Mary Elizabeth Mastrantonio) to tell her that her brother was killed while escaping from a prison in the Crusades. Guy's men come to arrest Robin, but he flees and hides in Sherwood Forest. There he meets the outlaws in the forest and becomes their leader. After an enemy raid, some outlaws are captured, bound to be hanged unless Marian, a cousin of the King, agrees to marry the Sheriff. Robin comes to the rescue. Sword fight with the Sheriff, that later is killed by the dagger Marian had received from the Sheriff and given to Robin. Robin and Marian get married, with the blessing of King Richard, just back from the crusades. The movie in general is not big on suspense, but however is not predictable either. The settings for the film are spectacular, especially the castle scenes and the forest shots. The action scenes are well done, even though they are quite violent. The special effects were good and the canera angles aswell (like the one that follows the flight of the arrow). I enjoyed the main love song from the movie: Everything I Do, I Do It For You by Bryan Adams. The acting made this movie great the special effects and music made it even better. I think that Costner plays a realistic Robin Hood, not some perfect superhero. He shows emotion and also adds a little humour to the movie In my opinion the best actor in the movie was Morgan Freeman. He is a very talented actor and his role as Azeem shows his incredible ability. He keeps things even with Costner, not overpowering him or under shadowing him. The friendship of Azeem an ...

MLA, APA, and Chicago Writing Formats Essay Example | Topics and Well Written Essays - 750 words

MLA, APA, and Chicago Writing Formats - Essay Example Also, on the APA, the reference page has the year it was published after the authors name. Lastly, the APA has a cover page (Long Island University, 2009). The MLA uses author name and page. The MLA has the page number for the references and the MLA also has no cover page. The most notable differences are the title page, the titles of the pages included (work cited/resources), and the required spacing (double vs single). I think that the APA is much easier to read and go through, but I like the citing rules for the MLA much better. That's probably because I have a hard time doing those myself though. (Long Island University, 2009). According to Long Island University (2009, pg. 1), APA is used in "psychology, education, and other social sciences;" MLA is used in "literature, arts, and humanities"; and Chicago is used "with all subjects in the "real world" by books, magazines, newspapers, and other non-scholarly publications." I see that one requirement of MLA documentation is that the student's last name and page number is required on each page in the running header.APA documentation requires a shortened title and page number on each page in the running header. MLA does not require a formal title page.Instead, student's name, instructor's name, course title and date are typed on separate lines flush with the upper-left margin on the first page. APA requires a separate title page that has a particular format (Long Island University, 2009). On the reference citations page, MLA requires "Works Cited" to be centered at the top of the page.MLA also has quite a different format for citing references than.APA requires "References" to be centered at the top of the page.Again, APA reference citations are much different than MLA (Long Island University, 2009). According to The Chicago Manual of Style Online (2009, pg. 1): The Chicago Manual of Style presents two basic documentation systems, the humanities style (notes and bibliography) and the author-date system. Choosing between the two often depends on subject matter and nature of sources cited, as each system is favored by different groups of scholars. The humanities style is preferred by many in literature, history, and the arts. This style presents bibliographic information in notes and, often, a bibliography. It accommodates a variety of sources, including esoteric ones less appropriate to the author-date system. The more concise author-date system has long been used by those in the physical, natural, and social sciences. In this system, sources are briefly cited in the text, usually in parentheses, by author's last name and date of publication. The short citations are amplified in a list of references, where full bibliographic information is provided. References Citation style for research papers. (2009). Long Island University. Retrieved June 14, 2009, from http://www.liu.edu/cwis/cwp/library/workshop/citation.htm Chicago-style citation quick guide. (2009). Chicago Manual of

Porters Views on Strategy Essay Example | Topics and Well Written Essays - 1750 words

Porters Views on Strategy - Essay Example Michael Porter is a University Professor at Harvard Business School and a very contributor to the fields of management and economics. In an article he wrote for the Harvard Business Review in 1996, and also in one of his books, he argues that competitive strategy is "about being different". He adds, "It means deliberately choosing a different set of activities to deliver a unique mix of value". It is important to note that Porter has focused on discussing competitive strategy and his views are based more on differentiating the company in the view of the customers. Porter has defined competitive strategy as "a combination of the ends for which the firm is striving and the means by which it is seeking to get there". Porter has provided for a very fresh and different view on the meaning of strategy. He highlights and emphasises on the facts that operational effectiveness is not strategy. Porter has in his article ‘What is Strategy?’, in the Harvard Business Review brought o ut some very important points. He argues that ‘Positioning’, which has been one of the major elements of strategy and has acted as the ‘heart of strategy’, is not being rejected by most managers. He discussed in this article that the current period believed that positioning is considered to be too static in the current dynamic world and the high use of technology. It is important to note that the information that has been provided here has been based on three major heads: 1. variety-based positioning 2. Needs-based positioning and 3 Access-based positioning