The market for health insurance Essay Example | Topics and Well Written Essays - 5000 words

The market for health insurance - Essay Example Rises in health insurance covers, has besmirched access to health cover (Berkowitz 30-45). Presently 7 percent of the United States nonelderly, acquire coverage through personal strategies bought frankly from insurance providers. Numerous plans at the national state and centralized, in addition to the standard propositions using the personal health insurance market as way of growing access to reasonable health policies. States license bodies that provide health insurance coverage and have determined laws that regulate their structure, finances, and responsibilities to the people that they insure (Berkowitz 46). Introduction Health care costs in the US, which have escalated quickly in actual terms in the last few decades, have put pressure on the state and national budgets. Future expansion in health insurance costs is estimated to threaten the monetary status of state and national governments unless primary strategy transformations take place. Also, for many American citizens, the la ck of health insurance coverage sophisticates access to health care. Health insurance markets are frequently focused on a single insurer accounting for over 50 percent of the market. Issues about focus on health insurance markets are connected to broader issues about the cost, value, and accessibility of health care. The market structure of the health insurance and hospital commerce may have helped is increasing health care costs and in restricting access to inexpensive health insurance and health care. Some debate market focus has amounted to higher care prices. Higher cost of health care or health insurance may then make health care less inexpensive and consequently less available for some homesteads. Patrons in the personal and small group markets characteristically face specifically challenging situations. Whilst health insurance purchased in the personal market has the advantages of being portable, and potentially being an enhanced match to an individual’s predilection f or health coverage than standards purchased via group strategies, it does have elements of essential concern. Amid these issues is how regulations and edicts surrounding the personal insurance market reflects is potential to meet numerous population needs. It is needed to comprehend these concerns to establish how market transformations would interrelate with these policies (Henderson 10-15). Others, nevertheless, agree that health care givers with strong bargaining weight should assist restrict health providers’ potential to increase costs, and that the advantage of minimal premiums coming from the potential to negotiate may be passed along to patrons. Some commerce analysts have expressed competition amid primary health care providers as strong, and some pricing trends show that competing has stalwartly impacted on insurers’ market plans. Additionally, some argue that economies of scale along with state and national control have contributed to the increasing level of focus on health insurance markets. The Obama government has made transformation of the American health insurance and health care structure utmost policy precedence. Numerous congressional attempt at broadening access to health insurance by rising the number of Americans with health care coverage, by minimizing the price of insurance faced by persons, by offering sturdy incentives for persons

Odyssey and the Aeneid Essay Example for Free

Odyssey and the Aeneid Essay From the cultural views, there are some differences between the Greek and Roman concept of heroes: the Achaeans attach importance to individuality whereas the Romans to community. Unlike the Roman Empire which we know is a kingdom, in the ancient Greece-also called Hellas-there are no countries but only city states scattered around the Balkan Peninsula. In this sense, the Achaeans do not have the notion about collective consciousness or what country is, so they tend to possess individual will, and so do the heroes at that time. We can see the evidence in the two works. On the one hand, in the Odyssey, Odysseus constitutes the standard Greek values of heroism: individualism. He mainly concerns if he can go back to Ithaca safely and how to regain his throne; that is, what he cares about is not really related to anyone else but is himself, his life, and his personal purposes. For instance, as a leader of his sailors, the hero Odysseus is proved to be the only survivor coming back to his Ithaca. So we can see that his cleverness and resourcefulness are only applied for his own individual survival. On the other hand, the Roman heroism is quite different. Aeneas is burdened with a great responsibility for his sacred mission ordained by Jupiter to found a new land. He concerns about not personal gain or welfare but other people and therefore he is the presentation of pietas, possibly the key quality of honorable Romans consisting of a series of dedication toward the family, followers, homeland, and the gods. Culturally, the Roman, or Virgilian ideology of heroes is distinctly different from that of the Greeks. The chief difference of their model heroism is that the Greek heroes symbolize individual will, glory, and feelings whereas the Roman heroes an ideal nationalistic ruler (Augustus, whom Virgil writes the Aeneid for) who with sacrifice, devotion, and duty for his people is regarded as a servant rather than the served.

Electroconvulsive Therapy for Severe Depression: Evaluation

Electroconvulsive Therapy for Severe Depression: Evaluation Can electroconvulsive therapy make a meaningful contribution in the treatment of Severe depressive illness? The work of mental health nurses. Contents Abstract Introduction Methodology of the review Critical Review of the literature The place of electroconvulsive therapy in the therapeutic armamentarium The place of electroconvulsive therapy in relapse prevention Mechanism of action Preference of site of stimulation Side effects of treatment Discussion Conclusions Appendix References Abstract This dissertation seeks to explore the evidence base for electroconvulsive therapy. It does so by considering the historical background to the procedure and its evolution to the present. It considers the professional and legislative guidelines which govern its use and contrasts the regulations in the UK with those in other cultures, notably the USA. In order to assist the exploration, the literature review is subdivided into five sections, each exploring a different area of interest. Electroconvulsive therapy is placed within a therapeutic spectrum of treatment for patients with major depressive illness and psychosis and is compared with other modalities of treatment. Its use in both acute treatment and its role in disease prevention and relapse is discussed. Current hypotheses of its possible mode of action are explored, and conclusions drawn about the strength of the evidence base in this area. There appears to be considerable discussion about the site of optimal stimulation for electroconvulsive therapy. This area is discussed in depth with a critical analysis of the studies which inform the evidence base in this area. The literature review concludes with an examination of the various side effects of the treatment. There is an element of discussion of the evidence and conclusions are drawn from the evidence extrapolated and presented. The whole dissertation is fully referenced. Introduction Electroconvulsive therapy was introduced into clinical practice in the late 1930s and rapidly gained a place in the standard treatment of major depressive illness. It was originated by the Hungarian, Dr Meduna, who mistakenly believed that schizophrenia and epilepsy were mutually exclusive conditions. He argued that epilepsy was never seen in schitzophrenic patients and therefore artificially inducing fits (epilepsy) in patients would cure schizophrenia. (Mowbray R M 1959). The effects on schitzophrenia were soon recognised to be minor and the most marked effect appeared to be in the patients with major depressive illness. The advent of effective classes of antidepressant, antipsychotic and mood stabilising drugs has seen a marked decline in the use of electroconvulsive therapy, but recent figures suggest that it is still used in over 10,000 cases per year in the UK (ECT Survey 2003). Currently the main use of electroconvulsive therapy is in major depressive illness although it also is considered still to have a place in the treatment of schizophrenia and some other mood disorders (UK ECT 2003), psychosis (Corrible E et al. 2004), and overt suicidal intent (Kellner C H et al. 2005). The Mental Health Act of 1983 allowed Psychiatrists to give electroconvulsive therapy to inpatients without consent if they were sectioned. This should be contrasted to the situation after the 1959 Mental Health Act, where psychiatrists had no clear guidance and a number of litigation cases forced a change in legislation. (Duffett R et al. 1998) The procedure itself involves anaesthetising the patient with a general anaesthetic and a muscle relaxant and the a small, brief pulse current (typically about 800 milliamperes) is passed between two electrodes applied directly to the scalp. This generates a seizure and there are a number of demonstrable biochemical changes in the brain after the event. (Nobler M S et al. 2001) Electroconvulsive therapy is usually given as a course over several weeks. The evidence base for length of time of treatment is not strong and appears to vary considerably between authorities. (Lisanby S H 2007) In 2003 NICE investigated the evidence base for electroconvulsive therapy and issued guidelines which suggested that it should only be used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode. (NICE 2003) One of the most extensive recent reviews on electroconvulsive therapy concluded that it had been demonstrated to be effective short term treatment for depressive illness in otherwise healthy adults. Many studies were cited and had shown it to have a greater effect than drug treatment. The authors noted shortcomings in many of the trials cited, especially in areas such as drug resistant depressive illness where electroconvulsive therapy is believed to be particularly helpful. (UK ECT Review Group 2003) One of the major side effects of electroconvulsive therapy is short and long term memory loss cited in many trials and studies (viz Gupta N 2001) Methodology of the review Cormack suggests that â€Å"Ultimately all good research is guided by and founded on a critical review of all of the relevant literature published on the subject.† (Cormack, D. 2000). It is therefore important not only to define what is currently believed about a subject, but also to place this in a historical context. This is particularly important in the field of electroconvulsive therapy, as the introduction to this dissertation has suggested, with great fluctuations in both understanding and application of this type of therapy over the years. One of the prime reasons for conducting a literature review is to establish the current evidence base for a particular subject. A critical review of the literature must be preceded by a careful literature search. It is often believed that searching the literature is a linear or â€Å"single episode† process. Current thinking suggests that this is seldom an optimal strategy. Bowling advises that a good literature review is â€Å"primarily a cyclical recursive process that mirrors the thinking and research process, where the discovery of new information results in new ideas, new knowledge and possibly new understanding. Once an overview, or initial opinion has been formed, it then becomes possible to revisit the initial reviews from a more informed perspective which, in turn, allows for a more perceptive interpretation of the data. (Bowling A 2002). The methodology used in this particular review was to allow for an initial period of reflection on the subject matter and to consult a small number of reference books to achieve an overview of the area. (Taylor, E. 2000). References were noted and some followed up in order to ascertain the main themes of the review. Once these were established, then methodical searches of a number of databases were carried out utilising the facilities of the local University library, the Post-graduate library (Client to personalise here) and a number of on-line search engines and literary sources including Cochrane, Cinhal, Ovid, BMJ and Lancet archives, Royal College of Psychiatrists archive and various NICE publications. Papers were accessed in both hard back and electronic forms. (Fink A 1998) Search terms included electroconvulsive therapy; evidence base; evolution; history; schizophrenia; psychosis; major depressive illness; mental health nurse; antidepressant drugs; Mental Health Act; psychiatrist. These terms were used in various combinations to sift papers with varying degrees of relevance to the topic under consideration. (Carr LT 1994) Inclusion criteria were papers less than 10 years old (unless there were specific reasons for older paper inclusion). UK sources were preferred to other ones. It should be noted that a substantial proportion of the body of literature on the subject of electroconvulsive therapy is American based. A number of authorities have suggested that this may be because the USA currently uses electroconvulsive therapy more frequently than the UK and therefore has a greater experience with it. Papers were only considered from peer reviewed sources unless making a historical point. (Bell J 1999). Each paper considered was then ranked according to its evidential value (See Appendix 1) and the highest value paper was presented for each point to be made. Critical Review of the literature The place of electroconvulsive therapy in the therapeutic armamentarium A good place to start this literature review is with the Olfsen paper. (Olfson M et al. 1998). This is an authoritative overview of the place of electroconvulsive therapy in the treatment spectrum. It has to be noted that this paper is already 10 years old and reflects clinical patterns of usage in the USA. The reason that this paper is selected for discussion is primarily on the vast size of its study cohort, which is 6.5 million patient contacts (249,600 with a diagnosis of depressive illness) spread over mainland USA. Critical analysis of the paper suggests that the authors reveal their viewpoint in the first few sentences of the paper and therefore the opinion part of the review must be understood on the basis that the authors consider electroconvulsive therapy a â€Å"safe and effective treatment for patients with all subtypes of major depression† citing the authority of the APA for this statement (APA 1997) The paper suggests that there is a strong evidence base to confirm that electroconvulsive therapy is at least as effective as antidepressant drugs pharmaceuticals for the treatment of major depressive illness. (Weiner R D 2004) The authors make the point that despite this general belief, electroconvulsive therapy is not as widely used as it should be due to three major misconceptions namely public concern about the safety of the procedure, reactive regulations and guidelines and the belief that it is not cost-effective. They then set about addressing each of these concerns Rather worryingly, the authors cite evidence of safety with the unqualified comment that â€Å"None of the depressed patients who received ECT died during the hospitalisation. In contrast, 30 (0.14%) of the depressed patients who did not receive ECT died in the hospital. (Schulz K F et al. 1995) Although this may well be the case, it is entirely possible that patients who were ill with other comorbidities (and therefore at greater risk of death) were not offered electroconvulsive therapy, as it required a general anaesthetic. One cannot jump to the implied conclusion that these figures suggest that electroconvulsive therapy is therefore intrinsically safe. (Mohammed, D et al. 2003) The authors draw a number of conclusions, perhaps the most significant of which is that current practice tends to reserve electroconvulsive therapy for the elderly, and those with comorbidities such as schizophrenia, dementia, and general medical (nonpsychiatric) disorders. They also comment that prompt use of electroconvulsive therapy is associated with shorter in patient stays and, by definition, more rapid resolution of the depressive state. Despite these findings, there is a large body of literature documenting the fact that many patients with major depressive illness remain largely unresponsive to therapeutic intervention. With this in mind one should consider the contribution of the Spanish research group under Gonzalez-Pinto who published a trial of a small group of patients (13) who had proved resistant to both venlafaxine and electroconvulsive therapy separately but who responded to both measures when used in a combined fashion. (Gonzalez-Pinto A et al. 2002). This was a non-randomised non-controlled trial and therefore constitutes evidence value at level III. Curiously the response was not proportional to the dose of venlafaxine used. The authors however, report the rather worrying side effect of asystole in 3 of the 13 patients immediately after the electroconvulsive therapy. A number of authorities suggest that there is a definite place for electroconvulsive therapy in the severely depressed patient who is a suicidal risk. The Kellner paper addresses this suggestion directly. (Kellner C H et al. 2005). Suicide remains one of the major associations of major depressive illness and carries a 15% lifetime risk for any patient who has been hospitalised with the same. (Bostwick J M et al. 2000) with symptoms such as profound hopelessness, hypochondriacal ruminations or delusions, and thoughts of suicide or self-harm during depression predict future suicide. (Schneider B et al. 2001). The Kellner study was a randomised crossover comparative follow-up trial making it evidence value of level 1b. There are a great many result strands from this study, but if one specifically considers the suicidal elements, then one can state that the study showed that of the 444 patients enrolled in the trial as having major depressive illness, 26% had suicidal ideation at a level of 3 or greater on the Hamilton rating scale (the measurement tool used in the trial) and 3% achieving a score of 4 (actual suicidal attempt). This group had a reduction of their scores to 0 in over 80% within the two week course of the electroconvulsive therapy. It was also reported that in the group who scored 4, 100% dropped to 0 by the end of the treatment. Despite there impressive figures for short term remission, one would have to note that the trial did not have any significant long term follow-up and there is no information on the rate of relapse after the initial treatment. (Rosenthal R. 1994). The authors state that they were aware of two successful suicide attempts which occurred whilst the trial was running (but after these patients had completed their treatment. The authors suggest that electroconvulsive therapy should be used early in the treatment regime once a diagnosis of suicidal risk has been made. To provide a balanced argument on the place of electroconvulsive therapy in the spectrum of treatment, one can consider the recent paper by Eranti (Eranti S et al. 2007) who tested out the hypothesis that has recently been published, that Repetitive transcranial magnetic stimulation (rTMS) is as effective as electroconvulsive therapy but does not have the same side effect profile that restricts the use of electroconvulsive therapy in some patients. (viz. Gershon A A et al. 2003 and Loo C K et al. 2005) This trial was a randomised, blinded comparative trial with a substantial entry cohort (260 patients) being followed up for 6 months after treatment giving it a level 1b significance. (Clifford C 1997). There were a number of possible outcome measures studied but, of relevance to our considerations in this dissertation, one can state that the authors found that Repetitive transcranial magnetic stimulation (rTMS) was not as effective as electroconvulsive therapy in the treatment of depressive illness both at the end of the treatment period and at the end of the 6 month study. The authors were able to comment however, that the rTMS was virtually free of demonstrable side effects. The place of electroconvulsive therapy in relapse prevention It is fair to comment that a brief examination of the literature shows virtually no good quality published material on this topic with the studies that have been done comprising individual case reports (viz Kramer B A 1990), naturalistic studies and small studies of retrospective cases (viz. Schwarz T et al. 1995), none of which have any control element and all of which are evidence level IV at best. A notable exception is Keller et al. who made a large UK based study of relapse prevention in major depressive illness with a randomised controlled trial over a seven year period involving over 500 patients. (Kellner C H et al. 2006). The trial is a level 1b evidence level trial and is of a particularly robust structure with great efforts made to achieve standardisation. (Denscombe, M 2002). The structure is a direct comparison between electroconvulsive therapy and a standard pharmacological regime (lithium carbonate plus nortriptyline hydrochloride). Both were given as a therapeutic course (the medication over a six month period) and the patients were followed up with DSM-IV assessments to determine their degree of relapse The analysis is long and complex but, in essence, the study clearly demonstrated that both groups had better results than a placebo control with similar percentages (about 33%) suffering a relapse and about 46% remaining disease free. The trial suffered from having a large group (about 20%) failing to complete the trial protocol. (Rosenthal R. 1994). This study does however, provide firm evidence that electroconvulsive therapy is at least as effective as pharmacological measures in reducing the likelihood of clinical relapse. Further evidence for longer term efficacy comes from the Gagnà © study (Gagnà © G G et al. 2000), which starts by acknowledging the fact that depressive illness tends to be a long term disability with long term pharmacological intervention a comparatively normal treatment strategy. The authors make a subtle distinction between continuance therapy (which is starting a new course of treatment after initial resolution and then relapse) and maintenance therapy which extends beyond the continuation therapy stage and is aimed at preventing relapse. This paper is noteworthy because, as the authors point out, there is general acceptance by healthcare professionals that long term maintenance therapy with pharmaceuticals is both rational and indicated in patients with a high likelihood of relapse of depressive illness. Treatment with continuation electroconvulsive therapy has failed to gain general acceptance. The authors argue that such an approach is particularly rational, at least in a group of patients who have demonstrated their ability to respond to electroconvulsive therapy in the past, are at high risk of relapse and who may be refractory to pharmacological intervention. The Gagnà © study is a retrospective case-controlled comparative study comparing the long term course of electroconvulsive therapy plus pharmacological maintenance therapy with long-term antidepressant treatment alone in a demographically matched group. The two groups comprised 60 patients. The maintainence electroconvulsive therapy group received the electroconvulsive therapy as a single treatment monthly after the normal intensive treatment course for the acute episode. It has to be noted that this regime is comparatively arbitrary as there appears to be no preceding published evidence base to support it. The results from this study are nonetheless quite impressive. Both groups are reported to have responded to treatment, but the group who were also maintained with follow up electroconvulsive therapy did markedly better in terms of resistance to relapse being almost doubled at two years (93% vs. 52%), and quadrupled at five years (73% vs. 18%). This result could also be expressed as a doubling of the mean time to relapse in the electroconvulsive therapy group (6.9 years versus 2.7 years for the antidepressant-alone group). A major criticism of this study would have to be a lack of standardisation of treatment in the electroconvulsive therapy group with some patients receiving univocal and others bipolar electroconvulsive therapy. The number and duration of each was left â€Å"to the clinical judgement† of the responsible clinician. This does not reduce the impact of the overall finding, but does make for difficulties in comparison with any other trials which might follow. (Berlin J A et al. 1999) A critical analysis of the study would also have to conclude that the study suffered from a comparatively small number of patients with assignments to the comparison groups not being random. More importantly, the trial assessor was not blinded to the patients group assignment. These factors make it difficult to confidently assign an evidence level to this trial. (Denzin, N K et al. 2000) The authors conclude their study with the comment that a larger, prospective study on the subject is currently underway. One should perhaps regard the results of this study as interesting, but not proven. In assessing the validity of this paper, one should note comments that it has generated in the peer reviewed press. Gupta makes a number of valid points of criticism (Gupta N. 2001), arguably the most important of which is that the study did not make any measurement of the well recognised effect on memory function that short term electroconvulsive therapy is known to have. (Isenberg K E et al. 2001). Gupta suggests that clinical effectiveness must be assessed only after a risk-benefit ratio has been properly determined. Certainly a valid point and one that was not addressed in the original paper. Mechanism of action A number of papers have been published reporting biochemical changes after electroconvulsive therapy. There seems to be a general agreement that depressive illness is associated with a disturbance in the monoaminergic-cholinergic balance within the cerebral cortex. (Schatzberg A F et al. 2005). A novel and significant advance was published in 1998 by Avissar (Avissar S et al. 1998) when a correlation with G-protein levels in leucocytes was found and was discovered to be significantly reduced in depressive illness. The significance of this paper was that the authors found that electroconvulsive therapy resulted in a normalisation of the G-proteins level which preceded (by about a week), and thus predicted, clinical improvement. Patients who did not respond to electroconvulsive therapy did not show a change in G-protein levels. The significance of this finding is enhanced with the knowledge that lithium is also known to alter G-protein levels (Schreiber G et al. 2000), as are some other treatments for bipolar disorder. (Young L T et al. 2003). It is also known the G-protein levels are raised in manic states thereby suggesting that it is a marker for affective mood states. (Schreiber G et al. 2001) Further evidence of altered metabolism comes from the Nobler study (Nobler M S et al. 2001). This study used Positron emission tomography (PET) to study glucose metabolism in different brain areas. It has to be noted that this was a small study of 10 patients who were assessed before and after a course of electroconvulsive therapy. This study involved highly sophisticated measurements and concluded that certain areas of the brain showed marked reduction in metabolic rate after electroconvulsive therapy and these changes were most significant in the frontal, prefrontal, and parietal cortices. The authors suggest that their results support the hypothesis that electroconvulsive therapy works by suppression of functional (non trophic) brain activity, most prominently in the prefrontal cortex. The authors comment that their findings are consistent with the earlier Drevets study which demonstrated a reduction in brain metabolism after successful treatment with antidepressant drugs. (Drevet s W C 1998) A more modern paper by Sanacora reported alterations in the GABA concentrations in plasma, and cortex after electroconvulsive therapy. (Sanacora G et al. 2003). It is known that patients with depressive illness have reduced levels of the neurotransmitter GABA. This study, again with a small entry cohort of 10 patients, assessed patients before and after electroconvulsive therapy. It was found that the levels of GABA increased with successive treatments. It was also found that the length of duration of the convulsions was proportional to the concentrations of GABA found in the cortex supporting the view that GABA decreases cortical excitability. It may also be significant that GABA concentrations have been found to increase after the use of selective serotonin reuptake inhibitor (SSRI) treatment. (Sanacora G et al. 2002). These findings suggest that enhanced GABA activity may be central to any antidepressant activity Takano et al. have recently produced a yet more sophisticated study along the lines of the Nobler investigation. (Takano H et al. 2007). This study also uses positron emission tomography (PET) and it studied patients before, during and after the application of electroconvulsive therapy. This is essentially a technical rather than a clinical study. It also has to be noted that all the data was derived from only six patients. The majority of the results are therefore not relevant to this consideration other than the fact that the authors concluded that electroconvulsive therapy exerts its effect by increasing the post treatment blood supply to the anterior cingulate and medial frontal cortex and thalamus. They refine this comment by acknowledging that it cannot be stated that this observed phenomenon is cause or effect, but simply an association with the mechanism of treatment and is associated with a resolution of symptoms. Preference of site and nature of stimulation There is a great deal of discussion in the peer reviewed literature about the optimal sites for electroconvulsive therapy application and whether univocal or bipolar stimulation gives better results. Unfortunately the vast majority of it is anecdotal and of poor evidential value. The Bailine study is a notable exception providing a randomised comparative trial with a moderate size of entry cohort (60) making it a level 1b trial. (Bailine S H et al. 2000). The authors compared the efficacy of bitemporal stimulation with bifrontal stimulation over a treatment period of 12 treatments. The study was assessor blinded. The rationale behind the trial was that bifrontal stimulation avoids direct stimulation of the temporal areas which are directly involved with cognition and memory functions. The authors reported that they found both placements to be equally effective in their ability to relieve depressive illness, but the bifrontal positioning achieved statistical significance in reducing cognitive and memory effects. Although not directly tested, the authors comment that right sided unilateral frontal placement has fewer cognitive side effects than bilateral stimulation but needs 2 5 times the current to achieve its therapeutic effect. (citing Letemendia F J J et al. 1993) One area of difficulty which, even a brief overview of the subject illuminates, is the level of stimulus that is required to achieve therapeutic results. Some studies do not specify the level of stimulus, others simply refer to a supra-threshold stimulus, a third group refer to a â€Å"titration of stimulusâ€Å". This makes direct comparison of results difficult. Some authorities have made the comment that not standardising the level of stimulus applied is similar to conducting a comparative trial of antidepressant drugs to placebo when the drugs are given at a sub-optimal dosage and therefore not achieving their maximal therapeutic effect. Krystal has attempted to tackle this problem by reviewing the regulations governing the administration of electroconvulsive therapy and also trying to achieve a generally acceptable standard of treatment. (Krystal A D et al. 2000) The USA limits (by statute) the maximum output charge for clinical applications of electroconvulsive therapy to 576 millicoulombs. The equivalent restriction in the UK is 1,200 millicoulombs for electroconvulsive therapy devices and this has been determined by the Royal College of Psychiatrists, and this limit is more than double the limit allowed in the USA. As far as the USA is concerned there is no evidence base to ensure that this limit will allow for consistently effective electroconvulsive therapy, which is something of a paradox considering that the USA considers electroconvulsive therapy more mainstream than does the UK. Krystal published a retrospective study of nearly 500 patients who had received electroconvulsive therapy. Although most of the patients reviewed had a clinically successful treatment, the authors noted that 15% of patients required the maximum stimulus intensity to trigger a seizure and 5% of the total did not have a seizure at all. The authors comment that the clinicians responsible for the patient had to use enhancing strategies to boost the therapeutic response with caffeine, ketamine, or hyperventilation. This still left a residual 5% of patients with a sub-therapeutic response at the maximum permitted output charge. Further problems can be encountered as not only can patients vary with regard to the amount of charge that they need to trigger tonic-clonic seizures, but the amount of charge can vary as the course of treatment progresses in each individual patient. (Coffey C E et al. 2005) The difficulty that therefore arises in these non-responders, is that there is no greater therapeutic response than placebo if a tonic-clonic seizure is not triggered, but the effects on cognition and memory impairment are still present. (PECT 2000). If this is added to the clinical and economic costs, it is clear that a case can be made for higher limits of initial triggering charge, at least in the USA. The other factor which may also be relevant and can be a major cause of inconsistency between studies is the pulse width with some electroconvulsive therapy machines delivering a shorter pulse width and longer stimulus duration than others. The majority deliver a pulse width between 0.5–0.75 msec. but other machines are capable of delivering pulse widths considerably beyond these limits. There has been no definitive study which has considered the possible effect of pulse width on either the therapeutic response or the likelihood of triggering a tonic-clonic seizure. The final point made in the Krystal paper is the fact that one of the reasons that the charge limit was set at the level that it is was the fact that the authorities wanted to minimise the theoretical risk of neuropathological damage. There is now evidence that the levels of stimulus charge necessary to cause such damage is far in excess of the imposed limits. (viz. Weiner R D 1994 and Devanand D P et al. 2004) The concept of stimulus titration is referred to in many of the clinically based papers reviewed. If this concept is considered in parallel with the comments by Krystal relating to the variation of charge required to produce the seizure, the situation can be clarified in an monograph by MacEwan who advises that it is an important feature of the treatment to allow sufficient time between the initial unsuccessful shock and the attempt at restimulation as the effect of the comparative refractivity after the first shock takes a little time to wear off. (MacEwan T 2002) Side effects of treatment Considering the rather gross and intrusive physical nature of the treatment, it is quite remarkable that the literature shows very few studies which have specifically explor

Essay --

In the area of mathematics, it has been stated that Aristotle â€Å"is the real father of logic† (Thompson, 1975, p. 7) and although it may be a minor exaggeration, it is not far off the truth. Aristotle’s ideas on philosophy and logic were great advancers in Western culture, and are still being discussed and taught today. The ancient Greeks focused their mathematics on many areas, but one main question continuously asked by the Greeks was â€Å"what are good arguments?† (Marke & Mycielski, 2001, pg. 449). This question brought about the study of logic. Aristotle’s philosophy on the importance of logic was unique for his time as he believed that logic had to be considered in all disciplines, and that the aim of logic was to provide a system that allowed one to â€Å"investigate, classify, and evaluate good and bad forms of reasoning† (Groarke). Aristotle studied and contributed to various disciplines including philosophy, science, and astronomy, but his greatest influence was in the study of mathematical logic and more specifically, the introduction of syllogism. As Ulrich (1953) states, â€Å"any discussion of syllogism necessarily involves logic as it is the field that the syllogism plays a very important role† (p. 311). Aristotle’s ideas surrounding logic and syllogism are still being used in mathematics today, and over the course of history they have influenced many mathematicians’ areas of study. (Marek & Mycielski, 2001) Influence on Aristotelian Logic In order to understand Aristotle’s influence on mathematical logic, it is important to understand his life and the people that influenced his studies. Aristotle was born in 384 BCE in Stagira, which was an ancient city in Greece located on the Chalkidiki peninsula (Amadio & Kenny). In 367 B... ...ead of as an axiomization of a body of knowledge† (Andrade & Becerra, 2008, p. 310). Conclusion Aristotle’s philosophy of logic and syllogism introduced a system of formal thought. One in which emphasis was placed on answering logical questions through using proof, deduction and reasoning. This contribution to the field of logic allowed future academics to draw connections of previous unknowns in many areas of study, but most notably in the field of mathematics. Aristotle’s contribution to logic, by introducing a system of syllogism, became influential within many disciplines, and his ideas remained a great focal point for many centuries. Although Aristotle will forever be seen as a great philosopher, his influence of the syllogism was one that greatly advanced the area of mathematical logic and opened the gateway for many more mathematical discoveries and ideas.

My Teacher, My Hero Essay

When my friends asked me to write again, I decided to start my compilation with something meaningful, a themed essay for the My Teacher, My Hero theme, contrary to last year wherein I had a hard time choosing who to pay tribute to, this year is much different, it was easy and I believe, it is the most obvious choice. Everyone has someone to keep them on their own feet as they walk through life. Normally, it would be your parent or friend, but mine is different, I had kept myself intact with the help of a teacher. Teachers are usually there to impart knowledge and give you an opportunity to move on with life, I was blessed to have someone during my college days who takes time to make sure that I was okay and the strength to hold on to when everything else went astray, he was Engr. Elmerito D. Pineda. I first met Engr. Pineda as my professor back when I was in First Year (Advanced Programming Languages in C) , back then, things were just inside the classroom – lectures, quizzes, exercises which brought my confidence back after losing my scholarship during the previous term but things turned different when I was in my Third Year and he became our thesis mentor. He turned out to be the #1 Supporter to what we have wanted in the first place, the Alumni Tracer for FEU – East Asia College. Despite both parties having to adjust to the situation of having a part-time mentor last year, we both exerted effort to follow-up and communicate with each other. Since I was always doing the documentation portion of most our projects, I was the one responsible for making follow-ups with the mentor, which happened to be Mr. Pineda. I took it as my responsibility to stay late, meet him after classes for checking and even go straight to his FEU Main class just to finish the proposal for our thesis. Unfortunately, our second term was cut short after failing the proposal defense – but when things thought that it was the end of our mentorship with Engr. Pineda, we were wrong. He stayed with us until the very end. He had always made sure that I was okay. He had always made me feel secure especially by showing me how much he believes in the entire group. When we are back for the third term with a different project and mentor, he made sure he would ask us about our thesis and he was one of the few people who first congratulated us after a successful defense – indeed, he showed me that he was true to his words when we started communicating, â€Å"Dito lang ako for you, parang si Ms. Bong (Evelyn Ruth M. Manuel)†. He never left the group, he never left me during the good times and the bad times. Even if he is not physically present, his presence would always be felt wholeheartedly, and in the little ways he does it, I am extremely grateful. As time pass by, I looked up to him as one of the best friends and as my â€Å"dad† in school. I still see him from time to time. He has helped mold my character to be as strong as it is right now. He has his own way of teaching me things, he doesn’t get mad easily when you do something wrong, however, he has his own way to show you that you are wrong and it is proven effective to me, I managed to make amends and never do things again. For all the things he has done for me, all I can do to repay is to be there for him as well. I know I would be supporting him in whatever he would aspire to do in his life. I also look forward to see him finish Doctoral of Information Technology sometime next year for it would add weapons to his already impressive curriculum vitae. I hope he touch more lives and help direct it to a better place, just like how he helped me push my life back on track. My life would never be perfect. I would always experience the roller-coasters of being a human being but I would always remember one thing, that indeed, I was blessed. I was blessed to have people that would guide me. I was blessed to have people who would accept me for who I am. Furthermore, I am blessed to have Engr. Elmerito D. Pineda in my life, whatever you do call him, he would always have a special place in my life, a great mentor, friend and a dad. Engr. Elmerito D. Pineda, hats off†¦ my 2011 would not be complete without having the opportunity to thank you for everything that you have done for me.

Suicide Essays

Suicide Essays Suicide Essay Suicide Essay Teenage years are the hardest times. Your having changes in your body, going through relationships, and trying to plan your future. When you go to look for answers, it seems like no one has them. Thats what starts teenagers to feel alone. When they feel this way they will try to medicate themselves by drugs and alcohol or violence. Studies show that teens who feel this way are Suicide, intentional, self-inflicted death. A uniquely human act, suicide occurs in all cultures. People who attempt or complete suicide usually suffer from extreme emotional pain and distress and feel unable to cope with their problems. They are likely to suffer from mental illness, particularly severe depression, and to Suicide is becoming a public-health problem. It is now the leading cause of death worldwide. Researchers believe mental illness in young people are the cause of the increase in suicide. Not only do suicides rates differ between age groups but also men and women. Men succeed in more suicide s but more women attempt. Methods of suicide can differ from drug overdose to hanging. Poisoning or overdose is the least amount of suicide rates. Hanging is the leading method worldwide. The United States has 60 percent suicides committed by guns. Where it is less easy to get a gun in Canada there is only 30 percent committed suicides. Only 15 to 25 percent of those who kill themselves leave suicide notes. People often think suicide is caused by difficult situations such as failure in school or marriage. Experts believe those are just triggers and its really caused by the brain, genetics or social forces. The majority of people who kill themselves are suffering from depression. Researchers believe that genetics play a role in suicidal behavior. They believe it runs in the family. There are also some psychological theories.

A Comparative Study on High School Students Between the United States and China Essay Example

A Comparative Study on High School Students Between the United States and China Essay Example A Comparative Study on High School Students Between the United States and China Essay A Comparative Study on High School Students Between the United States and China Essay Essay Topic: High School With the development of planetary economic system, the competition in instruction is going an of import portion of the international competitions. Students all over the universe are viing with non merely the pupils in their state but the pupils in the universe. To some grades, the future fight of a state relies on how great their pupils are. As for pupils, their high school clip is the critical period in their life, when they form their mentality on life and happen out what they want to make in the hereafter. High school pupils in both the United States and China have immense differences in their school life. First, course of study. Students in American high school are required to take Science, Mathematics, English, Social scientific disciplines, Physical instruction and other electives such as Computers, Foreign linguistic communication etc. About 40 per centum of U.S. high school pupils do non take any scientific discipline category more ambitious than general biological science. A nd 55 per centum of pupils do non take any math classs beyond two old ages of algebra and one twelvemonth of geometry. While in China, the academic course of study consists of Chinese, Mathematics, English, Physics, Chemistry, Biology, Geography, History, etc. The demand to Chinese pupils in Mathematics A ; Science is considered to be rather high. Second, clip on analyzing. Harmonizing to the research conveyed by BPP production squad, American pupils spend 302,400 proceedingss in school during their high school clip for 4 old ages while Chinese pupils spend 583,200 proceedingss. If adding that to the clip spent making prep and perusal after school, by the terminal of the high school, Chinese pupils have spent twice every bit many hours analyzing as American pupils. But even though Chinese pupils spend more clip perusal, it seems that their prep can neer be finished. Therefore, Chinese pupils try their best to heighten their learning efficiency in order to squash more clip. However, it doesn’t mean that American kids don’t work hard. The nucleus of the difference is the distribution of clip. American pupils devote their clip to playing athleticss, making parttime occupations, and even dating with others, which make them energetic and societal. From this facet, the instruction system of American high school is more flexible than Chinese sinc e it encourages pupils to develop comprehensively and acquire near to the society. Third, outlook of parents. In China, parents think extremely of the instruction for their kids. They tend to take roads for their kids to follow and do critical determinations for them, like which college to come in, or which major to larn. Particularly for the top pupils, parents normally pay for several sorts of lessons as portion of their investing in their instruction in order to open up a lead in the competition for their kids. But American parents seem more relaxed. The per centum of parents who think their child’s high school is learning the right sum of Math and Science is 70 % . American parents have thoughts about the hereafter of their kids but rarely make determinations for them. So Chinese pupils face with more force per unit area from parents. Different instruction manners result in different pupils. American pupils score extremely in one country relation to their international equals: assurance. They worship freedom and balance work and relaxation good, taking t hem be optimistic about the hereafter. On the contrary, Chinese pupils in high school ain much academic cognition so that they do better in scrutinies. But it can non do a decision hurriedly that whether high school in both China and U.S, A is good or non because the instruction system is based on the economic state of affairs of China and America. To do an terminal, to better the fight of a state, it is necessary to compare the instruction system to that in other states, find out advantages and disadvantages and do some alterations to cultivate endowments. Mentions: Net 1 BPP production squad. ? . [ DB/OL ] hypertext transfer protocol: //video.sina.com.cn/v/b/83732476-2036021381.html, 2012-08-17 Net 2 Wikipedia. Education in the People’s Republic of China. [ EB/OL ] hypertext transfer protocol: //en.wikipedia.org/wiki/Education_in_the_People’s_Republic_of_China # Secondary_education, 2013-06-13 Net 3 Wikipedia. Education in the United States. [ EB/OL ] hypertext transfer protocol: //en.wikipedia.org/wiki/Education_in_the_United_States # Secondary_education, 2013-06-13

Spanish Vocabulary for Lent, Holy Week, and Easter

Spanish Vocabulary for Lent, Holy Week, and Easter Easter is the most widely and ardently celebrated holiday in most of the Spanish-speaking world - even bigger than Christmas -   and Lent is observed nearly everywhere. The week before Easter, known as Santa Semana, is a vacation week in Spain and most of Latin America, and in some areas, the vacation period extends to the following week. Thanks to their strong Roman Catholic heritage, most countries celebrate Holy Week by emphasizing the events leading up to the death of Jesus (Jesà ºs or Jesucristo), often with large processions, with Easter set aside for family gatherings and/or carnival-like celebrations. Words and Phrases As you learn about Easter - or, if youre fortunate, travel to where its celebrated - in Spanish, here are some words and phrases youll want to know. el carnival - Carnival, a celebration that takes place in the days immediately preceding Lent. Carnivals in Latin America and Spain are usually organized locally and last several days. la cofradà ­a - a brotherhood associated with a Catholic parish. In many communities, such brotherhoods have organized Holy Week observances for centuries. la Crucifixià ³n - the Crucifixion. la Cuaresma - Lent. The word is related to cuarenta, the number 40, for the 40 days of fasting and prayer (Sundays not included) that take place during the period. It is often observed through various kinds of self-denial. el Domingo de Pascua - Easter Sunday. Other names for the day include Domingo de Gloria, Domingo de Pascua, Domingo de Resurreccià ³n, and Pascua Florida. el Domingo de Ramos - Palm Sunday, the Sunday before Easter. It commemorates the arrival of Jesus in Jerusalem five days before his death. (A ramo in this context is a tree branch or a bunch of palm fronds.) la Fiesta de Judas - a ceremony in parts of Latin America, usually held the day before Easter, in which an effigy of Judas, who betrayed Jesus, is hung, burned, or otherwise mistreated. la Fiesta del Cuasimodo - a celebration held in Chile the Sunday after Easter. los huevos de Pascua - Easter eggs. In some areas, painted or chocolate eggs are part of the Easter celebration. They are not associated with the Easter bunny in Spanish-speaking countries. el Jueves Santo - Maundy Thursday, the Thursday before Easter. It commemorates the Last Supper. el Lunes de Pascua - Easter Monday, the day after Easter. It is a legal holiday in several Spanish-speaking countries. el Martes de Carnaval - Mardi Gras, the last day before Lent. el Mià ©rcoles de Ceniza - Ash Wednesday, the first day of Lent. The main Ash Wednesday ritual involves having ashes imposed on ones forehead in the shape of a cross during Mass. el mona de Pascua - a type of Easter pastry eaten primarily in the Mediterranean areas of Spain. la Pascua de Resurreccià ³n - Easter. Usually, Pascua stands by itself as the word used most often to refer to Easter. Coming from the Hebrew pesah, the word for Passover, pascua can refer to almost any holy day, usually in phrases such as Pascua judà ­a (Passover) and Pascua de la Natividad (Christmas). el paso - an elaborate float that is carried in Holy Week processions in some areas. The pasos typically carry representations of the Crucifixion or other events in the Holy Week story. la Resurreccià ³n - the Resurrection. la rosca de Pascua - a ring-shaped cake that is part of the Easter celebration in some areas, especially Argentina. el Sbado de Gloria - Holy Saturday, the day before Easter. It is also called Sbado Santo. la Santa Cena - The Last Supper. It is also known as la Última Cena. la Santa Semana - Holy Week, the eight days that begin with Palm Sunday and end with Easter. el và ­a crucis - This phrase from Latin, sometimes spelled as viacrucis, refers to any of the 14 Stations of the Cross (Estaciones de la Cruz) representing the stages of Jesus walk (sometimes called la Và ­a Dolorosa) to Calvary, where he was crucified. It is common for that walk to be re-enacted on Good Friday. (Note that và ­a crucis is masculine even though và ­a by itself is feminine.) el Viernes de Dolores - Friday of Sorrows, also known as Viernes de Pasià ³n. The day to recognize the suffering of Mary, the mother of Jesus, is observed one week before Good Friday. In some areas, this day is recognized as the start of Holy Week. Pasià ³n here refers to suffering just as passion can in a liturgical context.

HUMAN RESOURCE Term Paper Example | Topics and Well Written Essays - 1000 words

HUMAN RESOURCE - Term Paper Example There are five factors to be analysed in the porters five forces and they are analysed below in correlation with the Apple Computers. The threat of the entry of new competitors The personal computers industry is the major threat for Apple Computers including the old competitors for Apple Computers. Competitors are coming up with innovative products that may cause the Apple Computers to face tough king of competition in the future. The intensity of competitive rivalry The intensity of competitive rivalry tends to focus on the elements such as the price of the product, the innovation and quality level of the product. All these factors are compared with the competition in the market. Companies that use advance technology tend to be stable in a competitive environment such as Apple Computers. Competitive rivalry faced by Apple Computers is from Dell incorporation, Hewlett Packard Company, and Microsoft Corporation. Dell computers have one of the most unique strategies in providing custom ized notebook and laptops to its customers, according to their needs and wants. Apple faces intense competition from Microsoft in areas of portable music players and other type soft software. The threat of substitute products or services Apple faces one of the biggest threats from its substitute products & services. The era of converging to the digital types of devices such as MP3’s, cell phones, playing games, and picture taking along with the internet has challenged Apple to a very large extent. iPod franchising protection is the biggest challenge for Apple computers. The bargaining power of customers Customers have a lot of choices from which they can choose their computer devices. The switching costs of customers are high and they have a lot of information available of other competitor products, but Apple computers have made their mark in all fields and they may not be facing high competition from the bargaining power of customers. The bargaining power of suppliers Apple computers although does not provide low quality products but still companies like IBM and Motorola may work intensively on every inch of computer production and therefore cause a threat from the bargaining power of suppliers. High switching costs are faced when Apple opts for changing suppliers. Generic business strategies The generic strategies from the Porter’s framework being practiced by Apple Computers are mostly the differentiation element and the focus element of the strategy framework. Apple computers imposes the differentiation strategy through their use friendly graphic interface and the integration of products and services is the main focus and target of Apple computers that makes them successful and is few of the sources that allow them to gain a competitive advantage. For having a stable focus, Apple computers segment their target market according to consumer characteristics so that consumers of their products are satisfied. HR policies of Apple Computers

Trevor comes to see the doctor Assignment Example | Topics and Well Written Essays - 1750 words - 1

Trevor comes to see the doctor - Assignment Example With time, the production of insulin becomes insufficient, leading to similar symptoms as type 1 Diabetes, which may be either gradual or asymptomatic. The patient is 61years and he has lived in Sydney for most of his life until he was 50 years, when he decided to relocate to his rural place. He leads a sedentary lifestyle and he has not undertaken physical exercises since he was a teenager. In addition, he faces the problem of lacking proper and healthy diet at home, mainly because he does not have a choice of the food he eats but has to accept what his wife prepares for him; occasionally, she provides him with steak and chips from fast food outlets. Risk factors he is involved in include heavy smoking, sedentary lifestyle, and having no control on his diet. The exercise regime is poor, although he admits taking brisk walks at home under pressure from his partner, a ritual that he does not enjoy due to physical discomfort of the exercise and lacks of endurance. He was once asked to be tested for diabetes type 2 but he declined. The physical assessment reveals raised blood pressure and blood sugar while lung field sounds are compro mised but can be heard. Other vital signs tested included heart rate, respiratory rate, temperature, and oxygen, which are normal routine checks for his clinical presentation. The initial results from physical assessments make the doctor to order further test for serum cholesterol and fasting blood to confirm the diagnosis. Investigation reveals raised serum cholesterol and a high fasting blood sugar, which points to the indication of Ischemic Heart Disease and Type 1 Diabetes. From the initial assessment, the patient’s lifestyle predisposed him to the risks of the diseases. The physical exam revealed that the patient could not endure resistance exercise, smokes heavily, and has never been mindful of his diet. Random blood sugar is abnormal, and the vital respiratory signs are

Compare and contrast discontinuous change Research Paper

Compare and contrast discontinuous change - Research Paper Example They are responsible for creating organizational environments that encourage improvement. However, human beings are naturally resistant to change. The organization has to overcome this resistance in order to increase engagement with the new structures. Employees have a difficult time adjusting to the new environment, and managers have to create an environment that will hasten the adaptation (Stanley, 2002). Employee training and changes in the work cultures are some of the methods of sustaining change. Progressive and visionary managers act as architects for change. They design and implement organizational change by basing their decisions on objective information. Successful changes are introduced gradually under the supervision of managers. Managers become advocates for change as well as fighting for their teams and projects. Aggressiveness, sound conviction, and courage are necessary for advocating for change. Employees have to be convinced on the advantages of embracing change, wh ich is a role for managers. They have to acknowledge past achievements, appraise present accomplishments and lay out the future of the organization after implementing proposed changes. Managers are responsible for explaining the impacts of change on individual employees and coordinate individual and organizational change. ... Effective change must make full optimization of existing resources so as to increase productivity. Managers have to encourage innovation, cultivate problem solving, address employee concerns, remain truthful, and help individuals transcend their self-interests. Employees must cultivate a desire to improve the condition of the company. This helps employees raise their concerns during the fact finding process. Change requires constant learning and employees have to be willing to engage in learning process. On the other hand, managers must create appropriate learning experiences and motivate their employees. This involves introducing better ways of doing the job and making employees aware of the reasons for performing certain tasks. Planning for change creates an orderly way of ensuring an organization meets the short-term and long-term goals. Employees have to be involved in the design practice as a way of reassuring change adaptation (Stanley, 2002). Change is inevitable in organizati ons, but almost two-thirds of major change programs are unsuccessful. The main cause of this failure is resistance by managers and employees. Change is accompanied by uncertainties and potential outcomes that cause resistance. Employees usually display reservation, which arises as a reaction to change. Resistance detracts the proficiency of the organization and becomes an enemy of change. Normal interactions between individuals and groups are interrupted and there is a breakdown between employees and managers. Individual rational assessments of change outcomes can conflict with those of management creating resistance. Individuals can also resist due to preferences and predispositions that are not based on rational assessment.

The Use of Literary Elements in Shakespeare's Hamlet Essay

The Use of Literary Elements in Shakespeare's Hamlet - Essay Example The metaphors are used by the author of the play to reveal that despite the fact that Claudius, Hamlet’s uncle, had killed his brother to attain the throne, they were extremely alike to each other. It shows Hamlet’s belief that both his uncle and father were men who valued their own power more than those people who were around them. It is because of this that eventually, both came to their downfall because had they valued their people, then the tragic events which took place in the play would not have happened. Another important metaphor that is used in the play is that related to the cannon fire, which accompanies the king’s toasts, and this helps to show that Claudius, the king, is united with the land that the rules. In reference to the cannon fire, Hamlet states, "†¦or that the Everlasting had not to fix'd his canon 'gainst self-slaughter!" (Act 1 scene 2). This is used to express Hamlet’s wish that his uncle Claudius would turn into a cloud (a pl ay with the name Claudius) so that when the cannons shot into that cloud, it would be able to kill him. This would, in essence, freed Hamlet from his promise to his father’s ghost that he would kill Claudius to avenge his death. Tone When one considers the tone of this play, one would say that it is extremely dark. This is especially because of the fact that almost all the characters within it either are thinking dark thoughts or are plotting to commit evil things. From the very beginning of the play, we see plenty of anxiety and uncertainty concerning the events that are taking place or are likely to take place. The mood in which Hamlet is put after talking to his father’s ghost is extremely dark, and those who know him come to believe that he is going mad. This dark mood is also transmitted to those who either are around him and their actions, directly or indirectly, reflect the darkness, which is in the play. The soliloquies, which Hamlet has concerning the dark asp ects of life such as betrayal and mortality, are some of the things that contribute to the tone of the play. However, from the first line of the play when the guard, Bernardo yells, â€Å"Who’s there!† (Act 1 scene 1) the dark tone of the play is set. It is later revealed that this may have been an expression of the anxiety, which the guards felt after seeing the ghost of their former king several times during the nights. Style One of the aspects of style that is revealed when one reads Hamlet is the use of verse among the main characters when they speak. These characters often use words, which have an unaccented syllable followed by an accented one. This creates a rhythmic pattern in their speech and it can be said that Shakespeare used this style of writing in order to keep the attention of the audience on the play and the characters within it. An example of the use of verse in the play is in Act 1 scene 2 when Hamlet states, â€Å"O, that this too too solid flesh w ould melt, Thaw and resolve itself into a dew!† When one considers Hamlet’s soliloquies, one will find that he often speaks in a formal tone, and this is used to reveal that he comes from the nobility.  

Ursula Burns Week 9 Essay Example | Topics and Well Written Essays - 500 words

Ursula Burns Week 9 - Essay Example She always represents the views of her workers and encourages them all through (Lussier & Achua, 2013). This is considering that she wants them to achieve success in their daily routines and aims at fostering their great abilities at work. She constantly aims at gaining extra success. In this regard, it is true that she represents all the above mentioned behavioral components. Yes. I believe that Burns shows excellent qualities of a servant leader, which makes her fit the bill. It is not possible to leave out the fact that she was brought up by a single mother who endeavored to see her children become successful in life and live better lives. She managed to set herself apart from other individuals placed in the same ranks with her. Above all, Burns had a chance to do for other people what her mother did for her (Lussier & Achua, 2013). Based on my knowledge of Ursula I believe that she meets the criteria for all the 12 qualities presented. Narrowing down to a particular quality would only deny her the great qualities she deserves. First, she shows that she had bought into the vision of the company. Specially, Burns desires to see the company grow and develop into a bigger and better one than it has ever been before (Lussier & Achua, 2013). She hopes that her employees will acquire significant achievements in the company as well. It is true that Burns is an excellent speaker and gifted communicator. This is considering that she managed to climb fast the management ladder at Xerox on account of her exceptional communication skills. Above all, she is endowed with out of the ordinary ethical attributes and self-certainty. This is evident in the subject that she never showed any signs of fear her skills or knowledge. She consistently shared her mind and presented her individual ideas without any worry. Ultimately, it i s her confidence that enabled people around her to confide in her without a doubt. Based on the facts of the case, Burns derives her personal

Nursing research Essay Example | Topics and Well Written Essays - 1250 words - 2

Nursing research - Essay Example It is important for an outcome measure to be reliable, sensitive to change, and valid. Hence, the outcome measure adopted is reliable in that the questions in the measure are easy to understand and enhances easy evaluation of the program. Importantly, the outcome measure provides an accurate indicator of the intended measure it should focus on, which makes the outcome measure valid (Royse, Thyer, & Padgett, 2009). On the other hand, it is evident that the outcome measure evaluated successful implementation of the program. Finally, the outcome measure is sensitive to change since its focus is on aspects that contribute to successful implementation of the program. The outcome measure, which is structured in form of a Likert-Scale questionnaire, will be the best tool to use in order to evaluate the outcome. The questionnaire, which is provided as Appendix 1, will evaluate the effectiveness of the implemented change. The questionnaire focuses on mothers since they are the best suited individuals to evaluate their children’s pain. Importantly, it is essential to point out that the items in the provided questionnaire conceptualize the elements of effective pain management in children. After the implementation of the change, the questionnaire will provide the healthcare facility with an opportunity to evaluate the success of the program. Evaluation requires a combination of human and financial resources in order for it to be effective. In this case, human resources will be an essential component of the evaluation process since they will provide the questionnaires to the parents for filling and consequently collect them after filling. On the other hand, the pain nurse is a component of the human resources required in the evaluation since she will walk through the pediatric ward and identify any inconsistencies in the program. Conversely, it is important to note that financial resources

The Use of Literary Elements in Shakespeare's Hamlet Essay

The Use of Literary Elements in Shakespeare's Hamlet - Essay Example The metaphors are used by the author of the play to reveal that despite the fact that Claudius, Hamlet’s uncle, had killed his brother to attain the throne, they were extremely alike to each other. It shows Hamlet’s belief that both his uncle and father were men who valued their own power more than those people who were around them. It is because of this that eventually, both came to their downfall because had they valued their people, then the tragic events which took place in the play would not have happened. Another important metaphor that is used in the play is that related to the cannon fire, which accompanies the king’s toasts, and this helps to show that Claudius, the king, is united with the land that the rules. In reference to the cannon fire, Hamlet states, "†¦or that the Everlasting had not to fix'd his canon 'gainst self-slaughter!" (Act 1 scene 2). This is used to express Hamlet’s wish that his uncle Claudius would turn into a cloud (a pl ay with the name Claudius) so that when the cannons shot into that cloud, it would be able to kill him. This would, in essence, freed Hamlet from his promise to his father’s ghost that he would kill Claudius to avenge his death. Tone When one considers the tone of this play, one would say that it is extremely dark. This is especially because of the fact that almost all the characters within it either are thinking dark thoughts or are plotting to commit evil things. From the very beginning of the play, we see plenty of anxiety and uncertainty concerning the events that are taking place or are likely to take place. The mood in which Hamlet is put after talking to his father’s ghost is extremely dark, and those who know him come to believe that he is going mad. This dark mood is also transmitted to those who either are around him and their actions, directly or indirectly, reflect the darkness, which is in the play. The soliloquies, which Hamlet has concerning the dark asp ects of life such as betrayal and mortality, are some of the things that contribute to the tone of the play. However, from the first line of the play when the guard, Bernardo yells, â€Å"Who’s there!† (Act 1 scene 1) the dark tone of the play is set. It is later revealed that this may have been an expression of the anxiety, which the guards felt after seeing the ghost of their former king several times during the nights. Style One of the aspects of style that is revealed when one reads Hamlet is the use of verse among the main characters when they speak. These characters often use words, which have an unaccented syllable followed by an accented one. This creates a rhythmic pattern in their speech and it can be said that Shakespeare used this style of writing in order to keep the attention of the audience on the play and the characters within it. An example of the use of verse in the play is in Act 1 scene 2 when Hamlet states, â€Å"O, that this too too solid flesh w ould melt, Thaw and resolve itself into a dew!† When one considers Hamlet’s soliloquies, one will find that he often speaks in a formal tone, and this is used to reveal that he comes from the nobility.  

Nursing research Essay Example | Topics and Well Written Essays - 1250 words - 2

Nursing research - Essay Example It is important for an outcome measure to be reliable, sensitive to change, and valid. Hence, the outcome measure adopted is reliable in that the questions in the measure are easy to understand and enhances easy evaluation of the program. Importantly, the outcome measure provides an accurate indicator of the intended measure it should focus on, which makes the outcome measure valid (Royse, Thyer, & Padgett, 2009). On the other hand, it is evident that the outcome measure evaluated successful implementation of the program. Finally, the outcome measure is sensitive to change since its focus is on aspects that contribute to successful implementation of the program. The outcome measure, which is structured in form of a Likert-Scale questionnaire, will be the best tool to use in order to evaluate the outcome. The questionnaire, which is provided as Appendix 1, will evaluate the effectiveness of the implemented change. The questionnaire focuses on mothers since they are the best suited individuals to evaluate their children’s pain. Importantly, it is essential to point out that the items in the provided questionnaire conceptualize the elements of effective pain management in children. After the implementation of the change, the questionnaire will provide the healthcare facility with an opportunity to evaluate the success of the program. Evaluation requires a combination of human and financial resources in order for it to be effective. In this case, human resources will be an essential component of the evaluation process since they will provide the questionnaires to the parents for filling and consequently collect them after filling. On the other hand, the pain nurse is a component of the human resources required in the evaluation since she will walk through the pediatric ward and identify any inconsistencies in the program. Conversely, it is important to note that financial resources

How Do We Know Something Is True in the Arts and Science Essay Example for Free

How Do We Know Something Is True in the Arts and Science Essay Hey Jamie! I’ve been wondering for a while now how you can really know if something in art or natural sciences is true.? I mean when you look at a piece of art or let’s say the way atoms connect with each other, or how the gravity works, how do you know it’s all true? Obviously there are laws that are connected with these things, however how can you be sure if what the law states is true? Jamie:You’re pretty much right about that, but I think it’s not about the truth for now – first there should be some kind of idea or a belief, before it can be confirmed, right? I mean, for instance Newton came up with the idea of gravity when an apple fell on his head, remember? It made him think about it more and more until the conception of some kind of force that affects everything on Earth popped into his mind, but I don’t think art works the same way†¦ Molly:Right†¦ Art’s totally different thing. Natural science have some rules they work with, even though there probably are some we still don’t know about, however we can notice something that happens the certain way. The rules are true. Well – people, or rather scientists claim so, but they are based on long-term observation and other research, right? Jamie:Right! If someone is absolutely certain that something is true, is it because this is the way he sees it or seeing it equals believing it is true? Molly:Well†¦ That’s a good question. I’ve heard that there are some ways to know that something is true – like I’ve mentioned before, observation, or rather a sense of perception, is one of them, but there is also reason and language that suggests people which is the objective, factual or relative truth. It’s more connected with natural sciences, however when it comes to art the way one can tell something is true is slightly different. Jamie:How so? I mean†¦ I don’t get what your point is. Molly:Look, if you have a piece of art, let’s say a picture of a battle, okay? The one who painted it, probably had some kind of knowledge about the battle he was drawing, right? Jamie:I think so†¦ Molly:So, let’s say, there is a person the picture revolves around, some kind of great figure, a king or other known man. The author of the painting wanted to show ordinary people the greatness of the person he pictured in the centre of his work. And there is a big chance that the person who’ll look at this exact piece of art, will think ‘Oh, that man was so great. ’, but how can he or she know it is true that he was as ‘great’ as the author portrayed him? Then, we could take a work of another author, the same battle, and there will be no person who will attract your attention at first, just the way the battle looked like, dead people, blood on the ground and other realistic fragments. If I was the one comparing these two pictures, I’d get a feeling that the first artist suggested the greatness of the man he portrayed because he was paid or had to do so, while the second one would be more true to me, because it would probably show the facts at some point. Jamie:Oh I see what you mean now! Hmm†¦ I have a feeling that in the end art and natural science are somehow connected when it comes to knowing the truth! Molly:†¦ Okay, now you got me confused. How can they be connected? Explain? Jamie:Oh look! If you take our chemistry book, you’ll find there all kinds of described experiments, right? However it is rare to find the outcomes of these experiments in the book. Molly:Yeah†¦? Jamie:And when you listen to your chemistry teacher, and he’ll tell you before you do the experiment that the product of the reaction should smell the certain way, as let’s say†¦ Hydro-sulfuric acid smells like rotten eggs. After finishing your research and experiment you would probably note that the smell of the acid was of rotten eggs, because this is what has been suggested by your teacher, right? Molly:Oh, now I see how it’s connected to art. Some kind of statement can be suggested to you and you are very likely to believe it, however, then you could find some other research that declines what your teacher claimed or that the guy portrayed in the picture was great. Jamie:Yes! Exactly! But then there arises a new question. Molly:Huh? What question? Jamie:Can we be sure of what people claim to be true to be actually true? Molly:Right†¦ In the end I think we are should stick to the rules that have been stated in the past, because they seem to be true, however after you said that†¦ I’m starting to doubt everything I know! Jamie:Sorry for that! Didn’t want to make you confused! Molly:No, it was actually pretty interesting! Jamie:Yup! But I think we can never be in 100% sure of what is true when it comes to art and natural science. Molly:Yeah, totally agree with you on this one.

Urban Walkability and Transit Oriented Development (TOD)

Urban Walkability and Transit Oriented Development (TOD) Introduction The transit oriented development approach is being adopted by many cities around the world, particularly those contested with transforming their car dependent neighbourhoods into more habitable and sustainable developments. The simplest way to describe the principles of TOD according to Calthorpe (1993) is â€Å"moderate and high density housing, along with complementary public uses, jobs, retail and services, concentrated in mixed – used development at strategic points along the regional transit system†. Yet, much as connectivity to regional significance through transit is important, it is the communities’ close interaction, supported by a walkable environment that Calthorpe claims is the â€Å"key aspect† of any flourishing TOD. Over the years, pedestrian friendly design thus generated considerable interests and a significant amount of literature and influential policy on urban walkability in TOD’s were developed in the Western world’s temperate urban zones. Presently, however, many of the world’s fastest developing urban areas are found in subtropical latitudes (O’Hare,2006). Western Australia, and particularly Perth, the urban centre of the region is one such case and serves as the focus of this research. The paper explores the key aspects and physical qualities of built environment related to urban walkability with an intent to encourage further discussion and studies on how subtropical TOD’s can be designed to enhance pedestrian movement as well as question whether the orthodoxy of existing urban design principles require some alterations to better adapt to subtropical regions. The paper establishes the accepted arguments and urban design principles essential to urban walkability and develops from a review of urban design sustainability, a framework that would encourage pedestrians’ movement and transport waiting in a subtropical TOD. A literature review is produced to confirm the growing importance of walkability and ultimately the paper explores, through field observations, how the established urban walkability principles apply in the subtropical regions. It concludes by giving some recommendations that could be applied to Claremont town Centre for an improved pedestrian friendly TOD. Accepted arguments for urban walkability + Literature review Recognised as the oldest form of urban transport, walking is a way of encountering and engaging with the local surroundings and wider society in a manner not quite possible when adopting other means of transport, especially motor transport. Gehl Gemzoe (2003), strongly highlight walking as a solution to bettering the public ground as part of the enhancement of the local neighbourhood and urban rejuvenation. With emerging concerns that car dependent cities will not be sustainable in the future, due to energy costs, fuel availability, congestion, pollution and other environmental impacts, much awareness is being raised about the importance of walking. According to US researches, studies show that there is a 30% more likelihood that compact-mixed use development residents would walk (to a restaurant/park) than those inhabiting vast motor-oriented environments (Cervero Radisch,1996). Hodgson, Page, Tight (2004) also conclude from their research that that TOD’s with appropriate design lead to more pedestrian and transit trips resulting in a decline in non-motorised transportation modes to reduce pollution emissions In conjunction to sustainability issues, the intra-generational equity theory and policy also acknowledge that a major part of the population constitutes of people who are extremely young, old, unhealthy, disabled or needy to have access or control over a private car (O’Hare,2006). Recently, considerable interest in improved walking environments has been generated as a result of the desire to encourage nonmotorized transportation modes to reduce pollution emissions and to improve public health by increased levels of walking (Evans-Cowley, 2006). A large body of research has confirmed that a favorable walking environment is a necessary condition for promoting walking and neighborhood interaction (Clifton, Smith, Rodriguez, 2007). Public health The World Health Organisation (WHO) Charter on Transport, Environment and Health as well as the WHO Healthy Cities Program have recognised the prominence of urban walkability long before the urban design and planning fields. The public health sector recognises that ‘active transport’ (such as walking, including walking to the bus or train) involves incidental physical activity. This incidental physical activity is an important component of active living (O’Hare 2000). Active living, together with a healthy diet, has the potential to reverse current international trends towards sedentary lifestyles and the accompanying health risks associated with obesity. Australia has been rated by different agencies as one of the world’s top four countries for obesity. Given that much of the world’s urban population growth is occurring in the tropical and subtropical zones, it is important to examine urban walkability principles with particular attention to conditions in those non-temperate climatic zones. A Perth study found commuters using public transport accumulated seven times more exercise than private motorists The prevalence of obesity in Australia has more than doubled in the last 20 years: 52% of women, 67% of men, and 25% of children are overweight or obese. Urban walkability principles in TODs: Jacobs (1960) spelled out almost half a century ago that urban design qualities relating to the quality of pedestrian experience are essential to support walkability. â€Å"Active frontages† and â€Å"eyes on the street† were recognised as few of the many crucial aspects. Based on the best practices from around the world, 8 principles vital to creating walkable TOD’s are identified in this paper. WALK Developing attractive pedestrian environment ensures accessibility and mobility for all. PLACE-MAKING Creating a sense of place makes encourages pedestrian activity and liveability. CONNECT Creating dense networks of transit routes results in a high degree of connectivity. TRANSIT Locate land uses so that they are transit supportive and close to high quality transport. MIX Planning for mixed use will promote pedestrian interest, safety, 24 hour activity. DENSIFY Sufficient density and compact form make transit viable and improve walkability. COMPACT Planning for compact areas with short commutes improves efficiency. SHIFT Controlling the amount/location of parking increases mobility. It is however important to understand that although listed individually, for a development to become truly transit oriented, we must be able to blur the boundary between these principles so that they are all interrelated Urban design theory and practice guidelines for walkable places were mostly developed in cities located in the temperate climatic zone. In the subtropics, summer is the season of discomfort for walkers, whereas in temperate cities it is the winter that brings discomfort to urban pedestrians. The coastal subtropical city lacks the icy winds, snow, sleet, frost, and other winter discomforts of the temperate city. The pleasant winter pedestrian conditions of the subtropical city are offset, however, by the summer challenges of heat, humidity and glare. The next section of this paper explores the need for an ‘intemperate’ approach to achieving urban walkability in the subtropical city Urban walkability in subtropical TODs Framework It is important to understand that in the fast growing subtropical urban regions of the world, climate and local topography are influential elements associated with walkability. Moving at a slower pace, pedestrians are prone to observe many more perceptible details and are exposed to the surrounding elements and climatic factors. Protection from sun, rain, humidity or heat must therefore be taken into account when planning a pedestrian environment. Drawing on research and keeping in mind the factors associated with subtropical urban regions, a framework of urban design principles is developed as strategies that would best enhance pedestrian movement or waiting in subtropical TOD’s. The key factors to making walking appealing are grouped in three major categories: SAFETY, ACTVITY AND COMFORT. Figure 1 – Framework Venn diagram, 2014. Figure 2 – A balanced street has ample sidewalks, comfortable bike facilities that connect to a network, and safe ways to cross streets, making active transportation possible even on larger roads. Image by EMBARQ. Stimulating walking necessitates that these travellers can move around efficiency, comfortably, and most importantly, safely. Physical design strategies that could be implemented in the ‘Safety, Activity, Comfort’ framework are discussed below : Safety: Ensuring wider sidewalk can provide for easy pedestrian movement and at the same time promote commercial activity/interaction Removing physical or perceived barriers to ensure that the pedestrian has flat and obstruction free band of sidewalk – â€Å"pedestrian zone† Providing pedestrian oriented quality lighting that illuminated their paths will add to the walker’s sense of safety Responsive walk signs at crossing lights designed with better timing and automatic changing to prioritise the needs of pedestrians, raised intersections, mini roundabouts or speed humps will encourage safe movement. Activity: Well-connected streets ensure that residents can conveniently access all parts of the TOD, thus activating the street use. Developing mixed-use street active frontages promote safety, security and foster vibrant social life in the streets. Attractive spaces with building orientation to the public street, visual interests, building articulation and landscaping encourage pedestrians to gather and linger Way finding aids/proper signage must be implemented to help people orient themselves and encourage movement through open public areas. Transit stations should be activated by cafà ©/newspapers stands or other facilities to make transport waiting wothwhile Comfort: The use of shelters in pedestrian and transit areas/stops allows for discomfort reduction and provides rest for pedestrians. Provision of footpath awnings, arcades, and other weather protection at least at certain intervals will serve as shelter from sun or showers. Providing a high degree of street amenities (benches, garbage cans, drinking fountains) and resting places will heighten the image of the street and attract all demographics to comfortably linger. As well as providing a solution to the heat humidity, street trees shade and protect pedestrians from the rain. Walkers can also be protected from cars when greenery is carefully designed along curbs. Sidewalk with a width proportional to the scale of the TOD area and planned walkability level ensures comfortable walking experiences for everyone. Case studies Subiaco City and Claremont Town centre, selected as case studies for this paper are recent both transit oriented areas developed in Perth region with a railway line passing through. The study area boundaries for each include the area within an 800-metre radius surrounding the train station. Subiaco city -Subiaco, known as Subi is a historic inner western suburb located around 3kms from Perth CBD and is focussed around a lively retail strip of Rockeby road. The Subi Centro project encompassing the North and West of the Subiaco railway station began in 1994 and incorporated many new dwellings, business centres and commercial space. An important aspect was the undergrounding of the railway line which in the past divided Subiaco. As an exemplar of urban regeneration supporting its heritage context, the project achieves a high quality public realm. Claremont Town Claremont Town centre, another western suburb finds itself midway of Perth CBD and Fremantle port on the north bank of Swan River. Claremont Town centre is a significant shopping area concentrated around St Quentin’s Avenue/Bay View Terrace and located south of the Claremont train station. The Claremont North East Precinct project is an on-going project started in 2005 as an initiative to revitalise the Northern part of the town which is currently disconnected from the southern part. It aspires a vibrant mixed used development around the Claremont football oval as a step towards social, economic and environmental sustainability. The purpose of this report, being to assess and enhance the quality of pedestrian environment, 3 methods is used to gather information: Ped-shed analysis is conducted at a 400m radius (5 min walk) and an 800m radius (10 min- walk) SAFETY-ACTIVITY- COMFORT assessment sheet is used to rate physical micro – attributes of the built environment on the streets. Observational analysis of the site – pictures/personal experience DATA ANALYSIS The information collected from these were used to assess to what degree the factors discussed in the framework and considered influential to walkability are either present or lacking in these two study areas. Pedshed ratio Analysis of the connectivity of both TODs was assessed through the ped-shed ratios calculated. A comparison of the two diagrams that Subiaco’s street grid network provides many paths and connected streets, encouraging them to walk and be within short walking distance of the train station. Claremont on the other hand, lacks this degree of pedestrian connectivity and offers limited route choice to the person walking. After analysing the connectivity of each site, visuals were gathered from field observations to compare one to another. The Safety-Activity-Comfort assessment sheet was then used to examine and rate each category. Key findings As seen from the rating, Subiaco city stands out terms of providing certain positive physical street elements that affect walkability. Observation from field analysis showed that street frontages on streets adjacent to the train station were quite lively and highly articulated. Seating areas, lighting, greeneries and shaded spots contributed to attracting pedestrian activity in the area. It was gathered from observations and research that Subiaco’s success as a pedestrian friendly locality was also due to the fact that the City of Subiaco Councillors had established a vision statement of â€Å"The Best Main Street Village in Australia† for the area. Rockeby street, in this regard, was developed as a place to come back to instead of just being a transit street and development trends, opportunities and changes were carefully thought of so as the area’s unique ‘sense of place’ was preserved. Famously advocated by Toderian(2014) as â€Å"streets that are for people to enjoy and linger, not just move through..places that are both initially attractive and ‘sticky’, inviting people to love it and not want to leave it†, positive ideas of sticky street concept seems to have been successfully adopted in designing Subiaco’s main street. With the objective of planning not just for the infrastructure and public transpor t, but also the shops, cafes and the people, Rockeby Street has flourished as iconic community hub of social, civic and commercial activity with public spaces as focal points. On the downside however, field observations also indicated a number of vacant shops or those in the process of closing down in Rockeby road retail strip. High rental rates, competition from nearby precinct and over restrictive licensing policies has caused a decline in cafà ©/retail strips and a 5% retail vacancy rate in the area (Tsagalis2012). It was also found that an alfresco dining licence in Subiaco was more expensive than Western Australia’s average and compared to a survey of local governments in Perth and the eastern states (Law, 2014).Mayor Henderson (2014) has approached this issue stating that â€Å"We are aware that council needs to step up to the plate and make some changes in order to create the vibrancy in the main street in Subiaco†. In an effort to encourage more local businesses to operate street trading/ alfresco dining areas to revitalise a spirited street and safe environment for the community, the council of the City of Subiaco has recently resol ved to amend existing associated fees. As of 31st October 2014, a notable reduction in application/licensing fees, a m2 basis fee and the initiation of low-cost short term options will be available for Subiaco retailers and it an increase in street activity is expected. While Claremont Town centre forms part of a prominent retail area, it comes primarily in the form of indoor malls which attract the pedestrians inside rather than being on the road. The main transit adjacent road, Grugeri Street, has a blank wall faà §ade with limited or no pedestrian activity. The street is also very limited in term of comfort since the awnings size is too small to provide shade or shelter. Bus tops and street amenities also lack variety and enhancement to attract people to linger. Recommendations Apparent from the observational audit and findings is that Claremont Town centre has many physical weaknesses in terms of walkability in a subtropical TOD. Because similar weaknesses may exist other western Australian TOD’s, some recommendations may apply for multiple sites and can be used as a guide for enhanced walking experiences. It was revealed from the site observations and findings of these 2 TOD’s in Perth that there is some way to go before Western Australia can claim to have a truly sustainable approach. Having established that urban walkability is vital to achieve a sustainable subtropical TOD, it is important for TOD planners to be able to adopt a revised framework of principles regarding the physical environment attributes that would work best for subtropical Perth regions and merge them with new innovative design strategies which would further enhance walking in Perth. It is also important for town/city planners to review rules and regulations in order to increase vibrancy in TOD’s rather than being over restrictive. Conclusion Having established that a successful TOD walkability is directly associated with a safe, comfortable and attractive pedestrian environment, this paper demonstrates that careful physical planning and good urban design solutions can very much enhance the pedestrian’s experience. It questions the needs of a subtropical city in term of its climate, topography and identity and then explores a framework of revised walkability principles that can be applied to the subtropical city. The case studies reveal responses and challenges to urban design for walkability in Perth and certain successful elements are recommended as strategies to improve Claremont’s TOD in terms of walking experience. It also questions whether over restrictive planning policies may need to be reconsidered to keep a TOD street alive and vibrant. It also recommends innovative strategies of urban design that other projects may copy or adapt in part for design and place-making approaches to give a unique sense of place to the subtropical TOD. Although each future TOD will deal with the numerous complex design challenges depending on particular circumstances around each project, it is the intention of this paper to stimulate discussion and hopefully more substantial research into the planning of walkable subtropical cities since so many of the world’s most rapidly growing urban areas are now situated in the tropical and subtropical zones.