American Beauty

There are numerous significant motives in the1999 film entitled American Beauty, directed by Sam Mendes. In this film, Lester Burnham– a 42-year-old, depressed suburban father has a mid-life crisis and voluntarily decides to turn his chaotic life around after developing a fascination for his daughters attractive friend, Angela. Similarly, The title American Beauty is proven to be significant with the satirical lust between Lester and Angela , Lester realizing the beauty throughout his life sincerely, and the American beauty rose used as a symbol. This representation allows the director to ultimately suggest that everyone will see the beauty in America and their lives. In the movie American Beauty, the lust portrayed is shown very satirically and creates a deep affect on the characters throughout the film. For example, lust is illustrated when Lester notices Angela for the first time and feels instantly compelled to her. Which gives the allusion of beauty but ultimately is very disturbing because of Angela’s age. Although, Lester suddenly feels the need to know Angela. Subsequently, after meeting her he says, â€Å" It’s the weirdest thing I feel like I’ve been in a comma for about 20 years and I’m just now waking up† (American Beauty). In stating this, Lester explains how he felt like he was living every day like the last and not really living at all until he met Angela. To elaborate, Lester states, â€Å"The highlight of my day is masturbating in the shower† (American Beauty). By using the word â€Å"highlight† sows that it’s the most arousing part of his day which he combines with masturbating. Although, after he meets Angela he feels as though he was â€Å"waking up† for the first time (American Beauty). This feeling leads him to start working out, smoking weed, and working at his old teenage job in order to get Angela interested in him. Therefore, the lust shown between Lester and Angela depicts the title American Beauty because of the want or need to feel wanted and loved by someone. Lastly, Lester realizing the beauty in his life helps prove the implication of the title. With Lester feeling as if his life is pathetic and boring in the beginning of the film, to the end where he feels as though he is â€Å"great. † For example, Lester states, â€Å" I am grateful for every moment in my stupid life â€Å" (American Beauty). Meaning that Lester knew most times his life was â€Å"stupid,† although he still saw the beauty in everything. Lester sincerely finds the beauty in his life right before he is murdered and continues to after he dies. He says, â€Å"I guess I could be pissed about what happened to me, but there is so much beauty in the world† (American Beauty). Implying that he felt as though he could be mad that his life was taken from him, but he finally witnessed his daughter being happy and in love and realized that he truly still loved his wife. Therefore, he has no choice but to be thankful for the life he had been given. This strongly depicts the American beauty by allowing Lester to sincerely see beauty in his dysfunctional life. The rose called American beauty is introduced various times as a symbol throughout the film. The rose is presented satirically for the first time when Carolyn is trimming her American beauty rose bushes in the front yard. Everything seems to be perfect with the white picket fence and the suburban house-wife outside doing yard work. Although, like the rose, everything is beautiful at first glace, but when you look deeper you see the thorns and the dysfunction within the family. In addition, the American beauty rose is also introduced countless times while Lester is fantasizing about Angela. For example, the moment Lester spots Angela for the first time he imagines her undressing for him while being the only ones in an auditorium. She opens her shirt and vibrant rose pedals come flowing from her chest (American Beauty). This represents the beauty that he not only sees in her; though, also the beauty that she brings to his life. Which is portrayed to be very satirical because of his fanaticizing about Angela who is a young girl. Hence, the significance of the title American Beauty and the representation that is shown through the American beauty rose. Although, some may say that the American beauty rose is portrayed sincerely in the film. They might argue that at the end of the film, when Lester has just seen the beauty throughout his life, there is a vibrant bouquet of American beauty roses on the table in front of him. Showing the sincere feelings of beauty that Lester is realizing for the first time while looking at his family portrait. People can also argue that in the next scene where Lester has been killed the roses are suddenly blackened and dead. Also, the vivid red blood splattered around the flowers helps portray the lack of color and beauty in the roses it self. This sincerely shows the ugliness of deaths and the arrival of death when Lester had just recognized the beauty in his life. Therefore one may argue the American beauty rose is portrayed as sincere as well as satirical. Subsequently, this shows the representation of American Beauty allows the director to ultimately suggest that everyone will see the beauty in America and their lives. While every character in the film was dysfunctional they all came to a realization of the beauty in their lives at the end of the movie. Although each character didn’t have to loose their life to see the beauty, the murder of Lester allowed the beauty to be revealed and also enables the characters to have a somewhat epiphany. In conclusion, Janet Maslin, a film critic from the New York Times states, â€Å"if you don’t feel the film’s piercing vision of what really matters, someday you will† ( 293). Therefore restating that everyone will see the beauty in the dysfunction of America someday before or after they die. American Beauty There are numerous significant motives in the1999 film entitled American Beauty, directed by Sam Mendes. In this film, Lester Burnham– a 42-year-old, depressed suburban father has a mid-life crisis and voluntarily decides to turn his chaotic life around after developing a fascination for his daughters attractive friend, Angela. Similarly, The title American Beauty is proven to be significant with the satirical lust between Lester and Angela , Lester realizing the beauty throughout his life sincerely, and the American beauty rose used as a symbol. This representation allows the director to ultimately suggest that everyone will see the beauty in America and their lives. In the movie American Beauty, the lust portrayed is shown very satirically and creates a deep affect on the characters throughout the film. For example, lust is illustrated when Lester notices Angela for the first time and feels instantly compelled to her. Which gives the allusion of beauty but ultimately is very disturbing because of Angela’s age. Although, Lester suddenly feels the need to know Angela. Subsequently, after meeting her he says, â€Å" It’s the weirdest thing I feel like I’ve been in a comma for about 20 years and I’m just now waking up† (American Beauty). In stating this, Lester explains how he felt like he was living every day like the last and not really living at all until he met Angela. To elaborate, Lester states, â€Å"The highlight of my day is masturbating in the shower† (American Beauty). By using the word â€Å"highlight† sows that it’s the most arousing part of his day which he combines with masturbating. Although, after he meets Angela he feels as though he was â€Å"waking up† for the first time (American Beauty). This feeling leads him to start working out, smoking weed, and working at his old teenage job in order to get Angela interested in him. Therefore, the lust shown between Lester and Angela depicts the title American Beauty because of the want or need to feel wanted and loved by someone. Lastly, Lester realizing the beauty in his life helps prove the implication of the title. With Lester feeling as if his life is pathetic and boring in the beginning of the film, to the end where he feels as though he is â€Å"great. † For example, Lester states, â€Å" I am grateful for every moment in my stupid life â€Å" (American Beauty). Meaning that Lester knew most times his life was â€Å"stupid,† although he still saw the beauty in everything. Lester sincerely finds the beauty in his life right before he is murdered and continues to after he dies. He says, â€Å"I guess I could be pissed about what happened to me, but there is so much beauty in the world† (American Beauty). Implying that he felt as though he could be mad that his life was taken from him, but he finally witnessed his daughter being happy and in love and realized that he truly still loved his wife. Therefore, he has no choice but to be thankful for the life he had been given. This strongly depicts the American beauty by allowing Lester to sincerely see beauty in his dysfunctional life. The rose called American beauty is introduced various times as a symbol throughout the film. The rose is presented satirically for the first time when Carolyn is trimming her American beauty rose bushes in the front yard. Everything seems to be perfect with the white picket fence and the suburban house-wife outside doing yard work. Although, like the rose, everything is beautiful at first glace, but when you look deeper you see the thorns and the dysfunction within the family. In addition, the American beauty rose is also introduced countless times while Lester is fantasizing about Angela. For example, the moment Lester spots Angela for the first time he imagines her undressing for him while being the only ones in an auditorium. She opens her shirt and vibrant rose pedals come flowing from her chest (American Beauty). This represents the beauty that he not only sees in her; though, also the beauty that she brings to his life. Which is portrayed to be very satirical because of his fanaticizing about Angela who is a young girl. Hence, the significance of the title American Beauty and the representation that is shown through the American beauty rose. Although, some may say that the American beauty rose is portrayed sincerely in the film. They might argue that at the end of the film, when Lester has just seen the beauty throughout his life, there is a vibrant bouquet of American beauty roses on the table in front of him. Showing the sincere feelings of beauty that Lester is realizing for the first time while looking at his family portrait. People can also argue that in the next scene where Lester has been killed the roses are suddenly blackened and dead. Also, the vivid red blood splattered around the flowers helps portray the lack of color and beauty in the roses it self. This sincerely shows the ugliness of deaths and the arrival of death when Lester had just recognized the beauty in his life. Therefore one may argue the American beauty rose is portrayed as sincere as well as satirical. Subsequently, this shows the representation of American Beauty allows the director to ultimately suggest that everyone will see the beauty in America and their lives. While every character in the film was dysfunctional they all came to a realization of the beauty in their lives at the end of the movie. Although each character didn’t have to loose their life to see the beauty, the murder of Lester allowed the beauty to be revealed and also enables the characters to have a somewhat epiphany. In conclusion, Janet Maslin, a film critic from the New York Times states, â€Å"if you don’t feel the film’s piercing vision of what really matters, someday you will† ( 293). Therefore restating that everyone will see the beauty in the dysfunction of America someday before or after they die.

Bedbugs Research

There will be multiple research objectives to gain a clearer understanding of the direction that the entire bed bug pest control industry is moving towards. Since the recent introduction of the low cost no-frills, ‘do-it-yourself’ equipment, there has been no solid data available to support as to how effective those techniques are nor is there qualitative data on customer’s perception as to how effective it is. Both approaches (quantitative and qualitative) are important since if the customers feel they have fewer bed bugs (qualitative) but empirical analysis shows that in fact the number of bed bugs present in their homes remain the same, such data is of great importance. Unfortunately the perception of customers is more important and their positive word-of-mouth recommendation of the do-it-yourself devices (despite their failure by quantitative measures) will create a huge market for failed products that will do consumers more harm than good in the long run. The research objectives would be to find out empirically whether the ‘Do It Yourself’ approach is more effective, less effective or the same as by using the services of a qualified exterminator. After the use of the methodology described below, the test groups would be questioned specifically as to how they felt (qualitative approach) three months later: (a) Their overall feelings/beliefs as if there are less or more bedbugs present; (b) About their feelings/beliefs in the effectiveness of the product that they’ve used. The same groups will also have their homes examined at the same time through the use of bed bug detecting dogs and exterminators who were trained in locating bed bugs to see (quantitative) if there were any bed bugs to be found in the homes. The results gathered from the two groups (described below) will be compared so that a future course of action for Bed Bug Pest Control Of New York Inc. could be formulated. It will be of crucial importance for the company, as well as the bed bug removal industry to find out the effectiveness of different methods of bedbug extermination. Research Methodology The first part of the research methodology would be to gather a statistically significant random group of 1000 consumers who have experienced a bed bug infestation in their bedrooms. This group should be halved into two equal groups of 500: Group A and Group B. Individual members of each of the groups must have experienced similar levels of complaints of be bug infestation as will be measured on questionnaires prior to the inclusion of the individual in the study. Each of the groups must be willing to try out the devices given to them and agree to the post-extermination interviews as well as inspections by qualified, unbiased exterminators. Zikmund, 2010) The first group of 500 (Group A) will use what we will define as the Do-It-Yourself (DIY) approach (use of devices such as double edged masking tape, devices to place under the legs of furniture, and other no-frills devices that are marketed on late night television, on websites which make dubious claims, and are found at supermarkets in well designed containers plastered with ‘As Seen on TV’ stickers) to attempt to remove the bedbug infestation from their homes. To make sure that the devices are applied, a representative of the study will be present to make sure that the devices are used. We feel that without this mechanism, there is a high degree of uncertainty as to whether the test subjects will truthfully use the devices, thus significantly skewing the results from data gathered from Group A. (Joselyn, 1977) The second group of 500 consumers (Group B) will exclusively use the services of qualified bed bug exterminators and will receive two visits, one week apart, to disinfect their homes using professional bed bug removal technology. During the first visit, the qualified exterminator will use the steam method of bed bug removal, which uses a vacuum cleaner sized device to shoot 400 degree steam throughout the hard to reach areas of the bedroom, closet and the insides of the bed frame and furniture. This method boils away the bed bug nests as well as destroys the eggs. The second visit will use the scientifically proven cold method of bed bug removal which, through the use of a freezing stream -100 degree compressed carbon dioxide, will reach the deep nests hidden far within the falls, floors and walls that is unreachable by any other means. Gathering Data Data Sources Many attempts by the company have been made to find any external data available on this subject without success. Due to the fact that bed bugs were practically extinct in the western world since the 1950’s, the lack of modern equipment (carbon dioxide removal equipment, many of the current DIY gadgetry), no reliable sources of external data are available. Thus the company will use internal data or more specifically data collected internally from the new website (please see IT section below). Types of Surveys All data collected will be done through an online website where each individual member of either Group A or Group B will answer the questions on their own. This will be done so the data will not be contaminated by the bias of the individuals who collect the data as well as to make sure that each individual is able to answer each question thoroughly in the comfort of their own home, and not with a member of the research team present. (Dillon, 1994) Observation Studies This part of the study will be performed by the individuals who at the end of the study will come inside the test subject homes with bed bug sniffing dogs to determine empirically whether any bedbugs are still present within the premises. There is no known method besides the bed bug sniffing dog that can reliably determine their presence. Experiments / Test Markets The individuals to test out the premises of the experiment will be gathered from a specifically set up website that will gather the random individuals who will participate in the experiment. Use of Information Technology Information Technology will be used in multiple ways throughout the survey to not only save marketing budget dollars for the company but also to make the entire process less intrusive for the test subjects. The 1000 total sample will be gathered through a specially created website which will ask consumers if they wish to receive a free extermination in exchange for their participation. After a few thousand names are gathered, the individuals will be asked (via email) to return to the website (via a link inside the email) to fill out a detailed survey about their current infestation: (a) How often they were bitten (b) How often they see bedbugs (c) to rate the level of their infestation (d) to see if they have used any methods to deal with the infestation in the past, etc.. The website will then randomly assign (to make the study double blind) the individuals into two groups described earlier in this presentation. A simple random generator built into the website can accomplish this, that any second year IT student can write for under $100. The researchers will not be able to see the names, races, gender or any other information about any specific individual to remove any potential bias. Each of the individuals will also be assigned randomly to an exterminator, who will not know that individual is part of any experiment. (Calabrese, 2011) The post-study interviews will all be done via the internet so as to not inundate the individuals with unwanted visits or telephone calls. The individuals who participated in the study will receive emails with a link to fill out the qualitative parts of the study, which will ask them not only to rate how they feel (using their own words) about their current bedbug situation but the overall experience. In case of Group A, the questions will include (a) describe the ease/difficulty in applying the DIY products (b) Did they cause a mess? (c) How they felt about the infestation a week later, 2 weeks later, 1 month later (d) Would they recommend it to their friends and why? McKnight, 2011) The use of web based technology would make the entire process more comfortable and may result in more honest answers since the questions will be answered at the convenience of each individual who participated in the experiment and not at the convenience of the organizers of the experiment. The final data will also be much easier to break up and analyze since every response will be stored in the database and thus the final data could be bro ken down and correlated using a vast array of different scientific approaches. Reference http://www.economywatch.com/world-industries/steel-industry/trends.html

Business Ethics Essay

INTRODUCTION There are decisions made every day in the business world, some big, some small. The biggest struggle professionals face when making these decisions are the ethical consequences they face. Every decision that is made is going to have an impact on at least one person, no matter the size of the decision. And there are ethical consequences to all decisions. In the following paper I will be comparing Maslow’s Stages of Behavior and Kohlberg’s Stages of Moral Development with ethical and unethical behaviors of businesses and society. Both Maslow and Kohlberg have established a hierarchy of either behavior or moral development. I will take both of these hierarchies and apply them to the behavior of business and society, as well as including service-to-self and service-to-others concepts. BACKGROUND (MASLOW & KOHLBERG) Before we can discuss how Malsow and Kohlberg play a role in ethical and unethical behaviors in business and society, it is necessary to understand the values of these theories, beginning with Maslow’s Stages of Behavior. Malsow presents these stages in a hierarchical format, beginning with the lowest order, up to the highest level. The first level is physiological needs, followed by safety, love/belonging, esteem, and finally reaching the highest level of self-actualization. 1 In this hierarchy the first level is usually achieved before reaching the second level, and this continues along the hierarchy. Therefore, the ultimate level of reaching self-actualization isn’t usually achieved until all lower levels have been reached and in a sense, conquered. Similar to this theory is Kohlberg’s stages of moral development. Kohlberg’s theory also states that the stages are reached in an order and one must be reached before the next, but can stop at any point, so that the highest level is not attainable by everyone. 2 Kohlberg’s stages of moral development consist of three levels and six stages. The first level is Pre-conventional morality (stages 1-2): Obedience and Punishment, Individualism and Exchange. The second level is Conventional morality (stages 3-4): Good Interpersonal Relationships, and Maintaining the Social Order. The third level is Post-conventional morality (stages 5-6): Social Contract and Individual rights, and Universal principles.3 FOCUS ON UPPER LEVELS For both Maslow and Kohlberg there is a heavy emphasis on reaching the final stage or level. Reaching the self-actualization stage of Maslow’s stages shows that one has fully developed behavior, and moral behavior. Reaching the final stage of universal principles of Kohlberg’s stages shows that one has fully developed morally, very similar to Maslow. For Maslow’s stages a person is capable of reaching this final stage and then regressing back to lower stages.4Usually reaching this higher stage is only temporary and is seen as peak experience.4 This could be in a sort of out of body experience. But once someone has reached this stage, it usually impacts them for the rest of their life, and they do not immediately go back down to lower levels. This stage could also be called, or is known as having integrity.5 This integrity is for oneself and for others, including â€Å"a total commitment to the highest standards of behavior†. 5 This is where ethical and moral reasoning and behavior comes into play. People who have reached or have experienced the highest level of Maslow are going to act morally and ethically in their behavior. The last stage of Kohlberg is universal principles. This stage â€Å"defines the principles by which we achieve justice†. 6 To me this stage entitles treating everyone with dignity. This reminds me of the integrity involved in the highest stage of Maslow. In this stage every human being is given equal respect and is treated with the highest dignity. People who have reached the highest stage of Maslow would not vote for a law or agree with anything that causes some harm to others while helping the majority.6 ETHICAL AND UNETHICAL BEHAVIOR Now that the theories and stages of Maslow and Kohlberg have been discussed, it is necessary to see how these stages play a part in making either ethical or unethical decisions in the workplace and in society. The first example to take a look at is the behavior of students cheating in school. This is a common example, but it could easily be applied to employees stealing from a company, or anyone taking shortcuts in life to get ahead. Many people would agree that cheating would correlate to students with less moral and ethical values. During a study by Kohlberg, it was seen that 70% of the students on the pre-conventional level have been found to cheat.7 The pre-conventional level indicates that people are not fully morally developed. These people seem to lack moral development, and therefore will act unethically. The people at these lower levels do not have the respect and dignity for others that the upper level people do. Because this is the case they are more willing to cheat, and don’t feel guilty for what they are doing. This can easily be transpired into the business world. People cheat and steal money because they have no respect or dignity for the people that they are affecting. They will not take into consideration all of the stakeholders at risk because of their actions. Take for example, Bernie Madoff and the scandal at Enron. This is a case famous across many business environments, for unethical behavior that caused harm to many stakeholders. No one would disagree that Madoff was a very savvy and smart business man. But, because of his actions he would fall into a lower level of Maslow. SERVICE TO SELF AND OTHERS People who have reached the highest level of Maslow (peakers, we will call them), and those who have achieved the highest level of development Kohlberg presents will have a service-to-others attitude. These people are less materialistic, and are more socially concerned.8 There seems to be a correlation between people in upper level Maslow who have higher levels of ethical development, and those who are in the upper stage of Kohlberg and have higher levels of moral development.8 This correlation also relates to how these people treat those who are around them. They are not self-centered and are instead focused on the well being of everyone around them. As mentioned before, they seem to be concerned with giving every human being the respect and dignity that they deserve. If someone is concerned with the way that they are treating others, this is seen as a moral consideration. And if they are concerned with how well they are treating themselves, it is seen as a non-moral consideration.8 So, those who are focused on service-to-others instead of service-to-self are more likely to belong to the higher levels of Maslow and Kohlberg. Those who are more concerned with themselves and have a service-to-self attitude; they are stuck in the lower levels. They are still trying to achieve the basic needs that Maslow sets out. HOW IT ALL FITS INTO AN ORGANIZATION The most difficult part about these two theories, are what they have to do with an organization, how employers can utilize this information to better motivate their employees, and people are going to treat themselves and others within the levels of Maslow and Kohlberg. One of the biggest examples of this, are how these theories can be incorporated into a non-profit organization. These organizations would be more known for their ethical behavior than most other companies. These companies can obtain an ethical culture by following and paying attention to the hierarchy of values that Maslow proposed.9 Maslow noted that in order to achieve the highest value the previous needs have to have been met. If a company takes this into consideration than they should make sure the lower needs of the employees are being met, if they expect them to behave ethically. This leads to an ethical culture. In the article that discusses this they translate the individual levels of Maslow into levels that an organization should achieve. These levels or needs are financial competence, accountability, reciprocity, respect, and integrity.9 They feel that in order to employees to attain the ethical values and culture that is wanted, the lower needs must first be met. This may include wage benefits and giving employees more responsibility to begin with. Eventually employees will feel a sense of respect from the employer and will work their way up to level 5. If all of the employees at this company are at the level 5, then they have an ethical culture. This is a way to apply the theories of Maslow and Kohlberg into an organization, even if is a for profit company, and achieve the ethical culture that is desired. CONCLUSION To sum up, Maslow and Kohlberg have developed a hierarchy of needs and stages of moral development, respectively. It is possible to use these models to understand the ethical and unethical behavior of people in businesses and in society. There is a focus on achieving self-actualization and universal principles. If someone has reached this level of self-actualization it transforms their identity, and they are more apt to act morally and ethically. In the same sense, those who are in the universal principle level of Kohlberg, treat all humans with the respect, integrity, and dignity that they deserve. The people in these upper levels are also known to have a service-to-others attitude, instead of service-to-others. Lastly, companies can use this information to make sure the basic needs of their employees are being met, in order to achieve an ethical corporate culture. ENDNOTES 1. SADRI, GOLNAZ, and R. CLARKE BOWEN. 2011. â€Å"Meeting EMPLOYEEE requirements: Maslow’s hierarchy of needs is still a reliable guide to motivating staff.† Industrial Engineer: IE 43, no. 10: 44-48. 2. Walker, Lawrence J. 1982. â€Å"The Sequentiality of Kohlberg’s Stages of Moral Development.† Child Development 53, no. 5: 1330-1336., 1330-1336. 3. W.C. Crain. (1985). Theories of Development. Prentice-Hall. 4. Christopher, John Chambers, Guy J. Manaster, Robert L. Campbell, and Michael B. Weinfeld. 2002. â€Å"Peak Experiences, Social Interest, and Moral Reasoning: An Exploratory Study.† Journal Of Individual Psychology 58, no. 1: 35 5. Strickland, Ruth Ann, and Shannon K. Vaughan. 2008. â€Å"The Hierarchy of Ethical Values in Nonprofit Organizations.† Public Integrity 10, no. 3: 233-235 6. W.C. Crain. (1985). Theories of Development. Prentice-Hall. 7. Emerci, Çetin. 2006. â€Å"THE OPINIONS OF MEDICINE FACULTY STUDENTS REGARDING CHEATING IN RELATION TO KOHLBERG’S MORAL DEVELOPMENT CONCEPT.† Social Behavior & Personality: An International Journal 34, no. 1: 41-49 8. Christopher, John Chambers, Guy J. Manaster, Robert L. Campbell, and Michael B. Weinfeld. 2002. â€Å"Peak Experiences, Social Interest, and Moral Reasoning: An Exploratory Study.† Journal Of Individual Psychology 58, no. 1: 35 9. Strickland, Ruth Ann, and Shannon K. Vaughan. 2008. â€Å"The Hierarchy of Ethical Values in Nonprofit Organizations.† Public Integrity 10, no. 3: 233-235

Asias Global Future in Business Culture Essay Example | Topics and Well Written Essays - 4250 words

Asias Global Future in Business Culture - Essay Example This paper makes a conclusion that that although globalisation is likely to bring about a gradual change in Asian business culture, it is highly unlikely that the Asia, which consists of many different cultures, religions and schools of thought can be radically changed as a whole. Americans still have a unique culture and for that matter a business culture despite being exposed to the attention and criticism of business people, governments and religious groups from all over the world. The way in which things are done in a country or a homogeneous culture have been shaped over prolonged periods of time and business culture also includes components that are of benefit to vested interests in a society along with religious values that are guarded with great zeal. Hence, although the forces of globalisation are likely to bring about greater understanding and perhaps some good ideas, any change in Asian business culture is likely to be far more gradual. Even though people in certain areas of a country are exposed to interactions with foreigners, not all of the people and regions within a vast country are likely to be able to benefit from such interactions. Exposure to foreign media does not bring about radical change because what is viewed is considered to be an interesting cultural oddity which can be seen but not practised. Business people deal with situations in order to try and maximise gain and thus a lot of the so called business culture is designed to protect vested interests.

Fogo de chao Essay Example | Topics and Well Written Essays - 1000 words

Fogo de chao - Essay Example The restaurant has 25 locations where it operates in the United States of America and 9 other locations in Brazil. The meaning of Fogo de Chao is ‘fire on the ground’ and summarizes the method of traditional gaucho of meat roasting over an open fire. The restaurant has many parts; part gluttony, part spectacle and mostly red meat. Fogo de Chao is a dining experience that is interactive where meats are carved tableside from skewers waiters who are dressed in Brazilian garb. Substitute to ordering, dinners have the liberty of trying anything and everything. Typically located in a space that is cavernous, the table meat-fest goes hand in hand with a huge and self-serve salad bar that is varied and the menu explains the different options of meat and provides drinks lists, mainly Brazilian caipirinhas. It is not hard to dismiss Fogo de Chao as a gimmick, other than it is actually very authentic. Not only is this all-someone can eat the style of table skewer of dining is popular in Brazil, where it is called riodizio (a restaurant serving riodizio is a churrascaria), however, Fogo de Chao is a Brazilian chain that is popular that immigrated to the United States rather than an Americanized take on that food of the nation. A lot of the servers are from are from Brazil, and nearly all of them worked in the other locations initially. The services are very impressive, given that the formula depends on each and every waiter’s responsibility for his/her meat(s) of the night, starting from prepping to cooking in the giant that are behind the scene s rotisseries used for serving. In addition to delivery and carve food, they supervise it from seasoning up to delivery at the optimum time. In all the locations in the United States are different, however, they are all upscale in terms of furnishing and decoration, with a lot of a fine than a look that is buffet, with a separate bar, distinctively a glass walled wine cellar that is

The Use of Cloud Computing in Public Libraries Assignment

The Use of Cloud Computing in Public Libraries - Assignment Example However with the introduction of cloud computing in public libraries a lot changed in terms of management of systems and resources. The introduction of this technology in public libraries meant that there would be increased operational efficiency, effectiveness in the use of resources and cost savings that went a long way in developing other sectors of the library. Cloud computing: Background Cloud computing refers to a computing model and net necessarily technology in which clients plug into the â€Å"cloud† in order to access information technology resources that are priced and provided on demand. Simply stated the term cloud is synonymous to the internet. The term cloud computing thus is based on cloud drawings that were used in the past to represent telephone network and in much later times to represent the internet (Buyya, Broberg, & Goscinski, 2011, p. 10). Thus cloud computing is internet based computing where there exist virtual shared servers which provide software, i nfrastructure, platform, devices and other resources as well as hosting to clients on what is known as pay as you use basis. Information is digitized such that it is provided in the cloud to customers. Users or clients can access these services that are available on the internet cloud without having the ability to operate or manage the resources that are involved (Velte, Velte, & Elsenpeter, 2010, p. 25). Scholars thus argue that the advantage of this computing model is the flexibility that it offers organizations in terms of concentrating on the core business processes of the organization without having to invest their time in training or gaining knowledge in the use of these resources that are needed to manage their business resources (Buyya, Broberg, & Goscinski, 2011: Velte, Velte, & Elsenpeter, 2010). In cloud computing customers do not the physical infrastructure upon which information technology services are provided; rather the clients rent the usage from providers. This is seen as very important for organizations because of the reduction in the costs involved in setting up information technology infrastructure. Companies thus consume resources as a service and pay only for those resources for which they use. Most of the cloud computing infrastructures consist of services which are delivered through the common centres built on servers (Rittinghouse & Ransome, 2010, p. 15). Characteristics of cloud computing There are six distinct characteristics of cloud computing technology. First is on demand self-services and this means that computer services such as applications and emails can be provided without the need of human interaction with each of the service provider (W, 2009, p. 27). Secondly is broad network access such that cloud capabilities are availed through the network and can be accessed through the standard mechanisms through any end user terminal such as computers, phones or PDAs. Third is resource pooling such that the providers resources are p ooled together to serve a number of clients using the multiple-tenant model with different physical and virtual resources dynamically assigned and reassigned in line with the consumer demand. These resources include storage, processing, memory, network bandwidth and email services among others (Gong, 2010, p. 275). Fourth is rapid elasticity such that the cloud

Difference between Leaders and Managers Assignment - 13

Difference between Leaders and Managers - Assignment Example Following these theories in leadership, leaders should depict voluntary action; this is the difference between leaders and managers. Leaders in the article are acting like managers, whose role is to control the employees. They fail in their roles as they are supposed to listen to their needs and look for a way forward to create an admirable working environment. The success of leaders has a different interpretation, as it is governed by many variables; this includes the leadership styles, aspects of the situation, and quality of followers (Bertocci 22). This means that they have to create a basis to enhance their relationship with employees. Â  In the recent business world, there is a need for an integrated education system, which will produce effective people in the job market. This is the main objective Ohio States studies. Through this kind of initiatives, business leaders in China will be in a position to relate professionally with both customers and employees, which is the most prominent object in any organization. With this, industries will eliminate strikes enhance increase their productivity (Bertocci 45).

Maggot Therapy in the Healing of Recalcitrant Infected Leg Wounds Essay

Maggot Therapy in the Healing of Recalcitrant Infected Leg Wounds - Essay Example Accurate figures of the incidence of infected leg wounds turning into recalcitrant ulcers have not been easy, as many of patients with such wounds prefer to be treated at home. Simka and Majeswki, 2003, estimate that in the United Kingdom the annual incidence of infected wounds turning into leg ulcers, as a result of venous insufficiency is 3.5 per 1000 individuals. With the elderly population in the developed world increasing as a result of the increased life expectancy the incidence of such infected wounds is expected to rise. In addition the possibility of such leg wounds recurring is high and Walker et al, 2000, point out that such infected leg wounds could take as long as thirteen months to heal. The impact of such long periods of disability on their normal activities and the economic impact of their inability to undertake their work responsibilities increases the responsibility of the healthcare professionals to seek ways and means of causing the healing of such infected leg ulcers within the shortest possible period of time. It is against this backdrop that complementary therapies to the currently employed management and care pathways of recalcitrant infected leg wounds gains significance. A part of this responsibility may be attributed to the underlying pathologies, but as the underlying pathologies cannot be wished away, it becomes important that alternate care pathways that reduce the healing times and increase the possibility of quicker successful outcomes be considered and more so when there is sufficient evidence that suggests the consideration of such therapies.

Evaluating the effectiveness of training on local employees in Asian Research Paper

Evaluating the effectiveness of training on local employees in Asian hospitality industries as a European human resources manager - Research Paper Example The Asian hospitality industry is in a constant state of evolution in a variety of ways.Primarily,changing social,economic and cultural values as a product of globalization and industrial development have improved accessibility of tourism-related locations to foreign customers and have also changed the methodology by which local employees interact with a broad demographic base of customers. As Asian countries become more developed and sustain competitive hospitality industries, the need to understand the diverse and complex lifestyles and attitudes of foreign (and sometimes domestic) visitors becomes a paramount need in order to satisfy clients and create a positive brand reputation for the specific hospitality business. Visitors maintain unique preferences and demands when it comes to their tourism experience and since front line employees are the first point of contact for these customers, it is imperative that the staff understands these needs and are offered appropriate training to make customer experiences rewarding and ensure long-term loyalty to the hospitality brand. In Asian hospitality industries that are led by expatriate European human resources managers, it becomes more difficult to streamline training and understand what drives local employee values, cultures and general beliefs related to lifestyle and the workplace environment. There are significant cultural differences between European leadership and Asian culture, thus making the job of providing adequate training even more difficult. This proposed research study evaluates the effectiveness of training on local employees in the Asian hospitality industry when considering the influence of European human resource management principles and ideals. 2. Literature review This section undertakes a review and analysis of existing literature on the Asian hospitality industry, cultural principles, and European values when or if they are extended into Asian businesses. 2.1 Cultural frameworks One primary understanding that needs to be explored in this proposed research study is the difference between European leadership and Asian employees at the cultural level. European human resources managers generally hail from cultures that are globalized and have a long-standing industrialized and commercial history. Much of this influence has come from Western countries, such as the United States, that acted as the framework for much of the modern human resources principles being used in a variety of industries today. European leaders are from individualistic societies, under Hofstede’s Cultural Dimensions Framework, whereby managers and employees value self-expression and independence in the workplace and tend to value personal goal attainment over that of group goal-setting and group-oriented rewards (Blodgett, Bakir & Rose, 2008). In this type of organisation or culture, individualists seek more decision-making authority and job role autonomy in order to remain loyal and satisfied so that they can become performance-oriented and seek to meet strategic goals. This individualistic attitude drives the majority of their human resources policies as it relates to employee training and learning. In Asian cultures, however, there is a strong, historical trend toward collectivism. This type of culture values group norms and group affiliation over individualized expression where â€Å"they view themselves as a member of an extended family, place group interests ahead of individual needs, and value reciprocation of favours and respect for tradition† (Blodgett et al, p.339). Employees that have strong collectivist values often seek opinion and networking from peers and operate well in very structured, centralized management hierarchies. Collectivists

Microbursts Research Paper Example | Topics and Well Written Essays - 1250 words

Microbursts - Research Paper Example Microbursts can cause production of high speed winds (about 100 mph or more), which last for about 5 to 20 minutes and have proven to be both damaging and destructive, especially to the airplanes. The microbursts are formed when falling rain drops mix with dry air and are evaporated, cooling the air above it as a consequence. As per theory, when air is cooled it sinks. Rapid cooling of air causes it to accelerate towards the ground and spread out and cause the diverging of wind patterns. Heavy rain and snow are also a source of microburst formation. Two types of microbursts are found: dry microburst and wet microbursts. The main difference between them is that the dry ones are formed by virga while the wet ones are formed by wet precipitation. (Caracena, 1990) To comprehend the concept of dry microburst, an understanding of what vigra is important. Basically, virga is that part of rain or snow that falls from the cloud but is evaporated before it reaches the ground. (Glickman, 2000) the evaporated vapor then carries out by the whole process described above. The most significant source of dry microburst are thunderstorms, which produce small amount of surface rainfall and hence, large amounts of vigra. On the other hand, wet microbursts majorly involve heavy rainfalls or snowfalls occurring at warm surfaces. (Fujita, 1985) The difference in the temperatures of the precipitation and the surface causes air currents to accelerate downwards and thus form the wet microbursts. In this case, important source is hail. Dry microbursts occur without precipitation, they are harder to predict or foresee and thus, are a far more potential threat to aircrafts than the wet. The large magnitude and unexpected nature of a microburst has resulted in a number of air crashes throughout history, more of which have occurred while landing. We read earlier that microbursts tend to spread out in all directions once they hit the ground. During landing, a plane is flying at a low

Why did (west) Germany experience a smoother consolidation of Essay

Why did (west) Germany experience a smoother consolidation of democracy after World War Two than has Mexico more recently - Essay Example democracy can be used to define the power of the people to elect the government representative that is capable of enacting just judgment without prejudice and hate freely. A democratic society allows individuals to experience the freedom without limitations on the choices they make in achieving progress. The people are the makers of a nation, and their policies need to be met without causing discomfort to attribute a free society. Dictatorship, corruption and poor power delegation have been some measures that have led to the unjust policies that limit democracy. Once democracy is achieved, individuals are capable of having their demands met by the government selected and express their desire openly through the personality that they have elected or through the free media. Monarchy and a dictatorship-filled government have been expressed as the systems that limit public participation in policymaking. Germany had defined the society that lacks democracy under their tyrannical leader Hit ler. Hitler had implemented efforts to conquer the world and ruled his nation with policies that he had formulated to benefit his selfish desires. On the other hand, Mexico has been struggling to achieve development even after achieving independence from the Spanish to define a poverty level that warrants intervention. This paper compares the democracy achievement of (west) Germany as compared to the modern day Mexico. Second World War, 1939-1945 had been blamed on the efforts by Hitler to expand his boundaries and gain domination of the world. Hitler had been defeated to lead to the rise of a new Germany attributed to the republic of Bonn (Prowe 1985, p451). This period had been marked with a period of crisis, which was mostly marked with increased political and social chaos. The nation had been used to the rule of the dictator who gave limited room for expression and discriminated against the Jews who were in war against the Nazi. The compositions that had defined Germany had been

Health Improvement Essay Example for Free

Health Improvement Essay To address this challenge, the world’s governments committed themselves at the United Nations Millennium Summit to the Millennium Development Goals, including the overarching goal of halving extreme poverty by the year 2015. Yet, our planet’s capacity to sustain us is eroding. The problems are well-known – degrading agricultural lands, shrinking forests, diminishing supplies of clean water, dwindling fisheries, and the threat of growing social and ecological vulnerability from climate change and loss of biological diversity. While these threats are global, their impacts are most severe in the developing world – especially among people living in poverty who have the least means to cope. Is this environmental decline inevitable in order for poverty to be reduced? We argue not. Indeed, quite the opposite is true. If we do not successfully arrest and reverse these problems, the world will not be able to meet the Millennium Development Goals, particularly the goal of halving extreme poverty. As this paper demonstrates, tackling environmental degradation is an integral part of effective and lasting poverty reduction. The 2002 World Summit on Sustainable Development (WSSD) provides the international community with a pivotal opportunity to redirect the global debate, and to forge a more integrated and effective global response to poverty and environmental decline. To succeed, we need to focus on the most important links between poverty, the environment and sustainable development. For many, ensuring sound environmental management means curtailment of economic opportunities and growth, rather than their expansion †¦ too often; it is viewed as a cost rather than an investment. Prepared as a contribution to the 2002 World Summit on Sustainable Development focuses on ways to reduce poverty and sustain growth by improving management of the environment, broadly defined. It seeks to draw out the links between poverty and the environment, and to demonstrate that sound and equitable environmental management is integral to achieving the Millennium Development Goals, in particular eradicating extreme poverty and hunger, reducing child mortality, combating major diseases, and ensuring environmental sustainability. Four priority areas for sustained policy and institutional change are highlighted: ?Improving governance for pro-poor and pro-environment policies, institutions and services, with particular attention to the needs of women and children; ?Enhancing the assets of the poor and reducing their vulnerability to environment-related shocks and conflict; ?Improving the quality of growth to protect the asset base of the poor and expand opportunities for sustainable livelihoods; ?Reforming international and industrialized country policies related to trade, foreign direct investment, aid and debt. Policy opportunities exist to reduce poverty and improve the environment The environment matters greatly to people living in poverty. The poor often depend directly on natural resources and ecological services for their livelihoods; they are often the most affected by unclean water, indoor air pollution and exposure to toxic chemicals; and they are particularly vulnerable to environmental hazards such as floods and prolonged drought, and to environment-related conflict. Addressing these poverty-environment linkages must be at the core of national efforts to eradicate poverty. Many policy opportunities exist to reduce poverty by improving the environment – but there are significant and often deeply entrenched policy and institutional barriers to their widespread adoption. The past decade of experience since the 1992 Earth Summit in Rio reveals some important lessons that help point the way forward. Three broad lessons are highlighted here: ?First and foremost, poor people must be seen as part of the solution – rather than part of the problem. Efforts to improve environmental management in ways that contribute to sustainable growth and poverty reduction must begin with the poor themselves. Given the right incentives and support – including access to information and participation in decision-making – the poor will invest in environmental improvements to enhance their livelihoods and well-being. At the same time, however, it is essential to address the activities of the non-poor since they are the source of most environmental damage. The environmental quality of growth matters to the poor. Environmental improvement is not a luxury preoccupation that can wait until growth has alleviated income poverty, nor can it be assumed that growth itself will take care of environmental problems over the longer-term as a natural by-product of increasing affluence. First, this ignores the fundamental importance of environmental goods and services to the livelihoods and well-being of the rural and urban poor. Second, there are many examples of how bad environmental management is bad for growth, and of how the poor bear a disproportionate share of the costs of environmental degradation. Ignoring the environmental soundness of growth – even if this leads to short-run economic gains – can undermine long-run growth and its effectiveness in reducing poverty. ?Environmental management cannot be treated separately from other development concerns, but requires integration into poverty reduction and sustainable development efforts in order to achieve significant and lasting results. Improving environmental management in ways that benefit the poor requires policy and institutional changes that cut across sectors and lie mostly outside the control of environmental institutions – changes in governance, domestic economic policy, and in international policies. Improving governance ?Integrate poverty-environment issues into nationally-owned poverty reduction strategies, including macroeconomic and sect oral policy reforms and action programmes, so that they can become national sustainable development strategies. Engage poor and marginalized groups in policy and planning processes to ensure that the key environmental issues that affect them are adequately addressed, to build ownership, and to enhance the prospects for achieving lasting results. Address the poverty-environment concerns of poor women and children and ensure that they are given higher priority and fully integrated into poverty reduction strategies and policy reforms – for example, the growing burden of collecting scarce water and fuelwood supplies, and the effects of long-term exposure to polluted indoor air. Implement anti-corruption measures to counter the role of corruption in the misuse of natural resources and weak enforcement of environmental regulations – for example, the destructive impacts of illegal logging and unregulated mining, or the preference for construction of new power and water investments over increasing the efficiency of existing investments. ?Improve poverty-environment indicators to document environmental change and how it affects poor people, and integrate into national poverty monitoring systems. This should be complemented by measures to improve citizens’ access to environmental information. Enhancing the assets of the poor ?Strengthen resource rights of the poor by reforming the wider range of policies and institutions that influence resource access, control and benefit-sharing, with particular attention to resource rights for women. This includes central and sub-national government, traditional authorities, the legal system, and local land boards, commissions and tribunals. Support decentralization and local environmental management – land, water and forest resource management, and provision of water supply and sanitation services – by strengthening local management capacity and supporting women’s key roles in managing natural resources. ?Expand access to environmentally-sound and pro-poor technology, such as crop production technologies that conserve soil and water and minimize the use of pesticides, or appropriate renewable energy and energy e fficient technologies that also minimize air pollution. This includes support for indigenous technologies, and the need to address the social, cultural, financial and marketing aspects of technical change. ?Promote measures that reduce the environmental vulnerability of the poor by strengthening participatory disaster preparedness and prevention capacity, supporting the formal and informal coping strategies of vulnerable groups, and expanding access to insurance and other risk management mechanisms. Reduce the vulnerability of the poor to environment-related conflict by improving conflict resolution mechanisms in the management of natural resources and addressing the underlying political issues that affect resource access. Improving the quality of growth ?Integrate poverty-environment issues in economic policy and decision-making by strengthening the use of environmental assessment and poverty social impact analysis. Improve environmental valuation at both the macro and micro level, in order to highlight the full cost of environmental deg radation for the poor in particular and the economy in general, and to improve economic decision-making. ?Expand private sector involvement in pro-poor environmental management to maximize the efficiency gains from private sector participation, while safeguarding the interests of the poor. This requires capacity within government to negotiate with the private sector – for example, to ensure that utility privatization benefits the poor – and to forge effective public-private partnerships that enhance the poor’s access to environmental services. ?Implement pro-poor environmental fiscal reform including reform of environmentally-damaging subsidies, improved use of rent taxes to better capture and more effectively allocate resource revenues, and improved use of pollution charges to better reflect environmental costs in market prices. Reforming international and industrialized country policies ?Reform trade and industrialized country subsidy policies to open up markets to developing country imports while avoiding environmental protectionism, and to reduce subsidies that lead to unsustainable exploitation – such as subsidies for large-scale commercial fishing fleets that encourage over-harvesting in developing country fisheries. . Make foreign direct investment more pro-poor and pro-environment by encouraging multinational corporations to comply with the revised OECD Code of Conduct for Multinational Enterprises, and to report on the environmental impact of their activities in line with the UN Environment Programme’s Global Reporting Initiative. ?Increase funding for the Global Environment Facility as the major source of funding for global public goods in the environment, such as a stable climate, maintenance of biodiversity, clean international waters and the protective ozone layer. These benefit the whole world as well as the poor themselves – so the rich world must pay a fair share for their maintenance. ?Enhance the contribution of multilateral environmental agreements (MEAs) to national development objectives by strengthening developing country capacity to participate in the negotiation and implementation of MEAs (for example, to ensure that the Clean Development Mechanism promotes investments that benefit the poor). Also, improved coordination is needed between MEAs so that scarce developing country capacity is used most effectively. ?Encourage sustainable consumption and production – industrialized country consumers and producers through their trade, investment, pollution emissions and other activities affect the environmental conditions of developing countries. Making rich country consumption and production more sustainable will require a complex mix of institutional changes – addressing market and government failures as well as broad public attitudes. Enhance the effectiveness of development cooperation and debt relief with more priority for poverty-environment issues, particularly for the poorest countries where aid and debt relief continue to have a valuable role to play in helping governments to make many of the changes recommended above. Mainstream environment in donor agency operations through staff training, development and application of new skills, tools and approaches, and revisions to the way resources and budgets are allocated. Transparent monitoring of progress against stated objectives and targets is needed in order to hold development agencies accountable and to ensure that a commitment by senior management to addressing poverty-environment issues is put into practice throughout the organization. Conclusion This paper looks ahead with some degree of hope and optimism for the future – there are sometimes win-win opportunities, and there are rational ways of dealing with trade-offs. Environmental degradation is not inevitable, nor the unavoidable result of economic growth. On the contrary, sound and equitable environmental management is key to sustained poverty reduction and achievement of the Millennium Development Goals. There are significant policy opportunities to reduce poverty and improve the environment, but more integrated and pro-poor approaches are needed. The World Summit on Sustainable Development is an opportunity to focus on what is most important and to forge a coherent framework for action, with clear goals and achievable targets backed-up by adequate resources and effective and transparent monitoring mechanisms. There can be no more important goal than to reduce and ultimately eradicate poverty on our planet. PART 1 Why the Environment Matters to People Living in Poverty â€Å"Water is life and because we have no water, life is miserable† (Kenya) â€Å"We think the earth is generous; but what is the incentive to produce more than the family needs if there are no access roads to get produce to a market? † (Guatemala) â€Å"In the monsoons there is no difference between the land in front of our house and the public drain. You can see for yourself† (India) In their own words, the environment matters greatly to people living in poverty. Indeed, poor people’s perceptions of well-being are strongly related to the environment in terms of their livelihoods, health, vulnerability, and sense of empowerment and ability to control their lives. Figure 1 provides a simplified framework for understanding how environmental management relates to poverty reduction, and why these poverty-environment linkages must be at the core of action to achieve the Millennium Development Goals and related national poverty eradication and sustainable development objectives. Environmental management for poverty reductionDimensions of povertyDevelopment goals Part 1 of the paper focuses on the poverty-environment relationship by examining how environmental conditions in both rural and urban settings relate to three key dimensions of human poverty and well-being: ?Livelihoods – poor people tend to be most dependent upon the environment and the direct use of natural resources, and therefore are the most severely affected when the environment is degraded or their access to natural resources is limited or denied; Health – poor people suffer most when water, land and the air are polluted; ?Vulnerability – the poor are most often exposed to environmental hazards and environment-related conflict, and are least capable of coping when they occur. We also are concerned with the relationship between growth and the environment and how it affects the poor and efforts to reduce poverty. The environmental soundness of growth matters considerably to the poor, and countries with similar levels of income and growth can have quite different levels of environmental performance. While Figure 1 illustrates the main pathways between environmental conditions and dimensions of poverty, in reality these linkages are multi-dimensional, dynamic and often inter-connected: ?Poverty is now widely viewed as encompassing both income and non-income dimensions of deprivation – including lack of income and other material means; lack of access to basic social services such as education, health and safe water; lack of personal security; and lack of empowerment to participate in the political process and in decisions that influence one’s life. The dynamics of poverty also are better understood, and extreme vulnerability to external shocks is now seen as one of its major features. Environment refers to the biotic and abiotic components of the natural world that together support life on earth – as a provider of goods (natural resources) and ecosystem services utilized for food production, energy and as raw material; a recipient and partial recycler of waste products from the economy; and an important source of recreation, beauty, spiritual values and other amenities. The nature and dynamics of poverty-environment linkages are context-specific – reflecting both geographic location and economic, social and cultural characteristics of individuals, households and social groups. Different social groups can prioritize different environmental issues (Brocklesby and Hinshelwood, 2001). In rural areas, poor people are particularly concerned with their access to and the quality of natural resources, especially water, cro p and grazing land, forest products and biomass for fuel. For the urban poor, water, energy, sanitation and waste removal are key concerns. Poor women regard safe and physically close access to potable water, sanitation facilities and abundant energy supplies as crucial aspects of well-being, reflecting their primary role in managing the household. ?Environmental management, as used in this paper, extends well beyond the activities of public environmental institutions. In relation to poverty, environmental management is concerned fundamentally with sustaining the long-term capacity of the environment to provide the goods and services upon which people and economies depend. This means improving environmental conditions and ensuring equitable access to environmental assets – in particular land and biological resources, and safe and affordable water supply and sanitation – in order to expand poor people’s livelihood opportunities, protect their health and capacity to work, and reduce their vulnerability to environment-related risks. This broader conception of poverty and environment, and of environmental management, is essential to understanding the linkages between them and to identifying appropriate policy and institutional options for improving these linkages. There have been some impressive gains since the 1972 United Nations Conference on the Human Environment – the first global conference devoted to environment and development issues. There has been a proliferation of environmental policies and institutions at national and sub-national levels, and environmental issues are firmly placed on the agendas of governments, civil society and the private sector. Major global environmental agreements have been forged and global environmental organizations established. Environmental sustainability has become a core concern of bilateral and multilateral development cooperation, and billions of dollars have been spent on environment-related programmes and projects. Tangible progress also has been achieved ‘on the ground’, although the picture is usually mixed. For example, in the 1990s some 900 million people gained access to improved water sources. However, this was merely enough to keep pace with population growth, and about 1. 2 billion people are still without access to improved water sources, with rural populations particularly under-served (Devarajan et al, 2002). Another example is the productivity of soil used for cereal production, which increased on average in developing countries from 1979-81 to 1998-2000. However, it fell in some 25 countries, most of them in Africa, with land degradation being one factor behind the decline (World Bank, 2002c). Despite these gains, pressure on the environment continues to mount worldwide, posing major challenges to the prospects for poverty reduction and human development in developing countries, in particular the least developed countries.

Health Essays Alzheimer Dementia Disease Essay

Health Essays Alzheimer Dementia Disease Essay Alzheimer Dementia Closing in on Alzheimer’s â€Å"Soon, Alzheimer’s disease will touch everyone in this country in some form or another, so the need to redouble our research efforts greater than ever before. We must have better treatments, earlier detection, and effective strategies to prevent Alzheimer’s. Scientists have made tremendous strides in the last two decades, but the clock is ticking.† -Samuel Gandy, MD, PhD, chair of the Alzheimer’s Association’s Medical and Scientific Advisory Council. There is no cure, but there is hope, for the world’s most leading cause of dementiaALZHEIMERS. â€Å"AD† is a neurodegenerative disorder, the underlying cause still being unknown. The clinical features or the underlying pathology can only be discovered on autopsy and thus the signs and indications of AD are instigated only after years of accretion of the credible causes. Some of the signs include:- Cognitive deterioration. Visual spatial confusion. Loss of recognition of persons and objects. Reduced mobility. Deterioration of muscles. Inability to feed oneself. Language disorientation. The onus of the illness lies in the deposition of fibrillized plaques containing amyloid beta(AB). The AB proposition shows potential for the reason that, as seen in patients with trisomy 21(downs syndrome), who have an additional copy of the gene for AB precursor, almost universally exhibit AD like indications prior to age 40. These signs of AD can be accredited to the cytotoxic potential of the mature aggregated amyloid fibrils. Consequently, a great amount of the research work on lead breakthrough is focused on:- Inhibition of fibrillization. Inhibition of AB precursor to AB. A different supposition understood to elicit the disease cascade, is centered on the effects of aggregated tau proteins. This speculation is sustained by the long standing observation that aggregation of AB plaques does not correlate with neuron loss. Although a great deal is known a propos the disease prognosis, causative or risk factors, the acquaintance we encompass of, in the present day, concerning the fundamental pathological origin or the core cause of the disease is zilch. Nevertheless, ApoE4, the foremost genetic risk factor for AD has been allied with surplus of AB build-up. The risk factors for AD are:- Advancing age. Head injury. Aluminum intake. ApoE4. Poor CVS health. Smoking. AD is most often established based on clinical signs and symptoms, and the history of patient’s infirmity, as a definitive diagnosis is only achievable by performing an autopsy. Common diagnostic tests include:- Memory testing. Intellectual functioning. Neuropsychological screening tests. Blood tests to rule out presence of other diseases. Functional neuro-imaging techniques like SPECT ad PET. Once diagnosed, on an average, survival is 7 – 10 years, the extremes being 4 years to 21 years. Essentials, statistics and incidence of Alzheimer’s:- 24 million people affected with AD worldwide. Slated to become 81 million by 2040. 1 out of 8 people above the age of 65 have AD. Only 19% with AD have the diagnosis recorded in their medical records. 7th leading cause of death in the United States. From 2000-2004, death rate due to AD has increased by 32.8%, while that of breast cancer, prostate cancer, stroke and heart disease has decreased by 2.6, 6.3, 10.4, 8% respectively. Costs of AD and other dementias amount to $148 billion annually. Current drugs in the global market for treatment of Alzheimer’s:- [1]ARICEPT: Key essentials about aricept: Was permitted for the treatment of mild to moderate Alzheimers by the FDA in 1996, and for the treatment of severe Alzheimers in 2006 Is the #1 prescribed Alzheimer’s drug—worldwide, more than 3.8 million people have been treated with Aricept. Aricept is a drug branded as a cholinesterase inhibitor. It is one of a group of prescriptions that appear to improve the cognitive ability (thinking, perception, judgment and recognition) in people with Alzheimer’s disease. Aricept can reduce behavioral troubles that may be exhibited by people with this type of dementia. Known as a cholinesterase inhibitor, Aricept delays the breakdown of the neurotransmitter acetylcholine in the brain. Acetylcholine helps communication between the nerve cells and is vital for memory. Side effects are typically mild and tend to disappear as treatment progresses. Common side effects are nausea, vomiting, diarrhea, fatigue, insomnia, muscle cramps. Less common effects are headaches and dizziness. Rare side effects are anorexia, gastric or duodenal ulcers, gastro-intestinal hemorrhage, bladder overflow obstruction, liver damage, convulsions, heart problems and psychiatric disturbances. [2]EBIXA: Ebixa fine points: Ebixa is one of a group of drugs called NMDA (n-methyl-D-aspartate) receptor antagonists. These receptors, along with the neurotransmitter glutamate, are implicated in transmitting nerve signals in the brain that may be imperative for learning and memory. Ebixa, which acts on NMDA receptors, facilitates to normalize transmission of nerve signals, and perhaps slow the decline of some indications of Alzheimers disease. Ebixa is not a cure for Alzheimers disease as it does not affect the fundamental degenerative progression of the disease. Ebixa may cause some unwelcome reactions. These may include fatigue, dizziness, sleepiness, headache, hypertension (high blood pressure), constipation, vomiting, anxiety, confusion, hallucinations and sleep disturbance. [3]EXELON: Exelon particulars: Exelon is one of a group of drugs known as cholinesterase inhibitors which is intended to treat symptoms in people with mild to moderate Alzheimers disease. Exelon works by reducing the breakdown of acetylcholine and thus escalating the amount of the chemical in the brain, a chemical thought to be vital for learning and memory. The prescription augments the action of acetylcholine by making the receptors it interacts with in the brain more responsive. Exelon is not a cure for Alzheimers disease as it does not affect the fundamental degenerative progression of the disease. Familiar side effects, in addition to nausea, vomiting, loss of appetite and weight loss, comprise of diarrhea, heartburn, stomach pains, dizziness, headache, weakness, fatigue and difficulty sleeping. A small number of people also experienced fainting. [3]REMINYL: Key specifics on reminyl: Reminyl ER is one of a group of drugs called cholinesterase inhibitors which is used to treat symptoms in people with mild to moderate Alzheimers disease. As of June, 2006, Reminyl became available only in the extended release (ER) format. It means that if you were taking Reminyl tablets twice a day prior to June 2006, you would now take a Reminyl ER capsule once a day. It augments the action of acetylcholine by making the receptors it interacts with in the brain more responsive. In the area of the brain first affected by Alzheimers disease, that dealing with cognition and memory, too little acetylcholine is available at the junctions between nerve cells to get messages across to the next nerve cell, The condition is helped, consequently, not only by preserving the acetylcholine from being destroyed by cholinesterase, but by making the receptors more responsive to the inferior amounts of acetylcholine. Reminyl ER is not a cure for Alzheimers disease as it does not affect the fundamental degenerative progression of the disease. probable side effects include: abdominal pain, diarrhea, indigestion, decreased appetite, difficulty swallowing, bleeding in the digestive system, weight loss, low blood potassium, low blood pressure, dehydration, seizures, agitation, aggression, hallucinations, weakness, fever, malaise, leg cramps, tingling in the hands or feet, ringing in the ears, headache, dizziness, tiredness, sleeplessness, runny nose, urinary tract infection, fainting or fluttering of the heart. INTERNATIONAL MARKET STATISTICS FOR DRUGS USED IN THE TREATMENT OF ALZHEIMERS:   BRAND GENERIC CLASS SPONSOR SALES in (million $) 2004 MARKET SHARE(approx) 2004 2005 Aricept donepezil CI Pfizer 1,266 1,580 58.10% Reminyl galantamine CI JJ 256 343 12.60% Exelon rivastigimine CI Novartis 320 340 12.50% Namenda memantine NMDAA Forest 5 247 9.10% Ebixa memantine NMDAA Lundbeck 28 86 3.20% Axura memantine NMDAA Merz 6 15 0.60% Cognex tacrine CI FirstHorizon 1 1 0.00% Others 87 107 3.90% TOTAL 1,969 2,719 100.00% Total Sales Figures = $2.7B (2005) with Aricept ®having 58% market share. DRUGS IN PIPELINE:- Name of the drug sponsor phase About the drug Data from previous phases. FLURIZAN Myriad 3 It is a selective amyloid lowering agent (SALA) that reduces levels of the toxic peptide amyloid beta 42 (AÃŽ ²42). Reduces the levels of the toxic amyloid beta 42 peptide through the allosteric modulation of gamma-secretase. FLURIZAN has completed Phase2 human clinical trial in 207 patients with Alzheimers disease. Phase 1 safety trial of FLURIZAN in healthy older volunteers identified no serious drug-related side effects. In nonclinical studies, FLURIZAN reduced the levels of the toxic peptide AÃŽ ²42 by approximately 70%, by modulating the action of gamma-secretase. Flurizan reduces amyloid pathology in the brain and prevents memory defects in transgenic mice. ALZHEMED Neurochem Inc. 3 Alzhemed is an oral small organic molecule that has been designed to interfere with the association between glycosaminoglycans (GAGs) and AÃŽ ² amyloid protein. It is thus thought to prevent GAGs from promoting ÃŽ ²-sheet and amyloid formation. Designed to prevent amyloid formation and deposition in the brain, and thus modify the course of AD. Alzhemed is expected to act on two levels: firstly to prevent and stop the formation and deposition of amyloid fibrils in the brain as well as to bind to soluble AÃŽ ², and secondly to to inhibit the inflammatory response associated with amyloid build-up in AD. Inhibit AÃŽ ² fibrillization and binds and reduces soluble AÃŽ ². VP025 Vasogen 1 Mediated via the regulation of microglial cell activation. Treatment with VP025 reversed age-related decreases in CD200 levels in the brain, reduced levels of microglial cell activation, and restored memory and learning function. Considerable amount of preclinical work has demonstrated: the ability of VP025 to reduce inflammation in models of a number of neurodegenerative diseases. the ability of VP025 to reverse detrimental neurological effects of chronic beta-amyloid exposure the ability of VP025 to reverse age-related inflammation in the brain AAB-001 Elan Pharmaceuticals, Inc., Wyeth. 3 Designed to bind and remove the AÃŽ ² peptide that accumulates in the brain. Immunotherapy approaches to the treatment of Alzheimer disease is based on the ability of antibodies raised against AÃŽ ² peptides to bind to and clear AÃŽ ² from the brain, thus removing the peptide and inhibiting the damage to neurons that AÃŽ ² inflicts. Anti-AÃŽ ² antibodies have been shown to prevent the accumulation of AÃŽ ² peptides in the brains of transgenic mouse models of AD (Shenk et al., 1999; Bard et al., 2000; DeMattos et al., 2001). In one clinical trial, patients immunized with AÃŽ ² peptide who actively generated anti-AÃŽ ² antibodies showed a significantly slower rate of decline in cognitive functions (Hock et al., 2003). Long-term follow-up studies of the patients who were involved in the failed phase 2a clinical trial of AN-1792 has shown that NTB (quality of life) scores remained significantly improved in antibody responders. In addition, CSF tau was significantly decreased in antibody responders (Gilman et al., 2005). Closing In on Alzheimer’s:- Lastly, fresh drugs tender genuine hope for repealing the malady. Concluding test outcomes will be out, for a complete novel generation of drugs designed to assault the fundamental basis of Alzheimers disease—medicines that propose, what one specialist calls legitimate, substantial, irrefutable hope for those with mild to moderate forms of the illness. Within three years, its nearly assured, well have disease-modifying drugs that fundamentally amend the nature of Alzheimers. From drugs which facilitate alleviation of merely the symptoms of the disease, we are now moving towards an era which will comprise of drugs that not only slow down the disease, but encompass the potential to wholly reverse it. Scientists are certain that one of the more than four dozen drugs now in human trials will succeed. One of the most hopeful of those, Flurizan, from Myriad Genetics, should complete its tests in the next 18 months. Exceedingly few drugs make it to Phase III clinical trials, the final stride before a drug goes to the FDA for authorization. Today, conversely, nine new Alzheimers treatments are in Phase III trials to test their effectiveness on a large number of patients. And dozens more are in smaller Phase II trials. This subsequent generation of drugs is deliberated to avert, obliterate and clean out deposits of beta-amyloid plaque that exterminate the brains nerve cells, leading to the distressing loss of memory, reason and, eventually, life that typifies Alzheimers. This optimistic information comes as the world awaits an epidemic of Alzheimers, the traumatic variety of dementia that Americans tell pollsters they dread more than heart disease, stroke or diabetes. Today, 5.1 million people in the United States suffer from the disease, but the supreme risk factor is age—the longer a person lives, the greater the likelihood—and in just four years millions of boomers begin to turn 65. One in eight people age 65 and older now has Alzheimers; half of those 85 and older have it. Connoisseurs say still if Alzhemed or another of these premature anti-amyloid drugs fails, that doesnt mean the amyloid theory is incorrect. It merely may mean that the drug didnt eliminate sufficient plaque to appreciably slow or arrest the disease. Finally, with the advent of such promising drugs into the market in the near future, there is potential to mitigate the humanity of the exorbitant fiscal burden due to the disturbing tempo at which Alzheimer’s is making headway. Keeping our fingers crossed might just help. References: http://www.myriad.com/alzheimers/flurizan.php http://www.vasogen.com/sec/vp025 http://www.alzforum.org/ http://www.alz.org/national/documents/PR_FFfactsheet.pdf http://www.alz.org/national/documents/PR_FFquotesheet.pdf http://www.medicinenet.com http://www.pharmaceutical-business-review.com http://www.theracarb.com/documents/investor_%20presentation.pdf http: //www.wikipedia.com

Electroconvulsive Therapy for Severe Depression: Evaluation

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