Greek and Chinese ways of life Essay

Throughout the course of history, civilizations have been developing all over the globe. Some of these civilizations have shared several goals, experiences, and problems. Two particularly noteworthy civilizations are those of Greece and China. Greece had many city-states within in it. Two major Greek city-states were Sparta and Athens. Despite belonging to Greece, these city-states were unique culturally, politically, and socially. The Han Dynasty in China is another civilization that was unique in terms of its cultural, political, and social development. Greek and Chinese civilizations have several similar and different aspects that have been the reason for their goals, experiences, and problems in life, but they both have also been unique culturally, politically, and socially. Athens, one of the most powerful city-states in Greece, had three major goals defined by its ruler, Pericles. His three major goals were to protect Athens, beautify it, and to make the Democracy stronger. In order for Pericles to strengthen the democracy he needed to increase the number of paid public officials. Read more: Constitution mini q answer key essay Before, only the wealthy could afford to hold public office, but by increasing the number of paid public officials it allowed even the poor to engage in self-government. Pericles believed that the Athenian constitution should be in the power of the people and by establishing a direct Democracy; he was able to enforce this in Athens. One way Pericles attempted to protect Athens was by using the money from the treasury of the Delian League to build Athens the strongest fleet of ships in the Mediterranean. The Delian League was an alliance of ancient Greek city-states, which were dominated by Athens. This was important in protecting Athens since it was surrounded by water. If they could control access to their surrounding waterways then they could decrease their chances of invasion. Athens is located right next to the Mediterranean Sea, which enabled them to develop their strong navy force for military use. This was only one way Pericles strengthened Athens; he also found a way to make Athens gloriously beautiful. Pericles beautified Athens by using money from the Empire to buy gold, ivory, and marble. He did this because those materials were expensive assets and helped make Athens a wealthier and powerful city-state. All these goals that Athens developed over time, helped protect it, beautify it and make it the strongest city-state of all time. Despite Athens’ prosperity, this city-state experienced many obstacles that ultimately stripped it of its dominance within Ancient Greece. Power shifted from Athens to Sparta during the Peloponnesian War. Sparta was focused primarily on militaristic endeavors while Athens celebrated peace, intellectual development, art, and beauty. Sparta had an inarguable advantage since all male citizens spent their lives training to become strong soldiers, and all women were responsible for being strong enough to bear more soldiers. Sparta’s attacks were most effective when fighting on land so Athens did have an advantage since it was surrounded by bodies of water and had the strongest navy in all of Greece. Under Pericles, Athens’ plan was to avoid land battle with the strong Spartan Army, so they waited for the right time to strike from the sea. Years passed and eventually Athens fell to Sparta’s strong military tactics. After Sparta won the war, it was then the strongest city-state in ancient Greece. Athens’ downfall shifting power in favor of Sparta was important because it reshaped the Ancient Greek World. These developments made Sparta the strongest city-state in all of Greece. Athens also had major economic inequalities which shaped their way of life. Athenian farmers often found themselves sold into slavery when they were unable to repay the loans they had borrowed from their neighbors. This forced them to pledge themselves as collateral. Years passed and the Athenian farmers asked their lenders to cancel the debts and to give them land. The lenders were not so keen on this idea, which led to a civil war within Athens between the farmers and the lenders. This civil war within Athens, gave Sparta the right time to strike. Once Sparta attacked, it was all over because Athens was not prepared to strike back. The war within made Athens weaker, giving Sparta the advantage it needed to win the Peloponnesian War. This civil war helped shape Athens’ future by distracting it from external concerns thus giving Sparta the chance to attack and ultimately win the Peloponnesian War. Sparta was a city-state within Greece that also had many goals, experiences and problems. One of Sparta’s main goals was to create an invincible force. They made their army an invincible force by training their warriors from a young age to become the men Sparta needed to fight Sparta’s wars. This allowed for the expansion of Sparta’s military power. One example of their military power was their victory in the Peloponnesian war. Sparta had strong military tactics, which helped them overcome the mighty city-state Athens. Athens was considered most powerful because of its prosperity, wealth, and strong navy fleet, but Sparta won the war due to their military power on land and the civil war which weakened Athens. The war changed the dynamic power between the two city-states, which caused a great deal of unique changes in these two city-states, and thus, all of Ancient Greece. The Han Dynasty within the Chinese civilization was another civilization that had many goals, experiences, and problems. One of the Han Dynasty’s main goals was the unification of China. The Han dynasty was able to unify China by incorporating principles of Confucian thought into social structure, laws, and spiritual beliefs. The incorporation of Confucianism helped to strengthen the economy, reconstruct the royal palace, and also allowed for the rise of aristocratic families. Confucianism brought the idea that people are born with a potential for morality. The Han incorporated this idea into their state policy, believing that rulers must support it. This caused the Han period to see a great reduction in harsh laws and punishments, and a turn to rule by merit doctrine, which is rule under one leader. The Han Dynasty’s unification transformed Chinese civilization in many ways leading to its cultural, political, and social uniqueness. The Han dynasty experienced great military expansion throughout its reign. Its powerful military forces were able to expand the kingdom all the way to Vietnam and Korea. Chinese culture, ways of life, schools of thought, and religion were spread to all of these conquered lands. This was a major accomplishment for the Han dynasty because it changed the world in more ways than anyone could suspect. Most of all, it made the Han Dynasty bigger and stronger, thus more capable of making even more influential changes. This expansion led to increase trade, which brought about the Silk Road, a massive network of trade routes which connected the East to other parts of the world. The Chinese used the Silk Road to trade mostly silk, copper, and iron; however this trade route grew to also support the exchange of many other objects such as spices, weapons, textiles, and more. The improved trading network and military expansion allowed the Chinese civilization to prosper as a nation, and to develop culturally, politically, and socially under no one’s terms but their own. Athens and Sparta were city-states within Greece, but they both had different forms of government. Athens’ government occasionally used tyrannical methods, but mainly followed a democratic model of government. The Spartans did not approve of tyranny so they produced a different form of government in order to avoid it. The Spartans’ form of government was called an Oligarchy. Oligarchic government is made up of four parts: the kingship which is unique in that there are two kings, the Gerousia (the council of elders), the Ephorate, and the assembly. These two forms of government helped these respective city-states within Greece to become some of the strongest nations in the world. Unlike Greece, China was a feudal state. The Han Dynasty was a heavily centralized state, much like that of Sparta. The Hans did not follow Athens’ form of democracy, which made them different from each other. Under the Han rulers, the doctrines of Confucianism were revived and followed. Under Confucian teachings, the ruler and the subject should have mutual respect for each other, the people and the ruler should both exhibit good behavior, and the ruler should be an example for the rest of the people. Everyone was expected to respect the ruler, even if he was a bad leader. Legalism was another governmental ideal that was spread throughout the Han Dynasty. Legalism stated that humans were naturally evil and required discipline and restraint by the government. Throughout the Han dynasty, these two forces influenced the government. Confucian teachings and Legalism shaped the Han dynasty’s goals, experiences, and problems which contributed to make them the nation they have become. Many differences between Athens and the Han Dynasty have caused them to become the nations as we know them today. One of the most influential differences between the two was the type of government they used within their civilizations. Athens had a democracy, whereas the Han Dynasty had a monarchical form of government. The difference between a democracy and a monarchy is that a monarchy is a form of government in which supreme power is given to an individual, who is the head of the state. The individual who heads a monarchy is called a monarch. Monarchies were the most common form of government in the world during ancient and medieval times. On the other hand in a democratic form of government the supreme power is held completely by the people under a free electoral system. These two forms of governments were prevalent in civilizations all over the globe. Many civilizations have prospered from these forms of governments, and most are still being used today. Another major difference between Athens and the Han Dynasty was that Athens was a small region of Greece whereas the Han Dynasty occupied a much bigger area all over China and was actively working to spread its kingdom. The amount of area a civilization conquered or owned helped determine if it was a strong civilization or a weak one. Athens despite being a small civilization in comparison with the Han Dynasty was still quite strong. Athens won its fair share of wars and battles, just like the Han Dynasty. One reason why Athens was a small civilization in compared to the Han Dynasty was because Athens was a city-state that was part of a greater empire, whereas the Han Dynasty was a great empire itself, making it stronger than Athens. Another difference between Athens and the Han Dynasty was that the Athenians were pagans, whereas the Han Chinese believed in Confucianism and Daoism. All these differences between the Han Dynasty and Athens have shaped the goals, experiences and problems for both civilizations in many ways. Within the Han society there were numerous agricultural inventions that helped to boost productivity throughout the dynasty. Among these were pulleys, and ox collars to enable the oxen to pull plows without choking. Another agricultural invention that increased productivity was winding gears which helped with mining. This differed from the Greek model in that the Greeks didn’t really contribute much to increase agricultural productivity. The Greeks believed that no new methods were needed because there were enough slaves to do the work. Productivity was one way in which the Greeks fell short of China’s standards. Without agricultural inventions the Han Dynasty would not have been nearly as prosperous since these inventions helped shape their way of life and boosted their economy. One major similarity between the Greece civilizations and the Chinese civilization was that their social inequalities and weaknesses of the lower classes of society brought them to their decline. In Greece, the soil conditions were not ideal for the growth of grain, but grain was an extremely important part of Greek life. Farmers turned to olives and grapes which were very well adapted to the soil’s conditions, but were high in terms of maintenance. Also, grape vines and olive trees did not produce fruits for at least five years after planting; however, farmers still had to pay money to take care of the land, while getting nothing in return. As a result, the majority of the Greek farmers went into debt. Once in debt, they were very often mistreated by their landlords, who forced them to become laborers or slaves. The Greeks let their slaves do all the work, so there was little need for inventions that could increase productivity. Weakness within Athens and other city-states caused them to fight for each other’s lands incessantly. Constant fighting between the city-states was the greatest weakness Ancient Greece faced. These problems within the Greek world shaped their ways of life in ways comparable and contrastive to the Chinese world. Within China, a weakness of the Han Dynasty was that the empire was debilitating gigantic. Near the center of the empire, government power was strong. However, as one moved outward toward the borders, government authority gradually declined due to lack of central government oversight. As time progressed, the once effective administration from the Han rulers became corrupt. For example, landlords would lie on their land taxes, so they could make a greater profit. Like Greece, the Chinese landlords would often double tax their already poor peasants, which eventually damaged the economy. When court officials tried to strip the corrupt landlords of their lands, they faced enormous resistance and were unable to change anything. Another weakness which contributed to the downfall of the Han Dynasty, like the Greeks, was internal fighting. The Confucian scholar gentry turned against the corrupt officials, while the officials struggled for power with everyone else. As all of this was occurring the lives of peasants continued to worsen. Eventually, the landholding elite held all the power in the country, and the policies of the emperor favored them. Then, Taoist ideals began to spread among the peasantry. Peasants across the country revolted in many instances, such as the Yellow Turban Rebellion, which ultimately led to the fall of the Han Empire. After the fall of the Han dynasty’s central government, power went to three warlords, officially beginning the Period of the Three Kingdoms. In the end, one can see that Greek and Chinese civilizations, though they have their similarities, have each evolved uniquely in terms of culture, political systems, and social norms and structure. Also, within these great civilizations the many differences and similarities within them have shaped their goals, experiences, and problems differently. Whether it is the form of government a nation follows, religious views, or societal beliefs, all of these factors bear influence on the civilization’s direction in the end. Works Cited Fleck, Robert. â€Å"The Origins of Democracy: A Model with Application to Ancient Greece. † Journal of Law and Economics 49 (2006). Print. Holliday, A. J. â€Å"Sparta’s Role in the First Peloponnesian War. † The Journal of Hellenic Studies 97 (1977): 54-63. Print. Homer, and Robert Fagles. The Odyssey. New York: Penguin, 2006. Print. Nylan, Michael. â€Å"Han Classicists Writing in Dialogue about Their OwnTradition. â€Å"Philosophy East and West 47. 2 (1997): 133-88. Print.

Quality & Culture Essay

How have the changing definitions of diversity affected healthcare management and the delivery of healthcare services in this organization? What does this situation say about Heritage Valley Medical Center’s organizational culture and organizational competency, if anything? If you were Ms. Harper, how would you handle this and what information would you present to the executive team, including measures and steps to change the attitudes and opinions presented? Utilize at least one scholarly source, cited in correct APA format that supports factual statements and conclusions about the topic. Review several of your classmates’ posts. Provide a substantive response to at least two of your peers by Day 7. Discussion 2 A woman arrives at a suburban emergency room in active labor. Both she and her husband speak very little English. The staff determines that the mother (and baby) is uninsured and unable to pay for healthcare services out-of-pocket. The baby is showing signs of distress and needs to be delivered. The on-call OB-GYN physician refuses to come to the hospital. He recommends that the patient be transferred to another facility. Provide a substantive 150 to 250 word initial post that fully answers the following questions: What ethical principles relate to this case scenario? What legal principles relate to this scenario? What might the legal consequences be to the health care organization if there is a delay in treatment? Utilize at least one scholarly source, cited in correct APA format that supports factual statements and conclusions about the topic. Review several of your classmates’ posts. Provide a substantive response to at least two of your peers by Day 7.

1984 By George Orwell Character Sketch Essay

1984 By George Orwell: Character Sketch Essay, Research Paper1984 by George Orwell: Character Sketchby Jeffrey Bowerman.The two chief characters in 1984 are Winston Smith and Julia. Winston has hisbeliefs. It is really difficult to do him believe in person else # 8217 ; s thoughts or prevarications.He is a small paranoid about people watching him. In the narrative 1984, people canbe watched through TVs ( telescreens ) . Because of this paranoia, he found atopographic point in his flat were he could sit without being seen. He spends much ofhis clip sitting in this corner composing in his journal. In his journal, he writesthings that could easy hold him killed. Winston is a quiet individual who has afew friends. He has a strong feeling about how the universe is and a strongerexperiencing about how it should be.Here is my illustration from the book that shows Winston # 8217 ; s character: # 8220 ; Just now I held up the fingers of my manus to you. You saw five fingers. Makeyou remembe r that? # 8221 ; # 8220 ; Yes. # 8221 ;O # 8217 ; Brien held up the fingers of his left manus, with the pollex concealed. # 8220 ; There are five fingers at that place. Make you see five fingers? # 8221 ; # 8220 ; Yes. # 8221 ;And he did see them, for a fleeting blink of an eye, before the scenery of his headchanged. He saw five fingers, and there was no malformation. Then everything wasnormal once more, and the old fright, the hate and the obfuscation came herdingback once more. But there had been a minute? he did non cognize how long, 30seconds, possibly? of aglow certainty, when each new suggestion of O # 8217 ; Brien # 8217 ; shad filled up a spot of emptiness and had become absolute truth, and when twoand two could hold been three as easy as five, if that were what was needed.It had faded out before O # 8217 ; Brien had dropped his manus ; but though he could nonrecapture it, he could retrieve it, as one remembers a graphic experience at somedistant period of one # 821 7 ; s life when 1 was in consequence a different individual.Earlier in that subdivision O # 8217 ; Brien had tortured him into believing two plus twopeers five.Julia # 8217 ; s feelings are non about every bit strong as Winston # 8217 ; s. She is slightlysneaky, and she is really good at evading The Thought Police. Julia is quiet, andshe likes to believe of the hereafter and the yesteryear instead than the present. Sheenjoys little things that are old and simple. Julia is slightly interested inthe manner the universe is turning. She enjoys nature and animate beings.Here is my illustration from the book that shows Julia # 8217 ; s character:She fell to her articulatio genuss, threw unfastened the bag and tumbled out some wrenchs and ascrewdriver that filled the top portion of it. Underneath was figure of orderly paper packages. The first package that she passed to Winston had a unusual and yetfamiliar feelings. It was filled with some sort of heavy, sand-like material whichyielded wherever you touched it. # 8220 ; It isn # 8217 ; t saccharify? # 8221 ; he said. # 8220 ; Real sugar. Not cloying, sugar. And here # 8217 ; s a loaf of staff of life? properwhite staff of life, non our bloody material? and a small pot of jam. And here # 8217 ; s a Snof milk? but look! This is the 1 I # 8217 ; m truly proud of. I had to wrap a spotof plundering unit of ammunition it, because? ? ? # 8221 ;But she did non hold to state him why she had wrapped it up. The odor wasalready make fulling the room, a rich hot odor which seemed like an emanation fromhis early childhood, but which one did on occasion run into with even now, blowingdown a passage-way before a door slammed, or spreading itself cryptically in acrowded street, sniffed for an blink of an eye and so lost once more. # 8220 ; It # 8217 ; s java, # 8221 ; she murmured, # 8220 ; existent coffee. # 8221 ;Julia had more interesting things in her bag after the java, this illustrationshows her involvement in old and simple things.If Winston had a level tyre, he would likely sit in his auto for a piece.After possibly one half hr, he would acquire out of the auto and trade with it. Whenhe was covering with it, he would non believe about the work really much. Winstonwould decidedly compose a batch about it in his journal.In 1984, all the dish lavation is done by the cooks. If Winston had to makethe dishes, he would likely non be really good at it. He would take a long clip.He likely would non interrupt really many dishes. If he had the option to utilize adishwasher, he would decidedly make it. Winston would likely hold a few dishesthat he liked utilizing and would utilize merely them. Before he met Julia, he would eatwithout much appetency and was skinny.If Winston were faced with a bully, he would respond with choler. After hisfirs t reaction, he would look the individual over. If he thought the individual werestronger, he would go afraid and huffish. Winston would get down to state theindividual that he was right, in hope of get awaying hurting. Winston does non wishproblem ; but if he has to cover with it, he does it with force.If Winston had to travel food market shopping, he would be every bit speedy as possible. Hewould likely non make the best possible occupation, and he would likely bury things.Winston would non utilize any vouchers or travel to certain shops because they werecheaper. He would non bask shopping. Winston would seek to acquire other people tomake the shopping for him.

PhD Finance - Risk Management Tools Assignment Example | Topics and Well Written Essays - 250 words

PhD Finance - Risk Management Tools - Assignment Example e high investment in terms of knowledge, time and other resources, it is important that all organizations develop and implement these techniques to mitigate or eliminate the apparent risks that might be facing the organization. According to Youngberg, Risks in the organizations can appear in many ways, and when the management has not put appropriate measures to reduce to reduce the impact of the risk, it can have serious and significant consequences on the performance of the firm (2011, p. 24). In many occasions, organizational risks appear with no or very little warning and thus organizations should always equip themselves with the appropriate risk management tools. A good example of this is the recent worldwide financial crisis which had negative impacts on the performance of many organizations that had not put appropriate risk management measures in place. Even though it is impossible for an organization to completely eliminate risks, it is not impossible to manage and reduce the impact of risks (Munier, 2012, p. 75). Therefore it is the responsibility of the managers to develop processes and policies which can assist in identifying the various risks facing the organizations as well as analyzing the risks. Frame points out that there are various techniques which can help in the management of risks in the organizations (2003, p. 59). The risk management techniques may include, formation of specialized committees to deal with risk other than those from accounting or finance, employment of risk officers, creation of a risk management enterprise, and giving particular attention to the microeconomic risks which do not usually receive much attention (Calabro et al., 2011, p. 49). Some of the microeconomic risks could include environmental risks such as climate change, political risks such as elections and the general risks affecting the ind ustry. Even though investing in tools and techniques of risk management can seem as an expense to the organization, lack of

Supply and demand Essay Example | Topics and Well Written Essays - 750 words

Supply and demand - Essay Example Logically, this will ensure maintenance in the revenues. It is evident that elastic demand is dependent on sensitive buyers compared to inelastic demand all influencing shifts in the quantity of units consumed. Cross price elasticity of demand ensues when the unit prices of a certain good escalate thus forcing an increment on the demand for a different product (Anderson, 2006).CPEoD= (%Δ. Therefore, CPEoD affects demand of substitutes since an increment in the price of a product (x), leads to increment for the product Y’s price, its substitute. CPEoD influences complementary goods on the basis that an increment or decrement in the demand of one product equally affects the other since they are consumed together (Benassy, 2008). Substitute goods refer to products whose utility supplements the function of another product. For instance, one can substitute tea with coffee. Therefore, increase in tea price while the price of coffee is constant results to high demand of coffee (Anderson, 2006). On the other hand, complements are goods that are not necessary and therefore, increase in their price leads to low demand. For instance, dà ©cor and design, which enhances serene of a place, amount to complementary goods (Benassy, 2008). Income elasticity of products’ demand measures the relationship that exists between change in quantity of demand and income change. A rise of income leads to increase in demand of certain products or vice versa. Normal goods always bring a positive elasticity of demand therefore, as income rises, demand also increases (Anderson, 2006). On the other hand, inferior goods results in a negative income of elasticity of product demand. Demand decreases as income increases. The availability of substitute product is the most determinant of cost elasticity of demand. The more goods and services have better substitutes, the more the demand is elastic for those goods and services. For instance, an increment in coffee prices

Deviation as an effective strategy for rhetorical effects Essay

Deviation as an effective strategy for rhetorical effects - Essay Example A portion of the critiques argue that the deviation in rhetoric settings infringe the rules of the normal language. For instance, Postner argues that a system of rules would kill poetry, disregarding the assumption that rules could determine the structure of poetry. It may be difficult to have norms for poetry (as each form of poetry will require its norm), but the category or difference from semiotic norms are indispensible in semiotic stylistics and rhetoric (99). Riffaterre expands these ideas by starting with the assumption that poetry expresses things and concepts indirectly, which occur in different forms of semantic and grammatical deviation. He develops a two-phase model for poetry reading (97). The first phase is where the reader encounters poetic ungrammaticalities based on their linguistic competence. At the heuristic stage, a mimetic or coherent referential interpretation is avoided as the reader faces difficulties resulting from textual indirection (saying a certain thing while meaning another). The retroactive (second) stage the reader successfully resolves mimetic deviations through interpreting them into a new system of semantic, thus the text acquires its intended poetic function (101). At extreme levels, mimetic ungrammaticalities become poetically grammatical. Examples of deviation in rhetoric include sentential adverb, omitting conjunctions, and understatement. For instance, writing that â€Å"he was a hero, a winner† rather than â€Å"he was a hero and a

HRM Essay Example | Topics and Well Written Essays - 2000 words - 3

HRM - Essay Example In Saudi Arabia, this system is referred to as ‘Bareed’. Up until a couple of years ago, Saudi Post did not have an addressing system in accordance with the international conventions. To improve efficiency, they decided to use global standards for postal system. Therefore, they created a unified national addressing system and set up postal codes for the entire kingdom. Using Global Information system, they set up an addressing system that is scalable as well as efficient. At present, Saudi Post has a very efficient network that spans across all the cities and villages of the country. It has 478 main post offices and 180 branch post offices. This study aims to look at the delay caused in second-class mail delivery system and the loss of mail of the Saudi Postal System that is also known as Saudi Post. For many years, the users of Saudi Post have battled issues of delayed delivery or loss of mail sent by second-class. This study explores the various methods through which t he Human Resources development can improve the efficient of the second-class mail delivery system. It also looks at the various training methods that can be put to use by the HR deport to ensure timely and safe delivery of the second-class mail. ... The priority is always given to the first class mails because of the service promised. However, it is also necessary to understand that the second-class mails also need to be delivered within the stipulated timelines. Therefore, quality of mail delivery should correlate to the service that has been promised to the customers. In addition, postal employees also have a very critical role to play to ensure timely delivery. It is necessary to provide adequate training to make sure that they understand the various aspect of mail delivery in accordance to the services. One key issue that has resulted in causing delays is the lack of training that the employees have and it makes them inefficient. The focus should never be restricted to only first-class mails because the other regular mail is neglected and piled up. This also results in loss of mails for some cases. Another challenge that prevents the timely delivery of mails could be that the employees do not follow up on the second-class ma ils in time. Role of Human Resources Human Resources or the HR department plays a very important role in contributing to the efficiency, productivity as well as strength of any organization. HR not only helps in building and training a solid workforce, it has the potential to carry out process improvements and build an agile organization that is respected for the way in which can better respond to the demands of the customer or the market. HR also has the potential to provide its employees with strategic tools as well as support system to enable them to perform their work efficiently. Human resource management can be defined as the understanding as well as the application of the different processes, policies as well as methodology that have an impact on the

Neurological Disorders Research Paper Example | Topics and Well Written Essays - 1750 words

Neurological Disorders - Research Paper Example Asia particularly the West and Central areas also are not spared from the disorder. Russia, Middle East and India have high prevalence of neurological disorders with multiple sclerosis on the top list. With this situation, not only the budget of the country and families with neurological cases are challenged but also in the treatment and researches. The discussion of pathophysiology, prognosis, treatment, considerations, and impact on self and family may lead to a better understanding of the disease. Among the neurological disorder that is of interest is the Parkinson’s disease. Parkinson’s disease is a slow degenerative disorder of the central nervous system affecting the cognitive, motor, and other bodily functions (Tortora, 2008). Despite the many medical researches that were conducted regarding the Parkinson illness, it still is the second neurological disorder affecting many. Unfortunately, the treatments are focused not on Parkinson itself but on alleviating the s igns and symptoms of it because the cause is unknown. It is believed that the disorder is the result of the interplay of genetics and the environment. It has been known that mutations in the genes are being passed from one generation to the next. Other factors like smoking, toxins, and deficiency in vitamin E are all contributory factors to the sensitivity of the nervous system which may in turn elicit its prevalence. Age is also found to be another culprit of the disease. In the study of Stephen and company (2003), they revealed that the rapid increase of incidences occur at the age of 60 with lesser percentage of victims below 50 of both sexes. They further found out that ethnicity and race also plays a role in the prevalence of Parkinson. Physiological Basis Although the pathophysiology of Parkinson’s disease is not fully understood, the disorder is a result of the interplay of several factors. Normally, stimulus from either outside or within the body causes impulses that could travel several meters along the billion neurons in just seconds to the brain. The impulse travels to the pre synaptic axons where it activates calcium gated channels that may trigger calcium influx. This may in turn activate neurotransmitters which diffuse into the synaptic gaps of the myelinated sheath to stimulate the next node. Thus, impulses leap from node to node along the mylelinated sheath until it is conducted to the brain for interpretation and proper action to take place. The fastest impulses involve those that innervate the skeletal muscles (Thibodeau & Patton, 2003). This might be the reason why individuals can retrieve their hands immediately if subjected to hot iron. Furthermore, actions are refined with the help of chemicals in the brain to adjust and guide actions. In the case of Parkinson’s disease, neurons of the substantia nigra undergo degeneration resulting in dopamine depletion. Dopamine is a neurotransmitter related to purposeful movement that inh ibits the excitatory action of another neurotransmitter called acetylcholine to maintain balance. In addition, it controls emotion and pleasure. Dopamine is believed to be located within the nuclei thus the role of cerebral nuclei is very crucial in Parkinson disorder. Cerebral nuclei are diencephalic gray matters located in the cerebral cortex within the basal ganglia that function to inhibit several motor actions. For the cerebral nuclei to function normally, neurons from

Adaptive Landcapes Essay Example | Topics and Well Written Essays - 250 words

Adaptive Landcapes - Essay Example Besides, Lansing (2009) also affirmed that with the use of ecological simulation, cultural as well as historical analysis modeling, the priests in the temples reflected the manner in which the water can be used in the different landscape of production. Hence, it can be affirmed that the book is a comprehensible narration of technical and social aspects of water management in Bali (Lansing, 2009). Ulun Danu Batur (a.k.a. Pura Ulun Danu Batur) was built during 1926 and is the second most important temple of Bali, which is dedicated to Dewi Danu. The temple comprises of nine different worship areas and contains around 285 different shrines and pavilions. The temple is donated to the goddesses of water, holy springs, and agriculture among other spiritual symbols of Bali. In the Balinese Hindus religion, Dewi Danu is referred as water goddess. She is one of the two ultimate deities of the Bali tradition who commands Balinese lakes, which is an important source of water and sustenance (Bali Safari and Marine Park, n.d.). Green revolution indicates the period between 1940’s until late 60’s, on which, the productivity of the agriculture has significantly increased due to high amount of advancements in the production of chemical fertilizers, artificial herbicides as well as the pesticides. Moreover, the advancements made it possible to increase the productivity of nutrients, which correspondingly increased the yield (Fitzgerald-Moore & Parai, n.d.). GoogleMap. (2015). Map of Mt.Batur. Retrieved from https://www.google.co.in/maps/place/Mt+Batur,+South+Batur,+Kintamani,+Bangli+Regency+80652,+Indonesia/@-8.2008252,115.3564797,12z/data=!4m2!3m1!1s0x2dd1f403ce5a1e5d:0x8851b0c51ddaa2eb GoogleMap. (2015). Map of Lake Batur. Retrieved from

Gender Inequality in the Workforce Essay Example | Topics and Well Written Essays - 1250 words

Gender Inequality in the Workforce - Essay Example Sexism is defined as a mindset or a belief that one sex is better or superior to another (Padavic & Reskin, 2002). It is actually discrimination based on gender. Males and females both can become the victim of sexism but usually, in workplaces, women face gender discrimination. Mostly gender discrimination is related to salaries, promotions, and recruitment. Also on a day to day situations, women encounter sexism. Â  Stereotypes are another form of popular belief about a particular group of individuals. These beliefs have no rational or logical basis but still, they are quite ubiquitous. Stereotypes can be related to genders, race, nationality or ethnicity. Any preconception about a social group without any logical and reasonable evidence can be categorized as stereotypes. They also play a role in discrimination in workplaces. Â  Both of these issues persist in workplaces today. This is mainly because of the diversity of the organizations. Today companies hire a diverse group of employees from different cultures and different genders. Because of this diversity issues like stereotypes and sexism come up regularly in organizations. Â  Females face both sexism and stereotypes. This is because of the mindset of the society regarding their kind. It was only in the 20th century when women were given the right to vote. Before them, they were considered unimportant to such an extent that their say in elections was not deemed important. Women are fighting with the same attitude even today in workplaces. The idea of female emancipation is not easy to digest for the society as a whole.

A View from the Bridge Essay Example for Free

A View from the Bridge Essay Marco is married and has got two children whilst Rodolfo is still single. When, both Catherine and Rodolfo see each other, it is almost like love at first site. Catherine uses flirtatious procedures to convey to the audience that she feels somewhat of him. When she starts using these actions, High heels Eddie does not like this and so sends her back to the room to get changed, Do me a favour, will you? Go ahead. This makes Catherine undergo embarrassment as Rodolfo was at the scene. I would want the audience to observe that both Catherine and Rodolfo have got feelings for each other and that Eddie is in the surroundings being jealous. Due to the relationship between Eddie and Catherine, Beatrices relationship is suffering as he is paying attention more towards Catherine then Beatrice. Another crucial scene/turning point in this play is when both, Rodolfo and Catherine are left unaccompanied in the apartment. Whilst in the room, Catherine questions Rodolfo about his motives, in which he is traumatized and was wondering if Eddie thought that too. This is because Eddie warns Catherine that he is after an American citizenship. She asks him, Would you still want to do it if it turned out we had to go live in Italy His reaction was, No; I will not marry you in Italy. I want to be a citizen. At this instant I would want the audience to become conscious that Rodolfo wants to marry Catherine just to be an American Citizen and that they could change their minds later on. Catherine replies to this and says that she does not want to leave Eddie after what he has done for her (Eddie has treated her as a daughter and paid for her to go to extra classes of her interest after leaving high school. ) She makes it sound that Eddie was an ex-lover or ex-husband of her, You thinks its so easy to turn around and say to a man hes noting to you no more? As a director I would want the audience to realize that Catherine is aware that she needs to grow up as she gets advice from Beatrice saying, Beatrice says to be a woman. At this point Catherine gets aggravated as she makes it sound as if she has to choose between Rodolfo and Eddie, I know him and now Im supposed to turn around and make a stranger out of him. She takes in mind what Beatrice suggested to her about being a woman which leads to her having sex with Rodolfo. This is a turning point to the audience and to Catherine. At this turning point I would want the audience to reconsider their views on Rodolfo about wanting to be an American citizen. No one would sleep with a woman and not have feelings for her. The light rises on Eddie. He enters the flat drunk and sees a glimpse of Catherine adjusting her dress and coming from the bedroom. At this particular moment, Eddie senses what the two have been up to. Rodolfo appears in the bedroom doorway. Eddie sees him and his arm jerks slightly in shock. He does this action as he wants to hit Rodolfo as he knows what they have been up to and that he is jealous and cannot bear it. He can not handle that Catherine is taking responsible of her own life. When a pause appears, as a director I would want to create tension in the audience as the characters are all hiked up. Shortly after the build up of tension, Eddie switches his actions and tells Rodolfo to Pack it up and Get out of here. Eddie gets dominant over Catherine by grabbing her and stopping her from following Rodolfo to her bedroom. She frees her arm, which indicates her rebelling against him and her wanting his approval. Eddie, at his point is jealous following what Rodolfo and Catherine have been up to and knows that he cannot have her. Soon after there is a sudden breakthrough of Eddies feelings as he, reaches out suddenly, draws her to him and as she strives to free himself he kisses her on the mouth. He kisses her to provoke Rodolfo and to see how she and he react. This all leads to violence in which, Rodolfo flies at him in attack. At this point Eddie kisses Rodolfo to show Catherine he is gay and to show her that Rodolfo did not prevent this from happening. The last crucial scene in this play is the last scene where Eddie gets killed. This consequence was created when Eddie did a very unintelligent thing of phoning the immigration bureau to report the two illegal immigrants, Rodolfo and Marco. He then regrets phoning the bureau up and tells them to move as they moved with more illegal immigrants which had a very violent family. This way Rodolfo and Marco would not get caught and would remain safe whereas the other illegal immigrants wouldnt. Soon after they decided, they did not have enough time to move, as the officers came to pick Rodolfo and Marco up. Eddie had begged Beatrice to tell them to move and soon after, she had realized what Eddie had done. She turned against Eddie and used harsh language against him, Hes a rat. At this time I would want my audience to turn against Eddie. This then lead to more violence of Eddie getting killed by Marco as he has suffered from his family being without food and money. I would want my audience to feel more sympathy for Marco rather than Rodolfo. The culture of this play is all in relation to a child who grassed his uncle to the immigration bureau seeing that he was an illegal immigrant. The kid was completely beaten up by his family and no-one wanted to know him after what he did. In an Italian family, the families need to be loyal to each other and if something goes wrong outside the family, the Sicilian community requires the law to be taken in hand and that justice should be done. I would want the audience to relate back to this during the last scene and keep this in mind as this is a sort of thing that Eddie had done but the consequences were much worse. If I was directing A View from the Bridge I would want my audience to see that there is a mixed relationship portrayed in this play. This is because of the actions, dialogue and motives used between the two characters. Throughout the play, I would want the audience to change their views on what they thought of the character of Eddie as he did some good quality things however he also did horrific things. The relationship between Eddie and Catherine would have never been further than an uncle and niece. Two relationships between, Eddie and Beatrice and Catherine and Rodolfo both got disturbed due to the actions undertaken by Eddie which affected the characters. I would want my audience to keep on re-evaluating their views on the relationship between Eddie and Catherine as this would make the play more interesting. Coming to the end of the play, the audience would have found out that Eddie did have feelings for Beatrice as his last words were My lovely B. BY JULAN SHAH Show preview only The above preview is unformatted text This student written piece of work is one of many that can be found in our GCSE Arthur Miller section.

Effectiveness of Second Generation Tyrosine Kinase Inhibitor

Effectiveness of Second Generation Tyrosine Kinase Inhibitor Susmi Suresh Effectiveness of Second Generation Tyrosine Kinase Inhibitors in the Treatment of Chronic Phase Chronic Myeloid Leukaemia: a systematic review Abstract Background: Chronic Myelogenous Leukemia (CML), a cancer of the myeloid lineage, affects around 15 per 100,000 people per year in the UK. Tyrosine Kinase Inhibitor (TKI) oral therapy is used to target the causative BCR-Abl protein. Second-generation TKIs namely dasatinib and nilotinib are understood to be more potent than the first-generation prototype imatinib. However, cost-effectiveness is hindering the widespread use of second-generation TKIs. The patency of these drugs will expire in the immediate future and so, the prices of these are expected to fall. A clear understanding of the efficacy of the potent second-generation TKIs will aid decision-making bodies such as NICE UK to form guidelines on front-line drugs. This review aims to collect and examine evidence from current literature on the effectiveness of second-generation TKIs in the treatment of chronic phase CML. Method: A systematic search of major databases was carried out and the results were screened using specific inclusion and exclusion criteria. Five major randomised controlled trials were identified. Data extraction and risk of bias assessment were carried out using standardised forms developed specifically for RCTs by the Cochrane Collaboration. Quality assessment of the trials was performed using the CASP tool. Results: The five chosen RCTs were the DASISION trial, the S0325 trial and the SPIRIT 2 which compared dasatinib with imatinib, and the ENESTnd trial and the ENESTchina trial which compared nilotinib with imatinib. A participant pool of 2692 patients had a mean age of 61 years and similar features. A total of n=789 and n=697 patients were randomly assigned to dasatinib and nilotinib arms. Second-generation TKIs were associated with greater response rates in patients than imatinib; for example, dasatinib was associated with an odds ratio (OR) of 0.0803 (95%CI 0.0434 to 0.1489 Pin the S0325 trial, and nilotinib OR= 0.1772 (95%CI 0.1217 to 0.2581 Pin the ENESTnd trial. Conclusion: Current evidence points to a greater efficacy of second-generation TKIs, namely dasatinib and nilotinib, than imatinib. Adverse events (AEs) were reported for all three drugs. Due to the lack of a direct comparison between second-generation TKIs, the effectiveness of dasatinib over nilotinib could not be inferred. In order to aid bodies such as NICE to choose the most apt and safe TKI for use as a first-line treatment choice, it is suggested that future studies aim for a direct comparison. Toxicity data should also be generated to supplement this process. Introduction       Chronic Myelogenous Leukaemia (CML), a cancer of the myeloid lineage, accounts for 8% of adult leukaemias in the UK (1). This acquired genetic disorder causes the pluripotent myeloid stem cells in the bone marrow to undergo unregulated growth (2). A proliferative advantage thus results in patients having abnormally increased levels of serum leukocytes. The WHO ICD-10 classifies this disease as a malignant neoplasm with Philadelphia positive, t(9:22) (q34:q11) translocation and crisis of blast cells. With an annual incidence of 14.8 per 100,000 per year (3), leukaemia, along with its subtypes, is the twelfth most common cancer in the UK. The disease has a male predominance and its incidence increases with age (4). Although no causative environmental leukomogens have been identified, several studies have observed higher incidence in patients exposed to very high doses of ionising radiation (5). CML is often triphasic, with an initial chronic phase (CML-CP) followed by the advanced phases of accelerated (intermediate) phase and a final blast crisis- all with deteriorating laboratory profiles and clinical signs. Tyrosine kinase inhibitor (TKI) oral therapy has been used to extend the clinical course (particularly that of CML-CP). CML today is one of the fewest cancers which can be treated to attain 79% survival rates (6). Since the introduction of TKIs, there has been a significant reduction in mortality rates in the UK- from 1.5 per 100,000 in 2000, to 0.6 in 2010 (7); TKI-attributed mortality reduction is however debatable (8). Currently, imatinib is used as first-line treatment and is available to patients in the UK. Approved by the FDA in 2001, imatinib has been shown to be very effective in the treatment of CML. Prognosis is excellent with an increase in 5-year survival rates by 32% since its introduction (9). Hailed as the magic bullet against cancer (10), there have been several setbacks since introduction. Firstly, patients soon developed resistance. This was counteracted with the development of second-generation TKIs: nilotinib and dasatinib for imatinib-resistant (or intolerant) patients (2). Secondly, TKIs are deemed as one of the most expensive cancer drugs. For instance, in countries such as India where the generic forms are used, the cost difference for a month course, when compared to that in the UK, is an astonishing  £4200 and  £620 for imatinib and dasatinib, respectively (11). As a result, the availability of TKIs is strictly regulated by NICE. Whereas NICE recommends nilotinib as a first line drug if the manufacturer makes Nilotinib available with the discount agreed as part of the patient access scheme (PAS), dasatinib is neither a part of PAS nor is it recommended in CML-treatment (12). NICE explicitly comments on the low cost-effectiveness as the major reason for this despite it acknowledging these drugs to be more effective (13). It is to be reminded that NICE uses clinical as well as economic data to form its guidelines. Prices are expected to fall when the patency of TKIs expires in the future. For example, the patency for imatinib will expire in December 2016 in the UK. This may lead to possible alterations in the NICE recommendations and the use of second-generation drugs for first-line treatments may be favoured. Knowledge on the effectiveness of second-generation TKIs will help us shape the choice of appropriate TKIs in the future, when the pharmaceutical industry will be flooded with their generic versions. As such, this review aims to examine current evidence on the effectiveness of second-generation TKIs in the treatment of CML-CP patients. The molecular basics of CML CML is an acquired neoplasm resulting from the formation of an aberrant gene. In the myeloid stem cells of patients, the breakpoint cluster region (BCR) on chromosome 22 and the Abelson murine leukaemia (c-Abl) on chromosome 9 undergo a (9;22) translocation (Figure 1) . This results in the formation of the aberrant BCR-Abl fusion gene which is seen in 95% of patients (who are so referred to as Ph+ve). The BCR-Abl gene is translated into the leukemogenic protein p210BCR-Abl, an aberrant tyrosine kinase (TK) enzyme that is capable of constitutive activity. TKIs inhibit these aberrant TKs. c-Abl, the non-aberrant version of the gene, has a kinase domain which houses the ATP-binding pocket, an SH2 upregulating domain and an SH3 inhibitory domain. The kinase is strictly auto-inhibited and shuttles between the nucleus and the cytoplasm. However, the BCR-Abl TK is localised in the cytoplasm and this is implicated in its constitutive TK activity (Figure 2). In the cytoplasm, it undergoes auto-dimerisation which activates the enzyme by triggering structural alteration. c-Abl works by phosphorylating the Grb2 substrate protein. This activates the SoS effector molecule which facilitates the conversion of Ras-GDP to Ras-GTP. This further activates Raf due to which MEK1/2 is phosphorylated. As a result, ERK, a critical regulator of Cyclin D is also activated. ERK induces the synthesis of Cyclin D, which along with cdk4, determines whether the cell cycle is allowed past the G1 Restriction point. Once past this checkpoint, cell cycle cannot be reversed and so, the resultant daughter cells are produced. Cyclin D phosphorylates retinoblastoma (Rb), which in its inactive state is unphosphorylated and attached to E2F (a transcription factor), and releases E2F. This allows the cell to enter into the S phase (14) to begin DNA replication. Expression of the BCR-Abl gene upregulates proliferation by constitutively activating the Ras signalling pathway (Figure 3); cyclin D is continuously produced. BCR-Abl expression also facilitates anti-apoptosis and disrupts adhesion (Figure 4). A disrupted adhesion to stromal cells and the extracellular matrix reduces the regulatory effect transmitted via focal adhesions (15). Also, clonal expansion is aided by the evasion of apoptosis. Thus, uncontrolled Ras signalling, upregulated anti-apoptosis and disrupted adhesion are understood to lead to the ultimate manifestation of CML   (16). TKIs inhibit these aberrant tyrosine kinases. Imatinib is a competitive antagonist of the tyrosine kinase domain of BCR-Abl (16). Tyrosine kinases exist in active or inactive states, depending on whether the activation loop located on the C-terminal domain is open or closed (Figure 5).In the inactive state, the activation loop is closed and folds towards the ATP-binding pocket (17). Imatinib and nilotinib bind to the inactive conformation (Figure 6) whereas dasatinib binds to both conformations. Several studies have shown second-generation TKIs to be more effective in treating chronic phase CML (18-20). One such study showed that dasatinib was 325-fold more effective than imatinib at inhibiting BCR-Abl in vitro; this is attributed to its ability to bind to multiple conformations (21). Methods (Appendix A) Results Five randomised controlled trials were identified (Table 9). These included three trials- DASISION, Second Phase S0325 and SPIRIT 2- that compared dasatinib with imatinib and two trials- ENESTnd and ENESTchina- that compared nilotinib with imatinib. All of these together show better outcomes for CML-CP patients treated with second-generation TKIs. The primary end point of all these trials, except DASISION and SPIRIT 2, was MMR rates at 12 months. The DASISION trial looked at CCyR at 12 months. The primary endpoint of SPIRIT 2, the largest dasatinib trial, is event-free survival at 5 years. This will only be measured in March 2018 but nevertheless, secondary outcomes such as CCyR rates at 12 months have been published. All other studies also measured CCyR at 12 months as the secondary outcome. The Dasatinib versus Imatinib Study in Treatment-Naive CML Patients (DASISION) (22) The study aimed to find whether patients given dasatinib had a higher CCyR by 12 months of treatment. CCyR and MMR at 12 months were compared for both drugs and it was concluded that dasatinib may improve long-term outcomes in CML-CP patients due to its shorter response time than imatinib (Table 9; Appendix B: CCyR and MMR measurement methods and scale). Considered as a landmark study, these results proved to be pivotal in accepting dasatinib as a standard second-generation TKI. A 5-year follow-up was conducted to understand whether dasatinib can be continued to be considered as a standard therapy for CML-CP patients. The results (Table 10) supported the original finding (23). The Second Phase S0325 Intergroup (South Western Oncology Group, East Cooperative Oncology Group, Cancer and Leukemia Group B and NCI Canada Clinical Trial Group) Trial (24) The study aimed to compare the response rates for dasatinib- and imatinib-treated patients. Following standard clinical measurement of CCyR rates (Appendix B), dasatinib was found to produce more early short-term cytogenetic and molecular response rates (Table 9). However, the study also noted Grade3-4 toxicities in 58% patients in the dasatinib arm, compared to only 35% in the imatinib arm. Toxicity data were not reported in DASISION or SPIRIT2. ST1571 Prospective International Randomised Trial (SPIRIT 2) (25) CCyR response rates for dasatinib- and imatinib-treated patients were compared. The study observed an increased response rate for dasatinib compared to imatinib (Table 9). With these results, the study concluded that dasatinib was favoured in CML-CP treatment. Evaluating Nilotinib Efficacy and Safety in Clinical Trials- Newly Diagnosed Patients (ENESTnd) (26) A multicentre three-arm trial, this aimed to assess the efficacy and safety of nilotinib compared with imatinib. Two groups of patients given different doses of nilotinib were compared to those treated with the standard imatinib dose. CCyR was found to be higher in both nilotinib arms, compared to the imatinib arm (Table 9). The study thus concluded that nilotinib at either doses produced a clinical response better than imatinib. A 5-year follow up (Table 11) aimed to evaluate the long-term outcomes in patients taking nilotinib; MMR and 5-year overall survival (OS) rates of these patients were examined (27). Patients treated with the higher dose of nilotinib were found to have more AEs. Despite this, due to the short-time with which MMR and CCyR were achieved, the study concluded to recommend nilotinib at 300mg twice daily over imatinib. Current evidence provided by DASISION trial and the works of Quintas-Cardama A et al., 2009 and Hochhaus et al., 2009 were referred by the researchers. These directly link shorter response time with increased long-term benefits and reduced risk of progression (28, 29). Evaluating Nilotinib Efficacy and Safety in Clinical Trials- China (ENESTchina) (30) The trial, conducted in Chinese patients, aimed to observe MMR rates at 12 months in nilotinib and imatinib treated patients. Also, conclusions on whether genetic and ethnic factors affect response to treatment were drawn using the results. Whilst MMR showed a similar pattern as seen in the original ENESTnd trial, CCyR at 12 months for the nilotinib arm was lower than the imatinib arm by 3.6%. Since CCyR at 6 months showed an increased rate for nilotinib (66.4% vs 57.1% for imatinib), the study noted this inconsistency to be favouring nilotinib. Previous studies were cited to have observed early CCyR indicative of better response (31, 32). Thus, it was concluded that nilotinib was more effective.   Study Intervention Dosage n Males (%) Median age Lost to follow up (%) CCyR at 12 months MMR at 12 months DASISION Dasatinib 100mg daily 259 56 46 15 83% (95%CI 78-88; P-value 0.01) MMR3x 46% (95%CI 40-52 P-value Imatinib 400mg daily 260 63 49 19 72% (95%CI 66-77; P-value 0.01) 28% (95%CI 23-34; P-value S0325 Dasatinib 100mg daily 123 60 47 na* 84% (95%CI 74-92; P-value 0.040) MMR3 59% (95%CI 48-68; P-value 0.059) Imatinib 400mg daily 123 63 50 na 59 % (95%CI 56-80; P-value 0.040) 44% (95%CI 34-55; P-value) SPIRIT 2 Dasatinib 100mg daily 407 61.4 53 0 53.4% (P-value MMR3 58.4% Imatinib 400mg daily 407 59.2 53 0 41.6% (P-value 43.1% ENESTnd Nilotinib 300mg twice daily 282 56 47 16 80% (P-value MMR3 44% (P-value Nilotinib 400mg twice daily 281 62 47 18 78% (P-value 43% (P-value Imatinib 400mg daily 283 56 46 21 41.6% (P-value 22% (P-value ENESTchina Nilotinib 300mg twice daily 134 67.9 41 na 77.6 (66.4 at 6 months) 52.2% (95%CI 43.4-60.9; P-value Imatinib 400mg daily 133 60.9 39 na 80.5 (57.1 at 6 months) 27.8% (95%CI 20.4-36.3; P-value Table 9 Study Characteristics; (*na= not available; x See Appendix B: Parameters for measuring effectiveness of TKI) Study Intervention Dosage MMR MMR4.5x 5-year OS (HR 1.01; 95%CI 0.58-1.73) Adverse Events* : Drug-related Pleural Effusion DASISION 5-year Follow-up Dasatinib 100mg daily 76 (P-value= 0.0022) 42(P-value= 0.0022) 91% 28% Imatinib 400mg daily 64 (P-value= 0.0251) 33(P-value= 0.0251) 90% 0.8% Table 10 DASISION 5-year Follow-up Study (*No new adverse events were reported; x See Appendix B: Parameters for measuring TKI effectiveness) Study Intervention Dosage MMR4.5 OS Overall Adverse Events ENESTnd 5-year Follow-up Nilotinib 300mg twice daily 54% 93.7% (95%CI 90.8-90.6) 32.9% Pleural Effusion: 1.8% Nilotinib 400mg twice daily 52% 96.2% (95%CI 93.9-98.5) 41.4% Pleural Effusion: 0.7% Imatinib 400mg daily 31% 91.7% (95%CI 88.3-95.0) 32.7% Pleural Effusion: 1.1% Table 11 ENESTnd 5-year Follow-up Study Discussion The pooled data from 2692 patients show that the second-generation TKIs were more effective than the first-generation TKI imatinib. The results from the three RCTs which compare dasatinib with imatinib give an average absolute risk reduction (ARR) of 26.0%; for nilotinib, average ARR is 24.6% (Table 12). Together, second-generation TKIs produce a very promising complete cytogenic response in 253 per 1000 patients per year. As a comparison, a Cochrane systematic review conducted by Aguilar MI et al., 2005 to understand the efficacy of oral anticoagulants in preventing ischemic heart attacks, collected data from five RCTs with a pool of 2313 patients. This showed that warfarin gives an ARR of 4.05% and so the use of warfarin as a common anticoagulant was continued to be supported (33). Hence, a very high combined ARR of 25.3% shown in this review emphasises the potency of second-generation TKIs in treating CML-CP. With continuous treatment using these TKIs, remission can be attained. à ‚      RCT Intervention Odds Ratio Absolute Risk Reduction (ARR %) ARR per 1000 population (per year) DASISION Dasatinib 0.5242 (95%CI 0.3437 to 0.7997 P=0.0027) 0.11089 (11.1%) 110.9 S0325 Dasatinib 0.0803 (95%CI 0.0434 to 0.1489 P 0.55409 (55.45%) 554.1 SPIRIT 2 Dasatinib 0.6217 (95%CI 0.4713 to 0.8203 P= 0.0008) 0.11825 (11.8%) 118.3 ENESTchina Nilotinib 1.1871 (95%CI 0.6578 to 2.1426 P=0.5691) -0.04282 (-4.28%) -42.82 ENESTnd Nilotinib (300mg) 0.1772 (95%CI 0.1217 to 0.2581 P 0.40358 (40.4%) 403.6 Nilotinib (400mg) 0.2025 (95%CI 0.141 to 0.2925 P 0.37672 (37.7%) 376.7 Table 12 Data processed by the review author Dasatinib Trials The DASISION trial was industry-sponsored and as such, the results are to be approached with caution due to a possible risk of bias. However, the largest dasatinib trial, SPIRIT 2 also shows a very similar ARR of 11.8%. Moreover, the European LeukemiaNet Panel used the results from the DASISION and other similar studies to set the 2013 guidelines in the management of CML-CP (34). Hence, the results are widely acknowledged by the scientific community. However, due importance must be given to toxicity data generated from these studies whilst interpreting the results. Whilst DASISION stated that adverse events (AEs) for both arms were similar, toxicity data were not explicitly reported in DASISION and SPIRIT 2 studies. The S0325 trial addressed this issue (See Results). The team suggested that the choice of TKI should only be made based on a patients individualised risk of progression, pre-existing comorbidity and compliance (24). With reference to this, the 5-year follow-up of DASISION emphasised that there were no new events reported outside of the initial 12 month period (23). Nonetheless, both teams reiterated the quick response of dasatinib in treating CML-CP as an indication of its greater efficacy. However, this increased effectiveness becomes equalised in the long-term, with both dasatinib and imatinib producing similar overall survival rates five years post-treatment (23). Nilotinib Trials Compared to dasatinib, the risk of AEs was only slightly increased in nilotinib patients. Unlike the other RCTs, ENESTnd trial observed imatinib-treated patients to have a high risk of AEs. Nausea and diarrhoea were reported in a very high percentage of patients- 41.1% and 46.1% respectively. The molecular mechanisms of AEs are not currently understood and no studies have been trialled in patients to quantify and assess TKI-related AEs. Hence, a clinically-relevant conclusion was not drawn from these results. Limitations One main factor limiting this review is the absence of direct comparative studies between dasatinib and nilotinib. The S0325 trials observed that the standard dose of dasatinib produced more AEs than imatinib and the ENESTnd trial showed that the higher dose of nilotinib produced more AEs than imatinib. However, these observations alone cannot be used to highlight nilotinib over dasatinib. Another limitation is the possibility of selection bias. Currently, numerous on-going clinical trials worldwide aim to compare the various TKIs. However, much data is yet unpublished. These could not be included in this review due to the lack of an appropriate critical appraisal tool, other than the CASP tool used in this review, with more rigorous criteria. Despite these, conclusions drawn from a large pooled study population of 2692 patients remain reliable. Nonetheless, inconsistencies on both efficacy and AEs data were present when comparing the five trials. The ENESTchina trial observed a better result with imatinib at twelve months than nilotinib (OR= 1.1871; 95%CI 0.6578 to 2.1426 P=0.5691). Additionally, the ENESTnd trial reported imatinib to be associated with higher AEs than dasatinib. However, the pooled data show a greater efficacy of dasatinib and nilotinib than imatinib. Dasatinib is also associated with more AEs than standard dose nilotinib and imatinib. The comparability of ENESTchina to other trials could be questioned. Patients from all ethnicities was a definite inclusion criterion and hence this study could not be excluded. The primary aim was to evaluate the efficacy and safety of nilotinibà ¢Ã¢â€š ¬Ã‚ ¦vs imatinibà ¢Ã¢â€š ¬Ã‚ ¦ (in) patients with newly diagnosed P

Problem of Protein Energy Malnutrition in Weaning Infants

Problem of Protein Energy Malnutrition in Weaning Infants This paper will examine the protein energy malnutrition problem amongst weaning children in Niger. By using secondary sources and by looking into precedent practices by different organizations to improve the situation, it will finally conclude with health promotion nutrition intervention plan which will include a collaboration and partnership with stakeholders who will as well have a great impact on the populations health determinants. For this project we will take the role of three nutritionists hired by Mà ©decins sans frontiers (MSF) to establish a best practice and protocol standardized health system in line with the solution of treatment. Firstly this paper will provide a background on the country and the subject of protein-energy malnutrition within different regions. Different existing intervention programs will be presented together with a personal health promotion intervention plan. This will be followed by the determinants that will mainly influence the program and its objectives. Secondly the strategies and practices of the intervention plan will be explained in depth. Thirdly, this project will present to collaboration and partnerships with different stakeholders in order to finally indicate how this programs is creating community capacity. Background context: Niger: Niger, or officially named the Republic of Niger, is located in Western Africa covering a surface of 1.270.000 km2 of which 80% consists of Sahara. Neighbouring countries are Nigeria, Benin, Burkina Faso, Mali, Algeria, Libya and Chad. Being landlocked it is one of the hottest countries of the world. Fifteen million people live in Niger of which only 5% in the capital Niamsey. The population density is only of 12.1/km2. The population is characterized by its fast growth rate (3rd rank worldwide) and has the number one highest birth rate and fertility rate of 7.2 births per woman which means that 49% of the Nigerien population is under the age of 15. Known also to be one the poorest countries in the world; Nigers economy has mainly been undercut by the drought cycles, desertification and the strong population growth (Niger, 2010). Protein-energy under nutrition: Protein -energy undernutrition (PEU), previously called protein-energy malnutrition is an energy deficit due to chronic deficiency of all macronutrients (which are proteins, fats and carbohydrates). In developed countries, PEU is common among the institutionalized elderly or among patients with decreased appetite. In underdeveloped countries protein malnutrition occurs because of the local diet with protein poor cereal products (Morley, 2007). The classification is determined by calculating weight as a percentage of expected weight per height using international standards. (Normal: 90-110%; mild PEU: 85-90%; moderate: 75-85%; severe: Pathophysiologically, the initial response to PEU is decreases metabolic rate. To supply energy, the body first breaks down adipose tissue or body fat. When these tissues are used up, the body may use protein for energy; visceral organs and muscle are broken down and decrease in weight. Loss in organ weight is the greatest in liver and intestine, intermediate in the heart and kidneys and least in the nervous system (Morley, 2007). Total starvation however can be fatal in eight to twelve weeks thus certain symptoms of PEU do not even have time to develop. Patients with protein-energy undernutrition often also have deficiencies of vitamins, essential fatty acids and micro nutrients which contribute to their dermatosis (skin disease) (Scheinfeld, 2010). Worldwide, the most common cause the malnutrition is inadequate food intake. Another very significant factor however is the ineffective weaning secondary to ignorance, poor hygiene, economic factors and cultural factors. The prognosis is even worse when PEU occurs with HIV infection (Niger, 2005). Protein-energy malnutrition in Niger: In Niger, the diet of most children is extremely monotonous, usually consisting of millet based porridge although the diet of older household members might be more diverse. This monotonous diet leads to nutrient deficiencies and consequently diseases such as Kwashiorkor and Marasmus develop. In 2005, a survey was conducted by MSF which stated that one child on five suffers from malnutrition. That year, the mortality rate of children under five exceeded the emergency threshold; 2 deaths per 10.000 children per day. Through the therapeutic feeding centres of MSF, the presence of doctors enabled to reduce the mortality rate to 6% that year. Care is also provided through 40 mobile nutritional care centres which allow children to be treated closer to home. Many are treated at home with ready-to-use therapeutic food (RUTF) and come to the once a week for a check-up (focus on Niger, 2006).The concept of RUTF will be explained further later. Due to weather conditions, an annual hunger gap exists between April and September when family food stocks run out and hundreds of thousands of children have little access to the nutrients they need for a healthy development (IAR 2007, 2008). The World Health Organization recorded in the 43rd week of 2009 recorded 2253 cases of moderate malnutrition and 2938 cases of severe malnutrition and 5 deaths caused by malnutrition. On yearly bases for the year 2009, 157.125 cases and 384 deaths were recorded between January 1st 2009 and October 25th 2009. 41% of those patients were diagnosed with severe malnutrition and 23% with moderate malnutrition (Bulletin hebdomadaire, 2009.) The table in appendix 1 shows the distribution of the different malnutrition diagnoses on patients in the different regions in 2009, the graph on the other hand shows a comparison to the previous years 2006 to 2009. A general decrease is noticeable but sudden peaks and lows are present as well which can be explained by the weather conditions. As in 2005, due to poor rains and severe locust outbreak, Niger registered a record grain deficit of more than 223.000 tons (Niger, 2005). Nutrition survey data and information in Niger are not compiled and analyzed well according the United States Agency of international development. Most nutrition surveys are conducted on ad hoc basis to meet the needs of varying agency objectives. Currently a joint survey by the Government, UNICEF and the centres for disease control has been conducted regionally. One of the goals of the program will therefore also be to encourage the constant recordkeeping of patients and updating the information. Determinants: Most important determinants program intends to influence: In general, protein-energy malnutrition amongst weaning children depends on many aspects of which only a few are biological. The main determinant is that this occurrence is brought upon children in difficult socio-economic conditions, such as those in Niger. Most of these factors are related to poverty which may in turn reason dietary imbalances mainly through the incapability to provide a nutritionally balanced diet. The following determinants are the main factors that play a role in this health issue: Education: The work status of the mother and her literacy rate are key in the cause of child malnutrition. If a mother had a good work status and a better education, this would reduce the probability of the child to having a poor nutritional status. The low incomes, the lack of cultivation knowledge are what may cause an unbalanced diet. Therefore, improving a mother and future mothers education will have a significant impact on their childrens nutrition. Climate/Topology: Access to food: source to drinking water. Nigers hot, desert-dominated topology gives birth to few fruits, vegetables and legumes, and serves as grazing ground for a limited amount of livestock. Consequentially, the few grains and cereals yielded by Nigers turf epitomize the rural diet. However, such produce provides only a miniscule percentage of the nutritional intake necessary, leading to varying levels of starvation and malnutrition. Family Size/Second Child Syndrome. In Niger, statistics show that 75% of girls married before the age of 18 and that 34% of them before 15. According to a source, it can be said thatsome as young as ten. Each woman has on average 7.6 children and statistics further show that there is a 1-in-7 risk of dying during pregnancy or birth (Niger, 2010). Measurable indicators that can verify whether a child is malnourished. Before creating a program which proposes a health promotion plan to reduce protein-energy malnutrition amongst weaning children in Niger, it is important to look at the measurable points that can determine whether this malnutrition is the case or not. According to the pharmaceutical company Merck (Morley, 2007); to determine the severity of protein-energy under nutrition it is important to look at the following points: Body mass Index. Plasma albumin. Total lymphocyte count. CD4+ count. Serum transferring. In the table below, many of these points are mentioned and it can be determined whether the child has a normal, mild under nutrition, moderate under nutrition or severe under nutrition (Morley, 2007). A diagnosis of whether a child has a under nutrition of protein-energy, may be based on the past eating habits of the child. Physical examinations, such as the ones in the table below aid in confirming this diagnosis: The table above clearly shows which values one has to take into consideration when assessing the severity of protein-energy malnutrition. Further research has shown that there are other ways to identify malnutrition in a child. This method, used by the UNICEF looks at ways to identify if a child of more than six months is acutely malnourished (Chamois, 2009). First, oedema (swelling) needs to be checked. This is checked by putting your thumb on each foot of the child for three seconds. If the print of your finger creates a shallow hole, then it can be said that the child has oedema. Secondly, the left arm circumference should be measured with a specific kind of measuring device a bit like measuring tape. This left arm circumference can identify according to a colour code, whether the child is very malnourished, moderately malnourished or not malnourished. From both of these identifications, there are different solutions that should take place depending on the result. Put oedema/left arm circumference picture. Other tests, as written in the article Protein-Energy Malnutrition: Differential Diagnoses Workup (Scheinfeld Mokashi, 2010)may also include: Detailed dietary history. Growth measurements. A complete physical examination is indicated. Height-for-age or weight-for-height measurements. Skin biopsy and hair-pull analysis. In order to narrow down our research for the program, the three main measurable factors will be: BMI. Height/weight ratio. Left arm circumference. Other existing programs: Until recently, malnutrition treatment has been restricted to facility-based approaches which are often miles away from rural communities and less than 40% of children with severe acute malnutrition (SAM) recover from hospital treatment. By the late 90s, many researchers knew that RUTFs were key to meaningful SAM recovery rates. In 2000 clinical trials were conducted for RUTFs administered at home. In this study, a remarkable 80% of the treated children reached their 100% weight for height goal after 12 weeks. Ready to Use Therapeutic Foods (RUTF) are high-calorie, fortified peanut butter-like pastes. Peanuts contain mono-unsaturated fats, which are easy to digest and are rich in zinc and protein: both good for the immune system and protein as well for muscle development (Therapeutic food, 2010). Peanuts are a good source of vitamin E and a powerful antioxidant that helps to convert food into energy. RUTF are also very high in calories which means that a child will get a lot of energy from just small amounts. This is very important because their stomachs have considerably shrunk. A study by the American Medical Association published recently on January 21st 2009, proved the effect of preventive supplementation with Ready-To Use Therapeutic food on the nutritional status, mortality and morbidity of children aged 6 to 60 months. Six villages were randomly chosen for intervention and six to no intervention. The results showed significant changes in weight-for-height z-score according to the World Health Organization Child Growth Standards over the 8 month follow-up (appendix 3) (Isanaka; Nombela; Djibo etc., 2009). Plumpynut, one of the examples of Ready-to-use therapeutic food is as effective as therapeutic milk products. The product does not require any additional water, cooking, refrigeration or other preparation and because there is no water in it, its conservation is relatively easy. The high energy, high protein, peanut based paste fortified with mile and vitamins. Typically comes in foil wrappers or small plastic tubes which are practical for children to eat them. During the severe nutrition crisis in Niger in 2005, plumpynut helped saved thousands of lives. Since 2005, the Socià ©tà © de Transformation Alimentaire (STA) factory in Niamey has been producing the lifesaving food. It is the only plumpynut factory in West Africa and the production has grown about 40 tons per month. Last year only the product was used to treat more than 120.000 severely malnourished children and 63.000 moderately malnourished children, allowing them to return to a healthy weight in three to four weeks. The micro nutritional content of a plumpynut is described in appendix 2 (Dolan, n.d.). A standard plumpynut treatment goes for four weeks at a cost of 12 Euros. Currently World Health Organization (WHO), World Food Program and UNICEF guidelines only recommend RUTF for severely malnourished children. Running the combat against malnutrition in Niger since 2001 (Focus on Niger, 2006); Mà ©decins Sans Frontià ¨res has been dispensing packets of plumpynuts in 22 centres in Niger since May 2005. The region in which Plumpynut was applied had the highest malnutrition rate in Niger. The region now has the lowest malnutrition rate in the country. An article in Field Exchange magazine (Wilkinson Isanaka, 2009), outlines the results of a study which addresses one of the ongoing debates concerning the treatment of infants >6m which supplemental milk is the most appropriate to use in their treatment? (Wilkinson Isanaka, 2009). Unfortunately, infants of less than six months are not always treated for malnutrition and cannot access to treatment programs until they reached six months of age. Statistics show however, that in countries like Congo, Myanmar and Niger, more than 20% of all admissions to treatment protocols are of infants less than 6 months of age. As it is very important to consider infants of this age, the aim of the treatment taking place in this article was to encourage the production breast feeding. The study was to compare two different milk supplements with a sample size of 146 infants. Results showed that it is vital to identify malnourished infants as early as possible when they are 6 months or less as breastfeeding can significantly cause weight gain and a healthier life for the baby. The strength of this program is that it involves infants of a certain age that does not always have access to treatment programs. An action plan has been researched and is currently still in process by an UN system called the standing committee on Nutrition (UN System Standing Commitee on Nutrition, 2006-2010). One of the goals of this action plan was to reduce the proportion of underweight young children by half from 28% in 1990 to 14% in 2015. In 2010 however, statistics show, that there are still 27% of children that are underweight. The article states that hunger and malnutrition are caused by poverty and ignorance, and that they will improve if livelihoods (economic growth and incomes) and education services improve (UN System Standing Commitee on Nutrition, 2006-2010). This action plan aims to establishing a global UN system where UN agencies, ministerial sectors and development actors to find a consensus, a common vision and language on the causes of hunger and malnutrition. This would be reached by wide communication and partnership building. The strength of this program is that a common interagency monitoring and evaluation strategy for food and nutrition programs should be achieved in a minimum of 20 countries in Africa, 20 countries in Asia and Latin America and in 10 other regions. In another article named Nutrition: A foundation for development created by a worker at the UN, defines key elements that bring success to nutrition programs (Shrimpton, 2002). A growth chart, that was developed in the 1960s in Nigeria has influenced todays key element for a successful nutrition program. This key element is the use of an information system that shows people whether their nutrition situation is getting better or worse. Many malnourished children look normal to their parents as they get compared to other children of the district or community. The strength of this program is that by showing the parents and children what they really are supposed to look like at their size and age will bring awareness to their everyday lives. Objectives: This program is in accordance with the objectives and targets put out by the UN System Standing Committee on Nutrition in 2006, but on a local (rural area villages) level, rather than regional and country levels. The importance of inter-organizational relationships is emphasized to ensure that the program is successful. Funding will be primarily from existing organizations in the conflict areas. The Niger Food Diet Pyramid, pictured below, is in coherence with a combination of Nigers readily available resources and the specially formulated food and liquid supplements aims to provide a comprehensible guide to the whole population in an attempt to better educate the general population about nutritional needs. One serving size is conveniently defined as one handful, proportional to each individuals size. Number of portions is indicated with a hand signalling the number in fingers; time of consumption is portrayed by the sun path ending with a moon. The base of the pyramid is water, to be consumed at least seven times throughout the day, as portrayed by the complete sun path, primarily because of the extremely hot and dry climate and topography of the country. The second level is made up of grains, starches and legumes, such as millet, sorghum, cowpeas, potatoes and, in the better irrigated areas, rice. These are recommended to be consumed five times a day, also throughout the day. The reason this food group is not above fruits and vegetables like it is in most western countries is that they are much more available than the latter in Niger, as a direct result to the climate and topography, as well as the poor irrigation provided by Nigers faultily placed rivers. The third tier up is made up of the vegetables found in the country: cassava a root vegetable corn, onions and cardoon a leafy green vegetable. Also included in this section are dates, the indigenous fruit to the country, but only to be found in the wetter, oasis-type regions. Recommended intake is twice a day, once during the day and again in the evening. The fourth tier is shared with sugar, peanuts and dairy (milk and butter). For the better part of the country, all of these items are hard to find, expensive and thus rarely consumed. Despite the scarcity, however, their nutritional value is essential to the human body at least once daily, and it is for this reason that, on this same tier, the food and liquid protein and calcium supplements such as Plumpy Nuts and ProSource, as well as calcium supplements like powdered milk are also pictured. The final tier is made up of meats, ultimately encompassing all available livestock, including cattle, sheep, goats, camels, donkeys, horses and poultry. The reason that no daily intake picture is present is that these animals are rare to find and are usually used for either for their milk/eggs or as a means of trade to access the other food groups. The goal is to have the pyramid posted at all mà ©decin s sans frontiers, UNICEF and WFP locations in Niger by the end of the current month. The short-term objective is to eliminate mortality of weaning infants in Niger. This program will be attempted by simultaneously training infants to breast feed and nursing poorly nourished mothers to health, for all mother-child patients that arrive at the existing MSF ambulatory and therapeutic feeding centers, in collaboration with UNICEF and WFP. On a case by case basis, this initiative should prove to be quite successful. If effectuated properly and supported by the local population, it should reduce infant mortality due to protein-energy, undernutrition-related causes significantly in its first year, and eradicate it completely by 2015. The long-term objective is to ultimately end undernutrition in Niger by targeting future mothers, primarily through education adapted to illiterate women with visual aids and hands-on workshops. This knowledge approach aims to provide a more comprehensive understanding of the human body and how to treat it. It would, in due course, allow the region to develop in a more healthy way, through a three workshop series on nutritional needs, sexual education and female empowerment to Nigers women, adapted for the 10-18 year old adolescent female population, to refocus from young adult and adult, post-malnutrition efforts, and go straight to the source. If the program is a success, family sizes should halve within 10 years, jointly reducing the number of undernutrition cases in the country. Additionally, this program thrives to initiate a womans movement that would allow a healthy development of rural communities. Strategies and activities: Only through the intake of necessary proteins and a reduction of overall malnutrition in both mother-to-be and child will the vicious cycle of poverty as it presents itself in Niger be broken (The World Bank, 1997). Despite MSFs attempts at teaching Nigers women about the importance of breast milk to an infant especially during the first 6 months of its life, allowing it to build up its immune system and avoid malnutrition all together many mothers are in such poor health that they resort to water (OneWorld, August 2009). Breast-feeding is not only fundamental for infant nutrition but also for reducing female fertility as it suppresses the responsible hormone and helps the post-birth uterus contraction, reducing future delivery complications (Figueroa, 2002). The short-term program, in line with Michael Goldens production line approach, will take place at the MSF ambulatory and therapeutic feeding centers already present in Niger and will be set up as follows (OneWorld, August 2009): Dehydrated mother and infant enter the center. Mother administered food and liquid to augment milk production. Infant sucks on tube delivering milk formula attached to mothers nipples, simultaneously teaching it to feed and stimulating milk production. When mother is restored to health and quantity/quality of milk is adequate, mother and infant leave the center and mother continues breast feeding for a recommended period of five months, her health closely monitored. Weekly check-ups and a continuous supply of necessary food and liquid are provided. Essential to the development and sustainability of the state is the eviction of malnutrition among the population, especially concerning the younger generation. This long-term program focuses on providing the necessary steps to improve pre-pregnant adolescent girls nutritional status thus allowing a future fetus to develop into a healthy human being in addition to a more concrete understanding of sex and female empowerment. It will be taught in a series of three workshops. Michael Goldens protocol, as demonstrated in his work in Ethiopia, appears to be aimed at the treatment of as many cases of malnutrition as quickly as possible. It is based on the efficiency of an industrial production line. Goldens five steps to ridding the World of Malnutrition (UNICEF, August 2003) can be described as an industrial revolution for the malnourished child. It does not focus on long-term improvement of the situation and cycles provoking such malnourishment but it does allow for immediate results. Thus, other programs and organizations can step in on a more long-term basis to provide education and actual diet balance. This is where the distinction for this long-term program needs to be made as it will serve as a second step in rural areas that are already receiving food and malnutrition aid through other domains, whether it is from the short-term program provided by this organization, or that of another. As much as education is essential to the elimination of malnutrition, food and sex are more important according to Maslows hierarchy of needs, see Figure below. The latter is situated at the bottom tier, namely Biological and Psychological Needs, whereas the former is categorized under Cognitive Needs, four tiers up. A balanced diet does not particularly concern a human being without food; he or she would rather just have food to begin with. Once they are less hungry, and have regained a bit of hope, they can be sat down and talked through the Niger-adapted food pyramid that has been constructed solely with pictures to provide a complete, visual outlook of what proper nutrition requires. Sexual education in Niger will pose as another difficult challenge, especially when the focus is on individuals in rural areas. Not only are the vast majority of women illiterate, but approximately 90% (Buckens, 2009) of the countrys population is Muslim. Hence, a visual method needs to be used to teach sexual education without offending the local population. Firstly, medical professionals, either doctors or nurses, will always be responsible for providing the classes. Studies have shown that they are among the most trusted and that their presence would allow a bit more flexibility in what can and cannot be shown. Secondly, visual aids must be clearly understood without having to provide graphic sexual images. The program needs to refrain from comparing human sex to reproduction in animals as this may also pose as an offence. Thirdly, the program will be segregated for men and women, to allow a more comfortable, gender-specific approach. No woman will be forced to participate; howeve r, they will be given the incentive to, as complimentary food and liquid nutritional supplements will be part of its foundation. Partnership development: In order to achieve or short term and long term objectives to reduce protein-energy malnutrition amongst weaning children in Niger, one has to consider the development of a partnership to maintain positive results. As nutritionists working for Mà ©decins sans Frontià ¨res, our goal with this program is to continue generating positive outcomes. Many international organizations such as UNICEF, UN agencies, World Food programme, together with MSF have been collaborating closely with the government of Niger and non-governmental partners on the ground. The existence and execution of the proposed program cannot be realized without the cooperation of different organizations and thus only excellent relationship between them can guaranty the success of the program. Therapeutic feeding centres in Niger provide nutritional and medical treatment for children between the age of six months and five years suffering from severe malnutrition. The five feeding centres in Niger are in Maradi, Dakoro, Keita, Tahoua and Aguie (MSFS response, 2005). In July 2005, international aid agencies prepared to distribute supplementary food rations at the therapeutic feeding centre in Maradi. Fearing that nobody would show up, the aid workers spread the word in the nearby villages. The modicum of mobilization led to a near riot as hundreds of women crowded in desperate to obtain food (Tectonidis, 2006). Such a scene points out to which extent the problem of malnutrition is present amongst the population. During the crisis year 2005, when nutritional emergency was caused by drought and an infestation of locust in the previous year, malnourished children began pouring into the therapeutic feeding of MSF. Until then, malnourished children were routinely hospitalized in therapeutic feeding centres but because of the substantial resources required, it has been impossible to open sufficient number of beds during emergency periods (the yearly hunger gaps)(Tectodinis, 2006). Today with the presence of ready-to-use therapeutic food such as Plumpynut, more severe cases can be accepted at the centre while the moderate cases will be send home with solid therapeutic food and will come back weekly for check-up but without having to be hospitalized. Most children treated in a stabilization unit do survive but are soon discharged to an outpatient program (Tectodinis, 2006). The TFCs will also help teach parents about proper nutrition until they gain respite from poverty (Bamford, 2008). In a study comparing therapeutic feeding centres and ambulatory care centres by the department of Health services at the University of Washington, the authors concluded the ambulatory rehabilitation to be more cost-effective (Chapko, Prual, Gamatià © etc; 1994). Mà ©decins sans frontiers. MSF is an international humanitarian aid organisation which has been setting up emergency medical aid mission to populations in danger in more than 70 countries around the word since 1971. Where health structures are insufficient, MSF collaborates with other organizations and local authorities. MSF works in rehabilitation of hospitals, dispensaries, vaccination programmes and water and sanitation projects. MSF seeks also to raise awareness of crisis situations and to address any violations of basic human rights (about MSF, 2005). In 2005, Niger represents one of the largest malnutrition-treatment programs in Mà ©decins sans frontiers history: a capacity of treating 20.000 severely nourished children per year, five therapeutic feeding centres and 25 ambulatory centres, representing a budget of around â‚ ¬10 million. UNICEF: Unicef, the united nations childrens fund, is the driving force that helps build a world where the rights of every child are realized. UNICEF, present in 190 countries, believes that nurturing and caring for children are the cornerstones of human progress and was created to overcome obstacles of poverty, violence, disease and discrimination on a childs path. Upholding the Convention on the Rights of the child and as part of the Global Movement for Children, UNICEF strives for peace and security and work to hold everyone accountable to promises made for children (who we are, 2008). UNICEF Niger is assisting most

My Friend, Chris Essay -- essays research papers

There are many people in this world who hold great reputations. There are far fewer people who posess great character. A reputation is built in just moments, and reflects what you do in front of people. Character, on the other hand, is built over years, and is reflected in what is unseen by others. Of all of my friends, one exemplifies great character more than any of the others. His name is Chris. Chris stands a little over 6 feet tall with thick, dirty blonde hair. His piercing blue eyes change color in the sunlight. He is very light complected, with a small amount of facial hair on the base of his chin. His long sideburns grow down the length of his ear. He is one of those adventurous guys who does things that I would never dream of doing. Realizing that life is short, his ambition is to make the most out of life that he possibly can. Chris has influenced me more than any other person on the campus. He did this by making me believe in who I really am.  « Always remember that life is what you make of it. You have the chance to become whatever you desire – it’s a gift that God gives you,  » he told me once.  «Some people spend their lives blaming others for their problems. Its far better to spend time and energy searching for answers -- instead of pointing fingers.  »   Ã‚  Ã‚  Ã‚  Ã‚  One of his great attributes is shown in the fact that he tries to cheer people up and make them laugh while they are experiencing great emotional stress or pain. He is known to play some great practical jokes on friends just to brighten their day. He once called a friend who was going through some personal problems and told him that he was being investigated by the Humane Society for animal cruelty. Chris even involved many of his fellow workers in the joke. Unfortunately, they forgot to tell the man that they were joking! Later that night, he remembered to explain to the man about the joke. Fearing that his friend would be upset, he sheepishly told him about his little endeavor. The man, instead of being angry, showed great relief. He even thanked Chris for what he did. The man said that it made him realize how unimportant his problems really were.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚ « I guess that I did go a little too far with that one,  « He said.  «But in the end, it all sort of worked out for the good -- thank God !  » While he has an incredible sense of humor, ... ...s of this world.  » This world is not his home, but a place where he can be a servant to those around him. Even during difficult times, he considers his weakness a strength.  « The Bible says that God’s grace is sufficient for us, because his strength is made perfect in weakness,  » he explained.  « I believe that God comes through for us when we can’t come through for ourselves. It gives God a chance to demonstrate the power of his great love.  » Because of such displays of true christian character, Chris has influenced me throughout my freshman year of college more than anyone else. He has made me learn that anyone can turn their life around -- if they would only rely on Jesus Christ and surrender their will to him. Chris believes that with all of his heart. Every once and a while, you meet one of those special people that you will remember throughout your entire life. These type of people are natural born leaders. They are builders, not of just brick and mortar, but of the human heart. They build you up when others tear you down. Just when you feel like giving up on society, someone does something that shows that there are still great people out there. Chris is one of those people.