Infertility A Growing Public Health Issue - 1029 Words

Infertility is the inability to achieve and sustain a pregnancy to delivery after at least 12months of regular unprotected ejaculatory vaginal sexual intercourse with an adult of the opposite sex. Epidemiology It is estimated that an average of 10% of the global reproductive-age population is unable to get pregnant or carry a pregnancy to term (1) Infertility affects between 60 million and 168 million people worldwide; generally one in ten couples experience primary or secondary infertility (2).The majority of those who suffer live in the developing world. (3) Universally, the prevalence rises significantly (among women with no children) with a womans age. (1) Worldwide rates of infertility vary dramatically corresponding to the incidence of preventable conditions leading to infertility--from a core prevalence of about 5% to rates as high the mid-30s in sub-Saharan Africa(4).Rates of primary infertility are generally between 1% and 8% with rates of secondary infertility reaching as high as 35%(3).Most primary and secondary infertility in developing countries is attributable to infectious disease which could be preventable if diagnosed early and treated properly. Justification of Infertility as public Health Problem The consequences of infertility vary dramatically depending on many factors (social, cultural and religious).Unwanted infertility causes decreased levels of well-being, with more severe social, economic, and health consequences extremely common in the developingShow MoreRelatedMobile Phone Use And Semen Quality870 Words   |  4 PagesGrowing up in a technology based society has its perks, our society has endless amounts of information at our finger tips. But, the increase in cell phone usage has brought up many concerns relating to our health. When I think about these health concerns, I think about my mother lecturing me, â€Å"Katheryn Paige Leyde, take your phone out of your front pockets right now!† I would role my eyes, and pull my phone out of my pocket. I never really thought of technology as a health hazard, but my motherRead MoreDomestic Violence on Women in Society1730 Words   |  7 Pageshabitual pattern of aggressive behavior. Research shows that verbal abuse against women in Pakistan is 97.5% by the husband and 90.0% by their in laws. Prevalence of physical abuse is 80.0% and 57.5% by in laws. Financial issues are most common reason of violence followed by infertility and not having a son. Another cause is joint family system. The global dimensions of this violence are alarming, as highlighted by studies on its incidence and prevalence. The government is a crucial factor which can reduceRead MoreGenetically Modified Food And Its Effects On Our Health1256 Words   |  6 Pageseconomy, our health is at a much greater risk. The GM proponents claim that GMOs provide more nutritional value although, health issues have been proven to increase since the development of genetically modified food. Moving forward, many people are becoming aware of these GMOs i n our food and the harmful effects they can have on our health, bringing this awareness to the government. Genetically modified food has been proven to create health issues among humans such as, infertility, autoimmune diseaseRead MoreRich, Wealth, Poverty, And Healthcare Essay1619 Words   |  7 PagesJackeline Arias Radford Skudrna ENGL101 26 November, 2016 Rich in Wealth means Rich in health In the 2000’s health care costs began to rise again after having risen at â€Å"double the rate of inflation,† in the 1990’s, it left 44 million Americans with no coverage. Between other costs of living like, childcare, food, housing, and rising costs of healthcare, some struggling low-income families were forced to choose between one of those necessities or paying for their healthcare. A study by CNBC showedRead MoreSexually Transmitted Infections ( Stis )1305 Words   |  6 PagesThe Problem Sexually transmitted infections (STIs) are caused by bacteria, viruses, and parasites and are spread by sexual contact through vaginal, anal, and oral sex. This health issue is to discuss the growing rate of chlamydia infections occurring at an increased rate among sexually active women under the age of 25 years. The Centers for Disease Control and Prevention (CDC, 2015) has estimated 2.86 million infections are occurring annually in the United States. The highest risk group for chlamydiaRead MoreGenetic Modification : Genetically Modified Organisms1523 Words   |  7 Pagesthe safety of GMO products. There is now little research on the issue but it is really only happening in countries outside of the United States. We are unsure of the toxic residues in GMO foods, how much herbicides and pesticides remain in the food that we eat, and how much toxic residue is left on other crops. No long term testing has been performed to assess the impacts of these toxic substances on the envir onment or human health. The research that has been done has been performed on animals. TheseRead MoreObesity : The Struggle That Americans Face Today1070 Words   |  5 PagesNelson English 2010-045 31 October 2014 Why Are Americans Bigger? I write this proposal on obesity as it relates to the struggle that Americans face today. As a young child growing up, I had a struggle with being bigger. I was on the verge of becoming obese in the ninth grade. Weighing in at 260 lbs, with common health issue that I may be diagnosed with, I knew I must range my life for the better. Obesity, diabetes, and high blood pressure runs in my family, so it is not a surprise when a relativeRead MoreObesity : Obesity And Obesity892 Words   |  4 PagesMany people are unaware that more than third or 35.7 percent of adults are considered obese in America. In recent years obesity is the health topic of choice these days because obesity in America is a growing epidemic. One out of twenty people in America have extreme obesity. According to a 2009-2010 survey conducted by the National Health and Nutrition examination this data states that about one third of children and adolescents ages six to nine are considered to be overweight or obese. Adol escentRead MoreWhat Are Genetically Modified Organisms?880 Words   |  4 Pagesand viral genes that do not occur in nature, or through traditional crossbreeding methods. Most all commercial GMOs are engineered to withstand a direct application of herbicide and/or to produce an insecticide. Moreover, a growing body of evidence connects GMOs with health problems, environmental damage and violation of farmers’ and consumers’ rights. According to GMO facts and frequently asked questions, most developed nations do not consider GMOs to be safe. In more than 60 countries aroundRead MorePolycystic Ovary Syndrome Essay1031 Words   |  5 PagesThere is one dream that every little girl has when growing up, that is becoming a mother; to love and watch her children grow. No one ever dreams of that not happening to them or being part of that group being label as infertile. It happens to millions of women living in the United States every day. Polycystic Ovary Syndrome is the most common endocrine disease that affects women of reproductive age, which is typically puberty to menopause. Polycystic Ovary Syndrome does not only affect a woman’s

Analysis Of The Book Blown Up Bits By Hal Abelson, Ken...

Encryption in the book Blown to Bits by Hal Abelson, Ken Ledeen, and Harry Lewis is a brief recap of what happened before privacy became significant for people around the world. The industry and technological advancements for encryption began with the Egyptians who ciphered their language in Hieroglyphics around 2000 years ago. This creation led to a problematic industry in the Information Age because of hackers abusing privacy. Though the fraudulent consequences of privacy are not protected by any amendment limitless resistance to being exposed to personal information has been growing ever since the beginning of security standards. What happened on September 11th, 2001 was not merely an inevitable catastrophe because the FBI warned the US Government and president years before 911 occurred. Encryption being a safety requirement in our era is the encoding of the data transferring through communicative means. Anyone can have access to the data, however, there is a password when trying to steal or intercept someone s information. The best way to encode your translation of personal information between two or more people is by verbal communication through whispers and speaking softly. Regulating encryption has always been a request from the NSA and the FBI because of exchanging violent plans or initiatives to seek perilous outcomes. The government disrupts personal privacy because the problem has occurred around 200 years later and was not protected by the Founding Fathers or

The Play Arcadia Essay Sample free essay sample

Arcadia is a drama about the people who deals with life in a different position. It depicts the varied personalities and characters of every person. Each single portrays different functions to do the drama more exciting and meaningful to the audience. This drama besides exemplifies the difference between two periods of the English Literature—Enlightenment and Romanticism period. Enlightenment period trades with order. rational idea. conformance to accepted regulations and signifiers. looks at the classical Greeks and Romans as the prototype of simpleness. proportion. and reticent emotion in linguistic communication and art. Whereas. Romanticism exemplifies the antonym. It deals with abandon in nature. freedom. and it stresses individualism. The characters of the said drama were categorized into two—modern-day 1s and the romantics. The two classs have been confronting struggles in their point of position about life. The contemporary 1s are the intelligent persons. Their involvements were focused to mathematics and scientific discipline ; other genres have no involvement about to them. We will write a custom essay sample on The Play Arcadia Essay Sample or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The contemporary characters were Hannah Jarvis. Gus Coverly. Chloe Coverly. Bernard. Valentine. and Robert Noakes. They perceive the romantics as anchorite ( Septimus ) . They look at things into a more complicated manner. They think that they are far better than the romantics. Indeed. sometimes being intelligent causes persons to do things complicated. They even have the inclination to look at others to be smaller than them. Sometimes the complexness of head brings every person to judge people by merely establishing it with their ain theories. That entirely would make pandemonium non merely between persons. but to the whole universe.

Olivers ignorance Essay Example

Olivers ignorance Essay In both novels the sufferings by the main female and male characters are very similar. The main female character in Oliver Twist is Olivers mother. There is little told about her except the fact that she is dying from exhaustion from the journey to the workhouse and from giving birth to Oliver. The surgeon also discovers that she is not married, the old storyno wedding ring. I see Olivers father is unknown leaving the baby to be an orphan and the absence of wedding ring may suggest a poor relationship experienced. However, in Therese Raquin, Camilles mother, Mme Raquin does not experience death but his father is of absence as well. In this case, the poor relationship experienced is by another main female character, Camilles wife Therese. Zola ends the chapter by Thereses unusual responses, She cast a vague wandering look upon this wall, without a wordwent to bed in disdainful indifference. Therese has many thoughts before going to bed with her husband, Camille. The indifference of going to bed without joy every night resembles them experiencing a poor relationship. Thereses misery is caused by lack of love which may be due to Camilles sickness. Zola describes in the last paragraph, The husband who was always trembling with fever went to bed. By constantly dealing with fever, Camille is unable to take care of his wife or to show any love to her, this may be the reason why a poor relationship exists. Compared to Oliver Twist, there are no signs of concern shown by Olivers father as well. Both males are the cause of suffering to the females in the two novels. We will write a custom essay sample on Olivers ignorance specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Olivers ignorance specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Olivers ignorance specifically for you FOR ONLY $16.38 $13.9/page Hire Writer In earlier paragraphs an image of Camille is given, his face covered with red blotches, he resembled a sickly, spoilt child arrived at man hood. This phrase emphasizes the idea of Camille being physically like a child, however his languid manner showing absence of maturity to marriage also represents his cognitive abilities like a child. In Oliver Twist, the baby is also physically and emotionally like a child, both characters are associated with a sense of ignorance and innocence to the outside world. For example, Camille is unaware of his wifes wants while Oliver is unaware of his mothers death. Both characters are unaware of the consequences that their ignorance may bring. In the endings to both openings, the authors focus on a character to leave the reader with a feeling that something undesirable is going to happen. For example in Therese Raquin, Zola uses Therese, She remained there a few minutes facing the black wall, which ascends and stretched above the arcade. As Therese watches the black wall full of thoughts, by having the wall stretched and ascending, it represents her thoughts growing as well which may lead to consequences. In Oliver Twist, Dickens uses Oliver, If he could have known that he was an orphanperhaps he would have cried the louder. This is an example of Olivers ignorance. He is ignorant to the fact that he is an orphan but automatically, this makes the reader think that he will find out soon, therefore a sense of mystery is imposed on the readers.  The introductory chapters have started to unfold part of the story, hinting what is to come by introducing the main characters unfortunate living standards. This idea is effective because usually readers will associate a more joyous life with better living standards. By constantly emphasizing other elements such as poor living conditions the author succeeds in imposing this perspective.

Medicare Health program Essays

Medicare Health program Essays Medicare Health program Paper Medicare Health program Paper One might ask what is Medicare? Well, Medicare is our countrys health insurance program for people age 65 or older, certain people with disabilities who are under 65, and people of any age who have permanent kidney failure. It provides basic protection against the cost of health care, but it does not cover all your medical expenses or the cost of most long-term care. You can choose one of two ways to get benefits under Medicare: the traditional fee-for-service system or the managed care program. The Health Care Financing Administration is the agency in charge of the Medicare program. There are two parts of Medicare. Hospital Insurance (also called Part A Medicare. ) Part A Medicare is financed by a portion of your payroll (FICA) tax that also pays for Social Security. The second part of Medicare is Medical Insurance (also called Part B Medicare. ) Part B Medicare is partly financed by monthly premiums paid by people who choose to enroll. People are automatically enrolled in Part B when you become entitled to Part A. However, because they must pay a monthly premium for Part B coverage, and have the option of paying for the coverage or turning it down. Each part of Medicare covers different kinds of medical costs and has different rules about enrolling. In order to be eligible for Medicare, one has to meet certain regulations. Most people 65 or older can get Medicare hospital insurance based on their own or their spouses employment. One is eligible at 65 if you either receive Social Security or railroad retirement benefits. If they are not involved with either of these, but you have worked long enough to have them they may receive them. People are also eligible if you would be entitled to Social Security benefits based on their spouses or divorced spouses work record. Before age 65, persons eligible for Medicare hospital insurance are if they have been a Social Security disability beneficiary for 24 months. Also eligible if they have worked long enough in a federal, state, or local government job and you meet the requirements of the Social Security disability program. Under certain conditions, spouses, divorced spouses, widows, widowers, or a dependent parents may be eligible for hospital insurance when he or she turns 65, based on work records. Also, disabled widows and widowers under age 65, disabled divorced widows and widowers under 65, and disabled children may be eligible for Medicare, usually after a 24-month qualifying period. Kidney failure patients have special rules too. Under these rules, sufferers are eligible for hospital insurance at any age if they receive maintenance dialysis or a kidney transplant and are insured, or are getting monthly benefits under Social Security or the railroad retirement system. Also, if they have worked long enough in government to be insured for Medicare. In addition, spouses or children may be eligible if she or he receives continuing dialysis for permanent kidney failure or had a kidney transplant, even if no one else in the family is getting Medicare.

34 Writing Tips That Will Make You a Better Writer

34 Writing Tips That Will Make You a Better Writer 34 Writing Tips That Will Make You a Better Writer 34 Writing Tips That Will Make You a Better Writer By Daniel Scocco A couple of weeks ago we asked our readers to share their writing tips. The response was far beyond the initial expectations, and the quality of the tips included was amazing. Thanks for everyone who contributed. Now, without further delay, the 34 writing tips that will make you a better writer! 1. Daniel Pay attention to punctuation, especially to the correct use of commas and periods. These two punctuation marks regulate the flow of your thoughts, and they can make your text confusing even if the words are clear. 2. Thomas Participate in NaNoWriMo, which challenges you to write a 50,000 word novel in a month. I noticed that my writing has definitely improved over the course of the book - and it’s not even finished yet. 3. Bill Harper Try not to edit while you’re creating your first draft. Creating and editing are two separate processes using different sides of the brain, and if you try doing both at once you’ll lose. Make a deal with your internal editor that it will get the chance to rip your piece to shreds; it will just need to wait some time. A really nice trick is to switch off your monitor when you’re typing. You can’t edit what you can’t see. 4. Jacinta In a sentence: write daily for 30 minutes minimum! Its easy to notice the difference in a short time. Suddenly, ideas come to you and you think of other things to write. You experiment with styles and voices and words and the language becomes more familiar 5. Ane Mulligan Learn the rules of good writing†¦ then learn when and how to break them. 6. Pete Bollini I sometimes write out 8 to 10 pages from the book of my favorite writer in longhand. This helps me to get started and swing into the style I wish to write in. 7. Nilima Bhadbhade Be a good reader first. 8. Douglas Davis While spell-checking programs serve as a good tool, they should not be relied upon to detect all mistakes. Regardless of the length of the article, always read and review what you have written. 9. Kukusha Learn to take criticism and seek it out at every opportunity. Dont get upset even if you think the criticism is harsh, dont be offended even if you think its wrong, and always thank those who take the time to offer it. 10. John England Right click on a word to use the thesaurus. Do it again on the new word and make the best use of your vocabulary. 11. Lillie Ammann After editing the work on screen or in print, I like to read the text aloud. Awkward sentences and errors that slipped through earlier edits show up readily when reading out loud. 12. H Devaraja Rao Avoid wordiness. Professor Strunk put it well: â€Å"a sentence should contain no unnecessary words, a paragraph no unnecessary sentences, for the same reason that a drawing should have no unnecessary lines and a machine no unnecessary parts.† 13. David Write as if you’re on deadline and have 500 words to make your point. Then do it again. And again. 14. Yvette Sometimes I type in a large font to have the words and sentences bold before me. Sometimes, in the middle of a document I will start a new topic on a fresh sheet to have that clean feeling. Then, I’ll cut and insert it into the larger document. I wait until my paper is done before I examine my word usage and vocabulary choices. (And reading this column it has reminded me that no two words are ever exactly alike.) So at the end, I take time to examine my choice of words. I have a lot of fun selecting the exact words to pinpoint my thoughts or points. 15. Amit Goyal To be a good writer is to start writing everyday. As Mark Twain said, the secret of getting ahead is getting started. Try using new words. i.e avoid repeating words. this way we learn the usage of different words. Do edit your previous articles. Start with small paragraphs like writing an article for a Newspaper, and proceed from there. 16. John Dodds Remove as many adjectives as possible. Read Jack Finney’s tale, Cousin Len’s Wonderful Adjective Cellar for a fantastical tale about how a hack becomes a successful author with the help of a magical salt cellar that removes adjectives from his work. 17. John Ireland I set my writing aside and edit a day or two later with the aim of making it terse. It has trained me to be more conscious of brevity when writing for immediate distribution. 18. Jai Try to write in simple way. Express your views with most appropriate words. 19. Mark Read great writers for inspiration. If you read them enough, their excellent writing style will rub off onto your dazzling blog. YOU ARE what you read (and write!). 20. Caroline I watch my action tense and wordiness in sentences when I am writing my technical diddley. For example, in a sentence where you say †¦Ã¢â‚¬ you will have to†¦Ã¢â‚¬  I replace it with â€Å"†¦you must†¦Ã¢â‚¬ , or â€Å"Click on the Go button to†¦Ã¢â‚¬  can be replaced with â€Å"Click Go to†¦Ã¢â‚¬ . Think of words such as â€Å"enables†, instead of â€Å"allows you to† or â€Å"helps you to†. If one word will work where three are, replace it! I always find these, where I slip into conversational as I am writing quickly, then go back and purge, purge, purge. 21. Akhil Tandulwadikar Don’t shy away from adopting the good habits that other writers use. Do not worry about the length of the article as long as it conveys the point. Of course, the fewer words you use, the better. Start the article with a short sentence, not more than 8 words. 22. Julie Martinenza Instead of adding tags (he said/she said) to every bit of dialogue, learn to identify the speaker by showing him/her in action. Example: â€Å"Pass that sweet-smelling turkey this way.† With knife in one hand and fork in the other, Sam looked eager to pounce. 23. Aaron Stroud Write often and to completion by following a realistic writing schedule. 24. Joanna Young One that works for me every time is to focus on the positive intention behind my writing. What is it that I want to communicate, express, convey? By focusing on that, by getting into the state that I’m trying to express, I find that I stop worrying about the words just let them tumble out of their own accord. It’s a great strategy for beating writer’s block, or overcoming anxiety about a particular piece of writing, whether that’s composing a formal business letter, writing a piece from the heart, or guest blogging somewhere ‘big’†¦ 25. Shelley Rodrigo Use others writer’s sentences and paragraphs as models and then emulate the syntactic structure with your own content. I’ve learned more about grammar and punctuation that way. 26. Sylvia Avoid long sentences. 27. Mike Feeney Learn the difference between me, myself and I. For example: Contact Bob or myself if you have any questions. I hear this very often! 28. Richard Scott When doing a long project, a novel, for instance, shut off your internal editor and just write. Think of your first draft as a complex outline waiting to be expanded upon, and let the words flow. 29. David Careful with unnecessary expressions. â€Å"At this point in time† came along during the Nixon congressional hearings. Too bad it didn’t go out with him. What about â€Å"on a daily basis?† 30. E. I. Sanchez For large documents, I use Word’s Speech feature to have the computer read the article back. This allows me to catch errors I have missed especially missing words or words that ’sort of sound the same’ but are spelled differently (e.g. Front me instead of ‘From me’). 31. Cat Either read the book â€Å"Writing Tools 50 Strategies for Every Writer†, by Roy Peter Clark, or read the Fifty Writing Tools: Quick List on his blog. Then join a writing group, or hire a writing coach. 32. Suemagoo Write the first draft spontaneously. Switch off your internal editor until it is time to review your first draft. 33. Lydia If youre writing fiction, its a great idea to have a plot. It will coordinate your thoughts and add consistency to the text. 34. Pedro Edit your older articles and pieces. You will notice that great part of it will be crap, and it will allow you to refine your style and avoid mistakes that you used to make. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Writing Basics category, check our popular posts, or choose a related post below:Possessive of Proper Names Ending in S"Latter," not "Ladder"Dissatisfied vs. Unsatisfied

Evaluate the claim that biometric technology is a viable and effective Essay

Evaluate the claim that biometric technology is a viable and effective alternative to traditional security methods - Essay Example Experts suggest that biometric technology is the most viable and efficient security measure compared to traditional methods, therefore, the paper aims to validate this claim. Discussion Biometric is the automatic person identification depending on the behavior or physiological attributes of that person. This authorization strategy identifies and verifies a person based on who he is before giving him access permission. The quest for increasingly reliable method of authorization to protect company information has called for biometric revelation and various companies and businesses have shown increased interest in the method. Commonly used physical biometrics is fingerprints, geometry of palms, characteristics of the face and retina, (Schuckers, 2010, p.89). Similarly, behavioral attributes are things such as voice recognition, patterns of keystroke, peoples’ signatures and gait and these technologies, voice recognition and signature are highly developed. Biometric security metho ds are indeed most effective authentication method compared to traditional methods such as smart cards and PINS or both. ... Technical support managers may have difficult time offering instructions to PIN users who have challenges with more basic associated technologies of signing in to certain network. Therefore, biometric technologies are more promising because they solve such problems and relieve the company of such expensive cost of hiring technical support staff, because in a system that uses one log in, biometric technology will be efficient in user authentication. Increasing number of organizations are recognizing biometric method efficiency in various applications, for example, in hospitals traditional methods are being replaced with biometric methods for authentication of users to ensure patients information privacy and confidentiality. Traditional methods such as swipe cards and passwords can be lost or stolen, and bad password management has left users writing passwords on papers and other materials or choosing general and possible works for faster remembrance, an activity that expose such pins to fraud and intruders. Biometric technologies, on the other hand, can be viable and efficient methods in solving these problems because they have strong techniques of authorization and authentication that can assure users of excellent security, (United States, 2004). Similarly, because biometric techniques uses user’s behavioral and physiological attributes in authentication and authorization, it is easy to detect and trace fraud and intrusion, (Ratha and Jain, 2005, p.85). Unlike traditional methods of authentication based of known characteristics – such as passphrases, smart cards – biometric techniques utilize distinct human traits such as voice recognition and prints of fingers that cannot be misplaced, forgotten, or lost. This is because human

Sustainable Urbanism in Lowry Range Essay Example | Topics and Well Written Essays - 8500 words

Sustainable Urbanism in Lowry Range - Essay Example Contemporary planning and development approaches suggest that privately-owned public spaces will be the Twenty-First Century reality for public spaces (Wallace 2005). As a leader in efforts to provide attractive and inclusive public spaces, New Urbanism also continues a development trend of reliance on the private sector’s provision and management of public activity and public space assets. Conflict exists between Constitutionally-protected rights of access, assembly, speech and expression and private property rights to exclude persons and activity. In the status quo, there are regulatory voids of excessive, ambiguous, and inadequate regulations that were attributable to direct private sector control and indirect public sector control. Analysis of the broader public forum regulatory structure for these spaces discovered that public use of certain spaces and certain commercial areas are especially vulnerable to these regulatory voids. Furthermore, it is important to note that e xpress public use rights in the form of public access/use entitlements play a unique role in supporting the public forum status of privately-owned public space (Endress 2005).Such administrative capacity is impeded by a limited understanding of the role of interstitial public spaces, by limited municipal resources for small park spaces, by strong commercial interests with small model development expectations, and by an entrenched property title bias toward bona fide public space assets.

Program Summary Essay Example for Free

Program Summary Essay The process of a program’s development is to acknowledge what exactly the program is, and what mission they set forth to achieve. Regarding the Far West Elementary School’s organization mission where they work as a team filled with parents, and staff who are dedicated to creating a caring, exciting environment that promotes responsibility, self esteem, and academic achievement where differences are valued and learning is a lifelong goal. Although the mission promotes responsibility the school lacks in English proficiency. This program curriculum is undeveloped because the staff is lacking the qualifications; they are teaching the children using non certified or non licensed skills. The material needs to be upgraded via the English curricula. In order for the limited English proficiency (LEP) skills to grow the qualifications of the staff must be qualified. Within this program it will provide thoroughness, communication, and financial management. These elements are needed because it will build the morale of the program, the current staff and students skills, and the community of the low cost area of Far West Elementary School. Assessments: Assessments will be to analyze the programs purpose and its empowerment. According to, Gutierrez (1994) defines empowerment as the â€Å"process of increasing personal, interpersonal, or political power so that individuals, families, and communities can take action to improve their situations†. I chose this quote because I felt it works well with the school and how one can increase their skills when it comes to defining the process and determining the goal. The assessments determine if the faculty member is qualified to teach in a professional manner? The assessments will be constructed by licensed bilingual counselors who document the knowledge, skills, and beliefs of the staff; it will focus on the case studies, the learning styles, and experimental work (Wikipedia, 2009) of students as well. Once the staff members are increasing their English proficiency skills the students will then become more advanced. This will serve as the process used for the staff being a positive outcome. The process will prove that the development of the plan was evaluated; it will identify the measure used to develop the plan, which were the workshop sessions. The data collected will be the presented through the students and their English skills increasing. The reporting and results will follow by the many programs that will be offered, by the families of the students skills improving, and the preparation of enrolling new students and staff within the school. The thoroughness the program will reflect will show how eager it is increasing the English skill in the community. It will drain all energy taken with the counselors using with their senior skills, in making sure all aspects of the program’s session are passed. This will include the performance of the community, the faculty, and the productiveness of the students. The measures the program assessments will take will be resourceful in present and future lives of the students. They will be constructed to abide by the mission of the school. Needs and Problem Statement: The programs needs and problem assessments would be to evaluate the staff and improve their proficiently in teaching the English language. Specific needs of the program to be focused on are alternative certification program, special support for teachers, and improving the skills for higher education. The influences and expectations play in a role in administrator’s role of the agency because the significance of it is to connect with their staff and oversea that duties of the agency are being done. According, to Far West Elementary School administrators their needs are to make sure that the (LEP) skills are increased by making sure the staff are taking advantage of all the training programs offered by the counselors and funders. Administrators are to make sure the pressure is on in understanding the fact that achieving the (LEP) skill betters the elementary school, the staff guiding and forcing the direction. The problem occurs when there aren’t any funds being allocated for the program. Program Planning: Grant funding will be set through the proposal planning for the program. The program will propose the government with its attribute and prove the program should is qualified enough for their funds. By, introducing yourself and introducing the program that you want funded, it will benefit the people of the community. The function of the grant proposal is to allow you to communicate and present your proposal of the plan or program is looking for funding. The purpose of the proposal is to gain funds for a program that will better someone or families. The purpose is to present your program before it is even considered a program. Grant proposals relates to a program plan by proposing ideas, suggesting programs or simply bringing new ideas to the table that need to be approved and funded. They both take in considerations to help others and address problems within a community. Communication is the element the program will be best at and portray. The relevance of communication in the program is top high because it’s used to connect the staff, students and their families and show what’s most important each other. Talking and expressing their needs of why increasing the limited English proficiency skill is the number one key within this program. Alternate funding: Alternate funding will be the bonding aspect within the program. It will include Ideas of nontraditional funding which includes activities that involve the community more than the government. The program is locating funding through fundraising like raffling off tickets for prizes; therefore more people will participate knowing they can win a prize. Another alternate funding strategy would be selling dinners in the community for reasonable prices; the program staff will present talent shows for the community which they will participate in as well. Activities will be listed as, special events like face painting and relay racing would bring more funds to the program. Another idea would be client donations where the staff will donate to the program, whether it’s volunteering or giving a money donation. A funding institution that works with human service organizations is Administration for Children amp; Families (AFC). Its mission along with Health and Human Services (HHS) is responsible for federal programs that promote the economic and social well being of families, children, individuals, and communities, (AFC, 2011). The expectations for evaluating this funding institution are campaigning to rescue and restore families, family and youth services, administration development, child care bureau and many other programs they set to fulfill through their expectations of the ommunity. These expectations influence the evaluation plan and programs by staying true to their mission and achieving their goals. Implementation: The implementation of the program will be tedious, long and drawn out however it’s all for a good cause. During the process and outcomes stage, the process will evaluate the documented and monitored interventions taken for the staff and describe the importance of the program. The data will acknowledge and understand why the skills need to be improved. It will prove why it acceptable in the targeted community. The implementation that will be put forth and fulfilled will show through the structure of the program. Also the stakeholders are the people who invest in the program to develop the skills therefore they are implementing the program as well. Once the proposal was presented to them their share and interest in the program wasn’t just want they invested in the agency but an actual investment. With having a better understanding of the mission of the agency and what the team, parents and staff are dedicated in achieving the stakeholders know for a fact that the group they are investing in has significant obligations they wish to fulfill. Evaluation: The evaluation of the program will be based on the community of Far West, a suburb of New Hampshire Far West community that holds a population of 30,000 where the elementary school holds 700 with 30% of the students who have relocated from a foreign country. Being that the students are from an Asian decent background they have limited experience in English writing, reading and speaking skills. The evaluation of the program opportunity is to improve the limited English proficiency (LEP) skills for teachers, students, and their families. It will evaluate what it negative in the program that needs fixing, it will allow the individual to see the reality of how building a program can really determine whether the program is qualified or not. Conducting assessments will provide the program with information of services at that are needed or services that are not, therefore funds will be saved in the program. Judging whether or not the staff is qualified will also demonstrate evaluations for further training. The evaluation of the program will cover needs being addresses, staff nderstanding and building a rapport with the students and staff and always and follow the mission and value statements of the agency. The evaluation will make sure projects being funded properly, all and outcomes of the programs strengthens the organization. During the empowerment evaluation process it will acknowledge who exactly needs their skills to be improved. Counselors will overlook classroom settings and become involved with the students, and allow them to give me their reasons on why wanting to improve their LEP skills. Staff and students participate with each other in improving the (LEP) skill. It will offer workshops with professional leaders who will oversee activities in upgrading certificates to licenses; therefore the teachers are developing the programs for the students and promoting a professional outlook of the programs. The importance of this program is to improve the skills of limited English proficiency, in the Far West Elementary School located in a low income housing community. This program was chosen for this location because of the presence of families with foreign backgrounds. The program focuses on improving the skill for parents as well, being they involved in the community as well. Overall the importance of the program summary is to provide thoroughness, communication and build the morale of the program; the current staff, students and parents to work together and achieve its mission to better the skills within the school, and the community of the low cost area of Far West Elementary.

Salmonella enterica typhi Essay -- Medical Health Biology Essays

Salmonella enterica typhi Introduction: Worldwide, typhoid fever affects roughly 17 million people annually, causing nearly 600,000 deaths. The causative agent, Salmonella enterica typhi (referred to as Salmonella typhi from now on), is an obligate parasite that has no known natural reservoir outside of humans. Little is known about the historical emergence of human S. typhi infections, however it is thought to have caused the deaths of many famous figures such as British author and poet Rudyard Kipling, the inventor of the airplane, Wilbur Wright, and the Greek Empire’s Alexander the Great. The earliest recorded epidemic occurred in Jamestown, VA where it is thought that 6,000 people died of typhoid fever in the early 17th Century. This disease is rare in the United States and developed nations, but always poses the risk of emergence. History: Originally isolated in 1880 by Karl J. Erberth, S. typhi is a multi-organ pathogen that inhabits the lympathic tissues of the small intestine, liver, spleen, and bloodstream of infected humans. It is not known to infect animals and is most common in developing countries with poor sanitary systems and lack of antibiotics, putting travelers to Asia, Latin America, and Africa in a high risk group. Of the 266 people infected in the United States in 2002, approximately 70% had traveled internationally within 6 weeks of the onset of disease. Microbiological Characteristics: This gram-negative enteric bacillus belongs to the family Enterobacteriaceae. It is a motile, facultative anaerobe that is susceptible to various antibiotics. Currently, 107 strains of this organism have been isolated, many containing varying metabolic characteristics, levels of virulence, and multi-drug r... ...asters have compromised sanitation. Although the incidence in the United States is very low, outbreaks and substantial epidemics still remain possible due to worldwide travel and unknowing carriers of the disease. The development of antibiotic treatments and several vaccines have presented the possibility of worldwide eradication. Until this is achieved, however, S. typhi and its characteristic typhoid fever will remain a threat for future epidemics. References Cited: Dennis Kunkel Microscopy, Inc. Health Canada: MSDS of Infectious Substances World Health Organization: Typhoid Fever Fact Sheet Centers for Disease Control and Prevention: Typhoid Fever Disease Information University of Florida Medical Micribiology and Infectious Diseases Department: Salmonella typhi Info Wikipedia.org: Typhoid Fever U. of Maryland Medical news: Typhoid Fever

Procter & Gamble Company Essay

In November 1981, Mr. Chris Wright, Associate Advertising Manager of the Packaged Soap & Detergent Division (PS&D) of the Procter & Gamble Co. (P&G) was evaluating how the division could increase volume of its light-duty liquid detergents (LDLs). 1 The excellent growth of Dawn dishwashing liquid since its national introduction in 1976 meant that P&G now manufactured and sold three leading LDL brands, holding a 42% share (by weight) of the industry’s $850 million in factory sales. Based on input from the three LDL brand managers who reported to him, as well as his own knowledge of the LDL category, Wright believed there were three major opportunities for volume growth: (1) the introduction of a new brand, (2) a product improvement on an existing brand, and/or (3) increased marketing expenditures on existing brands. In preparation for an upcoming meeting with Bruce Demill,, PS&D advertising manager, Wright began evaluating the volume and profit potential of the three options. Company Organization The company comprised eight major operating divisions organized by type of product: Packaged Soap & Detergents, Bar Soap & Household Cleaning Products, Toilet Goods, Paper Products, Food Products, Coffee, Food Service & Lodging Products, and Special Products. Each division had its own brand management, sales, finance, manufacturing and product development line management groups. One of the most important responsibilities of the brand group was the development of the annual marketing plan, which established volume objectives, marketing support levels, strategies and tactics for the coming year. The brand manager promoted the interests of his brand while the associate advertising manager assumed responsibility for building the business of all P&G brands in his or her category. The brand groups worked closely with the following four line departments in both the development and the implementation of their marketing plans: Sales: The brand groups and sales force frequently interacted. While the brand groups managed categories and brands, the sales force managed markets and accounts. As such, the sales force provided important perspective and counsel on trade and consumer promotion acceptance, stock requirements to support promotions, competitive pricing and promotion activity, and newproduct activity. Each brand group worked closely with the sales force to develop the optimal sales promotion plan for its brand together with appropriate merchandising aids. LDLS are defined as all mild liquid soaps and detergents designed primarily for washing dishes. Product development department (PDD). Since superior product performance was key to the success of P&G products, each brand group worked closely with PDD to ensure continued improvement of its brand’s quality. Fifteen professionals worked exclusively on research and development for LDLs. The PDD continually strove to upgrade product quality or explore new product formulations. If a potential new product was developed, it was extensively tested in consumer and laboratory tests before any test marketing began. Manufacturing department. The brand group provided the manufacturing department with detailed brand volume estimates (by month, size, and form/flavor) to facilitate efficient production, as well as five-year volume base forecasts for capacity planning. In addition, the brand group discussed promotions requiring label or packaging changes with manufacturing to determine the most efficient production methods. Manufacturing informed brand groups about ongoing manufacturing costs and provided potential cost-savings ideas. Interaction between the advertising and manufacturing departments was particularly frequent during any new-product development process, and included discussions on manufacturing requirements, custom-packing options for test markets, and critical paths for production. Finance department Based on volume and marketing expenditure forecasts provided by the brand groups, financial/cost analysts developed and fed back brand profit and pricing analyses as well as profit and rate-of-return forecasts on new products and promotions. This information was key in helping the brand groups to recommend action which would maximize volume and profit growth. Advertising services department. Within the department, there were nine staff groups which serviced the advertising department. These were market research, art and package design, TV commercial production, media, copy services, field advertising, marketing systems and computer services, promotion and marketing services, and advertising personnel. PS&D market research included the following: 1. Market analysis, including bimonthly  syndicated market data that P&G purchased from A.C. Nielsen Co., as well as selected data purchased from Nielsen, Selling Areas Marketing, Inc. (SAMI) and other suppliers for test markets. 2. Consumer research, including studies to: a. monitor how consumers used products and track consumer usage of, attitude towards, and image of P&G and competitive brands; b. test the performance of current products and possible product modifications under in-home usage conditions; and c. evaluate the advertising, packaging, promotion and pricing of P&G brands; also, to evaluate the potential of new-product ideas, using such techniques as concept research and simulated test markets. LDLs could be conceptually divided on the basis of product benefit into three major segments: (1) the performance segment (35% of category volume) provided primarily a cleaning benefit; (2) the mildness segment (37% of category volume) provided primarily the benefit of being gentle to hands; and the price segment (28% of category volume) whose primary benefit was low cost. Volume is measured in P&G statistical cases, each containing 310 ounces. Household growth was a better indicator of LDL volume than population growth (research indicated LDL household consumption varied only slightly with the number of people in the household). 4 ADW households still used LDL for pots and pans and small cleanups. Price brands were sold to retailers for an average of $7.50 per statistical case versus $17.00 per statistical case for the premium-priced mildness and performance brands. the greatest growth in the past 10 years. Some LDL brand managers expected the performance segment to continue to grow at the expense of the mildness segment, since market research indicated that more consumers rated performance attributes (such as grease cutting and longlasting suds) as the most important (see Exhibit 2). The price segment had been in decline, but was expected to stabilize at its current share level due to increasing consumer price sensitivity resulting from the depressed state of the economy. LDL brand managers did not expect this segment to grow because most price brands were not a good value, requiring two or three times as much volume to create the same amount of suds as a premium brand. P&G’s Ivory Liquid, the market leader, used this comparison in its advertising to persuade consumers that Ivory was a better value. The LDL market was relatively stable, with one new premium brand introduced every two and a-half years and an average of two price brands introduced and discontinued per year. As Exhibit 3 shows, 3 companies sold almost 75% of LDLs, with P&G holding a 42% share 6 of the market, Colgate-Palmolive Company a 24% share, and Lever Brothers, the U.S. subsidiary of Unilever, a 7% share. 7 The remaining 27% of the market consisted mainly of generic and private-label brands. As shown in Exhibit 4, marketing expenditures including advertising and promotion typically represented 20% of the sales of an established LDL brand.

Crime and Best Glorification

The best glorification of crime and criminals seems to be portrayed in the news, TV, and movies. Often you will see how a bank robber will get away with the cash and never get caught. In movies criminals seem to get away with their crimes if in some way the crime is justified. In today’s world it sometimes appears to be easier if you’re the bad guy. This mind set is due to the portrayal of the criminal in movies and on the news. A prime example of glorifying a criminal would be CSI. CIS is a television show that is based on crime scenes and criminal minds. CSI goes into a criminals mind and show how and why I crime happens. This makes the criminal mind seem fascinating and sometimes portrays the criminal as a genius. I feel almost making the crime and criminal as famous and as powerful as the show it’s self. Another example would be Law Abiding Citizen. The main character goes on a killing spire on the justice center of Philadelphia. Even though he has killed so many people you still feel sympathetic towards him because his family was brutally raped and murdered and the justice center did nothing. Due to the circumstances he decided to take actions in to his own hands. This movie, in many ways, makes the crimes and the criminal more glorious as if he had done the right thing. The news is another example of glorifying crime and criminals. The news often talks about how cops can not control gangs, how the gangs are growing and becoming more powerful. This makes the gangs more glorious and, in ways, only adds power to the gang. For young children growing up in gang-ran areas this may push them to join because of the media’s portrayal of the power associated with gangs. The best glorification of crime and criminals seems to be portrayed in the news, TV, and movies. The media truly seems to make it look easier to be the bad guy. In today’s news and movies the criminals seems to be powerful or justified.

Da Bluez essays

Da Bluez essays From years 1505 to 1870, the world underwent the largest forced migration in history. West Africa was soon to be convulsed by the arrival of Europeans and become the advent of the transatlantic slave trade. Ships from Europe, bound for America, appeared on the horizon, and their captains and sailors-carrying muskets, swords, and shackles-landed on the coast, walked up the beach in their strange clothes, looked around, and demanded slaves. A horrific chapter in history had begun, and neither Africa nor America would be the same again. Approximately ten million Africans were brought across the seas to the Americas to be manipulated into slavery. They were meant to work harsh labor, yet they were no longer meant to have a voice. A few Americans took the time to appreciate the hard work performed by the slaves; however, appreciation is a short step in the long road to equality. It was not until the late 19th century that America began to repair the damages done by this immoral trading of human beings. Once the slaves were freed after the Emancipation Proclamation in 1863, it did not do much to end the oppression and prejudice against the black race. Their freedom did not give them a heart; it did not prove they had soul. This is where their music becomes significant, and this is Blues music. Throughout their music, it took much less time for the black race to prove that they were not unlike the rest of humanity; in fact, they did have a voice, and a haunting one. Once Blues music was not only recognized, but also comprehended, admired and imitated, it opened the gates of immigration, and the nation to this day has matured in its ability to see gray. Included in the mass of faceless slaves, the boats entrapped and migrated a large number of griots. A griot was an African version of the European wandering minstrel. They spent their lives traveling from village to village, playing the role of a musician, storytel...

How to Get Out of the Sophomore Slump

How to Get Out of the Sophomore Slump In your sophomore year in college? Feeling uninspired and unmotivated? You just might be in whats known as the college sophomore slump. For most students, its what happens during your second year of college: youre over the excitement of your first year but not close enough to graduating yet to be focusing on life after college. So whats a college student to do in the meantime? Take a Class for Fun You might be feeling slumpish because you are having to take tons of prereqs before you can get into the nice, meaty courses required for your major. Or you may not even be sure what to major in. Either way, add a little spice to your routine by taking a class just for fun. It can be yoga, ballet, an art class, or anything thats out of the ordinary for you. Join a New Club or Organization Your first year in school, you were probably so busy adjusting to life as a college student that your time management skills were shall we say less than stellar. But now that you know the ropes, join a new club or organization that will provide you with a creative outlet and something enjoyable to do each week. Get Involved in Student Government Even if youve never done student government before, see if you can represent your residence hall, your academic class, or even a constituency you belong to (like transfer students, for example). It can be a great way to keep you motivated to talk to other students, stay on top of current issues, and develop some leadership skills. (Not to mention that it looks good on your resume.) Volunteer on Campus No matter where you go to school, chances are that there is some kind of volunteer program you can join. See who needs volunteers this year and you just might end up motivating yourself along with others. Volunteer in the Local Community Maybe a change of scene is more whats needed. If so, see what volunteer options are available in your local community. Mentor First-year Students You just might be in the sophomore slump because you are doing well in college which means that perhaps you can be a good role model for incoming first-year students who need some guidance about adjusting to college life. See if your school has a mentoring program you can join and if not, see about starting one yourself! Get a Fun Job On Campus True, most students work in college for the money. But if you need to mix things up a little, this can be a great way to still get income while also enjoying yourself. Work in the campus coffee shop, at the theater, or in any other avenue that offers a fun, engaging environment. Get a Fun Job Off Campus Perhaps you do need a change of scene from your campus but dont have the time to volunteer. Try to combine both your financial needs and your need for change into an off-campus job that is interesting and something new. Get Involved Politically What are local politics like near your school? Can you volunteer on someones campaign? Join a national campaign for a person or an issue you care about? Become involved in a movement for a cause that is near and dear to your heart? Start Planning a Great Trip Sophomore year can be a little challenging because there often isnt one big thing to look forward to. So why not create your own highlight of the year? See what your options are for planning a fun trip over Thanksgiving break, winter break, spring break, or even a long weekend coming up. It just might do the trick of getting you out of your sophomore slump and back into your normal groove.

Economic Essay Example | Topics and Well Written Essays - 1000 words

Economic - Essay Example This has caused concern for a number of factors in the market to include the banking and construction industry. When a low turn-over of homes occurs, new construction stalls and peters out and older pre-existing homes may cause a short burst in refurbishment industries but inventory movement remains stale. According to the media report, trust in real estate as an investment vehicle has declined by half since 2003. As with all complex phenomenon, a number factors explain why it is happening the way it is. Over time, the housing industry will find equilibrium as housing prices drop to a level the market deems sufficient for decreased prices and buyers may start purchasing again. One can anticipate the construction trades getting hit the hardest and see lay-offs and smaller contracting companies going under. Home improvement goods and services may see an uptick in business as more homeowners seek to repair or improve present dwellings instead of buying another home. Who are the key stak eholders that are impacted by the issue outlined in the report? Include a discussion of all groups that may be impacted by the issue raised in this report Highlight what you believe the main impacts will be in outline who you believe will be impacted most The construction companies and potential homeowners are the most severely affected groups here. The bankers will suffer only in the departments directly related to issuing and maintaining mortgage notes and securities. Of course, if the loans are packaged and leave the local lenders to be securitized in bundles of investments, the effect will only be on the amount of loan traffic coming into the local lending institutions. The construction trade tends to attract both unskilled and skilled laborers whose seasons of employment will most severely affected by the downturn of sales. Entire swaths of the industry will suffer a dearth of employment especially affecting the unskilled laborer. The skilled laborers do have the opportunity to move directly to providing services to remodel and refurbish existing homes for homeowners who find the prospect of buying a new home burdensome right now. What economic theories can be drawn from this media report? List and discuss what economic theories you can find in this article Provide a brief outline of the theory you are highlighting Provide evidence from the article to support these theories. Remember there may be more than one theory to discuss The Law of Supply and Demand is the most important economic theory to be considered in this media report. In its simplest form, it demonstrates that limitations or constraints on either supply or demand will have an effect on price (Kirzner, 2000). Prices, when unfettered, are the clearest signals for how to rationally allocate scarce or abundant economic resources. Economics at its most basic is the examination of the rational (or sometimes irrational, as in bubbles) allocation of goods and services. One important note, it is rele vant in a market or mixed economy but not necessarily in central planning or socialist economies where the Law of Supply and Demand tends to be fogged by irrational price signals and gross misallocation since the end-users don’t have a vote with their feet. The Law assumes that there is a price equilibrium at which producers and

The Work of Art in the Age of Mechanical Reproduction, Walter Benjamin Essay

The Work of Art in the Age of Mechanical Reproduction, Walter Benjamin - Essay Example The sense of originality has lost by use of pictures as compared to paintings. According to Benjamin, the reproducible film represents a historical shift that many audiences might fail to notice. Benjamin noted that the work of art reproduced mechanically has intervened to fill the void left by loss of aura. For instance, the loss of authority by the original work of art has been compensated by the use of a camera. Cameraman can direct the viewers eyes towards specific places and stories, as a result of being radical, revolutionary and totalitarian. Mechanical reproduction has introduced distraction as a new way of reception. There is a shift in the location of work of art that can be referred to as an aura to the mythological space. People are now capable of visiting places like museums, theaters, galleries and cinemas to see the work of art. Benjamin, however, complements the loss of aura. He notes that the loss has opened up politicization of the work of art put into use in different ways. He observes that a mechanical reproduction has managed to change contemplation regarding the screen as well as the films

Cross Listing Coursework Example | Topics and Well Written Essays - 500 words

Cross Listing - Coursework Example The company obtains benefits by the economic activities of that foreign country especially from the financial market’s ability to provide greater strength to the market value of that domestic company. Cross listing is also one of the methods of diversifying the investors’ risk profile. By investing in a company which is not a domestic company, allows much more diversification to the local investors as they are now subject to different sorts of risk exposures as compared to their other counterparts. These investors are subject to the risk of the economy of that cross listed company’s country. In short, cross listing provides another avenue of financial resources to the domestic company as well as provides a safeguard from a likely hostile takeover. It also provides a greater opportunity and flexibility to the foreign investors in managing and maintaining their portfolio of investments in a diversified manner. Essar Energy plc is one of the best private groups of India which have substantial investments in both the oil & gas sector as well as the in the power sector. Established in 1989 with petroleum sector only, the company has made remarkable achievements such that the company remained highly successful even in diversifying its operations by investing in refinery and later on, in the power generation and distribution sector. In June 2010, the company cross listed itself in London Stock Exchange after already having a presence in the local stock exchanges in India. The company managed to raise net proceeds of around $1.8 billion from the UK investor. This had been the largest IPO subscription in London Stock Exchange after 2007 by any company. Currently, the company is a constituent of FTSE 100 index of London Stock Exchange. After a tremendous turnaround and interest of the foreign investors in the stakes of the Essar Energy plc, the company

Cognitive Behavior Therapy: Palliative Care

Cognitive Behavior Therapy: Palliative Care Individuals that have been deemed by their medical team to have serious diseases that are resistant, nonresponsive or have failed reasonable treatments are often referred to specialists for comfort measures only. According to the World Health Organization, Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families (WHO, 1990). The National Center for Health Statistics (1996) estimated that 20% of all deaths and 30% of the deaths of elderly individuals occurred in extended care facilities. Extended care facilities are but one place where end-of-life issues are a common fact of daily life. However, regardless of the setting, each individual faces the end of life with his or her own view of life, death and the dying process. The estimated number of patients in palliative care varies due to the difficulty in capturing the actual numbers from hospitals, primary care practitioners, families and emergency rooms. The estimate of patients receiving the Medicare benefit for hospice and palliative care is approximately  ½ million, and it is estimated that, in 2000, approximately 20% of patients dying in the United States received hospice or palliative care services. It should be noted that although many, if not most, individuals in hospice/palliative care settings are age 85 or older, this level of care is not limited to older adults. Motor vehicle accidents, post-traumatic incidents, drug overdoses and other physiologically devastating disorders may result in permanent damage to the younger body as well as the older body. Mortality rates at a young age for those with mental illnesses is decreasing therefore it is estimated that by 2030 there will be 15 million individuals with mental illness residing in long term care facilities (SAMHSA, 2004). This chapter will focus on the reduction or modification of autonomic, psychiatric, or sensory symptom experience of these individuals through use of cognitive behavioral therapy. Cognitive behavior therapy (CBT) uses a structured and collaborative approach while helping individuals to recognize, evaluate and restructure the relationships between their thoughts, feelings and behaviors. Through a process of targeted interventions, the therapist assists individuals to identify, monitor and cognitively restructure the dysfunctional thoughts and/or to modify behaviors that are maladaptive, useless or even harmful (Beck, 1976; Turk, Meichenbaum, Genest, 1987; Freeman Freeman, 2005). CBT includes a range of both cognitive and behavioral techniques such as relaxation, guided imagery/visualization, biofeedback, behavioral experiments, guided discovery, stress management, training in pain or stress management strategies, and cognitive restructuring for dysfunctional thinking and many others . Although there is a paucity of research on the use of CBT in palliative care settings, CBT is effective for many of the psychological issues that are prevalent in palliative care including, depression, anxiety, pain management, and insomnia. The purpose of this chapter is to provide an overview on the use of CBT for assessment and treatment of psychological distress in palliative care settings. Assessment of Emotional Functioning in Palliative Care There are many challenges to the assessment of mood disorders in palliative care settings. An initial challenge is the myth that psychological distress is a normal reaction to end of life. Despite expectations, most individuals in palliative care settings do not have symptoms of anxiety, depression or dementia. Many individuals arrive at this stage of their lives or illnesses with a sense of calm resignation, if not expectations of relief and of going home to God, heaven or family members waiting for them in the hereafter. Therefore those individuals that are experiencing symptoms that require intervention may achieve significant benefit from the interventions. The most common presentations are those of depression, anxiety, pain management failures with exhaustion and anguish, and sleep disorders. The healthcare provider requires tools necessary to differentiate major depression from anger, sadness, and anxiety associated with the symptoms of an untreatable or chronic illness. Assessment of preparatory grief and depression. Another obstacle to the assessment process is simply overcoming the challenges of differentiating symptoms from normal grief of the illness itself. Differentiating between preparatory grief and depression is a key component to the proper assessment of depression in palliative care and has important treatment implications. Preparatory grief can be defined as what an individual must undergo in order to prepare himself for his final separation from this world (Kubler-Ross, 1997). Symptoms of preparatory grief include 1) Mood waxes and wanes with time, 2) Normal self-esteem, 3) Occasional fleeting thoughts of suicide, and 4) Worries about separations from loved ones (Periyakoil and Hallenbeck, 2002). Preparatory grief is a normal, not pathological, life cycle event (Axtell, 2008; Periyakoil and Hallenbeck, 2002). Major depression is defined as five or more of the following symptoms during the same two week period: depressed mood, marked diminish in pleasure, weight loss or gain, insomnia or hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of worthlessness or inappropriate guilt, lack of concentration/indecisiveness, and recurrent thoughts of death and suicidal thoughts or plans (APA, 1994). Table 1 provides a symptom list. The list is not intended to be all inclusive however it gives the clinician an overall view of symptoms that may be observed in the individual dealing with depression in a palliative care setting. Although some symptoms of grief and depression overlap, there are ways to distinguish between grief and depression. Table 2 summarizes the ways to differentiate symptoms of grief versus depression according to temporal variation, self-image, hope, anheonia, response to support, and active desire for an early death (Periyakoil Hallenbeck, 2002). The first step to proper recognition of depression involves the identification of possible risk factors (Wilson, Chochinov, de Faye, and Breitbart, 2000). Certain demographic characteristics, such as younger age, poor social support, limited financial resources and family history of a mood disorder, as well as a personal history of previous mood disorders place individuals at a greater risk for developing depression or anxiety in end of life situations. Risk for developing a mood disorder also is elevated with certain types of diagnoses, including pancreatic cancer and brain tumors, and particular medical interventions such as radiation therapy (Hirschfeld, 2000). Symptoms of the illness, including poor symptom control, physical disability, and malnutrition also place individuals at higher risk. The second step to the proper assessment of depression includes utilization of appropriate assessment tools. Many times it is the degree and persistence of symptoms that provide the information necessary when considering major depression. Major depression, which is estimated to occur in fewer than 25% of patients in end of life care, may be best screened with targeted questions such as: How much of the time do you feel depressed? In addition, for those individuals that have a difficult time describing their symptoms or history, asking family members to provide information about a previous history of depression or a family history can be very useful. Although studies validating assessment tools vary greatly, many of the self-report measures have been shown to be effective in palliative care patients. The most common utilized tools in palliative care settings frequently omit physical symptoms of depression. Many symptoms of depression overlap with the terminal disease process (Noorani Montagnini, 2007). Examples of self-report measures that omit somatic symptoms include the Beck Depression Inventory II (Beck, Steer, and Brown, 1996), Hospital Anxiety and Depression Inventory (Zigmond Snaith, 1983), and the Geriatric Depression Scale (Yesavage et al., 1983). The Hayes and Lohse Non-Verbal Depression Scale (Hayes, Lohse, and Bernstein, 1991) is a third party observational measure that can be completed by staff, family, or friends to assist with the diagnostic process. Terminally Ill Grief or Depression Scale (TIGDS), comprising of grief and depression subscales, is the first self-report measure designed and validated to differenti ate between preparatory grief and depression in adult inpatients (Periyakoil et al., 2005). Assessment of anxiety. The symptoms of anxiety may differ in individuals in the palliative care environment. Many times symptoms of anxiety have a physiologic component. For example in those individuals with chronic obstructive pulmonary diseases difficulty breathing, low oxygen levels and overall compromised respiratory function causes air hunger which is experienced as anxiety and even panic. Table 3 lists some of the common anxiety symptoms seen in this population. Family members are often at a loss as to what they can do to assist their loved one that is experiencing anxiety, and especially fearfulness. It is often useful to provide significant others with a checklist of items that are important to report to the healthcare provider. Involving the family has the benefit of giving them a structured guide for response which reduces their own anxiety in response to the patient. In addition the patient may relax more knowing that a family member is involved with their care in an approved, helpful manner. An example of a list of items for family members to watch for and report to the healthcare team is listed in Appendix 1. Cognitive Behavioral Interventions in Palliative Care Psychological intervention in the palliative care setting includes those aspects of treatment that would provide relief from emotional distress while an individual is dying. Often this time period includes depression, anxiety, grief and organic brain dysfunctions such as dementia and/or cerebral vascular diseases. Individuals and their family members are both considered the patient during these times. Many of these individuals are suffering from chronic, unremitting pain conditions which negatively impact their emotional health. Treatments for pain and chronic conditions also play a part in the individuals mental status. The use of Cognitive Behavior Therapy (CBT) is extremely useful for these individuals. Cognitive Behavioral Therapy has the strongest empirical support of any psychological intervention for the management of symptoms typically seen in a palliative care setting. The most common presentations of psychological distress in the dying patient include anxiety, depression, hopelessness, guilt over perceived life failures and remorse. Persistence of these thoughts and feelings interfere with functioning, makes the person generally miserable as well as those around them and can severely affect his/her quality of life. Medical treatments, such as antidepressants, anxiolytics and cholinesterase inhibitors, exist for these problems however supportive psychotherapy such as relaxation training, imagery, distraction, skill training, and negative thought restructuring improves the possibility of remission. CBT can also improve the symptoms of spiritual distress that may include feelings of disappointment, guilt, loss of hope, remorse, and loss of identity. CBT for depression. Symptoms of depression are common in end of life care. It can be one of the most distressing groups of symptoms an individual can experience and may interfere significantly with daily tasks of life. Some experts have estimated that up to 75% of patients with terminal illnesses experience symptoms of depression. Amelioration of some of the symptoms of depression can increase the amount of pleasure and meaning in life, as well as add hope and peace. Treatment for depression can reduce the experience of physical pain as well as general misery and suffering. In addition, reduction of the symptoms of depression may improve the treatment of coexisting illnesses more effective. Most importantly, given that one of the most serious symptoms of depression is suicidal ideation, it makes sense to treat depression in order to prevent successful suicidal outcomes. There is a paucity of literature in the area of the use of CBT with depression in Palliative Care, due to the high attrition rate resulting from physical morbidity and mortality (Moorey et al., 2009). Therefore, these factors pose significant barriers to conducting randomized clinical trials in Palliative Care to address these components. The following is a review of the sparse literature on CBT in Palliative Care with depression. In an attempt to address this problem, Moorey et al., conducted a cluster randomized controlled trial in order to determine if it was possible to teach nurses CBT techniques in order to reduce anxiety and depression symptoms in patients with advanced cancer (2009). Eight nurses were trained in CBT by attending several 1- and 2-day workshops and then were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Seven nurses did not receive training and served in the control group. A total of 80 home care patients entered the trial; however most of these participants were excluded due to being too ill to participate. A total of 16 patients were in the CBT group and 18 patients were in the control group. The participants received home care nursing visits in which assessments were conducted at 6-, 10-, and 16-week intervals. The individuals who received CBT reported lower anxiety scores over time, but no effect of the training was found regarding depression. It was noted that both groups experienced lower rates of depression over the course of the study. The authors noted the heterogeneity of the sample and the high attrition rate due to physical morbidity and mortality presented several barriers to conducting the study and may have played in a role in the findings (Moorey et al., 2009). Cole and Vaughan (2005), in their review on the feasibility of using CBT for depression associated with Parkinsons disease (PD), found that it is a promising option. The authors noted that depressed inviduals with comorbid PD experienced a significant reduction in depressive symptoms and negative cognitions. In addition they experienced an increased perception of social support over the course of treatment (Cole Vaughan, 2005). The recommended course of action for individuals in this setting included: stress management training, relaxation training, behavioral modification techniques for sleep hygiene, and cognitive restructuring. Modification of life stressors contributing to depressed mood should be identified and plans made to minimize stress and maximize quality of life. The use of thought restructuring is recommended in order to maintain a sense of purpose and fulfillment through meaningful activity and to adjust expectations of self and others. Individuals are also encouraged to return to previously enjoyed activities in order to maximize feelings of pleasure and happiness. Through systematic defocusing on physical conditions the person is able to experience more pleasant activities, which are also encouraged. Similarly, Dobkin et al, conducted a study which explored the effects of modified CBT for depressed patients with PD, in conjunction with a separate social support intervention for caregivers (2007). The patients received 10-14 sessions of modified CBT, while caregivers attended three to four separate psychoeducational classes. The modified CBT sessions were comprised of the same components of the previous Cole Vaughan, (2005) study, such as, stress management training, behavioral modification techniques for sleep hygiene, relaxation training, cognitive restructuring, modification of life stressors, and increasing engagement in pleasurable activities. The classes were targeted at providing caregivers with ways to respond to the patients negative thoughts and beliefs, as well as, strategies to offer appropriate support. As in the previous study, the modified CBT sessions were comprised of training in stress management, behavioral modification, sleep hygiene, relaxation techniques, an d cognitive restructuring. Participants reported a significant reduction in their depressive symptoms and cognitions and increased perception of social support at treatment termination and one-month post-treatment. CBT for anxiety. Along with depression, anxiety is a common mental health problem in palliative care settings and also appears to be alleviated with CBT interventions. In a small feasibility study examining the use of cognitive behavioral therapy techniques for mild to moderate anxiety and depression in hospice patients, four sessions of CBT techniques was found to significantly reduce anxiety and depression in a majority of patients (Anderson, Watson, Davidson, and Davidson, 2008). Overall, participants in the study found the CBT techniques acceptable, helpful, and qualitatively reported improved mood. A significant reduction in anxiety symptoms also was seen in a randomized controlled trial of CBT administered by home care nurses in patients with advanced cancer (Moorey et al., 2009). CBT techniques are particularly effective to assist with the management of anxiety related to breathing difficulties commonly seen with pulmonary diseases, such as chronic obstructive pulmonary disease (COPD). In a group of individuals with COPD, six sessions of guided imagery, a CBT relaxation technique, was found to significantly increase the partial percentage of oxygen saturation, which is a physiological indicator signaling more effective breathing (Louie, 2004). In another study, as little as 2 hours of CBT group therapy yielded a decrease in depression and anxiety among older patients with COPD, but there was no change in physical functioning (Kunik et al., 2001). CBT for pain management. Pain is not simply a biological response to unpleasant stimuli. It is a complex phenomenon that includes biological, psychological, behavioral and social factors that interact in complex ways to influence the pain experience. Some of the factors that can influence a persons experience of pain include: a) previous pain experiences, b) biologic and genetic predispositions, c) mood disorders such as anxiety and depression d) their beliefs about pain, e) fear about the pain experience, f) their individual pain threshold and pain tolerance level, and f) their skill with coping methods. Cognitive-Behavioral Therapy has the most empirical support for the management of chronic pain, especially when used as part of an interdisciplinary treatment approach to manage pain symptoms (Turk, Swanson, Tunks, 2008). Cognitive behavioral techniques can be used independently to assist with pain management or integrated into a comprehensive cognitive-behavioral case conceptualization framework to address pain (Turk, Swanson, Tunks, 2008). The three components to CBT for pain management are 1) Education and rationale for the use of CBT, 2) Coping skills training, and 3) Application and maintenance of CBT skills (Keefe, 1996). Useful behavioral interventions to assist with pain management include goal setting, relaxation strategies, such as deep breathing and guided imagery, and activities scheduling. Cognitive interventions would include increasing problem-solving skills and addressing an individuals maladaptive thoughts related to pain management. Examples of maladaptive thoughts include: 1) Ive tried every pain management intervention with no success, 2) I cannot do any of the things that I used to do, 3) nothing will help manage my pain, and 4) no one can help me feel better. CBT for pain manage ment has demonstrated efficacy in various diagnoses often addressed in palliative care. CBT has been found to be efficacious in the management of cancer-related pain in single studies (Syrjala, Donaldson, Davis, et al., 1995) as well as in systematic reviews (Abernethy, Keefe, McCrory, Scipio, Matchar, 2006). CBT for sleep hygeine. Insomnia, sleep duration and quality are major concerns for people with pain disorders such as osteoarthritis (Vitiello, 2009). Approximately 60 percent of individuals with chronic pain disorders report frequent nighttime awakening due to pain during the night. Disrupted sleep patterns exacerbate chronic pain intensity and experience which in turn causes more disturbance of the sleep/wake cycle. Successful treatment of interrupted sleep may reduce the pain experience as well as improve the overall quality of life for these individuals. Psychotherapeutic techniques that target sleep disturbances are easily incorporated within behavioral and cognitive management of other co-occurring disorders as well. Sleep disorders are common in patients who suffer from Parkinsons disease (PD) (Stocchi, Barbato, Nordera, Berardelli and Ruggieri, (1998). Specifically, insomnia, nightmares, REM sleep behavior disorder, sleep attacks, sleep apnea syndrome, excessive daytime sleepiness, and periodic limb movement in sleep result from changes in sleep structure, movement disturbances in sleep, disturbances in neurotransmission and medications. Individuals who are sleep deprived are at risk to develop infections, cardiovascular disease, hypertension, diabetes, depression, and require increased time to recover from stress (Schutte-Rodin, Broch, Buysse, Dorsey, and Sateia, 2008). CBT improves sleep by addressing unhelpful beliefs regarding sleep and misperceptions about the amount of sleep that one obtains. Many misperceive the amount of time they are actually asleep. People who suffer from insomnia actually sleep more than they are aware of because they are only attentive of when they are awake. Furthe rmore, many people believe they require 8 hours of sleep in order to be able to function during the day and any amount of sleep that is less is insufficient and will result in reduced ability to function during the day. Therefore, these beliefs and misperceptions can increase ones stress level about sleep and a stress response may result when one thinks about going to sleep. Clearly, a heightened stress response is not conducive to sleeping. CBT increases ones control over their unhelpful and inaccurate beliefs and enables them to replace them with more helpful and accurate beliefs (Whitworth, Crownover, and Nichols, 2007). CBT also addresses the behavioral components of ones sleep routine or patterns that interfere with ones ability to obtain restful sleep. Exercising, smoking, or drinking caffeinated drinks just prior to bedtime can interfere with ones sleep. All of these activities are stimulants that energize the body. Also, not having a bedtime routine, a regular sleep-wake pattern, or taking naps may interfere with ones ability to get restful sleep. Increasing ones sleep hygiene by developing positive habits that influence sleep such as, having a bedtime routine to prepare ones mind and body for sleep, regular exercise several hours before one intends to prepare for sleep, and avoiding coffee, alcohol, and smoking in the evening, as well as, increasing activities that produce relaxation (e.g., taking a hot bath one to two hours before going to bed, meditation, deep breathing, or muscle relaxation) can increase the likelihood of obtaining restful sleep. Another behavioral strategy utilized in CBT i s sleep restriction. This technique attempts to match ones actual sleep requirement with the amount of time one spends in his/her bed. The theory behind this approach is that reducing the amount of time spent in bed without sleep will increase ones desire to sleep (Harvey, Ree, Sharpley, Stinson, and Clark, 2007). Results of a study by Vitiello showed that treatment improves both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia without directly addressing pain control (2009). This study included 23 patients with a mean age of 69 years were randomly assigned to CBT, while 28 patients with a mean age of 66.5 years were assigned to a stress management and wellness control group. Participants in the control group reported no significant improvements in any measure while Individuals treated with CBT reported significantly decreased sleep latency (onset of sleep) by an average of 16.9 minutes and 11 minutes a year after treatment. Interruptions in sleep after sleep onset decreased from an average of 47 minutes initially to an average of 21 minutes after one year. Pain symptoms improved by 9.7 points initially to 4.7 points. Sleep efficacy (how rested does the person feel upon awakening) initially increased by 13 percent and 8 percent a year after treatment. The improvements remained robust in 19 of 23 individuals at a one-year follow-up visit. Furthermore, while many older adults experience insomnia, it is reported that up to two-thirds of those who experience these symptoms have limited knowledge regarding available treatment options. Sivertsen (2006), conducted a randomized controlled trial to compare the efficacy of non-benzodiazepine sleep medications with CBT. This study included 46 patients with a mean age of 60.8 years who were diagnosed with chronic primary insomnia. Participants were randomly assigned to either the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation), sleep medication (7.5 mg zopiclone each night), or placebo medication. Treatment lasted 6 weeks, and the CBT intervention and sleep medication treatments were followed up at 6 months. Data regarding total wake time, total sleep time, sleep efficiency, and slow-wave sleep was collected utilizing sleep diaries, and polysomnography (PSG; monitors physiological activity during sleep). Results revealed that total time spent awake improved significantly more for those in the CBT group compared to the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. In comparison, the zopiclone group did not reveal significant results from the placebo group (Sivertsen, 2006). The CBT group experienced a 52 percent reduction in total wake time at 6 weeks compared with 4 percent and 16 percent in the zopiclone and placebo groups respectively. A statistically and clinically significant finding was that participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, opposed to a decline of 1 percent in the zopiclone group. Total sleep time increased significantly between 6 weeks and 6 months for the CBT group. The zopiclone group showed improvements at 6 weeks and maintained these improvements at 6 months, but did not show further improvements. The CBT group showed significant improvements compared to the zo piclone group in total wake time, sleep efficiency, and slow-wave sleep; total sleep was the only area that did not yield a significant difference (Sivertsen, 2006). ADAPTING CBT TO THE PALLIATIVE CARE SETTING Overview of CBT in Palliative Care Cognitive-behavioral therapy is effective for many of common mental health issues seen in palliative care and often augments the success of pharmacological interventions. In addition to the individual with the terminal illness, their family members, as well as multiple health providers are considered integral members to the success of the collaborative relationship. Use of a CBT case conceptualization framework and various components offer flexibility, which makes the CBT approach feasible to implement within a palliative care setting. The following section provides an overview of the components of cognitive-behavioral therapy and necessary adaptations to palliative care settings. Collaborative Relationship As mentioned in previous chapters in this book, a collaborative relationship is a core component of an effective cognitive-behavioral intervention. In a palliative care setting, the collaborative relationship often involves more than just the client and the therapist. The interdisciplinary treatment team works with the individual to develop an individualized treatment plan that is central to the case conceptualization and goal setting of CBT. A variety of disciplines, such as nursing and social work, use CBT techniques in palliative care settings. Individuals receiving palliative care often need assistance with CBT interventions as their illness progresses. Individuals receiving palliative care often need assistance from the treatment team with practicing skills, such as relaxation techniques, and adapting CBT interventions as goals of care change. Some individuals in the Palliative Care setting may not be facing death in the near future, and if they are facing impending death, they may not be aware of it. In these cases the primary patient may be the family member or significant other. It is also common practice for most individuals to seek help for mental health problems from their family practitioner even though the typical family practitioner has very little training in psychiatric/mental health assessment, diagnosis and treatment. In cases where the family is relying on an under-trained health care provider it may be incumbent upon the mental health provider to negotiate the gap between family and medical care. Case Conceptualization and Goal Setting Therapy with the dying person should begin with having the person identify, explore and determine outcome goals regarding the issues at hand. Similarly to the primary care setting, case conceptualization and goal setting need to occur almost immediately. The therapist uses the Socratic Dialogue to explore the persons concerns and worries. This gives the individual more of a sense of control over what will be happening in the therapy session. Once this sense of control is established it becomes easier to explore other, more emotion laden topics. Goals should be small, obtainable and proximal to the session to be most effective. For example, Mrs. Jones I will be back to see you tomorrow. One of the things you have decided to practice is your deep breathing at least twice tonight and again in the morning. When I return I will check with you to see how you are doing with the practice. In palliative care setting, it may be necessary to discuss how other people involved in care can assist with reaching goals. For example, nurses might remind individuals to practice relaxation strategies during wakeful periods, as well as talk an individual through the relaxation technique when experiencing a high level of pain. Behavioral Interventions Pleasant Events Scheduling. Activities scheduling is a useful intervention to assist with mood disorders, pain management, and sleep hygiene issues seen in a palliative care setting. Engaging in pleasant events distracts an individual from negative thoughts and provides experimental evidence to support more adaptive thinking styles. Often times in palliative care the first barrier to overcome is identifying pleasant events that can occur in a palliative care setting due to health limitations. Pleasant events need to be person-centered, meaningful, and feasible activities that can be built into a daily routine. Meaningful pleasant events can be identified through both clinical interview and self-report methods. Clinical interview queries should include taking a history of an individuals daily schedule and identify activities the individual enjoyed engaging in on a routine basis prior to their illness. From the generated list of previously enjoyed pleasant events it needs to be determined which activities the individual can continue to enga

Macbeths Numerous Atmospheres :: Free Macbeth Essays

Macbeth's Numerous Atmospheres       The atmospheres in William Shakespeare's Macbeth are numerous, but begin as one surrealistic atmosphere initially with the witches' appearance at the outset. From there the atmosphere is incrementally added to regularly.    Charles Lamb in On the Tragedies of Shakespeare comments on the atmosphere surrounding the play:    The state of sublime emotion into which we are elevated by those images of night and horror which Macbeth is made to utter, that solemn prelude with which he entertains the time till the bell shall strike which is to call him to murder Duncan, - when we no longer read it in a book, when we have given up that vantage-ground of abstraction which reading possesses over seing, and come to see a man in his bodily shape before our eyes actually preparing to commit a muder, if the acting be true and impressive as I have witnessed it in Mr. K's performance of that part, the painful anxiety about the act, the natural longing to prevent it while it yet seems unperpetrated, the too close pressing semblance of reality,give a pain and an uneasiness [. . .]. (134)    D. F. Bratchell in Shakespearean Tragedy record's Charles Lamb's consideration of   Macbeth's atmosphere as essential to the purpose of the play:    For Lamb the essence of the tragedy in Macbeth lies in the poetically suggested atmosphere of horror and evil impulse, readily seized upon by the imagination of the perceptive reader, whereas stage representation concentrates the mind on the action. (133-34) Roger Warren comments in Shakespeare Survey 30 , regarding Trervor Nunn's direction of Macbeth at Stratford-upon-Avon in 1974-75, on opposing imagery used to support the opposing atmospheres of purity and black magic:    Much of the approach and detail was carried over, particularly the clash between religious purity and black magic. Purity was embodied by Duncan, very infirm (in 1974 he was blind), dressed in white and accompanied by church organ music, set against the black magic of the witches, who even chanted 'Double, double to the Dies Irae. (283) L.C. Knights in the essay "Macbeth" mentions equivocation, unreality and unnaturalness in the play - contributors to an atmosphere that may not be very realistic:    The equivocal nature of temptation, the commerce with phantoms consequent upon false choice, the resulting sense of unreality ("nothing is, but what is not"), which