Philosophy of Nursing Essay - 864 Words

Philosophy of Nursing Nursing should not be looked upon or practiced as a mere physical approach to healing. Nursing should encompass the aspect of restoring each individual patient to his/her maximum physical and emotional state of being. In order to achieve such a goal, a patient must be able to bond with her caregiver on a personal level (Blais Hayes, 2011). Jean Watson’s caritas factors sets an environment where the patient can obtain optimum health benefits (Blais Hayes, 2011). The goal of this paper is to state my philosophy of nursing, the important dynamics and values that led me to adopting this philosophy, and the reason why I choose nursing as a profession. I will further explain how Jean Watson’s principles of philosophy is†¦show more content†¦Witnessing the patience, strength, and compassionate attributions that nurses convey within their care was remarkable. Having the opportunity to make a positive difference in the life of another human being was a very overwhelmi ng and humbling experience for me. Therefore, these encounters set the foundation towards my pursuit of a nursing career. As a nurse, I familiarize and incorporate Jean Watson’s caritas principles into my professional and person life. Human caring is the core of the healing process (DiNapoli, Nelson, Turkel, Watson, 2010). Patients will often cease with the continuation of their therapy if it is not meaningful to them. A nurse should strive to understand and truly care for her patient in order to form a healing relationship (Zolnierek, 2013). Establishing trust within a relationship will enable a patient to reveal his/her true emotions towards the course of treatment. Watson proclaims that the act of caring reveals a stronger effect than medication alone (DiNapoli et al., 2010). I concur with this assumption based on my experiences as a nurse. Unfortunately, I have witnessed patients withdraw and slip deeper into depression while on medication for their diagnosis. However, I have also observed the quality and outlook of a patient’s life improve significantly after realizing someone truly cares for them. My personal selection of nursing philosophies were instilled upon meShow MoreRelatedNursing Philosophy Of Nursing727 Words   |  3 PagesIntroduction As a nursing student in the BSN program at West Coast University, I have discovered my skills and knowledge to prepare myself on how to be an efficient nurse as well as a nurse that truly cares for the best quality of care given to a patient. I have found some good qualities and insight in the paradigms to a philosophy of caring as a nurse. In this paper I will discuss the four paradigms of nursing which includes: Health, Nursing, Client/Person, and Environment. 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What Makes Fashion Heal - 2836 Words

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Not just in the sense of retail therapy and increasing self-confidence, but in relation to healing our body and mind, and increasing our sense of well-being. The purpose of this study was to determine if fashion could indeed heal us from within, or if it could only make us feel better superficially. This report covers fashion as a creative arts therapy, as well as investigating the evidence in relation to the efficacy of healing fabrics and textiles, and the potential use of fashion in relation to tactile and sensoryShow MoreRelatedThe Catholic Social Teaching Principles are a tool to achieve the common good. In the past and in800 Words   |  4 PagesThe Catholic Social Teaching Principles are a tool to achieve the common good. In the past and in today’s world the common good is short of being what is good f or the whole world and has become what is good for a single society. The Cherokee Indians face the common good of the United States’ culture being forced on to them. 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Acme Incorporated Accounting Practises free essay sample

This paper is an analysis of Acme Incorporated accounting practices on deferred income taxes and the discrepancies between tax and book depreciation methods found by the Certified Public Accountant (CPA), Stephanie Delaney, the new director of corporate taxation. We will write a custom essay sample on Acme Incorporated Accounting Practises or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page As a result of such discrepancies, Acme realizes large deferred tax liability, thus reducing the income taxes paid. In addition, Ms. Delaney found out about the policy of selling plant assets before they would reverse in the deferred tax liability account. This policy complemented with the rapid expansion of the plant asset base allowed a continuous defer of income taxes payable for many years. Despite finding the policies legal, Ms. Delaney doubted their ethics. The analysis discusses about the Acme’s reasons of selling plant assets before the deferred tax liability is reversed, its ethical implications, who might get harmed by such policies and what are Ms. Delaney’s responsibilities as a CPA and director of corporate taxation. As stated above, Acme has the policy of selling plant assets before the temporary differences reverse, thus avoiding deferred tax payments. When the temporary differences reverse, taxable income would be higher than financial accounting income. Acme would start paying taxes it deferred from the previous years, in case the tax depreciation exceeds book depreciation. To avoid it, Acme sells the plant assets. This policy coupled with the rapid expansion of the asset base suggests that the company is deferring tax liabilities when they sell the existing assets, by requiring new ones. Acme’s method of restructuring their assets, results in 100 % deferral of the tax liabilities. Furthermore, selling-off assets before the temporary difference reverses, enables Acme to minimize the taxes paid by using a legal strategy plan. The Federal Government provides such incentives to the businesses, so making use of deferring tax payable incentive, does not bring any legal or ethical issue. On the other hand, there is a concern that Acme is not paying its â€Å"fair share† of taxes, thus gaining on the expense of the Federal government. In addition, Federal Government would be harmed by Acme’s practice of deferring income tax payable, because it receives fewer taxes that otherwise they would receive if Acme would not practice the same policy. Furthermore, in case the replacement assets are more expensive to acquire, the cash flow is decreased, negatively affecting short-term investors and creditors benefits. Situations ethicality is one major problem that a CPA faces. Being a CPA requires to advocate objectivity and integrity of financial reporting. Since, Ms. Delaney is uncomfortable with the ethics of Acme’s accounting practices, than she should communicate her discomfort and concern to the Acme’s managers and also to the Audit Committee and probably to the Board of Directors. The selling of the plant assets before the temporary differences reversed in the deferred tax liability account is considered as a profitable and ethical policy by Acme Incorporated but it is not considered ethical by Ms. Delaney. Such policy benefits the corporation due to the huge decrease in the deferred tax payable. Before talking actions, the CPA has to be clarified upon the reasons of adopting such policies, which is why Ms. Delaney should talk with managers.

Jason P. McCauley World Civilization II Essays - Carbonari

Jason P. McCauley World Civilization II Paper # 2 April 5, 1999 Guiseppe Mazzini, Faith in Democratic Nationalism Before the nineteenth century, Italy was basically controlled by outside forces consisting of other powerful European nations, such as the French. At the beginning of nineteenth century however, there was a great philosophical change going on in the Italian territories that was heavily pushing Italian Nationalism. This movement was sometimes referred to as the Risorgimento. This cultural and political period of Italian history helped fortify the countrymen's nationalism and strove for a unified Italy. Under this movement called the Risorgimento, there were also different views among the leading nationalistic advocates. One such advocate that related more to the radical side of the debate was Guiseppe Mazzini. His thoughts and writings pushed strong nationalism in Italy, as well as the idea that a unified Italy, along with a unified Europe, would provide the world with huge moral improvements and would also greatly help the progress of Humanity. His main point being that only revoluti on and war supported by direct public action would lead to the true unification of the Italian state. With these strong beliefs, Mazzini and other advocates of this cause provided the basic structuring of the revolutions in 1848, and also later revolutions. Guiseppe Mazzini was born in Genoa, Italy on June 22, 1805. At the time when Mazzini was attending the University of Genoa, he was arrested for his democratic actions and was therefore exiled. As a result, Mazzini started up the Society of Young Italy, who's main aim was the establishment of a free and unified Italian State. After plans for a national uprising were discovered, many of the leaders of Young Italy were either executed or exiled. Mazzini was condemned to death but managed to proceed in his democratic works. His ideas continued through his writings as he was forced to seek refuge in London, although he did return to Italy for the revolutions in 1848 and 1849 against the French. He did live to see the unification of Italy, although it was far from what he had envisioned in his works. Mazzini then returned to Italy once more and died on March 10, 1872. During his childhood, Mazzini's parents instilled many thoughts and beliefs pertaining to the idea of a free and democratic government in Italy. For the rest of his life, he then pursued his ultimate dream of a unified Italian state through his political teachings and writings. One major notion that fueled this life long quest was Mazzini's great interest in moral improvement and the progress of humanity not only in Italy, but also throughout the world. Certain evil governments(840) which extend beyond their natural boundaries through conquest have slowed the progress of humanity by dividing countries and also trying to incorporate other nations into their own. Doing this will slow down or stop the ability for one country to assimilate its entire people into one nationalistic culture. This culture can solidify a country by the instilling its nation's historical traditions, a common language, and also the idea of all people striving towards the same goals for the good of the country a nd humanity. As a result of these ideas, no man can really be a part of humanity without a country to love and fight for and without countrymen to love and support him back. As Mazzini states, Our country is our home, the home God has given us, placing therein a numerous family which we love and are loved by ... In laboring according to true principles for our country we are laboring for Humanity;(841), where if we fight for our country and our principles, we can only be doing good things for Humanity as a whole. Another idea that Mazzini stresses heavily is the basis of a country's laws and how they should be obtained and directed. He states, There is no true country without a uniform law.(841), meaning that if the laws you abide by are not regulating everyone in that nation the same way, because of class systems or just abuse of power by the hierarchy, you are not truly a part of a nation where the ground you live on should give you basic unbreakable rights

Articles Of Confederation Essays (598 words) -

Articles Of Confederation From 1781 to 1789 the Articles of Confederation provided the United States with an ineffective government, however there were some strong steps taken in the articles to try and make the United States a better country. The articles created a loose confederation of independent states that gave limited powers to a central government, known as Congress. Some actions taken by Congress, such as the Treaty of Paris, and certain powers that were given to them were sometimes beneficial to the United States. Nevertheless, in attempting to limit the power of the central government, the Second Continental Congress created one without sufficient power to govern effectively, which led to serious national and international problems. The greatest weakness of the federal government under the Articles of Confederation was its inability to regulate trade and levy taxes. In the long run, the Articles of Confederation was a shot in the arm for the United States. The Articles of Confederation arranged a national government that would consist of a single house of Congress, where each state would have one vote. Congress had the power to set up a postal department, to estimate the costs of the government and request donations from the states, and to raise armed forces. Congress could also borrow money as well as declare war and enter into treaties and alliances with foreign nations. With this power, Congress was able to make the Articles of Confederation look good by signing the Treaty of Paris in 1783. This treaty, signed along with Great Britain, concluded the American Revolution. By its terms, Great Britain recognized the thirteen colonies as the free and independent United States of America. However, the most important power was that Congress had the right to obtain territory and control development of the western territories, which was previously controlled by their mother country, Great Britain. (Doc D) With the Articles of Confederation, the United States was able to break away from their mother country and become a free nation, setting up their own government. Although the articles set the United States free, it was unable to provide them with a solid government. Leaders like John Jay and James Madison criticized the Articles of Confederation because of the weak government. (Doc G) There were several problems between the states and the central government. For instance, sometimes the states refused to give the government the money it needed, and they engaged in tariff wars with one another, bringing interstate trading to a halt. The government could not pay off the debts it had incurred during the revolution, including paying soldiers who had fought in the war and citizens who had provided supplies to the cause. (Doc C) In addition, the new nation was unable to defend its borders from British and Spanish encroachment because it could not pay for an army when the states would not contribute the necessary funds. Another serious problem was that Congress could not pass needed measures because they lacked nine-state majority required to become laws. The states largely ignored Congress, which was powerless to enforce cooperation, and it was therefore unable to carry out its duties; duties such as trade regulation, which began to crumble with the entrance of the articles. The United States was unable to expand their market value with the population. (Doc B) With all of the difficulty between the people and the government, it is obvious that the Articles of Confederation weakened the United States. Congress did gain some control, and did some good deeds, but their control was too limited, and they could not get along with the people. The central government could not manage the trade regulation, nor could they levy taxes on the people. With no money being brought into the government, no country is able to be successful. American History

Free Essays on My Last Douchess

The Duke of â€Å"My Last Duchess† Outline Thesis: The Duke of Ferrara, the speaker is a jealous, arrogant and hypocrite man who was very controlling over his dead wife I. The Duke’s desire of control is displayed with each one of his actions A. He shows off the portrait of his dead wife B. He monopolizes his conversation with the envoy C. He tells the envoy when to sit and when to rise II. There is an irony in the control the Duke wants to impose over other people. He really does not have much control. A. He could not control his wife’s smiles B. He cannot control what the envoy will inform the count III. Arrogance is manifested by the Duke The Duke of â€Å"My Last Duchess† Murder, arrogance, hypocrisy, jealously and possessiveness are some of the main themes we can find in â€Å"My Last Duchess†. Robert Browning's poem, "My Last Duchess," features a sixteenth century Duke engaged in dialogue with an arbiter of a Count. "My last Duchess" is spoken from the perspective of the Duke and conveys the Duke’s personality through the literary form of a dramatic monologue. The subtitle of â€Å"My Last Duchess† is â€Å"Ferrara†, which makes a historical reference to the Duke of Ferrara. â€Å"The poem, "My Last Duchess" is based on incidents in the life of Alfonso II, duke of Ferrara in Italy†(Lombardy). According to Hecimovich â€Å"the situation is take [sic] from the life of an actual sixteenth-century, but Browning has imagined the specific incident†. The Duke of Ferrara, the speaker is a jealous, arrogant and hypocrite man who was very controlling over his dead wife. By talking about his previous wife, the Duke s hows of his power and the requirements his next wife should meet. His diction reveals his personality very clearly. The poem begins with the Duke pointing at the painting on the wall that portrays his last duchess. The reader is directed to imagine the Duke walking with the count’s agent through his art gall... Free Essays on My Last Douchess Free Essays on My Last Douchess The Duke of â€Å"My Last Duchess† Outline Thesis: The Duke of Ferrara, the speaker is a jealous, arrogant and hypocrite man who was very controlling over his dead wife I. The Duke’s desire of control is displayed with each one of his actions A. He shows off the portrait of his dead wife B. He monopolizes his conversation with the envoy C. He tells the envoy when to sit and when to rise II. There is an irony in the control the Duke wants to impose over other people. He really does not have much control. A. He could not control his wife’s smiles B. He cannot control what the envoy will inform the count III. Arrogance is manifested by the Duke The Duke of â€Å"My Last Duchess† Murder, arrogance, hypocrisy, jealously and possessiveness are some of the main themes we can find in â€Å"My Last Duchess†. Robert Browning's poem, "My Last Duchess," features a sixteenth century Duke engaged in dialogue with an arbiter of a Count. "My last Duchess" is spoken from the perspective of the Duke and conveys the Duke’s personality through the literary form of a dramatic monologue. The subtitle of â€Å"My Last Duchess† is â€Å"Ferrara†, which makes a historical reference to the Duke of Ferrara. â€Å"The poem, "My Last Duchess" is based on incidents in the life of Alfonso II, duke of Ferrara in Italy†(Lombardy). According to Hecimovich â€Å"the situation is take [sic] from the life of an actual sixteenth-century, but Browning has imagined the specific incident†. The Duke of Ferrara, the speaker is a jealous, arrogant and hypocrite man who was very controlling over his dead wife. By talking about his previous wife, the Duke s hows of his power and the requirements his next wife should meet. His diction reveals his personality very clearly. The poem begins with the Duke pointing at the painting on the wall that portrays his last duchess. The reader is directed to imagine the Duke walking with the count’s agent through his art gall...

Material and the Representational Essay Example | Topics and Well Written Essays - 1000 words

Material and the Representational - Essay Example Social and cultural geography have, over time, experienced a lot of change as a result of developments in schools of thought. Modernization processes of various countries have expressed the extent of the relationship between modernity and geography. There is literature that has indicated that modernization is a project of geography. With modernization and its key concepts such as globalization of affairs social and cultural geography have moved closer. In (Barnes et al. 2004), it is indicated that the reconstruction of geographical conditions is as a result of the production process which incorporates nature and society. In this reconstruction, there is the production of a restless hybrid quasi-object that welds together representational, symbolic and material practices of the production process, often characterized with competition. The coming together of social and cultural theory has revitalized human geography. Smith (2000) underlines that the recombination of social geography wi th cultural is a welcome idea. In this recombination, the role of material culture perspective is referred cited as being central. According to Jackson (2000), there are good reasons for contemporary social and cultural geography to incorporate material culture. In the same article, materialism role is demonstrated using food and textile. The flows of these goods and their related activities have social implications dictating the kind of relationships amongst people. While linking culture and the social process Smith (2000), demonstrates how both are related by work. In this taxonomy, culture is delineated as work which is a social process. Their symbiotic relational point-work- is deeply entrenched to political economy (Smith 2000). The materialism of the social geography is also one of the chief ways of representing how a society makes and sustains connections with the ‘social’. In his arguments Gregson (2003), indicates that reclaiming the ‘social’ has a direct relationship to social life materiality. This is so with specificity to key components of the society such as production processes, reproduction and organization. With regard to this reclamation, Gregson further indicate to the need to less contemporary questions on materiality and inequalities in the society. The issue of inequalities, both regional and urban transcends societies. Essentially, it has close relations with representation and the social materialism as regarding the role of organization and the production process. According to a World Bank report, inequalities present analysts with complexity of historical and geographical factors. In these inequalities there are factors such as weak resources endowment and distribution as well as market inaccessibility affecting development (World Bank 2005). As such, there have been long standing disparities. Further, the report alludes that regional inequalities are reflected when groups- social, racial and ethnical- are con centrated in common places. The concern for representation is manifested by the extent of effectiveness of decentralization of resources relative to power concentration. With imbalances in representation and, public policy carries biases and can therefore not adequately address spatial inequalities. This has effect on social mobility, risk

The relationship of ethical climate Research Paper

The relationship of ethical climate - Research Paper Example The wars fought to be a monarch, the brawls between various political parties, the rivalry for becoming the head of department and the intense competition to become the CEO symbolizes the inborn fancy humans have for Control ,command and to have immense clout to pilot people. This task is however not a piece of cake, while leading and managing people a person is not merely administering a subordinate or an inferior. If we place ourselves in the shoes of a manager or a higher authority, it would be an easy deduction that one has to tackle a substantial array of different ‘’psychological’’ conducts and has to knob the infinite mood swings at times. There are some evils linked with supervision particularly in organizations, the most treacherous to handle is the problem employees. This special clan of people creates problems falling in an either inconsequential category or a colossal group that instigates the employer to take some imperative action instantly. F or instance there are a number of reasons an employee can motivate an employer to show them the door: Insubordination, theft, excess absences and tardiness etc (J, 2006). The high turnover of the employees multiplies the ordeals for the management.   Therefore the employers chalk out diverse strategies to correct the awkward actions or simply opt for the termination approach. But the employee turnover can hurt the overall productivity and is often a symptom of other difficulties. (J, 2006).  ... There are some evils linked with supervision particularly in organizations, the most treacherous to handle is the problem employees. This special clan of people creates problems falling in an either inconsequential category or a colossal group that instigates the employer to take some imperative action instantly. For instance there are a number of reasons an employee can motivate an employer to show them the door: Insubordination, theft, excess absences and tardiness etc (J, 2006). The high turnover of the employees multiplies the ordeals for the management. Therefore the employers chalk out diverse strategies to correct the awkward actions or simply opt for the termination approach. But the employee turnover can hurt the overall productivity and is often a symptom of other difficulties. Other costs of turnover are associated with selecting, orienting and training new workers (Billikopf, 2003). So the healthier alternative is to craft some on-job techniques and corrective measures th at can improve the working ambiance. Details: Around the world the managers and officials are trying to manage the digressions of their problematic subordinates. There are different procedures that are chalked out by people to direct the trouble-creators. For instance confrontation, 360 degrees feedback, termination, environmental upgrading and augmentation in incentives are the few things that are commonly practiced to humanize the negative mind-sets. But if certain sociological theories of deviance are considered profoundly they portray another side of the picture. As in the ‘’labeling theory’’ states that the deviance is socially constructed process in

Extremely Fat and Barely Digesting Junk Essay Example | Topics and Well Written Essays - 1750 words

Extremely Fat and Barely Digesting Junk - Essay Example   Healthy food is cheaper for consumers, therefore more money remains in savings, living standard increases, healthy way of life can be (and should be) example for the further generation, it means much healthier and tough people. All people know that with a bad fuel car will drive for two or three meters then it will be broken. So the people are, people’s fuel is food and bad food can cause problems with proper digesting since the organism is the system of systems, malfunction of one will ruin others. Proved fact that abusive eating of fast food results in problems with health decreases savings, cultivates the improper way of life and disregards of healthy food. Failure of digesting system (diabetes or obesity) results in the problems with locomotor and endocrine systems and it can lead to fatal outcome. Healthy food provides enough energy for the proper functioning of the organism and human body remains healthy. Spreading of fast food concept can critically affect the society. Increasing of fast food institution taxation will not have the result, such institution will raise costs for favorite American food and they buy it even for enormous prices, it will make people from the low-income class feel the last hold slipping away. One should use other methods of impact; however, such methods will not be discussed in the present paper. The rate of people suffering from obesity and diabetes is constantly sky-rocketing. Understanding of what is healthy, and what is not will help people to fight killing diseases. It needs fundamental changes, and not only in the government, more importantly, to change the mentality. Society should eradicate the concept of eating-on-the-run. The most precious thing in human’s life is health; nothing in the world will help to return health. And junk food is strong means to deprive the health.  

Septic Shock Case Study: Causes and Effects

Septic Shock Case Study: Causes and Effects Introduction Septic Shock is a serious circulatory disorder often characterised by a whole- body inflammatory state and the systemic response to infection (Titheradge, 1998), with the most common cause being the contamination of blood with bacteria. Septic shock is defined as sepsis with hypotension which develops in almost half of all septic patients as a complication with a mortality rate of 40-60% (Titheradge, 1998). Septic shock often results in a progressive failure of the circulation to provide blood and oxygen to vital organs of the body resulting in impaired tissue perfusion and oxygen extraction (Thiemermann, 1997). The key symptoms include a severe fall in blood pressure (hypotension) with hypo-reactivity to vasoconstrictor agents (vasoplegia) which may lead to the dysfunction or failure of major organs including lungs, liver, kidneys and brain (multiple organ dysfunction, MODS) and ultimately death (Goligorski et al., 1997). Presently it is widely assumed that septic shock rarely shows similar symptoms in affected individuals and therefore it is difficult to detect and then consequently treat it (Groeneveld and Thijs, 1986). It is, however, also agreed that most of the therapeutic interventions invariably focus on the primary aim of fighting the refractory hypotension by the use of aggressive fluid infusions, glucocorticoids, large doses of vasoconstrictors (Baumgartner and Calandra, 1999) and occasionally renal replacement therapy (Wheeler Bernard, 1999). Yet these interventions do not offer consistent success (Parratt, 1997). In recent times, our understanding of the pathophysiology of septic shock has developed significantly through experimental and clinical trials, though the discovery of a suitable treatment with therapeutic efficacy is proving elusive (Baumgartner and Calandra, 1999). This is probably because of the heterogeneity of the clinical situations and the differences in host response to i dentical pathogens. Moreover evidence suggests that different pathogens which cause septic shock respond differently to the conventional treatments. Still, no effort has been made to treat patients according to the nature of the infecting organism (Gao, Anonymous, 1992). During the early 1990s nitric oxide (NO) emerged as a potentially substantial step towards the treatment of septic shock. This finding directed scientists to carry out numerous clinical trials and animal experiments with the objective of finding out more about the interrelation of NO and Sepsis (Cobb, 1999; Kilbourn, 1999). Later, the discovery of nitric oxide synthase (NOS) made this enzyme the primary target of therapeutic agents (Rosselet et al., 1998). However, recently a substantial amount of literature has been published with evidence contradicting the discoveries of earlier studies. Today more than a decade has elapsed without any resolution to the matter and even in this 21st century Septic Shock is invading the developing countries rapidly (Cobb, 1999; Kilbourn, 1999). This problem of a lack of significant advances in this field can be highlighted by the fact that 17 years have passed since the final publication of the Consensus Conference on sepsis and sepsis related syndromes (Rangel-Frausto, 2005). This paper conclusively defined sepsis and its symptoms with the hope of finding a suitable treatment in order to eradicate the disease (Rangel-Frausto, 2005). Today, however, the situation has not changed significantly with up to 750,000 new sepsis cases every year and 215,000 annual deaths in the United States (Trzeciak et al., 2008, Mitchell M. Levy, 2007). Additionally, in the population that survives such attacks, there is considerable morbidity with many scoring low in health related quality of life assessments (Kaarlola et al., 2003, Perl et al., 1995). Hence the 5 million lives campaign instigated by the US Institute of Healthcare Improvements, aims to minimize the prevalence of nosocomial sepsis (sepsis originating in a hospital) (Gao et al., 2008). This campaign aimed specifically at increasing safety and transforming the quality of hospital care (McCannon et al., 2007). Moreover, the Surviving Sepsis Campaign aims to improve the quality of life of septic patients using the best evidence available currently (Dellinger et al., 2004). Though the world mortality rates have declined in recent times, sepsis is gradually becoming more prevalent in the elderly in the developing countries (Gao et al., 2008).This is mainly due to the extended longevity of patients with chronic illnesses, the increased occurrence of immunosuppression, and the more frequent use of invasive procedures (Bone, 1991; Parrillo, 1993). Sepsis, severe sepsis, septic shock and multiple organ failure still dominate the mass cases of non coronary intensive care units (ICUs). This essay will attempt to explore the fundamental mechanisms leading to tissue and organ damage in septic shock through the investigation of a case study. Following this, the discovery and general biology of nitric oxide (NO) shall be discussed, and the experimental evidence implicating NO as an effector in sepsis, will be examined in detail. The results obtained from various pharmacologic interventions directed at NO in animal studies will also be considered. This report will also give an account of conventional and innovative treatments for the management of septic shock. Finally, data from the few available relevant clinical trials will be reviewed and possible future avenues of interest will be discussed. Systemic Inflammatory response syndrome and Septic Shock (Clinical Manifestation) Sepsis, severe sepsis and septic shock were inaccurately defined until a recently reviewed consensus conference in 1992 (Bone et al., 1992, Dellinger et al., 2004). In this meeting the term systemic inflammatory response syndrome (SIRS) was invented insinuating a clinical response arising from a nonspecific tissue damaging event (insult) (Rangel-Frausto, 2005). Sepsis as mentioned earlier is the result of substantial release of inflammatory mediators in response to an infection. However, often the same mediators are released in the absence of a documented infected in several medical conditions such as cardiopulmonary bypass (Wan S. et al., 1997), pancreatitis and trauma (Shanley TP. et al., 2006). Due to this, the early definitions of sepsis or septic shock were found to be misleading hence a North American consensus conference proposed a new terminology. In this conference sepsis was defined as a condition in which critically ill patients meet criteria for SIRS, in the context of infection. SIRS was defined as two or more of the following: 1) heart rate >90/min; 2) temperature >38Â °C or 12,000 or 20/min or a PCO2 3.5 L min-1 M-23; 2) hyperglycaemia (plasma glucose >120 mg/dL) in the absence of diabetes; 3) significant oedema or positive fluid balance (20 mL/kg over 20 h); 4) inflammatory variables: plasma C-reactive protein >2 SD above t he normal value or plasma procalcitonin >2 SD above the normal value and 5) mixed venous oxygen saturation (SVO2) >70% . (Dellinger RP et al., 2004). SIRS is generally not considered as a disease and its recognition does not provide any clinical conclusion. However, since it has proven to be a very useful for the identification of sepsis and its sequelae namely severe sepsis and septic shock it is regarded as a very important tool (Shanley TP. et al., 2006). Case Study: A 3-year-old boy was admitted to the intensive care unit because of fever, hypotension, and lethargy. A purpuric rash was noted on his arms and legs. Arterial blood gas analysis demonstrated hypoxemia and metabolic acidosis. The arterial lactate level was 10 mmol/L. He was intubated, resuscitated with crystalloid solution, started on broad-spectrum antibiotic therapy, and given dopamine to maintain a MAP above 55 mmHg. His chest radiograph revealed bilateral interstitial-alveolar infiltrates with a left sided predominance. Gram stain of the cerebrospinal fluid showed gram-negative cocci. The dopamine infusion was increased to 18Â µg kg-1min-1 for persistent hypotension and oliguria. Pulmonary and radial arterial catheter data yielded the following blood pressure, 85/30 mm Hg; MAP, 48 mm Hg; heart rate, 140 beats per minute; CVP, 10 mm Hg; pulmonary artery pressure, 22/14 mm Hg; PCWP, 12 mm Hg; cardiac index, 2.5L min-1m-2; and SVRI, 1226 dyne-sec-cm-5m-2. The boy was treated with ad ditional saline and an epinephrine infusion, which increased the MAP, cardiac index, and urine output. Arterial lactate levels decreased over the next 12 hours. Subsequent cultures of blood and cerebrospinal fluid grew Neisseria meningitidis. In this case the patient with acute organ failure and hypotension was diagnosed with septic shock. The young boy with meningococcal septic shock had a borderline-low cardiac index. Due to this a decrease in the cardiac index in this patient by the administration of an NOS inhibitor might not be desirable. This is suggestive of the fact that NO or its synthesising means cannot always be targeted in order to battle septic shock. I will attempt to go into further details with regards to this statement as we go along the essay. Nitric Oxide discovery: Joseph Priestly first identified gaseous NO in 1772. NO also named Nitrogen Monoxide is a very simple and tiny molecule consisting of one nitrogen and one oxygen molecule. Unknown of its fundamental physiological roles in the mammals, until the 1980s NO was widely considered as a mere toxic atmospheric pollutant (Konstantin J. Ovodov et al., 2000). In the 1980s researchers were examining how blood vessels expand (dilate) hence regulate the mean arterial blood pressure. Dilation of blood vessels, also termed vasodilation is a very important physiological response which partly regulates the blood pressure. By increasing the diameter of blood vessels, vasodilation causes the blood to travel more freely due to lower resistance (RF Furchgott, 1980). Since the blood vessel lumen widens during vasodilation, the blood imposes less outward pressure on the vessel wall hence reducing the blood pressure. In opposition, vasoconstriction reduces the diameter of the lumen increasing the BP. These physiological responses occur all the time in the human body regulating the BP and therefore are one of the most fundamental mechanisms of the human body. Dr Robert Furchgott and his group, later in 1980s investigated the role of acetylcholine in the smooth muscle relaxation and found that relaxation only occurred if a special class of cells called endothelial cells were present (RF Furchgott, 1980). These cells line the interior surface of blood vessels, forming an interface between circulating blood in the lumen and the rest of the vessel wall. Behind the endothelial cells are the smooth muscle cells which either relax or contract thus regulating the vascular tone (RF Furchgott, 1991). The same research group also discovered that smooth muscle were only able to vasodilate the blood vessels in the presence of endothelial cells. This indicated that there was some kind of factor that was being released by the endothelial cells which was involved in the dilation of the blood vessel. This factor was named Endothelium Derived Relaxing Factor (EDRF) and subsequently specified as NO (S Moncada et al., 1997). In 1977, Ferid Murad independantly investigated the mechanism of action of nitroglycerin and found that it worked by inducing the release of NO which in turn was able to cause relaxation of smooth muscle cells (F Murad et al., 1977). Louis Ignarro in 1986 finally resolved the whole perplex of EDRF and NO by declaring that EDRF was in fact NO. It was stated that both molecules showed identical properties when he compared gas Nitric Oxide and EDRF (Ignarro, L. J. Et al. 1987). In 1998, Nobel Prize in Physiology and Medicine was awarded to Drs. Robert Furchgott, Louis Ignarro, and Ferid Murad for their discoveries that vascular endothelial cells make nitric oxide (NO) and that such endothelium-derived NO stimulates cyclic guanosine monophosphate (cGMP) synthesis in the underlying vascular smooth muscle, causing relaxation (Kilbourn, 1999). Since the discovery of NO, vast number of its physiological roles in normal conditions have been reported including in the immune system, nervous system, reproductive system and other cellular functions. It has also been found to play important roles in variety of species ranging from mammals, to insects and plants. Role of Nitric Oxide in Biology Since it was first discovered to play a role in the dilation of blood vessels many new roles for Nitric Oxide (NO) have been discovered. In human body, NO is metabolised by its diffusion into red blood cells where it oxidizes the ferrous iron of oxyhemoglobin yielding methemoglobin and nitrate ions (NO3-) (J.M. Hevel et al., 1994 and Konstantin J. Ovodov and Ronald G. Pearl, 2000). This meachanism limits local NO build up and is particularly important in keeping NO concentration in naomolar range, at least in nonhydrophobic compartments (i.e. outside cell membranes) (Beckman Koppenol, 1996). Nitric oxide has been found to be produced by effectively every cell type in vivo and plays an important role in both controlling the normal function of cells as well as in regulating larger scale processes such as the reproductive, immune and nervous systems. A few of these biological functions for NO are described in more detail below. The Immune System Nitric oxide plays many important roles in the immune system although it is expressed in many cell types following endotoxin or pro-inflammatory cytokine treatment (C. Nathan et al., 1991 and R.G. Knowles et al., 1994). NO, in immune system, is produced in high amounts from specific cells called macrophages. Proceedingly to an infection, chemicals known as cytokines are release in vivo which activate the cells of the immune system such as macrophages, and help guide them to the site of infection (S. Moncada et al., 1991 and C. Nathan et al., 1991). NO produced by the macrophages is toxic to the bacteria and play an important role in their destruction (Fig 1). The production of nitric oxide in this way also helps protect against other types of infection including parasites and viruses (S. Moncada et al., 1991). However, too much nitric oxide production can not only lead to septic shock but has also been implicated in conditions where the immune system is too active autoimmune diseases like arthritis (Jang D and Murrell G A, 1998). The Nervous System Nitric oxide has been shown to be involved in both the peripheral and central nervous system. The three nitric oxide producing isotypes of enzyme (iNOS, eNOS, nNOS) (see section) in humans, one isotype (neuronal NOS (nNOS)) is found almost exclusively in the nervous system (Forstermann et al., 1995). nNOS is thought to be involved in promoting the transfer of interneuronal nerve signals. This is thought to take place by the stimulation of exocytosis (release) of endogenous chemicals called neurotransmitters of one neurone (Moncada et al., 1991; Forstermann and Kleinert, 1995). These NT then diffuse across the synaptic cleft (gap between neuronal terminals) and stimulate the neighbouring nerve cell terminal to transmit the signal (Otto Loewi, 1961). NO has shown to play a substantial role in diseases of the nervous system like Alzheimers and Parkinsons. In both diseases, the inhibition of NO has shown to slow down the progression of the disease in mice (Weill Cornell Team, 2005 and Jo hns Hopkins et al., 2004). Reproductive Biology Nitric oxide is one of the most important molecule in the course of reproduction and is involved in many aspects of it. As well as dilating the blood vessels and thereby helping to regulate maternal blood pressure, NO is also involved in implanting the early embryo in the uterus (Rogers, 1995). During pregnancy, nitric oxide is also suggested promote angiogenesis (a process in which new blood vessels are formed) (RayChaudhury et al., 1996). It is also known to play a role in the survival of trophoblasts (form placenta) (Enders et al., 1978). Furthermore deficiency of NO has been found in patients with preeclampsia (a medical condition in pregnancy) suggesting its partial role in growth of embryo (Yallampalli et al., 1994; Liao et al., 1996). In addition, drugs (Viagra) used to treat erectile dysfunction also affect nitric oxide signalling. Cellular function A notable number of cellular activities can be controlled by nitric oxide including cell division, cell movement and cell survival. The majority of cells in human body have the ability to undergo programmed cellular death. This is a self-destructive mechanism usually called apoptosis which often occurs when a cell is damaged and beyond repair, infected with a virus, or undergoing stressful conditions such as starvation (Kerr et al., 1972). Cells in these conditions go through apoptosis so that they dont hinder the proper functioning of the rest of the tissue. During apoptosis, the structures of the cell break down in an organised manner, forming a packaged cell that is smaller in size so that it can be easily removed by the cells of the immune system (Kerr et al., 1972). Nitric oxide was first shown to inhibit apoptosis hence promoting cell survival in human B lymphocytes (Mannick, J. B. Et al., 1994). Subsequently similar finding were reported in an ample number of other cells. However, high doses of nitric oxide also have deleterious effects. They can be toxic to many cell types and can lead to septic shock and multiple organ dysfunction syndrome (MODS) in which case NO causes cell death instead of promoting cell survival (Beal Cerra, 1994). Nitric Oxide and Inflammation (Pathophysiology of septic shock) This section will deal with mechanism by which wall fragments of Gram-negative or Gram-positive bacteria and other inflammatory agents induce nitric oxide synthase (iNOS) in cells and tissues. Exogenous toxins which enter the circulation stimulate the synthesis and release of a number of endogenous cytokines. During a gram-negative infection which can lead to septic shock, lipopolysaccharide (LPS) and endotoxins present on bacterial wall and many other inflammatory agents bind to a co-receptor (CD14) on the surface of specific immune cells like macrophages, resulting in their activation (J.C. Lee et al., 1996). LPS also bind to LPS-binding proteins which are produced by the liver. These proteins facilitate LPS binding to the CD14 co-receptor of the macrophages. The CD14 co-receptor is activated through the binding of LPS to a toll-like molecule (TLR4), (Re F, Strominger J. Et al., 2001) which is responsible for initiating the transmembrane signaling. TLR2 molecules act in the same way as TLR4, (Leppper PM et al., 2002) though; these are activated by gram-positive bacteria, mycobacteria and yeast. Gram-positive bacteria such as Staphylococcus aureus have further additional wall fragments such as peptidoglycan (PepG) and lipoteichoic acid (LTA). Both PepG and LTA have been shown to synergise to produce the characteristic features of septic shock, MODS and ultimately death in rodent models (S.J. De Kimpe et al., 1995 and G.M. Millar et al., 1997). These effects were not observed with either LTA or peptidoglycan alone, although high doses of LTA can cause circulatory failure but not MODS (S.J. De Kimpe et al., 1995). Gram-positive bacteria may also release other enterotoxins and exotoxins, for example toxic shock syndrome toxin 1, which are involved in the pathogenesis of sepsis (reviewed in (R.C. Bone et al., 1994)). The additional fragments released by Gram-positive bacteria bind to unknown receptors however, like LPS binding, cause the release of proinflammatory cytokines TNF-a, IL-1ß, and IFN-? (Thiemermann, 1997, Titheradge, 1999). These cytokines as well as IL-6 are often produced in response to immune stimulation of macrophages and monocytes hence also in septic shock patients. IL-1 and TNF each occur in two forms, a and ß. TNF- a and both forms of IL-1 are made by activated monocytes and macrophages, whereas TNF- ß is made by activated T lymphocytes (Review by J. Saklatvala et al., 1996). There are two receptors for both IL-1 and TNF and the two forms of each cytokine interact with the same receptors. IL-1 a and ß interact with the type 1 IL-1 receptor for signal transduction, whereas type II does not appear to transmit any signal and functions as an inhibitor of IL-1 action (J. Saklatvala et al., 1996). The two types of TNF receptor, p55 (type I) and p75 (type II) have different end effects; p75 mediates the proliferative actions of TNF- a while p55 receptor signals the inflammatory response and apoptosis (J. Saklatvala et al., 1996). Complex interactions between these different mediators produce intense pathophysiological modification, which eventually lead to diffuse tissue injury and ultimately sequential system failure (multiple organ dysfunc tion syndrome), which accounts for the majority of deaths among patients with sepsis, severe sepsis and septic shock (Beal Cerra, 1994). IL-1ß and TNF-a have a very short half life compared to IL-6 and therefore IL-6 is a very good indicator of cytokinemia. The initial studies of septic shock, showed a very strong positive correlation between IL-6 levels and fatal outcome (Casey L. Et al., 1993). NO is equally a very short lived molecule with an estimated in vivo half life of only 0.1 seconds hence again it is hard to measure its levels in order to detect the severity of cytokinemia hence the severity of sepsis or septic shock. There are several molecules that contribute to the pro and anti-inflammatory responses in septic shock (Table 4); however I shall only focus on a few due to the limited word allowance. In response to inflammatory agents in septic shock, the released cytokines (TNF-a, IL-1ß, and IFN- ?), bind to their specific receptors activating a protein kinase called tyrosine kinase leading to both the activation of the nuclear factor-kB (NF-?B) (a transcription factor) and the phosphorylation of intracellular protein (Gao et al., 2008). A precise mechanism by which these cytokines act was proposed by J. Saklatvala et al. in 1996 however this has yet to be confirmed. Nitric oxide producing cells contain I-?B which is an inhibitor of NF-?B. For the activation of NF-?B, proteolytic cleavage of I-?B from NF-?B is required which forms NF-?B. This biological change allows the activated NF-?B to translocate to the nucleus, where it binds to the promoter region of the iNOS gene inducing transcription. It has also been reported to induce other inflammatory agents, such as cytokines and leukocyte-endothelial adhesion molecules (Janssen-Heininger et al., 2000). Tyrosine kinase present inside the cell acts as a messenger molecule involved in the proteolytic cleavage of I-?B/NF-?B and hence in the activation of NF-?B and iNOS expression (Hecker M, et al., 1996). In septic shock, the translated products of iNOS mRNA subsequently assemble forming the iNOS protein which in turn causes local NO proliferation (Thiemermann, 1997). Fig 2 shows the signal transduction pathway of iNOS expression in response to inflammatory agents. The physiological role of iNOS is to enhance the formation of NO (due to iNOS activity), which in turn may contribute to either the pathophysiology of septic shock (clinbical symptoms) or the host defence (Reviewed in Gao et al., 2008). Fig 3 shows a simplified schematic of the Anti Inflammatory cascade in the context of septic shock. Excess NO produced by iNOS has been reported to both induce and inhibit NF-?B (Kalra et al., 2000; Umansky et al., 1998). In year 2000, it was proposed that low levels of NO may induce further NO production while high concentrations do the opposite exhibiting a feedback mechanisms that would oppose the over expression of genes regulated by NF-?B (Janssen-Heininger et al., 2000). In addition NO at high concentrations competes with O2 at the active site of NOS, thus providing a feedback mechanism of its own synthesis (Griscavage et al., 1995; Rengasamy Johns, 1993). Biological Synthesis of Nitric Oxide (Nitric Oxide Synthases) NOS structure and substrates for NO production: In mammals, NO is exclusively formed from the enzymatic oxidation of one terminal guanidino nitrogen of the amino acid L-arginine. When expressed in moles, this reaction utilizes 1 mol each of arginine and O2, and 1.5 mol of NADPH, yielding 1 mol of NO, 1 mol of L-citrulline and 1.5 mol of NADP (R.G. Knowles et al., 1994). The reaction sequence involves the generation of an Ng-hydroxy-L-arginine intermediate, followed by the oxidation of Ng-hydroxy-L-arginine in presence of molecular oxygen to form L-citrulline and NO (Dennis J. Stuehr et al., 1991 and R.G. Knowles et al., 1994). The enzymes that accelerate the reaction above are a family of relatively large heme proteins known as NO synthase (NOS) which resemble cytochrome P450 structurally (M. M. Chan et al., 2001 and Francois Feihl, 2001) (The general mechanism of NO production from NOS is illustrated in Fig 4). All members of this family share a similar homodimeric structure, where each monomer consists of a an oxygenase domain and a reductase domain, separated by a short amino acids (30aa) sequence for the attachment of the Ca2+-binding protein calmodulin. In addition to calmodulin attachment, enzymatic activity requires the presence of four cofactors: FAD, flavin mononucleotide (FMN), tetrahydrobiopterin (BH4), and heme (Francois Feihl, 2001). Fig 5 shows the general structure of the NOS enzymes. Nitric Oxide Synthase isoforms and their locus in the Human Body: There are three known isoforms of NOS, each the product of a different gene: neuronal NOS (nNOS or NOS-1), inducible NOS (iNOS or NOS-2), and endothelial NOS (eNOS or NOS-3). nNOS and eNOS were first described in rat cerebellum and bovine aortic endothelial cells, respectively, but their tissue distribution is far wider than suggested by their names. eNOS and nNOS are involved in regulating vascular tone (R.G. Knowles et al.,1992 and S. Moncada et al., 1991) and neurotransmission respectively, whereas iNOS is involved in the immune defence although it is expressed in many cell types following endotoxin or pro inflammatory cytokine treatment (R.G. Knowles et al., 1994). nNOS is typically expressed in skeletal muscle and myenteric plexuses. eNOS is ubiquitous in vascular endothelium, but may also be found in the kidney tubular epithelial cells, placenta (Forstermann et al., 1995), and neurons (Nathan Xie, 1994). In these tissues, the expression of nNOS and eNOS is constitutive, although it may be regulated (Michel Feron, 1997). For instance, the levels of transcript for eNOS in vascular endothelial cells is increased by shear stress (Topper et al., 1996; Uematsu et al., 1995) and exercise (Wang et al., 1997), reduced by inflammatory stimuli such as TNF-a (Nathan Xie, 1994) and variably affected by hypoxia (Le Cras et al., 1998; Toporsian et al., 2000). In the physiological state, the iNOS isoform is only present at a few locations, notably the respiratory epithelium, the gravid uterus (Nathan Xie, 1994), and perhaps the ileal mucosa (Hoffman et al., 1997). iNOS expression has been demonstrated in numerous cell types including macrophages, neutrop hils, vascular endothelial (Hoffmann et al., 1999), smooth muscle cells, endocardium, myocardium, fibroblast, mesangial cells, renal tubular epithelium (Kunz et al., 1994), neurons, hepatocytes, pancreatic islet cells and astrocytes (Nathan Xie, 1994). iNOS can be induced by a number factors including UV light; cyclic AMP-elevating agents; trauma; ozone and bacterial products described earlier (see section). On the other hand, many endogenous agents may oppose cytokine induction of iNOS. These include anti-inflammatory cytokines such as IL-10, chemokines such as monocyte chemoattractant protein-1 and growth factors such as tumor growth factor-ß (Forstermann et al., 1995). In all NOS isoforms, calmodulin binding is an absolutely vital for enzymatic activity. In the cases of eNOS and nNOS, this binding necessitates relatively high concentrations of Ca2+ (see Fig 7), in the range of 0.1-1 mM (Forstermann et al., 1995). In contrast, iNOS is able to bind calmodulin virtually independ ant of Ca2+ (Table 2). Therefore, once iNOS is expressed, NO synthesis may only be limited by the availability of substrates and cofactors (J. Stuehr, 1990). As NO produced from iNOS predominantly depends only on iNOS expression, it lasts much longer than NO formed from the other isoforms of NOS. In addition iNOS produces much higher concentrations of Ca2+ compared to the consecutive forms of NOS (Cobb et al., 1996). The production of NO by eNOS and nNOS, compared to iNOS, can be controlled relatively easily by decreasing or increasing intracellular Ca2+, whereas iNOS can only be controlled through transcription (Cobb et al., 1996). In most cell types iNOS protein levels are either very low or undetectable. However, stimulation of these cells by cytokines or growth factors, can lead to increased transcription of the iNOS gene, with subsequent production of NO. On the other hand, for the prevention of iNOS expression through endotoxins, TGF-ß (Szabo, 1995) and anti inflammatory gl ucocorticoids can be administered which lower the magnitude of vascular hyporeactivity. Glucocorticoids such as Dexamethasone inhibit iNOS activity by blocking arginine transport and inhibiting tetrahydrobiopterin biosynthesis (A.J.B. Brady et al., 1992 and Thiemermann C et al., 1993). Regulation of NO production In the normal as well as in extreme physiological states (e.g. during infection), nitric oxide is considered as one of the most important signalling molecules in vivo. It is however also highly reactive and highly diffusible due to it being a free radical (one unpaired electron) (see fig 8). It is therefore important that there is strict control and regulation of nitric oxide production. The synthesis of NO within cells can be regulated in several ways such as the cellular distribution of NOS, changes in NOS gene expression, enzymatic activation by phosphorylation and the presence of cellular inhibitors NOS activity. Intracellular distribution of NOS Nitric oxide is principally regulated through strict control over the location of NO production. The NOS isoforms can be targeted to different regions of the cell, where NO will be produced in close contact with its target proteins. The image below shows the distribution of iNOS (shown in green in image 1) and eNOS (shown in red) in a trophoblast cell. The nucleus is shown in blue. Co-localisation between iNOS and eNOS will show up as a yellow colour (Phil Dash, University of Reading). The image shows that eNOS and iNOS are fairly variably distributed inside the cell, with hardly any yellow colour suggesting very little overlap in their cellular distribution (Phil Dash, University of Reading).Although both iNOS and eNOS produce NO it is likely that their different cellular distribution will lead to NO interacting with different targets and therefore having different effects (Phil Dash, University of Reading). It is very likely that the distribution of NOS isoforms is an important mechanism for regulating when and where NO is produced. Therefore the current research on NOS mainly focuses on how endogenous signals trigger NOS transport and redistribution (Rahul S. Koti et al., 2005). Activation of NOS activity NOS enzyme synthesis is principally regulated by changes in intracellular calcium levels. The constitutive isoforms of NOS, (eNOS and nNOS) have shown to proliferate following increases in Ca2+, and therefore calmodulin levels, in the cell (Rameau et al., 2003). Additionally both nNOS and

The Triumph of Humility and Fierce Resolve :: Article Review, Jim Collins

Level 5 Leader Author Jim Collins (2005) in his article, Level 5 Leadership: The triumph of humility and fierce resolve (Collins, 2005), presents a compelling evidence for the need to have what he describes as â€Å"Level 5 leadership† at the helm, in order for organizations to reach high performance status (Collins, 2005). Collins stated that â€Å"Level 5† refers to the highest level in a hierarchy of executive capabilities that were identified during our research (Collins, 2005, p. 138). However, the original intent of Collins research was based on his pursuit to identify if a good company can become a great company (Collins, 2005). How Collins reached the concept of the Level 5 Leader can be linked to his research methods and findings. With 22 research associates at hand, Collins (2005) â€Å"set out to answer one, question: Can a good company becomes a great company and, if so, how?† (Collins, 2005, p. 139). To identify the companies he would research it appeared that Collins needed to make certain the organizations level of success was identified from a credible source. To achieve this, Collins selected to investigate companies noted as Fortune 500 companies from 1965 to 1995 (Collins, 2005) . In doing so, his foundational research approach was established. Through more analysis the final group described as good- to- great companies was narrowed down to 11 companies. â€Å"Those that made the cut averaged cumulative stock returns 6.5 times the general stock market for the 15 years after the point of transformation† (Collins, 2005, p. 139). In his attempt to rule out any issues with sustainability, the research identified companies that had obvious change, but the change did not last (Collins, 2005). These companies ended up being cut from the final group. Collins included both qualitative and quantitative method for this research to get through the final stretch (Collins, 2005). The researchers analyzed data, reports, and conducted interviews (Collins, 2005). Eleven companies meet the standards of a good to great company (Collins, 2005). The article noted that, â€Å"Level 5 easily made it into the framework as one of the strongest, most consistent contrasts between the good-to-great and the comparison companies† (Collins, 2005, p. 139). Meaning that, the organizations identified as good-to-great had leaders at the helm that met Collins definition of a Level 5 Leader. He describes then as a leader who â€Å"Builds enduring greatness through a paradoxical combination of personally plus professional will† (Collins, 2005, p.

Interactive video behavioral intervention Essay

Risk behaviors on youth are issues that the sociologists and psychologists regard as big deals. The youth comprises the major work force of the future yet the trends and the activities they do sometimes put them to the verge of having complications and diseases that are transmitted through having sexual intercourses. Their every day activities may lead them to something that can really matter especially with their health and their spirituality. Modernism and liberalism are issues that are usually faced by the youth today by which values that are regarded to be sacred before are now called passe and often treated as something for the centuries, not for the modern age. One of the issues mentioned are women engaging to pre-marital sex at a young age, and worse cases to multiple partners. Downs, Murray, et. al (2004) formulated a study that dealt with the behavior of females who are likely to commit to sexual activities involving oral and anal sex, together with the sexual intercourse itself. Their study aimed to determine some controlling factors with the behavior of women regarding sex. It provided different ways of informing the women of the possible consequences of having sexual intercourse with the opposite sex. Having a number of reviews of articles, they gathered 300 sexually active females (6 months before the study started) from different places in Pittsburgh are that are still subdivided from hospitals, clinics and a teaching hospital. The authors of the study first surveyed for the participants who are willing to be tested and undergo the study. Parents were also asked if they are willing to let their daughters below 18 years become the participants of the study. According from the article, parents were more than willing to let their daughters be part of the team or the respondents. Questions that asked the motives of having sex were asked during the interview. It will help the evaluators to assess the usual situations before the actual intercourse happens. The study also has its way of letting the participants choose a way that they will be best informed. In this way, they will have an idea of how they are going to control their sexual drives. The modes of the study are: interactive video clip, a book that offers the same content as the video and brochures that offer the same topic. One video clip from www. WhatCouldYouDo. org was shown to them that portrayed a girl and a boy that depended on the concept of â€Å"condom† love that is often pictured as something satisfying other than the act of abstinence. Their knowledge about STD was also measured trough the 40 questions posted in the study, and they have a percentage of 65. 5% correct concepts about the matter. On the other hand, 67. 7% of them has the right knowledge about specific STD issues. Controls without the interventions were more likely to still engage in the activity while those who have had the chance to be included in the team with video intervention through randomization were reported to have self control over the next few months. However, the study showed that knowledge of the participant regarding sexual and STD issues did not increased. It was stated in the reports that it could have been better if the control for the study did not receive any intervention to clearly see the effect of the programs in controlling the risk behavior of youth, specifically with the females. The study may be leading to situations by which female will not be choosing the option to have sex with their partners to express their feelings. Moreover, the intention of preventing STD in youth through some information integrated seminars and trainings are good ways in drawing down the lines in the limitations of the actions of the females, and the youth. Reference Julie S. Downs, Pamela J. Murray, Wandi Bruine de Bruin, Joyce Penrose, Claire Palmgren and Baruch Fischhoff. Interactive video behavioral intervention to reduce adolescent females’ STD risk: a randomized controlled trial Social Science & Medicine, Volume 59, Issue 8, October 2004, Pages 1561-1572

Poway Unified School District †Persuasive Essay

Poway Unified School District – Persuasive Essay Free Online Research Papers Poway Unified School District Persuasive Essay Stress is within all of us. How it is released is a different matter. Today kids are experiencing a large amount of stress from homework. The people who think that over 4 hours of homework a week are the people who demand kids to be adults. While kids want to just be kids. Poway unified school district wants to increase the homework per night average from 4 hours to the national average of 5 and a half hours. Poway unified school district should keep the hours per week of homework the same, to avoid stress, avoid being sick, and finely let kids be kids. At first 5 and a half hours of homework may seem like a good idea, but has anyone thought about the stress it would cause. Studies have show people who experience large amounts of stress are more likely to heart attacks and being sick. A young kid should not go home do homework puke get up puke again and not go to school and then worry about making up the homework that they missed, because they missed their lesson. Also, when you are a child being sick from stress isn’t fun, most of you have probably experienced being sick from stress. Thus, 5 and half hours of homework will increase stress levels and therefore increase the chance of being sick. Secondly, a survey showed that a group of 3rd who got 1 hour of playtime on top of their current reading lesson got 1.3% higher on their reading test scores. This shows that kids who are given time to play and have fun at least an hour more each day will in the long run be better then the one without time to play. What does this mean to amount of homework in a week? It means that by the time we complete our homework it is to late to play and therefore we lose 1.3% in our grades. That is very important in the long run, it could tell the difference from going to Stanford or a poor community college. Thus, getting at least 1 hour of recreation on top of homework is a necessity for having success in life. In another point of view, 5 and half hours of homework may seem like a good idea. For example, Dr Julian Betts, a professor found that â€Å"a student who did 15 minutes of math homework a night from the 7th grade to the 11th grade scored 65% higher on national math tests†¦.†. But, that is only 15 minutes of homework times 5 days, is an hour 15 minutes not 5 and half hours. This study is saying that we should have no more then 1 hour and 15 minutes of homework and is a complete waste of time to bring it as a point to increase homework to 5 and half hours. So an increase in homework would be totally inconceivable if all it takes to get a good score is 15 minutes a night (1 hour 15 minutes a week). Thus, homework should stay the same to avoid stress sickness and let kids be kids. We need to march down to P.U.S.D. (Poway Unified School District) to tell them keep the hours per week of homework the same until it stays the same for good, and we are doing this because if we don’t, kids will live a life of intense stress. We don’t want to end up like a grown up fearing for the risk of potential heart attack because of the massive stress that was put on us during our child hood. Research Papers on Poway Unified School District - Persuasive EssayThe Spring and AutumnStandardized TestingHip-Hop is ArtEffects of Television Violence on ChildrenPersonal Experience with Teen PregnancyThe Effects of Illegal ImmigrationTrailblazing by Eric AndersonResearch Process Part OneThe Hockey GameThe Masque of the Red Death Room meanings

Visual Arts in Pre

Visual Arts in Pre Pre-historic Greek artworks have influenced cultures and arts in many countries around the globe, especially in the sculptural and architectural arts. Right from the Roman Empire in the West to the Far East including Japan, ancient Greek artworks are a source of inspiration (O’Kelly 1982, p. 88).Advertising We will write a custom essay sample on Visual Arts in Pre-historic Greek Artworks specifically for you for only $16.05 $11/page Learn More The Greek architecture left a lasting impression in the architectural design of public buildings. Contemporary buildings and the ancient Roman arts copied a lot of things from the Greek. This paper compares the Parthenon, a well known surviving building of ancient Greek with the War Memorial Opera House in San Francisco, which is a piece of contemporary architectural artwork. The Parthenon building on the Acropolis, in 5th BC to replace an old temple destroyed during an invasion (Beard 2010, p.12). The temple bu ilding in Athens and it acted as a sign of Athenian dominance in the Greek Peninsula. The War Memorial Opera House located in San Francisco on Van Ness Avenue opposite the City Hall opened its gate to the public in 1932 (Couret 1998, para. 2). The building was among the last main American building built in the Beaux-arts style. This style of art borrowed a lot from the ancient Greek and Roman architectures. The Parthenon (Neils 2005, p. 3) Advertising Looking for essay on art? Let's see if we can help you! Get your first paper with 15% OFF Learn More The War Memorial Opera House (SFWMPAC Online n.d, n.p) The Parthenon building to served as a temple for one of the goddesses of Athens. It was built to offer thanks to Athena the goddess for their success and victory in the war. In fact, the name originated from a cultic statue housed in one of the rooms, in the temple. The building later invaded and turned into a church in honor of the Virgin Mary. On the other hand, the War Memorial Opera House was built to commemorate the people who died during the World War I. It also served to host the San Francisco War Memorial and Performing Arts Center since 1932 when it opened its doors (‘Parthenon, Lovell Minnick and Fisher Lynch Conclude Acquisition of H.D. Vest Financial Services’ 2011, para. 2). Classical Doric order or style, which, is normally calm and sturdy was used in building both buildings (Michos 2002, para. 7). The Parthenon, credited as one of the perfect Doric temple ever built in the world while the War memorial Opera House constructed using paired columns, an application of Doric order (‘The Webby Awards 2001(R) Will Take the Stage at San Franciscos War Memorial Opera House’ 2001, n.p). Doric style applied the directly standing columns on flat pavements known as stylobates and alternated metopes a feature common with the two architectural works under consideration. Ionic columns were also clearly used in both buildings. The materials used to make the two pieces of architecture were different mainly because of the different in their respective location. Wooden roofs, marble tiles and marble statues made up the Parthenon’s interior. Other materials used in the building were ivory and gold, and it stood on a limestone rock. Coffered ceiling; large aluminum and glass paneled chandelier made up the War Memorial Opera house’s interior. Sculptures are a common occurrence in the two buildings despite the difference in age (Clark 1997, para 5).Advertising We will write a custom essay sample on Visual Arts in Pre-historic Greek Artworks specifically for you for only $16.05 $11/page Learn More An explosion destroyed the Parthenon, but the War Memorial Opera house in San Francisco continues to stand. It maintains a lasting impression of the ancient Greek architectural designs, and buildings (Kaldor 2010, p 23). Technologically, the building has advanced, but it refuses to let go of its ancient world’s ‘theater feeling’. Until late 20th century, the Parthenon laid destroyed, but the Greek government set out to revive the ancient building. Now it is meant to become a museum, but unfortunately, the original design cannot be recovered. Only an impression of it is possible. References Beard, M., 2010. The Parthenon, Profile Books. Clark, A., 1997. After the quake: Andrew Clark attends the re-opening of San Franciscos refurbished War Memorial Opera House Financial Times, pp. 08-08. Couret, C., 1998. San Franciscos historic opera house re-opens, The American City County, 113(9), pp. 28-28. Kaldor, A., 2010. Great opera houses: masterpiece of architecture Masterpieces of Architecture Series. Antique Collectors’ Club, the University of Michigan. Michos, I., 2002. The enduring question about the Parthenon, Financial Times, , pp. 06-06.Advertising Looking for essay on art? Let's see if we can help you! Get your first paper with 15% OFF Learn More Neils, J., 2005. The Parthenon: from antiquity to the present. Cambridge University Press. O’Kelly, M., 1982. Newgrange: Archaeology, Art and Legend, London: Thames and Hudson. Parthenon, Lovell Minnick and Fisher Lynch Conclude Acquisition of H.D. Vest Financial Services, 2011. Entertainment Close Up, , pp. n/a. The Webby Awards 2001(R) Will Take the Stage at San Franciscos War Memorial Opera House, 2001. United States, New York: PR Newswire Association LLC. SFWMPAC Online, n.d., San Francisco War Memorial Performing Center. Web.

Overcomming adversity Essay Example | Topics and Well Written Essays - 500 words

Overcomming adversity - Essay Example Some are learning disabled. How we overcome these adversities in the traditional classroom marks our teaching effectiveness. As a teacher I am going to try my best to embrace diversity and different methods of learning in every way. This is just one experience but there is diversity in the way we learn, our socio-economic backgrounds, our ethnic backgrounds – The list can go on forever. I am going to give it my all to teach to the individual while creating a cohesive classroom where nobody feels left out and everyone feels like a little part of them as become a process of group learning in a positive way. Diversity is what makes life interesting and I plan to continue to emphasize this in each lesson plan I create! I plan to connect, not disconnect, ALL of my student’s to the curriculum. Only be embracing diversity can we overcome adversity in the classroom. A key way of overcoming adversity is to embrace online learning. This helps learning disabled students as it prov ides a better learning forum for them. Online education has undergone vast improvements over the last decade. Initially online courses were not acknowledged to the level that they are today. It was rare for a college or university to offer an online course. Today the case is a lot different. Far more than half of the universities and colleges offer online education. Over the years progression has lead to two different types of online models.

Find a case study of an ERP implementation and prepare a critical

Find a of an ERP implementation and prepare a critical summary. The will outline an ERP implementation that has been successful or unsuccessful - either is perfectly OK - Case Study Example 140). Also, the short-term solutions applied to the problems experienced during the implementation of ERP systems have substantial side effects whenever the systems go live. The essay presents an investigation into the management strategies adopted by the Pharma Inc. project team in their efforts to stimulate what is now referred to as the best practices of ERP implementation. The case involves a multinational pharmaceutical firm that decides to implement specific technical skills (SAP) to a large number of worldwide sites(Tan & Payton, 2010, p. 77). The single instance SAP is implemented through the manufacturing subsidiary department of the Pharma Inc. Ideally, the manufacturing subsidiary is termed a ‘primary site’ since it produces active ingredients used in other secondary sites that tablet and package the drugs. One attractive feature in this case study is that previous ERP implementation was only carried out on secondary sites. The manufacturing subsidiary in this case study was the first primary site to be implemented based on the new SAP system. Based on the skills gained in developing the global template, project members were solicited by the Pharma Inc. team to assist in the rollout of other primary sites. The overall level of preparation done by the project team members on the local site was right. The success of the project was encouraged by the fact that other manufacturing sites had already gone live based on the global template of an ERP system (Tan & Payton, 2010, p. 246). Project members understood that their primary objective was to comply with the industry standards in order to withstand any audit from the Food and Drug Administration. From this point of view, the project was seen as a necessary investment to avoid extra costs. All the stakeholders involved agreed in unison that the benefits derived from the ERP system would for the greater good

Health Effects of Water Fluoridation Research Paper

Health Effects of Water Fluoridation - Research Paper Example Questions concerning the health impact of fluoride have been raised by various experts arguing that water fluoridation carries with it significant health risks which may not be easily managed in the long run. This paper will provide an analysis of the health impacts and the current health situation in relation to the use of fluoride in the water, mostly in countries of Central Asia, including Pakistan, India, Sri Lanka, Bangladesh, and Nepal. This analysis is being carried out in order to establish a more thorough understanding of the impact of fluoride on health, details which can help health authorities in their policy-making activities concerning fluoridation of water in these areas. Body In general, fluoride is often added to water as a decontamination agent to remove bacteria and other possible contaminants (Sharma 2003, 1). In various countries, especially in developing countries, this is the only means of filtering their water supply. It is a cheaper and easier option for these territories whose need to decontaminate the water supply is imperative. Other, more developed, countries, have other decontamination processes and options, options which allow them to do away with the fluoridation of their water supply (Fawell, et.al., 2006, 18). In Central Asia, fluoridation of water is a common practice. However, in recent years various health issues in regard to the persistent introduction of fluoride in the water have been raised (Fawell, et.al., 2006, 15). Some of these health issues will be specified below.... It is a cheaper and easier option for these territories whose need to decontaminate the water supply is imperative. Other, more developed, countries, have other decontamination processes and options, options which allow them to do away with the fluoridation of their water supply (Fawell, et.al., 2006, 18). In Central Asia, fluoridation of water is a common practice. However, in recent years various health issues in regard to the persistent introduction of fluoride in the water have been raised (Fawell, et.al., 2006, 15). Some of these health issues will be specified below. Based on an assessment by the British Geological Survey (n.d, 2), fluoride build-up has become significantly apparent in the ground waters of Central Asia and Africa. Countries that have been affected worse include China, India, Sri Lanka, West Africa, and other African and South American territories (British Geological Survey n.d, 2). Fluorosis issues arose in India and became major issues for its various territor ies, including Pradesh and Tamil Nadu. Fluorosis also emerged as a major issue in Sri Lanka and Bangladesh (Fawell et al. 2006, 29). In Pakistan, fluorosis was also seen as a major health issue, and this prompted detailed research studies by the UNICEF on the subject matter (Fawell et al. 2006, 29). In recent years, recommendations on the elimination or at least the reduction of fluoride in the water have been suggested as a healthier option for the decontamination of water. To some extent, the reduction of fluoride use has been implemented; however, undeniably, the health effects of fluoride in water are still persistent. At low concentrations, fluoride is beneficial to the teeth, mostly in helping eliminate teeth decay;

Teachers Day Essay Example for Free

Teachers Day Essay Madam Aishath Adam, Senior Assistant Principal, Supervisors, members of the staff, Teachers and Dear Students. Assalaam Alaikum and Good afternoon. Today, we are here to celebrate great teachers and great teaching. As a fellow teacher, I find awkward to speak about teachers or for teachers. But, first, let me convey to all the teachers, my personal greetings and best wishes on the teachers’ day. Dear Teachers: Though a fellow teacher, I want to say I am proud of you. I am proud of your dedication to the profession and for the personal sacrifices you make to teach our children. I am delighted of your devotion to train their questing minds, and for your inspiration of their hopeful hearts. I am proud that you take this responsibility seriously —that you see it as sacred trust. We celebrate teachers’ day, because we value you. I want to remind you that all the parents, students and the wider community deeply appreciate your commitment to teaching and to the children. There is no substitute for education. Firstly, because it’s the most precious gift we can give our children. Secondly, because it’s the most critical investment in our future. And thirdly, because it’s the most effective strategy which will enable us to survive and to thrive in a changing world. Dear Students: I became a teacher because of some of the happy experiences I had in school. There were teachers who touched my soul; who helped me realize my own potential. I decided to become a teacher because I want to help change someone’s life. Sometimes, it is hard. We have our own families, financial life and life problems that challenge us, like everyone else. Sometimes we are exhausted by our workload and responsibilities. This is why teachers need encouragement and support. So that in turn, we can devote ourselves to our students. Dear staff and students; On Teachers’ Day every year, we remember our teachers, we remember our children’s teachers. We recognize these very dedicated people. People who give of themselves and take a personal interest in their students. Teachers who have touched our  lives, moulded us into what we are today, and are helping to shape tomorrow’s people, tomorrow’s students. Just as a country is as good as its people, so its citizens are only as good as their teachers. Therefore a great deal depends on you, teachers, and I salute you, all of you, those here today, and those absent, for your passion, dedication, commitment and contributions. I wish to all the teachers a successful career in teaching — a career in which you find happiness, health, friendship and love. Happy Teachers’ Day and thank you.

Genetic Engineering: The Controversy of Genetic Screening Essay

The Controversy of Genetic Screening      Ã‚   Craig Ventor of Celera Genomics, Rockville, MD, and Francis Collins of the National Institutes of Health and Wellcome Trust, London, England, simultaneously presented the sequence of human DNA in June of 2000, accomplishing the first major endeavor of the Human Genome Project (HGP) (Ridley 2). As scientists link human characteristics to genes-segments of DNA found on one or more of the 23 human chromosomes-prospects for genetic engineering will increase dramatically. One relatively simple but powerful application of the HGP is genetic screening. By abstracting and analyzing DNA from embryos, fetuses, children or adults, one can detect the presence or absence of specific genes. While some people think of genetic screening as a great scientific and medical advancement, others see it as a frightening and dangerous enterprise. With careful regulation, I believe genetic screening can affect individuals in a beneficial manner.    Pre-natal genetic screening is currently used in high-risk pregnancies for detection of diseases such as Down Syndrome and Huntington's chorea (Ridley 55, 98). As scientists determine the genes for additional genetic conditions, screening of embryos will provide more information to potential parents before their fetus is fully developed. If a screened fetus were found to carry genes for a particular disease or disability, its parents might selectively abort it. Many individuals who believe in pro-choice abortion laws advocate pre-natal screening for genetic diseases because the abortion of fetuses with undesirable traits may decrease the number of unwanted children. Those against abortion strongly oppose pre-natal screening, predicting an increase in abor... ...guidelines could eliminate many of these destructive effects. Pre-natal screening should only test for 'abortion-worthy' diseases determined by a national or international bioethics committee. Children and adults should be screened for particular diseases or conditions when/if family medical histories or physical examinations find reason to do so. With such policies, I believe that genetic screening will beneficially revolutionize obstetric and preventative medicine.    Works Cited Gibbs, Nancy and Michael Duffy. "We Must Proceed With Great Care." Time. Hubbard, Ruth and Elijah Wald. Exploring the Gene Myth. Boston: Beacon Press. Lemonick, Michael P. "Smart Genes?" Time 13 Sept. 1999. Ridley, Matt. Genome: the Autobiography of a Species in 23 Chapters. Perennial. Snell, Marilyn B. "Tempest in a Pill Box." Sierra 85 (2000): 18-19.