the role of tips in the management of portal hypertension
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human resource management阅读理解【题目】阅读下面的文章,根据文章内容,完成相应的选择题。
HUMAN RESOURCES MANAGEMENTHuman Resources Management(HRM)is the process of managing people and their relationships in an organization.These two processes are important in the success and growth of a business.In managing people, staffing is the most important component of HRM.It needs to make guidelines and procedures for hiring and placement.Staffing also involves the management of employees on matters like monitoring of holidays,absences,health and safety,disciplinary action,and dismissal. Another important element of HRM in managing people is keeping the employees in the company.The training of employees to enable them to improve their career development is very important.Good HRM policies ensure that there are clear regulations which show the pay levels for the different positions in an organization.It is important for the staff to know the career path,pay,training and other opportunities that are available to them.Performance management is another important component of HRM. The reason for this is that many employers use it to evaluate career improvement and to determine pay increases.The secondary role of HRM is the management of the relationships among people in an organization.This includes staff within departments as well as across the whole organization.The relationship between staff and management is animportant factor in the success of an organization.It decides how fast an organization will realize their goals.The focus of HRM is the people within an organization.Regular planning,monitoring and evaluation are important for the success of HRM.Successful management ensures that all employees know their role,career development and also feel part of an organization.操作提示:通过题干后的下拉框选择题目的正确答案。
Time management is a crucial skill in our fastpaced world.It is the art of organizing and planning how to devote your time to effectively accomplish your personal or workrelated tasks.Here are some key points to consider when crafting an English essay on the new chapter of time management:1.Importance of Time Management:Begin by discussing why time management is essential.It can lead to increased productivity,reduced stress,and a better worklife balance.2.Understanding Time Wasters:Identify common time wasters such as procrastination, constant interruptions,and multitasking.Discuss how these can be detrimental to ones productivity.3.Setting Goals:Explain the importance of setting clear,achievable goals.Goals provide direction and help in prioritizing tasks effectively.4.Prioritization:Discuss how prioritizing tasks can help in managing time better.This includes understanding the difference between urgent and important tasks.5.Planning and Scheduling:Elaborate on the benefits of creating a daily or weekly schedule.This can include using calendars,todo lists,and timeblocking techniques.6.Technological Tools:Mention the role of technology in time management,such as apps and software designed to help with organizing tasks and reminders.7.Breaking Down Tasks:Discuss the strategy of breaking down large tasks into smaller, manageable parts.This can make complex projects seem less daunting and more achievable.8.Avoiding Procrastination:Offer tips on how to overcome procrastination,such as setting deadlines,rewarding oneself for completing tasks,and understanding the root causes of procrastination.9.Learning to Say No:Emphasize the importance of setting boundaries and learning to say no to nonessential tasks that can distract from more important goals.10.Flexibility and Adaptability:Discuss the importance of being flexible and adaptable in time management.Unforeseen circumstances may require adjustments to schedules and plans.11.SelfReflection and Continuous Improvement:Encourage the practice of selfreflection to identify time management strengths and weaknesses.Continuous improvement is key to mastering time management.12.Conclusion:Conclude by summarizing the importance of effective time management and how it can lead to a more successful and fulfilling life.Remember to provide examples and perhaps personal anecdotes to illustrate your points. This will make your essay more engaging and relatable to the reader.。
Money management is a crucial skill in todays world,where financial literacy can significantly impact ones quality of life.Here are some key points to consider when writing an essay on money management:1.Importance of Money Management:Start by emphasizing the importance of managing money effectively.It helps individuals to meet their needs,plan for the future,and achieve financial stability.2.Budgeting:Discuss the concept of budgeting as a fundamental aspect of money management.Explain how creating a budget involves listing all sources of income and expenses,and then allocating funds to different categories such as housing,food,utilities, savings,and entertainment.3.Savings:Highlight the importance of saving money.Saving is not just about putting money aside for emergencies its also about building financial security and creating a fund for future investments or large purchases.4.Debt Management:Address the issue of debt and how to manage it wisely.This includes understanding the difference between good debt e.g.,student loans,mortgages and bad debt e.g.,credit card debt,and strategies for reducing and repaying debt.5.Investing:Talk about the role of investing in longterm money management.Explain how investing can help grow wealth over time and provide for retirement.Include different types of investments such as stocks,bonds,mutual funds,and real estate.6.Financial Goals:Discuss the importance of setting financial goals.Whether its buyinga home,starting a business,or planning for retirement,having clear goals can guide money management decisions.7.Emergency Funds:Stress the necessity of having an emergency fund.This is a separate savings account that covers unexpected expenses,such as medical bills or car repairs, without resorting to debt.8.Financial Education:Emphasize the role of continuous learning in money management. Staying informed about personal finance,taxes,and investment opportunities can help individuals make better financial decisions.9.Avoiding Impulsive Spending:Discuss the pitfalls of impulsive spending and the benefits of mindful consumption.This includes recognizing the difference between needs and wants and practicing delayed gratification.10.Technology and Money Management:Mention how technology can aid in money management through apps and software that track expenses,create budgets,and offer financial advice.11.The Role of Credit:Explain the importance of understanding credit scores and how they affect borrowing costs.Discuss responsible credit use and the impact of timely payments on ones financial health.12.Retirement Planning:Discuss the importance of starting to plan for retirement early. Include the benefits of compound interest and the role of pension plans,401ks,and IRAs in retirement savings.13.Estate Planning:Briefly touch on the topic of estate planning,including wills and trusts,to ensure that ones assets are distributed according to their wishes after their death.14.Conclusion:Conclude by summarizing the key points and reiterating the importance of effective money management for achieving financial independence and security. Remember to use clear,concise language and provide examples to illustrate your points. An essay on money management should be informative,engaging,and practical,offering readers actionable advice they can apply to their own financial lives.。
综合管理试题及答案英语一、选择题(每题2分,共20分)1. The correct spelling of the word "management" is:A) manegmentB) manegmentC) managemnetD) management答案:D2. Which of the following is not a function of management?A) PlanningB) OrganizingC) LeadingD) Innovating答案:D3. The process of setting goals and deciding on actions to achieve these goals is known as:A) OrganizingB) LeadingC) ControllingD) Planning答案:D4. Who is considered the father of scientific management?A) Henry FordB) Frederick Winslow TaylorC) Peter DruckerD) Max Weber答案:B5. What is the term used to describe the process of making things happen in an organization?A) MotivationB) CoordinationC) ExecutionD) Delegation答案:C6. In management, "span of control" refers to:A) The number of employees a manager can effectively manageB) The number of products a company producesC) The number of departments in an organizationD) The number of years a manager has been in their position答案:A7. Which of the following is a characteristic of an effective team?A) Clear communicationB) Lack of trustC) Poor leadershipD) Conflict avoidance答案:A8. What is the process of making decisions in an organization?A) PlanningB) OrganizingC) LeadingD) Decision-making答案:D9. The management concept that emphasizes the importance of employee satisfaction and motivation is known as:A) Scientific managementB) Administrative managementC) Human relations movementD) Systems theory答案:C10. In the context of management, "feedback" is:A) Information about the results of a decision or actionB) The process of setting goalsC) The process of organizing resourcesD) The process of motivating employees答案:A二、填空题(每题2分,共20分)1. The four main functions of management are planning, organizing, leading, and ________.答案:controlling2. The management theory that focuses on the importance ofthe social and psychological aspects of work is known as the________ theory.答案:human relations3. A management style that involves providing employees with the freedom to make decisions is known as ________ leadership. 答案:autonomous4. The process of ensuring that activities are carried out as planned is called ________.答案:monitoring5. The management principle that states that managers should focus on the most important tasks is known as the ________ principle.答案:80/206. A management technique that involves breaking down a large task into smaller, more manageable parts is known as ________. 答案:task analysis7. The process of identifying the causes of a problem and determining the best course of action to solve it is called________.答案:problem-solving8. The management concept that suggests that organizations should be structured in a way that reflects their goals and objectives is known as ________.答案:organizational design9. The process of measuring the performance of anorganization against its goals is called ________.答案:performance evaluation10. The management theory that suggests that organizations should be viewed as a whole, with each part interacting with the others, is known as ________ theory.答案:systems三、简答题(每题10分,共40分)1. Explain the difference between leadership and management.答案:Leadership is about inspiring and motivating a team to achieve a common goal, while management involves planning, organizing, and coordinating the efforts of a team to accomplish tasks efficiently.2. What is the significance of delegation in management?答案:Delegation is significant in management as it empowers employees, improves productivity, and allows managers tofocus on strategic tasks. It also helps in developing theskills of subordinates and fostering a sense ofresponsibility.3. Describe the role of communication in effective management. 答案:Effective communication is crucial in management as it ensures that information is accurately and timely conveyed, facilitates collaboration among team members, and helps in resolving conflicts. It also aids in setting clearexpectations and feedback mechanisms.4. How can a manager ensure ethical behavior in an organization?答案:A manager can ensure ethical behavior by setting a good example, establishing clear ethical guidelines, providing training on ethical practices, encouraging open communication, and implementing a system for reporting unethical behavior without fear of retaliation.。
Quality management systems are essential for organizations to ensure they consistently meet customer and regulatory requirements.Training in quality system processes is crucial for employees to understand and implement these systems effectively. Here is an essay on the importance of quality system process training.Title:The Significance of Quality System Process TrainingIn the contemporary business landscape,the implementation of a robust quality management system QMS is indispensable for organizations aiming to excel in their respective industries.The ISO9001standard,for instance,provides a framework for establishing,implementing,maintaining,and continually improving a QMS.However, the true effectiveness of such a system hinges on the employees understanding and adherence to its processes.This essay will delve into the significance of training in quality system processes and how it contributes to organizational success. Understanding the Quality SystemThe first step in quality system process training is to ensure that employees have a comprehensive understanding of what a quality system entails.This includes the principles of quality management,the organizations quality policy,and the specific processes and procedures that are in place to meet quality objectives.Training should cover the following aspects:The importance of customer satisfaction and how the QMS is designed to meet and exceed customer expectations.The role of top management in creating and maintaining a qualityfocused culture.The significance of continuous improvement and its integration into daily operations. RoleSpecific TrainingEmployees must be trained according to their specific roles within the organization.For example,while a production manager may need to understand the entire scope of the QMS,an assembly line worker might only require training on the processes directly related to their tasks.Tailoring training to the needs of each role ensures that everyone is equipped with the knowledge necessary to contribute effectively to the QMS. Compliance and Regulatory RequirementsTraining should also focus on compliance with industryspecific regulations and standards. Employees must be aware of the legal and regulatory requirements that impact their workand understand how the QMS helps the organization meet these obligations.This includes training on:Relevant laws and regulations that apply to the industry.The role of documentation in demonstrating compliance.The process for identifying and addressing nonconformities.Risk ManagementA critical component of quality system process training is the ability to identify and manage risks.Employees should be trained to recognize potential risks in their work processes and understand the steps to mitigate these risks.This includes:The process for risk identification,assessment,and control.The importance of proactive risk management in preventing quality issues.The role of risk management in the overall QMS.Continuous ImprovementTraining should instill a culture of continuous improvement within the organization. Employees should be encouraged to seek out opportunities for process optimization and efficiency gains.Training in this area might include:Techniques for process mapping and analysis.Methods for identifying areas for improvement.The process for implementing and validating changes to the QMS.ConclusionIn conclusion,quality system process training is a vital investment for any organization seeking to maintain a competitive edge through highquality products and services.By providing employees with the knowledge and skills to effectively implement and improve the QMS,organizations can ensure that they are wellpositioned to meet customer expectations,comply with regulations,and achieve sustainable success in the marketplace.。
关于营养师的英语作文Title: The Crucial Role of Nutritionists in Modern HealthcareIn the ever-evolving field of healthcare, nutritionists occupy a pivotal position, bridging the gap between medical science and dietary practices. Their expertise lies in understanding the intricate relationship between food and the human body, and how dietary choices can either promote or hinder optimal health. This essay delves into the significance of nutritionists, their responsibilities, and the impact they have on individuals and communities.Firstly, it is crucial to appreciate the scope of nutritionists' work. Their role is not merely about advising on what to eat and what to avoid. Instead, they delve into the nuances of individual dietary requirements, taking into account factors such as age, gender, lifestyle, medical history, and even cultural preferences. This holistic approach ensures that nutritional advice is tailored to each individual, promoting personalized healthcare.Moreover, nutritionists are at the forefront of educating the public about the importance of a balanced diet. In an era where processed foods and unhealthy snacks are abundant, it is increasingly difficult to make informed dietary choices. Nutritionists, through their workshops, seminars, and online platforms, disseminate knowledge about the nutritional value of various foods, the role of micronutrients in maintaining health, and the harmful effects of unhealthy eating habits.In addition to their educational role, nutritionists also play a crucial part in the management of chronic diseases. Diabetes, hypertension, and cardiovascular diseases are often linked to unhealthy dietary habits. Nutritionists work closely with patients and their healthcare providers, devising meal plans that not only control the symptoms of these diseases but also improve the overall quality of life. They monitor the progress of their patients, making necessary adjustments to the diet plan as the patient's condition improves or deteriorates.Furthermore, nutritionists are actively involved in research, contributing to the advancement of nutritionalscience. They collaborate with researchers, studying the effects of various dietary interventions on human health. This research helps to refine nutritional recommendations, making them more effective and relevant to modern-day lifestyles.The impact of nutritionists is not confined to individuals but extends to entire communities. In developing countries, malnutrition is a major health concern, affecting millions of people. Nutritionists, through their community-based programs, work tirelessly to address this issue. They provide nutritional education to local communities, distribute fortified foods, and monitor the nutritional status of vulnerable groups such as children and pregnant women.Moreover, in the wake of the COVID-19 pandemic, the role of nutritionists has become even more pronounced. The pandemic has underscored the importance of maintaining a strong immune system, which is largely dependent on a healthy diet. Nutritionists have been instrumental in providing dietary advice to help individuals strengthentheir immune systems and reduce the risk of contracting the virus.In conclusion, nutritionists are invaluable members of the healthcare team, playing a pivotal role in promoting optimal health and preventing chronic diseases. Their expertise in understanding the intricacies of nutrition and their commitment to personalized healthcare make them invaluable resources for individuals seeking to improve their dietary habits. As the field of nutrition science continues to evolve, the role of nutritionists will become even more critical in ensuring the health and well-being of individuals and communities.。
The terminology of quality management Quality certificationIt is a quality certification is an externally provided acknowledgement(by accredited certification bodies) that the quality management system is adequate in its provision and operation.The ISO 9000:2000 and 2008 series of standards Types of primary standardsa.ISO 9001:2000 and 2008. They contain the current quality managementsystem requirements of ISO. They are used for certificationpurposes.b.ISO 9000:2005 and ISO 9004:2009. They contain the quality managementguidelines of ISO. ISO 9000:2005 presents definitions while ISO9004:2009 is a set of guidelines for improving performance.c.ISO 19011:It covers quality auditing standards.d.ISO 14001:It relates to environmental management systems.The ISO 9000:2000 and 2008 series of standards ISO certified/registered or ISO complianta.ISO certified or registered means that an independentregistrar has audited an company’s processes and certifiedthat the ISO requirements are met. A written assurance isgiven to the company.b.ISO compliant means a company has met ISO’s qualitysystem requirements but has not been formally certified by anindependent registrar.*The ISO 9000 standards are process standards rather thanproduct standards.The ISO 9000:2000 and 2008 series of standards Criticisms of quality accreditationa.It is time consuming to produce documentsb.Rigid policies and procedures discourageinnovationc.The schemes encourage bureaucracyd.The formal methods may not be consistent withways of working in small and medium-sizedorganisations.Modern Japanese business practices and techniques Total quality management (TQM)a.DefinitionTQM is the process of applying a zero defects philosophyto the management of all resources and relationshipswithin the organisation as a means of developing andsustaining a culture of continuous improvement whichfocuses on meeting customers’ expectations.TQM means getting things right first time andcontinuous improvement.Modern Japanese business practices and techniquesTotal quality management (TQM)b.CharacteristicsI.The only thing that matters is the customerII.The all-pervasive nature of the customer-supplierrelationship including internal customerIII.The cause of defect should be prevented in the first place.IV.Employees have to be personally responsible for detect-free production or service in their domainV.Any level of defects must be unacceptableVI.Getting things right first time obsessivelyVII.Introduction of quality certification programmesVIII.The cost f poor quality should be emphasizedModern Japanese business practices and techniques Just-in-time (JIT) systema.DefinitionsI.JIT is a system whose objective is to produce products asthey are required by a customer rather than for inventory.II.JIT production is a system which is driven by demand for finished goods whereby each component on a productionline is produced only when needed for the next stage.III.JIT purchase is a system in which material purchases arecontracted so that the receipt and usage of material, to themaximum extent possible, coincide.。
Chapter One: Managers and ManagementMultiple Choice Questions1. When we classify managers according by their level in the organization they are described as _______.a. functional, staff and line managersb. top managers, middle managers and supervisorsc. high level and lower level managersd. general managers and administrative managers2. Conceptual skills relate to a manager’s ability toa. take a strategic view of how the parts of the organization function.b. solve detailed problems in groups.c. correctly evaluate organizational problems.d. understand and interact effectively with others in the organization.3. The ability to build networks and power bases that increase one’s power in the organization is referred to as _____.a. influence skillb. political skillc. controllingd. strategic skill4. A manager is someone whoa. actually performs the service or produces the product.b. works anonymously behind the scenes.c. sets the goals of the organization.d. supervises the work of others.5. Which of the following skills is most important for top managers (CEO’s)?a. Interpersonalb. Technicalc. Functionald. Conceptual6. A manager who has a reputation for being open and honest and understands how to motivate employees and customers is said to have good ________ skills.a. salesb. politicalc. Interpersonald. technical7. Annie’s Pies produces cakes and pies that come in 207 different flavors that are shipped across theUSA. Each week, 3 or 4 new flavors are added. Annie’s produces high quality cakes and pies using the best ingredients, it wastes little, and few employees work overtime because the business operatesa. effectively.b. reliably.c. efficiently.d. flexibly.8. Doing a job in a way that achieves results without wasting any resources is referred to as being ______.a. effective.b. efficientc. conservatived. Both a and b.9. The importance of managerial roles varies depending on the _____.a. manager’s salaryb. manager’s acceptance by the employeesc. size of the organizationd. length of time the manager has worked in the organization10. According to Mintzberg, which management category includes the roles of figurehead, leader, andliaison?a. interpersonalb. informationalc. decisionald. planning11. Which of the following roles is categorized as a decisional role?a. Monitorb. Disseminatorc. Resource allocatord. Leader12. An organization must contain all except which of the following characteristics?a. purposeb. peoplec. structured. product13. An organization is commonly considered aa. systematic arrangement of people to sell goods or services.b. structural grouping of people to accomplish a set of objectives.c. structural grouping of managers and subordinates who are attempting to increase profits.d. systematic grouping of people to establish procedures, rules, and regulations.14. Operatives can BEST be described asa. Those who actually do the tasks of an organization.b. Those who work anonymously behind the scenes.c. Manual laborers.d. Those who supervise others.15. The managers who work most closely with the operatives are known asa. top management.b. middle management.c. first-line managers.d. operative managers.16. The level of management that translates the goals of the organization into specific plans that lower-level managers can perform is known asa. top management.b. middle management.c. first-line managers.d. operative managers.17. _____ are responsible for making decisions about the direction of the organization and establishingpolicies that affect all organizational members.a. Operativesb. Top managersc. Middle managersd. First-line supervisors18. Performing the task right and considering the relationship between inputs and outputs isa. effectiveness.b. goal attainment.c. efficiency.d. a management characteristic.19. If you get more output for a given input, you havea. decreased effectiveness.b. increased effectiveness.c. decreased efficiency.d. increased efficiency.20. In an organization, _____ translate(s) into goal attainment.a. effectivenessb. efficiencyc. resource minimizationd. managerial functions21. If a college cuts the cost of an education by using mostly part-time faculty and at the same time failsto adequately educate its students, it can be said to be doing the wrong things well. In other words, the college isa. efficient and effective.b. efficient but not effective.c. effective but not efficient.d. neither efficient nor effective.22. Tim's Tire Shop is concerned only with using the least amount of labor possible as it repairs/replaces the tires of its customers. Its primary goal isa. effectiveness.b. goal attainment.c. efficiency.d. management characteristics.23. All of the following are included in the four components of the management process excepta. planning.b. organizing.c. leading.d. delegating.24. Mintzberg grouped the ten managerial roles into three primary headings. Which of the following isnot one of these headings?a. interpersonal relationshipsb. transfer of informationc. planningd. decision making25. As managers move up the organization, they do lessa. leadingb. controllingc. planningd. organizing26. Which of the following roles is most important for managers in small firms?a. disseminatorb. leaderc. spokespersond. figurehead27. Katz developed four critical skills that managers must possess. Which of the following is not one ofthose four skills?a. conceptualb. interpersonalc. technicald. connection28. Angelo is well known for his skills in using the advanced programming software of the engineeringfield. In fact, it was his specialized knowledge that led to his promotion as manager. Which managerial skill is Angelo demonstrating?a. conceptualb. interpersonalc. technicald. political29. Nancy’s strength as a manager lies in her ability to work with people. She is able to work with,motivate, and lead others easily. Nancy is demonstrating which managerial skill?a. conceptualb. interpersonalc. technicald. political30. Which of the following is not true about operatives?a. They have no responsibility for overseeing the work of others.b. They work directly on a job or task.c. They have no more than four employees who report directly to them.d. A person on an assembly line could be described as an operative.31. The managerial concept that focuses on task completion isa. efficiency.b. of little concern for first-line managers.c. mostly the job of top managers.d. effectiveness.32. Which one of the following best demonstrates the concept of efficient management?a. Getting activities completed.b. Maximizing output.c. Maintaining output with fewer resources.d. Increasing output and input.33. When a manager fails to complete the department's tasks but has used the resources sparingly andwisely, the results are said to bea. efficient and effective.b. efficient and ineffective.c. inefficient and effective.d. inefficient and ineffective.34. The planning function of management includesa. directing the activities of others.b. monitoring an organization's performance.c. comparing actual results with plans.d. establishing an organization's goals.35. The organizing function of management includesa. how tasks are to be grouped.b. conflict resolution among subordinates.c. comparison of actual results with a budget.d. definition of an organization's goals.36. The activities of motivating employees, directing others, selecting the most effective communicationchannels, and resolving conflicts refer to which management function?a. planning.b. organizing.c. leading.d. controlling.37. When a famous speaker, Such as the President of the United States, addresses a college graduatingclass, he or she is exhibiting Mintzberg's role ofa. liaison.b. disturbance handler.c. disseminator.d. figurehead.38. Concerning Mintzberg's managerial roles, which of the following statements is MOST accurate?a. Managers perform essentially different roles in different types of organizations.b. Managers perform essentially different roles at different levels of an organization.c. The emphasis managers give the various roles differs with various organizational levels.d. Roles of figurehead, disseminator, and liaison seem to be most appropriate for first-line managers.39. Which of the following statements is LEAST correct?a. Regardless of the organizational level, managers perform essentially the same functions.b. Most managerial functions are the same throughout the world.c. Small or large organizations perform essentially the same functions.d. The entrepreneurial role is more prevalent in small organizations than in large ones.40. Management is BEST described as the process ofa. personally completing tasks in an efficient manner.b. efficiently completing tasks with the help of others.c. using scarce resources to minimize output.d. organizing activities over a long period of time.Chapter Three: Foundations of PlanningMultiple Choice Questions1. Which of the following is not included in the definition of planning?a. Define the organization’s objectives or goals.b. Establish an overall strategy for achieving these objectives or goals.c. Allocate resources and develop a chain of communication.d. Develop a hierarchy of plans to integrate and coordinate activities.2. Which of the following is an argument against formal planning?a. Planning focuses on the future.b. Planning may create rigidity.c. Planning replaces creativity.d. Planning ignores prior successes.3. Which of following is not one of the reasons why managers should engage in planning as that wasstated in the text?a. Planning reduces cost.b. Planning minimizes waste and redundancy.c. Planning provides direction.d. Planning facilitates control.4. Plans that determine specific details about organizational objectives that are to be achieved arecalleda. strategic plans.c. long-term plans.d. detailed plans.5. Successful plans may providea. a false sense of security.b. only success.c. increased awareness of the environment.d. increased awareness of change.6. Which of the following statements is MOST accurate?a. Many studies confirm the positive relationship between planning and performance.b. All organizations that plan extensively outperform those that plan less formally.c. All organizations that plan outperform those that do not.d. Many studies confirm that planning does not lead to greater performance because labor unionsare weak.7. _____ plans are differentiated by their breadth.a. Directional and specificb. Single use and standingc. Strategic and tacticald. Long-term and short-term8. Which of the following is not a popular way to describe plans?a. breadthb. time framec. specificityd. length9. Tactical and strategic plans differ in all of the following ways excepta. time frame.b. scope.c. known set of organizational objectives.d. environmental effects.10. The greater the uncertainty, the more plans should be of the _____ variety.a. long-termb. short-termc. intermediate in lengthd. rigid11. When uncertainty is high and management must maintain flexibility, which of the following types ofplans are preferable?a. long-term plansb. no plansc. directional plansd. specific plans12. Which type of plan is used to meet a particular or unique situation?b. operational planc. single-use pland. standing plan13. Which of the following is not a step in objective setting?a. Specify deadlines.b. Allow the employee to actively participate.c. Link rewards to effort.d. Prioritize goals.14. Each MBO objective must havea. a percentage change specified.b. a concise time period.c. a reference to quality.d. a specified dollar amount.15. MBO advocates participative goal setting. Research comparing participative set and assigned goalson performancea. shows consistently higher performance with participatively set goals.b. shows consistently lower performance with participatively set goals.c. has not shown any strong or consistent relationships.d. has been biased by the researchers.16. Which of the following is not an ingredient in MBO programs?a. goal specificityb. participative decision makingc. performance feedbackd. general time period17. According to the philosophy of MBO,a. Feedback occurs at the annual performance reviewb. Goals follow a top-down approachc. Goals typically are broad, general statements of intentd. Constant feedback is provided18. MBO assists in answering "What's in it for me as an employee" bya. Linking rewards to goal attainmentb. Identifying employees' key job tasksc. Allowing employees to participate activelyd. Prioritizing goals19. Managers can overcome the criticisms of management by objectives bya. ensuring that employees have multiple goals.b. treating MBO as a single-event activity.c. punishing employees who fail to achieve goals.d. rewarding employees for setting easy goals.20. Which of the following is not a component of the MBO process?a. Objectives are determined jointly by subordinates and supervisorb. Progress towards objectives is reviewed every three months.c. Employees are given ratings based on reaching specific targetsd. Rewards are based on progress towards achieving objectives.21. Which of the following is a nine-step process that involves strategic planning, implementation, andevaluation?a. decision-making processb. strategic management processc. tactical management processd. long-range planning process22. In environmental SWOT analysis, the external organizational position is analyzed according to itsa. strengths and weaknesses.b. opportunities and weaknesses.c. strengths and threats.d. opportunities and threats.23. The starting point in strategic management process is usuallya. analyzing current mission, strategies and objectives.b. identifying opportunities and threats.c. conducting an environmental scan.d. identifying opportunities and weaknesses.24. After analyzing and learning about the environment, management needs to evaluate opportunitiesand threats. Opportunities area. internal resources.b. unmet needs.c. positive external environmental factors.d. internal competitive strategies.25. Which of the following is NOT a grand strategy that an organization can use for defining its all-encompassing focus?a. Stability strategyb. Market gain strategyc. Growth strategyd. Combination strategy26. Tim's Company is analyzing the technology that allows it to produce wireless communication equipment for less money. This technological breakthrough for Tim's Company is which of the following?a. strengthb. weaknessc. opportunityd. threat27. SWOT analysisa. Matches the organization's competencies with its environmental forcesb. Sometimes involves industrial espionage tacticsc. Occurs during the mission statement formulationd. Is most useful for helping an organization sustain its competitive28. The type of organizational strategy that emphasized increasing market share or the level of anorganization's operations is calleda. Stability Strategyb. Combination strategyc. Market gain strategyd. None of the above29. When Northwest Airlines began serving its own in-flight meals, which of the following strategies wasit pursuing?a. growthb. stabilityc. retrenchmentd. combination30. Larry's Company is in the process of buying a smaller competitor and incorporating that company'sresources into his business. This is an example of which of the following types of strategies?a. mergerb. stabilityc. retrenchmentd. acquisition31. Strategy formulation involves__________.a. developing and evaluating a set of alternative strategiesb. evaluating a set of alternative strategies and selecting the best for each levelc. selecting a strategy that will increase the level of operationsd. completing a SWOT analysis32. Susan's Ceramics is expanding the size of its unfinished products while decreasing the amount offiring and finishing of products it does. This is known as which of the following strategies?a. growthb. stabilityc. retrenchmentd. combination33. A company states that its product is reliable, even to the extent of never needing a service call, suchas Maytag, is practicing which of the following competitive strategies?a. cost-leadership strategyb. differentiation strategyc. focus strategyd. retrenchment strategy34. Lila's Luscious Lips produces a cherry flavored lipstick and is targeting the "teen" girl who is between 12 and 14 years old. The strategy pursued isa. cost leadership.b differentiation.c. focus.d. segmentation.35. The premise behind _____ is to design in quality as the product is being made.a. six sigmab. TQMc. reengineeringd. benchmarking36. A large discount store, like Wal-Mart, whose primary goal is to have the lowest prices in the industry,is using which of the following strategies to maintain a competitive advantage?a. cost-leadership strategyb. differentiation strategyc. focus strategyd. retrenchment strategy37. According to Michael Porter, the goal of the focus strategy is toa. exploit a narrow segment of the market.b. seek competitive advantages in large market segments.c. use technological innovation to target customers more accurately.d. bring suppliers and distributors together and combine efforts.38. Who determines employee goals in MBO?a. employeesb. managersc. managers and employeesd. managers and the CEO39. The basic idea in _____ is that management can improve quality by analyzing and copying the methods of the leaders in the field.a. reengineeringb. benchmarkingc. TQMd. six sigma40. Which of the following is not a competitive strategy that a business may use in order to gaina distinctadvantage, according to Michael Portera. retrenchmentb. cost-leadershipc. focusd. differentiationChapter Four: Foundations of Decision MakingMultiple Choice Questions1. __________ is not one of the eight steps in the decision making process.a. Identifying the problemb. Analyzing alternative solutionsc. Implementing the decisiond. Delegating the decision making2. Which of the following sequences is correct for the decision-making Process?a. Identify decision criteria, analyze alternatives, allocate weights to criteriab. Analyze alternatives, select an alternative, implement the alternativec. Select an alternative, evaluate decision effectiveness, weight the criteriad. Analyze alternatives, develop alternatives, allocate weights to criteria3. Once a problem is formulated, the next step is toa. Select an alternativeb. List all possible Solutionsc. Observe a discrepancyd. Decide what is critical in the decision4. When a manager who is contemplating all the features a new purchase should have prioritizes themost important, he or she is practicinga. selection of criteriab. problem formulationc. weighting of criteriad. analyzing alternatives5. After implementation has been accomplisheda. The decision-making process is completeb. The control function of management become importantc. The alternatives are rankedd. The manager must complete written evaluation forms6. When a plant manager who is trying to reduce turnover of production workers notices that turnoverhas decreased by 10 percent four months after he instituted a new training program, at which step in the rational decision-making process is this manager?a. Identify the problem.b. Evaluate the decision criteria.c. Analyze the alternatives.d. Evaluate the results.7. According to the concept of bounded rationality, decision makers are limited by _______.a. less than complete informationb. environmentc. timed. All of the above.8. __________ is selecting the first minimally acceptable alternative.a. Bounded rationalityb. Unbounded rationalityc. Satisficingd. Rational decision-making9. Suppose that you need a math elective to take in order to graduate. There are five different courses you could take. You call one friend and, on the basis of her terrific experience in onecourse, you choose that one. What would Herbert Simon call what you have just done?a. Bounded rationalityb. Unbounded rationalityc. Escalation of commitmentd. Rational decision-making10. ______________ occurs when a manager purchases stock in a company and refuses to sell it evenafter it has dropped 40 percent in value over the past 6 months.a. Optimizingb. Satisficingc. Bounded Rationalityd. Escalation of Commitment11. ____________ is one of the disadvantages of group decisions that typically results in groups thatare very cohesive.a. Conflictb. Groupthinkc. Dominationd. Compromise12. Which of the following is an advantage of group decision-making when compared to individualdecision-making?a. The group process takes less time.b. Groupthink may occur.c. More decision alternatives are generated.d. One person can dominate the group.13. Bounded rationality refers to the idea thata. Managers are bound by ethical considerations to be rationalb. Managers will promote rationalization as an aid to decision makingc. Managers employ model construction to simplify decision makingd. Managers are to behave according to rational guidelines within the bounds of their authority inthe workplace14. The tendency for decision makers to base their judgments on information that is readily accessibleto them is best described asa. Escalation of commitmentb. Representative heuristicc. Bounded rationalityd. None of the above15. “Decision making under risk” means ____________.a. the decision has no data on which to base his or her decisionb. the decision maker is used to dealing with high-risk situationsc. the decision maker knows all of the risks involved in the situationd. the decision maker can estimate the risk involved in making a decision16. How do managers know when they have a disparity or discrepancy in the decision-making process?The best way is to compare their current state and some standard. Which of the following would not be a relevant standard?a. previously set goalsb. past performancec. the performance of some unit in or out of the organizationd. use future projections17. Putting a decision into action and conveying the decision to the persons who will be affected by it isknown asa. problem identification.b. decision implementation.c. rational decision making.d. irrational decision making.18. When decisions must be made with limited information because full knowledge of the problem isunavailable and the probability of outcomes is unknown, the condition of __________ exists.a. uncertaintyb. certaintyc. riskd. bounded rationality19. Which of the following is not an assumption of the rational decision-making model?a. The problem is clear and unambiguous.b. A single well-defined goal is to be achieved.c. Preferences change slowly.d. Final choice will maximize economic payoff.20. Creativity is formed when the elements of creative skills, expertise, and _____ intersect.a. personalityb. experiencec. task motivationd. None of the above.21. In the decision-making process known as bounded rationality,a. the final choice maximizes economic payoff.b. the final choice minimizes economic payoff.c. the first choice that is "good enough" is chosen.d. all "good enough" choices are selected.22. Jane just conducted the performance appraisals of five of her employees. Her appraisal was heavilyinfluenced by the performance of the individuals during the last month. Jane's bias is an example ofa. availability heuristic.b. representative heuristic.c. escalation of commitment.d. optimal decision making.23. The decision-making process concludes witha. analysis of alternatives.b. identification of a problem.c. identification of decision criteria.d. evaluation of decision effectiveness.24. Problems where information is ambiguous or incomplete are which type of problem?a. well-structuredb. ill-structuredc. programmedd. nonprogrammed25. Well-structured problems area. Newb. Closely aligned with the assumptions of perfect rationalityc. Ambiguousd. Characterized by limited information26. When a decision maker relies on a programmed decision, he or Shea. may fall back on rules, procedures, or policiesb. will develop many alternatives from which to select a solutionc. will spend considerable time on the decisiond. must be dealing with a unique or unusual problem27. A procedure can be defined as aa. method to guide a manager's thinking in one general direction.b. hierarchy of authority relationships in an organization.c. series of interrelated sequential steps for problem solving.d. collection of explicit statements about what a manager can or cannot do.28. A rule is BEST described by which of the following?a. A general guideline designed to direct a manager's focus.b. A series of interrelated sequential steps.c. A prohibition against desired activity.d. An explicit and specific statement of correct behavior.29. A policy typically containsa. parameters to constrain behavior, not specific rules.b. nothing but explicit, unambiguous terminology.c. a sequence of steps to follow for approved decision making.d. specific rules.30. "Whenever possible, we promote from within" is an example of which of the following?a. ruleb. procedurec. policyd. nonprogrammed decision31. "Only employees with top-secret clearance may enter the sealed room," is an example of aa. rule.b. procedure.c. policy.d. nonprogrammed decision.32. As managers move up the organizational hierarchy, problems are more likely to becomea. well-structured.b. ill-structured.c. programmed.d. nonprogrammed.33. A conceptual style of decision-making reflects an individual whoa. thinks intuitively and has a low tolerance for ambiguity.b. thinks rationally and has a high tolerance for ambiguity.c. thinks intuitively and has a high tolerance for ambiguity.d. thinks rationally and has a low tolerance for ambiguity.34. Peggy Juarez uses a decision-making style characterized by low tolerance for ambiguity and a rational way of thinking. They generally turn out to be fast decisions of a short run nature. What style does Peggy use?a. analyticb. conceptualc. directived. behavioral35. Which of the following is not true about group decisions?a. Group decisions are faster.b. Group decisions tend to be more accurate.c. Group decisions are more creative.d. Group decisions are more widely accepted.36. Group decisions will usually be Superior to individual decisions whena. speed is a concern.b. accuracy is critical.c. minimizing the tendency of groupthink is importantd. flexibility is needed.37. Which of the following is NOT an example of a situation in which groupthink occurs?a. Group members rationalize any resistance to the assumptions they have made.b. Group members apply direct pressure on those who express doubts.c. Group members avoid openly showing lack of consensus.d. Group members question those who are silent and try to sway them.38. Bounded rationality differs from the rational model in that decision makers:a. act irrationally.b. focus on easy-to-find choices.c. seek advice from employees.d. act outside the boundaries set by their organizations.。
新职业英语课后参考答案Unit 1: Introduction to the Workplace1. Vocabulary- Ambitious: Having a strong desire and determination to succeed.- Collaborate: To work jointly on an activity in order to achieve or do something.- Deadline: A time or date by which something should be completed.2. Grammar- Present Simple Tense: Used to describe habits, general truths, and routines.Example: She always arrives at work early.3. Reading Comprehension- Main Idea: The article discusses the importance of punctuality and professionalism in the workplace.- Supporting Details: The article mentions that being on time for meetings and deadlines is crucial for building trust and a good reputation.4. Listening Comprehension- Key Points: The speaker talks about the benefits of teamwork and how it can lead to innovative solutions.5. Speaking Activity- Role Play Scenario: You are a new employee and need to introduce yourself to your colleagues.6. Writing Task- Write a short paragraph about why communication skills are essential in a professional environment.Unit 2: Effective Communication1. Vocabulary- Assertive: Expressing feelings, beliefs, or attitudes in a way that is open, honest, and respectful of other people's rights.- Convey: To express something in speech or writing.2. Grammar- Modal Verbs: Used to express ability, permission, obligation, or advice.Example: You should always double-check your work before submitting it.3. Reading Comprehension- Main Idea: The text explains the different types of communication styles and their impact on the workplace.- Supporting Details: The text describes how active listening and clear expression of ideas can improve team dynamics.4. Listening Comprehension- Key Points: The dialogue between two colleagues highlights the importance of clear communication to avoidmisunderstandings.5. Speaking Activity- Group Discussion: Discuss the role of feedback in the workplace and how it can be given constructively.6. Writing Task- Write an email to a colleague, providing constructive feedback on a recent project.Unit 3: Time Management1. Vocabulary- Prioritize: To decide the order in which tasks should be done, based on their importance.- Procrastinate: To delay or postpone action.2. Grammar- Future Simple Tense: Used to talk about future actions or events.Example: We will meet at the conference room at 10 a.m. tomorrow.3. Reading Comprehension- Main Idea: The article provides tips on how to manage time effectively in a busy work environment.- Supporting Details: The article suggests using to-do lists and setting realistic goals to improve time management.4. Listening Comprehension- Key Points: The speaker shares personal strategies forstaying organized and meeting deadlines.5. Speaking Activity- Interactive Discussion: Share your own time management techniques with the class.6. Writing Task- Create a weekly schedule for a hypothetical work week, including meetings, deadlines, and personal time.Unit 4: Professional Development1. Vocabulary- Networking: Building and maintaining relationships with others in the same industry or area of interest.- Seminar: A meeting or class for the discussion of a particular topic.2. Grammar- Present Perfect Tense: Used to describe actions that have occurred at an unspecified time before now or actions that began in the past and continue to the present.Example: She has attended several seminars on professional development.3. Reading Comprehension- Main Idea: The text emphasizes the importance of continuous learning and professional development in today's fast-paced work environment.- Supporting Details: The text lists various ways to enhance professional skills, such as attending workshops andseeking mentorship.4. Listening Comprehension- Key Points: The interviewee talks about the benefits of networking and how it has helped advance their career.5. Speaking Activity- Presentation: Give a short presentation on aprofessional development opportunity you would like to pursue.6. Writing Task- Write a reflective essay on how you plan to continueyour professional development in your chosen career.Unit 5: Teamwork and Collaboration1. Vocabulary- Synergy: The interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects.- Conflict Resolution: The process of resolving disagreements or disputes within a team.2. Grammar- Past Perfect Tense: Used to describe an action that was completed before another past action.Example: By the time the team arrived, the project had already been completed.3. Reading Comprehension- Main Idea: The article explores the concept of synergy and how it can be achieved through effective teamwork.- Supporting Details: The article provides examples of successful collaboration and the benefits it brings to。
AASLD PRACTICE GUIDELINESAASLD Practice Guidelines:The Role of Transjugular Intrahepatic Portosystemic Shunt(TIPS)in the Management of Portal HypertensionThomas D.Boyer1and Ziv J.Haskal2PreambleThese recommendations provide a data-supported ap-proach.They are based on the following:(1)formal re-view and analysis of recently published world literature on the topic(Medline search);(2)The American College of Physicians’Manual for Assessing Health Practices and De-signing Practice Guideline1;(3)policy guidelines,includ-ing the American Association for the Study of Liver Diseases’Policy Statement on Development and use of Practice Guidelines and the American Gastroenterologi-cal Associations’Policy Statement on the Use of Medical Practice Guidelines2;and(4)the authors’years of experi-ence in the care of patients with portal hypertension and use of TIPS in the management of these disorders.These recommendations are fully endorsed by the AASLD and the Society for Interventional Radiology.Intended for use by physicians,these recommendations suggest preferred approaches to the diagnostic,therapeutic, and preventative aspects of care.They are intended to be flexible,in contrast to standards of care,which are inflexible policies designed to be followed in every case.Specific rec-ommendations are based on relevant published information. In an attempt to characterize the quality of evidence support-ing recommendations,the Practice Guidelines Committee of the American Association for the Study of Liver Diseases requires a grade to be assigned and reported with each rec-ommendation(Table1).IntroductionTIPS has been in use for more than20years to treat the complications of portal hypertension and TIPS have been created in thousands of patients with liver disease world-wide.3–6Despite the extensive use of TIPS to treat the complications of portal hypertension there initially was a lack of consensus on which patients should receive a TIPS as compared to other forms of therapy.In1995a confer-ence sponsored by the National Institutes of Health con-cluded that TIPS was effective in the acute control and prevention of recurrent bleeding from varices but it was unclear when TIPS should be used as compared to med-ical and surgical therapy for these complications of portal hypertension.In addition,the efficacy of TIPS to control refractory ascites or treat the Budd-Chiari syndrome was unclear but promising.7Since then,more than one thou-sand patients have been enrolled in multiple controlled trials comparing TIPS to endoscopic and pharmacologic therapy in the prevention of rebleeding from varices and to large volume paracentesis in the treatment of refractory cirrhotic ascites.Further,about a1,000papers have been published on TIPS in the English literature alone.This body of work allows for more definitive recommendations about in whom and when to use TIPS in the treatment of the complications of portal hypertension.The guidelines are divided into two large categories. Thefirst category is a review of the technical aspects of the procedure,its complications and the data on which pa-tients are most at risk for an adverse outcome following a TIPS.The second category is a review of the indications for TIPS.The use of TIPS for primary prevention of variceal bleeding and in the control of acute bleeding are discussedfirst.Next the two indications for TIPS that have been subjected to controlled trials(prevention of recurrent bleeding from varices and refractory ascites)will be discussed and guidelines stly,all of the other indications for TIPS that have been described in the literature but have not been subjected to controlled trials will be discussed and guidelines created.To prepare these guidelines,a Medline search was per-formed from1966to2009.A total of1143articles were found under the subject heading“transjugular intrahe-Abbreviations:BCS,Budd-Chiari syndrome;GAVE,gastric antral vascularectasia;HVPG,hepatic venous pressure gradient;HRS,hepatorenal syndrome;IVC,inferior vena cava;LVP,large volume paracentesis;MELD,Model for End-Stage Liver Disease;PHG,portal hypertensive gastropathy;PTFE,polytetrafluoro-ethylene;SOS,sinusoidal obstruction syndrome;TIPS,transjugular intrahepaticportosystemic shunt.From the1Liver Research Institute,University of Arizona School of Medicine,Tucson,AZ,and2Division of Vascular and Interventional Radiology,University ofMaryland Medical School,Baltimore,MD.Address reprint requests to:Thomas D.Boyer,M.D.,University of Arizona,Liver Research Institute,Arizona Health Sciences Center245136,1501NorthCampbell Avenue,Tucson,AZ85750.E-mail:tboyer@;520-626-5952.Copyright©2009by the American Association for the Study of Liver Diseases.Published online in Wiley InterScience().DOI10.1002/hep.233831patic portosystemic shunt”.Controlled trials and large series were sought during this search.Recently published papers were also used as a source of references missed by the Medline search and the personalfiles of the two au-thors were also used as a source of references.The ProcedureA TIPS is created by an interventional radiologist or in Europe by a specially trained physician.The technique is reviewed in several publications and will not be discussed here.3,4,7The procedure may be performed under con-scious sedation(most common)or general anesthesia.If the procedure is going to be prolonged or the patient is hemodynamically unstable then general anesthesia is pre-ferred as this allows for careful monitoring by the anes-thesiologist.The success rate with TIPS for the decompression of the portal vein is high,Ͼ90%of cases in most series.8–14The Society of Interventional Radiol-ogy developed guidelines for creation of a TIPS in2001 and the consensus was that a technically successful out-come(includes both creation of the shunt and decrease in portal pressure toϽ12mm Hg)should be achieved in 95%of patients and clinical success(resolution of the complication of portal hypertension)should be achieved in90%of cases.Failure to achieve this threshold should lead to a review of the departmental policy and proce-dures.15,16Early mortality following TIPS placement was origi-nally reported to be quite high due to poor patient selec-tion but subsequent analysis demonstrated that pre-procedure clinical features(such as high model for end-stage liver disease(MELD)or APACHE II scores,high total bilirubin levels,emergent versus elective setting, presence of pneumonia-see below)accounted for this high death rate.In most situations death is due to pro-gressive liver disease perhaps as a result of portal diversion and not due to complications of the procedure itself,such as intraperitoneal bleeding(see below).14,17–19In a retro-spective series of1,750patients,the incidence of fatal complications(intraabdominal hemorrhage,laceration of the hepatic artery or portal vein and right heart failure) was1.7%(range0.6%-4.3%).Of interest the risk of fatal complications was3%in institutions that had performed less that150TIPS total as compared to1.4%in those who had performed a greater number.14These data sug-gest that there is a learning curve associated with the safe creation of a TIPS.Major procedural complications are expected in no more than3%of cases,and if rates exceed these levels,then internal quality assessment should be considered.16Authors of manuscripts on TIPS have been asked by the Society of Interventional Radiologists to re-port the approximate number of TIPS performed in their centers before instituting the reported study to get a better understanding of the amount of training required to per-form TIPS with an acceptable morbidity and mortality and it is hoped these data will be forthcoming.16The purpose of a TIPS is to decompress the portal venous system and therefore prevent rebleeding from var-ices or stop or reduce the formation of ascites.As to varices it is well established that if the hepatic venous pressure gradient(HVPG)or portal pressure gradient(PPG)after TIPS creation can be reduced to less than12mm Hg then the risk of bleeding will fall significantly.More recent data suggest that achieving a PPG ofϽ12mm Hg may not be required to prevent rebleeding.In one series the risk of rebleeding following TIPS revision was18%,7%,and 1%in patients whose PPG had been reduced by0%, 25%-50%,andϾ50%,respectively.20In a second series a 50%reduction in the initial PPG was associated with a rebleeding rate at one year of11%whereas those with a lesser reduction had a31%probability of rebleeding dur-ing thefirst year.21In the latter study the only absolute value for prevention of rebleeding was a PPG ofϽ12mm Hg but at the cost of an increased incidence of encepha-lopathy.Although the gold standard for prevention of rebleeding remains a HVPG ofϽ12mm Hg,further studies are needed to determine if lesser reductions have acceptable efficacy with a lower incidence of encephalop-athy.The optimal PPG that needs to be obtained for the control of refractory cirrhotic ascites is even less clear.In one series,the degree of portal decompression did not correlate with successful treatment of refractory cirrhotic ascites and the authors suggested a PPG ofϽ8mm Hg should be the hemodynamic goal.23The selection of a value of8mm Hg is based on limited data and because the development of cirrhotic ascites reflects changes in both hepatic and renal function,it may be difficult to establish an absolute value of decompression that needs to be achieved in most patients with refractory ascites.In pa-tients with significant preexisting encephalopathy inTable1.Quality of Evidence on Which a RecommendationIs BasedGrade DefinitionI Randomized controlled trialsII-1Controlled trials without randomizationII-2Cohort or case-control analytic studiesII-3Multiple time series,dramatic uncontrolled experimentsIII Opinions of respected authorities, descriptive epidemiology2HEPATOLOGY,January2010whom a TIPS may still be necessary for ascites control,a higher gradient may be appropriate(in order to limit worsening encephalopathy);this affords the opportunity to further enlarge the TIPS at a later date if diuresis is inadequate and encephalopathy is satisfactorily con-trolled.Further study in this area is warranted. Finally,in the authors’experience the effective gradi-ent needed to prevent rebleeding from gastric varices may be lower than12mm Hg and even with apparent decom-pression embolization of the gastric varices may be re-quired to minimize the risk of early rebleeding.Also, rebleeding from gastric varices may occur with small in-creases in portal pressure suggesting surveillance of this group of patients following a TIPS is of particular impor-tance.21Further complicating the issue is the problem of how the pressures are obtained.The classic way is to measure the free and wedged hepatic vein pressure and then to subtract the two values yielding the HVPG.22The use of the free hepatic vein or inferior vena cava(IVC)pressure is necessary to correct for the intra-abdominal pressure and allows for measurement of the true pressure gradient across the liver.After TIPS creation the portal pressure is obtained and the PPG calculated.Most radiologists use the right atrial pressure as the reference point because the hepatic vein is now part of the shunt and thus a free hepatic vein pressure cannot be obtained after shunt cre-ation as the diverted portalflow artifactually raises the pressure within the outflow hepatic vein that drains the TIPS.The right atrium is of course in the chest and the basal pressure in the chest is lower than the intraabdomi-nal pressure and the true PPG is not measured using this reference point.In addition,once the TIPS has been cre-ated the right atrial pressure tends to rise,thus complicat-ing the measurement.One solution to this problem is to use the IVC pressure as the reference value but this has not been adopted by the interventional radiologic commu-nity.No standardization of where in the IVC the pressure should be obtained has limited this approach and cur-rently the right atrial pressure is used by most interven-tional radiologists despite the above limitations.Some of these uncertainties could be resolved with standardization of how the HVPG or PPG is measured during creation of a TIPS so that the measurements are uniform and can be used to judge hemodynamic success more accurately. Pre-Tips Evaluation and Contraindications Most patients who are referred for a TIPS should be under the care of a gastroenterologist or hepatologist.It is this individual in consultation with the interventional ra-diologist who must reach the decision that a TIPS is the appropriate form of treatment for a complication of por-tal hypertension.As discussed in the following section it is clear that there are predictors of a poor outcome following TIPS.However,the risk of the procedure must always be balanced with the severity of the complication from which the patient is suffering and the likelihood of the patient surviving long enough to receive a liver transplant following creation of a TIPS.Thus,the decision to per-form or not perform a TIPS in a high risk patient should be reached by the gastroenterologist/hepatologist and the interventional radiologist together.Ideally,in a high risk patient,a transplant center should also be consulted pre-ceding thefinal decision.In the emergent setting of acute, uncontrolled variceal hemorrhage,contacts with trans-plantation centers may be secondary to the need for shunt creation.Listed in Table2are contraindications to the creation of a TIPS.These include both absolute contraindications to any form of portosystemic diversion,be it surgical or percutaneous.Absolute contraindications include con-gestive heart failure,severe tricuspid regurgitation and severe pulmonary hypertension(mean pulmonary pres-sures ofϾ45mm Hg as these patients are not candidates for a liver transplant).24Whether patients with more mild pulmonary hypertension can receive a TIPS safely is un-clear.Relative contraindications include anatomic ones that can complicate the creation of the shunt and reduce the technical success,including portal venous obstruc-tion,large hepatic tumors,extensive polycystic liver dis-ease,and hepatic vein obstruction.It is well established that shunts can be created in all of these cases with the right experience and under appropriate clinical circum-stances but the difficulty of creating the TIPS needs to be balanced with the need of the patient.Situations in which these relative contraindications might be outweighed by clinical necessity include palliative TIPS in patients with a hepatoma and refractory variceal bleeding,recanalization of occluded portal veins in patients with recurrent variceal bleeding or refractory ascites,or a patient with Budd-Table2.Contraindications to Placement of a TIPSAbsolutePrimary prevention of variceal bleedingCongestive heart failureMultiple hepatic cystsUncontrolled systemic infection or sepsisUnrelieved biliary obstructionSevere pulmonary hypertensionRelativeHepatoma especially if centralObstruction of all hepatic veinsPortal vein thrombosisSevere coagulopathy(INRϾ5)Thrombocytopenia ofϽ20,000/cm3Moderate pulmonary hypertensionHEPATOLOGY,Vol.51,No.1,20103Chiari syndrome and progressive liver failure in whom there are no patent hepatic veins.Preprocedure laboratory studies include serum electro-lytes,blood count,coagulation parameters,and tests of liver and kidney function.Cross section liver imaging by Duplex ultrasound,CT scan or MRI is appropriate in all but the most life-threatening situations in order to assess portal vein patency or the presence of liver masses.When a history of congestive heart failure,tricuspid regurgitation,cardiomy-opathy,or pulmonary hypertension is present,then cardiac evaluation is appropriate prior to TIPS.This evaluation may include cardiac echo,cardiology consultation,and,possibly atrialfluid challenge.However,in the absence of a cardiac history the routine performance of a cardiac echo preceding a TIPS is unnecessary in the opinion of the authors.How-ever,others feel that as up to16%of patients referred for liver transplantation may have pulmonary hypertension that an echo should be performed on all patients preceding a TIPS.24 Elevated right atrial pressures(typically measured at the start of the TIPS procedure)may warrant abandonment or delay of the procedure pending diuresis or further medical stly,patients with a significant coagulopathy may be able to undergo a TIPS following the use of clotting factors or platelets.Thefinding of a small liver during the evaluation is not a contraindication to creation of a TIPS but does indicate that the procedure may be difficult and prolonged. MortalityThe1-year mortality rates for TIPS are dependent somewhat on the indication for the procedure.When TIPS has been placed for bleeding varices1year survival varies from48%-90%.Survival rates are somewhat lower when the indication is ascites,being48%-76%.25–30In one series but not another survival rates were significantly worse when the indication was refractory ascites as com-pared to variceal bleeding.26,29These differences likely reflect variations in the severity of liver disease between the different studies.As the use of TIPS has increased there has been interest in models that predict outcome.MELD and a number of other models have been developed to predict survival fol-lowing TIPS.25–29The modified MELD model utilizes serum bilirubin,International Normalized Ratio(INR) for prothrombin time,and serum creatinine.Previously the cause of cirrhosis was also used but has been aban-doned.The three variables are used to create the following equation:[3.8log e(bilirubin[gm/dL])ϩ11.2log e (INR)ϩ9.6log e(creatinine[mg/dL].A second model used a bilirubinϾ3.0mg/dL(1point),ALTϾ100IU/L (1point),pre-TIPS encephalopathy(1point)and ur-gency of TIPS(2points)and divided patients into three groups(low risk-0points,medium risk-1-3points and high risk-4-5points).26These two models and Child-Pugh scores were used prospectively in a subsequent study to predict survival.30All three accurately predicted 3-month survival to a similar degree whereas1-year sur-vival was predicted best by the MELD model.Short-term mortality has also been predicted by using bilirubin alone or a combination of serum bilirubin,APACHE-II score and TIPS urgency.31,32Irrespective of which model is chosen the short term and one year survival can be pre-dicted with some accuracy.These survival estimates can be used to advise patients about expected outcomes and can also be used to decide which patients require referral to a liver transplant center.Recommendations1.TIPS should only be performed by experienced interventional radiologists(or specially trained physi-cians).Success and complication rates should be moni-tored and if they fail to meet expected rates then review of the program should be considered.Evidence-III2.The decision to perform a TIPS,especially in a high risk patient,should be reached by a team con-sisting of a gastroenterologist/hepatologist,interven-tional radiologist and where appropriate a transplant physician.Evidence-III3.Preceding creation of a TIPS,tests of liver and kidney function should be performed as well as cross-sectional imaging of the liver to assess portal system patency and exclude liver masses.Evidence-III4.Reduction in HVPG to less than12mm Hg should be achieved when the indication is bleeding esophageal varices.Embolization of gastric varices may be required despite adequate decompression of the portal-venous system.Evidence-II-25.The degree of reduction in HVPG to control ascites is unclear but at present a gradient of at least<12mm Hg has been suggested to be a reason-able goal.Evidence-II-26.Patients with high predicted30-day mortalities (MELD>15-18or serum bilirubin>4.0mg/dL)should be informed of their prognosis and TIPS performed only in the absence of other options.Evidence-II-27.In high-risk patients,the need for liver trans-plantation should be discussed before the performance of an elective TIPS.Evidence-III ComplicationsThe most common complications and their reported frequency are listed in Table3.TIPS dysfunction is defined as a loss of decompres-sion of the portal venous system due to occlusion or ste-4HEPATOLOGY,January2010nosis of the TIPS.Although there is no consistency between investigators as to the exact criteria that should be used to define TIPS dysfunction in reference to degree of stenosis,a value of50%is frequently used.In addition, a rise in the HVPG toϾ12mm Hg or a recurrence of the complication of portal hypertension for which the TIPS was performed indicates TIPS dysfunction.33,49Occlu-sion of the TIPS can either be due to thrombosis or hy-perplasia of the intima.Thrombosis of the TIPS usually occurs early and can happen within24hours of TIPS creation.The frequency of this complication is on the order of10%-15%when bare stents are used.34,35The cause of the thrombosis may be leakage of bile into the shunt,hypercoagulable syndromes,or inadequate cover-age of the TIPS tract with sufficient stent(s).36,37Throm-bosis of the TIPS is identified by Doppler ultrasound and patency re-established by repeat catheterization.In one controlled trial use of phenprocoumon(an anticoagulant) was associated with a lower rate of complete occlusion within thefirst three months following TIPS place-ment.38However,in the absence of more studies the rou-tine use of anticoagulation is not recommended.The major difficulty with TIPS is the unpredictable patency of the shunts due to pseudointimal hyperplasia within the parenchymal tract or within the outflow he-patic vein.The occluded stents are coated by a collage-nous matrix that is covered by endothelial cells.36,37,39,40 The incidence of stenosis varies from18to78%depend-ing upon the surveillance techniques used,frequency of assessment,and definitions of‘failure’,e.g.elevated por-tasystemic gradient,ultrasound velocity criteria,or per-cent diameter stenosis.9,11,12,42–46Most physicians rely on Doppler ultrasound to identify TIPS stenosis.Unfortu-nately,the earlier studies claimingϾ90%accuracy for sonographic prediction of shunt dysfunction have failed to stand under the light of larger prospective or retrospec-tive studies.In one series several ultrasonographic features were used to identify TIPS stenosis includingflow rever-sal,jet lesion,and decreasedflow in the TIPS or portal vein.The sensitivity of each of these tests varied from 10%-26%with a specificity of88%-100%.Thus,the negative predictive value was poor and the positive pre-dictive value acceptable.47In a second series of31oc-cluded or stenotic stents ultrasound predicted shunt malfunction in only11and incorrectly predicted patency in20and thus the sensitivity was only35%.48Many of the sonographic studies are methodologicallyflawed be-cause sonographic criteria of shunt dysfunction were used to trigger TIPS venography,however when sonography suggested no shunt dysfunction proof of shunt patency by venography was not performed.Part of the difficulty of using sonography is that it is an imaging study which measures velocity,from which diameter within a conduit can be estimated.However,with TIPS it is portal decom-pression,not percent shunt stenosis that is important in assessing TIPS function.One prospective study com-pared151Doppler sonograms with TIPS venograms and assessment of portal ing a success or failure definition of a portosystemic gradient ofϽorՆ15mm Hg,respectively,sonography provided a sensitivity and specificity of only86%and48%respectively.49Thus,an abnormal Doppler ultrasound is predictive of occlusion or stenosis whereas a normal ultrasound does not exclude TIPS dysfunction.The best indicator of TIPS dysfunc-tion is a recurrence of the problem for which the TIPS was originally inserted,either variceal bleeding,hepatic hy-drothorax,or ascites.If recurrent varices are identified by upper endoscopy then the TIPS is most likely insuffi-cient.47Documentation of patency can only be achieved with certainty by re-catheterization of the shunt.The development of covered stents has reduced the frequency of TIPS dysfunction.50Two large series have recently been published that have examined the use of polytetrafluoroethylene(PTFE)-cover stent-grafts for TIPS.One of the reports is of a series of71patients all of whom received the covered stents whereas the second re-port is a randomized controlled trial comparing the cov-ered stents to the standard bare stents.33,51In the nonrandomized series a total of eight shunt revisions were performed for an incidence of11.3%and primary pa-tency rates at6and12months were calculated to be87% and81%,respectively.51Although these results are better than what would be expected with bare stents,all patients did not undergo venography and therefore the true inci-dence of shunt stenosis is unknown.In the randomized study eighty patients with cirrhosis and either uncon-plications of TIPSComplications Frequency(%)TIPS dysfunctionThrombosis10–15Occlusion/stenosis18–78Transcapsular puncture33Intraperitoneal bleed1–2Hepatic infarctionϳ1Fistulae RareHemobiliaϽ5Sepsis2–10Infection of TIPS RareHemolysis10–15EncephalopathyNew/worse10–44Chronic5–20Stent migration or placement into IVC or too farinto portal vein10–20Data from Boyer and Vargus126and Ro¨ssle et al.127HEPATOLOGY,Vol.51,No.1,20105trolled or recurrent bleeding from varices or refractory ascites were enrolled in the study.Patients were followed with Doppler ultrasound and venography was performed at6,12,and24months post-TIPS.Five(13%)of the39 patients receiving the PTFE covered-stent-grafts had shunt dysfunction whereas18(44%)of those receiving the bare-stent had shunt dysfunction(PϽ0.001).In addition,early thrombosis of the TIPS was observed in three patients who received the bare-stents.The actuarial rates of primary patency in the covered and bare-stent groups were86%and47%,respectively at year one and 80%and19%at year two.Recurrence of the complica-tion of portal hypertension for which the TIPS was placed was also significantly more common in the bare-stent group as compared to the PTFE covered-stent group.The incidence of hepatic encephalopathy was less in the cov-ered-stent group(difference not significant)and survival was the same.33A second controlled trial of covered versus bare stents found a primary patency rate of76%and36% at2years respectively.The probability of remaining free of encephalopathy was significantly greater with covered(67%) as compared to bare(51%)stents.Survival at two years was not significantly different between the two groups.52In a retrospective series survival was significantly better in the PTFE covered-stent group as compared to those who re-ceived a bare stent.However,the two groups were from different times and it is difficult to know if patient selection as opposed to the use of different stents accounted for the observed survival differences.53The PTFE covered TIPS en-doprostheses are available in Europe,South America,and the USA.The use of the PTFE coated-stent-grafts should de-crease significantly the incidence of shunt dysfunction and recurrence of the complications of portal hypertension.It is unclear,however,whether this development will improve the cost-effectiveness of TIPS as compared to other forms of therapy.Puncture of the liver capsule is common but serious intraperitoneal bleeding is infrequent,1-2%of cases. Similarly creation of a biliary-venous or hepatic artery-portal veinfistula is rare.The development of jaundice or sepsis following TIPS suggests the former whereas pulsa-tileflow in the portal vein suggests the latter.54,55Hemo-lysis may occur following TIPS placement and appears to be due to damage to the red cells by the stent.56–58Rec-ognition that the rise in bilirubin levels is due to hemolysis is an important diagnosis as an alternative diagnosis is liver failure following the TIPS which caries a poor prog-nosis.59Hepatic infarction is a rare complication of TIPS and is generally related to injury and/or thrombosis of the hepatic artery that supplies the affected segment.60 Hepatic encephalopathy and TIPS dysfunction are the two complications that have limited the effectiveness of TIPS most significantly.The incidence of new or wors-ening encephalopathy following TIPS is20-31%.25,61,62 In controlled trials comparing TIPS to alternative forms of therapy the incidence of encephalopathy is always greater in those who received a TIPS(see below).Pre-TIPS factors associated with an increased risk of post-TIPS encephalopathy in one study included etiology of liver disease other than alcohol,female gender and hy-poalbuminemia.62In a second series increasing age,past history of encephalopathy and evidence of encephalopa-thy at the time of TIPS were predictive of post-TIPS encephalopathy.61It is important to note that if the en-cephalopathy was precipitated by variceal bleeding then prevention of rebleeding should make it less likely that the patient will have recurrent encephalopathy.Only if the hepatic encephalopathy is uncontrollable is a TIPS con-traindicated.15In most patients the encephalopathy re-sponds to standard therapy and only rarely(ϳ5%)must the TIPS be occluded to control the encephalopathy.63,64 A TIPS also can be reduced in caliber,should excessive encephalopathy prove difficult to control and yet allow for continued portal decompression.65Based on one small randomized trial there appears to be no benefit in the prophylactic use of nonabsorbable disaccharides or anti-biotics in the prevention of post-TIPS encephalopathy.66 TIPS in the transplant candidate.Patients awaiting liver transplantation frequently bleed from varices or have refractory cirrhotic ascites and therefore are candidates for a TIPS.Because these patients will subsequently undergo a hepatectomy there are complications of a TIPS that are unique to this population.A TIPS is created within the substance of the liver and most interventional radiologists attempt to place the stent as close as possible to the hepatic vein/inferior vena cava ostium to reduce the risk of devel-oping stenosis within the hepatic vein.With the excep-tion of cases of benign or malignant portal vein thrombosis,the stent should extend the shortest possible distance into the main portal vein both to allow creation of a durable shunt and yet not complicate the portal to portal vein anastomosis performed during transplanta-tion.When the stent extends into the inferior vena cava (or atrium)or deep into the main portal vein,then trans-plantation difficulties can arise.In one series of12pa-tients who had a TIPS preceding liver transplantation, four patients had portal vein stents near the coronary vein or extending into the superior mesenteric vein and in one venous reconstruction was required.67In a second series of24patients who had a TIPS created preceding trans-plantation,eight patients had more complicated surgeries that were attributable to the presence of a TIPS.Four of the stents were in the inferior vena cava,one in the supe-rior mesenteric vein and in three the portal vein was6HEPATOLOGY,January2010。