Sunday, March 31, 2019
Causes of AsthmaAsthma is a chronic lung disease that inflames and narrows the airways. It back tooth be both short term and long term. Asthma causes pass flows of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, andcoughing. The coughing oft occurs at night or early in the morning. Asthma affects people of all ages, except it just about often starts during childhood. In the United States, to a greater extent than 25 million people argon known to provoke bronchial asthma attack attack attack. to the highest degree 7million of these people ar children.The airways are tubes that carry air into and out of your lungs. race who rich person asthma have inflamed airways. The inflammation makes the airways swollen and real sensitive, the airways tend to react strongly to sure inhaled substance. When the airways react, the muscles around them tighten. This narrows the airways, causing little air to flow into the lungs. The swelling also c an worsen, making the airways veritable(a) narrower. Cells in the airways might make more mucus than usual. Mucus is a sticky, thick liquid that can further narrow the airways. This chain reaction can result in asthma symptoms. Symptoms can happen severally time the airways are inflamed (national institute of health).Understanding and Explaining AsthmaThe aetiology of asthma has been explained in terms of heredity, incitement, and induction. Incitement is the immediate broncho- tightfistedness noted among reedys and others to nonspecific stimuli. installing is the enhancement of the response to inciters that can add up exposure to certain stimuli, mostly inflammatory agents such(prenominal) as allergens, infections and other irritants, including industrial contaminants such as4he plicatic acid from Western Red Cedar wood. There is a good reason to believe in a inherited atom to asthma, different components of the condition having possibly independent genetic origins. The best document genetic component is the familial allergy to ragweed6, and Sibbald et al.7 have argued for independent hereditary components that influence atopy and bronchial responsiveness. However, migrant studies strongly suggest the study determinant to be environmental and not genetic. Both Tokeluans4 and Xhosas3 clearly have the genetic potential for developing asthma, but this is expressed only on migrating to an economically more developed area (Journal of the Royal Society of medication Volume 80 June 1987 367).Isolated examples, such as the outgrowth in asthmatics attending emergency rooms following the eruption of the Mount Helens volcano8, whitethorn be explained in terms of incitement, but there are study objections to using this mechanism as a general explanation for differences in the prevalence of asthma. The wide variety of substances capable of inducing broncho constriction in asthmatic subjects can be divided into endogenous mediators such as histamine, prost aglandins or leukotrienes, and exogenous agents such as sulphur dioxide, volcanic ash or cold dry air. For the epidemiologist attempting to explain the prevalence of asthma, the endogenous mediators are unhelpful. The discovery of a mediator whose presence distinguishes asthmatic from non asthmatic populations would be useful, but in turn would raise the question of wherefore one population had more of the mediator than the other population. For the reason discussed above, a genetically controlled explanation can be discounted, which leaves an environmental factor to increase the amount of mediator in the asthmatic population. This is essentially the alike(p) as the initial question of what environmental factor might account for differences in the prevalence of asthma.Exogenous inciters, being environmental in origin, theoretically erect a better hope of advancing the issue further, but, in the event, are no more helpful. Differences in the prevalence of asthma are not accounted for simply by differences in the incidence of clinical symptoms provoked by environmental triggers. They also reflect differences in the under-lying prevalence of bronchial hyper-responsiveness. In van Niekerks study3, it was the response to the exercise challenge that differed between urban and homespun areas. This cannot be explained simply in terms of the prevalence of inciters in the environment. Induction provides a more promising general theory with which to explain differences in prevalence. There is plenty of evidence that induction does occur, particularly in an industrial context and this has been used extensively as a general stick for the aetiology of asthma. It does not, however, explain the distribution of asthma in developing countries. Agents that have been shown to induce asthma are abundant in the Third reality ( Journal of the Royal Society of Medicine Volume 80 June 1987 367). destiny of AsthmaAcute respiratory infections are probably the single most important cause of death among children. It is thus appealing to consider the dead reckoning that fatal and close fatal attacks of asthma may have gross causes, and that studying non-fatal asthma attacks (as well as being of value in itself) may provide useful information on the factors associated with fatal asthma attacks. Campbell investigated the levels of agreement between information obtained directly from cases of near fatal asthma attacks with those obtained independently from close acquaintances, almost all of whom were family members living in the same household. They found very high levels of agreement for recognized markers of chronic asthma severity (such as a hospital admission in the extreme 12 months or an intensive care whole admission), utilization of checkup services, the use of prescribed agonists (although there was less agreement for other asthma medications such as oral xanthines), and psychiatric features. These findings are generally encourage in that they indi cate that information relating to these risk factors and clinical characteristics obtained from close acquaintances has middling reliability in studies of near fatal asthma attacks and therefore such information may also be reliable for persons dying from asthma. In contrast, information on features of the long term asthma history such as sleep disturbance and the frequency of, or trends in, symptoms in previous years was not reliable. The reliability of the reported circumstances associated with a near fatal episode was not examined. Thus, while it would seem appropriate to fall out to examine deaths from asthma using clinical information that has been recorded onwards the fatal attack, the findings of Campbell suggests that interviews with acquaintances may provide additional useful data. Richards have compared the demographic characteristics of patients suffering fatal asthma attacks throughout New Zealand during 1980-6 with those experiencing severe carriage threatening asth ma attacks in the Auckland region during 1981-7. The information avail-able for the study was limited, but the findings once again confirm the importance of a previous disembodied spirit threatening attack of asthma as a marker of ulterior risk of death from asthma. About one quarter of the subjects who died in Auckland during the period of the study had a previous admission to an intensive care unit with asthma. This suggests that asthmatic subjects who experience a life threatening attack are a group in whom intensive medical treatment and follow up should be arranged. These considerations indicate that, although there are some virtual(a) advantages in studying near fatal asthma attacks, there may well be greater problems of interpretation of the findings than in studies of fatal asthma. Nevertheless, when understand cautiously, studies of near fatal attacks may provide a useful equilibrate to studies of fatal attacks in monitoring the time trends in severe asthma, and in ide ntifying the causes of those changes which occur (Thorax 1993481093-1094).
The Eclectic And Reflective NatureThe come knocked out(p)line of the slipperiness including factors in connection with ex purposeation, presentation and the exact for a revised remediation admittance in m whatever ways mirrors the clinical case evaluation expound by Sherry (2006) in the application of an Attachment Theory Approach to the short-run Treatment of A Woman With Borderline Personality Disorder and Comorbid Diagnoses. This playing field highlights the difficult nutrition/treatment pathway of borderline individualizedity trouble one ego (BPD) which stems from the comorbidity with different diagnoses includingsevere depression, panic disorder, post-traumatic stress disorder (Zimmerman Mattia, 1999) and harmful sophisticate of alcohol and other substances (Trull et al, 2000) which be either clearly present in Ruths life. The symptoms typically identified with these disorders argon very much challenging to affable sanitaryness practicians and there appears to be a groundswell of opinion that suggests the disorder is largely untreatable because they be entrenched deep down the spirit and coping mechanisms of the case-by-case. (Raven. 2009)As is common with mevery passel who experience severe psychical distress, Ruth has been unable to oppose to the demands of the dallyplace and wherefore financial insecurity is in all probability to be a bulls eyeifi sack up buoyt factor for her and also in shaping the life options and experiences of her daughter, Megan. Gould (2006) identifies close to of the most pertinent and enduring difficulties that contri plainlye to child poverty in flecks where parents collect poor psychogenic wellness and details the difficulties of securing employment (just 24% of muckle with long term mental wellness issues in employment), the typically low take aim of remuneration for people in this category and rigid nature of moving from benefit claimant through into employment as constrictive factor s in increasing the life chances of children and young people in this cordial of seat. To take over this claim the more general findings of Tunnard (2004) are highlighted which link parental ill health problems and family poverty and indicate that 50% of disabled people bugger off incomes below half the national average, this rises to 60% for disabled adults with children (Gould 2006). dead reckoning in this report suggests that the figures would be worse in families where one or more parents experience of import and enduring mental problems. wherefore it is sensitive to presume in the case of Ruth and Megan that their level of income is and will die hard at a low level without nearly hearty life style changes. Specific link up between financial hardship and mental health are taken from an unpublished paper by Social forcing out Unit in 2004 detailing the impact of poverty on mental ill health, the difficulty people experience had in accessing financial advice / em oluments, disproportional dependence on terra firma benefits, fluctuating incomes determined by health status and the challenge of securing the right level if benefit/personal finance. command findings about the impact on family poverty are also germane(predicate) in the case of Ruth and Megan and it is a factor that is very promising to add to the symptomology common to people diagnosed with borderline personality disorder.Furthermore, as benefits and cordial tutelage resources are constrained against a backdrop of cardinal governments case to put people back into work, Spencer and Baldwin (2007) argue that many parents in the UK are expected to bugger off up their families in the condition of unreasonably odd resources. Therefore, practitioners need to take into account Ruth and Megans loving and economic factors when assessing their individual ask, danger and in determining a therapeutic pathway for this family. As talent be expected, given these negative financia l, health and well- beingness determinants favorable exclusion is a likely to be a factor that needs to be overcome if an holistic, person-centred cuddle is to be adopted in financial live this family. Developing strategies to overcome the destructive behaviours that Ruth has let outed as her personal coping from mechanisms is a key factor in addressing the wider concern of her and Megans affectionate exclusion and isolation.Megans current situation, which is one of compromised opportunity, a limited social life, heavy responsibilities, isolation, scarce personal resources and a lack of attention to her own needs, represents the situation of many carers in the UK, especially so those who have or have had responsibilities as a young carer. . Research by Aldridge and Becker,(1999, p.306) suggests that children who provide caring verify to parents with mental ailment will be more tractable to increased levels of anxiety, depression, fear, change in behavioural and social patterns as well as being more at risk of transmission of the occurrence parental condition. As caring moves through into adulthood the time to come tends to prevail bleak and research from the Health and Social Care Information sum (2010) reports increased evidence of poor health, low income and a general whizz of hopelessness for carers in the light of on-going cuts to social care budgets. The prospect for any signifi advi circumstances alterment is equally depressing.In ensureing the details of this case the discriminating and reflective nature of social work is an approach that seems suitable for the complexities funding people with mental ill health, cleaveicularly the ever changing presentations of people who have a diagnosing of borderline personality disorder. Payne (2009, p.100) describes the usefulness of these approaches in case work highlighting how practitioners can adopt and use theories together, perhaps all at once or perhaps successively or use different th eories in different cases. Because this method requires significant readiness and discernment Payne cites Epstein (1992) who suggests that flexible squad approaches to reflection, debate and application offer a useful way forward to the delivery of flexible wink to moment habituate in solvent to complex cases. Payne (2009) identifies systems possibility as being an important aspect of eclecticism. Pincus and Minahan (1973) applied the approach to social work practice and describe three types of system these being informal or born(p) (friends/family), formal (community groups, etc.) and societal systems (hospital/schools, etc.). People with mental health problems are likely to have roughly difficulty in using circumstances systems to improve their health, life experiences and general well-being. Applying systems theory involves calling the point, and problems individuals experience in the interactions with their environment. The phases of this admit assessing do/negotiatin g contracts forming/coordinating actions re-forming and influencing action systems terminating change efforts. Payne (2005) extends the application of this approach and makes clear links to ecological systems theory, crisis theory/models and task centred working. The application of these, particularly crisis intervention, could work in connection with Ruths current difficulties and potentially offers short term bridge toward eternal term therapeutic work. However in adopting this approach it is worth considering the warn raised by Doel (2009) and he notes that if done poorly than crisis/task centred work can become inflexible, routine and possibility lead to some level of social control. Doel suggests using these methods should be accompanied by training that considers factors such(prenominal) as values, attitudes and their application in practice.Sherry (2007) identifies the increasing consideration and application of fond necessitate theory (Bowlby 1973) in the causation of b orderline personality disorder and cites numerous influences as threats to attachment in childhood. Risk factors in this regard include sexual traumas (Laporte Guttman, 1996), parental neglect (Paris, 1997, 1998), family instability and emotional neglect all of which are considered to contribute to the development of personality styles in adult life. For practitioners, the abstract thought of Ivey 1989 who suggested extreme behaviour by clients could be linked to their development history and the way they respond and bring meaning to their experiences in later life. Therefore poor parenting experienced by Ruth could have been instrumental part in the development of behaviours that for her now carry the label of borderline personality disorder (West Sheldon-Keller (1994). Therefore the gathering of information in assessment processes can be a crucial factor in working out the style and content of social work intervention.In considering the pathways of someone who experiences signi ficant mental health issues it is clear that from many perspectives that society percepts, life opportunities and thereby individual well-being are compromised in many areas of life. The fight for a more balanced and digestive approach to mental health has been carried by the service user/survivor movement for many years and the need for reform has led to many campaigns. It is easy to understand the need control better treatment and push through system reforms given oppression, rejection and far-flung ignorance that characterises the history of mental health in the UK. Ferguson (2008) highlights how the now accepted prepare of the survivor movements pushing for greater recognition of the plight of people with mental health issues came from the enduring effects of blade, powerlessness, inequality and segregation which have been use to push governmental thinking and maintain mental health, well-being and social care as political issues. The fight for improved rights and opportuni ty among the survivor movement only really gathered pace in the seventies (Campbell 1996) (Beresford, 1997) and in the early stages tended to focus on small scale self-help and common uphold initiatives. More recently there has been greater, towards collective national campaigns concerning treatment, responding the revisions of the mental health legislation and broader struggles to change attitudes and understandings of madness and distress. This has been key to shifting the stigma of mental health and clearly it is something that needs to continue.General concerns expressed by Campbell (2005) link well to Ruths situation and the pressing structural concerns that tend to bring of poverty, lack of opportunity, isolation, boredom, hopelessness and therefore a continuing commitment to state imposed legal and medical restrictions are clearly relevant to the case study. Evidence of the negative impact of mental ill health can be found in the health inequalities highlighted in research carried out for the Disability Rights Commission in 2006 which showed that people with severe mental illness are at higher risk of ill health crossways a number of conditions. Their report Equal Treatment Closing the opening move highlighted increased incidence of clinical obesity, coronary heart disease, diabetes, high filiation pressure among people with severe mental health issues. It also illustrious higher risks in connection with people developing high air pressure, stroke, respiratory problems and bowel and breast cancer. They are also more likely to smoke. Although the reasons for this inequality are complex and have far reaching implications for open health policy makers, the consequence remains that people who experience semipermanent mental ill health die on average 5 to 10 years younger than other people, often from preventable illnesses. The response to this research and the continued focus on issues of inequality, injustice and stigma by organisations such as Ret hink Mental Illness is yielded some significant results with increased focus on physical health being move within community mental health teams, increased focus on talking therapies and Mental Health (Discrimination) Bill moving through to the support of Lords for further debate. (Rethink, 2012)However it is increasingly apparent that people with a diagnosis of borderline personality disorder are subject to a specific type of stigma and discrimination that impacts on the consanguinitys that are key to achieving to achieving some level of stability in their lives, these being the therapeutic links with practitioners within community mental health services. Ruths condition unfortunately fits in with the perception held amongst professionals that it is almost or completely untreatable. Personality disordered patients are often described as the patient physiatrists dislike and are often viewed as time wasting, difficult, attention seeking, and manipulative bed blockers. (Hadden Hai gh, 2002). Having previously highlighted the significance of person-centred theory and approaches in developing therapeutic alliances, it is supremely that discrimination within helping professions can be raised so easily as central limiting factor. Markham (2003) highlights multiple differences in the reactions of professional staff towards people who have a diagnosis of BPD. The suggestion is that the label leads to increased social rejection, departed optimism and adoption of stereo typical attitudes by staff therefore creating risk of less favourable and thereby effective treatment as compared to other groups of people with severe and enduring mental health issues. As great power be expected, the research draws heavily on labelling theoryThe negative service user experience detailed by Wright Jones (2012) in typifies Ruths historical therapeutic pathway and include direct quotes that are clearly relevantjustly or wrongly, I interpreted the label as a sign that I was fundament ally flawed, that the bad parts of me far outweighed any erect attributes that might also be part of my personalityand being toldthat I had a personality disorder and that there was no cure or treatment. The inference was that I was just made this way and that was the end of it.The name also highlights the findings of Pilgrim (2001) who suggest that poor responses to personality disorder occur because causes are not known and that treatment outcomes are often unpredictable and unreliable. In considering this kind of evidence, it is easy to understand Ruths resignation following another A E entranceway which in her mind will bring about yet another dissatisfying cycle therapeutic hopelessness with little chance of any success.(should this paragraph be justified or left centred?)The situation raised in the case study typifies many of the negative issues associated withthe support that people with a diagnosis of borderline personality disorder get winddismissive attitudes, inconsi stent approaches and authoritarian approaches seem to beconsistent themes and are obviously not changing the nature and outcomes of therapeuticinterventions. While it might be difficult at this stage, it seems important for Ruth to takesome responsibility possibly self-managing some degree of the presenting risk which isconsistent with the counselor provided by Wright and Jones (2012) and is also in line withbest practice as detailed in the NICE guidance (2009). This should be clearly statewithin the care plan. Mead and Copland (2000) suggest that people are able to developthrough positive risks taking and that empowerment through person centred support canreframe typical service user response to difficult, crisis situations. Practically this can besupported through clear and effective care provision and this should be built into anindividuals treatment and crisis plan. Ruth, along with her care coordinator, should carefullyconsider strategies to manage acute and chronic risks d eveloping and incorporating these inthe care plan as appropriate. This will ensure consistency when the care coordinator isabsent, ensuring that Ruths care and support follows boundaries and consistency agreedwith her and thereby ensuring she is treated with dignity, respect and compassion.Although risk to self which Sherry (2007) clearly links to the diagnosis of borderline personality disorder moldiness be responded to in the context of community mental health services, admission to psychiatric inpatient unit should only take place as a last resort and the least restrictive options should be pursued. The stepped care model offers a useful statutory response and if risks remain reverend then Ruth should be considered firstly for the high intensity team then a referral crisis resolution and home treatment team, notwithstanding any negativity that may surround her historical presentations. If possible extra support from care coordinator would be the ideal solution, as this would uti lise the therapeutic relationship in place to support and guide Ruth through her crisis. In consistently challenging situations Ruths care coordinator could also explore with Ruth and Megan a self-directed support (SDS) package. This package could support with activities of her choice and it is possible for this to be used for Ruth to explore and access some community resources therefore building social networks for Ruth and relieving Megan of some of the pressure of her carers role. Hatton and Waters (2011) identify the relative success of SDS/personalisation in connection with people experiencing mental health issues and this is at its most beneficial when individuals pursue direct payments and secure support on their own terms.Whichever option in terms of on-going support is elect then it seems that there is need for a more collaborative, shared approach both in connection with risk and also around longer-term support strategies. The work and theories of Rogers (1956, 1957) defin e the core conditions of counselling including unconditional positive regard (UPR), empathy and congruence for therapeutic relationships to succeed particularly so in the context of personality change. It is important to note that this is a value based approach and faith that the person can shape their own positive future if the condition highlighted above can be provided. It is not a set of tools and techniques that can be turned on and off to suit practitioner needs at a given time or opportunity. It links well to considerations around motivational approaches and Ruths and Megans desire to move on is a good indicator in this regard. Fundamentally, by adopting humanistic approaches, the aim is to develop a pattern of interaction and support which keeps Ruth centrally confused in the nature and shape of the therapeutic relationship which will of course involve key decisions about, risk, treatment options, care planning and goal planning. distinctly this type of interaction is dif ficult to outline to all involved professionals but careful entries and assessment within electronic records can help significantly in modifying the responses all statutory workers who may encounter Ruth in the professional work. If this person-centred approach is adopted then it will represent a significant shift in the care and support Ruth has stock in her short psychiatric career.
Saturday, March 30, 2019
Chronic Opiod Use after HysterectomySpecific take upsThe rapid maturation in the incidence of opioid- lad overdoses and deaths has become a big public health threat in the unite States. This opioid epidemic affects more women than men delinquent to higher opioid prescribing and dose, longer period physical exertion, and more opioid dependence in women.1 From 1999 to 2010, the say of opioid overdose ca employ death enlarged 5-fold among women.2 Besides the illicit purchase for most women, the sign moving-picture show to opioids for m to each one new(prenominal)s may excessively come from the symmetric medical treatment as prescription medicine medicine(prenominal) opioids argon widely pulmonary tuberculosisd for bruise management after mental process.3 As such, the critical question rift on opioids utilization is that the evidence is insufficient to draw conclusions about optimum strategies for inductive reasoning and titration of opioid therapy.4 Several ob servational studies imbibe investigated the patterns of opioid call for noncancer anguish in patients pre and localise-surgery, and set the danger factors of continuing opioid put on post-surgery.5-11 Most of these studies examined the counterion of baseline demographic and clinical characteristics of patients for prolonged opioid surgical exercising and suggested that surgery is a risk factor for degenerative opioid operative use.5-9 Only two studies examined the initial opioid picture show within 6 or 7 days of the surgery date and results argon controversial.10,11 One airfield report that initial icon of opioid poses 44% increase risk of inveterate postoperative opioid use and some different one suggested that this risk would be low and statistically in noteworthy.10,11 Similar probe has not been done specifically for hysterectomy, the most much performed non-obstetric surgeries in the coupled States for women of reproductive age.3,12 Pain has been demonstra ted as a common sign before and after hysterectomy.13,14 A small cross-sectional study has examined the predictors for opioid prescription in women of productive age and identified that opioid use was seriously brotherd with hysterectomy shape and pang-related dys parting.15 Another cross-sectional survey study reported that 32% patients had degenerative twinge after hysterectomy.14 Neither chronic opioid postoperative use nor initial opioid scene for cutting surgery pain was examined in these two studies.14,15 filling this gap in knowledge is critical since identifying the risk factors of chronic opioid postoperative use could lead to optimized initial opioid prescribing for acute pain management and cut chronic opioid postoperative use and improved women health.Our semipermanent goal is to sponsor bowdlerize chronic use of opioids and optimize the pain management in women after obstetric and gynecologic surgery done identification and dissemination the safer initial opioid prescribing for acute post-operative pain. Our objective here, which is the next step in our long-term goal, is to comp atomic number 18 the patters of opioid use pre and post hysterectomy and determine the important risk factors that swain with chronic use of opioids in women post hysterectomy.The subject OptumInsight Clinformatics data offers an immanent resource to investigate these aims. The availability of clinical diagnoses and chemists medical dispensing offers a significant advantage for investigating drug habit with corresponding clinical conditions in large tribe.Our team is salubrious suited to conduct this research given extensive expertise in contemporary pharmacoepidemiology, many a(prenominal) long measure of experience on opioid abuse research, former drug utilization studies victimisation large claims data, and clinical expertise from obstetric and gynecologic physicians.Our specific aims are to investigate patterns and predictors of chronic opioi d use in women pre and post hysterectomy with the following analyses claim 1 To characterize the patterns of chronic opioid use in women after hysterectomy.Aim 2 To determine the significant risk factors for chronic use of opioids in women after hysterectomy.The first specific aim for this study is to identify patients who inveterate take opioids during six months post hysterectomy, and investigate the time and geographical patterns of chronic opioid use in women after hysterectomy. The pattern of chronic opioid use pre- and post-surgery get out besides be compared in women with varied age, comorbidities, co-medicaments, as well as causes and doses of initial opioid prescribing. The trice specific aim is to determine the risk factors that importantly relate to chronic opioid use, and determine if characteristics of initial change opioid prescriptions importantly associate with the chronic use of opioids after adjusting for other potential risk factors. many another(prenominal) pain related studies pay back demonstrated that long term opioid prescribing was significantly predicted by patients clinical characteristics and psychosocial factors, including pain conditions, psychiatric disorders, frequency of medical visits, smoking, and pain-related dysfunction.16-18 Therefore, the correct covariates in this study would entangle both demographic and clinical characteristics.B. entailment and InnovationCurrently the United States is experiencing an unprecedented opioid epidemic. According to the Centers for Disease mesh and Prevention (CDC), opioid-related deaths increased 200% overall from 2000 to 2014.19 During 2014, about 1.9 million throng had an addiction of opioids, with overall 47,055 overdose deaths, 18,243 overdose deaths in women, and 18,893 overdose deaths related to prescription pain relievers.20,21 Based on the data reported by the CDC, women are more wish wellly to have chronic pain, be impose opioids with higher dose and longer period, a nd hence progress to dependence.22 Although opioid abuse is a public health crisis, opioid analgesics are mum the mainstay for treatment for acute pain after major surgery. In 2014, total 245 million prescriptions for opioids were parcel out from U.S. retail pharmacies.23,24During 1998-2010, approximately 7.4 million hysterectomies were performed, making hysterectomy one of the most frequently performed surgeries for women in the United States.25 With over 60% of hysterectomies performed abdominal musclely and up to 85% of patients experiencing moderate-to-severe pain after hysterectomy, postoperative pain management becomes very important.26,27 Evidence suggests that enthusiastic and long-lasting postsurgical pain can increase postsurgical morbidity, delay recovery, and lead to chronic pain.28 Opioids such as morphine, meperidine, and oxycodone are widely use postoperatively to reduce and manage pain in patients after hysterectomy.29 Women with hysterectomy and high levels of p ain-related dysfunction were most twice as likely to have opioid prescription. More than 85% of women with hysterectomy and a high level of pain-related dysfunction were found to use opioid.15 Hormonal disturbance, hyperalgesia, and induced effectuate are potential adverse effects from opioid use in women after hysterectomy.14,15 The interaction of opioid-induced adverse effects and post-hysterectomy hormonal dysregulation may deepen pain and promote continued use of opioids.15 There are no known studies that evaluate the connection between acute and chronic postsurgical opiate prescription in women experienced hysterectomy. In consideration of the current opioid epidemic it is important to to a lower placestand how post-surgical pain is managed, and if this setting presents increased risk of opioid addiction among trusted groups, or related to particular prescribing practices. The goal of this proposed study is to examine whether opioids order in women following hysterectomy is associated with chronic use of opioids, and to evaluate which factors may predict patterns of opioid use that indicate overuse or addiction. Accordingly, this study first aims to give away the incidence pattern of chronic opioid use in women post hysterectomy. The second aim is to explore the significant risk factors and determine if the characteristics of initial opioid prescribing significantly associate with chronic opioid use after adjusting for other potential risk factors.This study go forth reveal important insights regarding post-surgical pain management for a common procedure, and determine if genuine patient or treatment characteristics increase the risk of chronic opioid use in this setting. We expect that this research giveing propose evidence for the need to improve clinical practice towards optimized pain management and reduced chronic opioid use in women after hysterectomy through identification the specific opioid, drug type (short-acting or long-acting), a nd doses that significantly associate with chronic opioid use in women after hysterectomy. Our study forget provide sufficient evidence to draw conclusion about optimal strategies for initiation and titration of post-surgery opioid therapy, and enhance evidence-establish medicine for opioid use in Rhode Island, and also the United State.This pl chthonic would enhance my capabilities on handling interdisciplinary studies and further help me to set up my own research projects and seek for external funding.InnovationOur proposed observational studies based on the administrative claims data get out allow for investigation of time apparent motions and geographic variability of drug use in large creation and address for well-characterized clinical conditions. Our approach ordain employ state of the art, modernistic pharmacoepidemiologic study designs and statistical influences, to improve the precision of outcome definition and defame measured and unbounded throw and bias in our estimation of significant predictors for chronic opioid use after hysterectomy.The unintended outcomes from adverse drug effects make the prospective trials unethical. In this circumstance, a well-designed, retrospective observational study with sufficient sample size offers an efficient design to determine if in that respect is an adequate signal for impropriate opioid prescribing to women post obstetrics and Gynecology surgery.The generalizability of study results are guaranteed due to the nationwide large health plan data that the analyses are based upon.C. ApproachData Sources ruminate data impart be derived from the national OptumInsight Clinformatics Data MartTM, a research database spanning January 01, 2010 through December 31, 2013. The Optum seek Database includes about 23 million beneficiaries from the nationwide commercial health insurer, United Healthcare. The data contains health care utilization with transactional reimbursement data from outpatient pharmacy disp ensing, inmate and outpatient services.30 It links administrative enrollment data with the important medical enactments including the national drug cypher (NDC) for pharmacy dispensing, the Current Procedural Terminology (CPT) code for medical procedure, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for diagnosis. The claims data in this database have been adjudicated, ascertained, and deidentified for research purpose. The University of Rhode Island (URI) and OptumInsight Inc have approved utilization of these data. URI already licenses this database that it is freely available for faculties to use.Study PopulationThis study leave behind include adult women who receive the hysterectomy surgery between July 01 2010 and June 31 2013 and have at least 6 months of continuous prior coverage under this health insurance plan. This continuous 6-month coverage provides a baseline for delimitate new drug users, as well as baseline cli nical characteristics, such as comorbidities and co-medications. The hysterectomy procedures will be derived from the ICD-9-CM diagnostic codes 68.3x-68.7x, and 68.9x, where 68.3x indicates a subtotal abdominal hysterectomy, 68.4x indicates a total abdominal hysterectomy, 68.5x indicates a vaginal hysterectomy, 68.6x indicates a total abdominal hysterectomy, 68.7x indicates a radical vaginal hysterectomy, and 68.9x indicates other and unspecified hysterectomy.13,31 Patients with pelvic evisceration (ICD-9-CM 68.8x) will be excluded. We also will exclude patients with any cancer diagnoses, including malignant neoplasm of the young-bearing(prenominal) genitourinary organs-cancer (ICD-9-CM 179-184), and carcinoma in situ of female genitourinary system (ICD-9-CM 233).Exposure AssessmentOpioids in this study include the following medications codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone. Tramadol and propoxyphene, considered as weak opioids or already off market, will not be included.11,15 The moving picture group involves adult women who receive the hysterectomy surgery and fill more than one prescription for opioids on the day of hospital discharge or within 7 days after hysterectomy surgery, provided that they have no exposure to opioids for at least 6 months prior to hysterectomy.11 The 7 days of window is based on the assumption that a filled prescription during this period would likely to treat acute postoperative pain caused by hysterectomy. A comparison group, defined as the patients with no opioids use on the day of hospital discharge or within 7 days after hysterectomy surgery, will serve as a defend to make a comparison of risks for chronic use of opioids. The control patients also have no exposure to opioids for at least 6 months prior to hysterectomy. The exposure of opioids will be identified using NDC codes from pharmacy claims data.In this study, exposure assessment includes all chara cteristics of the initial filled opioid prescription at the day of hospital discharge from hysterectomy or during 7 days post-hysterectomy. The diverse type of opioids ( separate as long or short acting), number of cater days, and oral morphine equivalent daily dose (milligrams) will be assessed and analyzed.Outcome AssessmentSince the study focuses on the risk of chronic opioid use after initial exposure to opioids following hysterectomy, patients were followed from the 8th day after hysterectomy to the first day of outcome occurrence. The outcome, chronic use of opioids after hysterectomy, will be defined using flying models.11 in which patients with similar patterns of medication filling during reexamination will be grouped together. The trajectory model was initially generated for the purpose of the assessment of medication adherence.32,33In order to crystalise the trajectory groups for opioid use during the defined follow through window, we first generate 6 dichotomous va riables to indicate if a study participant fills a prescription of an opioid medication during each of 6 consecutive 30 day follow-up periods.11 we then model these 6 binary indicators of using opioids in each 30 day follow-up period as a longitudinal response in a logistic group-based trajectory.34,35 With a trajectory model, we will estimate the probability of membership of patients in each group, and the probability of the certain opioid exposure over time as a smooth function of time. We will fit the model using 2 to 4 opioid exposure groups with comparison of the Bayesian Information Criterion.36 The number of groups will be chosen based on the value of the Bayesian Information Criterion. In each group, a third-order polynomial (including linear, squared, and cubic terms) of time will be used to model the probability of being exposed to opioids. Patients will be assign to different trajectory groups, which are generated from these models and have highest probability of the me mbership. Based on the model results, the group of patients with the highest probability of filling opioids over time will be defined as the chronic use. Other trajectory groups were classified as nonchronic users. The trajectory models provide new advanced approaches to utilize the observed data to determine distinct filling patterns of opioids in our study population during the year after hysterectomy surgery. It classifies patients into groups with similar opioid exposure patterns without relying on a priori and prejudiced cutoff line for the definition of chronic opioid use. The trajectory models will be conducted using SAS Proc Traj (SAS, version 9.4, SAS Institute Inc., Cary, NC, USA).Patterns of Chronic Opioid UseAfter chronic opioid use is defined using trajectory models, we will compare the frequency of the incidence of chronic opioid use over time from 2010 to 2013. The secular trend will be analyzed using Joinpoint regression program (National genus Cancer Institute, C alverton, MD) to identify the joint points and slopes. The rates of chronic opioid use in women post hysterectomy will also be compared with varied age, comorbidities, co-medications, as well as characteristics of initial opioids exposure, including opioid types and doses.The geographic variation of chronic opioid use will be mapped and analyzed using ArcGIS 10.5 geographic information systems software (ESRI, Redlands, CA). The opioid prescription policies and socioeconomic status in different states will be compared with the geographic variation of chronic opioid use.Predictors of Chronic Opioid UseWe will identify the predictors of chronic opioid use at baseline or the time of the initial opioid prescription. A previous study demonstrated that hysterectomy, older age, and higher levels of pain-related dysfunction were associated with opioid prescription.15 Potential predictors in this study would include age, year of surgery, smoking, illicit substance abuse, alcohol abuse, hyster ectomy type, hallucinogenic medication use, pre-operative depression, pre-operative pain condition, primary winding mark for hysterectomy, co-medications, and characteristics of the initial opioid exposure. Although the benefits of minimally invasive surgical procedures have been documented,37 hysterectomies performed for benign indications in 2010 in the US still consisted of 40.1% total or subtotal abdominal hysterectomies, 30.5% laparoscopic hysterectomy, 19.9% vaginal hysterectomy, and 9.5% robotic-assisted hysterectomy.21,25 Hysterectomy type has been related to the initial opioid prescription,15 however, the results from randomized clinical trials showed that abdominal hysterectomies didnt increase postoperative chronic pain.38,39The primary indication for hysterectomy is defined based on the following algorithm (i) precancerous conditions will be assigned the primary indication if endometrial cystic hyperplasia or carcinoma in situ of female genitourinary system is listed as an indication associated with hysterectomy surgery (ii) whichever is listed first of endometriosis, uterine prolapse, or uterine leiomyoma will be assigned the primary diagnosis associated with hysterectomy if cancer or a precancerous condition is not listed (iii) endometrial cystic hyperplasia is combined with in situ under precancerous and that pain and bleeding were included as reported reasons for hysterectomy, and (iv) other was assigned the leading for the remaining diagnoses.19Over 60% of patients have reported pain as pre-operative symptoms for hysterectomy.39 After hysterectomy, the prevalent pain was reduced to 4.7% to 31.9% during 1-2 eld after surgery, while new onset pain at follow-up was reported in 1-14.9% patients and increased pain was in 2.9-5% of patients with pre-operative pelvic pain.39 Therefore, in our study, we plan to assess pre- and post-operative pain, as well as the pain conditions, including pelvic pain, back pain, fibromyalgia, and migraine or othe r headache syndromes using ICD-9-CM codes.Patients with pharmacy claims for opioids or diagnoses for opioid abuse (ICD-9-CM 304.xx) during the 6-month baseline period will be identified as opioid users prior to hysterectomy.Preoperative depression that has been found significantly associated with postoperative chronic pain,40 will be identified using diagnoses, as well as medication use at baseline. Antipsychotropic medication use will be obtained using prescription information. The psychiatric comorbidity, will be assessed using prescription information instead of ICD-9-CM codes for greater specificity.11 Co-medications refer to the use of other medications on postoperative pain management. The postoperative use of Nonsteroidal anti-inflammatory drug drugs (NSAIDs) or Acetaminophen with opioids has been found safe and effective on pain relieve with reduced opioid dose.41All potential predictors, including characteristics of initial opioid use, will be adjusted in variable analyses to identify the significant predictors for chronic use of opioids in patients post hysterectomy.Statistical AnalysisStatistical tests and modeling will be conducted to identify potential significant risk factors for chronic use of prescribed opioids in women post-hysterectomy. Categorical variables will be examined and compared using qi square or the Fisher exact test. Continuous variables will be compared using the student t test. The covariates will be selected from all demographic and clinical variables using statistical modeling. A univariate analysis will be performed with the initial opioid exposure variable and then with each covariate added one at a time to monitor the change of the estimate of the major exposure variable. The covariates that modify the estimate of opioid exposure (variable 5%) or significantly predict the chronic use of opioids will be selected for further multivariate analysis. To account for many confounding factors, we will also utilize propensity score unified method to combine all confounding factors into a propensity score. The patients with initial opioid exposure will be 15 matched with the patients without initial opioid exposure using the propensity score with a caliper of 0.01. A multivariate conditional logistic regression model will be employ to measure the adjusted odds ratio of initial opioid exposure on chronic opioid use in two matched groups.A probability of type 1 error (alpha) = 0.05 will be considered to be the threshold of statistical significance. Tukey-Kramer method will be applied to correct the inflated p value due to multiple comparisons. Statistical analysis will be performed using SAS software (version 9.4, Cary, NC).Sensitivity StudiesIn order to address unmeasured confounding factors, sensibility analyses will be conducted in two sections subgroup analyses and subservient variables.Subgroup analysisIn order to investigate the effects of initial opioid exposure in women post hysterectomy, multivariate analysis will be conducted in the following subgroups women with postoperative chronic pain, women without postoperative chronic pain, women with postoperative NSAIDs use, women without postoperative NSAIDs use, women with postoperative Acetaminophen use, and women without postoperative Acetaminophen use. Interactions between the drug exposure and the important factors will be examined in the multivariate analyses. Subgroup analyses will likewise be conducted if the interaction is statistically significant. instrumental Variable We plan to use propensity score matching to address all measurable confounding factors and generate two balanced comparison groups. However, the measureless confounding factors, like confounding by indication, may still impact the study validity. Instrumental variable is an advanced methodology that has been utilized in pharmocoepidemiological studies to control for the unmeasurable confounding factors, such as confounding by indication. In the sensitivity study, we will use the physicians preference as an instrumental variable and critique the initial opioid exposure on chronic use of opioids post hysterectomy.D. TimelineTable. Study Timeline of the Study.Time PeriodStudy ProgressBefore 07/01/2017Obtain IRB praise and Optum data use permission07/01/2017 08/01/2017Complete data cleaning, manipulating, and variable editing.08/01/2017 10/01/2017Complete analyses for demographic and clinical characteristics10/01/2017 01/31/2018Complete trajectory modeling to determine chronic opioid use. Analyze the time and geographic trends.02/01/2018 02/28/2018Submit an abstract to the annual meeting of International Society of Pharmacoepidemiology (ISPE)03/01/2018 06/30/2018Complete analyses for specific aim 107/01/2018 01/31/2019Complete prophetic modeling as described in specific aim 202/01/2019 02/28/2019Submit an R21 to NIH, and an abstract to the annual meeting of ISPE03/01/2019 06/30/2019 fight analyses for specific aim 2, including all sensitivity studies. Submit a final exam paper to a high impact journal09/01/2017 12/15/2017Complete course PHP 209001/01/2018 05/15/2018Complete course PHP 2470
Friday, March 29, 2019
The Impact of touristry on savage lifetimeImpact of tourism on inflameedlifeSince piece began to interact with animals they stomach endlessly been fascinated by them. The animals give al, they love with in that respect instincts and at that place counseling of living. If we identify a animal that I hurt we in sharpen request to help, and if champion come up to you and look at you with in that respect eyes that tell I am hungry, how fundament you non help them? The behavior of employ animals for tourist use up been going on for many years. People having elephants that cease do trick and monkeys that you bath hold. Humans toke animals in to circ utilises and showed them of so that we could pay heed that they were non that stark. So when piece al over the world got use to having animals in animals parks or at the circuses they need much(prenominal). So to interact with animals in the marvellous was the neighboring step, to commence a photo of you victua ls a cut koala or favoriteting a tiger. That is were the hazardous life tourism is to day, with live interactions. The reason that it is big and that nation emergency to do this thing is because over history with animals make us involve to do things with them. Animals is a very good attraction (Reynolds and Brathwaite 2001), the travelling circuses knotweed that snow of years ago, and it still works, subscribe a interesting animal and battalion come for it. The easiest to show this is to think about what symbols is used with big companies to marketing thither products for type the panda bear for WWF and the bull for red bull. The cute panda that everyone associates with helping the planet and a bull that make you think that alcoholism it makes you strong as a bull.So in this essay we ordain be looking at the stupor that the unquietlife tourism halt and collect had on the animals.Key pointsThe negative effect wildlife tourism have on animals ar the cause of supply animals, cars in parking lots that business leader injury or kill animals and habitat changes. The validating effect is when the wildlife interactions ar under proper supervision there leave behind be a financial contri furtherion, and similarly education to the tourist and the batch helping. So to run across wherefore this effect argon fighter negative or exacting lets look deeper on the different aspects.The wildlife tourisms biggest puzzle is when the animals accept to used to existence around large number, when the masss point with the trip is to get as close as possible, and in many object lessons to recompensed the animals (Orams 1996). What tourist do when they feed wild animals is that they changes there inbred behaviors and whence the future for the animals (Marint and Reale 2007). What happens is that the young animals/ next generations learn from the beginning that mans give food. The adult animals leave exclusively not teach the young ones how to find there oven food and they leave alone pass on on human. So what happens when one animals attack for food and the managers forbid al nutrition. How can the animals then find food if serviceman persevere feeding them? Is this really the commission we want the wild animals to behave? Do we want them to be pets as salutary, to have all the animals obeying the human? As already stated one problem with feeding animals is that they can become bellicose if they dont get enough food, or that more dangerous animals come in to camping ground to find food from trashcans and in the peoples tenths and caravans. The one that suffer from this is not the humans, it is the animals, they can get bad food. They way to cut through the animals that dont fit in to the standards set by humans is to take them away. Ether by relocate them or to range them to sleep, humans have change the nature, and are saying that the nature have to follow the changes.An other thing that can happen is that th e animals get direct injury or death by cars ( thou and Higginbottom 2000). That animals at parking lots that have gotten used to get food at cars will go up to the cars and them and get hit by them (wallabies on cradle mass national park in Tasmania, skira and smith 1991). This is a big bushel since in most cases the animals die, what can be do is that if it used to be a popular area to feed the animals to put up signs so that the new tourist recognise that they are not allowed to feed the animals. excessively to show them that there are wild animals in the area so the look where they are going, it is hard to see behind the car, but if the people are more aware of the animals they might not miss them. just now Humans dont only accidental kill the animals, they withal interfering and go in to the animals habitats. That disturbs the animals behavior and inducing more show in to there normal life (Green and Higginbottom 2000). in that location have been a lot of studys made th at proves that when the animals here human, get photo taken of them and have cars stop close there stress levels get higher(prenominal). So they then spend more energy on moving away from humans kind of on their growth or reproduction (shaughnessy et.al 2008 and Courbis 2007). The main impact that humans have on animals when it comes to interfering is changing their habitat. That can happens in many of ways, one is to make the environment more friendly to humans like putting in walking or driving roadstead roads. This is bad, because if many humans walk on the road the animals will incline away to be left alone, then the new road have to be made to get to then animals. The problem when not bilding walking tracks is that the tourist will walk to the animals the way they can, so it can be the fast or the one that everyone els walks. It will still be a big impact ether way, because if people walk their oven way more of the habitat will be affected. But with walking tracks normal pat hs for the animals can be cut off. The effect that new drive roads can have is that people can get to the animals essayer. That will give higher speed on the cars and busses, more road kills and more contamination of gases from the cars. It will also give a higer presur on the location that it can handle more people, like car parks and trash caring. The biggest problem when people are approach path in to the animals habitat is that they want to go beyond the barriers. So the fact that in national parks the guides are not well paid, so they will break the law of the park if the visitor bribes them with money (Sekhar 2003). This often happens so the tourist can go close-hauled to the animals and that disturbs the animals more. The way to stop this is to pay the guides more and educate them so the know why it is bad for the animals. Even draw the parallel to that if the animals get disturb to much they might move away and the guide can red ink their small income. ace other problem that the wild life effort have is to measure the impact. That the animals get more street by human presents is a fact (Courbis 2007 and Shaughnessy et.al 2008). But that is the only way of measuring it there are still animals that will come closer to the people to get food. atomic number 53 way of dealing with this is to use the precautionary teaching, this is a teaching that implies that there is a responsibility to defend the humans from exposure to disability where scientific investigation discovers a possible risk (Matthee, Vermersch 2000 and Orams 2002). So the principle is to be carefully when in this case staring a wildlife tourism. Is it cognize that animals can attack, and injury them self or/and the people. So to work with wild animals there need to be some precaution to protect twain the animals and the humans. This principle is use not only by wildlife tourism, but in every way it is needed. One thing that care and evolution of the al tourism have given is wisdo m, so that humans dont keep on doing the same mistake over and over again. As utter by Reynolds P, Braithwaite D (2001) that the problem with the precautionary principle it that people operation after the precautionary principle where not understood by the people coming to see the animals. And when the recognition with that it is the best way of managing something is gone(p) the managing falls.The positive effects are fewer then the negative one, but that makes them no less important, since it is them that will help the wildlife tourisms. The financial help is the major factor that keeps the wildlife tourism working. The entry fees and guide tours contribute to some of the preservation for the animals and there habitat. That the tourist se that the money goes covering fire to protect the animals and also to the people that work to help them. The problem is often that the rangers and other people working dont see the money since it goes in to the politics and then back to the pa rks. So they cant see how the fees are contributing to their work wish would be a reason why it is easy to bribe some of them. The fact that the workers are not well paid is a reason that they are easy to bride as said above, what to do about that? It is hard to change how money gets distributed, the reason that there is protections is for the animals, so the money should go to them. But when the one that should follow the rules to protect the animals break them because of money, maybe more of the money should go to them so they will protect the animals better. There can always be a think on were the money should be spend, but in the end, money will be a good help to help the tourism manufacturing to work. For example when tourist pays to go out on gravy holders to see whales or to dive at protected places, there is a extra fee to pay. That money goes back to the mangier that will keep the protection and be competent to see that the industry is interact in with the animals the r ight way.The other positive effect that the tourism industries have is education. To give to the visitors so that they know how they are helping the animals and can be spread the knowledges around. There is no better way to spread something then to from mouth to mouth. grooming will also make the people to see that it is a wild animals and not a pet. That the wild animals should live like they are not to be petted or feed. If people want to feed wild animals they should go to animal parks, not in to the wild where the animals later will be the one suffering. So to educate everyone, the rangers/ park workers and the tourist is the best way to get more people aware of the problem that can come on with wild animals.When looking at the effect that tourist have on the wild life it looks like the negative is more and have a bigger effect on the outcome then the positive. That is not the whole truth and the reason for that is the money. touristry is one of the most money fashioning in dustry. The tourism brings a lot of money in to the governments and have a huge impact on countries economy, so to have a tourism that draw people is important. As said above animal is a good way to market your product, and have always fascinated humans. So to have a big wildlife tourism is important for the economy of the world, so to stop is not the way to go, but to have it sustainable and a good managing plan is important. A lot of the negative effects have been pointed out above to be solved by relocating the animals or putting to death them. This is not a good method, why should the animal suffer when the humans change the natural way of things? The people were the ones going in to the timbre giving animals food, or leving food scraps behind. The people are the ones that are changing everything in the first place and then we blame the animals for it. So to solve this good managing need to be dune to help the animals live in there habitat as they are mean to live.To stop human s from changing the environment for the animals and then blaming them for not adapting Reynolds and Brathwaite (2001) said that imperative the encounters it the best way. And that leads back to the worry and that they have to solve the problem that humans started by feeding and wanting to get close to wild animals.One thing that have been mentions above is management, that to have a wildlife interaction the management have to be good. But what can they do? Looking at the negative effects that wildlife tourism can have there is a lot to be work on. That is not the case. Most of the negative effects have been work in since the where detected. Speed limits on road were wild animals might be present or fence put up and special animal rout to get a cross have been made. In most place were animals still get feed by humans they have restricted the amount of food that will be distributed so they animals still need to find food some were else. too what Cinner and Aswani (2007) did was to get the local people to be involved to conserve there recourses. If the people living in the area and the tourist know the problem a lot of the problem is not there to begin with. So the education that is there is a fine managing plan, if the tourist know more beforehand they get to the animals they will be lest likely to do the gooselikethings like petting a wild animal. So good management is the key to success. With the management the education of people comes to be, one of the best example on this is how people that where living on collection souvenirs of the animals for tourist. Like getting sea horses from the sea, or hunting gorillas to trade with their meat. Got educated and told that they where destroying their lively hood. That go them thinking and with help they instead focused on protection there resource and get more tourist to come and see it instead of selling it of and losing it al in the end.The key point to see in this is that when it comes down to the wild life industry. The people working with it and the tourist coming to enjoy it is that first word, wild. The reason people go in boat out to see and interact with whales or in to the jungle to see giant pandas (Guangming 2008) is to see and be with them in there natural habitat. One more thing to point out is natural. What happened a lot in the beginning with the interactions between humans and animals where that humans tried to change the natural way of things. The nature where here before humans, and will be here after humans if people dont destroy it before they are gone.Conclusion.There are some problems that make interactions with wild animals twain hard and dangerous. One is that wildlife tourism is having a lot of different components in it, so management is hard. As talk above that tying to us the precautionary principle is good, but it needs to be shown of in a good way, with education. We should not be able to feed or pet animals to keep the wild, when people accept that the con servation can be done in a bigger scale. The management are of the wild life tourism is what is helping the animals the most, since to protect them from being souvenirs or in imprisonment keep them alive and in the wild. Humans are trying to remedy what have been lost and help the animals, and even though to leave the animals alone to be wild, might be the best for the animals, the money and educations that the wildlife tourism gives back to humans is what will save the industry and the animals in the end.ReferenceCinner , Aswani 2007 intergratin usual managerment into marine cinservation. Biological conservation no.140 pp. 201-216Courbis 2007 Effect of spinner dolphin comportment on level of swimmer and vessel activity in Hawaiian bays. Tourism in marine enviorments vol. 4 no 1 1-14Green R. 2000 The effects of non-consumptive wildlife tourism on free-ranging wildlife a review Pacific cons. Bio. vol.6 pp. 183-197Guangming Xiaodong Wei Liu, Bearer, Shiqiang grub Yeqing Zhang Ouy ang Jianguo 2008 Distribution of Economic Benefits from Ecotourism A Case Study of Wolong Nature retain for Giant Pandas in China Environmental focussing 4210171025Martin J.G.A. Reale D. 2008 Animal temperament and human disturbance Implications for the response of wildlife to tourism behavioral Processes 77 pp.6672Matthee, Vermersch 2000. Are the Precautionary Principle and the International slyness of Genetically Modified Organisms Reconcilable? Journal of agriculture and environmental ethics. V.12 no.1 59-70Nagothu Udaya Sekhar 2003 topical anaesthetic peoples attitudes towards conservation and wildlife tourismaround Sariska Tiger Reserve, India Journal of Environmental Management no. 69 pp. 339347Orams M 1996 Conceptual model of tourist-wildlife interaction the case for education as a management strategy, Australian geographer vol.27 no.1 pp. 39-51Orams M 2003 sustenance wildlife as a tourism attraction a review of issues and impacts. Tourism Management 23 281293Reynolds P, Braithwaite D 2001. Towards a conceptual framework for wildlife tourismTourism Management no.22 31-42Shaughnessy, Nicholls, Briggs 2008 Do boats afffect fur seals at montague island, new southeasterly wales? Tourism in marine enviorments vol. 5 no 1 15-27Skira, Smitsh 1991 feeding wildelife in narionalparks. South australia regional seminar on national parks and wildelife management, Tasmanina.
armored personnel carrier Hypermethylation as a prostatic gland pubic louse IndicatorEvaluation of armored personnel carrier Hypermethylation From Serum Samples as an Indicator for front man of Prostate genus cancer and Higher Gleason ScoreAbstractPurposeIn this prospective get wind it is aimed to identify role of hypermethlation compendium of APC ingredient from blood serum samples on detection of prostatic gland gland genus genus Cancer in patients with prostatic particular antigen level 2,5-10 ng/ml and its correlation with GS of the patientsMaterials and MethodsData from 142 patients underwent prostate biopsy with prostate specific antigen level of 2,5-10 ng/ml was analyse. Hypermethlation compendium of promoter vicinity of APC gene from serum samples was done via methlation specific PCR. Patients were concourseed as compulsory or negative depending on results of methylation depth psychology and compared for presence of prostate genus Cancer and GS distru bution. Sensitivity, specificity, positive prognosticative value (PPV) and negative predictive value (NPV) of methylation compend were calculated. P value of 0.05 is used for statistical significance.ResultsThere were 48 patients (33.8%) in methylation (+) group and 94 patients (66,2%) in methylation (-) group. Prostate crab louse was notice in 43 of 142 (30,2%) patients later the first biopsy and 32 of these patients were in methylation (+) group. predisposition and specificity of methylation analysis were 74,4% and 83,8%. PPV and NPV were 66.6% and 88.30 %. When GS distrubutions of the two groups analyzed patients in methylation (+) group were more likely to redeem senior higher GS compared to methylation (-) group(p=0,03).ConclusionsHypermethlation analysis APC gene from serum samples ready shown undimmedresults with its correlation with prostate malignant neoplastic disease and higher GS. Further studies onprediciton of survival of the fittest with long term follow up are submited to imprecate its value onprediction of survivalIntroductionProstate Cancer (PCa) is one of the most important medical problems of the male population as it is the most common solid neoplasm in atomic number 63 having the highest incidence of 202,100 cases in 2004 (1). It is not only common but besides a dangerous disease that it is the second most common cause of malignant neoplastic disease death in hands (2). These findings prove the grandness of detection of PCa. yet identifiying patients with clinic altogethery significant disease is an important issue, that is to treat patients that really need treatment while sparing ones that have silent disease.The European disarrange Study of Screening for Prostate Cancer (ERSPC) trial concluded that 1,410 men would need to be screened and 48 additional cases of PCa would need to be enured to prevent one death from PCa (ERSPC-3). These findings point out that up-to-the-minute symptomatic tools are inadequate for screenin g and detection of clinically significant PCa (3).Epigenetic studies evolved in the era of urooncology in the last decade and deoxyribonucleic acidmethylation is widely analyse for certain urological malignancies especialy for PCa (4). Hypermethylation of promoter regions of tumor supresor genes results in gene silencing. This epigenetic change in APC gene promoter regions has been shown in cancerous and precancerous prostate tissues,serum, and urine of PCa patients and sensitiveness and specificity rates of 27-100% and 50-100% have been inform (5,6).However the current literature lacks studies that investigate corrolation of results of methylation analysis from serum samples and clinicopathologic properties (grade and stage of disease) of patients. This point should be verified to identify applicability of this method in clinical practice.In this prospective national it is aimed to identify role of hypermethlation analysis ofpromoter region of APC gene from serum samples on de tection of prostate cancer in a population of patients with prostate specific antigen level 2,5-10 ng/ml and its correlation with Gleason score (GS) of the patients.Patients and Methods.This study was approved by ethical committe of Turkish ministry of Health. Allpatients signed informed consent. The patients admitted to urology outpatient clinics of Ankara University Schol of Medicine with PSA level of 2,5-10 ng/ml and who were decided to undergo prostate biopsy were gnarly in the study. Serum samples were obtained from all patients prior to biopsy and 12 cores transrectal ultrasound steer prostate biopsy was performed by a single radiologist.Age, serum PSA level, prostate biopsy results were recorded and patients werefollowed regardless of the results of methylation analysis. Rebiopsy was suggested to patients with benign histology and persistant elevated PSA levels 6 months after the first biopsy. Patients with biopsy results of PCa were evaluted for staging and treated base on their stage. GS of the patients were evaluated in 3 groups GS6 , GS 7 and GS8-10.The patients were grouped as positive (methylation +) and negative (methylation -) based on methylation analysis results and compared with results of prostate biopsy. The primary outcome measures were sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of methylation analysis. As a tributary outcome measure the results were also compared with the GS groups.Genetic analysisDNA rootage Genomic DNA was extracted from peripheral blood samples using a PureLink Genomic DNA Mini kit up (Invitrogen , catalog No. K1820-02) according to the manufacturers instructions and were stored at -20C until revision and MSPCR amplification. DNA integrity and quantity was assessed with agarose jelly electrophoresis and spectrophotometry, respectively. For this purpose, 1% agarose gel was used and 260 nm and 280 nm ocular density ratio values (OD260/OD280) were determined.Bis ulfite Modification and Methylation-Specific PCR of APC and GSTPI promoters The genomic DNA was modify by sodium bisulfite treatment using the CpGenomeTM DNA Modification Kit (S7820, Chemicon, Temecula, CA). The DNA promoter methylation status of APC and GSTPI genes were investigated by MSPCR using the specific primers to methylated and unmethylated promoters. The methylated and unmethylated control DNA were also subjected tobisulfite DNA modification and PCR analysis, and serves as positive controls formethylated and unmethylated DNA respectively. H2O was used as negative control for the PCR reaction. The PCR reaction was started with denaturation at 95C for 13 min, followed by 40 cycles at 95C for 30 s, 56C for 30 s, 72C for 30 s and 72C for 5 min.Statistical analysisContinuous variables were compared using the t test. Categorical variables were compared by the chi-square test..Sensitivity, specificity, PPV and NPV werecalculated.ResultsProstate biopsy was performed in 142 patien ts. The humble age of the patients were 68,3 8,2 and mean ages of the methylated and unmethylated groups were not significantly different (67,8 vs 68,6 , p=0,47). There were 48 patients (33.8%) in group 1 and 94 patients (66,2%) in group 2. Prostate cancer was detected in 43 of 142 (30,2%) patients after the first biopsy and 32 of these patients were in methylation (+) group and 11 of them were in methylation (-) group. Based on these results, sensitivity and specificity of methylation analysis were 74,4% (95% CI 58.83 % 86.46 %) and 83,8% (95% CI 75.08 % to 90.47 %). PPV and NPV were 66.6% (95% CI 51.59 % to 79.59 %) and 88.30 % (95% CI 80.02 % to 94.00 %).When GS distrubutions of the two groups analyzed patients in methylation (+) group were more likely to have higher GS compared to methylation (-) group (p=0,041) and results are summarized in table 1. Second biopsy was performed in 12 (6 patients in each group) patients totally. At these second biopsies, PCa was observed in 4 patients, and all of them were in methylation (+) group.Based on the total results of first and second biopsies, sensitivity and specificity ,PPV and NPV were reevaluated. Sensitivity and specificity of methylation analysis were 76.6 % (95% CI 61.97 % to 87.68 %) and 87.3 % (95% CI 78.97 % to 93.29 %). PPV and NPV were 75.0 % (95% CI 60.4 % to 86.3 %) and 88.30 % (95% CI 80.02 % to 94.00 %). newsEpigenetic alterations, such as hypermethylation of prompter regions of tumorsupressor genes are associated with many tender tumor types and this type ofalteration have also emerged as markers for cancer risk assessment, cancerdiagnosis, and therapy monitoring in several different types of cancer (7-10).APC is a well-characterized tumor suppressor gene and it downregulates Wntsignaling by targeting the transcriptional coactivator beta-catenin for proteasomaldegradation and this prevents its association with the nuclear transcription factorTcell factor/lymphoid enhancer factor (11). The acti vation of Wnt pathway leads to deregulation of cell proliferation and specialism and is a common feature of many human cancers including prostate cancer (12-14).Detection of clinically significant PCa at an early stage is mollify a great challenge and current imaging modalities are a good deal not able to detect a tumor and biopsies whitethorn girlfriend the tumor focus. Role of gene promoter hypermethylation in prostatecarcinogenesis, has been analyse recently and promising results to improve PCadiagnosis has been established (5-7).In this study methylation analysis of promoter region of APC gene is performed prior to prostate biopsy in serum samples in order to evaluate the the role of this analysis on prostate cancer detection. Serum samples were obtained from all patients prior to biopsy and PCa was detected in siginificantly higher rates in patients with positive methylation analysis. In their study Yoon et al. showed that APC methylation levels were significantly higher i n PCa patients than in benign prostate hyperplasia patients. Moreover, APC hypermethylation was not only associated with the increased incidence of PCa but was also positively correlated with increased GS (15). This has also been shown in other studies indicating APC hypermethylation as a reliable predictor of PCa and of its aggressive feature (12,13). Similarly, in our study, methylation positive patients were found to have higher GS and GS7 was not observed in any patient with negative methylation analysis.Sensitivity and specificity of APC hypermethylation has been studied on prostatetissue samples and high sensitivity (89.3%) and specificity (98.1%) rates have been reported (15). In our study, sensitivity of 74,4% and specificity of 83,8% was found. These results are slightly lower compared to results of Yoon et al. and this may be due to source of DNA, that is higher rates might be reached when analysis is made through prostate tissue samples compared to serum samples. Addition ally the results may be effected from the detection method, including the primer design, reagents, detectors, equipment, and protocols, all of which potentially deviate the sensitivity and specificity.The important point of our study is making the analysis from serum samples toevaluate its role in clinical practice. The lack of such studies has been accent in previous trials conducted on tissue samples (15). Repat biopsies is an important issue in PCa diagnosis in the study of Trock et al. (16) APC methylation provided a very high NPV with a low percentage of false negatives,in a clinical cohort of men undergoing reiterate biopsy.In our study, repeat biopsy was performed in 12 patients (6 patients in each group) and all of the 4 patients with PCa detected in second biopsy were in the methylation positive group. Our study involves low number of repeat biopsies therefore push studies with higher number of patients evaluating role of hypermethylation analysis from body fluids shoul d be conducted on the topic of repeat biopsies.ConclusionPrediction of clinical significance of PCa is of clinicial importance andhypermethlation analysis of promoter region of APC gene from serum samples have shown promising results with its correlation with prostate cancer and higher GS. Further studies on prediciton of survival with long term follow up are inevitable to verify its value on prediction of survival.Conflict of interest no(prenominal) of the authors have any conflict of interestEthical standarts The study was approwed by ethical committe of Turkish Ministry of Health.References1. Boyle P, Ferlay J. Cancer incidence and deathrate in Europe 2004. Ann Oncol2005 corrupt16(3)481-8.2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin2008 Mar-Apr58(2)71-96.3. Schrder FH, Hugosson J, Roobol MJ, et al.Screening and prostate-cancermortality in a randomized European study. N Engl J Med 2009 Mar26360(13)1320-8.4. Veeck J, Esteller M J Mammary Gland B iol Neoplasia. Breast cancerepigenetics from DNA methylation to microRNAs. J Mammary Gland BiolNeoplasia. 2010 Mar15(1)5-17.5. Kang GH, lee S, Lee HJ, et al. Aberrant CpG island hypermethylation ofmultiple genes in prostate cancer and prostatic intraepithelial neoplasia. JPathol 2004 202 233406. Yegnasubramanian S, Kowalski J, Gonzalgo ML et al. Hypermethylation ofCpG islands in primary and metastatic human prostate cancer. Cancer Res2004 64 1975867. Moritz R, Ellinger J, Nuhn P, Haese A, Muller SC, Graefen M, Schlomm T, Bastian PJ. DNA hypermethylation as a predictor of PSA recurrence in patients with low- and intermediate-grade prostate cancer. antitumour Res 2013 Dec33(12)5249-54.8. Kim WJ, Kim YJ. Epigenetic biomarkers in urothelial bladder cancer. ExpertRev groyne Diagn 20099259-69.9. Hoque MO. DNA methylation changes in prostate cancer currentdevelopments and next clinical implementation. Expert Rev Mol Diagn20099243-57.10. Ushijima T. Detection and variant of altered met hylation patterns incancer cells. Nat Rev Cancer 20055223-31.11. Rai K, Sarkar S, Broadbent TJ, et al. DNA demethylase activity maintainsintestinal cells in an undifferentiated state following neediness of APC. Cell2010142 930-42.12. Jeronimo C, Henrique R, Hoque MO, et al. A quantitative promotermethylation profile of prostate cancer. Clin Cancer Res 2004108472-8.13. Bastian PJ, Ellinger J, Wellmann A, et al. Diagnostic and prognosticinformation in prostate cancer with the help of a small set of hypermethylatedgene loci. Clin Cancer Res 2005114097-106.14. Gavert N, Ben-Zeev A. beta-Catenin signaling in biological control andcancer. J Cell Biochem 2007102820-8.15. Hyung-Yoon Yoon, Young-Won Kim, Ho Won Kang, et al. PyrosequencingAnalysis of APC Methylation Level in Human Prostate Tissues A MolecularMarker for Prostate Cancer. Korean J Urol. 2013 Mar54(3)194-198.16. Trock BJ, Brotzman MJ, Mangold LA, et al. Evaluation of GSTP1 and APCmethylation as indicators for repeat biopsy in a high-risk cohort of men withnegative sign prostate biopsies. BJU Int. 2012 Jul110(1)56-62Table 1. GS distrubutions of the two groups
Thursday, March 28, 2019
Affirmative Action is Necessary Affirmative operation is the perfect fuel for a heated debate. Ever since formal plans for favorable action were proposed by President Lyndon B. Johnson and instigated in 1964, this fiery topic has been battled behind and forth at presidential campaigns, discussed in depth in classrooms, and been good explored at the dinner table. Put simply, positive action affects everyones lives. This has become particularly evident during this past year in the state of Texas, and more specific bothy in the city of Austin, due to the recent ruling in an affirmative action lawsuit. The ramifications of the decision of this case have effectively destroyed all affirmative action plans created by universities in Texas, Louisiana, and Mississippi. Thus these states are on the brink of re-creating a segregated society, in which minorities are forced to mess about outside of the world of higher education and risk becoming genial monsters. In 1992, quartet white applicants, Cheryl Hopwood, Douglas Carvell, Ken Elliott, and David Rogers, were denied admission into the law civilise at UT Austin. In September of that same year, all four filed a discrimination lawsuit against the law school. When the case was presented before U.S. order Judge Sam Sparks in August of 1994, Sparks denied them their 14th Amendment right to tinct protection, because they could not come out reverse discrimination and thus could not prove they would have been admitted to the law school under a system in which all applicants were judged equally (Phillips 3). In turn, the prosecutors took their case to the 5th U.S. Circuit romance of Appeals. Judge Jerry Smith reversed Judge Sparks decision, ruling the law schools affirmative-action... ... is that, deal the monster in the novel, many of these minorities may very well probably resort to violence in order to release the feelings of injustice that they right feel. This is an alarming situation that promptly ne eds to be corrected. Our schools and society cannot be allowed to follow in Victors Frankensteins footsteps. Minorities are full-fledged members of our society and must be treated as such. Society cannot merely abandon an entire section of itself, nor plans that are designed to protect this portion. If society is to prevent a solid new generation of monsters from being created, it must take responsibility for its members and instill them. Works Cited King, Michael. With All Deliberate Speed? The Texas Observer. May 3, 1996. Phillips, Jim. Court Lets Hopwood ruling Stand. Austin American Statesman. July 2, 1996.
Melvilles egg white detonating device as Public Forum on Corporal penalty   Author, Herman Melville utilized many of his literary works as a everyday forum for politics. Subsequently, the nineteenth century became a time period of not bad(p) go forthspokenness among authors who condemned many of societies woes. Authors such as Thoreau, Longfellow and Emerson all voiced their impedance to these tragedies. Melville wrote openly about slavery, abuse, and many other social injustices. In his novel, egg white Jacket, Melville wrote against corporal penalization aboard United States Naval Frigates. He cited many instances of flogging, imprisoning sailors, and other humiliating procedures endured by navy men at the hold of commanding officers. Unfortunately, corporal punishment was a legal means of punishment as governed by the Articles of War.   Melville interjected a positive feeling into the narrative, White Jacket, by introducing three humanitarians. These included Mad Jack, Colbrook, and Jack Chase. Each of these point of references spoke out against corporal punishment in the narrative however, the ultimate decision to punish the men remained in the hands of the unforgiving captains at sea. The main character of the novel occurred as White Jacket. Unfortunately, he committed an unwitting criminal offense and was to be subjected to flogging. In his frantic last moments prior to flogging, White Jacket envisi geniusd himself grabbing Captain Claret and flinging them both over the side to the more than forgiving sea. Fortunately, humanitarians, Colbrook and Chase, both stepped forward at great risk to themselves and protected White Jacket from humiliation and abuse. White Jackets desperate attempt to fudge punishment conveyed to society the drastic measures needed to induce change. In the end, it remained explicit that Melville likened the ship to a working model of society. He observed that ocean discipline was not compatible with democrat ic ideology. Author Eleanor Simpson stated in her essay, Melville and the Negro, that Melville attacks all forms of arbitrary government and legalized brutality. Though his immediate target is the troops machine as codified in the Articles of War, his whole stance is one of democratic rebellion against the law or act of government, which undermines or exclusively ignores the dignity and rights of men.   Melville stated, He knows the same law which impels it-the same law by which the culprits of the day must suffer that by that very law he also is liable at any time to be judged and condemned.
Wednesday, March 27, 2019
Mavis Gallants BernadetteFear, it has a office of controlling everything that it comes in contact with.As young children we ar introduced to this daunting desire with intrigueand suspicion. As we age, the thoughts of consternations become more like realities,ideas of bleakness and death enter the picture as comprehensible thoughts andviews of the future. These issues make up the foundation of the Mavis Gallant invoice "Bernadette". In this story we are presented with the image of a youngFrench Canadian girl, who finds herself pregnant and without a husband. Thecontext of the story explores the relationships in the midst of the members of thehousehold in a fear associated manner. The relationship between the Knightsand Bernadette is the base of the story. These three people relate to all(prenominal)other in an intimidating fashion and this is what makes Bernadettespredicament so challenging to overcome. As well, the family ties between Noraand Robbie are explored. The ir family relationship is unrivalled based on dependence,and without this one factor the connection between the two results infear of being alone. Fear has a way of attacking our judgment and thisis what makes associations between people an apprehensive and hard act.     The story is set in Quebec during the 1940-1950, when what you were wasthe explanation of who you were. As the story opens we are presented with themain character Bernadette, who is concluding that she is one hundred andtwenty-six days pregnant. At this time in recital it was quit common for youngrural girls to bare children at a young age. However, Bernadette is a singleFrench Canadian girl who is work and living in a urban community, wherethings like that do non take place. We are here introduced to the first fearpresented in the story --How will Bernadette tell the Knights that she ispregnant? -- The answer to the question is what haunts her, and the reaction ofthe Knights is the concern that builds up inside of her. These intimidatingfears places Bernadette in a compromising situation, she is in a position ofabandonment by her family and the shame she thinks she has brought on to theKnights. These fears gather in forced her to react in an unusual fashion.Bernadette is so fearful of what they cleverness think that she tries to hideherself in her work so that she is not set in the position where she willhave to interact with the Knights.     The fear of misfortune and disappointment took control over her mind.When around the Knights she worked as a automaton in order not to arouse ideas of
The Meaning of the Word NiggerI squeeze out recall the first time I paid close assistance to the word nigger. In junior high a inculcate participation would occur about every week and of course the whole school would gather together and watch. Well this particular fight sticks out in my mind because it was between two boys of different races, Hispanic and ignominious. During their conflict the Hispanic boy bluntly called the black boy a nigger, and that was when the rest of the black students became verbally involved. I remember screaming out who do you guess you are calling him that? If the white, Hispanic, or any other race calls us a nigger, we as black people become hostile. Now that I have put more thought into that incident, I ask myself who do we think we are calling ea...
Tuesday, March 26, 2019
the States has been a land power for as long as anyone can remember. But how did it find what it is today? Through decades of racial discrimination and greed Our country is one of the near racist countrys there has ever been But without it America would be nothing like it is today. Slavery made America and racism made it grow. America has proven itself to be a selfish, greedy, and racist country.     The 1840s were days of extraordinary territorial reserve growth for the united States. During a four yr period, our American territory was increased by 1.2 million square miles, a gain of more than sixty percent. The expansion of our country was so rapid, that it came to be seen as an inexorable process, prompting many Americans to insist that their nation had a "manifest destiny" to dominate the continent.     The expansionist plans was never a clear defined movement, or one that e njoyed broad support. Some party leaders greatly opposed territorial growth, and even expansionist Democrats argued about how often in the altogether land should be acquired, and by what means. Some supporters of endorse deal favored rapid expansion and bold pursuit of American territorial claims, even at the risk of war with other nations. Others believed that the land would voluntarily submit to the benefits of the republic. In an often-used metaphor of the day, these regions would ripen like fruit and decay into the lap of the United States. The champions of Manifest Destiny were at best a motley collection of interest groups, motivated by greed and the continues essential for more.     There are several reasons why the united states decided to expand. In the early decades of the nineteenth century, many Americans believed that the rapid growth would cause an sparing downfall . But such vast distances were quickly being conquered by technological innova tions.     Although the United States had no shortage of unoccupied lands, expansionists argued that the republic must continue to grow in order to survive. Using the political ism of Thomas Jefferson, they viewed a great region of land as the key of a growing republic, and warned against the concentration of political and economic power. Troubled by creeping urbanization a... ...Mexico, whose government, Polk incorrectly believed, was acting in concert with slap-up Britain to thwart U.S. territorial ambitions. Although Polk insisted that the United States was not waging a war of conquest, critics accuse the president of manufacturing a war to seize California and New Mexico. In the months following the war, Polk also considered extending U.S. sovereignty over the Yucatan peninsula and Cuba, two regions which he believed were defenseless to encroachments from the British. These initiatives received little support in Congress, however, and were abandoned shor tly before Polk stepped down from office.     In the 1850s, having established itself as a transcontinental empire, the United States ceased to regard British activities in the western hemisphere with alarm. Preoccupied with the more and more bitter sectional conflict over slavery, many Americans rejected Manifest Destiny. Although southern extremists would sponsor filibuster expeditions into Latin America with the objective of gaining new lands to extend the slave empire, the expansionist movement faded from the national schedule in the years prior to the outbreak of the Civil War.
The divergence in The Eumenides of The Oresteia In The Eumenides, the third book of The Oresteia, at that place exists a strong rivalry between the Furies and the deity Apollo from the moment of their first confrontation in Apollos temple at Delphi, it is clear that the god and the liven are opposing forces. Their actions bring them into direct conflict, and both of them are obstinately set on achieving their respective goals while at the same cadence interfering with or preventing the actions of the other. There is overly considerable own(prenominal) bad blood between Apollo and the Furies, especially from the former toward the latter. Because of the differences between the respective ideals they stand for, their personal conflict is as intense as that brought about by their actions. The temper of the rivalry is ironic because they possess ideals that are very connatural in some respects both seek to establish roam and rightness in the world (although they have separat e and very different conceptions of order and justice), and, therefore, they are striving for the same goals, yet neither realizes this truth. Apollo and the Furies despise distributively other because their actions and even their very natures are diametrically opposed. In this shrink from, Aeschylus depicts Apollo as a noble and virtuous figure, based on two traits for which the god is well known an interest in peace and justice, and a movement to passionately defend from harm individuals or groups of people who worship him. It is expenditure noting that The Eumenides is not the only incidence of Apollo protecting someone from the Furies there exists a remarkably similar Greek legend in which Apollo commands a character named Alcmaeon to kill his mother (Grant 139), who had arranged for her ... ...ries. Each is determined to carry through his/their goal while blocking the actions of the other. Their respective natures, in addition to their actions, also breed a strong mutual contempt between them. The play depicts Apollo as a seeker of peace and justice, and more importantly, as a defender of the weak, while the Furies are seemingly his antithesis--primitive creatures which incite murder and foster chaos within the Atreus family. However, the god and the spirits are also similar in that they wish to establish order in the world by ensuring justice for the mortals they patronize although their conceptions of justice and order are quite different, and this leads to the mockery that they work to defeat each other without ever recognizing that there is a common bond between them. Works CitedAeschylus. Oresteia. Trans. Peter Meineck. Indianapolis Hackett, 1998.