Disseminated Intravascular Coagulation Essay

I decided to write my paper about the coagulation system, including clot formation, but mainly about Disseminated Intravascular Coagulation. Disseminated Intravascular Coagulation, also known as DIC, is a pathological activation of blood clotting mechanisms that may happen in response to a variety of diseases, or illnesses. However, DIC, is most commonly observed in severe sepsis and septic shock. DIC is not a specific illness, rather it is a complication or an effect of the progression of other illnesses or diseases. (Porth, 2011). When the body becomes injured, certain proteins in your blood become activated and travel to the injury site to help stop bleeding and control hemostasis. Hemostasis is the normal process of sealing off a blood vessel to prevent blood loss and hemorrhage. It is abnormal when it fails to appropriately clot the blood, or when this clotting is insufficient to stop the bleeding. Following an injury, there is an immediate vessel spasm that promotes vasoconstri ction, which tries to diminish the blood flow. Collagen from the damaged site, releases platelets which adhere to the damaged vessel, and there, they undergo degranulation and release cytoplasmic granules, ADP, Thromboxane A2, and Serotonin which is a vasoconstrictor. The ADP then attracts more platelets to the area, and the Thromboxane A2 promotes platelet aggregation, degranulation, and even more vasoconstriction. This process promotes the formation of a platelet plug. The damaged tissue now releases Factor III (3), which, with the aid of Ca++, will activate Factor VII (7), which initiates the extrinsic mechanism of clotting. Factor XII (12), which comes from active platelets, will activate Factor XI (11), which initiates the intrinsic mechanism. Both active Factors VII (7), and active Factors XI (11), promote a cascade-like reaction, eventually activating Factor X (10). Activating Factor X (10), along with Factor III (3), V (5), Ca++, and Platelet Thromboplastic Factor, all activate prothrombin. Prothrombin activator converts prothrombin to thrombin.Thrombin converts fibrinogen to fibrin. Fibrin initially forms a loose mesh, but then Factor XIII, (13) causes the formation of cross link-like structures, which convert fibrin into denser fibers. Platelets and red blood cells become caught up in this mesh of fiber, and the end result is the formation of a blood clot. (Liebman, et al, 2008). Disseminated Intravascular Coagulation, as stated earlier, leads to the formation of small blood clots inside the blood vessels, and may occur in 30-50% of patients with sepsis. It develops in an estimated 1% of all hospitalized patients. DIC occurs at all ages and in all races, and no particular sex predisposition has been noted. (Matsuda, 1996). As stated above, that massive activation of the cascade-like reaction as a normal clotting mechanism, now causes a generation of microthrombi to release that make vessels occlude and leads to tissue ischemia. All these clot formations devour the available coagulation proteins and platelets. They become depleted and severe hemorrhage may result. The common bleeding sites are the mouth, nose and venipuncture sites. There is extensive bruising, and multiple organ failure. Laboratory findings show the PT and APTT are usually very prolonged and the fibrinogen level is markedly reduced. High levels of fibrin degradation products are noted. There is severe thrombocytopenia. The only effective treatment is reversing the underlying cause. Platelets may be transfused if counts are less than 5-10,000/mm and massive hemorrhage is occurring. Fresh frozen plasma can also be administered in an attempt to replenish the coagulation factors, though these are only temporary measures and may result in an increased development of even more thrombi. The prognosis varies depending on the cause and extent of the intravascular thrombosis. For patients with DIC, regardless of the cause, it is often sad, and between 10% and 50% of these patients will die. DIC with sepsis has a significantly higher rate of death than DIC that is associated with trauma. References Leibman, H.A., Weitz, I.C. Disseminated intravascular coagulation. In:Hoffman, R., Benz, E.J., Shattil, S.S., et al, eds. Hematology:Basic Principles and Practice. 5th ed. Philadelphia, Pa: Saunders, Elsevier, Churchill, Livingstone; 2008: 132. Matsuda, T. Clinical aspects of DIC-disseminated intravascular coagulation. Pol Journal of Pharmacology. Jan-Feb 1996;48(1):73-5. [Medline]. Porth Mattson, C. 2011. Essentials of Pathophysiology. (3rd ed.). Philadelphia, Pa:Lippincott, Williams, and Wilkins. Schafer, A. I. Hemorrhagic disorders:disseminated intravascular coagulation, liver failure, and vitamin K deficiency. In:Goldman, L., Ausiello D. eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders, Elsevier, Churchill, Livingstone; 2008:chap 181.

How to Improve Our Government Essay

People every day make mistakes, and find flaws in their everyday tasks. No one person in this country can consider his, or herself, perfect. Knowledgeable people do exist in this world though, and our government strives to find and elect these representatives. These representatives then make decisions that affect our country in ways some might find positive, though others perceive as negative. Representatives could make decisions that would only impact our government in a negative way. Our government has its flaws, along with the people running it. I can think of several ways to help to improve the government and its efficiency. A decrease in government funding for our National Defense would increase funding in other important areas. People across our nation need jobs, and are struggling to find a source of income. If we used some of the funding that we attribute to our Nation Defense, then this money might benefit in the use of creating new jobs and opportunities for people. Not only would we have money to provide jobs, but this funding could be used to help create and search for new information in the field of Cancer Research. The government funds provide people that lack occupations and have no source of income, with a reliable way of obtaining money for themselves to provide for his or her, and/or his or her family. These welfare recipients may draw unemployment after applying and meeting the requirements need to obtain this welfare money. These requirements may not be strict enough, which would lead to the allowance of the unemployed to gather money while being lazy in the process. Due to the lack of work ethic found in people, drug use may attribute to this laziness. A requirement may need to be added in order for the recipients to pass a drug test (a test for multiple drugs) in order to draw unemployment, in return saving the wasted money the government provides to the unworthy. The government could invest much of their funding in renewable energy sources. The post installation outcome of these windmills, energy providing dams, etc. would help save money later on in the future. With these funds being provided to help â€Å"Go Green†, the earth itself would take a drastic increase in cleanliness. The government then might avoid conflicts  with foreign nations in the search for the fossil fuels, of which we currently use as energy. Doing this might then allow us to pull our troops out of these foreign nations, saving lives and money provided for the troops. The government has a reliable system that has gotten our country out of some troubled times, and may be one of the most united governments the world has seen. As previously stated though, nothing and no single person is perfect. With these little changes in the way the government goes about, it may impact funding, our unity, and occupations for the people of the United States, allowing people to live and prosper, with freedom and peace throughout.

Harley Davidson Company Essay

Situational analysis Harley Davidson, an international motorcycle company, started out as a small three man operation in 1903, by the Davidson brothers and William Harley manufacturing heavyweight motorcycles. This included financial services for the motorbikes, accessories and branded apparel. It experienced great success during both World Wars, and managed to survive the trying times of the Great Depression. After World War II, Harley Davidson brand begin to build on the image of the V-twin cylinder engine established in the 1920’s by shifting from manufacturing military bikes to recreational ones. During the 1970’s and 1980’s Japanese competition nearly destroyed the company. Competitors introduced technological advanced bikes at a lower cost due to mass production. Technological advances and economics of scale and efficiencies made competitor’s products superior in some instances. Harley responded by a re-evaluating its marketing strategy centered on a lifestyle image. This included a re-organization and brand building program, including the Harley Owners Group (HOG), Harley Davidson was able to re-capture its market share. It established these groups along with better customer service that helped it establish itself as a dominate company in the motorbike industry. It had a differentiated focus and various target markets as the environments changed. It was positioned effectively as a way of life with a sense of freedom as opposed to selling the best motorbikes. The marketing campaigns focused more on the lifestyle associated with the product and worked on its social image. The marketing team used differentiation to create more awareness of the product by reinforcing Harley from a psychological perspective as a symbol of freedom, developing and maintaining relationships. Harley Davidson South Africa was established in 1996 and has prospered due to very high annual growth rates. It succeeded as an emotionally driven brand, one that customers choose for a sense freedom, biker image or as a status symbol. It is this emotive response that Harley Davidson capitalizes on in its marketing strategy and that is re-enforced with the Harley Owners Group magazine, events and the international customer rental service. Despite the company’s success it faces some unique challenges. Currently all merchandise  is imported from the U.S.A., as a result pricing decisions are problematic relative to competitors. Harley continuously evolved its brand but lacked focus on black upcoming consumer (black diamonds) and on women initially. It will need to do some valuable market research and determine the best way forward with very careful implementation of the strategy to best target black diamonds and increase growth in this ‘untapped’, high disposable i ncome market. 1: Product Policy Product Policy is defined as â€Å"A strategic rule or rules covering how a good or service is promoted to potential consumers† (Kotler and Keller, Year!). Harley-Davidson has since grown from one dealership to seven independent dealerships between 1996 and 2007. Harley product policy was to focus more into customers’ needs rather than the company, this is the strategy that was introduced in the early 1980’s and was subsequently implemented in South Africa. These customer-orientated services have differentiated the company from competitors, in the minds of customers in South Africa as it was about image, sense of Freedom and status. This help in dismissing the myth / reputation of its â€Å"bad boy† image. This was seconded by the gender split of 28% female and 72% of male’s riders in South Africa. Harley South Africa set  out to promote Harley’s into females who are independent with high salary income as the new market segment; the strateg y was to treat them as equals and as owners in their own right. Post 2007, the product policy changed to â€Å"Black Diamonds† with an effort to attract and increase the black market into Harley riders. Their marketing strategy was different as it had done very little above the line advertising, dealers were given freedom to determine their own promotional activities modified to their own client’s needs and demands. Classification: Specialty goods – Customers are willing to make an extended search to find Harley and in some cases, might be willing to travel 20 or 30 KM to find the bike. â€Å"Marketing mix† is a general phrase used to describe the different kinds of choices organizations have to make in the process of bringing a product or service to market. The Product which is one of the 4P’s is used in defining the marketing mix and is categorized into 4 pillars namely Product Mix; Product Design; Product Development and Product Life Cycle (Kotler & Keller, 14th Edition) 1. PRODUCT MIX: Product policy lies at the heart of the marketing mix and encompasses all qualitative aspects of the products offered. Product-mix refers to the range of products offered by an institution. Offering products that are valued and demanded by customers is key to the success of Harley in South Africa. 2. PRODUCT DESIGN The goal of product design is not to create a different product to satisfy every possible client need. Harley should design products that respond to several different needs with only a few variables. Product design variables must be appropriate for the markets that the Harley has decided to target. 3. PRODUCT DEVELOPMENT Product development is the process of continually refining client-oriented products. It includes several phases, such as exploring customer needs, screening ideas, evaluating products through pilot testing, revising product  design based on the results and finally, launching the products. All of these phases are intertwined. 4. PRODUCT LIFE CYCLE Below is the summary of the four phases of the Harley product life cycle which include introduction, growth, maturity and decline. Core Benefits of owning a Harley: * Harley members have an enduring relationship built on trust and dependability supported by good service and meaningful advice as most of the riders especially females had no technical capabilities of some of the riders. * Become part of the Harley family which include meeting with business associates, share a cup of coffee with new riders and also talk to a friend. This has made most riders to have a â€Å"sense of belonging†. * Harley offer in-house finance and insurance program for riders / customers. * A full one-year membership in the Harley Owners Group (H.O.G) comes with every purchase of a new, unregistered Harley motorcycle. * Associate  memberships for H.O.G family members and passengers also benefit and become part of the Harley family membership. * Owner’s memberships are renewable at a discount and they can also become a member for life. * Full access to the company’s website, magazines each year, and a subscription to the special member publication, toll-free customer service and even a touring handbook for trip planning. * Harley also organizes and sponsor special events for H.O.G members including bike parades. * Analysing the Brand equity of Harley Davidson: When purchasing a Harley, the customer is endowed with an added value of a sensation of freedom offered by the product, the sense of belonging and a sense of exhibitionism offered by a Harley. Harley Davidson does not market the functional purpose of the bike but rather the emotional and psychological attributes of freedom and belonging. The success of the marketing approach and achievement of brand promise of such psychological attributes are well evidenced by the successful financial performance of Harley Davidson. The following case facts indicate that Harley commands higher prices, market share and profitability: * Steady share of half the USA heavyweight motorcycle market in 2006; * Annual growth in unit sales in South Africa had averaged 46% over the past few years. * Harley still held the majority share in SA market, an estimated 67%. The above indicates that Harley Davidson has strong brand equity credentials. We can further analyse the brand equity of Harley Davidson by applying one of the Brand Equity Models, ‘The Brand Resonance Model’ (Kotler and Keller YEAR) and applying the 6 fundamental building blocks of the resonance model to Harley Davidson: Building brand Equity The right brand knowledge structures targeted at the right consumer can build substantial brand equity (Kotler and Keller YEAR). An analysis of how Harley uses the 3 brand equity drivers (Kotler 2014) to build brand equity: 1. Brand elements – Harleys brand benefits are less concrete (freedom, sense of belonging etc) and thus it ensures that its brand elements focus on emotional and psychological attributes. E.g. slogans such as â€Å"The fun is not in the destination, the fun is in the journey†. In addition company marketing themes never emphasize on the bikes mechanical specifications but rather the associated lifestyle for owning a Harley. 2. Marketing activities – product/service – Lifestyle – How do customers make contact with the Harley brand: * Internal Branding – Harley’s primary focuses is on internal branding Harley makes extensive use of marketing through its brand community, the H.O.G. H.O.G members have a consciousness of kind† or sense of felt connection to Harley. i. H.O.G. as a channel for internal marketing has proved to be more effective than Harley’s external  marketing campaigns. ii. HOG is not organic but company-sponsored and facilitated because it’s one of the main and primary marketing activities. iii. H.O.G is a business strategy. The entire business model supports the H.O.G. iv. Harley’s cultivation and engineering of the H.O.G plays a significant role in growing and strengthening the brand * Individual Customer marketing v. Harley places a lot of marketing attention and focus on the individual customer. Significant investment is made towards dealerships being well equipped to cater for H.O.G meetings, vi. High individual customer focus pays off in terms of, significant sales arising from repeat customers, accessories, customisations of initial purchase, trading upwards after initial purchase etc. vii. Individual marketing to women on a personal basis as they walked into the store with their husbands or partner’s. This was successful in building brand equity amongst female customers. * External Branding is minimal. Harley does not do much mainstream advertising. This has a benefit of cost saving from not having to rely heavily on mainstream high cost advertising channels. Harley prefers to grow through existing dealerships. For example, Dealerships are equipped with coffee areas where staff can connect with customers that walk into the stores. 3. Leveraging secondary associations * Harley frequently associates itself with charity rides and motorcycle events. This allows it an opportunity to build on its brand promise of exhibitionism and belonging While applying the logic of the brand value chain (Kotler 2014) backwards, high profitability & market share arise from strong customer awareness and customer associations, which in turn arise from successful marketing programme investment. It could be inferred that Harley has generated valuable return from its marketing approach consistently over a period, indicating successful brand equity building over the years. Target Market: Harley Davidson’s new target market is the, ‘Black Diamond’. This has been their focus as they believe this market has potential. In 2007 the market totalled 2.6 million, while they managed to make sales totalling 709. This meant they had 27% of their target market. This was a drop when compared to the previous year. Post 1994 this target market has had opportunities that did not exist before. We also saw the emergence of BEE, which continues to make Black people more financially stable. This therefore makes this market an ideal market to focus on. Market profile: As much as the female rider target market is growing (28% by 2007) and has potential Harley needs to understand that there are still cultural issues that this market has to deal with. Such issues include that fact that for the black community for a woman to drive a motorcycle it might be not acceptable. Therefore, this would need Harley to come up with strategies to deal with this cultural perception in order for them to benefit from this market. Future product policy: Product Portfolio: Harley Davidson has managed to introduce accessories which are priced differently. This works as those that cannot afford to buy the motorcycles can still settle for other biker accessories thus improving margins. Harley needs to continue to widen its product mix. Usually a biker will buy one bike unless they can afford to buy more, therefore for Harley to continue gaining from this consumer they need to also focus more on their accessories which not only bikers like but also non bikers and family members. It was mentioned that 70% of the purchasers were non bikers. Harley however needs to be careful that its product system does not disadvantage its brand. This is seen as an exclusive brand and one needs to be careful that a product diversification does not bring down the value of the brand and result in consumers perceiving it as cheap. It is therefore important that we keep the current product portfolio as exclusive as possible to protect the brand. With the increase in fuel prices, Harley might need to consider a two-way stretch where they might need to produce cheaper motorcycles which are more  fuel efficient to encourage people who might not want to consider investing in a Harley due to costs. Strategies for growth: Driving in a Harley club is a spectacular moment, whether or not the bike itself was bought for show. Cruisers are differentiated products and Harley is the leader in that market but that is a double edge sword as its guaranteed popularity and high expectations as a result. They are effectively selling a lifestyle and for more people to buy into it and to keep those on board they need to focus on strengthening the product differentiation, design, brand and service differentiation. Bikes as an extension of personality and customers will associate with a product that delivers on the highest promise. The design of the bikes and features that are most useful and necessary to the rider are important, the customisation has resulted in unique end products for each customer, the quality in terms of performance and conformance need to me maintained at a level above the competition. Because customer needs and tastes vary, the service levels required to keep customers happy also varies, the service dimension of the business is therefore important in creating a strategy. By creating awareness about the product and pricing mix and different after sales service options available to the customer (delivery, training, consultation, HOG, maintenance and repair options), Harley Davidson SA can bridge the information gap and appeal to a larger market. Targeting the Black diamond: This is one of the fastest growing segments in the South African economic context, the majority being young and qualified and earning a more than descent constant salary. Mostly growing up post apartheid, this group is less stereotypical and more adventurous and likely to try new things than was previously not associated with the age segment. This is the new financial muscle of the South African economy and Harley Davidson should explore it purely as a potential market for its affluence and exploratory capacity if not for its perceived desire for opulence and status. As a product that provides pleasure, fun and value, there is no reason not to tap into this virgin market that hasn’t yet grasped its stance or identity  relative to the previous politically influenced generation. Harley-Davidson Services According to Kotler and Keller, †The customer will judge the offering by three basic elements: product features & quality, services mix and quality, and price† (Refer to Fig 12.1). In our technologically age it is now easier for any company products to be replicated and even produced much cheaper too. This makes the element of â€Å"service quality and mix† very important to marketers. The service quality and mix Harley-Davidson offers to its customers will be a source of competitive advantage. The customer value hierarchy diagram places an ‘augmented product’ at a very high level (Fig 12.2). Customers will value an augmented product because of its additional features and services that come with it. Harley-Davidson should aim for service differentiation at all stages of the buying process and after purchase: (Ordering Ease, Delivery, Bike-riding training, customer consulting, maintenance and repair). The customer service personnel employed by Harley-Davidson will affect the quality of service. The company would need to ensure that they hire and train the right people for the jobs. Employee satisfaction would be critical to making sure the employees have a positive attitude as they work with customers. The marketing department at Harley-Davidson has to understand the needs and wants of their customers in order to satisfy them. Customers are concerned with reliability, service dependability and maintenance costs of the motorbike. A service-quality management system would also need to be set up plus monitoring systems to ensure that all customer complaints are handled properly.

Main Elements of Self Determination Theory Case Study

Main Elements of Self Determination Theory - Case Study Example This implies that SDT focuses on self-motivated and self-determined decisions. Since its inception in the 1970s, SDT has evolved to become a crucial element of social psychology based on empirical research. As mentioned, SDT is mainly anchored on intrinsic motivation. This refers to the need to partake in an activity due to the activity’s satisfactory value. Thus, this need is contrary to extrinsic motivation which refers to the engagement in a given activity in order to fulfill certain goals or obligations. Therefore, SDT can be said to be centered on the following crucial elements: Â  As mentioned, intrinsic motivation refers to the naturally occurring motivation in the event of engaging in certain occurrences (Deci and Ryan, 2005: 49). Therefore, this motivation is highly associated with social development. Cognitive evaluation is a necessary tool in the assessment of the degree of intrinsic motivation. Intrinsic motivation may, thus, be cultivated through the employment of social context events such as rewarding systems. Therefore, intrinsic motivation must be backed by the necessary environment in order to result in the desired self-cultivated drive (Ryan and Deci, 2010: 68). Â  Contrary to intrinsic motivation, extrinsic motivation is based on external influence. However, external motivations may also be internalized through various processes, thus, contributing significantly to social development. Extrinsic motivation, thus, forms a crucial element of SDT. Extrinsically motivated behaviors may take various forms. However, their integration into an individual’s lives provides the required platform for self-motivation. Â  

Entrepreneur Paper and Presentation (Minicomputer) Essay

Entrepreneur Paper and Presentation (Minicomputer) - Essay Example Between 1944 and 1945, the navy trained Olsen in Electrical Engineering. The training at the navy and his work experience at a General Electric Factory where he served to troubleshoot their FM radios enabled Olsen to join MIT as an undergraduate in February 1947. At MIT, he studied Electrical Engineering where he concentrated on magnets and generators but it was not until he graduated that he heard about computers after being offered a job in the computer lab (473). It was his love for electronic that earned Olsen a position in MIT computer lab and not the grades as was the norm. This was in 1950 during which period; the IBM computer was so large and operated on bunch cards. Olsen applied great vigor during his stay at MIT where he worked as a liaison engineer on the Whirlwind in his first year. Olsen is noted to have challenged the inefficiencies at MIT and, as a result, he was put in charge of the TX-0, a project to that enabled him to direct the building of   the first transisto rized research computer(474). Olsen grew more determined that soon interactive, real-time mini- computers (474)   Olsen ventured into the entrepreneur field in 1957 when together with Harlan Anderson, an MIT colleague, approached the American Research and Development for a loan and founded DEC (475). Through DET, the minicomputer was possible, it was small and so cheap compared to the large IBM mainframe; cost was down by from between $1 million and $ 3million to about $125, 00 to $ 150,000. DET was already bathing in success just a few years from its formation. Olsen however knew too well not to overrate their ability and at one point had to decline an order of 100 minicomputers by NASA since he felt their rate of production was still too small (476). Olsen also knew how to stay ahead of his competitors. While his competitors were looking into how to improve on his products, Olsen and his assistance were working on new products. This was for instance portrayed in 1964

M4A1 PART B Essay Example | Topics and Well Written Essays - 500 words

M4A1 PART B - Essay Example This is the reason why measures taken by management and employees are often too late or inadequate. For example, in 2006, Jerry York, a GM board member had urged the automaker to unload Saab and Hummer but the idea met resistance and ended in ultimate losses (Krolicki, 2009). Now, one of these concerns is near bankruptcy whereas the other one is supervised by court. Out of resistance, the current culture of GM is less tolerant to differences, portrays less appetite for risk taking and exploiting the opportunities in hand, and appears to be narrow-minded to the social concerns that are emerging everyday and endangering its stability and existence in future e.g. increasing labor cost with excessive payload of surplus labor, and also the lack of attention paid to environmental issues. Due credit must be given to our predecessors but with the changes in absolutely every segment of our lives, GM must prepare itself first for the present and then for the future by first letting go of its same bureaucratic culture which is a souvenir from baby bombers. GM is trying hard to compete with the companies that value the importance of cultural diversity, innovation and technology along with appropriate leadership. It has acted like a shelter for many managers who were afraid of getting out of their comfort zone and face the current challenges (Krisher, 2012) . Instead our culture has provoked them to use the chain of command principal, as an excuse for lack of performance and innovation. Considering the last near bankruptcy experience, GM culture has to change. In the light of past experiences, I would recommend that GM needs to evaluate the need for change and incorporate all necessary amendments not only in its operations and processes but in the overall organizational culture with a special emphasis to our most valued assets, our human resources. According to

Thief of the identity Article Example | Topics and Well Written Essays - 250 words

Thief of the identity - Article Example (Atkins). With effects such as long term loss of memory, one’s identity deteriorates since one cannot remember what surrounds their lives. (Sabbagh). Not being in cognizant with what is going on around is tantamount to loss of identity. In addition to this, the impacts of the disease on the physical appearance are outstandingly disturbing when one thinks about it. The disease eats up the radiance in one, by working up on the face, the skin and the whole body structure. (Atkins). One looks totally different from the way they used to before the disease comes in. It is by virtue of the loss of the original physical appearance that one is considered as having lost his or her identity to the disease. The disease is therefore tantamount to the thief that steals away one’s identity. To conclude, this disease is quite scary given its impacts and the fact that it cannot be treated. (Atkins). The fact that its cause is yet to be established is also much alarming. In this paper, the fact that the disease is a thief of identity has been looked at. This is through the impact of the disease to the brain and physical appearance. There are many other impacts of the disease that can be traced to loss of identity such as emotional swings. However, not all these could be covered given the scope of this

Physiology outside report Essay Example | Topics and Well Written Essays - 500 words

Physiology outside report - Essay Example (Underwood, 2003, quotes Matallana, n.d.) Claps (2002) reports in his article, "Fibromyalgia: exercise can offer relief for people who live with this painful malady" that experts now know that fibromyalgia, which affects more women than men, does exist. The term fibromyalgia describes the symptoms. Fibro refers to the fibrous tissues of the body and myalgia indicates muscular pain that is widespread. It's a form of muscular rheumatism where normal pain is amplified by the brain and spinal cord which controls the central nervous system. Even a simple touch, or something that is not really considered to be pain, will reduce pain and increase mobility; hence, improving quality of life. Although it may seem painful to exercise, if performed correctly, physical fitness will break the cycle of pain and improve sleep which will decrease depression. Sleep problems and depression are two of the major fibromyalgia symptoms. The pain can cause an individual to forego exercise yet as Claps (2002) quotes Goldenburg (2002) on how physical fitness can break the pain cycle, "Pain causes muscle spasm. Spasm interferes with oxygen (flow) to the muscle.

Data exchange Essay Example | Topics and Well Written Essays - 500 words

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Evidence of achievement Essay Example | Topics and Well Written Essays - 2000 words

Evidence of achievement - Essay Example b. An understanding of work preferences is integral to developing a bond of understanding between the student, the mentor and the demands of the nursing profession itself. In addition to the outgrowth of trusting working relationships among professionals, the mentorship development program provides a 'safety net' to blunt the consequences of learners' errors. This supervision allows me to learn from my mistakes safely, while at the same time advancing to greater positions of responsibility to achieve integration. c. During internship, the practicalities of classroom fundamentals come into play as a physical reality. While it has long been said that hands-on training is the only means to achieve true comprehension of a functional task; having the intellectual background provides a stronger basis for 'jumping in' to new learning environments. It gives my supervisor-mentor an easier point of reference to begin the induction to new departments, and new learning environments as needed. .. . If the student has already completed a portion of a structured training program, and as the student progresses, the mentor will gain an appreciation for learning style, and be able to tailor instruction accordingly. b. Learning strategies are integral to academic success; but largely come from within the self, from the student's self-determination to advance themselves towards the purpose of becoming a true nursing professional. Having the added experience of having once been a beginner at the task at hand, the professional mentor has the ability to advise, and assist in the deployment of these strategies in a way that meshes most effectively with the particular demands of the position. c. A good mentor will be experienced with the inner workings of the learning process as it pertains to the nursing position at hand, and will be able to reflect on their own needs, questions, and uncertainties when the mentor was new at the position. This lets an effective supervisor-mentor to devise impromptu tests, questions, and brief quizzes, with no fore-knowledge of what was challenging for them personally. A strategy personally useful in learning is when the mentor/instructor gives a lesson, or hands-on demonstration followed by an immediate quiz. c. 3.) a. Professional growth is intertwined with personal growth within a modern nursing environment, as the student grows into a more complete person on an individual level, who becomes therefore also a competent nursing professional. Mentorship/supervision is essential in that it allows a safer means for the student to perform real medical procedures and care to gain an appreciation for the

Impact of education on economic and social outcome of citizens Article

Impact of education on economic and social outcome of citizens - Article Example To be educated is indeed a wise undertaking in the world of today and it holds more ground than it used to in the times of our forefathers. There is so much to seek, learn and understand that the man seems to go missing in the quagmire. However if he is educated he makes his own way through the zig-zag pathways and thus reaches his destination on all counts. It is a matter of fact that being educated in the current times facilitates one self in estimating what life is bringing for a person. It opens up his range of options and presents to him ideas out of the box as well. What this does is to make him do the analysis in a straight forward manner. No analysis is possible without getting to know the facts first of all. If a person is educated and understands the norms that are taking place within his life or generally, he will get to know what the strengths of the same undertakings are and how it would affect his own live as well as the ones whom he loves and takes care of. He gets to inquire the weaknesses present with the knowledge that he has obtained over a period of time and thus weighs them in light of the strong points that were previously ascertained by him in due course of time. In the world of present times, being educated means that a person is talked of in a high and esteemed manner. He is given respect by one and all since he can understand the difference between the good, the bad and the ugly. He can sense problems where the illiterates could think merry. He can make out for the troubles that lie ahead in different situations through his sheer ability of forecasting and visualization. He can look at the missing links better than an average man. He can understand his own psyche, individual basis and the manner under which he exists within the tenets of the society. He knows who he is and what is expected of him. He can create links with each other on the basis of his literate self and his education speaks for his own self in terms of his dressing, the way he meets strangers and new people, the way he eats and dines, the manner in which he greets people and so on and so forth. The differences seem to become apparent more often than not and this is something that is apparent within a person who is educated and who knows how to comprehend difficult circumstances with eloquent measures. More than anything e lse, it is his resolve that remains firm at the best of times and he remains committed to his world of ethics and morals since this is a very quintessential step in the wake of his different undertakings, measures and behaviors in the world that he lives in. It is true that from a general standoff education pretty much plays a pivotal role in the development of any nation. This markedly sets the tone for the people to harness their skills and potentials which they are quite unaware of before they actually get out in search of educating themselves and their families. The reforms have to be brought from the top side of a nation, whereby the government needs to take bold steps to promote it no matter how hard it is on their budgets. Awareness does not come out of the blue for the people, it has to be injected courtesy education and one must understand the real rationale behind putting emphasis on this subject before one actually moves ahead and does

Crystal palace Essay Example for Free

Crystal palace Essay Also, what Swift shows is that it is reason itself and man’s ingeniousness that prevent him from reducing life to a few moral principles. Paradoxes and countercurrent tendencies pervade the human mind, as it moves from good to evil. The Houyhnhnms would not be able to construct the complex society specific to humans. They have no books, no systems of thoughts or philosophies. Their enlightened and perfect state depends thus on minimal reasoning and on a few righteous principles. The human society, by contrast, builds intricate systems that often contradict other systems and philosophies. It is not only vice that is proper of human nature but also curiosity and a perpetual thirst for knowledge. The Biblical myth of the first man’s corruption through knowledge stands true in Gulliver’s narrative. The other societies that Gulliver meets in his travels point to the human tendency towards discovery but also manipulation. Man hunts the truth but also manipulates and interprets reality according to his own inner impulses. The Yahoos’ condition as the servants of the Houyhnhnms is also very significant. They seem to represent humanity in its basest form, without the polish of civilization. The Houyhnhnm that houses Gulliver during his stay in their country remarks that this mixture of reason and vice makes the human race more dangerous and more powerful than mere brutality: â€Å"But when a creature pretending to reason could be capable of such enormities, he dreaded lest the corruption of that faculty might be worse than brutality itself† (Swift 183). The Houyhnhnms cannot attain the technological and scientific progress mastered by man because they do not manipulate truth and they do not know the meaning of power and corruption. By contrast, the dwarfish people of Lilliput manage to subdue Gulliver, despite the fact that he is a giant among them. The human society can progress but it cannot advance significantly in morality. The Houyhnhnms’ society is perfect because it is based on an economy of just ideas and principles. They cannot understand crime as a concept and think it absurd because of its lack of utility: â€Å"He was wholly at a loss to know what could be the use or necessity of practicing those vices† (Swift 195). The utopian world cannot belong to man because he is inevitably driven by feelings and passions that often do not conform to the common moral standards. Moreover, the Houyhnhnms world is one where absolute truth dominates and there is no falsehood: â€Å"†¦They have no word in their language to express lying or falsehood† (Swift 187). This is also unattainable in the human society since man will always be biased because of his subjectivity. Overall, Swift shows that a utopian society is impossible for man on account of the inherent faults and particularities of the human spirit. Dostoevsky’s Notes from the Underground reveals a similar conception of the utopian society. According to the underground man, the human society will always construct ideal and fantastical worlds to escape from reality. The paradox is that man seems to be equally infatuated with both happiness and sufferance. The â€Å"crystal palace† represents the unattainable ideal that lives in the lofty regions of the human imagination. As a utopian representation, the palace is made of crystal precisely because it contains all the answers and no questions: â€Å"Then †¦ new economic relations will be established, all ready-made and worked out with mathematical exactitude, so that every possible question will vanish in the twinkling of an eye, simply because every possible answer to it will be provided. Then the ‘Palace of Crystal’ will be built† (Dostoevsky 69). This mathematical and transparent construction is a symbol for perfection and self-sufficiency. The palace does not harbor any doubts: â€Å"What would be the good of a ‘palace of crystal’ if there could be any doubt about it? †(Dostoevsky 77) However, the human world is not even satisfied with its own ideals. The underground man believes resents that this ideal edifice cannot be mocked and derided: †You believe in a palace of crystal that can never be destroyed a palace at which one will not be able to put out ones tongue or make a long nose on the sly† (Dostoevsky 77). The palace is therefore the object of man’s desires for but also the object of his mockery. Dostoevsky puts forth the idea that the human world can never fit into the crystal palace with all its desires and aspirations although it can neither renounce this dream completely. As Swift had pointed out, man is torn between opposite principles, between sufferance and happiness and is unable to reduce his feelings to a few linear and uniform desires. Moreover, the ideal can be inconsistent with reality but man will persevere in his desires merely because it has an actuality for him: â€Å"But what does it matter to me that it is inconsistent? That makes no difference since it exists in my desires, or rather exists as long as my desires exist. † (Dostoevsky 78) Another issue that Dostoevsky emphasizes is that man will always pursue his ideals no matter how inadequate they are precisely because he is a complex being, entirely different from the animals. Dostoevsky gives as an example the basic necessity for shelter and compares a hen-house with the crystal palace: â€Å"You see, if it were not a palace, but a hen-house, I might creep into it to avoid getting wet, and yet I would not call the hen-house a palace out of gratitude to it for keeping me dry† (Dostoevsky 78). Man is not satisfied with mere principles of utility and economy. This idea is also identifiable in the representation of the utopian world of the Houyhnhnms, as already mentioned. The perfect world of the horses is content with a few basic and absolute principles that also serve the ideal of economy. Both Swift and Dostoevsky show that man could not live in a utopian world. While Swift shows that man the utopian world could never be created by man because of the inherent vices that corrupt human nature, Dostoevsky points out that man would actually be dissatisfied if he inhabited an ideal society. The two authors reveal the essential aspects of the human nature and the human society, pointing out that man could not live in a utopian state although this will always be his ideal. Works Cited: Dostoevsky, Fyodor. Notes from the Underground. New York: Macmillan, 1918. Swift, Jonathan. Gulliver’s Travels. New York: Penguin, 1981.

Eternal Sunshine Of The Spotless Mind Film Studies Essay

Eternal Sunshine Of The Spotless Mind Film Studies Essay In this analysis of the style and structure of Eternal Sunshine of the Spotless Mind (Michel Gondry, 2004), the following research question shall be addressed: how does filmic style and narrative structure evoke atmosphere, define character, and provide cues that generate audience reactions? It will be argued that the film constructs a bittersweet tale of love using an unconventional and fragmented narrative structure; portraying the effects of memory erasure by immersing viewers within the subjective world of the protagonists mind. Eternal Sunshine tells the story of Joel Barish and Clementine Kruczynskis passionate, yet often painfully incompatible romance. From its humble beginnings at a beach party, their relationship blooms over the period of about two years, but ultimately fails. When Joel learns that Clementine has undergone a surgical procedure on a whim to remove all memories of him, he is so wounded that he tracks down the doctor and demands the same operation immediately. Midway through the procedure, however, Joel begins to regret his impulsive decision, realizing the importance of his past, as well as the inevitable loss of some of his most cherished memories with Clementine. The first five shots of Eternal Sunshine are highly significant in terms of both narrative structure and stylistic implications. The film begins by fading-in from black to a deep focus close up of an unshaven Joel, awakening the morning after the memory-erasing procedure (though this narrative information is not revealed until much later). The off-screen sound of a car door closing rouses him, and it is later discovered that this noise comes from the memory technicians departing after the operation. A variety of shot lengths are used in this opening sequence to communicate information about Joels facial expressions, body language, and surroundings. Ultimately, the act of waking coupled with the natural morning sunlight creates an atmosphere of a new beginning, although it is one tinged with a sense of loss. The use of hand held cameras simultaneously evokes the illusion of realistic footage, and viewers are invited to question why Joel awakens this way, establishing a narrative enigm a concerning past events. Joels waking expression is rather vacant, conveying the barren emptiness of his now spotless mind. The shot is illuminated from the right, and upon opening, his dark hazel eyes are drawn to this light source as he utters a sigh. The next medium shot is an eye-line match that frames Joels window, using an upward tilted perspective from his bed. The morning sunlight shines through, providing the only lighting for the scene and signifying a new beginning. The exclusive use of natural lighting additionally suggests an existence devoid of memories, as the atmospheric lighting techniques that accompany memory throughout the film are absent. Subtle, non-diegetic music; sound that does not have a source within the story world (David Bordwell and Kristin Thompson, 330), also commences here, with a triple meter bass ostinato accompanying guitar chords. A straight cut introduces the next medium close up of Joel sitting up in bed, tracked by the camera. He sighs, rubs his forehead and begins to remove the bedspreads, which provides a match-on-action transition into the next shot a long shot of Joel moving towards the end of his bed. The dà ©cor of the space is very plain and uninspired, heightening the atmosphere of emptiness. A piano melody enters above the guitar as sunlight engulfs Joels darkened silhouette on the end of his bed. Before the next shot a short ellipsis is implied, and it commences outside as a medium long shot of Joel, now shaven and dressed in dull winter clothing. Sunlight momentarily shines directly into the lens before the camera tracks him to his car, revealing a large dint on its side. Confused and irritated, Joel thuds his briefcase upon the car bonnet as ambient background noises of children playing blends with the music. Although no dialogue is spoken in these shots, the sparse instrumentation and minimalist structure of the background music serves to heighten the mood of an existence that is somehow lacking essence. Hence, the opening shots be gin to define Joels character, whilst providing cues to evoke an atmosphere of a somewhat empty new beginning. Eternal Sunshine is essentially a love story, and a clear binary opposition a category with two mutually exclusive parts that depend upon each other (Graeme Turner, 104) is established between Joel, who is introverted and withdrawn, and Clementine, who is extroverted and eccentric. This opposition allows the characters to effectively compliment and conflict with each other, thus forming the basis of the narrative complication. Despite this somewhat traditional aspect of the story, the manner in which the narrative is structured is by no means conservative. In Film as Social Practice IV, Turner notes that conventional narratives begin in a stable point of equilibrium, which is then disrupted by some power or force motivating the protagonists quest, usually ending with the restoration of equilibrium (107). Eternal Sunshine, however, follows no such structural formula, and events are presented in a fragmented, non-linear fashion. Indeed, the film actually commences after the relations hip, moving from the present to a series of reverse order memory flashbacks and flashbacks within flashbacks, before finally returning to the present (whilst constantly interweaving secondary plotlines involving the Lacuna team). Another opposition of sorts is therefore established in the narrative itself between memory and present events, with the complicated structure serving to disorientate viewers and portray the complex nature of an individuals personal memories. In Postmodern After-Images, Peter and Will Brooker state that resistance to linearityà ¢Ã¢â€š ¬Ã‚ ¦ [is an] archetypal postmodern technique (58), and thus Eternal Sunshine uses a postmodern narrative style to communicate its story of memorys role in love. Throughout the film, myriad elements of the mise en scene evoke atmosphere, develop character and provide audience cues. Firstly, colour and costuming serve to accentuate the binary opposition between Joel and Clementine. Joel is only ever seen wearing very dull colours, foregrounding the reserved nature of his character, and he often blends into large crowds. On the contrary, Clementines eccentricity is revealed by her kaleidoscopic clothing choices. Also, the colour of Clementines dyed hair acts as a symbolic indicator of the state of her relationship with Joel, changing chronologically from green, to Red Menace, Agent Orange, and finally Blue Ruin. Green is traditionally a colour associated with new life, and it suitably marks the beginning of the relationship. The deep red dye appears to symbolize a climax of romantic passion, and indeed many of Joels best memories are from this colour stage. Orange perhaps embodies a diluted, fading version of this passion, while blue denotes an atmosphere of sadness and depression, appropriately appearing at the point of the relationships ruin. In one particularly symbolic scene, a crane shot frames Joel and Clementine lying together on the frozen Charles River. Some distinct cracks are easily observed in the ice beneath them, indicating the fractures that will inevitably appear in their relationship, and this notion of an intrinsically flawed romance adds to the bittersweet tone of the film. Finally, many elements of the mise en scene are skillfully utilized within subjective shots to portray the erasure of Joels memories: characters suddenly disappear, text on signs and letters fades or vanishes, objects are deleted from shots in fragments, and facial features are smeared. For example, in the beach-house scene, Joels memory of the event literally crumbles piece by piece in his mind. The use of atmospheric lighting is one of the most important filmic techniques employed by Gondry to construct the subjective memory scenes in Eternal Sunshine. In the present, lighting is generally either natural or realistic, but memory shots adopt a more unique lighting approach, emphasizing this narrative opposition. Firstly, low-key lighting and darkness often play a major role in such scenes, with lights either gradually fading to black or suddenly turning off to represent the removal of memories. The most prominent and effective use of atmospheric lighting, however, is a clearly recognizable spotlight effect that pervades memory scenes and becomes a lighting motif throughout the film. This peculiar device ranges from a small, torch-style light, through to a very large and powerful spotlight reminiscent of a helicopter searchlight (the best example being in the Charles River memory scene). The spotlight effect seems to serve a dual function: in one sense, it represents an intru sive, artificial intervention in Joels memory (implying the operation procedure), and he and Clementine are often trying to escape its glare. Also, especially in darkened scenes, the restricted glow of the spotlight could represent the limits of remembered detail in Joels mind, as is argued by Jason Sperb in his article Internal Sunshine: Illuminating Being-Memory in Eternal Sunshine of the Spotless Mind, when he states: The spotlight signifies the limited perception of Joels remembering, which remains in and of the present. He cannot again completely experience the moments he thinks he remembers; Joel can only see limited illuminations, fragments in his imagination vaguely informed by his understanding of the past (7). The circular shape of the spotlight could also bear some importance, perhaps signifying the cyclic nature of Joel and Clementines relationship. Finally, throughout the film, this and other lights occasionally turn red to imply a state of urgency or alarm. Hence, the combination of the elements of the mise en scene succeeds in creating atmosphere and crafting the effects of memory erasure within Joels mind. Perhaps the most striking element of cinematography in Eternal Sunshine is the almost invariable use of hand-held cameras. This imperfect, sometimes clunky technique often creates the illusion of genuine home video footage an aspect that undoubtedly increases the authenticity of subjective memory scenes. As Ellen Kuras (the films cinematographer) stated in an interview, the camera movement is not always the most gracefulà ¢Ã¢â€š ¬Ã‚ ¦ with the entire film shot handheld, we ended up using sled dollies, wheelchair and chariot dollies, but no traditional dollies at all (John Pavlus, 2). In terms of movement, the camera often wanders freely, glancing around objects and tracking characters using mobile framing. Such techniques are most evident in memory scenes, and some scenes in the present utilize more conventional framing, perhaps serving to accentuate the stark juxtaposition between memory and the present. In the scene where Joel and Clementine meet on the train, initial long and me dium shots become more intimate medium close ups and close ups as the awkward tension between them reduces and they begin to feel more comfortable conversing. Similarly, clever tricks of size perspective are used in the childhood kitchen scenes to achieve the illusion that Joel is child-sized. Cinematography techniques are also exploited to convey the effects of memory erasure in subjective scenes, and the most notable of these are disorienting blurring effects and racking of focus, where the lensà ¢Ã¢â€š ¬Ã‚ ¦ [is] refocused at various planesà ¢Ã¢â€š ¬Ã‚ ¦ adjusting perspective relations (Bordwell and Thompson, 243). Finally, speed of motion is also occasionally altered within memory scenes, with normal and reverse fast-motion effects used (for example, when Joel is sketching the skeleton picture) to suggest an atmosphere of distorted temporality. The soundscape throughout the film is similarly used with great effect to evoke atmosphere and provide cues that generate audience reactions. Firstly, an internal diegetic voiceover is sometimes used, with Joels diary entries narrating certain scenes from both the present and within memories, encouraging viewers to sympathize with his plight. Some clever sound-image relations are also present, for example, when Joel hastily decides to squeeze through the doors of a leaving train, his voiceover ironically declares that he is not an impulsive person. Similarly, in a memory scene, Joel yells, its all falling apart to Clementine, as a car actually falls from the sky in the background. Indeed, a series of interesting sound techniques are implemented within memory scenes. For example, off-screen voiceovers of the memory technicians working in the present are often heard, reinforcing the fact that certain scenes are occurring subjectively within Joels mind. Effects such as degrading the sou nd quality, slightly asynchronous sound, which à ¢Ã¢â€š ¬Ã‚ ¦occurs earlier or later than the events which we see in the image (Bordwell and Thompson, 337), and the use of a digital deleting sound-effect all serve to depict the erasing of Joels memories. Finally, in film, the rhythm, melody, harmony, and instrumentation of the music can strongly affect the viewers emotional reactions (Bordwell and Thompson, 325), which applies throughout Eternal Sunshine. For example, a playful woodwind scherzo accompanies Joel and Clementines meeting on the train, adding to the flirtatious tone of the scene. Similarly, a chromatically sliding cello often signifies disturbing moments, and the dissonant yet beautiful broken guitar chords in the beach-house scene serve to heighten the bittersweet atmosphere and affect the audiences emotions. The final stylistic element that requires analysis is the use of editing throughout Eternal Sunshine. Continuity, which is the style that generates the illusion of a smooth, unbroken continuity across cuts by focusing our attention on story and characters and away from style (Budd, Craig and Steinman, 112), is rather varied in the film, with certain memory scenes and most present scenes adhering to the conventions of this style. For example, in the dining dead scene, a series of shot-reverse shots and eye-line matches are used to depict Joel and Clementines tense conversation. Such techniques give the scene a paced interest and offer balanced character perspectives, whilst remaining easy and natural for viewers to follow. Also, a montage is used to convey a large quantity of information to viewers in a short amount of time when Joel goes home to gather all Clementine-related objects. Unlike scenes in the present, continuity is often radically altered in subjective scenes. For example , when Joel tries to turn Patrick around to face him in the bookstore, a series of quick jump cuts repeatedly prevent the action. Also, jump cuts are often used to suddenly change memory locations, or to entirely erase characters (especially Clementine) from scenes. Finally, it is necessary to examine the films closing scene and its implications. The ending, although slightly ambiguous, seems to be a rather tragic prediction of Joel and Clementines future. The final shots observe the couple walking away together along the snowy Montak beach, suggesting the possibly of a happy ending. Suddenly however, quick jump cuts loop and replay their actions multiple times, indicating that their relationship is destined to continually fail and recommence in an inevitable cycle of love and pain. Thus, with particular attention devoted to the opening shots, it has been argued that via its mise en scene, cinematography, sound, and editing, Eternal Sunshine successfully evokes atmosphere, defines character, and provides cues that generate audience reactions. Ultimately, these stylistic elements, in conjunction with the fragmented narrative structure of the film, subjectively portray the effects of memory erasure within Joels mind, whilst constructing a bittersweet tale of an inevitably failing romance. List of Works Cited: Eternal Sunshine of the Spotless Mind. Dir. Michel Gondry. Focus Features, 2004. Turner, G. Film as Social Practice IV. London: Routledge, 2006. Bordwell, D. and Thompson, K. Film Art: An Introduction. Fifth Edition. Boston: McGraw Hill, 1997. Budd, M., Craig, S. and Steinman, C. Continuity Style Editing. Consuming Environments: Television and Commercial Culture. London: Rutgers University Press, 1999. 112-123. Brooker, P. and Brooker, B. Postmodern After-Images: A Reader in Film, Television and Video. Sydney: London, 1997. Sperb, J. Internal Sunshine: Illuminating Being-Memory in Eternal Sunshine of the Spotless Mind. Kritikos. 2 (2005):1-12. Pavlus, J. Forget Me Not American Cinematographer 85.4 (2004):1-3.

Web Based Technology and Continuing Medical Education

Web Based Technology and Continuing Medical Education This dissertation explores the use of Web based technology to enhance and maintain procedural skills in the context of continuing medical education. The research was initiated by the perceived need for novel and alternative methods of providing procedural skills training to health practitioners. This observation, supported by learning needs analysis, led to the design and implementation of a Web based educational resource aimed at doctors and other healthcare practitioners. The assessment part of the research focused on an empirical evaluation of the effectiveness of this Web based educational resource. This dissertation draws on a number of strands of Health Informatics: Principals of Heath Informatics Research Methods Clinical Information Systems Creating Online Educational Resources Whilst on a small scale, the results are relevant to medical educators involved in developing and evaluating web based educational resources. BACKGROUND Medical practitioners receive comprehensive procedural skills training and it is expected that this is maintained and regularly updated to limit skills decay and ensure clinical competency. Skills decay is defined as the loss of a trained or an acquired skill after a period of nonuse. Skills decay rapidly as the period of nonuse lengthens; and the extent of the decay is influenced by the characteristics of the skill and how and when these skills were learnt. Arthur et al., (1998) Skills are classified either as closed loop or open loop tasks. Arthur et al., (1998). Closed loop tasks are fixed sequence tasks with a defined beginning and end, for example, the preoperative anaesthetic machine check. Open loop tasks are tracking and problem solving tasks, for example, managing patients hypoxia. Arthur et al., (1998) in their review on the rate of skills decay and its influencing factors concluded that closed loop tasks decay more slowly than opened loop tasks. Arthur et al., (1998) also mentions that mental tasks decay more quickly than physical tasks and after 28 to 90 days of nonuse of the trained skills, task performance declines by 23% and by 40% after a year of nonuse. Clinical practice alone may be insufficient to prevent skills decay as indicated in a simulated airway management training study Kovacs et al., (2000). Skills decay quickly without practice; and procedural skills are only optimally retained when trainees regularly practiced the procedure on their own, in their own time and received periodic feedback. Training on simulation modalities, mannequins, fresh cadavers and live patients have the potential to successfully teach the procedural skill with significantly less skills decay over time as compared to didactic teaching alone. TI L et al., (2006). The traditional one to one apprenticeship model of medical procedural skills training and the in-hospital continuous medical education and maintenance of a skills base are often inefficient, expensive, and labour intensive. Patients, who are often used as practice tests subjects during skills training, safety is reliant on the medical practitioner skills retention and task competency. Maintaining procedural skills competency may prove to be increasingly more challenging as expense, time constraints, available manpower, lack of resources and patients reluctance to be used as experimental models make this endeavor increasingly impossible to set up. The resultant worldwide move towards competency based training programs and self directed problem oriented based learning has made necessary the search for alternative valid and reliable educational methods for skills training and its maintenance. Fortunately, the last decade has seen an explosion in the use of technology to enhance medical education. Web-based educational programs, computer aided virtual reality situations, and high fidelity simulation has played an increasingly important role in medical education owning to its efficiency, ability to provide flexible learning experiences, multimedia capabilities, and economies of scale and power to distribute instructional content internationally. Vozenilik et al., (2004) In the last 5 to 10 years extensive empirical research has been conducted on the use of computer aided and web-based instruction in medical education where there has been overwhelming support for these mediums of instruction. Unfortunately the literature is strikingly sparse on the use of Web based instruction for procedural skills training and in the few studies where empirical research has been carried out; study designs were not robust enough to withstand interrogation or had inconclusive results. LITERATURE REVIEW A review of the literature was conducted to ascertain what work had been done in the field of Web based learning, medical education and procedural skills training. A CINAHL and Medline search was carried out exploring all citations up to June 2010. The search using Medical Subjects Headings (MeSH) Computer Aided Instruction, Internet, CME returned 322 publications. Adding the MeSH term Review returned 21 reviews of which four were relevant. Replacing CME with Procedural Skills Training produced only one noteworthy empirical research paper and 2 publications worthy of discussion. Relevant systematic reviews of the literature are summarized in the table below: 3 Title Author / Date Findings Review Conclusions Assessment of the Review Internet-Based Learning in Health Professionals: A Meta-analysis Cook et al., 2008 201 eligible studies with qualitative or comparative studies of Internet based learning accounting for 56 publications Internet formats were equivalent to non-Internet formats in terms of learner satisfaction and changes in knowledge, skills and behavior. Internet based learning is educationally beneficial. Comprehensive work with a robust study design. Skills outcomes included communication with patients, critical appraisal, medication dosing, cardiopulmonary resuscitation, and lumbar puncture. Unfortunately the study had many limitations as many publications were poorly designed with low methodological quality, without validity and reliability evidence for assessment scores and with widely varying interventions What the meta analysis did suggest was that no further studies comparing Internet based interventions with traditional methods or no intervention were merited as these types of studies would almost invariably be in favour of Internet Based interventions. The author of the review suggested that the questions that warranted further research would be when and should Internet based learning be used and how could it be effectively implemented giving impetus to the exploration of Internet based skills training and maintenance. Title Author / Date Findings Review Conclusions Assessment of the Review The Effectiveness of Computer-Aided (CAL) Self-Instructional Programs in Dental Education: Rosenberg et al. 2003 1024 articles systematically reviewed. 12 publications included in the final review. Five studies significantly favored CAL. CAL is as effective as other methods of teaching and can be used as an adjunct to traditional education or as a means of self-instruction. This study is a comprehensive review of controlled randomized studies with clear and relevant inclusion criteria assessed with good inter and intra rated reliability. The reviewer limited the study to dental students. Forms of Computer Aided Instruction was not clearly defined or specified in the inclusion criteria. It is unclear whether web based studies were included. The skills referred to in the studies were dental diagnostic not procedural skills. The apparent dearth of studies assessing procedural skills justified the investigation undertaken by this dissertation. Title Author / Date Findings Review Conclusions Assessment of the Review Internet-based medical education: a realist review of what works, for whom and in what circumstances. Wong et al. 2010 249 papers met their inclusion criteria. Learners were more likely to accept a course if it offered a perceived advantage over available internet alternatives, if it was easy to use technically, had elements of interactivity and gave formative feedback. This study is a realist review and the methodology used answered the question of the study which aimed to provide a theory driven criteria to guide development and evaluation of Internet based tools. The findings and guidelines suggested in this review would later be incorporated in the design of the resource to be investigated in this dissertation. Title Author / Date Findings Review Conclusions Assessment of the Review eLearning: a review of Internet-based continuing medical education (CME). Wuton et al. 2004 16 studies met their eligibility criteria Internet based CME programs were as effective as traditional formats of CME A comprehensive and appropriate search of databases. Randomized controlled trials of Internet based education in practicing health care professionals. These results showed that Internet based interventions do have a place in CME and that these effects on skills behavior warrants further investigation. Title Author / Date Review Conclusions Assessment of the publication Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training. Chenkin et al. 2008 Web based tutorial may be an useful alternative to didactic teaching for learning of procedural skills A randomized control trial with non inferiority data analysis. The non inferiority margin was specified at a 10% margin however the actual amount of improvement was not specified. Blinding bias was not assured and the trial relied on the reputation of the investigator. No mention of inter rated reliability was made. Despite its inherent weaknesses, the trial suggested that web based intervention is as good as the alternatives; however, the study incorporated the use of simulation and live models to teach the actual procedural skill. David Cook is a prolific writer of many reviews and publications investigating Internet based formats in medical education. His noteworthy publications Web based learning: pros, cons and controversies Cook, (2007) and Where are we with Web based education Cook,( 2006) extolled the benefits overcoming barriers of distance and time with novel instructional methods, and extenuated the disadvantages which included social isolation, upfront costs and technical difficulties of Web based education. He concluded that Web based instruction can be a potentially powerful tool and strongly recommended that the focus of future studies should concentrate on the timing and application of Web based learning tools. Summary of literature survey The review of the literature has outlined the use of Web based procedural skills training as an area that requires further research. Empirical research and systematic reviews that has been carried out thus far has been limited. The literature research conducted for this dissertation (though in its self may have been limited) was unable to find publications exploring the whole use of the Internet as a means of procedural skills training and skills maintenance. Justification and Learning needs analysis To assess the effectiveness of an Internet based learning resource in the context of procedural skills training, a skill had to be chosen that was relevant, involved both a physical and mental task, and had the potential of decaying. A procedural skill is defined as the mental (knowledge) and motor activities (behaviour) required to execute a manual task and usually involves patient contact. Kovacs (1997). Furthermore, a learning needs analysis was undertaken to assess the value of this topic choice. Justification Intubation with a Laryngeal Airway Device (LAD) was chosen as the representative procedural skill. When a patient collapses from a cardiac or respiratory cause, timely control of the patients breathing and airway with prompt delivery of cardiopulmonary resuscitation (CPR) and defibrillation have resulted in life saving survival and neurological recovery. The LAD is a breathing maintenance device that can, with minimal training, be inserted effortlessly into the mouth of the patient allowing for breathing and oxygenation. It is increasingly being used in the repertoire of techniques available to frontline practitioners (practitioners first on call to resuscitation events) in emergencies where the technique has proven to be easy to use and life saving in the management of an airway crisis. Kette, (2005). In a survey of family medicine practitioners, all practitioners surveyed agreed that insertion of an LAD during a resuscitation procedure was a core procedural skill that most practiti oners were required to perform in any setting; 86% admitting that they had been called upon at some point to perform the procedure. Wetmore et al., (2005). Insertion of a LAD with knowledge of the patients anatomy, indication and contraindication for use and technique of use both under a controlled setting and in an emergency is representative of a procedural skill a frontline practitioners is expected to perform. Learning needs analysis A key step in developing an effective educational website is performing a learning needs analysis to determine what the learning needs the resource hopes to address are and why these needs were not met by existing learning or teaching arrangements. Cook Dupras, ( 2004). A questionnaire not previously validated, making use of closed type questions, were used to assess three broad areas; knowledge and training, skills application and Internet accessibility. Eleven frontline practitioners were asked to provide an indication of how often they were called to attend resuscitation or airway management situations in the last two years. They were surveyed regarding training received in LAD usage and insertion, their desire to obtain more information or skills updating, and whether there was a perceived need for Internet-based continuing medical education courses on LAD usage and intubation. Their attendances at CME workshops in the last year were surveyed and the barriers to CME workshop attendance were assessed. The respondents were surveyed regarding access to the Internet and previous exposure to e-learning modules. This was done to assess whether the uptake of the resource would be biased towards participants with Internet access, frequent Internet uses or previous e-learning experiences. The results of the learning needs analysis showed that most respondents (90%) received exposure to the device. It is a requirement of their post as frontline practitioners, to be Acute Life Support (ALS) trained where usage of the device in resuscitation is taught. Half the respondents indicated that they were not comfortable with their level of knowledge; and 63% felt unconfident about inserting the device as they were on average, only exposed to two resuscitation scenarios per year. All had Internet access at work and at home; and half had previous experience of online learning. Only one percent of the respondents were able to attend a CME session in the last year, citing lack of time and convenience as the main reasons. 80% of respondents were interested in taking courses through the Internet, as continuous education credits are a requirement of a license to practice in medicine. Interest in the topic was high and given the above self-appraisal, it was felt that the course was nee ded and should appeal to this population. METHODS The method section is dealt with in two parts. The first will focus on the development and design of a Web based educational resource and the second on the evaluation of the resource. 1. Development and design The idea was to develop an educational resource that could be used to train, reinforce knowledge and maintain a procedural skill by employing and integrating principles of effective adult learning with the unique features of the web. The development was driven by educational needs and outcomes of learning needs analysis completed by participants in a previous part of this study. 1.1 Development Theories The course design reflected Adult Learning Principles and the aim of the course was to improve knowledge (cognition), integration of attitude changes (confidence) and in so doing result in a change in behaviour (competency). Gale (1986). With accessibility of the Web based educational resource, it was hoped that the resource would be accessed frequently until the task becomes automatic or accessed as a refresher when required or at regular intervals. The resource incorporated principals that were shown to be effective. It was centered on the learners needs, was focused on a specific task and recognised past experiences of the learner (Gale 1986). The theories used in the development of the resource included; Experiential Learning Theory, which concluded that experiential learning should have personal relevance, should be self-initiated and lead to pervasive effects on the learner. Rodgers (1969) Constructivist Theory where learning is an active process with learners constructing new ideas and concepts based upon past and current knowledge. Bruner (1966) Information Processing Theory where knowledge is presentation in sequences or chunking to accommodate short attention spans (Miller 1956). The educational resource strived to be pedagogically sound uniquely applying these principles online. Information was presented in small chunks in a sequential fashion, was self-contained, had interactive components and contained assessments with instant feedback. Online communication did not occur in real time as which happens with video conferencing and online chat rooms, instead the resource used communication that was asynchronous where participants logged on, viewed and downloaded course material, read postings and submitted interactive tasks. The advantage of using an asynchronous format was that learners and/or the instructor did not need to be online at the same time allowing the participant to work at his or her own pace. The asynchronous nature of this web based learning environment allowed for barriers of time, location and expense to be overcome. Sanoff (2005) 1.2 Moodle Description University College Londons (UCL) Moodle was the platform used to develop the educational resource. There are many applications offering free alternatives to the commercial software WebCTTM and BlackboardTM, however the UCL Moodle was chosen as a matter of convenience because it was accessible, independent of specific operating systems, fit for purpose and easy to use without much technical computer knowledge thereby potentially removing barriers to any future course design and development.. Moodle (Modular Object Oriented Dynamic Learning Environment) is software freely available to use and was developed by Dougiamas. Moodle. org (1999). The Moodle software was designed on pedagogical principles that encourage learner interaction in a virtual learning environment. Moodle is a course management system used to support Web-based courses and has a number of innovative tools that could be used to create courses that promoted collaborative learning. Moodle is able to run without modification on Unix, Linux, FreeBSD, Windows, Mac OS and Netware. (Moodle. Org). After an initial learning curve, the program was easy to use with simple but comprehensive online instructions. Moodle It did not require pre-existing computer programming knowledge, and in fact the author of this dissertation considered herself a novice computer user. Moodle is written in hypertext pre-processor (PHP) which is HTML embedded scripting language used to create dynamic Web pages.  PHP allows for connecting to remote servers, checking email, URL encoding and setting cookies. It offers good connectivity to many databases including MySQL, and PostgreSQL,  which Moodle uses as a single database. MySQL is a  relational database management system  that runs as a server providing multi-user access to a number of databases. (www.php.net). Moodle had the support for easily displaying multimedia aspects of the educational resource and the interface could be used in over 70 native language translations. The Web based educational resource was easily built up using multimedia activity modules and design elements, which included with easy navigation; Authentication and enrollment, Syndication with a chat forum made available to others as newsfeeds, Current evidence based didactic teaching, Interactive quizzes allowing import/export in a number of methods Hyperlinked resources to provide for branched learning, The use of a Wikipedia, A glossary of commonly used terms, Instructional video presentations. All the attributes of the Moodle made for an international transportable tool ideal for knowledge presentation, learner interaction, comments and reflection, dynamic and interactive assessments, flexibility, extendibility, and most importantly, support for autonomous learning and continued educational development around the world. The only noteworthy disadvantage of using the UCL Moodle was an imposed instructional design. 1.3 Resource Description The educational resource was named; VIRTUAL [emailprotected]: Onà ¢Ã¢â€š ¬Ã¢â‚¬Å"line Laryngeal Airway Device training. à ¢Ã¢â€š ¬Ã¢â‚¬Å" Virtual suggesting both the virtual reality of an Internet based generated environment and the adjective, meaning practically or almost Collins English Dictionary ( 2008). The Web based educational resource was developed for distance learning and contained all the elements of a totally Internet delivered educational resource. The content of the course was drawn from the authors personal experience using the Laryngeal device; peer reviewed journal articles, manufactures product information and videos downloaded from the Internet. Permission for the use of copywriter-restricted material was sought and obtained where appropriate. 1.3.1 Screen Design The screen design refers to how the information was arranged and presented on the display screen. The guidelines used followed those (amongst others) suggested by DoD HCI Style Guide (1992). The screen was kept simple, orderly, clutter free and consistent with a limited, non-dominating colour palate of four colours à ¢Ã¢â€š ¬Ã¢â‚¬Å" blue, black, white and blue à ¢Ã¢â€š ¬Ã¢â‚¬Å" green, a combination that has been shown to cause little fatigue and distraction. Kelley (1988). The content of each lesson was presented on a plain white background with black text in a non-jarring informal style font that made the lessons easy to read. Clark (1997). One template was used and the navigation bar, top bar and individual lesson heading bars kept the same with only the content of each lesson changing. All the content was displayed statically on one screen with individual lessons accessed by scrolling vertically down to the individual lesson. Unnecessary menus and long selection lists were avoid ed. This allowed for an overall view of the content, minimized pointer and eye movements and caused less distraction with easy navigation. (Gruneberg 1978). A discussion forum, interactive quizzes and an end of resource examination were included to allow engagement and self-assessment. The quizzes and examination included a range of question types à ¢Ã¢â€š ¬Ã¢â‚¬Å" multiple choice questions, true/ false, photo matching and random short answer matching type questions. These varieties of questions were shown to improve the learning experiences of adult learners. (Mackway-Jones, 1998). Information was provided in chunks and the writing style kept informal, with plain, simple language and in conversational tone with some elements of humour. There were fewer than 60 à ¢Ã¢â€š ¬Ã¢â‚¬Å" character positions on a standard 80 à ¢Ã¢â€š ¬Ã¢â‚¬Å" character line, spacing between characters were 25 à ¢Ã¢â€š ¬Ã¢â‚¬Å" 50% of character height and spacing between lines were equal to the character h eight, this to increase reading efficiency. 1.3.2 Course Content The course material was presented as text, graphics, power point presentations, hyperlinks and video demonstrations of the procedural skill presented in animation and on an actual patient. Knowledge was provided in five short lessons that followed the natural sequence of usage and intubation with a Laryngeal device. Aims of the resource and objectives of each lesson were stated at the beginning of the course. Here too a glossary of commonly used terms and a baseline knowledge assessment quiz were included. Each lesson was kept succinct with hyperlinks to websites and folders for those seeking extra information. This was to limit download times. Each lesson was concluded with an interactive quiz used to reinforce and test the knowledge learnt. Instant responses were provided to the quizzes after submission with suggestions to either revisit the lesson or to continue depending on the results obtained in the quizzes. The resource was concluded with an end of course examination and the c ourse was predicted to take 1 to 2 hours to complete. The resource content was accessed with a secured password with all content downloadable by way of an Internet connection. All the participants were supplied with a secure company email address and all the ISTCs had Internet access. Permission was requested for the use of company time and resources e.g. airway device training mannequin and time during the working day for those who chose to access the resource at work. Participants were supplied with instructions on how to use Microsoft Word and how to log on to and navigate the Moodle site. The course material was available online for two weeks with access monitored. 1.4 Pilot Study The aim of the pilot study was to assess the ease of navigation, gauge the time it took to complete the course, the integrity of the hyperlinks and the validity and reliability of the content and examination questions. Font preferences, layout and download speeds were also assessed. A prototype of the resource was tested on a selected sample of five participants of similar profile to the participants used in the study. The participants of the pilot study were excluded from participating in the actual study. An external panel of three Consultant Anaesthetists and two trainee Registrar Anaesthetists where used to provided expert advice. The Consultant Anaesthetists were selected based on their special interest in emergency medicine or difficult intubation scenario teaching. A few typographic errors were corrected, aims and objectives were clarified, difficult navigational issues were corrected and some content deemed repetitive and lengthy by the pilot participants were excluded before rolling out the resource. These changes however, were minor and further usability studies were deemed unnecessary. 1.5 Content Validation The content presented was current, evidence based and peer reviewed for content validity by the panel of experts (made up of three Consultant Anaesthetists and two trainee Registrar Anaesthetists), who deemed the content to be relevant and appropriate. The panel of experts and the pilot participants also judged good face validity. 2. Evaluation of the Resource The study evaluates effectiveness and acceptance of a Web based educational resource used to train and maintain a learnt procedural skill in the context of continuous medical Education (CME). The evaluation of the resource was undertaken in two parts. First the effectiveness of the resource was evaluated and the endpoints measured were changes in knowledge, confidence and technical ability. This evaluation made use of a summative framework redefined by Saettler (1990); which takes place after interaction with the resource. A before and after interventional ipsative assessment was undertaken where participants performance was compared to their own over a period of time. The second part of the evaluation was undertaken to assess the acceptability of the Web based educational resource as a medium for procedural skills training and this was done by way of an evaluation questionnaire completed by the participants after course completion. 2.1 Participants and Setting The participants and settings were specifically targeted, as they would ultimately be interested stakeholders and end users of this type of resource. The research was conducted at five Care UK TM Independent Centers (ISTCs) on practitioners employed at these facilities. The ISTCs are part of the governments initiative to reduce long NHS waiting times for elective surgery by adding increased capacity and alternative treatment venues for patients. There are approximately 25 ISTCs in the United Kingdom with Care UK TM represents 20% of this market. The ISTCs were chosen as a setting because: They are not part of the UK NHS medical training scheme and therefore have no formal programs of medical training or teaching that similar grades of staff in the NHS would receive. Contractual obligations of the ISTC contract decreed that the ISTCs could not employ medical practitioners from the NHS; therefore, most of the medical staff employed at the ISTCs have trained abroad and are waiting either to enter a formal career path within the NHS or wanting UK work experience. This situation has resulted in a mixture of nationalities, non-uniform medical training and medical staff with differing levels of post qualification experience and more importantly, a high staff turnover. (ref) These resulting factors were conducive to a system of competency-based appraisals and continuous medical education, which could be addressed with Web, based educational resources. Participants in the study were all frontline practitioners employed at Care UK TM ISTCs, which employs 48 practitioners of this grade. This represents 50% of all frontline practitioners employed in ISTCs throughout the UK. This intended sample size of 48 adequately represented the wider population in this type of analysis. frontline practitioners are the first practitioners on call to the resuscitation of a collapsed patient where they would be called upon to secure the patients airway and ensure oxygenation until the Anaesthetists or the resuscitation team arrives. It is expected that frontline practitioners are trained and certified with acute cardiac and life support skills and confident in dealing with clinical emergencies. In reality, analysis has shown that frontline practitioners in these ISTCs, though some trained and certified, rarely use these skills due to the infrequent nature of resuscitation clinical emergencies, making these scenarios potentially high-risk events when they do occur. Frontline practitioners are made up of Resident Medical Officers (RMOs), Anaesthetic Assistants (ODAs) and Recovery Room Practitioners (RNs). RMOs are doctors who have completed their medical training and have at least two years post graduate work experience as qualified doctors. They are employed to provide 24 hours on site medical management of patients at the ISTCs and like general practitioners (RACGP 2006) and doctors outside NHS academic hospitals, are usually first on call for emergencies and the sole source of medical advice on the premises on which they work. Anaesthetic assistants and recovery room practitioners are nursing practitioners

Heroism in Epic of Gilgamesh Essay -- Epic Gilgamesh essays

Heroism in Gilgamesh  Ã‚   Heroism entails several things; a selfless act, courage, or the accomplishments of bold and daring expeditions. A hero can often be of divine ancestry. But every hero has faults and these faults along with heroic deeds make the man, or woman; a hero. Gilgamesh loved his friend Enkidu more than he loved himself. A phrase indicating this love for Enkidu is on page 35: "We must go down into the forest together./. . .I will go before you/And ... ...h the heroic and non-heroic qualities differently. In the end we are all the same, we have no choice, all of us must deal with each other's Gilgamesh. Work Cited Sandars. N. K. The Epic of Gilgamesh. New York: Penguin Books, 1972.

Elements Unifying a report :: essays research papers

Writing reports comes easy to most people, but the trick is to make the report easy and inviting for others to read. It is difficult to pick up and read a report that is dull and boring. I am not talking about the subject of the report but rather the look of it. A report may be chocked full of useful, important, and exciting information; but it may never get read in its ¡Ã‚ ¦ entirety because it looks uninteresting. One way to make a report more inviting to read is the use of eye catchers. An eye catcher is something that captures the eye; it aids you in gaining the reader ¡Ã‚ ¦s attention. Examples of eye catchers are: „ «Sidebars „ «Pull Quotes „ «Drop Capitals Later in this report we will also go over other ways to build a great paper; such as, coversheets and unifying elements. Sidebars  Ã‚  Ã‚  Ã‚  Ã‚   Why use a Sidebar? „ «Makes the report easier to read „ «Summarizes the main message „ «Reinforces the important concepts of the main message Pull Quotes A pull quote is a small selection of text pulled out and quoted in a larger font. One of the benefits of using a pull quote is to draw the attention of the skim reader; it clearly highlights key points of the article or report. Pull quotes add style to a document and also breaks up the monotony of text. A pull quote can be placed within an article, span multiple columns, or be placed in an empty column near the article. Below you will find a good example of a pull quote from Glamour magazine. This one sentence can cause a reader to stop and read it. If the pull quote interests the person enough, he or she may read the balance of the article. The following are some guidelines for doing pull quotes: need to be thought provoking, need to be quick bites of information, and need to include only a single thought. Drop Caps Drop caps add visual interest and directs the reader ¡Ã‚ ¦s eye to the beginning of a section of text. You can use drop caps to enhance the appearance of your document. A drop cap is also another way to put emphasis on a word without using bold or italicized font. Drop caps provide a visual break in long articles or in the main text. You can vary the size, color, and font of a drop cap to achieve a more pleasant appearance. Roger Parker's Newsletters from the Desktop offers these additional tips for using drop caps: