Cognitive And Dialectical Behaviour Therapy Borderline Personality Disorder Nursing Essay

Cognitive And Dialectical Behaviour Therapy Borderline Personality Disorder Nursing Essay AIM: To give a brief history of Borderline Personality Disorder and research the effectiveness of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy. Method: A review of the literature and review of controlled trials and uncontrolled trials. Conclusion: In the management of Borderline Personality Disorder, there are many problems to consider, out of these problems self-harm and suicidal tendencies are considered the most important to treat. Chapter 1 Introduction 1.0 Despite the many treatment options for people with Borderline Personality Disorder (BPD), many professionals in mental health services continue to believe that personality disorders are untreatable. This essay provides evidence the effectiveness of Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) with Borderline Personality Disorder. Background To understand BPD, I will attempt to give a historical overview of BPD. Philippe Pinel in the 1800s, first described people who engage in deviant behaviour, but with no signs of thought disorder such as hallucinations or delusions as mania without delirium or in French manie sans delire (Friedel, 2004). Although the meaning of the term has changed through many writings on the subject over time, the writing of Cleckley and his use of the label psychopath in The Mask of Sanity brought the term into accepted usage (Meloy, 1998). The Mask of Sanity is a book written by Hervey Cleckley first published in 1941; he gave the most significant clinical description of psychopathy in the 20th century. An expanded edition of the book was published in 1982, when the name was changed from psychopathy to Personality Disorder. In 1972, newer editions of the book reflected a closer alliance with Kernbergss (1984) borderline level of personality organization, in particular defining the structural criteria of the psychopaths identity integration, defensive operations and re ality testing. The diagnosis borderline was introduced in the 1930s to label patients with problems that seemed to fall somewhere in between neurosis and psychosis (Stern, 1938). Adolph Stern a psychoanalyst described the symptoms, which are now considered to be the criteria of BPD. He suggested the possible causes and what he thought the most successful psychotherapy treatments were. He renamed the disorder, by referring to patients with symptoms as the borderline group (Friedel, 2004). In 1940, the psychoanalyst Robert Knight introduced his explanation theory of borderline disorder. Ego or sense of self psychology deals with mental function, which allows us to effectively combine our thoughts and to develop helpful responses to our life around us. He stated that people with BPD have impairments in a lot of of these functions, and he referred to them as borderline states (Friedel 2004). The next important input was made by the psychoanalyst Otto Kernberg (1967); he introduced the term borderline personality organisation. He proposed that mental disorders were determined by three distinctive personality organisations: psychotic, neurotic and borderline personality. Kernberg has been a strong promoter of modified psychoanalytic therapy for patients with borderline disorder (Friedel 2004). The first research on BPD was published by Roy Grinker in 1968, which he called Borderline Syndrome (Friedel 2004). The next major article was published in 1975 by Gunderson and Singer. They defined the major characteristics of BPD. Gunderson then went on to publish a research instrument to enable an accurate diagnosis. Internationally researchers were then able to verify the validity and integrity of BPD (Friedel, 2004). This followed with BPD becoming a genuine psychiatric diagnosis and appeared in the DSM-111 in 1980. Personality disorder categories are not firmly grounded in theory, nor are they empirically based (Livesley, 1998). Some critics say that personality disorder categories are so flawed that the best option is to abolish them and start afresh, but most pragmatists recognise that so much has been invested in them that they are very likely here to stay (Blackburn 2000a; Livesley, 1998). The Nice Guidelines for Personality Disorder (2009) state that borderline personality disorder is associated with significant impairment, especially in relation to the capacity to sustain stable relationships as a result of personal and emotional instability (NICE 2009). The severity of the symptoms, are related to the severity of the individuals personal/social situations. Stone (1993) argues that some people with BPD can still function at high levels in their lives and careers. Paris (1994) stated that about one-third of patients with BPD reported severe abuse involving an incestuous perpetrator; about one-third reported milder forms of abuse; and about one-third do not report abuse. Personality disorders are common conditions; studies indicate prevalence of 10-13% of the adult population in the community and are more common among younger age groups (24-44 yrs) and equally distributed between males and females. However, the sex ratio for specific types of personality disorder is variable e.g. antisocial personality disorder is more common among males, and borderline personality disorder more common amongst females (DOH 2003). Cognitive Behaviour Therapy (CBT) can be seen as an umbrella term for many different therapies that share some common elements. The earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Aaron T.Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today. One specific form of cognitive-behavioural therapy is dialectical behaviour therapy (DBT), a broad-based, cognitive-behavioural programme developed specifically to reduce self-harm in women with borderline personality disorders (Linehan, 1993a; Linehan 1993b). Recent research has shown that dialectical behaviour therapy (DBT) is one of the first therapies that have demonstrated to be effective for treating borderline personality disorder as well as being effective in treating people who display varied symptoms and behaviours associated with mood disorders, including self-harm. DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of mindful-awareness, distress tolerance, and acceptance. 1.2 Rationale As a mental health nurse coming from a forensic background, I have experience of working with clients with personality disorder. I feel that by getting more of an understanding of CBT interventions, it will make a huge difference to my future practice in the future. McKenna et al (1999) state that it is unacceptable for health care not to be based on sound evidence of its effectiveness, and back up their practice with research-based evidence (NMC, 2008) to ensure effective clinical practice. Often nurses find it frustrating working with disorders of personality. These clients can be manipulative, socially inappropriate and difficult, for these reasons, such clients need all the patience and skills nurses have to offer. But despite this service in the NHS, services have been varied and inconsistent (DoH, 2003). Besides functional impairment and emotional distress, borderline personality disorder is also associated with significant financial costs to the healthcare system, social servi ces and the wider society (NICE 2009). 1.3 Aims and objectives The aims and objectives of this project are to review the evidence on the efficacy of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy with people who have Borderline Personality. 1.4 Methodology and parameters This literature review was conducted using the following resources Electronic databases: Cochrane library, CINHAL, Medline, Psychinfo, Psychology and Behavioural Sciences and Academic Search Premier Key journals were hand searched: British Journal of Psychiatry, Journal of Personality Disorders, Mental Health Practice, Journal of Personality and Mental Health University and Trust libraries Google Google scholar The following types of literature were sought and reviewed where available Randomised control trials Systematic and structured review Quantitative and Qualitative research studies Position statements/guidelines from professional bodies Government policies (NICE (2009), NSF (1999) Text Books Inclusion and exclusion criteria Eligibility for this review was determined by the following criteria: à ¢-  Participants: adults with BPD (diagnosed according to DSM-III/DSM-III-R, DSM-IV, DSM-IV-TR or ICD-10 criteria for BPD), with or without co-morbidity. à ¢-  Intervention: psychological therapies, including CBT, DBT à ¢-  Comparators: CBT/DBT or treatment as usual à ¢-  Outcomes: self-harm, suicide, interpersonal and social functioning à ¢-  Study type: published papers were assessed according to the accepted hierarchy of evidence, whereby systematic reviews of RCTs are taken to be the most authoritative forms of evidence, with uncontrolled observational studies the least authoritative. à ¢-  Exclusion criteria: papers on personality disorder without separate BPD subgroup analyses. The studies were obtained through a number of sources, as above. Searches were performed by entering the key words Borderline Personality Disorder, Cognitive behaviour therapy into several databases, which yielded many secondary references of current best evidence. Search filters developed consisted of a combination of subject headings. The topic-specific filters were combined with appropriate research design filters developed for systematic reviews, RCTs and other appropriate research designs. These articles were selected after careful reading of the title and abstract to identify the most useful. I then limited my search to full articles which made my search a lot easier. The definitive text that will be used to aid my search will be NICE Clinical Guidelines for Personality disorder 78. This guideline makes recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) who meet criteria for the diagnosis in prim ary, secondary and tertiary care (NICE, 2009). BPD is present in 1% of the population, and is most frequent in early adulthood. Women present to services more often than men. BPD is not often formally diagnosed before the age of 18, but the features of the disorder can be identified earlier. Its path is changeable but many people do recover (NICE 2009). This search will comprise both British and international articles. When choosing which articles were going to be relevant, I found it impossible to ignore the amount of articles I had on DBT and as DBT was evolved from CBT and made specifically for BPD, I decided to bring it into my research project. The articles are mixed quantitative and qualitative research. The qualitative means of gathering subjective data is centred on an individuals experience, beliefs, empowerment and quality of care and does not solely concentrate on clinical outcomes for the individual. One could argue that this is the most appropriate aspect of research for mental health nurses as mental illness is individual for each person involved in the process and although BPD is not a mental illness. The National Service Framework for adult mental health sets out our responsibilities to offer evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or difficulty (NIMH 2003). While these can be misconceived as an easy option form of research, qualitative research offers rich, reflective and exhaustive data that is invaluable and has a profound contribution to make to take to practice. The qualitative evidence was lim ited with regards to the treatments reviewed, with an emphasis on DBT. Quantitative research is a formal, objective, and rigorous statistical process for generating information about the world (Burns Grove 1999), whereby the researcher would gather a range of numerical data in order to answer the research question, or prove, disprove a hypothesis (Parahoo 2006). Philosophies or schools of thought in research are called paradigms (Parahoo 2006). One such paradigm is positivism. Parahoo (2006) asserts that positivism relies on observations by the human senses to create fact (empiricism), and believe in the unity of science, and the notion of cause and effect (determinism). The positivist researcher will endeavour to test a hypothesis or theory using the deductive process of a course of experiments. This paradigm utilises a quantitative approach in its research methods. For the positivists, quantitative research is believed to provide hard evidence and objective fact that can provide knowledge on which to base best practice (Parahoo 2006). Efficacy studies focus on the usefulness of a specific helping methodology for a particular kind of problem. Comparisons are made between the methodology in question and some other methodology between clients with some disorder who do receive the treatment and those who do not or between two different methodologies for treating the same disorder. These studies are carried out under controlled conditions. Many of the studies are well designed and demonstrate efficacy. In a healthcare context, efficacy indicates the capacity for beneficial change (or therapeutic effect) of a given intervention. Chapter 2 The Literature Review Having undertaken a critical review of the literature, I have come to explore a number of issues which I feel necessary to consider, key themes emerging from this literature review are the impact of CBT DBT on suicidal behaviours, the impact of CBT DBT on self-harming behaviours, and the impact of CBT DBT on engagement. This chapter sets out to explore these themes in more detail. On the whole the most suitable research design to answer this is the Randomised Controlled Trials (RCT); hence the evidence base reviewed include accessible RCTs undertaken in those with a diagnosis of BPD (NICE, 2009). The causes of BPD are complicated and remain uncertain. Contributing factors may include an inherited vulnerability, a particular temperament, early life experiences and, in subtle neurological or hormonal disturbances (NICE 2009). NICE (2009) state that the history of specific psychological interventions designed to help people with borderline personality disorder is intertwined with changing conceptions of the nature of the disorder itself. Swartz (1990) wrote that BPD is more common among drug and alcohol users. And within these dependents there will be more women diagnosed than men. Zanarini (1998) also adds that the disorder is more common in those with eating disorders, and also among people with self-harming behaviours (Linehan et al., 1991) 2.1 Defining Cognitive Behaviour Therapy and Dialectical Behaviour Therapy NICE (2009) define CBT as a structured psychological treatment that focuses on helping a person make connections between their thoughts, feelings and behaviour. Originally CBT was used as a treatment for depression which has now been modified to treat BPD. CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs, to engage in experimental reality testing, and to develop better coping strategies. The goals of these interventions are to reduce the delusional beliefs, and consequently their severity, and to encourage effective coping and decreasing distress. This essay will attempt to assess the contribution of CBT and the disorder by discussing reviews on effectiveness. CBT for BPD was developed with the idea that people with BPD have learned distorted beliefs and thoughts overtime. Distressing emotional responses and behaviours develop as a result. Beck Freeman (1990) outlined such beliefs, relating to dependen cy, distrust, and rigid perceptions. The distorted thoughts are modified by monitoring,  analysis and questioning.   Davidson (2000), adds that particular attention should be paid to the problems that can disrupt therapy, and so disrupt the therapeutic relationship (NICE, 2009), such as non-engagement, loss of structure, losing focus and lack of compliance. CBT for BPD attempts to create change by improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness (Friedel, 2004). The therapist and patient will construct a list of problem areas. A set of tasks will be developed that will generate and reinforce new attitudes and behaviours, which will replace the old attitudes and behaviors that have caused problems in the past. Within the past 15 years, another, newer psychosocial treatment termed Dialectical Behaviour Therapy (DBT) was developed. DBT joins standard cognitive behavioural techniques with acceptance based strategies, as well as strategies designed to keep the therapy balanced between change and acceptance (dialectical strategies). Marsha M. Linehan, a psychologist from the University of Washington in Seattle, developed DBT specifically for people with BPD, especially those who engage in self-destructive and self-injurious behaviours. DBT is based on the belief that the symptoms of BPD result from organic impairments in the brain that control emotional responses. The early behavioural effects of this impairment are exaggerated, as the person with this biological risk factor interacts with people who do not validate their emotional pain and dont help them learn effective coping skills. DBT has gained significant support in the treatment of BPD because of the results it has achieved in several r esearch studies. It has been shown that DBT can be taught to and used by many, but not all, mental health professionals. For the time being this seriously restricts the use of this helpful treatment approach. DBT seeks to validate feelings and problems, but it balances this acceptance by gently pushing to make productive changes. DBT also deals with other opposing or dialectical tensions or conflicts that arise, such as the patients perceived need for a high level of dependence on the therapists, and the fear and guilt aroused by such extreme dependency. DBT combines both cognitive and behavioural techniques and designed specifically to treat BPD. It is a combination of individual psychotherapy and psychosocial skills training that has been shown via controlled clinical trial to be effective in treating individuals with BPD (Linehan, 1993b). One of the most limiting factors of treating and delivering therapies is that there is not enough staff in the NHS trained to a high standard ( NICE 2009). Cunningham (2004) interviewed fourteen women with BPD to discover why and how DBT is effective. The women were provided with tools to help them deal with their problems and so enabled them to to see the disorder as a controllable part of themselves rather than something that controlled them (NICE, 2009). Cunningham (2004) found that although their problems did not disappear, they became more manageable. It also seemed to have encouraging results on their relationship interactions, and, in addition DBT instilled hope and an ability to try to live independently (NICE, 2009) 2.2 Suicidal acts NICE (2009) define suicidal acts as, deliberate; life threatening; resulted in medical attention; medical assessment consistent with suicide attempt. The main problem staff face in managing BPD is suicidal behaviour (Paris Zweig-Frank, 2001). There is also an association between BPD and depression (Skodol et al., 1999; Zanarini et al, 1998), and Solof (2000) adds that the combination of the two disorders increases the number of suicide attempts. People with BPD possibly will take part in a number of negative and reckless behaviours including self-harm, eating disorders and substance misuse. Self-harming in BPD has different meanings to each individual, including relief from feelings and distress, such anger, or to reconnect with feelings after episodes of emptiness (NICE, 2009). Because of the high occurrence of self-harm, the risk of suicide is higher (Cheng et al, 1997), with 60-70% of patients with BPD making suicide attempts at some point in their lives (Oldham, 2006), however, unsuccessful attempts are far more common and the actual rate of completed suicides is estimated at between 8-10%. A specific therapy for BPD, DBT tak es a behavioural approach to self-harm and suicidal acts that include skills training in emotional regulation and validation of client experience (NICE, 2009). Cognitive-behavioural therapy along the lines of Beck, Freeman, Associates (1990) has been investigated in at least two uncontrolled trials. Brown, Newman, Charlesworth, and Chrits-Cristoph (2003) found significant decreases on suicide ideation, hopelessness, depression, number of BPD symptoms, and dysfunctional beliefs after 1 year of cognitive-behavioural therapy for suicidal or self-mutilating patients with BPD. Results were maintained at a 6 months follow-up. Effect sizes were moderate (0.22-0.55). Dropout rate was 9.4%. Arntz (1999a) found positive effects of long-lasting cognitive-behavioural therapy in a mixed sample of personality disorders, including 6 patients with BPD. Two patients with BPD dropped out prematurely, but the other four attained good results. Linehan et al (1991) conducted a randomised controlled trial using 44 chronically parasuicidal women with BPD to assess the effectiveness of DBT. Among the two groups, there was very little difference between measures of depression, hopelessness and suicidal ideation. Overall the group which received DBT had an average of 8.46 inpatient days compared to the controlled group which had 38.86 days. A naturalistic follow up review was conducted on 39 on the women one year later, to determine the effects of DBT. The women that had completed the DBT course had fewer parasuicidal episodes, but after 18-24 months there were no significant differences between the two groups, although psychiatric inpatient days were still lower for the DBT group. Rathus et al. (2002) went on to conduct a study with a group of 111 suicidal teenagers. 29 were assigned to DBT, while the other 82 had treatment as usual (TAU). It is worth mentioning that the DBT group had far more severe symptoms pre-treatment. The study therefore was not randomised. During the 12 week treatment, the DBT group had fewer inpatient hospitalisations, although the number of suicide attempts made during the treatment did not differ between the groups, but, the attendance and completion was higher in the DBT group. A smaller case study was conducted by Hengeveld et al (1996); he reported of 9 female patients who were given a 10 week course of CBT, they had all attempted suicide at least twice. Of the 9 women, four of those were diagnosed with BPD. Following up the women 10 months later, by phone or examining medical records, all four BPD patients had reports of further suicide attempts (NICE, 2009). Linehan et al. (2006) conducted a one-year randomized controlled trial with one year of post-treatment follow up. The objective was to evaluate the hypothesis that unique aspects of DBT are more efficacious compared to treatment offered by non-behavioural psychotherapy experts. The study included 101 female participants with recent suicidal and self-injurious behaviours that met DSM-IV criteria. The subjects who received DBT were half as likely to make a suicide attempt. 2.3 Self-harm NICE guidelines (2009) use the definition that self-harm is self-poisoning or self-injury, irrespective of the apparent purpose of the act. Self-harm BPD is connected with a range of diverse meanings for the individual, including release from distress and feelings, such as emptiness and anger, and to reconnect with feelings after an episode of dissociation (NICE, 2009). There have been positive attitudes from patients about DBT, as it has helped improve their ability to control their emotions, improves their relationships and significantly reduces the occurrence of self-harm (NICE, 2009). In a large sample, Tyrer et al (2003) found that CBT was equivalent to TAU for the treatment of recurrent self-harm and noted that this method was less effective for patients with BPD. In an uncontrolled study by Brown (2004), patients with BPD with self-harming tendencies received CBT over 12 months; they then stayed in contact with them by phone over the next 6 months. Therapists were on call to emergency phone calls throughout. A randomised controlled study by Verheul et al (2003) was carried out to compare DBT with TAU for patients with BPD, 58 women received treatment for a year were randomised to DBT or TAU. The results: the 12 month attrition rate (37%) for DBT was substantially lower, compared to TAU (77%); DBT treatment also resulted in a large reduction of self-harming behaviours than TAU. A follow up review of this study was carried out by Van den Bosch et al (2005), to ascertain whether the previous results were continued over the following 6 months. It was discovered that the benefits of DBT after the treatment were sustained, and levels of self-harm were lower. It must be said, however, that the definitions of self-harm were all slightly different in each of the RCTs, this can make it very difficult to compare results (NICE, 2009). Another case study series by Alper (2001), presents data on 15 women in a forensic setting, with a diagnosis of BPD. Nurses in the hospital carried out the DBT, and over 4 weeks there was a significant reduction in the occurrence of self-harm. Alper (2001) also carried out qualitative interviews with the nurses to describe how they felt about the treatment, they were all very positive. Bateman Tryer (2004) state that the extensive implementation of DBT is a acknowledgment of its founder, Marsha Linehan, with its mixture of acceptance and change, skills training, manualisation, and an opinion that is willing to embrace this comprehensive approach (NICE, 2009). The evidence strength though, is not justified, however (Tyrer, 2002b), and answers about the long-term success of this therapy as a treatment for BPD are premature. In view of the fact that the original trial, which was handicapped by many methodological limitations, there has only been one study that supports the findings clearly, which was that of Verheul et al (2003) (NICE, 2009). 2.4 Non-engagement For effective treatment, commitment to therapy is required, and research shows that fewer people drop out of DBT than other therapies (Verheul et al 2003) Haigh (2003) interviewed service users and according to them the services could be improved if staff recognised and accepted that BPD can be treated; they felt a more positive experience at their preliminary referral would aid further engagement with services; therapeutic relationship endings were dealt with effectively; and when signs of improvement are observed, services should not be removed immediately, as this tends to raise anxiety and discourage future progression (NICE, 2009). Hodgetts et al (2007) studied five people with BPD. The participants were told that DBT was the only treatment for BPD. This raised expectations and anxieties in the service users. Some preferred the structure of DBT, but others would have preferred a more flexible treatment that is adjusted to each individuals needs. Service users each felt differently about individual therapy and group therapy. One participant dropped out of therapy as she found the challenges too much to deal with. The same lady reported that she was turned away from the crisis team as she was already involved in the DBT group; this was another reason for her departure. All of the participants in this study found that the therapeutic relationship is essential, also they appreciated the importance of collaborative working and sharing their experiences (NICE, 2009). Other studies have reported quite high drop out rates from CBT, for example up to 37% (Verheul et al, 2003). It is probable that some patients did not engage because they did not find the therapy useful, but ratings from patients who had at least five sessions of CBT suggest that both the patients and therapists view the experience of therapy to have been a positive one. Even so, some patients simply did not attend. Chapter 3 Discussion and Conclusion This research project has tried to look at research evidence on the efficacy CBT and DBT in the management of Borderline Personality Disorder. This work has been done using the NICE Guideline (2009) as the definitive text. This is because this guideline is main reference document in clinical practice. Borderline Personality Disorder is one of the most challenging entities for todays therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of ones own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy. Because the BPD diagnosis have common characteristics with schizophrenia, psychoses, anxiety and depression, Gunderson (2001) believes it to be a wastebasket diagnosis, which lacks diagnostic accuracy and strength, and so would only be useful to service users that did not fall into other diagnostic types. It is thought that BPD has responded badly to the treatments, and a lot of health professionals also unfortunately, believe this to be true (Friedel 2004). It seems that overall the non-RCT outcomes suggest that individual therapies are more suitable to people with BPD. Positive outcomes were shown generally, these need to be compared to the RCTs before definite conclusions can be made (NICE, 2009). It seems that the evidence base is fairly poor for therapies of BPD, the studies are minimal, the number of patients are low and the outcomes too numerous, with very little commonalities between studies (NICE, 2009) Giesen-Bloo et al (2006) are critical of DBT, stating that it fails to reduce core symptoms related to deeper personality change. The most difficult problem is that DBT is resource-intensive and expensive. Where it is available, there are usually long waiting lists. However, DBT is the treatment of choice for individuals experiencing severe impulse and self-harming behaviours. 3.1 Strengths and limitations of the review Having never done a substantial piece of work before, I did not realise the amount of work required to achieve it. I was aware of how to narrow down a search, which was needed due to vast amount of information available, but the confusion came as I particularly wanted to look at standard CBT for BPD, which very little research has been done. There was far more research for DBT, and so I decided I would explore this t

Women in World War II

Women served an important role in WWII. They not only took the challenge and stepped up to take the places of the men off fighting in the war to work in factories, but they also fought side by side with those risking their lives and fighting for their country. They were needed everywhere during the war. There were an unbelievable amount of job opportunities for women during the war and many supported the brave acts of voluntary enlistment. â€Å"‘A woman’s place is in the home’ was an old adage, but it still held true at the start of World War II. Even though millions of women worked, home and family we considered the focus of their lives† says Brenda Ralf Lewis. Without the help of those women who were brave enough to step, the war may have not ended as successfully as is did. Women’s jobs were very important in WWII. Women participated a great deal on the home front war effort. While the men in their lives were off fighting in the war, women were working in factories fulfilling the men’s jobs producing ammunition, tanks, and other weapons urgently needed during the war. According to Buzzle. com, â€Å"Women took over places initially meant for men and excelled in the same as well. If women weren’t in factories they were at home providing for their families. Supplies were rationed because of the shortages caused by lack of trade from other countries that were at war as well, such as Japan and Southeast Asia. Families were given booklets for each member which determining the amount received. Utilities such as toaster and waffle irons; flashlights and batteries; tea; toys and games; vacuum cleaners and vending machines were no longer manufactured because the materials were more of a priority for scrap metal to build the necessities for war. Use it up/ Wear it out/ Make it do/ or do without† became a well-known saying around the United States during the war according to Dot Chastney. During the war women were expected to step up in the places of the men. Some were brave enough to go out into the field while others didn’t have much of a choice but to work in factories in order to stay closer to home with their families. The war had an impact not only on the fighters and workers, but on the children as well. They were deprived of the education they deserved because funding started to go to the war efforts. Having to deal with the war caused people all around to make decisions that were best for everyone around rather than a specific group of people. One good thing that came out of the war was the extraordinary opportunities offered to women. Not only did it show that women can work as well as men did in those working conditions, it widened women’s work options, and let them contribute what they had to offer to the war. While men were at war, jobs were needed to be filled. War was heating up and according to Brenda Ralf Lewis. It was not entirely unexpected and anticipating the event was different from experiencing it first hand, which caused upheaval as m millions geared up to cope with its demands. † Jobs were a huge demand at this point and who else to fill the jobs? That’s right. The countries very own women. Women were granted with extraordinary opportunities. â€Å"Women learned new skills as they replaced men in war work, using expertise and physical strength many never knew they possessed. This did not always go down well with men still working in the wartime factories†, acknowledges Brenda Ralf Lewis. Being able to work in factories, women learned techniques they never knew they had and if it hadn’t been for the war, they probably never would have ever experienced it. Opportunities for women consisted of Army nurses, Navy nurses, Women Auxiliary Army Corps (WAAC), Women Accepted for Volunteer Emergency Service (WAVES), women Marines, the Coast Guard preserve, jet pilots, and so many other amazing opportunities. There were not only needed for fighting on the front, but for factory jobs as well. Women quickly learned to work with the machines and build the necessary weapons that were in high demand during the war. Rosie the Riveter was a metaphoric figure used to represent the strength, dirty jobs, and work women provided for the war effort. Penny Colman states â€Å"Rosie the Riveter was supposedly based on Rose Bonavita, a riveter in the United States. † During the war more than six million women joined the workforce. In August of 1943 Newsweek Magazine reported: â€Å"They [women] are in the shipyards, lumber mills, steel mills, foundries. They are welders, electricians, mechanics, and even boiler makers. They operate street cars, buses, cranes, and tractors. Women engineers are working in the drafting rooms and women physicists and chemists in the great industrial laboratories. † Ever since then women proved that they can work in a man’s workplace and do just as well. Any job that was a man’s, was a women’s as well. Women were soon â€Å"the most needed workers of all† according to Brenda Ralf Lewis. Factory workers became known as â€Å"the soldiers without guns†. If women hadn’t stepped up to the line, winning the war wouldn’t have been as easy as it was for us. Not only did the women in factories and shipyards have a big part in doing their part in the war contributions, but so did the women who were out on the field fighting alongside with their men risking their very life. Women working and fighting on the line of protection had the toughest jobs. â€Å"Those working on the front line lived in constant danger as they worked to preserve life while everything happening around them was designed to destroy it† says Brenda Ralf Lewis. In the beginning women were discriminated and were doubted when doing the jobs on the front line. Thousands of women joined the women’s uniformed services in World War II. There was, inevitably, resistance to the idea of women in uniform, but their contribution was vital† reports Brenda Ralf Lewis. Not long after joining the armed forces they were able to prove the doubters otherwise. The Allied armed services drew thousands of women into military life, from all over the world. The United Stat es and Britain accounted for most employing women in all three armed forces and, in the case of the United States, in the Coast Guard and Marines as well. There were many different military branches women were able to join at that time. Some included Women’s Arm Auxiliary Corps (WAAC), Women’s Army Corps (WAC); Women’s Auxiliary Ferrying Squadron (WAFS) was incorporated with the Women’s Air Force Service Pilots (WASP) as well. Other countries such as Britain, Canada, Australia, South Africa, India, New Zealand, Burma, France, The Netherlands, Norway, Poland, and the Soviet Union all offered forces dedicated to women and the services they offered. Many questioned the fact if women should be allowed to serve at all. Women in the military had image problems. They were seen as femme’s fatales; their role was trivialized or they were dubbed ‘unfeminine’ for deserting their proper place, home. Not only did they prove them wrong by going out into the field and fighting on the front, but they also put their feminine qualities to work. Women became great undercover spies. According to Simone Payment, â€Å"Spies have been used in times of war and peace since the beginning of civilization and women have long been involved in these espionage pursuits. In the United States, female spies participate in both the Revolutionary War and the Civil War. But it wasn’t until World War II that they became an official-and incredibly important-part of the war effort. Many female spies made a difference in World War II, often at a great personal cost†. Many never questioned the thought of a dainty and delicate woman to be able to posses such power. Women were able to go undercover easily by just being themselves and going along with their daily lives. Women took the risks of being captured and tortured if they were ever discovered. Some women that contributed their lives to the ware are: Tatiana Nikolaevna Baramzina who was born on December 12, 1919 in Glazov and was also the recipient of the Gold Star Award. In 1943, Tatiana was sent to the Central Women's Sniper Training School and upon her graduation in April, she was later sent to the 3rd Belorussian Front. She managed to kill around 16 enemies in the first three months itself. Unfortunately, she was captured by the enemies and tortured before she was shot point blank. Tatiana Nikolaevna Baramzina passed away on July 5, 1944. Today, the street where she grew up has been re-named in her memory. Another woman that dedicated her life to the war was named Hannah Szenes who was born on 17th July, 1921 and was trained to parachute by the British army into Yugoslavia during World War II. This task was given in order to save the Jews of Hungary. Her secret mission was not revealed even when she was tortured following her arrest at the Hungarian border. Hannah Szenes had to brave immense tortures, yet she did not lose heart. She bravely battled it out and tried to sing to keep her spirits high. She also kept a record of events in her diary till November 7, 1944, when she was finally executed by a firing squad. During the war, the efforts of many women had gone by unnoticed. Overall women had and enormous impact on the war with their contributions and dedication to help provide, step up and win the war. Without the help of the women, we might have never won. Every woman had an important role and they did it with great honor. To this day, women are in all different branches of the military.

Finance and Investment Questions - 1714 Words

Finance and Investment Questions Analyze how you, as the Chief Financial Officer (CFO) of a big box store that has potential pollution, environmental-disposal, or demolition problems, would handle †¦ Public expectations of our private enterprises are shifting. After a decade of scandal and corporate collapses, the public recognizes the direct connection between positive corporate citizenship and the public good. This is highlighted by a growing push for greater corporate transparency in aspects such as financial reporting and internal reform. As the text by Schlageter (2012) notes, increasingly, successful CEOs are the ones that realize their commitment to transparency and ethical business practices can provide their organization with a competitive advantage. Corruption is the antithesis of growth, and flourishes where secrecy is allowed. For the big box store in question here, the focus must be on reducing secrecy through greater honesty and thoroughness in financial reporting. In order to quell the internal r esistance of those in the leadership core that might prefer secrecy, the company must also develop a comprehensive strategy for rolling out reforms to its environmental issues, presuming these are the central concern here. By addressing prior shortcomings, taking responsibility for them through honest financial reporting and preemptively announcing plans for improvement, a big box firm can weather the short-term storm of public criticism. ==================Show MoreRelatedThe Investment Decision, the Financing Decision and the Dividend Decision Are Sides of the Financial Management Triangle with Visible Interface. Examine This Statement Critically1666 Words   |  7 PagesTHE INVESTMENT DECISION, THE FINANCING DECISION AND THE DIVIDEND DECISION ARE SIDES OF THE FINANCIAL MANAGEMENT TRIANGLE WITH VISIBLE INTERFACE. 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Research Papet - 1558 Words

(Henrietta Lacks)HeLa Cell Lines Medical researchers use laboratory-grown human cells to learn the intricacies of how cells work and test theories about the causes and treatment of diseases. The cell lines they need are â€Å"immortal†Ã¢â‚¬â€they can grow indefinitely, be frozen for decades, divided into different batches and shared among scientists. In 1951, a scientist at Johns Hopkins Hospital in Baltimore, Maryland, created the first immortal human cell line with a tissue sample taken from a young black woman with cervical cancer. Those cells, called HeLa cells, quickly became invaluable to medical research-though their donor remained a mystery for decades. In her new book, The Immortal Life of Henrietta Lacks, journalist Rebecca Skloot tracks†¦show more content†¦Blood from human placenta. (The placenta, which nurtures the developing fetus, contains powerful hormones and a host of viruses and bacteria, as yet not fully investigated.) 2. Beef embryo extract (the ground-up remains of a three-week-old unborn cattle embryo. 3. Fresh chicken plasma obtained from the blood of a live chicken heart. For some unknown reason, Henriettas cancer cells continued to grow vigorously. The cells did not age. Instead, if fed properly they could live and multiply indefinitely. Amazingly, her new tissue culture cell line proved to be immortal. These malignant cells became the first successful human tissue culture cell line in medical history-the now famous HeLa cell line commemorating the legendary Henrietta Lacks. Gold claims the cell line brought revolutionary changes (as well as havoc) into the field of cancer virus research. Viruses could be now seeded onto glass tubes containing sheets of live cells; and for the first time, virologists could directly observe the effects of viral infection on living cells. HeLa cells proved so hardy that when passed around the world to various laboratories over the next few decades, the immortal cells frequently contaminated other tissue culture cells lines used in cancer and cancer virus research. Henrietta Lacks: The Godmother of Virology Also on February 5, 2010, a review was posted of a new book entitled The Immortal Life of Henrietta Lacks, by

Educator as an assessor - 3333 Words

TABLE OF CONTENTS QUESTION 1: Definitions of assessment conceptS 2 a. Moderation 2 b. Recording 2 c. Continuous assessment 2 d. Criterion-referenced assessment 3 QUESTION 2: â€Å"THE NOBLE PROFESSION† – THE PURPOSE AND IMPORTANCE OF ASSESSMENT IN THE SOUTH AFRICAN CURRICULUM 3 QUESTION 3: COMPARISON OF FORMATIVE AND SUMMATIVE ASSESSMENT 4 QUESTION 4: ASSESSMENT ACTIVITY SCORING RUBRIC 7 QUESTION 5: DESCRIPTION AND IMPLEMENTATION OF ASSESSMENT PRINCIPLES 8 a. Validity 8 b. Fairness 8 c. Currency 8 QUESTION 6: DISCUSSION OF THE ROLE OF THE MODERATOR IN ASSESSMENT 9 a. The Role of the Moderator before Assessment is Conducted 9 b. The Role of the Moderator following Completion of Assessment Tasks 10 QUESTION 7: APPLICATION†¦show more content†¦Assessment can also diagnose any obstacles to learning, learning difficulties or learning hiatuses (Dreyer, 2014:17). 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Burden Invasive Pneumococcal Disease Health And Social Care Essay Free Essays

Streptococcus pneumoniae claims 1 million child deceases every twelvemonth worldwide ( 1 ) . Approximately 90 % of deceases occur in developing states. For every 1 kid that dies of pneumonia in a developed state, more than 2000 kids dice of pneumonia in developing states ( 2 ) . We will write a custom essay sample on Burden Invasive Pneumococcal Disease Health And Social Care Essay or any similar topic only for you Order Now The SAARC states overall are in the zone with high incidence of pneumococcal disease ( 1 ) but no survey has attempted to happen out the same. The child mortality rates ( lt ; 5 ) are high in the part ; runing from 17/1000 for Srilanka to 149/1000 for Afghanistan. Pneumonia claims 11 % of U5 child deceases in India, Maldives, Bangladesh and Pakistan ; 23 % of U5 child deceases in Afghanistan and 19 % in Bhutan with lowest in Srilanka 6 % . ( 3 ) . Pneumonia is the taking cause of U5 decease in Pakistan ( 4 ) but merely 50 % receive antibiotic intervention ( 5 ) . The Million Death Study reported that pneumonia accounted for 27AÂ ·6 % deceases out of entire 12260 deceases in kids from 1-59 months ( 6 ) . S. pneumoniae is one of the major causes of fatal pneumonias in kids ( 7 ) . Besides pneumonia S.pn is besides known to do meningitis which is another fatal status for kids. Many more diseases are to the name of S.pn like ague otitis media, joint gushs and bacteraemia etc. Estimates of pneumococcal disease load are needed so as to use the resources for kid endurance. In Bangladesh, the theoretical account predicts a pneumococcal disease incidence of 3351 instances per 100,000 kids younger than 5 old ages. A population-based, active-surveillance, active-case sensing survey measured an invasive pneumococcal disease rate of 447 instances per 100,000 kids younger than 5 old ages ( 8 ) . Unfortunately the grounds for appraisal of pneumococcal disease in low/middle income states is less. The load of pneumococcal disease is highest in kids and the aged population in both more and less developed states. The intervention of pneumococcal infections is complicated by the world-wide outgrowth of opposition to penicillin and other antibiotics ( 9 ) . The pneumococcal conjugate vaccinums are helpful but the effectivity of these vaccinums is dependent upon the pneumococcal disease load and serotype coverage of the vaccinum. ( 10 ) Aim: The primary aims of this systematic reappraisal are To cognize the load of invasive pneumococcal disease. To find the demand for debut of pneumococcal conjugate vaccinum in the immunisation agenda. Methods: We performed a systematic hunt of the published literature and besides tried to get information about the unpublished literature from assorted research workers of the part. Beginnings of Datas: The hunts were current as of January 2013 and we identified articles with information on pneumococcal invasive disease among kids lt ; 5 old ages of age. We searched 3 Databases: Pubmed, Embase and The Cochrane library. The mention lists of the obtained articles were farther searched for surveies. Non English articles were non included. The hunt inside informations are given in the appendix I. Searching were done by 2 writers ( NJ, HK ) . HK helped in obtaining full text articles. Definitions Used: SAARC states: South Asian Association for Regional Co-Operation includes Afghanistan, Pakistan, India, Nepal, Bhutan, Bangladesh, Srilanka and Maldives. Burden of pneumococcal disease: We have defined load of pneumococcal disease as the figure of positive pneumococcal isolates from the suspected population. Pneumonia: Symptoms: cough or hard external respiration, and marks: external respiration gt ; 50 breaths per minute for infant aged two months to less than one twelvemonth, take a breathing gt ; 40 per minute for kid aged one to five old ages, and no thorax indrawing, stridor or danger marks. ( 11 ) Severe pneumonia: Symptoms: cough or hard eupneic plus any general danger mark or chest indrawing or stridor in a unagitated kid. General danger marks for kids aged two months to five old ages: unable to imbibe or suckle ; pukes everything ; paroxysms ; lethargy or unconscious ( 11 ) . Clinical diagnosing of meningitis is more straightforward than that of pneumonia. The definition of pneumonia is based on the incorporate direction of childhood infections ( IMCI ) attack, which includes other ague lower respiratory tract infections and deficiencies specificity. In add-on, aetiologic diagnosing of bacterial pathogens is easier in CSF than in blood. Meningitis: ( 11 ) Suspected: Any individual with sudden oncoming of febrility ( gt ; 38.5 AÂ °C rectal or gt ; 38.0 AÂ °C axillary ) and one of the undermentioned marks: cervix stiffness, altered consciousness or other meningeal mark. Probable: A suspected instance with cerebrospinal fluid ( CSF ) scrutiny demoing at least one of the followers: cloudy visual aspect ; leucocytosis ( gt ; 100 cells/mm3 ) ; leucocytosis ( 10-100 cells/ mm3 ) AND either an elevated protein ( gt ; 100 mg/dl ) or decreased glucose ( lt ; 40 mg/dl ) . Confirmed: A instance that is laboratory-confirmed by turning ( i.e. culturing ) or placing ( i.e. by Gram discoloration or antigen sensing methods ) a bacterial pathogen ( Hib, Diplococcus pneumoniae or meningococcus ) in the CSF or from the blood, in a kid with a clinical syndrome consistent with bacterial meningitis ( WHO, 2003 ) . Non Pneumonia Non Meningitis: All infections other than pneumonia and meningitis have been categorized under this header. Invasive Pneumococcal disease: When Diplococcus pneumoniae has been identified from one of the otherwise unfertile sites of the organic structure like blood, CSF, pleural fluid etc either by civilization or by LAT/PCR or other technique. The surveies where the defined instances have some other parametric quantities or if there were some other standards no effort was made to standardise them. Inclusion standards: Surveies ; prospective/retrospective ; with kids lt ; 5years of age as /or portion of the studied population. Surveies done in infirmary or community scene. Surveies with possible informations available on S.pneumoniae isolated from kids lt ; 5 old ages of age. Surveies with at least 12 months of surveillance were included in order to get the better of the seasonal nature of pneumococcal diseases. Surveies conducted in SAARC states. The inclusion was decided by 2 writers ( NJ, KK ) and choice appraisal was done by 2 writers ( NJ, KK ) . Discrepancies, if any, were resolved by treatment with 3rd writer ( MS ) and the finding of fact was considered concluding. If the exact information was non available we have contacted the writers and tried to decide the disagreements The surveies which have commented merely on pneumococcal serotypes A ; /or antibiotic opposition have been excluded from pooled analysis. We excluded instance studies, columns, vaccinum surveies, literature reappraisals and the surveies in which nasopharyngeal aspirates, pharynx swabs or oropharyngeal swabs were the lone samples to find the causative being. Data aggregation and direction: Three writers ( BE ; AK, SS ) abstracted informations individually from the included surveies in a predesigned tabular array that included survey design, puting, no. of suspected instances, no. civilization samples taken amp ; positive civilizations obtained, and no. positive civilizations for Diplococcus pneumoniae. The information from Hospital based surveies and population based surveies were abstracted individually. To decide the disagreements sing the abstracted informations treatment with the other referees were done and consensus was reached. Sing some losing informations the writers were contacted and if the disagreements were non resolved they were non taken up for pooled analysis. The community based surveies available merely give information about pneumococcal pneumonia instances in the community. Datas analysis: Data analysis was done utilizing CMA V2 by 4 writers ( NJ, MS, KK, and AA ) . The similar surveies were pooled together. Sub group analysis for finding the IPD load in India was done and besides sub-group analysis for finding IPD in kids lt ; 5 old ages was done. The community based surveies, infirmary based prospective and retrospective surveies have besides been analyzed individually. Consequences: Datas reviewed: We found 700 published articles through electronics and manual searching. After rubric and abstract testing 40 full text articles were retrieved and 21 surveies ( 8, 12-31 ) were included for the reappraisal and 19 were excluded ( 32-50 ) ( fig 1 ) Community based surveies were non available from Afghanistan, India, Nepal, Bhutan A ; Srilanka. Because the life conditions are about same and there is besides geographic similarity we have considered the surveies from Bangladesh and Pakistan as representative of the SAARC states. Similarly there were no infirmary based surveies from Afghanistan and Bhutan so we have taken the surveies from remainder of the states and generalized them for these states. We have included a sum of 21 surveies for this systematic reappraisal A ; mentioned in tabular array I. The inclusion was decided by 3 writers ( MS, NJ, KK ) and quality marking was done by 3 writers ( MS, NJ, KK ) . The surveies with mark of 6 or more were considered to be good quality grounds. Hospital Based Prospective Surveies: SAARC states: We identified 15 infirmary based prospective surveies ( 12-19, 22, 24-27, 29, 31 ) from assorted SAARC states and analyzed them for finding the invasive pneumococcal disease load in kids populating in these states and besides did a subgroup analysis for kids less than 5 old ages of age. These surveies show that 3.5 % ( 95 % CI 1.9-6.4 ) of kids admitted to infirmaries with diagnosing of invasive diseases like terrible pneumonia or meningitis or sepsis are due to S. pn ( fig 3 ) . Eight surveies ( 13, 15, 16, 18, 24-27 ) show that 1.5 % ( 95 % CI 0.6-3.4 ) of kids admitted as terrible pneumonia have S. pn as the causative being ( Fig 5 ) . Ten surveies ( 12, 14, 16, 17, 19, 22, 24, 26, 27, 29 ) of the included surveies show that 7.6 % ( 95 % CI 4.1-13.7 ) of kids with likely or confirmed meningitis have S.pn as a causative being ( fig 7 ) . S.pn is one of the major bacteriums doing 20 % ( 95 % CI 12.9-29.9 ) of invasive bacterial diseases ( fig 4 ) . 11 % ( 95 % CI 6.5-17.9 ) of terrible bacterial pneumonia are caused by S.pn ( fig 6 ) . S.pn has been an aetiologic agent in 33.1 % ( 95 % CI 23.1-44.8 ) instances of bacterial meningitis ( fig 8 ) . Children less than 5 old ages of age: Out of the 15 surveies merely 11 surveies ( 13, 15, 17, 18, 22, 24-27, 29, 31 ) have clear information on invasive pneumococcal disease in kids less 5 old ages of age. The surveies show that S.pn causes 2.7 % ( 95 % CI 1.1-6.2 ) hospitalizations due to all invasive disease ; in kids lt ; 5 old ages of age ( fig 9 ) . Merely 7 surveies ( 13, 15, 18, 24-27 ) had clear information on pneumococcal pneumonia in kids lt ; 5 old ages of age and showed that 1.5 % ( 95 % CI 0.5-4.3 ) of terrible pneumonias are due to S.pn ( fig 11 ) . Similarly 6 surveies ( 17, 22, 24, 26, 29 ) showed that S.pn is the being responsible for 7.1 % ( 95 % CI 2.6-17.5 ) meningitis instances in the age group ( fig 13 ) . S.pn remains the major bacterial cause of all invasive diseases in kids U5 old ages of age doing 19.2 % ( 95 % CI 11.5-30.3 ) of invasive bacterial diseases ( fig 10 ) . 10.8 % ( 95 % CI 6.4-17.6 ) terrible bacterial pneumonias are due to S.pn ( fig 12 ) and 35.1 % ( 95 % CI 22.1-50.8 ) of pyogenic meningitis is due to S.pn. ( fig 14 ) . Bharat: We found 9 surveies from India ( 12-19, 22 ) which showed that S.pn causes 7.9 % ( 95 % CI 3.8-15.7 ) of invasive diseases in kids ( fig 15 ) . S.pn has been an aetiologic agent in 3.9 % ( 95 % CI 1.2-11.7 ) kids with terrible pneumonia ( fig 17 ) and is besides a major bacterial cause of pneumonia in kids doing 14 % ( 95 % CI 5.8-30.1 ) of bacterial pneumonias ( fig 18 ) . S.pn has been a causative agent in 10.4 % ( 95 % CI 5.8-18.1 ) of kids with meningitis ( fig 19 ) and once more a major bacterial cause of pyogenic meningitis ( fig 20 ) . The hospital prevalence of S.pn in Indian kids is more than that of all other SAARC states. Children less than 5 old ages of age: Five surveies ( 13, 15, 17, 18, 22 ) gave clear information on pneumococcal diseases in kids under 5 twelvemonth of age in India. The image does non alter in this age group of Indian kids where S.pn is prevailing in 8.2 % ( 95 % CI 4.1-16.6 ) of all hospitalized kids with suspected invasive bacterial disease ( fig 21 ) and S.pn becomes a major bacterial cause of invasive bacterial diseases with 21.2 % ( 95 % CI 9.4-41.0 ) of all invasive bacterial diseases are due to S.pn ( fig22 ) . 5.4 % ( 95 % CI 2-14.1 ) of terrible pneumonias in infirmary wards are due to S. pn ( fig 23 ) A ; 16.5 % ( 95 % CI 12.8-16.2 ) meningitis in kids less than 5 old ages describing to infirmaries are due to pneumococcus. In 13.6 % ( 95 % CI 5.5-29.8 ) of all bacterial pneumonia ( fig 24 ) A ; 39.3 % ( 95 % CI 27.5-52.6 ) of pyogenic meningitis ( fig 26 ) S.pn has been isolated and is a major cause of these diseases in India. Hospital Based Retrospective Surveies: Two infirmary based retrospective surveies ( 21, 28 ) from India were included in this reappraisal. The pooling of these surveies together showed that 15.5 % ( 95 % CI 0.5-88 ) of invasive pneumococcal disease instances amongst the entire admitted patients with invasive bacterial diseases ( Fig 27 ) . The assurance intervals for this group are broad because one survey ( 21 ) which is merely on bacterial meningitis and has a little sample size with comparatively more proportion of pneumococcal isolates. Population Based Surveies: Four surveies ( 8, 20, 23, 30 ) from the SAARC states were included in the reappraisal. These surveies are from Pakistan and Bangladesh. These surveies merely discuss the kids under 5 old ages of age. These surveies show that approximately 13.4 % ( 95 % CI 6.7-25 ) of all invasive bacterial diseases in community are due to S. pn ( fig 29 ) Inference of all the analysis: The consequence from the population based surveies ( 13.4 % ) is comparable to that from the infirmary based prospective surveies ( 19 % ) and besides to those obtained from retrospective surveies ( 15.5 % ) . The pneumococcal disease prevalence in SAARC states varies between 13 % – 19 % of all invasive bacterial diseases. Discussion: Our findings show that S. pn is prevailing in 19 % of all hospitalizations in kids of SAARC states and is hence one of the major cause of concern every bit far as child wellness is concerned. Pooling the Indian surveies we found that pneumococcal diseases are 25 % of all invasive bacterial diseases in kids of India. These figures might be an underestimation of the current state of affairs as the surveies discuss merely hospitalized instances, the milder signifiers may travel unreported. S.pn is a major bacterial cause for terrible pneumonia and besides for pyogenic meningitis in kids of this part. The community based surveies besides show that in 13 % of bacterial instances were due to S.pn but once more these surveies besides discussed the terrible diseases merely and did non describe the milder signifiers. The consequences of our reappraisal are comparable to other reappraisals ( 1 ) which showed high prevalence of pneumococcal diseases in India. The consequences of community based surveies show that __ % of all bacterial invasive diseases in community are due to pneumococcus which is comparable to the consequence from the infirmary based prospective surveies. An unpublished information from one site of a multicentric test ( ISPOT survey ) from India showed that approx 38 % of kids with terrible pneumonia ( Radiologically confirmed ) had S. pn isolated from the nasopharyngeal aspirates or pharynx swabs. The survey besides showed that unwritten Amoxil administered at place was effectual in handling terrible pneumonia. The No Shots survey from Pakistan ( 51 ) concluded that place intervention with high dose unwritten Amoxil in instances of terrible pneumonia is tantamount to WHO recommendations of hospitalizations and i/v antibiotics. Similarly in another survey from Pakistan showed that local wellness workers were able to handle terrible pneumonia instances at place with high dosage Amoxil ( 52 ) . Survey from Bangladesh ( 53 ) reports the rhinal passenger car rate of 47 % and besides reports the early colonisation in rural population. The survey besides reports that 69 % of invasive strains were immune to cotrimoxazole. The ANSORP survey reported 41 % non-susceptible strains to penincillin in Srilanka and approximately 4 % in India ( 54 ) . The IBIS survey ( 16 ) reported 60 % opposition to chloramphenicol, Principen, trimethoprim-sulfamethoxazole, or Erythrocin ; with 32 % isolates resistant to more than 3 antimicrobic drugs. Kunango et Al ( 55 ) reported that out of 150 clinical isolates from invasive pneumococcal infections, merely 11 ( 7.3 % ) isolates were comparatively immune to penicillin, although 64 were immune to one or more antibiotics particularly cotrimoxazole, Achromycin and Chloromycetin. In the ISCAP test ( 56 ) the opposition form of S. pneumoniae to assorted antibiotics was: cotrimoxazole 66.3 % , chloramphenicol 9.0 % , oxacillin 15.9 % and erythromycin 2.8 % .So the antibiotic opposition becomes another menace. In India, the most common serogroups colonising the nasopharynx of kids are 6, 14, 19, and 15 ( 38, 57 ) . IBIS survey ( 16 ) studies serotype 1,6 and 19 to be the most common serotypes isolated from either blood or CSF samples of the kids with invasive disease. Rijal et Al ( 49 ) found that serotypes 1,5 A ; 4 were most normally isolated from the patients of IPD and besides reported that 52 % of isolates were immune to cotrimoxazole. Decision: The systematic reappraisal concludes that S. pneumoniae is a major bacterial cause of invasive bacterial diseases in kids of SAARC states. The outgrowth of immune strains of Diplococcus pneumoniae are indicating towards the demand for revisiting the intervention recommendations and besides do a call for explicating preventative steps to decrease the prevalence of invasive pneumococcal diseases. The usage of antibiotic which is less immune and easy to administrate should be considered. Pneumococcal conjugate vaccinum, after cognizing the prevalent serotypes and there coverage, should be considered by the policy shapers. Conflict of Interests: None stated Role of the Funding Agency: The reappraisal was supported and funded by ICMR, New Delhi. The support bureau did non interfere with the reappraisal procedure or the consequences. Recognitions: We would wish to thank Dr. Samir K Saha ( ICDDR, Bangladesh ) , Dr. Z.A. Bhutta A ; Dr S.Q. Nizami ( AKU, Karachi, Pakistan ) for supplying us with their publications on pneumonia ; we would besides wish to thank Dr. Kay Dickerson of John Hopkins University U.S. for assisting us with the statistical methods. How to cite Burden Invasive Pneumococcal Disease Health And Social Care Essay, Essay examples

The Impact of Space Debris on the Environment

Question: Discuss the impact of space debris on the environment? Answer: Introduction The collection of de-functioning man-made objects in space such as spent rocket stages, old satellites, and fragments from disintegration, collision parts and erosion are known as space debris or space junk. There are many sources of space debris. They can be dead spacecraft, lost equipment, boosters as well as weapons. During the past fifty years, nations in the world concerning space-fare have been trashing near the space of the earth without caring about the future effects on the global environment. Every year many satellites and rockets are being launched into the orbit of the earth. As a result, multiple objects have become Resident Space Objects or RSOs (BaiocchiWelser, 2010). This leads to space junk or space debris. Space debris impacts on the outside environment and internal environment of the earth as well. Scanning through the concept of global warming which is a very crucial part of the impact of space junk. The rise in average temperature of the surface of the earth due to the effect of the greenhouse gasses like the emission of carbon dioxide which is emitted from the burning of fossil fuels or deforestation is called Global warming. Global warming traps heat which is prevented from being escaping from the Earth. The effects rise due to global warming is known as greenhouse effects. The gasses which are being emitted due to global warming is called greenhouse gasses. The most significant greenhouse gas is water vapor, carbon dioxide, methane, nitrous oxide and ozone (Loomis, 2015). The slight increase in atmospheric levels of carbon dioxide (CO2) causes a considerable increase in temperature. Space Debris The space debris is a kind of junk or wastes that have been left by the human in space. In other words, the wastages materials which are no longer serves a useful purpose have been left by astronauts in the space called as space debris. The space debris can be formed by many resources such as discarded equipment, defunct satellites and rocket stages. The satellites can be damaged due to the high speed of the space debris which is running in the orbits of the earth. Also, many times satellites were destroyed due to the collision with the space debris. The space debris is very dangerous for the future space missions. Moreover, there is a huge risk factor is working behind the collisions which lead to the potential damages of rockets and it is increasing continuously. Moreover, this space debris also affects the atmosphere of earth. In other words, it is one of the main reason for global warming(Anderton, 2011). The Types of Space Debris The worlds first artificial satellite was launched in 1957 by the Soviet Union. Many effective reasons were involved behind the satellite launch such as new technological, military, political and scientific developments. During the process of the launch, many space debris was created in space. In that time, many countries including America were starting to send their space shuttles as well as satellites in space without any consideration about the impairment of the environment through the debris of space which has been created by launches of space shuttles as well as space satellites (Stjerna, 2013). To increase the space race, many Governments, as well as cell phone companies, DTH companies, and GPS, receives companies have launched thousands of satellites in space. Also, those satellites increase the majority of the space debris. Therefore, form the year 1957 till today there have been many satellites and space shuttles have been sending into the orbits of the earth and they have m ade a huge amount of space debris in space. Talking about the space ship junk, most of the astronauts left the parts of their rockets and space crafts which are no longer to use in the orbit of the earth because it is very expensive to retrieve those used parts of space ships. As a result, those large space debris were continuously revolving in the earths orbit until they fall back down or collide with other space junk(Stjerna, 2013). On the other hand, when the space shuttles were launched, there more than one rocket boosters were needed for the extra power force which helps to reach high enough to space and those rocket boosters were fired up in one by one stage(Draper Watson, 2006). In other words, those rocket booster does not have any role to play except boosting the main space shuttles. At the time of final stage, the last rocket booster was fired off very late, and other space crafts were getting trapped in the earths orbit. Moreover, those rocket boosters collided with other satellites and create many small pieces of space debris which are very harmful to the environment of earth. There are two types of space debris were discussed in above section which influences the danger for the future mission due to the collision of space debris. Talking about the impact of those space on the space environment is very effective and harmful. Many types of research proved that the space junks which were formed due to the collision of two or more martial space objectives are moving around the orbit of the earth until they were fall back (Stabroth et al., 2008). Apart from that, many space centers left flying fuel tanks in space for the emergency purpose. Whatever, those fuel containers also flow up due to collision with space debris and create massive space junk through the explosion. Moreover, due to the explosion, many raw materials were burned up and create inorganic space wastage which increases the temperature of earths orbit. Minimize the Effects of Space Debris After the accomplishment of the mission, most of the spacecraft left a huge amount of junk in the orbits which is one of the significant reason of space debits. NASA and other space centers should pay more attention to the equipment related junk which was converted into space debris. On the other hand, space shuttles and space satellites should be manufactured according to the space environment(Williamson, 2006). If the space environment is continuously damaged, then the future mission of space journey will be completely hazard. Apart from that, the astronauts should implement the following protection strategies to decrease the space debris. The protection strategy In order prohibit the current space debris population most of the designers of space vehicles implement many protective techniques in their production process. There is a different kind of space debris moving in the orbit of the earth; some space junk might be radioactive. So, the space shuttles and as well as space satellites should be protected by a strong shield. Also, the shield includes some several layers of various natural parts. Polymers like polyvinyl chloride are one of the significant layers of the shield(Bueren, BohemenVisscher, 2011). Collision avoidance in space When two or more space debris crashed into each other, then a collision happens. To decrease the level of the collision, many governments decided that the parts of the satellites should be made according to the catchable shape of ground-based space surveillance systems. NASA and other space centers should be more careful about the current position of their satellites and shuttles(Hu, 2012). The waste materials of the rocket booster are one of the main reasons for collision. After the fired off the booster, the layers of the rocket was separated in the orbits of the earth. On the other hand, the astronauts need to focus on the used materials of themselves should be preserved safely. Talking about the fuel containers that should be handled by experienced astronauts because the explosion of fuel tanks is the significant cause of the collision(Rae, n.d.). Impacts of Space Debris Environment on the Space System Operation The four factors determine that how space debris environment affect the operation of a space system. They are: Time in orbit Orbital altitude Projected area Orbital inclination From the above four factors, time in orbit, orbital altitude and projected area are the dominant factors(Bohannon, 2015). During shuttle mission, satellites also collide which results in large space debris. Apart from large debris, small debris has also caused damaged to operational space systems(Haugen, Musser Lovelace, 2010). The damage can be divided into two parts. The first category of damage is caused to subsystems or surface and the second category is the effect on operations. When other explorers come to space to explore and invent innovative ideas, concepts and planets, they face serious problems with millions of space debris floating in space during their journey(Kortenkamp, 2008). Here are some examples of damage that impact the surface of operational system: The shuttle windows get damaged. The severing of SEDS-2 or Small Expendable Deployer System-2 tether. Other exposed shuttle surface get damaged. HST high gain antenna also gets damaged. During the wide field imaging, the astronomers observe an increase in some trails per plate. These trails are caused by space debris. The space debris trailing entirely negate photometric observation when debris crosses narrow photometric field(Watson, 2015). Impacts of Global Warming and its Measurements As stated by scientists about the model of the climate, that, during the 21st century there will be an increase in temperature of 1.1 degree Celsius to 2.9 degree Celsius. This temperature is the lowest emission scenario and 2.4 degree Celsius to 6.4 degree Celsius is the highest(Dickey Zakaib, 2011). The scientist predicts that a rise in temperature of more than 2.5 degree Celsius could result in great losses in GDP or Gross Domestic Product. The increase in temperature also affects hundreds of millions of people via the increased coastal flooding, increase in health impacts as well as the reduction of water supplies. On the other hand, glaciers have shrunk, lakes are breaking up earlier, plants and animal ranges have shifted, and trees are flowering sooner. According to Intergovernmental Panel on Climate Change or IPCC, the extent of changes in climate impacts on particular regions(Budzianowski, 2011). They will vary over time as well as with the ability of various environmental an d societal systems for mitigation or adaption for a change. Different fuels which can cause global warming is used by spacecraft. However, all the above effects are caused by the spacecraft and its components used. Effective measures to reduce global warming caused due to space debris Here are some ideas for solutions from space("Erratum", 2015). These solutions are however tough and imaginary to accomplish, but the implementation will be different from the ideas. 1. A big asteroid should be dragged with a mass larger than 500000 tons to hide a part of the sunlight. 2. The upper parts of the clouds should be whitened to increase the reflectivity by 3 percent. It will also reflect a larger amount of sunlight(Zastrow, 2014). 3. A big mirror should be launched with a surface are of a 1600000-kilometer square, or many smaller ones circling round the earth. They will reflect 1 percent of sunlight. To normalize the temperature of the earth, this would be enough(Simon, 2010). Now, some realistically possible ideas should be followed for solutions from space. They are as follows: 1. During the space exploration, astronauts should take less amount of principal products with them to minimize the production of waste(Sparrow, 2012). They should make reusable products instead of disposable products. The spacecraft should have a reusable unit where used products are reproduced again for further use. 2. On the walls of the spacecraft and rocket, insulation should be added to minimize the production of heat. While sleeping time, astronauts should switch off the engines to reduce heat production. As a result, global warming will not rise(Allin, 2011). Conclusion During any space mission, when space shuttle leaves Earth and enters the space, it leaves behind the parts in space which is not required for their whole journey. These parts help a space shuttle to leave the earth against the gravitational force. These parts cause space debris. This space debris falls in the category of large space debris. It is a type of pollution caused by humans. Apart from soil, water and air, space is also polluted. It is the responsibility of the science and humans to keep a neat and clean space. References Baiocchi, D., Welser, W. (2010). Confronting space debris. Santa Monica, CA: RAND. Bohannon, J. (2015). Video: Watch 60 years of space junk accumulate in 1 minute. Science. https://dx.doi.org/10.1126/science.aae0154 Budzianowski, W. (2011). Time delay of global warming. International Journal Of Global Warming, 3(3), 289. https://dx.doi.org/10.1504/ijgw.2011.043424 Dickey Zakaib, G. (2011). Telescope will track space junk. Nature. https://dx.doi.org/10.1038/news.2011.254 Haugen, D., Musser, S., Lovelace, K. (2010). Global warming. Detroit: Greenhaven Press. Loomis, I. (2015). Private firms spy a market in spotting space junk. Nature. https://dx.doi.org/10.1038/nature.2015.18425 Simon, S. (2010). Global warming. New York: Collins. Sparrow, G. (2012). Space exploration. Mankato, Minn.: Smart Applie Media. Watson, T. (2015). Incoming space junk a scientific opportunity. Nature, 526(7575), 621-622. https://dx.doi.org/10.1038/nature.2015.18642 Zastrow, M. (2014). NASA decides to bag an asteroid / bring home asteroid chunk. Nature. https://dx.doi.org/10.1038/nature.2014.16597 Allin, C. (2011). Atmosphere and air pollution. Ipswich, Mass.: Salem Press. Anderton, J. (2011). Debris. Oxford, UK: Angry Robot. Bueren, E., Bohemen, H., Visscher, H. (2011). Sustainable Urban Environments. Dordrecht: Springer Verlag. Draper, S., Watson, J. (2006). The space mission adventure. New York: Aladdin. Erratum. (2015). Artificial Satellites, 0(0). https://dx.doi.org/10.1515/arsa-2015-0011 Hu, W. (2012). Advances in electric and electronics. Berlin: Springer. Kortenkamp, S. (2008). Space junk. Mankato, Minn.: Capstone Press. Rae, B. Collision. Stabroth, S., Homeister, M., Oswald, M., Wiedemann, C., Klinkrad, H., Vrsmann, P. (2008). The influence of solid rocket motor retro-burns on the space debris environment. Advances In Space Research, 41(7), 1054-1062. https://dx.doi.org/10.1016/j.asr.2006.12.024 Stjerna, M. (2013). Mission Space. Cork: BookBaby. Williamson, M. (2006). Space junk makes an impact. IEE Review, 52(1), 40-44. https://dx.doi.org/10.1049/ir:20060105