Polycystic Ovarian Syndrome (PCOS) Causes and Symptoms

Polycystic Ovarian Syndrome (PCOS) Causes and Symptoms Polycystic Ovarian Syndrome in the Reproductive Woman: An Epidemiological Approach Abstract One of the most prevalent disorders among women with reproductive age is polycystic ovarian syndrome (PCOS). Though the etiology of this syndrome is unknown, it can be diagnosed on the basis of three cardinal characteristics. This paper defines the issue along with a brief background and its significance. It also explores the prevalence and incidence rate worldwide and especially in Pakistan. Moreover, it will enlighten the major risk factors and long term concerns which have made life of women miserable. A review of treatment which includes pharmacological and non-pharmacological ways that is diet and exercises will be highlighted. Furthermore, it provides recommendation at individual, community, institutional, national and government level. It also explores the need of future researches among women with PCOS. By approaching all these aspects, women can combat with PCOS and reduce forthcoming morbidities. Women of all ages experience multiple health issues. Particularly, women during her reproductive years encounter gynecological and endocrine disorders that exasperate their lives. Among all disorders, polycystic ovarian syndrome (PCOS) is the most common endocrinopathy. PCOS was referred as Stein-Leventhal Syndrome after Irving Stein and Micheal Leventhal, who first described it in 1935 (KINZA). However, record of PCOS dates back from atavistic era. Hippocrates, Soranus of Ephesus and Moises Maimonides identified women with oligomenorrhea, sterile conditions, masculine and healthy appearance which suggests PCOS (Azziz, Dumessic, Goodarzi, 2011). According to National Institute of Health Conference (1990), â€Å"Women are defined to have PCOS if they have chronic anovulation and evidence of androgen excess for which there is no other cause† (Guzick, 2004, p. 181). The diagnostic criteria’s for PCOS are convened by the National Institute of Health in 1992, the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine i.e. Rotterdam criterion in 2004 and the Androgen Excess and PCOS Society in 2006. However, a Rotterdam criterion is widely used. According to Rotterdam criterion, presence of any two cardinal features is sufficient to diagnose a woman with PCOS. These features include oligomenorrhea or anovulation, clinical or biochemical hyperandrogenism and polycystic ovaries. This criterion also defines the morphology of polycystic ovaries i.e. â€Å"the presence of 12 or more follicles measuring between 2 and 9 mm in diameter and/or an increased ovarian volume of greater than 10 cm3† (Sirmans Pate, 2014, p. 3). PCOS has a high prevalence and incidences not only in western areas, but also in Eastern areas, specifically in Asia. Rehman, Salahuddin and Obaid-ur-Rehman (2005) estimated 20% women from the general population, and 10% women of reproductive age suffer from PCOS. A study conducted in UK reported that 20% 25% white women suffer from PCOS whereas the ratio was found to be much higher in South Asian women i.e. 52% (Karachi: Seminar told ovarian disease, 2010). A prospective study conducted in Greece, Spain and United States concluded that about 4% 8% of women were diagnosed with PCOS (Teed, Deeks Moran, 2010). In India, a cross-sectional study revealed that 51 out of 96 women have PCOS (Bhattacharya Jha, 2011). Furthermore, 20.7% women of reproductive age group are affected in Pakistan (Baqai, Khanam, Parveen, 2010). The morbidity rate of PCOS is expanding to a great momentum due to lack of awareness regarding preventive measures and inappropriate healthcare facilities. Its long t erm consequences do not limit to the reproductive axis; women with PCOS are at high risk for acquiring metabolic and cardiovascular illnesses (Avery Mayer, 2007). Inspite of its deleterious impacts PCOS has persisted for many years. It also remains a challenge for the clinician’s to diagnose and manage it. However, better understanding of the complexities of PCOS will ultimately lead to improved health outcomes and effective clinical care. This compelled us to converse over the epidemiology of PCOS. â€Å"PCOS has been identified as an area of clinical need and as a public health issue† (Hailes, 2011, p. 28). The exact etiology of PCOS is yet unknown, but several sufficient determinants are associated with its occurrence (Rehman et al., 2005). Insulin resistance is the major underlying factor. About 50-80% of the women with insulin resistance reported to have PCOS. Insulin plays both direct and indirect roles in the appearance of the disease. High levels of insulin work synergistically to the luteinizing hormone. Together they increase the androgen production of theca cells which lead to lipid abnormalities (Zacur, 2003). Moreover, elevated insulin level inhibits hepatic synthesis of sex hormone–binding globulin leading to increase amount of unbound or free testosterone (Ehrmann, 2005). Ahmed et al. (2008) highlighted genetics as an important risk factor for PCOS. Deregulation of the cytochrome P450c17 gene affects ovarian function which results in hyperandrogenism (Ahmed et al., 2008). Ehrmann (2005) reported that an abnormality in the hypothalamic-pituitary-ovarian axis (HPOA) is associated with PCOS. Rojas et al. (2014) concluded that an increase impulse frequency of HPOA raises the production of luteinizing hormone (LH). This in turn increases the synthesis of androgens, suggestive of PCOS (Ehrmann, 2005). Other factors include altered steroid metabolism that is dysregulation of 11b-hydroxy steroid dehydrogenase (Ahmed et al. 2008). In a retrospective study, women on antiepileptic drugs reported menstrual irregularities. Hence a positive relation between antiepileptic drugs and PCOS was found (Zacur, H., 2005; American Pregnancy Association, 2014). Vitamin D deficiency may place a woman to develop PCOS (Thys-Jacobs, Donovan, Papadopoulos, Sarrel, Bilezikian, 1999). Serum 25-hydroxyvitamin D (25OHD) decreases if women have higher body mass index (BMI), fat and insulin resistance. Hence, vitamin D deficiency alters intracellular calcium, which results in ovarian dysfunction (Khan et al., 2014). Untreated PCOS have various ramifications, including reproductive, metabolic, cardiovascular and psychological alterations. According to Legro et al. (2013), endometrial hyperplasia and endometrial cancer may occur due to deficiency of progesterone. Moreover, women with PCOS are prone to develop Diabetes Mellitus (DM) type II in later life. A case control study revealed that 7.5% of women end up with DM type II (Legro, Kunselman, Dodson, Dunaif, 1999). In addition, PCOS can affect circulatory system in an indirect way as women develop dyslipidemia and cardiovascular diseases. Anxiety and depression are the most common psychological issues reported by women with PCOS (Way, 2013). Lifestyle modification should be adopted by women suffering from PCOS. These amendments include weight control, stress management and dietary modification. A small amount of weight loss as little as 5% can help a woman to regulate the menstrual cycle and ovulation. Weight control can be beneficial for a woman to sustain mental well-being, and enables her to partially culminate the risk of cardiac and metabolic disorders (Boyle Teede, 2012). Moreover, dietary management includes the consumption of low glycemic index, high fiber and low fat diet to reduce the associated symptoms of PCOS. No ideal pharmacological treatment has yet been found that completely treats PCOS. However, symptomatic treatment is usually preferred. Low dose of oral contraceptive pill, cyclic progestin and metformin are used as first line treatment for PCOS. These drugs help in treating ovarian dysfunction, menstrual irregularities and hyperandrogenism (Garad, Teede, Moran, 2011). Elter and colleagues concluded from their clinical trial that OCP in combination with metformin is more effective in suppressing the androgen level as compared to OCP alone (Ahmed, Qureshi, Anjum, Akhtar, Anhalt, 2008). In presence of hirsutism spironolactone (200mg/d) is commonly prescribed (Guzick, 2004). Clomiphene citrate is recommended to induce fertility in women with PCOS. It triggers FSH secretion and mature ovarian follicle. Herbal therapies are also used to cure PCOS which includes liquorice, kasip fatimah, spearmint tea, etc. All three herbs have anti-androgenic properties. In Turkey, RCT concluded that wo men who receive spearmint tea have decreased levels of free testosterone (Goswami, Khale, Ogale, 2012). Recommendation and future research PCOS is endemic in Pakistan, particularly in the reproductive women. To reduce the incidence rate following recommendation can be helpful. At an individual level, it is significant to provide psychological support to the women suffering from PCOS. This will enhance her self-confidence and enable her to cope effectively. Moreover, counseling services should be readily available for newly diagnosed women. These services should emphasize on weight management via diet and exercise. Proper instructions regarding drug dosage, side effects and the importance of compliance is crucial. The physical changes in the women with PCOS not only impact her well-being, but her family is equally affected. Therefore, family concerns should be addressed. Further, regular follow up should be stressed. It is estimated that 70% of women with PCOS remain undiagnosed in the community due to lack of awareness (March et al., 2010). Therefore, several screening programs should be organized to assess women’s physical, metabolic, and reproductive health. These programs help women to identify any alterations in their bodily functions. Further, it helps health care workers to plan effective need based interventions for them. Community health centers should arrange weekly monitoring of blood pressure, weight and BMI. Health institutions should initiate yearly screening programs for lipid profile, glucose levels (Boyle et al., 2012) and Vitamin D levels. Various mediums can be used to increase awareness in the population. Women should be educated to self-monitor the symptoms of PCOS. This could be achieved through the distribution of pamphlets, brochures, and flyers at institutional level. Similarly, at national level mass media like television shows and commercials, plays an important role. Awareness is an essential tool to save future daughters, wives and mothers from PCOS. Government in affiliation with health and education sectors should make policies to initiate awareness among school going girls, regarding menstrual irregularities and warning signs of PCOS. Also, the government should introduce free health services in district and tehsil hospitals to maintain sexual health of women (Beydoun et al., 2009). In collaboration with non-governmental organizations awareness sessions and support groups should be planned for high risk and previously diagnosed women to prevent them from complications. More parks and walking tracks should be made, and specific hours should be allocated for women. PCOS remains a debating issue for researchers as its causes and outcomes are emerging day by day. Matzke (2011) suggested that large sample studies in non-randomized clinical trials should be conducted. This would increase validity, reliability and applicability of the researches. Longitudinal studies should be conducted, and an individual should be followed for more than 5 years exactly after the diagnosis. The purpose of long term monitoring is to evaluate the significant changes that occur due to PCOS (Matzke, 2011). There is a need to modify the name of PCOS as this term only focuses on cyst and ovaries. Therefore, a name that defines its intricacy and reflects its characteristics in metabolic, hypothalamus, pituitary, ovarian, and adrenal interactions should be suggested (National Institute of Health, 2012). A few studies indicate that fertility drug such as clomiphene citrate may increase the risk of ovarian cyst if taken for a long period (American Pregnancy Association, 2014) . In this regard, further experimental researches should be performed to evaluate the evidence of PCOS in such women. A Chinese medicine cryptotanshinone is known for its significant effect in endocrine and metabolic disorders. However, this medicine is only tested on rats and showed a significant decrease in the symptoms of PCOS (Yu et al., 2014). Therefore, clinical trials of this drug are suggested. Ayurveda is a traditionally used treatment regimen. An experimental uncontrolled study was done to investigate the effectiveness of samprapti kriya and other herbs for curing sub-fertility in PCOS. Results showed that 85% of the women get cured and75% were able to conceive (Siriwardene, Karunathilaka, Kodituwakku, Karunarathne, 2010). About 70% of Pakistani people prefer alternative therapies over conventional medicines (Kokab Ahmad, 2011). Therefore, further research is required to validate the effectiveness of ayurveda treatment. In conclusion, PCOS have emerged as a devastating endocrine disorder among  women worldwide. The chief cause is unknown yet. This syndrome displays a variety of reproductive, metabolic, cardiovascular and psychological features. Management primarily focuses on lifestyle modification along with certain pharmacological medications for presenting symptoms. To eradicate this disorder, efforts are required at individual, community, institution and governmental level. Working on future research needs would help us to achieve better outcomes in upcoming years.

Poety

Similarities of Music and Poetry The song â€Å"I Swear this Time I Mean it† is by a band called Mayday Parade. The song is on their Anywhere but Here album that was released in 2009. This speicfic song has a lot of similarities including poetic devices, denotation and connotaion and also musical presentaion. Poetic devices are very common in music including the song â€Å"I Swear this Time I Mean it†. The first poetic device noticed in this song is rhyme. Rhyming is when two words sound the same or have the same ending. Rhyming words usually occur at the end of poetic lines.An example from the song would be â€Å"If luck is on my side tonight my clumsy tongue will make it right. † The rhyming words are â€Å"tonight† and â€Å"right†. The singer is saying if hes lucky tonight he'll fix his his mistakes and make them right. The singer uses rhyme to pull the song together. The next poetic device noticed in the song is personification. Personification is when an unhuman object is givin a human characteristic. An example from the song is â€Å"Oh Florida please be still tonight. † That is personification because Florida can't move in the first place.The last poetic device in the song is repitition. Repition occurs in the song when he sings â€Å"And I'll sing a melody† and â€Å"Sleeping softly while I sing† the singer repeats the word â€Å"sing† throughout the song. Every word has denotation and connotation. Denotation is the dictionary definition of a word. Connotation is â€Å"an idea or meaning suggested by or associated with a word or thing†. An example from the song is the word â€Å"serene†. Denotation of the word serene is â€Å"Unaffected by disturbance; calm and unruffled. † A connotation of the word serene would be calm, tranquill or also peaceful.I know the connotation of the word serene because once i knew the definition i knew other words with the same meaning. Anoth er word from the song is â€Å"clumsy. † The denotation of clumsy is awkward in movement or handling things. Connotation for clumst would be the words awkward or gawky. I know the connotation because â€Å"awkward† is in the defintion. The last word for denotation and connotation is â€Å"overrated† The denotation of overrated is â€Å"an estimate that is too high† A connotation for the word overrated would be exaggerated.I know the connotation because exaggerated also means to overstate something. Musical presentation is imporant in music because thats how singers express themselves and their songs. The first musical presentaion of the songs is rythm. Rythm is important in songs because its the beat of the music playing. Songs usually have the same rythm throughout a song changing at the chorus. The necxt musical presentation is the instruments they use to create the song. While listening to the song you can hear the guitar, the bass and the drums and al so they use a microphone to tone and make their voices louder.The last musical presentaion is the mood of the song. The singers mood seems regretful and sad. I think this because the song is slow and if you listen to the lyrics you know what the songs about. He let a girl down and he wants her to forgive him and take him back. Thats also how you can hear the sadness in the song. There is a lot of similarities between poetry and music. They both express feelings and use similar writing techniques. This speicfic song has a lot of similarities including poetic devices, denotation and connotaion and also musical presentaion.

Cosco Business Model Analysis

The ancillary are businesses that is in or next to the warehouse to extend the product and services to make the costumers more satisfied and to shop more frequently 2. Is Cost supplying, manufacturing, or retailing its product? Cost is an intermediate between the manufactures and the retailers, but is still a retailer that sells to the end user. Cost Is a sort of a retailer that buys most of their merchandise directly from manufactures and sells It In warehouses to members who are Involved with some sort of business. Members can be business and Individual with a evidence of business existence). Cost Is also offering services to their embers as gas stations, car washes, one-hour photo centers and so on. 3. Who is the end user of Costs product? Other businesses (EBB) but also individuals with a member card can shop at Cost warehouses for personal use. What does the business need? O Key activities/ capabilities- Cost has a great power to put pressure on the suppliers to lower the price as they buy huge volumes.In that way Cost can sell their products to a lower price o Key resources ; Intellectual property (name, trademark, copyrights , patents, trade dress)adds value and its one of the most important factors in Costs success. Important factor cause of the high competition in the retail business. ; Own warehouse* everything internally o Key partners Services as check printing services, auto and home insurance, online investing do provide benefit for the members, Are generally provided by a third-part and vary by country and state. This service separate Cost from their competitors ; What does Cost offer? Value Proposition- tiny range – Limit specific Items pallets and ranks- simple display – low prices o Performance- custom oriented – additional products, services, and warranty o Many of their consumable products are only offered for sale in case, carton or ultimate-pack quantities = for business o â€Å"Getting the Job done† – Ca r wash, insurance, check printing, food court* services to makes shopping and life easier for the customers, and encourage members to shop more frequently o Design brand/status- Important success factor o Price/ cost reduction Offer lower prices because of the high sales volumes and rapid inventory turnover.That combined with the operation effectiveness by volume purchasing, effective distribution, reduced merchandise (self-service warehouse) creates a lower gross margin and Cost can therefore sell their products for a lower price. Just in time o Risk reduction Cost has a strong brand name and has members who pay to be able to buy there. Combined with a high member satisfaction that generally accepts return of merchandise, and a 90 days return policy, technical support, extended warranty on electronics. Accessibility Online shopping to provide their members a full accessibility with home delivery o Convenience/usability Who are Cost serving and how are they reaching and taking care of them? O Costumer segments Mass market- Segmented- Business and special members o Channels – Costumers can buy it in store or online Dedicated Personal assistance- provided by a third party (customer services) ; Self service- Key factor- self service lower the labor cost ; Automated services- membership, CRM Communities – magazines, coupons* keep members and attract new How are we financing the business?

About Kennedys Presidency - Free Essay Example

Sample details Pages: 6 Words: 1922 Downloads: 5 Date added: 2019/05/05 Category Politics Essay Level High school Tags: John F Kennedy Essay Did you like this example? John F. Kennedy, son of the prior ambassador of Great Britain Joseph P. Kennedy and grandson of the mayor of Boston John F. Don’t waste time! Our writers will create an original "About Kennedys Presidency" essay for you Create order Fitzgerald, was deliberately prepared for public service and politics by his father and was instilled with a sense of pride for the Kennedy image. When he was discharged from the Navy for medical reasons after being awarded the Navy and Marine Corps Medal, along with the Purple Heart, Kennedy was thrust into politics by his father who had made it his goal to have one of his sons be the first Roman-Catholic president of the United States. Although somewhat detached in personality, Kennedy served with distinction and proved a dynamic leader, especially through the crisis of the Cold War. Had he not been assassinated only a little under three years into his first term as president, Kennedy would have accomplished so much more. Kennedy rose to the presidency is 1961 due in large part to his fathers transfer of presidential ambitions from Johns older brother, Joe, to John himself. As children, the Kennedys enjoyed a privileged life thanks to their rich and politically connected Boston family, attending mostly elite, Protestant affiliated boarding schools to equip them from for the challenges of Harvard. Their access to notable tutors and leaders like Arthur Krock and Sir Winston Churchill propelled them ahead, reflecting their patriarchs drive that later determined a great deal of the familys political fortune. Before being elected, Kennedy served three terms in the U.S House of Representatives for Bostons Eleventh Congressional district and then proceeded to serve in the Senate from 1952 until his presidential victory. As President Kennedy recalled to journalist Bob Considine, I was drafted. My father wanted his eldest son in politics. ?Wanted isnt the right word. He demanded it. You know my father. Ambassa dor Kennedy admitted to telling John it was his responsibility to run for Congress and pushing him to do so (Watson 3-5; Simsung 467). In the Campaign of 1960, Kennedy benefited from a well financed and well-organized campaign, his fathers wealth allowing him to outspend his opponents in the primaries while still remaining competitive in the general election. Kennedys campaign was the first to include professional pollsters and experts in television advertising, and as he won primary elections in New Hampshire, Wisconsin, and West Virginia, many of the losers claimed his fathers money bought the elections. Despite these accusations, Kennedy managed to convince Democratic leaders that he was a viable candidate, securing the nomination of the first ballot at the Los Angeles Democratic National Convention with 806 delegate votes (Sisung 469). In terms of his running mate, Kennedy chose Texas Senator Lyndon Baines Johnson; this was a surprising move for many as Johnson had previously attacked Kennedy personally at the convention, bringing attention to his lack of experience, his poor health, and his fathers preference to steer away from the affairs or interests of other groups before World War II. However, once everyone got passed the initial shock, Kennedys choice proved to be wise; Johnson effectively balanced the ticket as he has strong support among white southerners, an area in which Kennedy as a New Englander had little (Sisung 470). Talk of the Cold War and the nuclear arms race with the Soviet Union dominated the 1960 presidential campaign and were vital international issues through Kennedys political career; both Kennedy and Nixon pledged to strengthen American military forces, promising a tough stance against the Soviet Union and international communism. Kennedy warned of the enemys growing arsenal of international ballistic missiles and gave his word that he would revitalize American nuclear forces and criticized the Eisenhower administration for allowing a pro-Soviet government in Cuba. Kennedys inaugural address stressed the contest between the free world and the communist world, and he vowed that the American people would, pay any price, bear any burden, meet any hardship, support any friend, oppose any foe to assure the survival and success of liberty (The Cold War). During his campaign, Kennedy faced opposition from the leading Protestant clergy who argued that a Catholic couldnt be president as they couldnt put the United States over the Roman Catholic Church. Knowing that he had to confront this issue, Kennedy told the clergy that he wasnt the Catholic candidate for president and promised that he would sooner resign the presidency than allow religious pressures to infringe the national interest. He also announced that he was not interested in whatever glory was attached to being the first Catholic President, that he just wanted to hold the position and happened to be Catholic, and that he didnt regard every Democrat who doubted the electability of a Catholic as a bigot. However, Kennedys religion did give him certain political assets as it gave him the chance to recapture a portion of Catholic voters who has previously stopped voting Democratic nationally, but he was never under the impression that all Catholics would willingly support him. Af ter all was said and done, while Kennedy may have only gotten 38-46 percent of the Protestant vote, the 78-80 percent of the Catholic vote and other ethnic groups helped him carry several of the urban-industrial states in the electoral college (Sisung 470, Sorenson 126-127). Support from African American voters, which he had won from Nixon after he made phone calls to get Martin Luther King Jr. released from police custody, also helped push Kennedy ahead in the election. By helping the most influential civil rights leader, Kennedy carried 70 percent of the African American vote, which later proved crucial in several northern cities (Sisung 471). With support from both of these parties, along with other voters, Kennedy had a realistic chance of victory. However, it was the young mans style during four nationally televised debates that propelled him over the finish line and into the presidency, his good looks projecting a confidence that Nixons demeanor did not. These debates revitalized Kennedys campaign and boosted him in the polls. By election day, Kennedy had 49.7 percent of the total vote with 22 states and 303 electoral college votes while Nixon had 49.6 percent of the total vote with 26 states and 219 electoral college votes (Sisung 471). Towards the beginning of his presidency, Kennedy was faced with a conflicting choice on the matter of a CIA-sponsored invasion known as the Bay of Pigs; while he had reservations about the plan due to his concerns about its chances of success and how it would affect not only his image but the countrys as well, he failed to cancel the operation as he was reluctant to call off an anti-Castro effort that had been concocted during the EIsenhower administration. Kennedy falsely believed that the United States would have plausible deniability in the affair and neglected to demand a thorough military review of the invasion plans, resulting in less than satisfactory results (Graff, 494). Upon the day of the invasion, it was made clear that not only were the invasion plans based on false, unrealistic assumptions, but that Castros military forces were too strong and his regime too popular for a counterrevolution to succeed. Most of the invaders were captured and later ransomed, over a hundred were killed, and some were rescued from the sea by US Navy forces. In the end, Kennedy effectively picked up the pieces, accepting total responsibility, and began to regard the invasion as a lesson. He took from the incident the idea that the president has to have operational control during international crisis instead of heavily relying on experts and that there was a need for a better counterinsurgency capability in order to prevent future Castros from obtaining power in the first place. As time went on, Kennedy made high-level personnel changes in both the CIA and the military and strengthened oversight and coordinating functions, the lessons and these changes proving useful du ring the Cuban Missile Crisis (Graff, 494-495). In June of 1961, shortly before the Bay of Pigs, Kennedy met with Soviet leader Nikita Khrushchev in Vienna, Austria to negotiate in terms of the arms race. Khrushchev threatened to cut off Allied access to Berlin and ordered the contruction of the Berlin Wall to stop the flood of East Germans into West Germany just two months later. This was seen as a threat to Kennedy, spurring him into action as he ordered the substantial increase in American intercontinental ballistic missiles forces, added five new army divisions, and increased the nations air power as well as its military reserves. Meanwhile, the Soviets resumed their nuclear testing and Kennedy reluctantly followed suite in early 1962 (The Cold War). After the Bay of Pigs, Secretary of State Dean Rusk placed himself closer to the president. Rusk believed the world during the 1960s to be caught up in revolutionary changes. He also believed that the U.S foreign policy should give new nations with both technical and humane assistance to help them achieve a more modern way of thinking and democracy. Rusk advocated diplomacy, highlighting civility and communication between the United States and the Soviet Union. This diplomatic attitude and ability to assess competing points of view eased not only the tensions during the Cuban Missile Crisis but also aided in the negotiation of the Limited Nuclear Test Ban Treaty in 1963 (U.S Department of State). In October of 1962, an American U-2 spy plane photographed nuclear missile sites being built by the Soviet Union in Cuba. President Kennedy didnt want the Soviet Union nor Cuba to know that he has discovered the missiles and chose to meet in secret with his advisors to discuss the issue. Eventually, Kennedy came to a decision; a blockade was placed around Cuba to prevent the Soviets from delivering any more military supplies while Kennedy demanded the missiles be removed and the site destroyed. Everyone was unsure of how Soviet leader Nikita Khrushchev would react to these demands; however, both leaders recognized how devastating a nuclear war would be and publicly agreed to a deal in which the Soviets would disassemble both the missiles and the site in exchange for a pledge from the United States not to invade Cuba. In a separate deal that was kept undisclosed for over 25 years, the United States also agreed to remove its nuclear missiles from Turkey (Cuban Missile Crisis). Kennedy didnt have much influence with individual members of Congress and paid very little attention to the legislative process, seemingly lacking the energy and will to do so. He disliked the intense bargaining and time-consuming follow-ups and chose to establish a congressional liaison office headed by Lawrence F. OBrien rather than directly deal with Congress on normal legislative matters. However, OBrien was inexperienced on Capitol Hill and was seen as an unnecessary buffer between the president and Congress. This left members of Congress without the personal contact with the president that was expected and ultimately feeling shut out by Kennedy (Sisung 472). Despite his evasion of certain legislative duties, Kennedy managed to pass three out of five high-priority bills that were on his 1961 legislative agenda; legislation for housing, aid to depressed areas, and increased minimum wage. Kennedy had also proposed a civil rights bill, but this didnt pass during his presidency as he didnt want to risk losing the support of the Democratic party, who held control over Congress, as well as Congress itself which was comprised of a conservative coalition of about 70 Republicans and southern Democrats by pushing too hard on the sensitive matter. This conservative coalition had been attempting to block any liberal-activist and federal expansion programs, along with any bill that may give African Americans civil rights, since 1938 and continued to do so during Kennedys presidency (Sisung 472-473).