Risk Study Report (occupational health and safety) Research Paper

Risk Study Report (occupational health and safety) - Research Paper Example Individual and commercial insurance is a good way to reduce the personal as well as commercial financial risks. I have selected the J. Paul Getty Museum as the visiting location. The location is situated in Los-Angeles. Los Angeles itself is blessed with beautiful landscapes and the building of the museum is made uniquely so that it would attract as many visitors as the museum can hold. On the other hand the entry to the museum is absolutely free, while visitors are charged $15 for the parking. However, after 5p.m the parking is free too. Museums are good places to find cultural, religious and ancient aspects of the location. Around 1.3 million people visit the museum each year (The J. Paul Getty Museum, 2012). The most significant feature of the tourism business is the capability of the operators to deal with the risks and associated factors regarding the tourism business. It is equally viable for the operators to maintain a smooth, receptive and cost efficient insurance that will ensure to meet the legal necessities and requirements. Risk management ensures to make clear reduction in the unnecessary and unintentional events. However, it is important for the risk managers to develop such strategies to reduce the impacts of the unplanned events. The third important perspective of the risk management is to improve the capability to have full control on all the events and associated risks and maintain cost-efficient insurance within the business environment. Risk management strategies will ensure to enhance the recognition of the risks, analyze the risks and the make strategies to reduce the risk. It not only benefits the organization but also the individuals. On the other hand, the risk management techniques will help to face the accident and help us to be prepared for any accidents. The techniques will also reduce the severity and the after effects of the accidents. Financial damages are heavily influenced by the

Personal Statement Example | Topics and Well Written Essays - 500 words - 47

Personal Statement Example This was a trial for me on whether I could handle the PA career and most of all whether it was really what I wanted to do when I grew up. As a medical assistant, I got to perform services that a PA performs under direct supervision from the medical doctors I was working for and this got me really interested in this line of work. I had the opportunity to carry out what I had grown to love which was to help people and make them feel better as well as putting smiles on their faces even though they were physically unwell. I became a volunteer at the American Red Cross as well as at the Veteran’s Foundation after my job. This was propelled by the suffering I had witnessed in Iraq as well as it was another experience for me to be a PA. Being a volunteer meant I now had an opportunity to assist people through providing therapeutic and preventive services no matter how minimal an impact I made. The satisfaction from seeing the smile on people’s faces who had been suffering health wise before made me go to bed happy and satisfied which was a rare occurrence for me. My final journey towards making the decision and following my passion came when my mother had to undergo an open heart surgery. There was a team of physical assistants on the table with the doctor assisting him with everything and this sealed the deal for me. I was determined more than ever to join this career and fulfill my dreams and seeking admission into this program is the deal breaker. I would like to specialize and focus primarily on urgent care as I will be handling people without primary care physicians or those who are too scared to visit emergency rooms but they would still like remedies for their injuries or illnesses that are not too serious. This line of specialization is appealing because it is what I have learnt and gained experience on from volunteering at the Red Cross. Being granted this

Domestic monetary systems Essay Example for Free

Domestic monetary systems Essay With a population of 170 million, the Islamic Republic of Pakistan is strategically located in South Asia, sharing borders with India to the East, China to the North East, Afghanistan to the North West and Iran to the West. To the south lies the Arabian Sea, this provides close proximity to the Gulf Cooperation Council (GCC) countries. The country is predominantly Muslim with a major portion of the population (65%) residing in the rural areas. Although significant progress has been made in recent years, the country still lags behind as far as social infrastructure and human development are concerned. (Bajwa, 1999) Structure of Government and Politics: The constitution of the country, promulgated in 1973, holds out the country as a parliamentary democracy with all powers vested in the parliament. However, for much of the past decade, Pakistan was run along the lines of a military dictatorship, with Parliament subservient to the President and vast powers vested in his self. After the gradual transfer of power to democratic forces following an election on the 18th of February, the resignation of General (Retd) Pervaiz Musharraf, and the election of Asif Ali Zardari as the new President, parliament is reviewing the balance of power between the Presidential Palace and the Parliament House and it is expected that, soon, the country would revert back to the old format of the President being a ceremonial Head of State and the Prime Minister running the country independently with Parliament backing. (Malik, 2001) At present, there is a coalition government in place that comprises the Pakistan Peoples Party (PPP). It is led by the President of the country, Asif Ali Zardari, who happens to be the widower of famed democratic leader Benazir Bhutto, assassinated by terrorist elements during an election rally in the city of Rawalpindi last year. Other coalition partners include the MQM (Muthaida Quami Movement translated as United National Movement) and the ANP (Awami National Party). The Opposition is deeply divided and primarily consists of the Pakistan Muslim League (Q) and the Pakistan Muslim League (N). The main political issues on the domestic front are, as mentioned above, the repealing of anti democratic laws enacted as part of the constitution by the outgoing military regime and the issue of the deposed judges of the supreme court that were sacked by the former military regime when they refused to remain puppets. Apart from this, there is the dire issue of reconciliation between neglected provinces. However, the inability of the new coalition government to actively address issues of popular appeal and an over indulgence in issues of power sharing and power consolidation lend it ever decreasing credibility in the eyes of the general public. Although the new government has been in power for almost an year, its performance has been dismal. The popular mandate of democracy that has shot the PPP and its coalition partners into power has not been implemented. The Prime Minister, Yousuf Reza Gillani, remains a puppet and the Presidential Palace remains the main power fort. Despite the fact that the opposition is ready to support the government on national issues, such as the reinstatement of deposed judges and the repealing of undemocratic laws, the government has so far shown quiet restraint to address these issues. Foreign Policy: â€Å"Pakistans foreign policy has been marked by a complex balancing processthe result of its history, religious heritage, and geographic position. The primary objective of that policy has been to preserve Pakistans territorial integrity and security, which have been in jeopardy since the states inception. † (US Library of Congress) The aforementioned paragraph adequately describes Pakistan’s foreign policy ever since it came on the map of the world in 1947. Being predominantly Muslim, the country finds itself sentimentally attached to the Islamic World, in particular the Middle East. A developing country, lacking skilled manpower and capital to exploit the wealth of natural resources that its lands have been bestowed with, the country’s foreign policy has had to take in account the economic impact that relations with other countries can have. Moreover, traditional enmity with the giant neighbor on its eastern borders (India) has forced it to make balancing measures with staying in the good books of China and supporting pro Pakistan elements in Afghanistan. (Bajwa, 1999) Pakistans foreign policy is deeply aligned with the United States goal of War on terror. After the September 11 attacks, Pakistan renounced terrorism and became a frontline state in the war against terrorism. The country is the main supply route to NATO forces stationed in Afghanistan and is a major non NATO US ally. Despite this close alignment with the United States, the country often finds itself in a tricky situation when it comes to its tribal belt bordering Afghanistan. These areas are largely unregulated since independence from the British in 1947, operate with full autonomy while pledging allegiance to Islamabad. Pakistan is blamed for â€Å"not doing enough† to quell terrorist incursions from these tribal areas. Tribes here are said to be providing safe havens to terrorist and Taliban elements with the theory that the top brass of Al Qaeda and the Taliban is hiding here. NATO led forces have made several air strikes in the area which Pakistan declares as encroachment on its sovereignty but takes little steps to discipline these tribal belts. Part of this inaction is based on the fact that a stable Afghanistan, aligned with India is not in the best interests of Pakistan. Traditional enmity with India over the Jammu Kashmir disputed territory has led the two countries to fight three full scale wars in 1948, 1965 1971 and one limited war in 1999. Pakistan perceives a pro Pakistan Afghan government or an unstable Afghanistan as a hedge against encirclement by India. It is this threat to its security that leads it to, introvert if not extrovertly, refrain from taking any drastic steps to quell those destabilizing elements in Afghanistan that originally emanate from its terrotiry. (Bajwa, 1999) On the economic front, Pakistan is primarily an exporter of textiles accounting to about 57% of the country’s exports. Prime markets are North America and Europe. Good relations are important with these two blocks of nations as they provide trade facilitation and, at the same time, help with soft loans and aid to help in social and economic development. Remittances also play an important part in the country’s balance of payments and a large amount of Pakistani’s work in the Middle East, Europe and America. The country’s foreign policy also has to take account of these factors. (Malik, 2001) Thus, to sum up, as implied earlier, the country’s foreign policy is driven by its perceived security threat, religious affiliation with the Islamic fraternity of nations and the dependence upon economic aid and facilitation by friendly countries. While the policy has been largely successful in maintaining the country’s territorial (if we exclude the secession of East Pakistan in 1971 due to Indian intervention) integrity and safeguarding its economic interests, continuing on such lines indefinitely is not an option and it is important that the country makes a strategic review of its policy and seek alternative ways of addressing outstanding issues. Domestic Monetary Systems: Speaking In purely political economic terms, the government of technocrats that took power in October 1999 was faced with a huge crisis. Business confidence was low, investors were hesitant and the economy seemed to be heading for a deeper depression. Political legitimacy for the regime was another issue. Quite smartly, the policy makers then decided to lower interest rates. The idea was that low interest rates would encourage private sector borrowing, push up aggregate demand, increase corporate sector profitability, help in the generation of employment and quite importantly provide legitimacy to the regime. The concept to create this artificial boom was not a bad idea at all, but the fact that this approach only stocks problem for the future are alarming. While banking is referred to as â€Å"the refined management of money†, during the last 9 years, the country bore witness to the greatest mismanagement of scarce resources in the history of the country. The rise of consumer banking in an undocumented economy meant that people borrowed cheap and spent it on unproductive activities like buying consumables, investing on a volatile stock market vacationing in Europe. New investment in capital was made, but the bulk of the corporate sector used the low interest rates to either replace existing machinery or reschedule existing loans at cheaper rates. Thus, the economy was inflated by the use of an expansionary monetary policy that increased the dependence on oil and fuel. Worse, the effect is more severe as a high proportion of petroleum consumption is used by private car owners. Had the government tried to balance total economic and social benefit with total economic and social costs, by for example, encouraging public transport as opposed to private car ownership, the economy would have been less affected by the oil price hikes. Switching to Compressed Natural Gas was instead provided as a viable alternative but the result was lower gas supply for domestic and industrial use. Today, the Pakistani economy is representative of an over inflated balloon and attempts to deflate it are having serious repercussions. The state bank of Pakistan has raised interest rates to 15. 5% in attempt to curb inflation running as high as 20%. Measures have been introduced to reduce the money supply. This would help ease inflationary pressures on the demand side. However the argument goes that high interest rates would discourage investment, lead to low business confidence result in excessive saving as people would consume less and save more. This would mean that a â€Å"general glut† would appear in the economy with high inventories and unused capacity. Unless there is adequate demand outside the economy, employment levels may fall and output would decrease, leading to further slow growth, possibly complete stagnation. Given the current world economic scenario, with recession in the US, the sub prime mortgage crisis, competition from low cost producers such as China and India and the overall geo political scenario, monetary contraction is only making matters worse. Another important problem is the fact that unethical business practices like cartelization and hoarding are ever prevalent in this country. Moreover, the country is highly dependent upon imports of fuel and other items to aid its industries. Thus, a major portion of the inflation that the country faces is cost push in nature. However, the aim remains to target aggregate demand. (Janjua, 2008) This policy of the government makes some sense as the economy is artificially inflated. However, by not targeting the cost push factors and solely targeting the demand factors by reducing money supply, the government is not helping consumer and business confidence. The government’s inaction can be explained by two reasons. First, the country has recently obtained a hefty loan of USD 7. 6 billion from the IMF. A condition of this loan is to restrict money supply further. This is typical of many IMF financings which focus on monetary betterment as opposed to the level of unemployment and GDP growth. Secondly, many of the cartels have representation in the government and due to the absence of a strict legal system; any action against them is made impossible. Foreign Trade: A very interesting scenario is presented in the Economic survey of Pakistan 2007-8, which states that exports â€Å"suffer from serious structural issues which need to be addressed primarily by the industry itself, with government playing its role of a facilitator. † It then goes on to tell how textiles are the most important contributor to exports (56. 67%) and the issues that the industry faces as a result of its inability to innovate, become efficient and embrace fashion trends in its primary foreign markets. A new surprise is found in the face of food items (the country is running out of water, by the way) accounting for 13% of total exports, petroleum products (meager resources at best) accounting for 6% of total exports, manufactured leather products 3. 7% and chemicals and pharma products almost 3. 27% of total exports. Aggregate these and you find that the top five exports make up 83% of total exports. (Ministry of Finance, 2008) The point of doing this analysis is to show that as an economy; Pakistan is heavily exposed to, what is called in financial management terminology, unsystematic risk. Its lack of diversity makes it more prone to microeconomic shocks in the prime exports that it makes. Another worrying problem is the terms of trade, (a monetary measure of the price of exports upon the price of imports). Sadly, whereas the terms of trade were highly in favor of Pakistan until 1998-99 (115. 7), they have since then nose dived to stand at 58. 35 (2007-8). What this implies is that although the country has been exporting a lot more in volume, in value terms, international trade is becoming increasingly disadvantageous for Pakistan. Even if you take the effect of rising oil prices out of this analysis, the terms of trade had, never the less had fallen to 73. 6 by 2004-5. This lack of value addition makes us it more suspect to microeconomic level industry shocks that could further damage its standing in the export market. (Ministry of Finance, 2008) The previously mentioned most accurately describes the Pakistani government’s policy towards foreign trade. Although it has been working tirelessly to gain access to markets in Asia, Europe and North America for its export industries, the emphasis has remained towards increasing textile exports. This support of textiles and agricultural items to a certain extent has not fared well for other industries and sectors. Export diversity is low and so is value addition. Moreover, the country has not been able to reposition itself with regard to reliance on imports. So in so, that even though the country is an agricultural country by definition, due to poor harvests and lack of support, in certain years, we see that staple food items are imported by this agricultural country. Although natural consequences favor that Pakistan produces and exports textiles and food items, unfortunately, but both these industries have certainly lost their efficiency at doing the job that is intended of them. The textile industrys inability to change coupled with power shortages and political nightmares and our lack of water resources for agriculture coupled with reluctance from commercial banks to serve this sector means that there should be a policy change at the federal level. The high level of competition that these industries face means that the government has to take steps not only to help these industries blossom and at least maintain their market share, but to ensure that comparative advantage is exploited in other fields as well. The Pakistani government has been providing support to the traditional industries for some time now with mixed results. Therefore, instead of a status quo â€Å"wait and see† policy, a change is warranted. Thus, a policy shift should be made towards growth of value adding, job and export oriented activities. Exchange Rate Policy: Interest rate parity and purchasing power parity holds that changes in exchange rates between currencies can be explained by differences in interest rates and inflation rates respectively between countries. Building on this premise, the Rupee Dollar (PKR:USD) exchange rate remained range bound between PKR 59/USD to PKR 62/ USD for almost 8 years, starting 2000. The reason was that the country followed a managed float, with the central bank intervening in the market whenever the exchange rate would go out of range. This was happening against the backdrop of the fact that interest rates and inflation rates were considerably high in Pakistan and the currency was expected to depreciate. (State Bank of Pakistan) This managed float policy changed in early 2008 when the new government took power and the country reverted to a floating system. The rupee has since lost 33% of its value against the US dollar and currently stands at PKR 80/USD. (State Bank of Pakistan) The current policy is more realistic in its economic nature as the country, lacking substantial foreign currency reserves and a permanent balance of payment deficit could not continue to support an artificially strong exchange rate. Furthermore, this new policy of floating exchange rate systems will benefit the country with regard to its exports becoming cheaper when priced in USD. However, whether demand for the country’s exports picks up is another issue. More over, the effect of the rise in the prices of imports also has to be considered as many inputs in the production process are imported. Conclusion: The analysis of Pakistan’s monetary, foreign trade, exchange rate and foreign policy reveals the tendency in many developing countries to take decisions regarding economy based on politics. The short term benefits include lending credibility to the person in power, but the long term effects are almost always devastating. References: Bajwa Naseem, F. (1999) Pakistan : A Historical and Contemporary Look. Karachi : Oxford University Press. Asif Malik, M. (2001). Ideology and Dynamics of Pakistan. Karachi: Publishers emporium. Lipsey G. , H. Harbury, C. (1992) First Principles of Economics. London: Oxford University Press. Library Of Congress. For Researchers. Retrieved from http://www. loc. gov/rr/ State Bank Of Pakistan. Publications : Financial Stability Review. [Data File] Retrieved from http://www. sbp. org. pk/fsr/2006/index. htm Janjua Ashraf, M. (2008).. Government Borrowing and State Bank’s Authority. The Daily Dawn Economic and Business review Retrieved 12th december 2008 from http://www. dawn. com/2008/11/24/ebr14. htm

Electroconvulsive Therapy for Severe Depression: Evaluation

Electroconvulsive Therapy for Severe Depression: Evaluation Can electroconvulsive therapy make a meaningful contribution in the treatment of Severe depressive illness? The work of mental health nurses. Contents Abstract Introduction Methodology of the review Critical Review of the literature The place of electroconvulsive therapy in the therapeutic armamentarium The place of electroconvulsive therapy in relapse prevention Mechanism of action Preference of site of stimulation Side effects of treatment Discussion Conclusions Appendix References Abstract This dissertation seeks to explore the evidence base for electroconvulsive therapy. It does so by considering the historical background to the procedure and its evolution to the present. It considers the professional and legislative guidelines which govern its use and contrasts the regulations in the UK with those in other cultures, notably the USA. In order to assist the exploration, the literature review is subdivided into five sections, each exploring a different area of interest. Electroconvulsive therapy is placed within a therapeutic spectrum of treatment for patients with major depressive illness and psychosis and is compared with other modalities of treatment. Its use in both acute treatment and its role in disease prevention and relapse is discussed. Current hypotheses of its possible mode of action are explored, and conclusions drawn about the strength of the evidence base in this area. There appears to be considerable discussion about the site of optimal stimulation for electroconvulsive therapy. This area is discussed in depth with a critical analysis of the studies which inform the evidence base in this area. The literature review concludes with an examination of the various side effects of the treatment. There is an element of discussion of the evidence and conclusions are drawn from the evidence extrapolated and presented. The whole dissertation is fully referenced. Introduction Electroconvulsive therapy was introduced into clinical practice in the late 1930s and rapidly gained a place in the standard treatment of major depressive illness. It was originated by the Hungarian, Dr Meduna, who mistakenly believed that schizophrenia and epilepsy were mutually exclusive conditions. He argued that epilepsy was never seen in schitzophrenic patients and therefore artificially inducing fits (epilepsy) in patients would cure schizophrenia. (Mowbray R M 1959). The effects on schitzophrenia were soon recognised to be minor and the most marked effect appeared to be in the patients with major depressive illness. The advent of effective classes of antidepressant, antipsychotic and mood stabilising drugs has seen a marked decline in the use of electroconvulsive therapy, but recent figures suggest that it is still used in over 10,000 cases per year in the UK (ECT Survey 2003). Currently the main use of electroconvulsive therapy is in major depressive illness although it also is considered still to have a place in the treatment of schizophrenia and some other mood disorders (UK ECT 2003), psychosis (Corrible E et al. 2004), and overt suicidal intent (Kellner C H et al. 2005). The Mental Health Act of 1983 allowed Psychiatrists to give electroconvulsive therapy to inpatients without consent if they were sectioned. This should be contrasted to the situation after the 1959 Mental Health Act, where psychiatrists had no clear guidance and a number of litigation cases forced a change in legislation. (Duffett R et al. 1998) The procedure itself involves anaesthetising the patient with a general anaesthetic and a muscle relaxant and the a small, brief pulse current (typically about 800 milliamperes) is passed between two electrodes applied directly to the scalp. This generates a seizure and there are a number of demonstrable biochemical changes in the brain after the event. (Nobler M S et al. 2001) Electroconvulsive therapy is usually given as a course over several weeks. The evidence base for length of time of treatment is not strong and appears to vary considerably between authorities. (Lisanby S H 2007) In 2003 NICE investigated the evidence base for electroconvulsive therapy and issued guidelines which suggested that it should only be used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode. (NICE 2003) One of the most extensive recent reviews on electroconvulsive therapy concluded that it had been demonstrated to be effective short term treatment for depressive illness in otherwise healthy adults. Many studies were cited and had shown it to have a greater effect than drug treatment. The authors noted shortcomings in many of the trials cited, especially in areas such as drug resistant depressive illness where electroconvulsive therapy is believed to be particularly helpful. (UK ECT Review Group 2003) One of the major side effects of electroconvulsive therapy is short and long term memory loss cited in many trials and studies (viz Gupta N 2001) Methodology of the review Cormack suggests that â€Å"Ultimately all good research is guided by and founded on a critical review of all of the relevant literature published on the subject.† (Cormack, D. 2000). It is therefore important not only to define what is currently believed about a subject, but also to place this in a historical context. This is particularly important in the field of electroconvulsive therapy, as the introduction to this dissertation has suggested, with great fluctuations in both understanding and application of this type of therapy over the years. One of the prime reasons for conducting a literature review is to establish the current evidence base for a particular subject. A critical review of the literature must be preceded by a careful literature search. It is often believed that searching the literature is a linear or â€Å"single episode† process. Current thinking suggests that this is seldom an optimal strategy. Bowling advises that a good literature review is â€Å"primarily a cyclical recursive process that mirrors the thinking and research process, where the discovery of new information results in new ideas, new knowledge and possibly new understanding. Once an overview, or initial opinion has been formed, it then becomes possible to revisit the initial reviews from a more informed perspective which, in turn, allows for a more perceptive interpretation of the data. (Bowling A 2002). The methodology used in this particular review was to allow for an initial period of reflection on the subject matter and to consult a small number of reference books to achieve an overview of the area. (Taylor, E. 2000). References were noted and some followed up in order to ascertain the main themes of the review. Once these were established, then methodical searches of a number of databases were carried out utilising the facilities of the local University library, the Post-graduate library (Client to personalise here) and a number of on-line search engines and literary sources including Cochrane, Cinhal, Ovid, BMJ and Lancet archives, Royal College of Psychiatrists archive and various NICE publications. Papers were accessed in both hard back and electronic forms. (Fink A 1998) Search terms included electroconvulsive therapy; evidence base; evolution; history; schizophrenia; psychosis; major depressive illness; mental health nurse; antidepressant drugs; Mental Health Act; psychiatrist. These terms were used in various combinations to sift papers with varying degrees of relevance to the topic under consideration. (Carr LT 1994) Inclusion criteria were papers less than 10 years old (unless there were specific reasons for older paper inclusion). UK sources were preferred to other ones. It should be noted that a substantial proportion of the body of literature on the subject of electroconvulsive therapy is American based. A number of authorities have suggested that this may be because the USA currently uses electroconvulsive therapy more frequently than the UK and therefore has a greater experience with it. Papers were only considered from peer reviewed sources unless making a historical point. (Bell J 1999). Each paper considered was then ranked according to its evidential value (See Appendix 1) and the highest value paper was presented for each point to be made. Critical Review of the literature The place of electroconvulsive therapy in the therapeutic armamentarium A good place to start this literature review is with the Olfsen paper. (Olfson M et al. 1998). This is an authoritative overview of the place of electroconvulsive therapy in the treatment spectrum. It has to be noted that this paper is already 10 years old and reflects clinical patterns of usage in the USA. The reason that this paper is selected for discussion is primarily on the vast size of its study cohort, which is 6.5 million patient contacts (249,600 with a diagnosis of depressive illness) spread over mainland USA. Critical analysis of the paper suggests that the authors reveal their viewpoint in the first few sentences of the paper and therefore the opinion part of the review must be understood on the basis that the authors consider electroconvulsive therapy a â€Å"safe and effective treatment for patients with all subtypes of major depression† citing the authority of the APA for this statement (APA 1997) The paper suggests that there is a strong evidence base to confirm that electroconvulsive therapy is at least as effective as antidepressant drugs pharmaceuticals for the treatment of major depressive illness. (Weiner R D 2004) The authors make the point that despite this general belief, electroconvulsive therapy is not as widely used as it should be due to three major misconceptions namely public concern about the safety of the procedure, reactive regulations and guidelines and the belief that it is not cost-effective. They then set about addressing each of these concerns Rather worryingly, the authors cite evidence of safety with the unqualified comment that â€Å"None of the depressed patients who received ECT died during the hospitalisation. In contrast, 30 (0.14%) of the depressed patients who did not receive ECT died in the hospital. (Schulz K F et al. 1995) Although this may well be the case, it is entirely possible that patients who were ill with other comorbidities (and therefore at greater risk of death) were not offered electroconvulsive therapy, as it required a general anaesthetic. One cannot jump to the implied conclusion that these figures suggest that electroconvulsive therapy is therefore intrinsically safe. (Mohammed, D et al. 2003) The authors draw a number of conclusions, perhaps the most significant of which is that current practice tends to reserve electroconvulsive therapy for the elderly, and those with comorbidities such as schizophrenia, dementia, and general medical (nonpsychiatric) disorders. They also comment that prompt use of electroconvulsive therapy is associated with shorter in patient stays and, by definition, more rapid resolution of the depressive state. Despite these findings, there is a large body of literature documenting the fact that many patients with major depressive illness remain largely unresponsive to therapeutic intervention. With this in mind one should consider the contribution of the Spanish research group under Gonzalez-Pinto who published a trial of a small group of patients (13) who had proved resistant to both venlafaxine and electroconvulsive therapy separately but who responded to both measures when used in a combined fashion. (Gonzalez-Pinto A et al. 2002). This was a non-randomised non-controlled trial and therefore constitutes evidence value at level III. Curiously the response was not proportional to the dose of venlafaxine used. The authors however, report the rather worrying side effect of asystole in 3 of the 13 patients immediately after the electroconvulsive therapy. A number of authorities suggest that there is a definite place for electroconvulsive therapy in the severely depressed patient who is a suicidal risk. The Kellner paper addresses this suggestion directly. (Kellner C H et al. 2005). Suicide remains one of the major associations of major depressive illness and carries a 15% lifetime risk for any patient who has been hospitalised with the same. (Bostwick J M et al. 2000) with symptoms such as profound hopelessness, hypochondriacal ruminations or delusions, and thoughts of suicide or self-harm during depression predict future suicide. (Schneider B et al. 2001). The Kellner study was a randomised crossover comparative follow-up trial making it evidence value of level 1b. There are a great many result strands from this study, but if one specifically considers the suicidal elements, then one can state that the study showed that of the 444 patients enrolled in the trial as having major depressive illness, 26% had suicidal ideation at a level of 3 or greater on the Hamilton rating scale (the measurement tool used in the trial) and 3% achieving a score of 4 (actual suicidal attempt). This group had a reduction of their scores to 0 in over 80% within the two week course of the electroconvulsive therapy. It was also reported that in the group who scored 4, 100% dropped to 0 by the end of the treatment. Despite there impressive figures for short term remission, one would have to note that the trial did not have any significant long term follow-up and there is no information on the rate of relapse after the initial treatment. (Rosenthal R. 1994). The authors state that they were aware of two successful suicide attempts which occurred whilst the trial was running (but after these patients had completed their treatment. The authors suggest that electroconvulsive therapy should be used early in the treatment regime once a diagnosis of suicidal risk has been made. To provide a balanced argument on the place of electroconvulsive therapy in the spectrum of treatment, one can consider the recent paper by Eranti (Eranti S et al. 2007) who tested out the hypothesis that has recently been published, that Repetitive transcranial magnetic stimulation (rTMS) is as effective as electroconvulsive therapy but does not have the same side effect profile that restricts the use of electroconvulsive therapy in some patients. (viz. Gershon A A et al. 2003 and Loo C K et al. 2005) This trial was a randomised, blinded comparative trial with a substantial entry cohort (260 patients) being followed up for 6 months after treatment giving it a level 1b significance. (Clifford C 1997). There were a number of possible outcome measures studied but, of relevance to our considerations in this dissertation, one can state that the authors found that Repetitive transcranial magnetic stimulation (rTMS) was not as effective as electroconvulsive therapy in the treatment of depressive illness both at the end of the treatment period and at the end of the 6 month study. The authors were able to comment however, that the rTMS was virtually free of demonstrable side effects. The place of electroconvulsive therapy in relapse prevention It is fair to comment that a brief examination of the literature shows virtually no good quality published material on this topic with the studies that have been done comprising individual case reports (viz Kramer B A 1990), naturalistic studies and small studies of retrospective cases (viz. Schwarz T et al. 1995), none of which have any control element and all of which are evidence level IV at best. A notable exception is Keller et al. who made a large UK based study of relapse prevention in major depressive illness with a randomised controlled trial over a seven year period involving over 500 patients. (Kellner C H et al. 2006). The trial is a level 1b evidence level trial and is of a particularly robust structure with great efforts made to achieve standardisation. (Denscombe, M 2002). The structure is a direct comparison between electroconvulsive therapy and a standard pharmacological regime (lithium carbonate plus nortriptyline hydrochloride). Both were given as a therapeutic course (the medication over a six month period) and the patients were followed up with DSM-IV assessments to determine their degree of relapse The analysis is long and complex but, in essence, the study clearly demonstrated that both groups had better results than a placebo control with similar percentages (about 33%) suffering a relapse and about 46% remaining disease free. The trial suffered from having a large group (about 20%) failing to complete the trial protocol. (Rosenthal R. 1994). This study does however, provide firm evidence that electroconvulsive therapy is at least as effective as pharmacological measures in reducing the likelihood of clinical relapse. Further evidence for longer term efficacy comes from the Gagnà © study (Gagnà © G G et al. 2000), which starts by acknowledging the fact that depressive illness tends to be a long term disability with long term pharmacological intervention a comparatively normal treatment strategy. The authors make a subtle distinction between continuance therapy (which is starting a new course of treatment after initial resolution and then relapse) and maintenance therapy which extends beyond the continuation therapy stage and is aimed at preventing relapse. This paper is noteworthy because, as the authors point out, there is general acceptance by healthcare professionals that long term maintenance therapy with pharmaceuticals is both rational and indicated in patients with a high likelihood of relapse of depressive illness. Treatment with continuation electroconvulsive therapy has failed to gain general acceptance. The authors argue that such an approach is particularly rational, at least in a group of patients who have demonstrated their ability to respond to electroconvulsive therapy in the past, are at high risk of relapse and who may be refractory to pharmacological intervention. The Gagnà © study is a retrospective case-controlled comparative study comparing the long term course of electroconvulsive therapy plus pharmacological maintenance therapy with long-term antidepressant treatment alone in a demographically matched group. The two groups comprised 60 patients. The maintainence electroconvulsive therapy group received the electroconvulsive therapy as a single treatment monthly after the normal intensive treatment course for the acute episode. It has to be noted that this regime is comparatively arbitrary as there appears to be no preceding published evidence base to support it. The results from this study are nonetheless quite impressive. Both groups are reported to have responded to treatment, but the group who were also maintained with follow up electroconvulsive therapy did markedly better in terms of resistance to relapse being almost doubled at two years (93% vs. 52%), and quadrupled at five years (73% vs. 18%). This result could also be expressed as a doubling of the mean time to relapse in the electroconvulsive therapy group (6.9 years versus 2.7 years for the antidepressant-alone group). A major criticism of this study would have to be a lack of standardisation of treatment in the electroconvulsive therapy group with some patients receiving univocal and others bipolar electroconvulsive therapy. The number and duration of each was left â€Å"to the clinical judgement† of the responsible clinician. This does not reduce the impact of the overall finding, but does make for difficulties in comparison with any other trials which might follow. (Berlin J A et al. 1999) A critical analysis of the study would also have to conclude that the study suffered from a comparatively small number of patients with assignments to the comparison groups not being random. More importantly, the trial assessor was not blinded to the patients group assignment. These factors make it difficult to confidently assign an evidence level to this trial. (Denzin, N K et al. 2000) The authors conclude their study with the comment that a larger, prospective study on the subject is currently underway. One should perhaps regard the results of this study as interesting, but not proven. In assessing the validity of this paper, one should note comments that it has generated in the peer reviewed press. Gupta makes a number of valid points of criticism (Gupta N. 2001), arguably the most important of which is that the study did not make any measurement of the well recognised effect on memory function that short term electroconvulsive therapy is known to have. (Isenberg K E et al. 2001). Gupta suggests that clinical effectiveness must be assessed only after a risk-benefit ratio has been properly determined. Certainly a valid point and one that was not addressed in the original paper. Mechanism of action A number of papers have been published reporting biochemical changes after electroconvulsive therapy. There seems to be a general agreement that depressive illness is associated with a disturbance in the monoaminergic-cholinergic balance within the cerebral cortex. (Schatzberg A F et al. 2005). A novel and significant advance was published in 1998 by Avissar (Avissar S et al. 1998) when a correlation with G-protein levels in leucocytes was found and was discovered to be significantly reduced in depressive illness. The significance of this paper was that the authors found that electroconvulsive therapy resulted in a normalisation of the G-proteins level which preceded (by about a week), and thus predicted, clinical improvement. Patients who did not respond to electroconvulsive therapy did not show a change in G-protein levels. The significance of this finding is enhanced with the knowledge that lithium is also known to alter G-protein levels (Schreiber G et al. 2000), as are some other treatments for bipolar disorder. (Young L T et al. 2003). It is also known the G-protein levels are raised in manic states thereby suggesting that it is a marker for affective mood states. (Schreiber G et al. 2001) Further evidence of altered metabolism comes from the Nobler study (Nobler M S et al. 2001). This study used Positron emission tomography (PET) to study glucose metabolism in different brain areas. It has to be noted that this was a small study of 10 patients who were assessed before and after a course of electroconvulsive therapy. This study involved highly sophisticated measurements and concluded that certain areas of the brain showed marked reduction in metabolic rate after electroconvulsive therapy and these changes were most significant in the frontal, prefrontal, and parietal cortices. The authors suggest that their results support the hypothesis that electroconvulsive therapy works by suppression of functional (non trophic) brain activity, most prominently in the prefrontal cortex. The authors comment that their findings are consistent with the earlier Drevets study which demonstrated a reduction in brain metabolism after successful treatment with antidepressant drugs. (Drevet s W C 1998) A more modern paper by Sanacora reported alterations in the GABA concentrations in plasma, and cortex after electroconvulsive therapy. (Sanacora G et al. 2003). It is known that patients with depressive illness have reduced levels of the neurotransmitter GABA. This study, again with a small entry cohort of 10 patients, assessed patients before and after electroconvulsive therapy. It was found that the levels of GABA increased with successive treatments. It was also found that the length of duration of the convulsions was proportional to the concentrations of GABA found in the cortex supporting the view that GABA decreases cortical excitability. It may also be significant that GABA concentrations have been found to increase after the use of selective serotonin reuptake inhibitor (SSRI) treatment. (Sanacora G et al. 2002). These findings suggest that enhanced GABA activity may be central to any antidepressant activity Takano et al. have recently produced a yet more sophisticated study along the lines of the Nobler investigation. (Takano H et al. 2007). This study also uses positron emission tomography (PET) and it studied patients before, during and after the application of electroconvulsive therapy. This is essentially a technical rather than a clinical study. It also has to be noted that all the data was derived from only six patients. The majority of the results are therefore not relevant to this consideration other than the fact that the authors concluded that electroconvulsive therapy exerts its effect by increasing the post treatment blood supply to the anterior cingulate and medial frontal cortex and thalamus. They refine this comment by acknowledging that it cannot be stated that this observed phenomenon is cause or effect, but simply an association with the mechanism of treatment and is associated with a resolution of symptoms. Preference of site and nature of stimulation There is a great deal of discussion in the peer reviewed literature about the optimal sites for electroconvulsive therapy application and whether univocal or bipolar stimulation gives better results. Unfortunately the vast majority of it is anecdotal and of poor evidential value. The Bailine study is a notable exception providing a randomised comparative trial with a moderate size of entry cohort (60) making it a level 1b trial. (Bailine S H et al. 2000). The authors compared the efficacy of bitemporal stimulation with bifrontal stimulation over a treatment period of 12 treatments. The study was assessor blinded. The rationale behind the trial was that bifrontal stimulation avoids direct stimulation of the temporal areas which are directly involved with cognition and memory functions. The authors reported that they found both placements to be equally effective in their ability to relieve depressive illness, but the bifrontal positioning achieved statistical significance in reducing cognitive and memory effects. Although not directly tested, the authors comment that right sided unilateral frontal placement has fewer cognitive side effects than bilateral stimulation but needs 2 5 times the current to achieve its therapeutic effect. (citing Letemendia F J J et al. 1993) One area of difficulty which, even a brief overview of the subject illuminates, is the level of stimulus that is required to achieve therapeutic results. Some studies do not specify the level of stimulus, others simply refer to a supra-threshold stimulus, a third group refer to a â€Å"titration of stimulusâ€Å". This makes direct comparison of results difficult. Some authorities have made the comment that not standardising the level of stimulus applied is similar to conducting a comparative trial of antidepressant drugs to placebo when the drugs are given at a sub-optimal dosage and therefore not achieving their maximal therapeutic effect. Krystal has attempted to tackle this problem by reviewing the regulations governing the administration of electroconvulsive therapy and also trying to achieve a generally acceptable standard of treatment. (Krystal A D et al. 2000) The USA limits (by statute) the maximum output charge for clinical applications of electroconvulsive therapy to 576 millicoulombs. The equivalent restriction in the UK is 1,200 millicoulombs for electroconvulsive therapy devices and this has been determined by the Royal College of Psychiatrists, and this limit is more than double the limit allowed in the USA. As far as the USA is concerned there is no evidence base to ensure that this limit will allow for consistently effective electroconvulsive therapy, which is something of a paradox considering that the USA considers electroconvulsive therapy more mainstream than does the UK. Krystal published a retrospective study of nearly 500 patients who had received electroconvulsive therapy. Although most of the patients reviewed had a clinically successful treatment, the authors noted that 15% of patients required the maximum stimulus intensity to trigger a seizure and 5% of the total did not have a seizure at all. The authors comment that the clinicians responsible for the patient had to use enhancing strategies to boost the therapeutic response with caffeine, ketamine, or hyperventilation. This still left a residual 5% of patients with a sub-therapeutic response at the maximum permitted output charge. Further problems can be encountered as not only can patients vary with regard to the amount of charge that they need to trigger tonic-clonic seizures, but the amount of charge can vary as the course of treatment progresses in each individual patient. (Coffey C E et al. 2005) The difficulty that therefore arises in these non-responders, is that there is no greater therapeutic response than placebo if a tonic-clonic seizure is not triggered, but the effects on cognition and memory impairment are still present. (PECT 2000). If this is added to the clinical and economic costs, it is clear that a case can be made for higher limits of initial triggering charge, at least in the USA. The other factor which may also be relevant and can be a major cause of inconsistency between studies is the pulse width with some electroconvulsive therapy machines delivering a shorter pulse width and longer stimulus duration than others. The majority deliver a pulse width between 0.5–0.75 msec. but other machines are capable of delivering pulse widths considerably beyond these limits. There has been no definitive study which has considered the possible effect of pulse width on either the therapeutic response or the likelihood of triggering a tonic-clonic seizure. The final point made in the Krystal paper is the fact that one of the reasons that the charge limit was set at the level that it is was the fact that the authorities wanted to minimise the theoretical risk of neuropathological damage. There is now evidence that the levels of stimulus charge necessary to cause such damage is far in excess of the imposed limits. (viz. Weiner R D 1994 and Devanand D P et al. 2004) The concept of stimulus titration is referred to in many of the clinically based papers reviewed. If this concept is considered in parallel with the comments by Krystal relating to the variation of charge required to produce the seizure, the situation can be clarified in an monograph by MacEwan who advises that it is an important feature of the treatment to allow sufficient time between the initial unsuccessful shock and the attempt at restimulation as the effect of the comparative refractivity after the first shock takes a little time to wear off. (MacEwan T 2002) Side effects of treatment Considering the rather gross and intrusive physical nature of the treatment, it is quite remarkable that the literature shows very few studies which have specifically explor

Plant Material Essay -- Plants, Seeds

Plant material The seeds of A. precatorius were collected from the medicinal plant garden of Department of Pharmaceutical Sciences, Dr. H. S. Gour University, Sagar, M.P., India. Seeds were sterilized and germinated by following the protocol described in our previous publication .[15] Initiation of A. precatorius cell cultures Different explants from aseptically germinated seeds viz. leaves, epicotyle and petiole were tested for culture initiation by variation in plant growth regulators (PGR) and Agrobacterium mediated transformation. Non-transformed callus cultures were initiated by placing explants on solidified MS medium supplemented separately with the hormones: 1 mg/l naphthalene acetic acid (NAA); 1 mg/l Kinetin (Kn); 0.5 – 2.0 mg/l 2, 4- dichlorophenoxy acetic acid (2, 4-D) and there combinations (Data not shown). For transformation experiments, leaves were excised from 30 d old in vitro germinated plantlets of A. precatorius. A. tumefaciens strains (MTCC 431, MTCC 609, MTCC 2250 and MTCC 2251) were used to establish transformed callus cultures. These strains were procured from Microbial Type Culture Collection (MTCC), Institute of Microbial Technology (IMTECH), Chandigarh, India. A minimum of 30 explants were used for each experiment. All explants cultured on sterilized petriplates comprising MS medium solidified with 1.0 % agar and supplemented with 30 g/l sucrose. The pH was adjusted to 5.7 Â ± 0.2. The medium was autoclaved under 15 psig pressure at 121Â ºC for 20 min. The explants were co-cultivated with Agrobacterium strains for infection to induce transformed callus. For this purpose, Agrobacterial colonies were cultured for 48 h on solid nutrient agar medium at 28 Â ± 2Â °C. Ten loopful bacteria were then... ... in a maximum synergistic promotion of glycyrrhizin accumulation i.e. 4.9-fold higher compared to transformed control culture. The present study indicates the potential of these biotechnology-based methodologies for large-scale production of glycyrrhizin. Furthermore, in order to develop a process for commercial production of glycyrrhizin by plant cell cultures some additional yield enhancement strategies may be worked out like, optimization of medium composition, environmental condition and addition of precursors. Acknowledgments The authors are thankful to Dr. Ashish Baldi, Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Hauz Khas, New Delhi, India for his valuable and timely assistance. The author VSK wishes to acknowledge All India Council for Technical Education, New Delhi for providing junior research scholarship.

Essay --

Proposal for a Uniform Dress Code Pickerington School District should require students to have a uniform dress code. The current dress code policy is very minimal and is not adhered to by the students. Faculty overlook the students who don’t abide by the current dress code as it would take away from their teaching time. One of the main concerns that is brought up when the topic of school uniforms is discussed is freedom of expression. Many people worry that not allowing children to wear certain clothing will â€Å"stifle their creativity† (p. ) or restrict their First Amendment rights (Nevada, 2008). There are many reasons for having uniforms in public schools. School uniforms have been shown to improve test scores, raise school pride, increase attendance, reduce violence, and teaches students to dress professionally. School uniforms can also avert the wearing of gang colors (Wilson, 1998). Self-Expression vs. Safety The most common argument against school uniforms is that they take away the students right to self-expression. Yes, school uniforms limit what the students have to wear, but students can still have their own ways of self-expression. Students can still express their style of choice with their hair and what accessories they wear. Their shoe choice is also a form of self-expression. Students can make the uniforms their own style without breaking the dress code. School is a place to learn. Outside of school, self- expression is limitless. Some parents also believe that it could interfere with students' natural behavior to experiment with different identities. Having uniforms in schools helps erase the defined line of the social classes. Typically, popular kids in the higher social classes wear the trendiest clothing... ...h the cost of a year's worth of school uniforms. The cost of a year's worth (Five tops and five bottoms) of school uniforms or standardized dress code clothing is $150. The savings add up plus students who don’t have to focus on what to wear to school are going to focus more on academics, which leads to improved grades. States Laws on Uniform Dress Codes The State of Ohio has a law that permits school districts to implement uniform dress codes. The school district must advise parents and students 6 months prior to any such implementation. This law also allows for any feedback from administrators, faculty and parents. A uniform dress code policy must fall under the guidelines of a districts discipline policy. The law requires that religious garb like yarmulkes and head scarves cannot be prohibited. The actual dress code is at the discretion of the school board.

Domestic Violence Essay

The Negative Results of Childhood Exposure to Domestic Violence The phrase â€Å"domestic violence† typically refers to violence between adult intimate partners. It has been estimated that every year there are about 3.3 to 10 million children exposed to domestic violence in the confines of their own home (Moylan, Herrenkohl, Sousa et al. 2009). According to research conducted by John W. Fantuzzo and Wanda K. Mohr(1999): â€Å"[e]xposure to domestic violence can include watching or hearing the violent events, direct involvement (for example, trying to intervene or calling the police), or experiencing the aftermath (for example, seeing bruises or observing maternal depression)† (Fantuzzo &ump; Mohr, 22). The effects of exposure can vary from direct effects such as behavioral and developmental issues to interpersonal relationships, all of which lead to detrimental prospects on the child’s development. This paper will explore those effects and how it affects children . Exposure to violence in the first years of life brings about helplessness and terror which can be attributed to the lack of protection received by the parent. The child can no longer trust their parent as a protector (Lieberman 2007). This lack of trust early in life can bring about serious problems later in life, as there is no resolution to the first psychosocial crisis, trust vs. mistrust. For these children exposed to domestic violence, the imaginary monsters that children perceive are not only symbolic representations or a dream. The monsters that children who witness domestic violence have to deal with carry the reflection of their parents. Children who witness domestic violence face a dilemma because the children’s parents are at their most frightening exactly when the child needs them the most. The security of the child is shattered as their protector becomes the attacker in reality and the child has nowhere to turn for help (Lieberman 2007). â€Å"Exposure to family and community violence is linked with aggressive behavior. One of the theoretical perspectives that explains this link is social learning theory, according to which children learn from the aggressive models in their environments. Additionally, victimization may compromise children’s ability to regulate their emotions, and as a result they may act out aggressively† (Margolin &ump; Gordis 2004, 153). â€Å"Posttraumatic stress symptoms and posttraumatic stress disorder (PTSD) are important consequences of exposure to violence because they can impair social and behavioral functioning† (Margolin &ump; Gordis 2004, 153). Research has shown that children exposed to domestic violence demonstrate impaired ability to concentrate, difficulty with schoolwork, and significantly lower scores when their verbal, motor, and cognitive skills were being tested (Fantuzzo &ump; Mohr). It seems as if the academic and cognitive difficulties from exposure affec t the child possibly through its impact on psychological functioning. For example, PTSD and depression may hinder with learning and the ability to perform well in the classroom (Margolin &ump; Gordis 2004). Researchers have found a positive correlation between externalizing (aggression) and internalizing (lowered self esteem, depression, anxiety) and domestic violence exposed children. Children exposed to domestic violence have been found to be four times more likely to develop internalizing or externalizing behavior problems than children who are not exposed to violence. The disruption of the development of basic competencies harms the child’s ability to manage emotions effectively and increases internalizing and externalizing behaviors (Martinez-Torteya et. al., 2009). This is particularly problematic for preschool aged children as younger children display more intense externalizing and internalizing behavioral responses to parental conflict than older children do (Ybarra, Wilkens, &ump; Lieberman 2007). These responses are due in part to less mature cognitive skills. Because these skills have not advanced yet, there is an increase in the likelihood of the child expressing psychological vulnerabilities following the conflict because of cognitive errors. Exposure to domestic violence compromises interpersonal relationships that are the foundation of children’s daily lives in addition to having direct effects. â€Å"Social support is a key buffer against the negative effects of violence. Because parents are key sources of social support, the disrupted parenting associated with family violence may exacerbate negative effects of exposure to violence. More generally, children exposed to violence may be sensitized to hostile interactions and may have difficulty negotiating peer conflicts. These interpersonal difficulties can rob children of social support and increase their risk for associating with deviant peers† (Margolin &ump; Gordis 2004, 154). In a study conducted by C. McGee, it was reported that many children found it difficult to develop friendships for reasons such as holding back from others as well as fear of inviting others to their home (Adams 2006). In conclusion, it is clearly shown that domestic violence has a negative effect on the children who witness it. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes (Anda &ump; Chapman &ump; Dube &ump; Felitti &ump; Giles &ump; Williamson, 2001, p.1). In fact, childhood stressors such as witnessing domestic violence and other household dysfunctions are highly interrelated and have a graded relationship to numerous health and social problems (Anda &ump; Chapman &ump; Dube &ump; Felitti &ump; Giles &ump; Williamson, 2001, p.2). It is obvious and clearly shown that the children who witness domestic abuse have serious long term mental effects.