Analysing Personal Dream s through Activation Information...

We spend six years of our lives in sleep and many of us do not think about what occurs while asleep. Everyone has experienced more than a few dreams while asleep, that is because, whether you know it or not, everyone dreams while asleep. Based off the Activation Information Mode Model theory, dreams are random neurological firings that have no particular meaning. The reason dreams feel so real and personal is because they are based from recent memories located in the brainstem. Although dreams are meaningless, our brain tries to make connections. Through the Activation Information Mode model people are able to analysis personal dreams. Dream Theory In 1977, American psychiatrist and dream researchers, Allan Hobson and Robert McCarley,†¦show more content†¦In the start of the dream I was dreaming and woke up to write down that dream in the journal. Unfortunately, I could not remember the dream and I felt stressed and pressured to have an interesting dream. When I finally woke up my dream journal was blank. The reason I dreamt about writing in the dream journal is because three day before, my teacher assigned us to write al of our dreams down and I never could remember my dreams so I felt stressed to have at least ten dreams. In the dream I was frustrated because I couldn’t remember the dream. The dream had no meaning because dreams are just neurological firings that are synthesized by the upper brain. Another dream I had took place on November 19, 2013. During this dream Katherine Heigl was dying of cancer inside of an office cubicle. The cubicle was filled with files of papers and had a desktop computer on the desk. Inside he office someone bought Panda Express to eat. That night I went to sleep watching Grey’s Anatomy on Netflix. In that episode Izzy, played by Katherine Heigl, was diagnosed with cancer. The papers were prevalent in my dreams because my bed was covered in notes and other forms of paper. Also, my favorite place to eat is Panda Express and I ate that for dinner before I went to sleep. This dream is a recollection of everything I did within the past few hours of falling asleep, which fully supports the AIM model theory. On November 20, 2013 I dreamt that I was feeding Grace, Jahnell’s baby, withShow MoreRelatedContemporary Issues in Management Accounting211377 Words   |  846 PagesNo doubt such abilities reflect Michael’s early grounding in both the practice of accounting and its economic theorization, the former at Ford and the latter initially at the London School of Economics and thereafter as a lifetime endeavour. But personal though his achievements may be, they are also reflective of a wider tradition of significant involvement in the practical sphere by senior British accounting academics. For we must remember that it was Professor Edward Stamp who was one of the firstRead MoreMarketing Management130471 Words   |  522 Pagesareas of management Market segmentation Market targeting and positioning Product management Brand management Pricing Channel design and management Retailing and Wholesaling Integrated Marketing Communication Advertising management Sales promotion Person al selling Public relations Understanding individual consumer behaviour Understanding industrial consumer behaviour Customer satisfaction Customer relationship management Marketing of services Rural marketing Types of marketing research Process of marketing

Essay on Victim and Crime Evulation - 1159 Words

Victim and Crime Evaluation Larry Fulse CJA /354 May 5, 2014 Joeseph Caulfield The Criminal Justice system today is our scale of judgment. It plays a major part in how we live and how we continue to live among all the dangers, evil and corruption that surrounds us. Without it there wouldn`t be the fine line of right and wrong, there wouldn`t be justice. Those that are considered victims in our criminal justice would turn and become the aggressors and the criminals if we didn`t have a Legal System, and we would live in a world of chaos. Many individuals each have a role to play in our Criminal Justice System; there are the criminal and the victims who create the unfortunate events to which justice has to be served and then there†¦show more content†¦In the United State today, there is no standard when it comes to punishment and sentencing. This area of the criminal justice system is one that is in constant flux. Sentencing practices and goals are always under scrutiny. From â€Å"getting tough on crimes† to more rehabilitative approaches, th e views and goals of sentencing are ever changing. Since time began, there was crime and with crime came the need to punish criminals. How criminals were punished and the methods behind the punishments changed throughout the times. Standards of punishment moved from banishment and fines to torture and â€Å"blood feunds.†(Siegel Senna, 2005). A more organized system of punishment came forth with the formation of Common Law which was brought over to the United State from England. With the development of a system, there was a move away from physical punishment towards methods more acceptably used yet today in the United States. â€Å"Today there is many things criminal justice system aims to do by imposing punishments and sentences goals of punishment have moved from satisfying the victims, as in early days, to move of a broad scale. There are theories on how punishment and sentencing may serve to reduce crime as a whole. General and specific deterrence, incapacitation, rehab ilitation, retribution, and reformation are just some of these goals.†(Siegal Senna, 2005). Victim input into sentencing decisions is most keeping with the objective of restitution, which places

Prozac Nation Free Essays

Prozac Nation tells the story of Elizabeth Wurtzel’s childhood, her troubled relationship with her father who left her and her mother and refused to accept his responsibilities to his family, her move to Harvard, and her mental decline leading to several stays in hospital and a suicide attempt. Finally, after trying many different psychotherapists, psychiatrists, and medications, she tries Prozac and it helps her rise above her despair. In the Afterword to Prozac Nation, written for the paperback edition in 1995, Wurtzel asks the question that will have occurred to many of her readers. We will write a custom essay sample on Prozac Nation or any similar topic only for you Order Now What on earth makes a woman in her mid-twenties, thus far of no particular outstanding accomplishment, have the audacity to write a three-hundred page volume about her own life and nothing more, as if anyone else would actually give a shit? (p. 354) She gives a long answer, the crux of which is: I wanted this book to dare to be completely self-indulgent, unhesitant, and forthright in its telling of what clinical depression feels like: I wanted so very badly to write a book that felt as bad as it feels to feel this bad, to feel depressed. I wanted to be completely true to the experience of depression—to the thing itself, and not to the mitigations of translating it. I wanted to portray myself in the midst of this mental crisis precisely as I was: difficult, demanding, impossible, unsatisfiable, self-centered, self-involved, and above all, self-indulgent. (p. 356) Wurtzel certainly succeeds in her aim to portray herself as capricious and self-preoccupied. Indeed, according to her own description, she seems so impulsive, self-preoccupied, needy in relationships, and manipulative that readers will probably wonder whether depression is indeed Wurtzel’s most basic problem. It’s very tempting to speculate that Wurtzel has just as much claim to a diagnosis of borderline personality disorder as she does to depression. Wurtzel says that her psychiatrists gave her a diagnosis of atypical depression, and DSM-IV-TR tells us that personality disorders may be more common in those with atypical depression. Of course, even if I were a psychiatrist, which I’m not, would be ridiculous to offer a diagnosis based on an autobiography. What is clear, however, is that Wurzel’s goal of telling some general truth about clinical depression is not accomplished. Reading Prozac Nation is a very different experience from reading other memoirs of depression such as Tracy Thompson’s The Beast and Martha Manning’s Undercurrents because Wurtzel manages to provoke such a mixture of conflicting feelings in her reader, while other authors of depression memoirs provoke far more consistent sympathy. By the end of the book, one feels far more sympathy for Wurtzel’s mother and her friends than one does for her. Normally, I count myself as able to identify and empathize with people who suffer from serious mental illnesses, but I have to confess that, given the way she describes herself, unless she has changed dramatically, I’d recommend her friends to run a mile rather than put up with her manipulation. Note that one gets a similar impression from Wurtzel’s second memoir, More, Now, Again, (reviewed in Metapsychology April 2002) in which she becomes addicted to Ritalin and cocaine, and spends most of her time lying and hiding her addiction from her friends, mother and publisher. In Prozac Nation, Wurtzel several times suggests that she was addicted to depression and makes clear that her self-defeating behavior was often willful. What makes it so hard to sympathize with her is that that her problem seems to be her personality, rather than some affliction she has to overcome. To be more precise, Wutzel describes herself sometimes as the agent of her predicament, and other times as the victim of it, and it’s unclear for the reader what reasons there are for these switches. She manipulates people close to her: for instance, she tells calls her therapist at all times of the day and night, and then tells her therapist that if she does not listen to her problems, her (Wurtzel’s) blood will be on her (the therapist’s) hands. Sometimes even her crying seems like a deliberate action. But at other times she feels immobile, and can’t get out of bed. Consider, for example, how she feels after her brief romance with a man called Rafe, uring which she was miserable, clingy, and insecure, and she explicitly ignored his request that he spend time away from her, since he needed to be with his family, who had their own needs. I couldn’t move after Rafe left me. Really. I was stuck to my bed like a piece of chewing gum at the bottom of somebody’s shoe, branded with the underside, adhering to someone who didn’t want me, who kept stamping on me but still I wouldn’t move away. (250) Wurtzel’s alternating acceptance a nd denial of her agency bemuses the reader, and ultimately makes Wurtzel a less credible witness to her own mental states. Far from knowing exactly how it was for Wurtzel, even though it is clear that she was desperately unhappy for most of the time, readers will be confused and exhausted by her narrative. Far from undermining the work, these features are what make Prozac Nation so distinctive, standing out among other memoirs. It is a tour de force, and a powerful evocation of Wurtzel’s experience, although it’s not so clear whether that experience is depression, borderline personality disorder, or some other mental disorder. How to cite Prozac Nation, Essay examples

Love in Romeo and Juliet and Sonnets 18, 29 and 130 Essay Example For Students

Love in Romeo and Juliet and Sonnets 18, 29 and 130 Essay Shakespeare is reputed to be one of the most eloquent and influential writer, poet, actor and playwright in English Literature. Born in 1564 in Stratford-upon-Avon to John and Mary Shakespeare, Shakespeare was part of a successful middle class family. He grew up in a time where poetry and acting was at an all-time high which helped towards him leading a very successful profession. Throughout his career, he wrote 36 plays and 154 sonnets, four of which will be delved into in this essay. These four are his play â€Å"Romeo and Juliet† and sonnets â€Å"18, 29 and 130†. These works of art are a few examples of how Shakespeare uses his clever wit, brilliant mind and his deep understanding of human emotions to show the feelings of romantic love, requited and unrequited. These texts also portray Shakespeares mastery over the English language, successfully stirring deep emotions within the reader through his subtle manipulation of language, grammar and structure. This essay will delve into how romantic love is presented throughout the four writings and will compare how it is presented to the reader. Firstly, Shakespeare’s play, Romeo and Juliet, is one of the most famous romantic tragedy stories in English Literature. A story with love being the most influential and imperative theme, a force of nature that supersedes all other values and emotions. The plot revolves around to â€Å"star-cross’d lovers† who fall in love at first sight. Love is first expressed at the beginning of the play through the prologue of Act 1. Here, Shakespeare includes the phrase â€Å"star-cross’d lovers† referring to two couples that are the centre point characters of the play. He is using a metaphor to get across the fact that the two lovers will have a relationship that will be thwarted by outside forces. The chances of their relationship growing into something fruitful are unlikely and in turn empower the affair the two fall in to. These forces are the two families the duo belongs to, who are locked in a struggle that stems from an â€Å"ancient grudge† which only breaks after their death. This phrase can also be interpreted as that the two characters were destined to meet and cross paths and not necessarily refer to the tragic end that befalls the two stars. Metaphors are also used in the sonnets. Similarly to the aforementioned point, in sonnet 18, metaphor is used to show love and romantic attraction. It is used to flatter the lover with buttery and flowery description. It is represented when Shakespeare says â€Å"thy eternal summer shall never fade†. Here, he is trying to say that his lover’s beauty will not diminish with time and she will remain forever young. This shows love as he is saying that she is so beautiful that she will stand the test of time. The love between the poet and the beloved is so powerful that it transcends nature and even death cannot stop it. Shakespeare expresses this in the last two lines, where he says that her beauty and youth will be preserved through the sonnet itself. He is saying that their love will live on through many generations. It can also be interpreted as the poet’s lover and love itself will become a part of nature as the line embodies summer as a comparison to their love. In stark contrast, metaphor in sonnet 130 is used to a completely different effect. Instead of using it to exaggerate the beauty of his love with dubious and implausible comparisons, he uses it to undermine his lover and to some extent insult her. The sonnet is full of apparent insults, which was an absurd use of the sonnet form in the Elizabethan times, where In the fourth line, Shakespeare says that â€Å"black wires grow† on his lovers head. If the metaphor was used to show love in this sonnet, the poet would not have said something that would seem to say that she is not perfect. Compared to love poems at the time and sonnet 18, Shakespeare seems to be a non-conformist through this sonnet as most poems would exaggerate their beauty of their love, where as he does the opposite. In this case, most poets would have compared their lover’s hair to something like golden threads to show that it is shiny, which was the norm back then. They also would have said that it is silky and smooth. However, these incarnations of love had become rather cliched and, maybe the reason why Shakespeare did not use metaphors that way. It would not been as head turning as these allusions were already worn out. Shakespeare’s use of metaphor for a negative impact in this sonnet may have been to try and give a realistic impression of his love. The interpretation of Romeo and Juliet within the society of today EssayThe repetition of the word â€Å"state† brings together the two sections of the poem. The structure of â€Å"sonnet 18†, â€Å"sonnet 130† and the prologue of Romeo and Juliet are very similar in the way they portray romantic love. Each text is loosely structured around the style of sonnet developed by Francesco Petrarch from Renaissance Italy. While very similar, Shakespeare adds his own personality to the sonnet form, such as including a lot of iambic pentameters within the texts. The 14 lines of poetry are three quatrains with alternating rhyme scheme of A, B, A, B, followed by a rhyming couplet. The rhyming couplet in all three texts gives them a striking ending and often contained a moral, solution to the problem conveyed in the earlier lines or a twist to the story. To draw this essay to a close, it can be said that the relationship of romantic love is implemented into the play and the sonnets in many ways in order to show the different levels of compassion and fondness. Romantic love in many people eyes is the lustful intent of falling in love with someone to do intimate things, whereas others would say it is not just about the outer beauty but also about falling in love with someone’s behaviour and characteristics. It can also be presented as having complete loyalty to the person you have fallen in love with, no matter what happens, and that the mere thought them should make you happy and filled with joy. Through the works of Shakespeare, romantic love can be seen to have many different meanings and can be interpreted differently. If it is taken from sonnet 18, romantic love can be something that only occurs when you constantly compliment your lover with over the top and dream like characteristics, while in sonnet 130 it encompasses all parts of them, not just their outer beauty. It is about looking at them with the mind’s eye and looking past their physical flaws. In sonnet 29, romantic love is more focused on the fact that it can bring joy to a person who is in despair and that nothing is above true love. Romeo and Juliet explores both side of romantic love, the side that is pure bliss and delightful through to the part that causes anguish and desolation. The beauty of love is shown when they first meet and fall in love, both their moods improve drastically and they both want to be together no matter what. They both depict each other using other worldly descriptions and that nothing will tear them apart. This leads to the other face of love. The face that is truly ugly and one that no one should need to see. This branch of love is seen when both lovers end up killing themselves due to not being able to be together because of a family feud. Throughout all four pieces of work, there is a distinct and repetitive pattern in the way Shakespeare portrays love. This is established through the way he uses iambic pentameter to give off a harmonious feel to the sentences. People of today may take a certain dislike to some of Shakespeare writings, while appreciate understand some others. Sonnet 18 and Romeo and Juliet are examples of how they may not be fond of his work, as in the case of the play, the speed at which love blossoms into a full blown relationship and marriage is way too fast, and many people nowadays know that a relationship like this is impossible to keep a hold on. In the sonnet, he uses a lot of exaggeration to his devotion to his love, this would put off readers as most know that the external looks is not what determines a good relationship. This is the reason why sonnet 29 and 130 would appeal more to people of this day and age. These two sonnets show that love is about inner beauty and that when you think about the person you love, it should bring you happiness.

Definition of Cognitive Psychology

History of the Shakespearean Sonnet

History of the Shakespearean Sonnet It is not known exactly when Shakespeare wrote his sequence of 154 sonnets, but the poems’ language suggests that they originate from the early 1590s. It is believed that Shakespeare was circulating his sonnets amongst his close friends during this period, as clergyman Francis Meres confirmed in 1598 when he wrote: â€Å"†¦the sweete wittie soule of Ouid liues in mellifluous and hony-toungued Shakespeare, witness †¦ his sugred Sonnets among his private friends.† The Shakespearian Sonnet in Print It wasn’t until 1609 that the sonnets first appeared in print in an unauthorized edition by Thomas Thorpe. Most critics agree that Shakespeare’s sonnets were printed without his consent because the 1609 text seems to be based on an incomplete or draft copy of the poems. The text is riddled with errors and some believe that certain sonnets are unfinished.​ Shakespeare almost certainly intended his sonnets for manuscript circulation, which was not uncommon at the time, but exactly how the poems ended up in the hands of Thorpe is still unknown. Who was â€Å"Mr. WH†? The dedication in the frontispiece of the 1609 edition has sparked controversy among Shakespeare historians and has become a key piece of evidence in the authorship debate. It reads: To the only begetterof these ensuing sonnetsMr. W.H. all happiness andthat eternity promised byour ever-lasting poet wisheththe well-wishing adventurerin setting forth.T.T. Although the dedication was written by Thomas Thorpe the publisher, indicated by his initials at the end of the dedication, the identity of the â€Å"begetter† is still unclear. There are three main theories regarding the true identity of â€Å"Mr. W.H.† as follows: â€Å"Mr. W.H.† is a misprint for Shakespeare’s initials. It should read either â€Å"Mr. W.S.† or â€Å"Mr. W.Sh.†Ã¢â‚¬Å"Mr. W.H.† refers to the person that obtained the manuscript for Thorpeâ€Å"Mr. W.H.† refers to the person that inspired Shakespeare to write the sonnets. Many candidates have been proposed including:William Herbert, Earl of Pembroke to whom Shakespeare later dedicated his First FolioHenry Wriothesley, Earl of Southampton to whom Shakespeare had dedicated some of his narrative poems It is important to note that although the true identity of W.H. is of importance to Shakespeare historians, it doesn’t obscure the poetic brilliance of his sonnets. Other Editions In 1640, a publisher called John Benson released a highly inaccurate edition of Shakespeare’s sonnets in which he edited out the young man, replacing â€Å"he† with â€Å"she†. Benson’s revision was considered to be the standard text until 1780 when Edmond Malone returned to the 1690 quarto and re-edited the poems. Scholars soon realized that the first 126 sonnets were originally addressed to a young man, sparking debates about Shakespeare’s sexuality. The nature of the relationship between the two men is highly ambiguous and it is often impossible to tell if Shakespeare is describing platonic love or erotic love.

The prevalence of substance use on children Research Paper

The prevalence of substance use on children - Research Paper Example In a 2003 national survey, half of all seniors’ in high school reported they had tried taking illicit drugs at least once. It was further revealed that 41% of students in 10th grade and 23% of those in 8th grade had tried drugs that were illegal (U.S. Department of Health and Human Services, 2007). Such findings are worrying because substance use is associated with several negative consequences, such as academic problems, physical aggression, developmental problems, delinquent and criminal behavior and health problems in the long term (Buu et. al, 2009). In addition to this, children who develop into chronic substance users are bound to experience social or psychological problems. The survey also showed that 41 to 65% of persons with constant lifetime substance abuse are prone to having at least one mental health disorder. Approximately 51% of those persons with one or more lifetime mental health disorders also had a constant lifetime history of substance use disorder (Doweiko, 2009). It was found that the 15 to 24 year old age bracket had the highest rates (U.S. Department of Health and Human Services, 2007). Substance use is categorized as being different from substance abuse. The American Psychiatric Association defines substance abuse as a pattern of substance use that man ifests itself through significant and recurrent adverse consequences that are related to repetitive substance use. There are various factors that increase the risk for substance use among the youth. Some of the causes of substance use include delinquency, perceived substance use by peers, low family pride and family substance use problems. A study done in 2009 found that substance use by parents, socioeconomic status of the family, family mobility, instability in neighborhood residence and frequent change in neighborhood placed children at the risk for developing substance use disorders. Youth with mental health disorder also

HRIS Implementation Plan in a middle-sized company Essay

HRIS Implementation Plan in a middle-sized company - Essay Example In many cases, errors occur when a person is entering data manually into databases. Data cleansing is thus crucial since some errors are unavoidable. However, automation of data like in the case of HRIS results in errors and intricacies that are not easily corrected. Additionally, attempts to locate and correct may result in complication of the problem. A good example is when dealing with data regarding the employees’ employment history, which is interrelated to other employment aspects such as pay rate and positions held. Attempts to make correction in one of the field might result in automatic alteration of data in other categories. To overcome this problem, it is important to implement an application that acts as an interphase between the different fields to enable data transfer from one database or application to another. This ensures that employees’ data entry is only done once and transferred across different databases without making alterations. Additionally, the application should be capable of linking employees’ data to the security profile to ensure that only the right people make changes on employe es’ data. Process 2 or tracking employee job performance entails enabling the HRIS system to evaluate employees more quickly and efficiently and creating a uniform system for employee system. It is important that managements define what performance is for the different job specifications. After 1determining performance, the organizations should set goals to direct the managers and employees. A salient factor that would jeopardize implementation of process two is unclear alignment of employee’s goals with the corporate culture and goals. To prevent this, the HR department should concur with the management to ensure the goals set are attainable. In some instances, the set goals are unrealistic and some employers end up blaming the employees for underperformance. It is thus important to

Analyzing the causes of change Essay Example | Topics and Well Written Essays - 1000 words

Analyzing the causes of change - Essay Example This led to a position for Nokia which was not so mobile like before. The changes in the political environment included relaxation in the regulatory norms in telecommunication industry which attracted increasing number of foreign players in the telecommunications and mobile handset industry. The increase in the number of competitor and the launch of newly designed handsets in the market posed major challenges for Nokia (Burnes, 2009, p.52). The inclination of the customers towards the camera handsets launched by the competitors of Nokia led to the decline in market share of Nokia. The rise of Nokia to the leadership position in the 1990s created increasing job opportunities and rise in the income level of the people of various economies. The rise of the middle income group was the potential market that was tapped by the competitors of Nokia. The mobile handsets of Nokia were old fashioned that dated 10 years back. The market trends saw the launch of flashy and newly designed handsets with colourful screens and folding patterns (Reiss, 2012, p.39). The changes in the mobile handsets matched with the evolving social trends and demands of the customers. Nokia was unable to keep up with the recent changes in the market for which the market of Nokia declined in the recent years. Even the most loyal Finnish market of Nokia witnessed a decline in share from 93% to 80%. The technological advancements in the telecommunications industry and the increase in market share of LG, Motorola posed major threats to the business of Nokia in the several markets across the world. The mobile phone operators like Vodafone favoured the other mobile handset makers as they desired to provide services on mobile handsets that were updated to the market trends. Nokia did not believe in co-branding while the market trends saw increasing number of joint ventures and co-branding of products in order to meet the demands of customers (SENGUPTA, BHATTACHARYA and SENGUPTA, 2006, p.31). The sharin g of technology in the market helped the other market players to tap the customer segments who were looking for changes in the available features of the mobile handsets. These temporal changes in telecommunication device offerings to the market were due to the strategic policy making of the competitors (McLoughlin and Aaker, 2010, p.21). The changes in the political, economic, social and technological environment led to the loss of interest for Nokia among the market segments. Nokia could not identify the changes that took place in the market and failed to undertake strategic policies of change management in a timely manner. All these factors led to the decline in mobility of Nokia in the recent years. Use of multiple cause diagrams: forces of change management The decline in the market share of Blackberry smart-phones could be represented with the help of a multiple cause diagram to determine the factors that led to the changing scenario in the business of Research in Motion (RIM), the makers of Blackberry. The multiple cause diagrams would help the organization to respond to the forces of change and also enables the company in addressing the key variables in order to solve the complex dynamics of prevailing

Sepsis Systemic Immune Response Health And Social Care Essay

Sepsis Systemic Immune Response Health And Social Care Essay Sepsis is defined by the clinical signs and symptoms of a systemic immune response to infection. (1-2) Currently, sepsis on a worldwide level creates a significant level of mortality; and results in approximately one third of all Intensive Care admissions. (3-5) In Victoria alone there are approximately 8500 admissions to Emergency Departments with patients suffering from sepsis (3) and this number is increasing. Sepsis treatment can be initiated with a broad spectrum antibiotic, and then transferred onto a specific antibiotic regimen. Currently the level of pre hospital data available on the management of sepsis is very limited and the most advanced model has been initiated in the United Kingdom; including a pre hospital screening tool and then the hospital management known as the Sepsis six. (6) Pre hospital management can be utilised to the full potential of paramedics training and knowledge with the administration of pre hospital antibiotics; however this is not without risk. Per haps the resistance to hand over the authority to paramedics in the United States is the notion of creating a super bug; similar to Methicillin-resistant Staphylococcus aures. This paper proposes that the administration of antibiotics in the pre hospital field does carry some risk, but the research suggest that the benefits clearly outweigh these risks. A new pre hospital guideline must be created due to the sheer number of Emergency Department admissions. The potential to make a significant difference to a patients outcome is imperative. Epidemiology It has been highly researched and reported across the world that sepsis is a major cause of morbidity, mortality and places an enormous financial burden on the respective health system. (2, 5, 7) Statistics from Australia, United States and the United Kingdom are similar in nature and provide a wealth of information regarding the epidemiology of sepsis. Sepsis in the United States has been recognised as a public health issue, (8) with studies reporting that there are 300 reported cases per 100,000 with approximately 40% mortality. (5, 7-9) Severe sepsis in the United kingdom accounts for 27% of Intensive Care Unit admissions (4) and this is comparable with 23.8% of Intensive Care admissions in Victoria, Australia. (3) However it may be noted that this data is not very recent and that in the time of study the incidence was increasing by approximately 9% per year; whilst also reporting a decrease in the number of deaths associated with sepsis from approximately 45% to 37.7%. (5, 7, 9) Whilst many studies report the number of admissions, few report the age distribution of patients presenting with sepsis. Sundararajan et. al. highlight that the age distribution within their study was bimodal which identified that the age brackets at the extremes of the spectrum were over represented; with children less than 1 and adults in the 70-79 age bracket. (3) Upon further investigation into the types of causative pathology causing sepsis in these patients; gram positive organisms account for 28%, gram negative for 20%, fungal infections 2% and other organisms for 49%. (3) These figures are comparable with a study conducted by MacArthur et. al. of approximately 2634 patients with approximately 30% identified as gram positive and 26% gram negative bacteria. (10) Pathophysiology and clinical features What is Sepsis? Sepsis is an infection induced syndrome and the clinical appearance in nature is the consequences of cellular interactions between the host and invading pathogen. (2, 11-12) Sepsis may be initialised by prolonged local inflammation to eliminate and clear the invading pathogen. The second line of defence against invading pathogens involves the production and activation of leukocytes at the local site of infection. (13-14) Throughout this phase, immune cells identify the pathogen through pattern recognition protein receptors on the cells. (15) An example of one of these receptors are toll like receptors and these are among the recognition receptors which have the ability to activate immune cells, inducing the production of pro-inflammatory cytokines and chemokines by the stimulation with bacteria and viral proteins (depending on the infection). (15-16) The invading pathogen may initiate the complement pathway of the immune system, allowing leukocytes to phagocytose [digest] the pathoge n. If the host fails to limit the invading pathogen to a local area, the pathogen may invade the bloodstream. (16) If phagocytosis continues in the blood stream, toxic substances released by the pathogen may leak directly into the bloodstream; these include endotoxins released by gram negative bacteria (17) and lipoteichoic acid and peptidoglycan released by gram positive bacteria. (18) These by-products of phagocytosis and death of the cell may trigger a systemic activation of the complement system and stimulate the production of inflammatory cytokines. (19) Subsequently leading to an increased excessive and prolonged inflammatory response. (20) The result of this prolonged response leads to Systemic Inflammatory Response Syndrome (SIRS) which is the result of either direct or indirectly through the production and activation of nitrous oxide, oxidants and proteolytic enzymes which is known to have the potential to lead to inflammation induced organ injury. An example of this would be Acute Respiratory Distress Syndrome. (16, 20) SIRS is characterised by two or more of the following: body temperature >38Â °C or 90 beats per minute, respiratory rate >20 per minute or arterial CO2 >32mmhg or a need for artificial ventilation, and white blood count greater than 12,000/mm3 or 10% immature forms. (21) SIRS can be also initiated not only by infection, it may also develop as a result of trauma, ischemic injury or sterile inflammation. (22) What is severe sepsis? If SIRS is left untreated, this response then cascades into what is known as severe sepsis. Severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion or hypotension responsive to fluid resuscitation. (23) This can progress to septic shock, which involves persistent hypotension unresponsive to fluid administration. (23) An example of severe sepsis is called Multiple Organ Dysfunction Syndrome (MODS). This occurs when the infection of the bloodstream leads to progressive failure of two or more organ systems which result from a prolonged and uncontrolled inflammatory response. This organ dysfunction can lead to potential organ failure and death. (19) Analyse evidence relating to the prehospital management of sepsis to identify risks and benefits of paramedic-initiated antibiotic therapy; Sibley and Sibley (23) suggest that if Emergency Medical Services (EMS) or Paramedics have a patient suffering from suspected sepsis, that they must be managed with oxygen therapy, well documented vital signs and IV access to initiate fluid resuscitation. (24) The goal for EMS is to maintain systolic blood pressure just above 90mm Hg, with a Mean arterial pressure of 65mm Hg as any higher has the potential to worsen cardiac output, with adverse reactions. (24-26) Other studies support the notion of maintaining Mean arterial pressure at 65mm Hg as there is no clinical benefit to increasing this value higher. (27-28) Sibley and Sibley (23) contradict many other studies which suggest that early empiric antibiotic treatment of patients suspected of having sepsis is a standard practice; and the earlier treatment is initiated, the more positive the outcome. (2, 6, 8, 10, 16, 25, 29-30) Empirical antibiotic treatment is the use of a broad spectrum antibiotic whilst therapeutic treatment with antibiotics is the initiation of antibiotic treatment after blood cultures are taken and the specific pathogen is identified. (31) Whilst empirical antibiotic treatment in the management of sepsis may be the initial drug of choice, it is in the patients best interest that appropriate antibiotic therapy is continued within the hospital. Appropriate antibiotic therapy is defined as the use of an antimicrobial agent that is correct on the basis of all available clinical, pharmacological and microbiological evidence. (32) With respect to the pre-hospital administration of antibiotic therapy, a recent study concluded that, if a patient is suffering septic shock, with each hour of delay in antibiotic administration after the onset of hypotension was associated with an average decrease in survival of approximately 8%. (33) However, a potential problem with empirical antibiotic treatmen t is that because sepsis is not the result of a single pathogen, the use of empirical antibiotics may not cover the pathogen causing the disease or illness. Broad spectrum antibiotics may bide time until blood cultures and appropriate testing can be done within a hospital setting. The current research suggests that the antibiotic selection used to treat conditions such as sepsis has a profound impact on patient outcomes (34) and this is also the case with inadequate antibiotic therapy, where the invading pathogen is not being effectively treated. (31) With regard to the empirical treatment, there are many different forms of pathogens that can cause sepsis, including Staphylococcus aures, Streptococcus pneumoniae, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. (10) With this in mind, the aforementioned figures that roughly 28% of septic patients are caused by a gram stain positive, and 20% of patients are gram stain negative, and the rest being approximately 52% (3, 10), the notion is that broad spectrum antibiotics may not cover these specific pathogens, therefore rendering treatment useless. Potentially this could l ead to a negative or adverse outcome. An International Initiative, the Surviving Sepsis Campaign (30, 35) and the Critical Care Community in the United Kingdom (6) initially concentrated on educating emergency department staff to promote the introduction of management of sepsis known as Early Goal Directed Therapy. Upon review, poor implementation of this initiative and resuscitation lead the education staff involved to a move to target the staff working in areas outside of the emergency department, including the implementation of an operationalised resuscitation management plan referred to as the Sepsis Six. The Sepsis Six involves the administration of high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measure serum lactate and haemoglobin and the insertion of a urinary catheter to measure urine output. The Sepsis Six can be implemented by hospital staff with different skill sets in the first hour following the diagnosis of sepsis and can make a significant contribution to decreasing mortality. (6) With respect to the rationale of the Sepsis Six Robson et. al. proposes that components of this treatment can be initiated pre hospital, and interestingly, the authors also highlight that pre hospital sepsis care is unusual, but pre hospital cardiac care is common. The question remains as to why that is. Given that all the literature available suggests that there is a significant decrease in morbidity and mortality associated with early antibiotic treatment. Within Ambulance Victoria, the current management for the treatment of severe sepsis has not been established. Only a guideline is specifically written for meningococcal septicaemia which allows paramedics to administer Ceftriaxone in the pre hospital field in the suspected case of meningococcal septicaemia. (36) Walker (37) proposes that in the year 2003, meningococcal disease affected approximately 500 Australians with approximately 100 of these cases presenting in Victoria. It would seem logical that an appropriate guideline is established for sepsis and severe sepsis based on the available data from Sundararajan et. al. (3) which suggest within a 4 year time frame, approximately 34,000 admissions to hospital were identified as suffering from sepsis. However, it must be recognised that this only accounts for 1.1% of the total number of admissions to Victorian emergency departments. (3) This is considerably more hospital admissions when compared with meningococcal septicaemia, with similar, if not more deadly consequences. Perhaps the thought of utilising empirical antibiotic therapy causing a super bug with sepsis is debateable. Whilst many studies report that Methicillin-resistant Staphylococcus aures is developed within the hospital system (38) rather than the community based setting; this attitude is changing with larger numbers of community acquired Methicillin-resistant Staphylococcus aures being reported, (39) with an estimated 50% of the population being a carrier of the bacteria. (40) The concern of doctors and other health professionals to the thought of initiating treatment with an empirical antibiotic may be a result of previous dealings with Methicillin-resistant Staphylococcus aures. Methicillin-resistant Staphylococcus aures has evolved and mutated to be come resistant over generations with different strains of antibiotic that were initially effective at eliminating the bacterial pathogen. (41) The thought that exposing such a broad spectrum antibiotic; for example ceftriaxone, (a cephal osporin antibiotic) is that the exposure of a drug like this may potentially initiate a genetic mutation in potentially a wide spread of different strains of pathogens. Many studies have investigated the use of empirical antibiotics and also the possibility of not only one pathogen causing disease, therefore developing an appropriate antibiotic regime. This makes logical sense however, with consideration to the potential to cause a genetic mutation, exposing a pathogen to several antibiotics may have the potential to produce a resistant strain to not only one antibiotic, but several. The surprising news is that these studies have proven to have little or no extra effect in reducing mortality. (42-43) Walker (37) proposes that the administration of pre hospital antibiotics by paramedics does have the potential for complications, including adverse reactions such as anaphylaxis and vasomotor collapse. However, the risk of antibiotic administration is no different to the administration of any other drug, with potential side effects and adverse reactions specific to individual patients. Synthesise recommendations for paramedic management of sepsis based on available evidence. Pre hospital data available on the treatment and management of septic patients are scarce. It is evident that more research needs to be undertaken in order to correctly identify septic patients and initiate early treatment. However the question remains as to whether data will ever be available due to the potential adverse reactions and the ethical dilemmas surrounding the prospective withholding of treatment to patients. The data that is available suggest that paramedics can make a difference in the potential outcomes of these patients. A mortality rate of close to 40% is unacceptable. It is proposed that paramedics undertake a similar model to the Sepsis Six with an available pre hospital screening tool; similar to what the United Kingdom propose. This involves the identification of systemic involvement of the immune system by utilising the classification for SIRS; whilst using this in conjunction with history of a new infection. Taking both of these into consideration, persistent h ypotension, low oxygen saturation and lack of urine output classifies pre hospital patients as suffering from severe sepsis. (6) Paramedics are an integral part of the health care team and within the United States they are being overlooked and potential skills are being disregarded and this is still not understood when the literature suggest that early treatment does make a difference in outcomes. With regard to the early administration of antibiotics, not all patients will call at the onset of symptoms. Many will wait until the condition is unbearable or they feel like they are deteriorating, therefore it is important that empirical antibiotic therapy is undertaken at the earliest opportunity. From the available literature; the United Kingdoms model is the gold standard in terms of pre hospital screening and management of sepsis. Paramedics are highly trained health professionals and are able to manage septic patients accordingly, and as previously mentioned, the sepsis six involves high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measured serum lactate and haemoglobin and urinary catheter and measure urine output. This paper does not propose that paramedics undertake all of the treatment outlined, but instead have the ability to initiate oxygen therapy, deliver intravenous fluid and antibiotics; and potentially have the ability to take blood cultures to hand over to the hospital. However, it must be emphasised that extra on scene time to complete these assessments and treatment must be taken into consideration as well as how long till the nearest hospital. Also important to note that paramedics must notify a receiving hospital so that the hospital ca n appropriately triage (44) and utilise the pre hospital taking of blood in the commencement of faster treatment and provide the ability to initiate an appropriate antibiotic regime. Perhaps a review of the current guideline in Victoria is needed to extend the scope of paramedic practice to screen for potential septic patients, as the literature suggest that this current proportion of patients are exponentionally increasing. However; it may be easy to speculate changes that need to be made to the system, and this will take time and money. Walker (37) proposes from a management perspective there are significant costs associated with the antibiotics, training and assessment and ongoing replacement of antibiotics on all vehicles. Therefore it is imperative to continue research and therefore implement a new guideline into ambulance practice; which will benefit the health of all invested parties. The early recognition and management of sepsis has implications on potential patient outcome. Sepsis has an extremely high mortality associated with it and as mentioned previously the sooner antibiotics can be administered; the rapid decrease in patient morbidity and mortality. With respect to the high numbers of presentations to Victorian emergency departments and intensive care admissions; this is mirrored throughout the world. One of the important points to understand that the admissions to intensive care can be avoided if sepsis is recognised earlier and paramedics may have a significant impact on the recognition and administration of antibiotics, as septic patients have the potential to be very unwell. The financial burden on the health system is enormous with one study speculating that the United States approximate spend on sepsis alone to be sixteen billion dollars. (2, 7) Data is unavailable from Victoria and Australia; however the costs associated with providing antibiotics for the management of sepsis will cost less than treating in an Intensive Care Unit. Conclusion One of the main recurring themes throughout this paper is that sepsis and severe sepsis have a high association with morbidity and mortality, even though the number of presentations have increased. The point needs to be emphasised that current management is not good enough. The research within hospitals is evident, that early antibiotic treatment of patients suffering from sepsis has profound effects on survival and recovery. Paramedics are potentially the first line of health care workers exposed to patients suffering severe sepsis and have the ability to act with broad spectrum antibiotics. Within Victoria, ambulances already carry Ceftriaxone; an example of a broad spectrum antibiotic. A guideline specific to sepsis needs to be developed and implemented in the pre hospital field, potentially on the basis of the United Kingdoms model of recognising severe sepsis. The cost benefit analysis of implementing a new guideline, with the possible administration of antibiotics to more patie nts would severely outweigh the costs associated with an admission to an intensive care facility. The notion of taking pre hospital blood and notifying a receiving hospital of the potential septic patient may initiate appropriate treatment faster. Paramedics have the ability to make a difference with this time critical patient.

Passion to Change the World in John Miltons Paradise Lost :: Milton Paradise Lost Essays

Passion to Change the World in John Milton's Paradise Lost The world I see around me every day is one based on reason, scientific principles, tolerance, freedom, and most of all, a deep-rooted skepticism toward any form of absolute truth. When I think about Paradise Lost, I cannot help but to ponder what implications Paradise Lost has in this cold post-modern world. The world was a very different place in 1666, and not to say Milton’s ideas where meaningful to everyone in the 17th century, but for many people today Paradise Lost is, to put it rather bluntly, little more than a fairy tale. My thoughts have led me to one question; can a post-modern society such as ours learn anything from Paradise Lost that we can use to help better our world, or do our vast technological skills and post-modern philosophies provide a sufficient means for us to find joy, happiness and meaning in our lives? The post-modern world is full of complexity, skepticism, and moral ambiguity. Jean-Francois Lyotard, in â€Å"Defining the Postmodern,† explains that post-modernism arose from a rejection of modernism and its failed ideologies, ideologies that gave us such memorial events as Auschwitz, and have left us with deeply engrained feelings of skepticism toward our world and ourselves. Lyotard illustrates how mankind, in a post-modern world, â€Å"is in the condition of running after the process of accumulating new objects of practice and thought,† which to Lyotard is â€Å"something like a destiny towards a more and more complex condition.† Lyotard points out the implications of this ever increasing complexity when he observes that â€Å"our demands for security, identity, and happiness†¦appear today irrelevant in the face of this sort of obligation to complexify, mediate, memorize and synthesize every object,† and â€Å"consequently, the claim for simpl icity, in general, appears today that of a barbarian† (1612-5). Our world is in every way leading us into, as Lyotard points out, â€Å"a more and more complex condition† (1614). Truth, for example, was once thought of as a single transcendent idea, accessible by a means such as science, religion, or philosophy. However, as citizens of a post-modern world, we have to deal with a more complex definition of truth than ever before. Friedrich Nietzsche, in 1873, said, â€Å"truths are illusions of which we have forgotten that they are illusions; metaphors which have become worn by frequent use and have lost all sensuous vigor† (878).