National Museum of the American Indian (The Smithsonian Institution, Term Paper

National Museum of the American Indian (The Smithsonian Institution, Washington, D.C.) - Term Paper Example as the past were key parts of the plan idea: â€Å"it should have been a living exhibition hall, neither formal nor calm, situated in nearness to nature.† The area which was picked for the historical center contained a stream, and this regular element, alongside the bearings of the road outside and the common north, south, east and west headings were considered. This is on the grounds that local Indian culture puts high an incentive on congruity between all parts of human life and the normal world and much more profoundly: â€Å"the grounds encompassing the structure are viewed as an augmentation of the structure and an indispensable piece of the exhibition hall as a whole.†2 The Seattle conceived engineer, Johnpaul Jones, who is of Choctaw, Cherokee and Welsh legacy, talked with a broadly drawn gathering of local seniors and they chose early that the structure and encompassing region would be not the same as the neoclassical or pioneer historical center styles: â€Å"The gallery doesn’t have a straight line in it, and is intended to look as if wind and water cut its curves†¦Ã¢â‚¬ 3 These bended outside dividers are the primary component to strike the guest who shows up by walking: â€Å"Theres a great new nearness transcending the elm trees on the National Mall in Washington, D.C., - and dislike whatever else youll see there. Maybe a dream from an old bluff city of the desert Southwest - five stories worth of nectar hued limestone, harsh slashed as though by the breeze yet streaming like a waterway of bending cantilevered dividers - had been thudded down at the secondary passage of the U.S. Capitol.†4 The site was analyzed by the local seniors, who distinguished a main issue and covered a mystery object there. This spot currently lies at the focal point of the domed Potomac chamber which misleads the east of the passage region. The passageway was not situated to confront the Mall, yet rather it looks east towards the rising sun and, unexpectedly, towards the U.S. Legislative center. The stream was regarded with the formation of a wellspring and a

Economic Profile for the Airline Industry Essay

Monetary Profile for the Airline Industry - Essay Example At long last the paper watches the impact of legislative approaches on the achievement and disappointment of the aircraft business. The deregulation of the US aircraft industry went before that in the European market by around 10 years (Alderighi et al, 2004, p. 2). In any case, on the two landmasses the procedure of deregulation and privatization actuated significant basic changes. Deregulation permitted numerous transporters to sign partnerships to abuse economies of scale (Alderighi et al, 2004, p. 2); scaled down value levels and extended the quantity of administrations. It influenced the business structure and elements both on the flexibly and request side. In the aircraft business there are two kinds of organizations - customary bearers and minimal effort firms (Alderighi et al, 2004, p. 7). Customary organizations offer items with various quality - economy and business - at various costs and can give a full scope of items and administrations at a greater expense. Minimal effort transporters offer a limited scope of administrations at much lower costs. This is along these lines, on the grounds that customary full-administration bearers with center point and-talked frameworks have a significant expense plan of action, while ease transporters have a minimal effort plan of action (Gillen et al, 2004). Value flexibility of gracefully gauges how the provided amount reacts to changes in costs (Mankiw, p. 100). In the light of the aircraft business, flexibility of gracefully implies the degree to which carrier organizations can alter the quantity of trips for the distinctive carrier fragments. Given the high upkeep costs, escalated capital structure inside the business (Skapinker, 2001), additionally the exacting guidelines and diminished adaptability in showcase conduct, there are very few open doors for fast changes in carrier travel flexibly, implying that in the short-run gracefully is inelastic. As time goes on period, however, as history has demonstrated, the business can adjust to evolving request. One model is the deregulation in the business that essentially expanded gracefully in the course of recent years (Alderighi, 2004). 5. Industry request The procedure of globalization has expanded versatility of merchandise and individuals (Alderighi et al, 2004, p. 3). On one hand development of payload transport has fundamentally expanded the interest for aircraft transport. On the other, visitor explorers progressively appreciate the solace of aircrafts. It can consequently be presumed that the carrier showcase request contains distinctive market fragments, in view of shopper type, separation and area. Business voyagers structure the alleged solid market (Adlerighi et al, 2004, p. 7) though the feeble market involves relaxation explorers. Furthermore, the movement advertise is isolated into long stretch and short-pull travel, and universal, and North American long stretch travel (Gillen et al, 2004). 6. Value flexibility of interest Value flexibility of interest quantifies the level of responsiveness to change in costs of charges (Mankiw, p. 90). Since the carrier business request is shaped by two totally different kinds of customers - business and relaxation - there is no single flexibility esteem for the aircraft travel request (Gillen et al, 2004). Value versatility of interest is likewise impacted by time and separation viewpoints. This is along these lines, in light of the fact that

SUMMARY South African Opposition Picks New Voice Essay

Zoonotic Diseases Essay Example

Zoonotic Diseases Essay Conceptual This report presents a joined epidemiological and financial structure for surveying zoonoses utilizing a ‘‘one health’’ idea. The system takes into consideration a comprehension of the cross-segment monetary impact of zoonoses utilizing improved hazard examination and posting a scope of expository instruments. The objective ofâ the structure is to interface the check yields of creature and human infection transmission models, financial impact models and appraisal of hazard the board choices to increase improved comprehension of variables influencing the acknowledgment of hazard the board designs with the goal that speculation arranging incorporates the most encouraging mediations (or sets of intercessions in a coordinated manner). A progressively complete comprehension of the expenses of the illness and the expenses and advantages of control measures would advance more extensive use of the most proficient and compelling control measures, adding to improved creature and human wellbeing, better employment results for poor people and macroeconomic development. Watchwords: Zoonoses, Tuberculosis, Brucellosis Acknowledgments/Foreword IN THE NAME OF ALLAH, THE BENEFICENT, THE MERCIFUL I might want to communicate my true appreciation to Relief International for monetary help and giving us the possibility of taking a shot at this task and commitment towards improvement of people and animals. We will compose a custom article test on Zoonotic Diseases explicitly for you for just $16.38 $13.9/page Request now We will compose a custom exposition test on Zoonotic Diseases explicitly for you FOR ONLY $16.38 $13.9/page Recruit Writer We will compose a custom exposition test on Zoonotic Diseases explicitly for you FOR ONLY $16.38 $13.9/page Recruit Writer I am thankful to my undertaking boss Dr. Dost Muhammad Baloch, co-manager Dr. Muhammad Azam Khan Kakar, Dr. Ejaz of RI, Dr Abdul. Rehman, the lab accountable for DI lab Quetta and every one of my colleagues companions for their benevolent co-activity and support for finishing this Project Successfully. I additionally offer my thanks to Department of Biotechnology and Informatics for giving the essential prerequisite to Completion of Work. Chapter by chapter guide Abstractii Acknowledgments/Forewordiii Table of Contentsiv List of Figuresv List of Tablesvi Terminology/Notationvii Acronyms/Abbreviationsvii. 1Introduction1 1. 1Statement of the Problem:2 1. 2Research Hypotheses:4 1. 3Significance of the Study:4 1. 4Purpose of the Research:4 2Literature Review5 3Materials Methods10 4Results/Discussion12 5Conclusions15 References16 List of Figures Figure 1: Cycle of M. Bovis Transmission among cows and people. The thickness of the bolts Suggests level of probability1 Figure 2: Spread of Brucellosis between steers Humans2 List of Tables Table 1: Animal Count Pishin Dist. (2005)10 Terminology/Notation Abbreviations/Abbreviations SppSpecies DLSDepartment of Livestock administrations T. B Tuberculosis L. ULivestock Unit Introduction The use Zoonoses, or Zoonotic sicknesses, are brought about by irresistible specialists that are transmissible under normal conditions from creatures to people. Zoonoses may ascend from wild or residential creatures or from results of creature source. Various irresistible sicknesses, including infections, microbes, and parasites, can be transmitted from creatures to individuals through an assortment of disease courses, including creature chomps, vectors (for example , bugs), and creature to-human contact (I. e. , inward breath of respiratory beads or skin-to-skin contact). A few instances of normal Zoonotic sicknesses incorporate lyme illness, rabies, ringworm, and plague. Zoonoses have been known since early authentic spells. There are heavenly references to contamination, a bacterial zoonoses mostly transmitted to people by insects; and a few antiquarians battle that an ailment initially portrayed by Thucydides during the Plague of Athens (430â€425 B. C. E. ) was typhus, a mite borne zoonoses. ). Certain zoonoses, for example, yellow fever, jungle fever, and rabies, are notable to the overall population, yet countless lesser-realized zoonoses exist in constrained cycles in various pieces of the world. There are without a doubt numerous zoonoses holding up in nature that can possibly cause genuine general wellbeing outcomes whenever brought into people. Figure 1: Cycle of M. Bovis Transmission among steers and people. The thickness of the bolts Suggests level of likelihood * Figure 2: Spread of Brucellosis between cows Humans *Statement of the Problem: The Department of Livestock administrations (DLS) has put forth a few attempts to actualize the guideline in Pishin locale of Baluchistan. Notwithstanding such endeavors are set up, customers are compelled to utilize unhygienic and lacking meat and milk; they will undoubtedly live with the danger of meat borne infections; and different instances of fakes accelerate occasionally The interest of meat and meat items are higher than the current flexibly for which meat industry relies upon import of live creatures from various territories. The interest for meat is more prominent than the gracefully from residential sources. In this vein, less writings keep up that the overall flexibly deficiency isn't just because of shortfall number of food creatures in Pishin yet in addition due to disapproval of privately delivered meat by the inhabitants. There is absence of research exercises on meat borne sicknesses; it is periodic and secluded in nature, and the aftereffects of the greater part of them stay as undocumented discoveries. A portion of the Literatures report the commonness of bacterial, viral and parasitic infections as meat borne zoonoses in region Pishin. Some of them are brucellosis, tuberculosis numerous other Zoonotic maladies. Scarcely any literary works contend that the impact of zoonoses may be minimal through meat utilization in Pishin because of predominant cooking style †fricasseeing the meat and afterward cooking in the weight cooker †in any case, it doesn't preclude the nonattendance of the spore shaping pathogens and conceivably their in-fabricated poisons in the cooked meat. As to nearness of pathogenic microorganisms, Gautam 2005 refered to in Sankhi (2006:110) has identified Salmonella Spp in wild ox meat, lamb and chicken; and Escherichia coli has been accounted for as the dominating microbes followed by Staphylococcus and Salmonella Spp, and other microscopic organisms of Entero-bacteriaceae family in crude meat acquired from bison, goat, cow, sheep and poultry in Pishin. A portion of these detailed microorganisms are strong makers of poisons which causes demise of people. Given these circumstances, it is clear that the meat and milk items secured, prepared and promoted in the region is hazardous for human utilization presenting potential general wellbeing perils. A comparable significant worry of meat area in Pishin is contamination of condition because of the waste results of meat produced from butchering and dressing activity. The butcher destinations are missing legitimate seepage channels just as waste removal framework; squander materials are arranged into region squander tank, avenues and open regions. Irresistible diseasesâ * Major reason for passings in people * Major monetary misfortunes in local creatures * Major reason for untamed life obliteration * Major effect on creating nations and neediness Issues incorporates * What is the momentum status of these irresistible infections? (T. B Brucellosis) * Do we realize what truly cause these maladies? * What might we have to know to foresee the rise and reappearance of an illness? Research Hypotheses: This Awareness among meat word related and purchasers helps execution of the Slaughterhouse and Meat Inspection Act in Pishin region. Arrangement of adequate administrative foundations bolsters the usage of Slaughterhouse and Meat Inspection Act in. Importance of the Study: The current investigation finds an extraordinary chance to do look into in the zone of meat and milk business in Pishin with specific accentuation to learn the usage status of Slaughterhouse and Meat Inspection Act in. Different discoveries of this investigation are useful in crossing over the information hole existing in the accessible literary works identified with execution of meat enactment in the zone. Moreover, the investigation opens up different measurements for the exploration exercises in regards to strategy execution process in meat division in the nation. The administration authority can have the chance to get essential modifications its current arrangements, systems, and projects and exercises dependent on the different discoveries of the current research study. Motivation behind the Research: * To see the creatures tainted with Zoonotic maladies (Tuberculosis Brucellosis) in Pishin area. * To screen out transporter creatures in the territory hence to create methodologies to forestall Brucellosis and tuberculosis in the region. Writing Review Zoonotic ailments are brought about by a wide range of pathogenic specialists. Much of the time, people are incidental or ‘‘spill-over’’ hosts of a sickness natural cycle kept up by creature has, including creepy crawlies (Kayali et al. 2003; Schelling et al. 2003). In view of the dissemination of Zoonotic specialists between creatures, people, and the earth, the expense of an ailment influences human movement and wellbeing notwithstanding other monetary areas. As indicated by the Institute of Medicine (2009), Zoonotic pathogens caused over 65% of developing irresistible ailment occasions in the previous six decades. The immediate expense of Zoonotic ailments in the course of the most recent decade has been assessed to be more than $20 billion with over $200 billion aberrant misfortunes to influenced economies overall (World Bank 2010). Over the most recent 60 years, many industrialized nations have effectively controlled or disposed of Zoonotic maladies through exorbitant open venture encouraging coordinatedâ interventions, including ‘‘test and slaughter,’’ feed bans, mass immunization of residential creatures and untamed life, wellbeing instruction and milk sanitization. These are exceptionally powerful strategies for taking out Zoonotic d

Essay Topics About Education

Essay Topics About EducationEssay topics about education cover many topics that have been discussed by most writers. This includes the basics, common topics and the more specific ones. There are some essays that deal with a lot of topics and are often confusing to the reader.Education topics are divided into many sections including the subject matter, such as English and Math. Then there are various theories and studies on the topics that are included in the topic. This may include learning styles, developmental disorders, body language and so on. As for learning styles, different people have different types of learning styles. Thus there is need to know all the different learning styles in order to be able to write about them properly.There are many different ways to research and do things to get the right facts. There are many ways to search through the Internet, books and magazines. Some students even go to the library to find out the facts they want to include in their essay. Oth ers would simply take the time to ask their teachers about their questions.Students and professors alike will have an opinion about the topics that are covered in an essay. These opinions will be influenced by the subject matter of the essay and the style of writing. It will also depend on the style of the teacher. That is why it is important to consider the style of the teacher before writing.Essays that deal with very specific topics may also be called special essays. In this case, all the students should have their own individual essays. This makes the class so much easier because every student has an equal opportunity to write their own essay. They will also learn to communicate with each other on topics and thus be more open to discussion on the topic.The importance of general knowledge must also be remembered. Many students tend to neglect the topic of general knowledge and this is where essay topics about education begin. It is very important to know how to present the inform ation in a way that all the students can understand it. This is not only a matter of information but also a matter of comprehension. Some students also forget some facts while others have a hard time remembering some of the facts.The concept of general knowledge should be included in all the topics about education. Not only does this make the topics interesting to the readers but also provides the students with a broader range of subjects to discuss in the classroom. This will help the students not only to learn more about the subject but also to learn how to read other people's body language. All these students can use this to further their communication skills.Students do not have to write the topic of their essay themselves. The school or the teacher can guide them in the right direction. They can even send them through a template of a topic that has already been covered.

Eryximachus The Role of Contradiction - Literature Essay Samples

Through all the speeches of the Symposium, Eryximachus’ speech may be the most difficult to understand. Looking at Eryximachus’ initial, more scientific approach to love, under which he views love as something that can be quantitatively measured, one many find it difficult to accept the more abstract arguments of a â€Å"universal† love that he poses later on in his speech. Thus, one can ask: Why does Plato present such a striking, almost contradictory, set of arguments within Eryximachus’ speech? The initial portrayal of Eryximachus shows him to be a man of science. From the very onset of Eryximachus’ speech he begins with the statement, â€Å"I feel sure it’s from medicine, my own area of expertise that I’ve realized how great and wonderful a god Love is, and how his power extends to all of human and divine life.† These words indicate a man who clearly takes pride in his occupation in medicine. This â€Å"pride† in his occupation then continues to manifest itself in his following arguments. As shown in the statement, â€Å"Love is not only expressed in the emotional responses of human beings to beautiful people, but†¦ in the bodily responses of every kind of animal, in plants growing in the earth,† Eryximachus’ pride in medicine is shown in his adherence to the belief that love can be viewed, and therefore explained, in terms of medicine and science. This â€Å"scientific† view is supported by the fact that Eryxima chus’ assertions imply that he believes that love is a quality that can be quantitatively measured. This is seen in his words â€Å"bodily responses† which supports the idea that Eryximachus believes that he can physically view and acknowledge the presence of love in all living things. Another important aspect of Eryximachus’ speech is seen in the very nature of the speech itself. Because Eryximachus’ speech is so distinct from the other speeches, it is clear that Plato uses this argument as a representation of a very specific way to view love. This tactic is seen in the fact that Eryximachus’ speech uses a disproportionate number of personal pronouns—the words â€Å"I† and â€Å"my†Ã¢â‚¬â€which supports the idea that Plato clearly desires to distinguish Eryximachus’ speech from that of the other characters by showing to the readers that Eryximachus, himself, believes his speech to be unique to the other speeches. In addition, Eryximachus’ first words, â€Å"This is what I think,† also provides another layer of separation between his speech and the other speeches by stating the obvious and asserting that what he is about to say about love is totally original. From the start, this separation between Ery ximachus’ speech and the other speeches helps provide a clear visual of how Eryximachus thinks, allowing readers to compare and contrast this line of reasoning with a different one in Eryximachus’ next argument. Eryximachus’ following argument portrays a very different line of reasoning from the argument prior. After speaking of the quantitative aspects of love, Eryximachus asserts a more abstract and philosophical argument, one that contends that love is a universal force. Eryximachus’ statement, â€Å"When those elements I mentioned before (hot and cold, dry and wet) are influenced by the well-ordered Love, they are in harmony,† provides a glimpse of the idea that love is far more than just a â€Å"bodily response,† but rather a universal force that rules the balance between opposite forces. This â€Å"universal† view of love is also shown in Eryximachus’ statement, â€Å"So Love as a whole has great and mighty—or rat her total—power, when you put this all together,† which portrays Love to be an omnipotent and all-encompassing power. In addition, the fact that the word â€Å"Love† is capitalized hints at the idea that Eryximachus views Love as a god, a view that adds to the more â€Å"abstract† and spiritual basis of his new argument. After reading the entirety of Eryximachus’ speech, one cannot help but to be confused. After all, Plato presents a striking dichotomy between Eryximachus’ arguments. On one hand, Eryximachus seems to adhere to the scientific method, on the other, Eryximachus seems to base his definition of love on philosophy. In fact, these very contradictions undermine Eryximachus’ speech rather than strengthen it. So why does Plato present Eryximachus’ speech in this manner? Perhaps, Plato is concerned with an idea beyond the topic of love. By giving such contrasting views of love, Plato subtly hints at his view of the relationship between science and philosophy. The very undermining of Eryximachus’ speech due to the two perspectives reflects Plato’s view that science and philosophy are incompatible. Perhaps more intriguing is the fact that because Eryximachus’ is a scientific man by trade, Plato is also asserting the shallow nature of science in ità ¢â‚¬â„¢s understanding of abstract qualities such as love. This negative view of Eryximachus by Plato is seen in the pompous portrayal of Eryximachus’ character. For example, Eryximachus’ statement, â€Å"I feel sure it’s from medicine, my own area of expertise, that I’ve realized how great and wonderful a god of love is†¦,† shows Eryximachus to be someone who repeatedly tries to remind everyone that he is a doctor, despite the fact that it is clear that the other characters already know that he is a doctor. It is the very weakness of Eryximachus’ speech that explains to the audience that men who base their views solely off science are incapable of understanding love and other ideals through the correct way of philosophy. Plato, therefore, may have created this dual-faceted argument in order to establish the idea that it is philosophy, not science, that is able to answer the truly important questions in life.

The Many Variations and Common Themes of Constitutions

After a war or a conflict between two countries or groups, laws are usually set out as a form of recovery for the country or group that fought in the war. This is known as a constitution, which aids to governing and shaping a country. A renowned example of a constitution is the United States constitution, which was written and ratified a few years after the American Revolutionary War. Not only does the U.S. have a constitution, but also France, Iraq, Vietnam, and other nations. Even ancient civilizations established one, such as Greece, Rome, Babylon, the Iroquois Confederacy, and others. Constitutions imply different themes, such as rights and justice, but imply one major theme. The constitutions of France, Iraq, the United States of America, Vietnam, ancient Greece and Rome, Babylon, and the Iroquois Confederacy all imply achieving righteousness through eliminating malevolence, just government, recovery from struggles, and justice. Hammurabi’s Code implies the message of achieving righteousness through the elimination of wickedness for the sake of the Babylonians. It is quoted that his goal for the civilization of Babylon is â€Å"to bring about the rule of righteousness in the land, to destroy the wicked and the evil-doers; so that the strong should harm the weak† (Hammurabi’s Code, Hammurabi, King of Babylon). His Code of Laws, which was based on â€Å"an eye for an eye† rule, implied harsh but fair consequences for citizens who transgressed the boundaries; this was Hammurabi’sShow MoreRelatedâ€Å" Compare and Contrast One Body of Work from Each of the Four Artist- John Glover, Russel Drysdale, Lauren Berkowitz Barbara Reid. in Your Discussion Address the Significance of Intentions to Their Practice.†1182 Words   |  5 Pagesresponses. Impressios of its power and beauty, expressions of individuals responses, symbolic religious orientation, the range of landscape a rt works extends onwards. 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Alexander The Great Of The Persian Empire - 1831 Words

Alexander the Great also known as the King of Macedonia and conqueror of the Persian Empire is reflected as one of the greatest military geniuses of all times. He was embalmed for later conquerors such as Hannibal the Carthaginian, the Romans Pompey and Caesar, and Napoleon. Alexander was born in 356 BC in Pella, the ancient capital of Macedonia. He was son of Philip II, King of Macedonia, and Olympias, the princess of neighboring Epirus. He came famous at a young age of 12. It was at that time when he showed his skills to his father and many others when he tamed Bucephalus, who was an unruly horse that no one could ride. Although Alexander encountered many obstacles throughout his conquests, he was able to maintain focus in his men as well as himself, which is why he was capable of accomplishing all that he did. Therefore, throughout Alexander’s conquest much of his success can be credited to his great leadership skills, which include his courage, confidence, respect for his men, and strategic military skills, which are all contributing factors to him becoming one of the greatest leaders in history. Alexander’s success arose during his childhood and carried over into his reign as king of Macedonia. Alexander was born on July 20 356 BCE in Pella, the capital of Macedonia, to his parents Philip II, king of Macedonia, and his wife, Olympias. Alexander grew up in royalty, which gave him interest in becoming king and ruling his own empire. Alexander’s father,Show MoreRelatedAlexander The Great : Alexander The Great And The Persian Empire930 Words   |  4 PagesAlexander the Great was skilled and respected military leader. After inheriting the throne from his father, King Philip II, Alexander would go on to conquer the Persian Empire, unite Greece and spread Hellenistic views across Greece. 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Not only did Alexander of Macedon conquer enormous areas of the known world but also he demonstrated dynamic leadership and masterful strategy on a large scale and tactics on the battlefield. During his life, he ruled the largest empire the world had ever seen, which stretched from ancient Greece to India. The son of King Phillip II of Macedon, Alexander was educated by the philosopher Aristotle and first led MacedonianRead MoreThe War Of The Persian War854 Words   |  4 Pagesof are the stories and the ruins of the city of Troy. Another famous war was the Persian wars. This war was the first big war between the persian empire and Spartans/Athens. After the Persian war, the Peloponnesian war took place, which was led by sparta. Than in Ancient Greece there were two main conque rors, Philip II and Alexander. As they are father and son, Philip II did a lot less than his son Alexander. Alexander wanted to fulfill his father s visions, which he exceeded his expectations. The

How to Make Fitzroys Storm Glass

Admiral Fitzroy (1805-1865), as commander of HMS Beagle, participated in the Darwin Expedition from 1834-1836. In addition to his naval career, Fitzroy did pioneer work in the field of meteorology. The Beagles instrumentation for the Darwin Expedition included several chronometers as well as barometers, which Fitzroy used for weather forecasting. The Darwin Expedition also was the first voyage under sailing orders that the Beaufort wind scale  was used for wind observations. Storm Glass Weather Barometer One type of barometer used by Fitzroy was a storm glass. Observing the liquid in the storm glass was supposed to indicate changes in the weather. If the liquid in the glass was clear, the weather would be bright and clear. If the liquid was cloudy, the weather would be cloudy as well, perhaps with precipitation. If there were small dots in the liquid, humid or foggy weather could be expected. A cloudy glass with small stars indicated thunderstorms. If the liquid contained small stars on sunny winter days, then snow was coming. If there were large flakes throughout the liquid, it would be overcast in temperate seasons or snowy in the winter. Crystals at the bottom indicated frost. Threads near the top meant it would be windy. Italian mathematician/physicist Evangelista Torricelli, a student of  Galileo, invented the barometer in 1643. Torricelli used a column of water in a tube 34 ft (10.4 m) long. Storm glasses available today are less cumbersome and easily mounted on a wall. Make Your Own Storm Glass Here are instructions for constructing a storm glass, described by Pete Borrows in response to a question posted on NewScientist.com, attributed to a letter published in the June 1997 School Science Review. Ingredients for Storm Glass: 2.5g potassium nitrate2.5g ammonium chloride33 mL distilled water40 mL ethanol10g camphor Note that man-made camphor, while very pure, does contain borneol as a by-product of the manufacturing process. Synthetic camphor doesnt work as well as natural camphor, perhaps because of the borneol. Dissolve the potassium nitrate and ammonium chloride in the water; add the ethanol; add the camphor. It is advised to dissolve the nitrate and ammonium chloride in the water, then mix the camphor in the ethanol.Next, slowly mix  the two solutions  together. Adding the nitrate and ammonium solution to the ethanol solution works best. It also helps to warm the solution to ensure complete mixing.Place the solution in corked test tube.  Another method is to seal the mixture in small glass tubes rather than using a cork. To do this, use a flame or other high heat to crimp and melt the top of a glass vial. No matter what method is selected to construct a storm glass, always use proper care in handling chemicals. How Storm Glass Functions The premise of the functioning of the storm glass is that temperature and pressure affect solubility, sometimes resulting in clear liquid; other times causing precipitants to form. The functioning of this type of storm glass is not fully understood. In similar barometers, the liquid level, generally brightly colored, moves up or down a tube in response to atmospheric pressure. Certainly, temperature affects solubility, but sealed glasses are not exposed to the pressure changes that would account for much of the observed behavior. Some people have proposed that surface interactions between the glass wall of the barometer and the liquid contents account for the crystals. Explanations sometimes include effects of electricity or quantum tunneling across the glass.

Television is the Downfall of our Society Essay - 616 Words

Television is the Downfall of our Society Can you imagine the actual number of people who watch T.V.? People spend more time before the television, than any other thing. Nowadays, even children, to be more specific, toddlers spend most of their time watching T.V. Shouldn?t they be playing with their toys inside or outside, playing in the yard, going to the park for a walk or to play on the swings and slides? Don?t you remember when you were young when your parents took you to the park? All kids went to the park, but nowadays, the park has been substituted with the television and video games (for youth). Maybe this is also a reason why many of our children are obese. Because the television producers have created television show†¦show more content†¦Noton?s World is a very good example of this also, because he performs experiments and talks about science and math during his show. Shows such as cartoons aren?t very educational; however, they can be very entertaining for these children. There are also shows, s uch as The Alyson?s Sisters, which deals with everyday occurrences that relate to them. These twins fall into this age group and the show talks of things that happen to them during and outside of school. For instance, the show talks about their first date, first dance, first kiss, first boyfriend, Etc. For teenagers, shows such as The Fresh Prince, Boy Meets World, Hang Time, Sister Sister, Family Matters, and Change of Heart are being shown on T.V. These shows usually are shown after 3:00 p.m. or during the weekend the time when teenagers are out of school. Teenagers watch these shows because they can relate to the characters. These characters go through the same things that teenagers go through. Sometimes, they wish that they could go through those awesome things that happen to those fictional characters. However, shows like the Jerry Springer Show, aren?t or shouldn?t be watched by teenagers, because it forces a way of being and thinking into their minds. If you have ever watched the Jerry Springer Show, you don?t want to be a guest, or you always say that won?t happen to me. But nowadays, a lot of teens are doing things that are seen in talk shows like the Jerry SpringerShow MoreRelatedThe World Of The Age Of Medi Entertainment And Relevancy985 Words   |  4 Pagesmost, the obtainment of our information that we are receiving is a mere means of entertainment thanks to the universalization of media and television. Postman discusses the consequences of living in a technologically advanced age by discussing four aspects of society that are most affected: the news, religion, politics, and education. Society has shifted from words of reason and sensibility to the epitome of trivial media content. The general overview of television is not what gives a problematicRead MoreThe Media And Its Impact On Society1430 Words   |  6 Pagesway that we are obtaining our information is a mere means of entertainment thanks to the universalization of media and television. Postman discusses the consequences of living in a technologically advanced age by discussing four aspects of society that are most affected: the news, religion, politics, and education. Society has shifted from words of reason and sensibility to an era with an epitome for trivial media content. Generally, the overall idea of television is not what makes it problematicRead MoreEffects Of Mass Media On The Media781 Words   |  4 Pages Another major development in the emergence of mass media was the invention of television. Television brought about news programs, reality programs, and product commercials along with many other types of informational programs. 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Video Game Video Games - 888 Words

Have you ever played or owned any type of video game? Video games are very addictive, especially your favorite one. Call of Duty is a popular video game that is full of violence and shootings. The quality of this video game looks just like real humans, shootings, guns, cities, towns, roads, etc. Call of Duty started off as a simple video game and is now expanding into a whole series that people keep purchasing. Children of all ages are involved in playing this game, and most people are against it. Call of duty has many negative qualities such as inactivity, and it causes violence in the world; however, its positive value is that it is used for entertainment. Judgment There are many different causes that end up causing obesity (â€Å"Obesity†). Today, more and more children around the world are becoming lazy and eating more and being less active (â€Å"Obesity†). Playing any type of video game, especially Call of Duty, is very addictive. It is addicting in a way that all the person is interested in is video games, and that is what their time is spent on. This causes inactivity, and inactivity causes obesity. Children are the main ones who are getting addicted to playing video games and it tends to make them sit down on the couch in a dark and gloomy room staring at a television playing the game all day long. Before they know it, twelve hours or more have passed and the whole day is gone. Over the course of those twelve hours and counting, three bags of chips, two boxes of macaroni,Show MoreRelatedVideo Games And The Video Game1299 Words   |  6 Pages  A video game is an electronic game that involves human interaction with a user interface to generate visual feedback on a video device such as a TV screen or computer monitor. The word video in video game traditionally referred to a raster display device, but it now implies any type of display device that can produce two- or three-dimensional images. The electronic systems used to play video games are known as platforms; examples of these are personal computers and video game consoles. These platformsRead MoreVideo Game : Video Games1658 Words   |  7 PagesVideo games first entered into the world around the 1970s, while the violence started occurring in the games about 20 years later (Anderson and Bushman 354). Some of the first violent video games included â€Å"Mortal Kombat, Street Fighter, and Wolfenstein 3D† which had amazing effects that were top notch at the time (Anderson and Bushman 354). Wolfenstein 3D was the first big video game that gave gamers the opportunity to shoot in the first person point of view (Anderson, Buckley, and Gentile 5). OverRead MoreVideo Games : Video Game1933 Words   |  8 PagesEnglish 132 9 March 2015 Video Games A video game is an electronic game that involves human interaction to generate visual feedback on a video device. 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Market Analysis of Green Kinetic Product Free Sample for Students

Question: Create a Marketing Plan to Introduce the Green Kinetic Product into the Melbourne Metropolitan Market. Answer: In order to introduce the Green Kinetic product into the Melbourne Metropolitan market, it is important to scan the micro and macro environments in this particular area. PESTEL analysis is an effective tool that can be used to assess the attractiveness of the market environment of a particular place (Strydom, 2006). The factors characterising this market analysis tool are outlined below. Political- Melbourne enjoys a stable political environment that is characterised by peace. There are no reported cases of conflicts in this city since these can negatively impact on the viability of business. This gives Green Kinetic Ltd the green light to invest in this city since its business operations will not be disturbed by conflicts. Economic- According to Invest Victoria (2016), this city is an affluent society where a two income family with children earns a weekly income ofA$2,346 while 32 % of one person households have a weekly income of between A$300 A$599 and more than 30 % of the residents in this city earn above A$1,000 per week. This shows that the economy is stable such that Green Kinetic Ltd can be in a better position to sustain its operations. Social- The demographic profile of Melbourne shows that it has a relatively young population out of the 4.5 million people in this city (Invest Victoria, 2016). This age group is widely viewed as technological savvy and they are likely to be attracted by the handsome features of the Green Kinetic product. More importantly, Melbourne is comprised of a well-educated and multicultural society with a good sized workforce constituting about 61 % of the population. This shows that here are quite a number of opportunities of grabbing a large market share for Green Kinetic Product given that the market in this city is comprised of many potential buyers. Technological- Melbourne is characterised by advanced information and communication technology such as the internet. The majority of citizens in this city have access to the internet and this can help Green Kinetic Ltd to successfully harness this communication tool for conducting business through online marketing. Environment- Environmental laws are enforceable in Melbourne and Green Kinetic Ltd will also be compelled to abide by them. Companies are compelled to ensure that they limit greenhouse gas emissions in their operations since these negatively impact on the environment. Legal- the legal framework in Melbourne guides the operations of various businesses in this particular city. For instance, the competitive laws are enforced to promote competition among businesses in a bid to improve the services offered to the consumers. In this case, it can be seen that Green Kinetic Ltd is not the only player in this energy sector since it is characterised by other competitors. As such, it can be concluded that the company stands better chances of successfully penetrating the Melbourne market since its product is characterised by key features that make it unique from other substitutes offered by other competitors. On top of that, the market is characterised by favorable conditions for business. References ABS (2016). Australian Demographics Statistics Catalogue, 3101.0. Invest Victoria, 2016. Greater Melbourne Demographics. Retrieved from: https://www.invest.vic.gov.au/resources/statistics/greater-melbourne-demographics Kotler, P. Armstrong, G. (2010). Principles of marketing. Cape Town, CT: Pearson. Strydom, J. (2006). Marketing principles. CT: JUTA.

Basic Accounting Assignment free essay sample

Generally Accepted   Principles, Balance sheet, Accounts receivable, Income statement, Debt, Liability, Double-entry bookkeeping system, Accounts payable 1- Explain the collecting, recording, classifying, summarizing, analyzing and reporting process of accounting. Collecting:- Data obtained from various sources with the help of appropriate measures is called collection of data. Recording:- Arranging the data into its chronological form is called recording of data. Classifying:- Division of data according to nature of events is called classification of data. Ledger is used for classifying transactions Posting is the process of transferring transactions from journal to ledger. Summarizing:- This involves presenting the classified data in a manner which is understandable and useful to the management and other interested parties. Follow statements are prepared:- Income statement Balance Sheet Cash flow statement Analyzing:- The comparison of data in a business is called analyzing of data. For example, analyzing of present data with past data, or actual data with projected data. We will write a custom essay sample on Basic Accounting Assignment or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Reporting:- Forwarding the results to financial users like chairman, directors, managers etc. is called reporting of data. Discuss in detail the nature of accounts i. e. assets, expenses, liabilities, revenues and capital by giving examples. Assets:- The resources of a business are called assets. They are of two types:- Fixed Assets: Land, Building, Equipment, Vehicle etc. Current Assets: Cash, cash at bank, A/c receivable, debtors, prepaid expenses. Expenses:- The amount spent in a business with a view to gain profit in the future is called expense. Examples are rent expenses, salaries expenses, advertisement expenses etc. Liabilities:- The financial responsibilities of the business for which it is liable are called liabilities. They are divided into two types:- Fixed Liabilities (Bank Loan, Bonds Payable, Mortgage Payable. ) Current Liabilities (Notes Payable, Unearned Income, Creditors. ) Capital:- The amount of money invested by the owner in the business is called capital. Revenue:- The incomes and the profits earned in the business through selling are called revenues. For example, Sales, Service revenue, Interest, commission earned. Drawings:- The amount of money taken away by the proprietor for personal benefits is called Drawings. 3- Describe the accounting rule of debit and credit for accounts like assets, expenses, liabilities, revenues and capital. Assets Increase in Asset is debit. Decrease in Asset is credit. Liabilities Increase in liabilities is credit. Decrease in liabilities is debit. Revenues Increase in revenues is credit. Decrease in revenues is debit. Expenses Increase in expense is debit. Decrease in expense is credit. Capital Increase in capital is credit. Decrease in capital is debit. Select any twenty categories from the above and identify a transaction that will have the required effect on the business. 1- Purchased Goods on credit 25,000. 2- Gave services for cash 5,000. 3- Brought cash in business 65,000. 4- Adjusting entry of out standing salaries 9000. 5- Wages wrongly debited to Sales 400. 6- Salaries wrongly debited to Drawings 600. 7- Paid to accounts payable in cash 1500. 8- Good s returned by customer worth 650. 9- Withdrew cash for personal use 550

Sample Residency Essay For Family Medicine

Sample Residency Essay For Family MedicineHere is a sample residency essay for family medicine. It is written for a family physician, but you can probably adapt it to fit other doctors as well. If you have any questions or concerns, it would be nice to have someone else point them out to you.Family medicine is a great choice for the residency application because there are numerous family-oriented and physician-oriented schools. The reason for this is that family medicine is a field that has always made a connection with the family. It is also a field that is expected to accept families. There is also a requirement that the applicant's children are under the age of 18.Many of the medical schools offer undergraduate programs, although they may focus on certain health care practices. The programs also may have to be accredited by the National Commission for Certifying Agencies. As you will be entering an elite medical profession, this means you will need to show proof of your competency . You can do this by submitting scores from CLEP or American Medical Association.Typically, the medical schools that offer courses for family medicine are not highly ranked or academically respected, so it is important to choose the right school. You may want to consider the holistic approach or holistic education that some of the programs offer. It is also important to consider what kind of health care practices you may have in mind, as a family physician will likely be handling a number of different patients at the same time.You will need to submit more than one essay to your medical school, and the format must match the ones given to the other applicants. In general, you will need to explain why you want to enter medical school. For instance, are you hoping to become a family doctor? This will tell the admissions committee a lot about you.While you may be concerned about the competition in the residency program, you should think of it as an opportunity to make an investment in yo urself. A residency can open many doors for you, and you will be setting up a career path. In addition, getting a degree in family medicine opens many doors to travel, advanced training, and employment. The key is to pick a school that has the flexibility to allow you to experience all the comforts of a formal, four-year program while doing all the research and general education required to make a professional career in family medicine. Only after you have decided on which school to attend should you start looking at the details of the application.Having done the application process for your residency, you should now be ready to turn it into an official record. You will have to send in the application and anything else you have, along with the recommendation letter from your teaching or supervising physician. If you have any relatives who are also doctor candidates, you can add a letter of recommendation from them, too. These are just a few of the requirements.

Spirit Catches You Essays - Anthropology Of Religion, Epilepsy

Spirit Catches You In the book "The Spirit Catches You and You Fall Down" by Anne Fadiman, a child named Lia Lee is taken away from her parents by Child Protective Services and placed in foster care. Because they aren't giving her medication for epilepsy. Although resulting in some medical benefits those benefits were lost because of destructive psychological and emotional damage to Lia. Dr. Neil Ernst decided to call child protective services when Lia Lee's parents Nou Kou and Foua were reluctant to give her her medicine. Dr. Neil Ernst said: "I felt it was important for these Hmongs to understand that there were certain elements of medicine that we understood better than they did and that there were certain rules they had to follow with their kids' lives. I wanted the word to get out in the community that if they deviated from that, it was not acceptable behavior."(pg. 79 Fadiman). Dr. Ernst could have also been arrested for not reporting it. There were some alternatives to calling Child Protective Services such as my favorite one; having a nurse visit the Lees' three times daily to administer the medications, but this thought did not occur to Dr. Ernst and/or seemed unreasonable at the time. Although Fadiman does not mention what Dr. Ernst thought about this course of action, I can only suspect that it would have been too expensive to have a nurse visit three times a day. Also they shouldn't be rewarded for their noncompliance by having someone else administer their daughter's medication. It might have also provoked the Lees' to anger because they didn't like to give Lia the medicine because of how the medicine made her depressed and sullen. After Lia was taken away for a period of a few weeks, Nou Kou almost beat an interpreter named Sue Xiong who was interpreting for a CPS (#) social worker. Nou Kou said: "I was outside and Sue came inside and she called me and said, Come in here, you come in here. At that time I was ready to hit Sue, and I got a baseball bat right there. My son-in-law was with me, and he grabbed me and told me not to do it."(pg. 91 Fadiman), so you can see the Lees' were violent natured. The second reason the Nou Kou and Foua did not want to give their daughter the medicine was that they believed like other Hmongs that people with epilepsy are caught by a good or bad spirit which makes them fall to the ground (the Hmong word for epilepsy translates into: the spirit catches you and you fall down) and while their under siege they get messages from the gods. Many people in their culture with epilepsy become cultural healers or shamans. The plan of sending a nurse would have been my plan. It would have been allot of time and money though. And when the Hmong community is already draining our resources through welfare doesn't make much sense to spend more money on them. It also would not have said that"our medicine is better" as good either. Although Dr. Neil's plan of letting CPS handle it worked out for him it did not work out for Lia for she had more seizures at her foster home with the medicine than at home with missed and half dosses. The reason is because she did not want to be separated from her parents, and the emotional damage from the separation. Some people would say it was selfish and lazy that Dr. Ernst did not at least try to use a nurse to administer the medication. I believe if I was Him that I would try sending a nurse for Two weeks to see if it would work and then make a decision. But on the other hand I believe that these stubborn, ignorant people shouldn't be pampered when they are already helping themselves to so much (#) from the tax payers through welfare. Because of these two issues of Dr. Ernst's quickness to make a decision, and the Hmong community taking so much and giving nothing back, it is hard for me to make a decision and I feel myself "slipping" towards Dr. Ernst's decision. I don't blame Dr. Ernst for his decision which I think is the most logical choice and even if he tried my Two weeks idea it still wouldn't make sending a nurse any less expensive. All I am saying is that he should not have worried about teaching the Hmong

A Growing Problem essays

A Growing Problem essays The escalating divorce rate is a growing problem in American culture and will not get better unless drastic steps are taken. Divorce rates have steadily increased in the United States since the early 1920s. In 1920 there was approximately 13.4 divorces per 100 marriages. In the 1988 it jumped to 32.8 divorces per 100 marriages and at present it is close to 50 divorces per 100 marriages and climbing (divorce rates chart). Researchers say that the fastest growing marital status category in America is divorced people. I believe something needs to be done to preserve the once sacred institution of marriage and family values in the United States. Divorce has a profound impact on children. Children of divorce are 3 to 4 times more likely to have psychological problems, juvenile delinquencies and suicide among other detrimental problems. A child of divorce is more likely grow up and be in a marriage that ends in divorce. The child is more inclined to view divorce as an easy way out of a situation instead of working on their marital problems. They feel divorce is an acceptable option as they have seen their parents divorce. Here are few of the important factors that I believe contribute to the ever-escalating divorce rates in the United States. First, lawmakers enacted the no-fault divorce law in the 1970s. Researchers believe that the new law caused an explosion of divorces. A no-fault divorce is one in which neither spouse blames the other for the breakdown of their marriage. Both spouses agree that irreconcilable differences have arisen and that their marriage is irreparable (no-fault divorce). A no-fault divorce does not require proof in a court of law by the divorcing party. Essentially a no-fault divorce makes it much easier and much faster to get a divorce. Currently, divorce laws in nearly every state give greater legal rights to spouses who want to end the marriage than ...

Contract law, Doctrine of consideration Case Study

Contract law, Doctrine of consideration - Case Study Example Professor Patrick Atiyah1. Consideration can be defined as "An act of forbearance of one party, or the promise thereof, is the price for which the promise of the other is bought, and the promise thus given for value is enforceable." F. Pollock2. A redundant or free promise is hence, legally unenforceable. Such promises do not involve consideration and consequently, they are not regarded as contractual promises unless made as a formal contract by deed. In English Law a promise made under contract is unenforceable in the absence of consideration. Further, the legitimacy of a simple contract can be ensured only if there is consideration from the party accepting the offer. Increasingly, judges are being encouraged to find consideration in cases; this is so that contractual claims can be assessed on the basis of the real intention of the contracting parties to one and another, rather than a strict and narrow interpretation of case law. Consideration is only at issue in simple contracts, Courts often have to find consideration to be able to infer that a contract exists. In a Contract By Deed, consideration is unnecessary; as it is clear what is due form whom. In addition, where the traditional narrow view of consideration may lead to inconsiderate results, Courts may accept a request for applying the principle of equitable estoppel. Therefore, a contract which contains promises unsupported by consideration is void ab initio. Valid consideration has the following features: 1. Consideration must move from' the offeree to the offeror, that is, the person making the offer must be expecting something in return. 2. Consideration must be something of value, however trifling to the offeror, or something of detriment to the offeree. 3. Consideration must be sufficient in law, but need not be sensible in fact. An offer of sale of a Rolls Royce Car for 1 is valid consideration though not sensible. However, if this car is offered gratis, there is no consideration and the agreement is unenforceable. 4. Consideration must impose an obligation in the future; it is unusual and inadequate to base an offer on past consideration3.In the case Currie v Misa it was held that, "A valuable consideration, in the sense of law, may consist either in some right, interest, profit or benefit accruing to the one party, or some forbearance, detriment, loss or responsibility given, suffered, or undertaken by the other"4. Hence, reciprocity is essential to the doctrine of consideration, in other words, a promisee cannot enforce a promise unless he has

The role of the brain in addiction Essay Example | Topics and Well Written Essays - 2000 words

The role of the brain in addiction - Essay Example Photoreception and Signal Transmission: The photoreceptor cells of the retina are the cones and rods. Light stimulus causes changes in the visual chemical of the cones and rods producing a receptor potential. This passes through the bodies of the rods and cones and acts at the synapses to induce a signal in the bipolar cells. This signal is then transmitted to the ganglion cells. The axons of the ganglion cells leave the eyeball posteriorly to become the optic nerve. The two optic nerves enter the cranial cavity and join to form the optic chiasma. In the optic chiasma, the axons from the nasal (medial) halves of the retinas cross over to the opposite sides. From the optic chiasma on either side of the brainstem, the optic tracts continue. The optic tracts relays information to the LGB (lateral geniculate body) of the thalamus. From here, information is carried to the occipital lobes of the cerebral cortex, where the information is perceived as conscious vision. Due to the crossover, the right visual field is perceived within the left hemisphere, and the left visual field is perceived within the right hemisphere (Lesson assignment, n.d.) The nervous pathways for sound The neuron associated with the hair cells of the organ of Corti (located in the basilar membrane of the inner ear) carries the sound stimulus to the brainstem. Through a series of connections, the signal reaches Brodmann's area number 41, in the temporal lobe of the brain where the stimulus is perceived as sound.

An audit looking at how many patients are with thyroid dysfunction

An audit looking at how many patients are with thyroid dysfunction What is the function of thyroid gland and thyroid hormones The thyroid gland is located in the anterior part of the neck, attached to the thyroid cartilage. It consists of two lobes, approximately 5 cm each, that lie either side of the trachea joined in the middle by an isthmus. The thyroid gland is responsible for the production of three thyroid hormones: Calcitonin (involved with calcium homeostasis), Thyroxine (T4) and Triiodothyronine (T3). Everyday, approximately 100  ¿Ã‚ ½g of T3 and T4 are secreted 90% of which are in the form T4. Most of T4 is later converted to T3 in the liver and Kidneys. T3 is 10 times more active than T4. [1] The thyroid hormones are responsible for the control of basal metabolic rate. Expand? How is Thyroid hormone regulated The functional unit of the thyroid is the follicle. A spherical arrangement of secretory epithelial cells around a protein rich colloid. It is at this cell-colloid boundary that thyroid hormones are formed by iodination of thyroglobulin formed from tyrosine.[1] The follicular cells are involved in active absorption of iodine from the plasma which is required for thyroglobulin synthesis. The formed thyroid hormone is stored in the colloid until its secretion is triggered by thyroid stimulating hormone from the anterior pituitary which triggers the degradation of thyroglobulin in the follicular cells to release thyroid hormone. Thyroid hormone secretion is under the control of the hypothalamic-pituitary axis. The hypothalamus releases Thyrotrophin Releasing Hormone (TRH) which stimulates the anterior pituitary to secrete Thyroid Stimulating Hormone (TSH). The TSH reaches the thyroid where it binds to the TSH receptors on the surface of the follicular cell, stimulating it to produce and release thyroid hormones. The homeostasis of thyroid hormone concentration is maintained by a negative feedback loop whereby increased concentration of thyroid hormone inhibits Thyroid Stimulating Hormone release from the anterior pituitary by decreasing the affinity for TRH. This leads to a decrease in TSH causing reduced amount of thyroid hormone to be released by the thyroid gland. This feedback loop enables us to monitor patients on thyroid hormone replacement therapy (such as Levothyroxine) by measuring TSH levels. If for instance the prescribed dose is insufficient, it would lead to inadequate inhibition of the pituitar y gland and a raised serum TSH level. The reverse would occur with levothyroxine excess. () This cannot be done in patients with secondary hypothyroidism. So what do we do then? Common pathologies Thyroid disease is the second most common endocrine disorder after diabetes.  ¿Ã‚ ½ Hypothyroidism Hypothyroidism is defined as an underactive thyroid gland leading to decreased levels of T3 and T4. The annual incidence of hypothyroidism in the UK is 4 per 1000 in women and 0.6 per 1000 in men.[3] Symptomatic hypothyroidism is known as myxodema. Hypothyroidism is categorised into primary and secondary. Primary hypothyroidism results from disease processes affecting the thyroid gland itself, slowly decreasing thyroid function and thyroid hormone production. Onset of symptoms is therefore gradual, developing over months or even years. Secondary hypothyroidism is relatively uncommon. Secondary hypothyroidism develops when the pituitary is unable to produce enough TSH to induce enough T3 and T4 production from the thyroid gland. The causes of secondary hypothyroidism can include a pituitary tumour. Patients with hypothyroidism could present with a number of signs and symptoms including:  ¿Ã‚ ½ Tiredness  ¿Ã‚ ½ Somnolence  ¿Ã‚ ½ Slow cognition  ¿Ã‚ ½ Cold Intolerance  ¿Ã‚ ½ Depression  ¿Ã‚ ½ Bradycardia  ¿Ã‚ ½ Weight gain  ¿Ã‚ ½ Calf stiffness  ¿Ã‚ ½ Menstrual disturbance  ¿Ã‚ ½ Carpal tunnel syndrome  ¿Ã‚ ½ Hearing impairment  ¿Ã‚ ½ Dry, thin and pale skin  ¿Ã‚ ½ Puffiness below the eyes  ¿Ã‚ ½ Bradycardia The most common cause of primary hypothyroidism in the UK is autoimmune thyroiditis. In Hashimoto ¿Ã‚ ½s thyroiditis autoantibodies are produced against thyroglobulin. This leads to inflammation of the thyroid gland as it is infiltrated by lymphocytes causing goitre formation. Hashimoto ¿Ã‚ ½s thyroiditis is remarkable in this respect that it initially causes hyperthyroidism as inflammation of the thyroid gland releases stored thyroxine. Once this released thyroid hormone is metabolised the patient progresses to normal and then a hypothyroid state. [1] Other notable causes of hypothyroidism include:[4]  ¿Ã‚ ½ Iatrogenic: Radioiodine ablation or thyroidectomy as a treatment for hyperthyroidism  ¿Ã‚ ½ Thyroiditis: Subacute (de Quervain ¿Ã‚ ½s) thyroiditis  ¿Ã‚ ½ Drugs: Lithium, Amiodarone, thalidomide, rifampicin and sutinib as well as drugs used in the treatment of hyperthyroidism  ¿Ã‚ ½ Iodine deficiency: common in some developing countries but very rare in the western world At the opposite end of the spectrum lies Hyperthyroidism where there is increased Free T4 and a reduced level of TSH and has the opposite effect on the body than the one noticed in hypothyroidism e.g. tachycardia, heat intolerance etc. Hyperthyroidism is not covered further as this audit focuses on hypothyroidism. Diagnosis and treatment Symptoms of hypothyroidism are quite non-specific and can commonly occur with other medical conditions not related to the thyroid. Diagnosis of hypothyroidism therefore should not be made on clinical symptoms alone and it is essential to test thyroid function biochemically. This is done by measuring Thyroid Stimulating Hormone and Free Thyroxine (T4) in blood. The normal reference range for TSH is 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4] A TSH level within the normal reference range has over a 99% predicted value to rule out primary hypothyroidism or hyperthyroidism.[5] In hypothyroidism the patient would have a high Thyroid Stimulating Hormone level, with or without a low Thyroxine level. Depending on thyroid function tests hypothyroidism is further divided into: a) Overt hypothyroidism: patients with a high Thyroid Stimulating hormone level and a Low serum free Thyroxine (T4) b) Subclinical hypothyroidism: Patients with a high Thyroid Stimulating Hormone but a normal Thyroxine (T4) level Treatment depends on whether the patient has overt or subclinical hypothyroidism. Patients with overt hypothyroidism should be treated with Levothyroxine to render them  ¿Ã‚ ½euthyroid ¿Ã‚ ½.[5] According to NHS statistics 12 million Levothyroxine prescriptions were issued during 2006.[6] The goal of the treatment is to reduce the TSH back to within the reference range. The dose of Levothyroxine is usually titrated up from 25-50  ¿Ã‚ ½g daily however a recent trial has shown that this is unnecessary for most patients.[7] The study recommended that patients with no cardiac symptoms should be started on the full dose of 1.6  ¿Ã‚ ½g/kg. The following figure illustrates the algorithm for treatment of -pregnant adults with primary hypothyroidism:[4] Algorithm for management of non-pregnant adults with primary hypothyroidism [4] It is very important to monitor levothyroxine therapy as over or under prescription can be dangerous. Thyroid Stimulating Hormone (TSH) is the key method of monitoring levothyroxine therapy in patients with primary hypothyroidism. Unlike the thyroid function tests used to diagnose thyroid disease, free T3 and T4 levels are not very useful in monitoring treatment as their levels are influenced by the prescribed dosage of thyroid replacement hormone and are not accurate indicators of the individual ¿Ã‚ ½s requirement. TSH without T3 and T4 is also a cheaper test to carry out in General Practice. Current guidelines state that patients should have their Thyroid Stimulating Hormone level tested eight to twelve weeks after starting levothyroxine.[4] The dose can later be fine tuned accordingly to get the TSH level in the lower half of the reference range.[5] Besides monitoring TSH levels, an assessment of the patient ¿Ã‚ ½s symptoms should also be made as some younger patients may need higher doses to relieve their symptoms in which case it is acceptable to have the TSH between 0.1-0.4 mU/Litre. The Quality and Outomes Framework (QOF) guidance suggests that all Patients on long term thyroid hormone replacement therapy should have their TSH levels tested yearly to make sure their replacement dose remains optimal.[8] Audit 1. Reason for audit move it to the top to include the rest of the study Despite the yearly TSH tests, studies have shown that a considerable number of hypothyroid patients managed in primary care have TSH levels outside of the reference range. Okosieme et al reported that in 2009 data collected from 11 GP practices showed that 37.2% of the 1037 patients on the hypothyroidism register were inadequately managed.[9] When we take into account the high prevalence of hypothyroidism (9.3% in women and 1.3% in men)[3] the results of the Okosieme et al study suggests that the total number of patients with suboptimal thyroid hormone replacement is significantly large. Imperfect thyroid hormone replacement could have damaging repercussions for health. It may adversely affect blood pressure, body weight and lipid profile. Since the basal metabolic rate of the body is controlled by thyroid hormones it is perhaps not surprising that a decrease in thyroid hormone levels leads to a decrease in metabolic rate and thus can cause weight gain. Even in euthyroid subjects there is a negative correlation between free T4 and Body Mass Index (BMI).[10] This suggests that even a small under-prescription of thyroid hormones could, over a period of time, lead to obesity. Reduced Thyroxine levels also cause a dyslipidemia characterised by increased Low Density Lipoproteins (LDL) and a decrease in High Density Lipoproteins (HDL) with normal or slightly raised cholesterol levels.[11] Such a lipid profile is associated with a higher risk of atherosclerosis. The thyroid hormones also seem to have a role in blood pressure homeostasis as hypothyroid patients recorded a higher systolic and diastolic blood pressure after stopping thyroid replacement therapy.[12] Thus inadequate replacement may cause hypertension which, together with the dyslipidemia described above adds to the risk of atherosclerosis and its subsequent cardiovascular complications. Conversely, excessive thyroid hormone replacement has its own perils, having enhanced risk of atrial fibrillation, osteoporosis and fractures linked to it. Excessive thyroid hormone increases the risk of developing atrial fibrillation especially in older patients. Studies have shown that a low TSH level in patients over 60 years old have a threefold higher risk of developing atrial fibrillation.[13] Patients over treated with levothyroxine also show increased loss of bone mineral putting them at increased risk of osteoporosis.[14] Subsequent studies have shown that patients with a suppressed TSH i.e. = 0.03 mU/Litre also had an increased risk of fractures however this was not observed in patients with low but unsuppressed TSH (0.04  ¿Ã‚ ½ 0.4 mU/Litre).[15] This highlights the need for maintaining optimal thyroid hormone replacement in primary hypothyroid patients in the General Practice setting to reduce the above mentioned risk factors. The 11 GP practices used by Okosieme et al showed that there is significant room for improvement as one third of the patient population on levothyroxine had TSH levels outside the reference range.[0.11] Thus this is a worthwhile area for audit to establish current standards of care in our practice, Dr Dean Partners, Heald Green Health Centre. Since this audit has not been carried out before in the practice it would give an idea of how well the practice manages patients on thyroid hormone replacement therapy. The suggestions for improvement would be beneficial to the patients of the practice and might also help with obtaining QOF points. This audit would also be beneficial to me personally introducing me to the concept of audit cycles and giving me the opportunity to conduct my very first audit. It would also help me get a better understanding of management of hypothyroid patients which is the second most common endocrine disease in the UK after diabetes mellitus. 2. Criteria to be measured Serum Thyroid Stimulating Hormone is used as the gold standard for biochemically diagnosing hypothyroidism and monitoring thyroid hormone replacement therapy.[4] The reference range indicating adequate replacement is usually around 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4, 9] However this figure slightly varies according to local guidelines. For this I have chosen to use TSH between 0.1  ¿Ã‚ ½ 4.0 mU/Litre as a reference range for adequate thyroid hormone replacement as this is the reference range used by the local Primary Care Trust (Stepping Hill Hospital) and the practice. Patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 3. Setting standards For setting the standard I have found that there are no specific guidelines stating what proportion of patients should be achieving the above mentioned criteria. There are no NICE guidelines for the treatment of hypothyroidism. The QOF guidance states that patients should have their TSH levels tested yearly but it does not state the standard of care required. Having discussed this with GP at the practice I have decided that a theoretically ideal standard i.e. 100% of patients meeting the above criteria would be very impractical in theory from a resources perspective. Given the fact that suboptimal thyroid hormone replacement could be harmful, it is nonetheless important to achieve a high standard of care. Therefore I have decided on an optimum standard: 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 4. Preparation planning Before starting the audit I had a discussion with the GP tutor about worthwhile areas for audit. As I had never conducted an audit before he explained the audit cycle. As thyroid dysfunction was an area of interest for me I suggested undertaking this audit. The GP tutor agreed that this would be a useful area for audit and advised to me to review the literature to find out if it would be an appropriate audit from a clinical point of view and was an area where practice could be improved. After preliminary reading clinical reviews I formulated a step by step template of the things I felt should be covered and got the GP tutor ¿Ã‚ ½s approval to go ahead. The data was collected with the help of the GP tutor. As the practice keeps electronic records of all patients, EMIS Population manger search function. Using the search function we identified all patients who had been prescribed thyroid hormone replacement medication for the past 12 months. We then identified patients who in the past 12 months had had their TSH levels tested. We then selected patients who had a TSH =0.1 mU/Litre and TSH =4. Subtracting the number of patients which meet the TSH search parameters from the total number of patients on thyroid hormone replacement would give us the number of patients who were outside the reference range of TSH. 5. Initial data collection Criterion Number of Patients taking thyroid hormone replacement medication (n) Number of Patients with TSH levels within reference range Standard (%) Patients with primary hypothyroidism on thyroid replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 206 167/206 (81%) 90% Discussion Results: what they are. How close to the standard. Are they good enough? (no, didn ¿Ã‚ ½t meet the standards). Why didn ¿Ã‚ ½t they meet the standard? Merge results discussion with limitations discussion The data collected shows that the current practice is 9% below the standard set. The standard required i.e. 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. However this was the case with only 167 patients (81%). This means that 39 patients (19%) did not meet the standard set. There could be several reasons why the results did not meet the standards set. One factor influencing TSH levels is the use of medicines which interact with thyroid function. Due to the limitations of the software used in data collection (as discussed below) we were unable to exclude patients who were on medication known to interact with thyroid function such as Amiodarone, Lithium, etc. Amiodarone, a fairly commonly prescribed drug to prevent arrhythmias, can cause deranged thyroid function as it contains iodine (37mg of iodine in 100mg of Amiodarone). This can cause a severe iodine overload and can lead to hypothyroidism as well as thyrotoxicosis.[0.16] Inclusion of such patients would bring the percentage down unfairly because management of such patients is a lot more complex and the TSH levels are not always a good indication of the adequacy of their thyroid hormone dosage. Patients with hypothyroidism due to Amiodarone are monitored by their Free T4 levels instead of TSH. [0.16] Another factor which could have contributed to the high number of patients with TSH levels outside those defined in the criteria is the possibility that patients with abnormal TSH levels often don ¿Ã‚ ½t get their levothyroxine dose optimised. A study published in 1995 reported that at one GP practice in Suffolk 71% of patients with abnormal TSH levels did not have their medication dosage change as a result.[17] If patients do not have their thyroid hormone replacement optimised as a result of abnormal TSH not only does it defeat the purpose of carrying out yearly TSH tests, it also means that these patients would continue to have an abnormal TSH when tested again. Currently we do not have the data to find out how many of the patients in our practice with abnormal TSH had not had their dose changed after a previous abnormal TSH in an attempt to bring it within the reference range specified in the criteria. Ranging from poor patient compliance to the way the data has been collected Lack of dose adjustment after abnormal TSH The way results were collected. Limitations of software used. Limitations of the results collected ie things missed: how many patients actually had test done in the last 12 months (QOF points). How many were over and how many were under prescribed. This audit has limitations. The data was collected from electronic records using the EMIS Population Manager. The limited search algorithms of the software meant that we couldn ¿Ã‚ ½t distinguish patients with a TSH below the reference range from those above it. All we were able to obtain was a single figure of how many people were within the reference range. Due to the limitations of the EMIS Population Manager software we were also unable to test how many patients with hypothyroidism had actually had their TSH levels tested in the past 12 months as stated in the QOF guidance  ¿Ã‚ ½ 2004.[8] Thyroid Function Tests are done for a large number of patients whose symptoms are actually caused by a non-thyroid illness. Due to this reason we could not search for people who had their thyroid function tested in the past 12 months as that data would have included a lot of non-hypothyroid patients. Instead we had to search for patients who had been prescribed levothyroxine therapy in the past 12 months. And then further narrow the search parameters TSH levels in the past 12 months to obtain the data. This meant that the people who have not had their thyroid functions tested in the past 12 months were excluded from our data. The positive aspect of only testing people within the last 12 months is that the data reflects current level of care. The data collection software shows patients as being within the normal TSH range if they have had at least one TSH test within the normal range during the last 12 months. If the patient has been started on levothyroxine therapy recently their TSH levels wouldn ¿Ã‚ ½t have had enough time to return to normal. However this is likely to be statistically insignificant. The way to get round these limitations of the EMIS Population Manager would have been to study the clinical notes of all patients who were prescribed levothyroxine in the past year. By looking at the notes we would be able to exclude patients who are unsuitable for the purpose of this audit i.e. those patients in whom the TSH level is not a valid indicator of thyroid hormone requirement e.g. those on Amiodarone or lithium or patients with secondary hypothyroidism. Looking at the notes would also allow us to check the number of patients who had not had their TSH levels tested in the past year. Reading through the notes would also allow us to obtain more information such as age gender etc which might be helpful in indentifying some of the factors responsible for suboptimal thyroid hormone replacement. However reading the notes of over 206 patients would have taken a considerable amount of time. Since this was my first audit I decided to avoid gathering qualitative data and decided that the using electronic records would be sufficient for the purposes of this audit. Changes to practice to hit the target. Tietable to implement that change and when to re-audit? Practicality, why change? Positives and negatives of changing. There are a few approaches which could potentially be taken to improve the standard of care. In order to improve the standard of care to meet the goal of 90% all patients on the hypothyroidism register should have yearly or six monthly blood tests to measure their TSH levels. all patients with abnormal TSH levels should be invited for an appointment with the GP and should be considered for a change in their current dosage. This would be a good opportunity to assess why their TSH levels are abnormal and check that the patient is adhering to the prescribed treatment regimen. If the dose remains unchanged the reason should be recorded in the notes so that the information is available for the second cycle of the audit. Doing this will allow us to make sure that patients are kept at the optimum dose of levothyroxine to reduce the risks associated with under or over prescription. Seeing patients like this would however increase the workload placed on the surgery and its resources. However by talking the patients as and when they have their TSH levels tested the strain on the resources would be spread out over a year. Since the current audit identified 39 patients with abnormal TSH levels, this would mean an extra 3-4 patient appointments per month over the period of a 12 months. This should be discussed at the doctors ¿Ã‚ ½ meeting. Twelve months after the implementation of the change of practice a second data collection should be done to complete the audit cycle and evaluate the impact, if any, the change in practice has had on the management of hypothyroid patients. Write to the patients to invite them to come in for a dose adjustment? Consider collecting better data by reading the notes. That would take too long. Consider specialist referral if symptoms persist. What have I learned: 1 about the condition, 2 about auditing. Conducting this audit has given me the chance to take an in-depth look at all aspects of hypothyroidism which has been an area of interest for me for some time. In the course of researching for the audit I have been able to review various guidelines, clinical reviews and other journal articles. Not only has that improved my understanding of the management of thyroid disease in primary care immensely. It has given me a sense of how a condition is followed through in general practice from first presentation to treatment to long term management. I have also realised that management of chronic conditions such as hypothyroidism is an ongoing process as the patients ¿Ã‚ ½ condition and requirements change continuously for instance if their body mass index changes significantly their thyroid hormone requirements would also change and the dose would have to be altered. Also if a patient is planning on or has become pregnant they would need to be referred to specialist endocrinologists. I have been able to review the evidence which forms the basis of current practice. Researching this topic by reading clinical reviews has made me realise the advantages of using original literature and how much beneficial it can be in achieving a comprehensive understanding of a topic. Being involved in a general practice standard-based audit has enabled me to learn about the role and significance of audits in healthcare. I have become familiar with the audit cycle and its different steps. Having conducted an audit myself, I can see the important role audits have in measuring and improving practice. It is a systematic way of monitoring standards of care and is very useful in facilitating change of practice through an evidence based approach. It has also allowed me to learn how to quickly and efficiently find relevant papers using such resources as ISI Web of science and medline. Conclusion and summary Timetable change re-audit 6. Description of change 7. Data collection (2) 8. conclusions be almost impossible to achieve due to variables like poor patient compliance or use of interactive medications e.g. Amiodarone and Lithium. It would also be vastly impractical from a reasources point of view to aim for a 100% standard.