Judicial Rulings with Prospective Effect in Australia

Question: Examine about the Judicial Rulings with Prospective Effect in Australia. Answer: Presentation: A rent understanding was gone into among Andrew and Kathy. Under the particulars of the understanding, Kathy rented her reason situated in Rownville Flats in New South Wales to Andrew for a time of five years. The reason for which Andrew claimed the property was for rehearsing physiotherapy and for directing activity classes. The time of rent initiated from 1 April 2015. The rent was an enlisted rent and Kathy was the proprietor of such property. In August 2015, some development and fixing works were being carried on in the arcade for three weeks which made trouble Andrew in doing his physiotherapy rehearses. In this manner, he grumbled about such fixing actuates to Kathy. In an answer Kathy affirmed him that the fixing work would not be carried on for long. Andrew likewise submitted a few questions with respect to certain stuffs in the premises which required substitution. However, Kathy didn't give any consideration to him. Andrew knew about the way that he needed to cause a great deal of costs for doing those substitutions and in this way he took a choice of surrendering his business. He chose to rent the rent to Courtney who consented to proceed with the leading of activity classes. Kathy didn't allow for the task of the rent. Legitimate issues associated with the case The lease of properties in New South Wales is administered by Residential Tenancies Act 1987 and the Landlord and Tenant (Rental Bonds) Act 1977(Stratton, 2013). Under the arrangements set down under the enactments, an occupant can just rent the rented premise with the assent of the landowner (Hepburn Jaynes, 2013). In the moment case, under the particulars of the current understanding (Clause 5) between the proprietor (Kathy) and tenant(Andrews), the inhabitant was not permitted to dole out the leased reason or rent it to some other individual without the composed assent of the landowner. Along these lines, legitimately the occupant has no privilege to rent the reason to some other individual without taking the assent of the landowner (Pagura, 2015).But in the current case, it would be exceptionally out of line to Andrew on the off chance that he isn't permitted to rent the reason to Courtney. It is a built up rule that the Court may now and again veer off from the real language of an enactment to do equity to the gatherings (Douglas et al., 2015). The Courts have the duty to apportion equity to the gatherings showing up before it. It may not be consistently conceivable to render total equity by clinging to the genuine arrangement set down under the enactments. Here and there, it gets unavoidable to go astray from the real arrangements of the enactments with the goal that total equity might be done to the gatherings. Under the realities of the moment case, Andrew couldn't be relied upon to maintain a sound business given the quantity of blocks he was confronting. Andrew was having a great deal of trouble to lead physiotherapy exercises in the leased reason. Right off the bat there were things which required quick substitution however the proprietor paid no notice towards tending to such issues. Furthermore, the fixing exercises which were going on in Kathys arcade made a lot of impediment Andrew. Under these conditions, Andrew couldn't be sensibly expected to satisfy the reason for which he had taken the reason on rent. Subsequently, Andrew had properly chosen to surrender his business as he was not having the option to make any benefit out of the physiotherapy exercises. Things turned out to be more terrible when Kathy declined to help out him. Given that Andrew was confronting trouble in maintaining the business, Kathy could have expanded her assistance by supplanting the needful things in the reason. Accordingly, the proprietor has acted in an out of line way by two different ways: right off the bat, via completing fixing works which made a great deal of bother Andrew for a time of nonstop three weeks and besides by not helping out her occupant in supplanting the floor covering or fixing the tap. Kathy ought to have permitted Andrew to rent the rent on the grounds that legitimately on the off chance that we see Kathy had no complaint in giving somebody to direct physiotherapy exercises access her reason. The individual to whom Andrew needed to rent the reason consented to carry on the comparable exercises which Andrew was doing in the reason. Consequently, when a landowner can lease her reason to an occupant for carrying on a specific action, there is no motivation behind why she can't permit a similar reason to be utilized by someone else for carrying on comparable exercises in the reason (Wosskow, 2014). She could have denied the selling of wellbeing items and gym equipment from the reason yet she could have effortlessly permitted Courtney to direct physiotherapy exercises in her reason. The demonstration of landowner for this situation is very preposterous and unjustified. Also, Andrew was not in a situation to bring about such a great amount of costs in supplanting the applicable things in the reason which required quick substitution. His choice to surrender the business is very sensible in light of the current situation. Kathys refusal to let Andrew rent the reason to Courtney is completely outlandish. Truth be told so much tact ought not be given to the proprietor; else it would be exceptionally unjustifiable to the occupant. A proprietor should deal with all the necessities required in a reason. On the off chance that she didn't need her reason to be rented by the inhabitant, ought to have in any event consented to supplant the things which the occupant requested for. By the by, she had would not do the fundamental substitutions. Subsequently, the proprietor has not been reasonable for the occupant and she has exploited the reality she was the proprietor of the reason. The inhabitant in the current conditions has not had the option to carry on his business appropriately in the leased reason and the unfriendly conditions have not allowed his business to business. Along these lines, it has been unjustifiable to the occupant and hence, in the light of the current conditions, he ought to be permitted to rent his reason to Courtney. However, the statement under the rent understanding doesn't permit the inhabitant to rent the leased reason without a composed authorization of the proprietor, yet conditions of the moment case are unique and they need exceptional consideration too. Had the proprietor been helpful and had she given all help to her inhabitant, we could have made an alternate inference. Be that as it may, in the moment case, the landowner has basically made maltreatment of her optional force and in this way she ought to be limited from denying Andrew to rent the reason. This would be a reasonable choice in the light of value and great inner voice. References: Douglas, J., Atkins, E., Clift, H. (2015). Legal Rulings with Prospective Effect in Australia. In Comparing the Prospective Effect of Judicial Rulings Across Jurisdictions (pp. 349-358). Springer International Publishing. Hepburn, S. J., Jaynes, S. (2013). The nature and extent of privileges of evacuation. Property Law Review, 2(3), 123-138. Pagura, I. (2015). Law report: Leases,'what you have to know'. Diary of the Australian Traditional-Medicine Society, 21(2), 119. Stratton, J. (2013). Contextual analysis 2: The privilege to lodging. Interesting issues: Legal Issues in Plain Language, (85), 28. Wosskow, D. (2014). Opening the sharing economy: An autonomous audit.

Report (addressing the key issues surrounding financial and marketing Essay

Report (tending to the key issues encompassing money related and showcasing uses of the executives data framework - Essay Example MIS frameworks empower associations to change unmanageable volumes of information into groups that underpins quicker dynamic. Quicker dynamic engages associations with the ability to get by in today’s quickly changing business condition. MIS frameworks likewise empowers associations run reproductions dependent on crude information which permits them to respond to ‘what if’ questions in regards to their system. Extensively, MIS increase data utility across anâ organization. Data accessibility is essentialâ to the dynamic procedure at all degrees of the association: useful, operational and key. In this conversation we will take a gander at the key issues encompassing use of MIS in two significant business forms, to be specific: promoting and money. Showcasing the executives data frameworks (MkIS) are automated frameworks intended to help the accessibility of data required to guarantee compelling promoting exercises of an association. These necessities of the association must be met by the showcasing data frameworks in the event that it gives the association operational, diagnostic and community oriented usefulness (Harmon 2003). The operational needs angle is tended to by the client the executives applications that attention on day by day client exchanges and client care. The investigative capacity is finished by MkIS choice emotionally supportive networks that empower information examination on factors influencing the economic situations, for example, clients, rivalry and innovation. The cooperative MkIS applications make it simpler for supervisors to share data and work together for all intents and purposes. Additionally, it helps with urging associations to work together with their clients on item structures and inclinations . Overseeing showcasing data by methods for IT has gotten a vital component of viable promoting. MkIS offer new methodologies for improving the inner efficiencies of a firm particularly with

Drug and Alcohol Rehab Programs for Beginners

Drug and Alcohol Rehab Programs for Beginners Addiction Coping and Recovery Methods and Support Print Drug and Alcohol Rehab Programs for Beginners By Buddy T facebook twitter Buddy T is an anonymous writer and founding member of the Online Al-Anon Outreach Committee with decades of experience writing about alcoholism. Learn about our editorial policy Buddy T Medically reviewed by Medically reviewed by Steven Gans, MD on October 13, 2016 Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital. Learn about our Medical Review Board Steven Gans, MD Updated on October 15, 2019 ONOKY - Eric Audras/Brand X Pictures/Getty Images More in Addiction Coping and Recovery Methods and Support Overcoming Addiction Personal Stories Alcohol Use Addictive Behaviors Drug Use Nicotine Use A first-time rehab experience can be scaryâ€"but it can also give you the lift you need to adopt a sober lifestyle. Learn what is it like to go into a rehab program.?? No Locks First, there are no locks are on the doors. You are free to leave at any time. Even if you have been adjudicated by the criminal justice system into the program, you can still walk out. You may face the consequences later, but you can choose to leave. The reason there are no locks is that no rehab or treatment program is going to work unless you are willing. If you enter rehab knowing that you are going to drink or use drugs again, you are likely wasting your money and time. If you decide to stay, youll encounter similar conditions regardless of the facility you choose. Alcohol and Drug Rehab Recovery Begins With Treatment Initiation The First Stop: Detox Some residential rehab facilities feature their own in-house detoxification programs, but more centers today require clients to complete detox prior to entering their facilities.?? You may need to get clean and sober before you can even enter rehab. The trend today is to have you go through the withdrawal process at a facility that specializes in dealing with drug and alcohol withdrawal symptoms.?? Typically, this transition occurs on a short-termâ€"five to seven daysâ€"inpatient basis, although the time frame can vary.?? The Facilities Each residential rehab facility is different in its physical facilities.?? They range from almost primitive camp-type settingsâ€"usually for troubled teensâ€"to the most luxurious facilities imaginable, and everything in between. Like most other things in life, you get what you pay for or what you or your insurance can afford. The type of physical facilities the program offers may have little to do with how successful or effective their program might be in keeping you sober. So, its important to research the type of treatments offered as well as their success rates.?? Education Education is the core component of all treatment and rehab programs. It may vary from facility to facility. The process is aimed at getting you to look at your addiction honestly and realistically, and change your attitude about your drug and alcohol use.?? In the early stages of recovery, most alcoholics or addicts may still be holding on to some  denial  about the seriousness of their problem or may be ambivalent about quitting drugs and alcohol for good. Treatment programs try to break through that denial and ambivalence to try to get you to commit to a clean and sober lifestyle. Typically, you will learn about the nature of alcoholism, the dynamics of addiction, the effects drugs and alcohol have on your body, and the consequences if you continue to use. Where to Find Free Alcohol and Drug Treatment Programs Counseling and Group Therapy During your rehab, you will probably receive individual counseling with a trained addiction counselor and you will possibly participate daily in group therapy meetings with others at the facility.?? These sessions are designed to teach you the skills that you will need to live life without drugs and alcohol. You will learn how to recognize situations in which you are most likely to drink or use drugs and how to avoid these circumstances in the future. You will learn new coping skills. The group sessions are designed to teach you the value of seeking support from others who are going through the same experiences and challenges that you are. In some facilities, these group sessions may be actual 12-step meetings. In other facilities, they may be facilitated by staff members.?? Family Meetings Many successful drug and alcohol rehab programs include members of your family in your treatment program. Some programs include family members and friends throughout the entire rehab process, from the initial assessment through continued follow-up aftercare. Research has shown that including family and friends in the educational process significantly improves rehab outcomes. In the family meetings, your family members will learn about the dynamics of addiction, learn to identify strengths and resources to help encourage you in your recovery, discuss how they have been affected by your substance abuse, and learn how they also can begin to heal their own wounds.?? Many rehab facilities require family members to attend Al-Anon meetings if they want to visit you while you are in treatment, to learn how they may have been enabling you and contributing to the problem with their actions and reactions to your substance abuse. Aftercare Program The typical residential drug and alcohol rehab program will last about 28 days, sometimes longer, during which you remain in a structured environment where no drugs are alcohol are available. Successful rehab programs have a strong aftercare program plan designed to meet your individual needs. By now your counselor probably knows you well and will suggest the next steps based on where you are on your recovery journey. Your aftercare plan may include intensive outpatient treatment, residence at a halfway house, attendance at 12-step meetings, weekly check-ins with your counselor, and other suggestions to help you avoid the situations and triggers that might cause you to relapse.?? What Happens When a Loved One Goes to Alcohol or Drug Rehab?

The Effect of Physical Education on Academic Achievement...

The controversial topic in the realm of physical education is if physical education should remain in schools. Higher up’s are complaining about test scores and suggesting that cutting physical education programs would lead to better test scores. Technically, this would lead to more time spent sitting in a desk and listening to lectures in class, which is supposed to improve test scores. So, the solution to increase test scores is to take the small chance of physical activity that children receive during the school day and keep them almost completely sedentary for six-plus hours. When physical activity is restricted during school hours, children do not regain the lost physical activity after school, resulting in children who remain†¦show more content†¦There is nothing more important than health, especially in this day and age. It’s concerning that only 29 percent of high school students surveyed by the CDC (2011) had participated in at least 60 minutes of physi cal activity on all seven days before the survey. The CDC also noted that only 31 percent of these high school students attended physical education class daily. Only 8 percent of elementary schools, 6.4 percent of middle schools, and 5.8 percent of high schools provide daily physical education to all of its students (SHPPS, 2000). The government is missing the fact that physical education can actually improve test scores, not the opposite. There was a study done in Mississippi with elementary and middle school students, whose aim was to find associations between health-related physical fitness and academic achievement using standardized Language Arts and Math scores (Blom, Alvarez, Zhang, Kolbo, 2011). Besides the standardized test scores, objective measures of fitness were used, along with attendance records, discipline records and socio-demographic information of the area. The participants included 2,992 Mississippi public school children in grades 3-6. The results indicated a strong positive correlation between fitness and standardized test scores in Language Arts and Math. The more fit students had higher test scores and fewer absences overall. The study also revealed that students with the lowest numberShow MoreRelatedPhysical Activity And A Child s Academic Achievement847 Words   |  4 PagesABSTRACT It’s a well-known fact that physical activity and being healthy leads to a positive lifestyle. There have been numerous debates about the relationship between physical activity and a child’s academic achievement. In 1947 to 2009, 59 studies were used for the â€Å"comprehensive, quantitative synthesis of literature† (pg. 521) for data analysis. 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Top Essay Topics for Placement Test Tips!

Top Essay Topics for Placement Test Tips! The test is straightforward and easy only as long as you are getting ready for it several months before. It gives you an experience of sitting in a true ECAT test center. Before you test, make sure to review. Placement tests aren't timed. Selenium Webdriver is just one of the most well-known testing frameworks. It is able to interact with all the different elements in a webpage. By covering all the various functionalities on your site with Selenium tests, you'll be in a position to rapidly catch new and reappearing old bugs. Your Selenium tests will be simple to read and understand. Students will be permitted to request 1 math placement test retake. Proofreading and revising is critical in offering a polished essay. Scoring well in school exams won't decide your future, but if you prefer to attain high targets and a prosperous life, you must think before it's too late. Students who are not sure of their Spanish language skills should check with their academic advisor and could possibly be provided a Spanish Placement Advisor Referral Form so as to select the Web. Good placement is valuable to your success in college. No appointment is demanded. Exceptions are dependent on the writing coordinator. The Chronicles of Essay Topics for Placement Test Use varied sentence structures Demonstrate a number of sentence structures in your writing to find a greater score. Your language selection will be dependent on this issue. Initially, you'd be given a particular topic to talk about which would wind up getting a more challenging interview vogue query. Mba essay help secure high quality essay writing service all services there are dozens and dozens of essay writing services from which you can purchase an. Confirm that you know the question. In case you have any questions please inform us in the comments below. It might be that you've been instructed on the sort of essay to write or, as an alternative, you could have been given free rein regarding what styles to select. You must tie 1 idea to the next, so the reader can follow through. Its principal attempt is to persuade a reader to adopt a specific point of view or maybe to take a specific action on the matter. Then devote the remainder of your essay to supporting it. Definitions of Essay Topics for Placement Test Food is now less difficult to prepare. In every one of the two, you will use a completely different assortment of words. What are the variety of ways to reach a purpose of sustainable fashion. For an Essay contest, the style in which you express yourself depends upon the subject you've got to write on. You will be provided a selection of topics. A common unfavorable behavior emerges here. What You Should Do About Essay Topics for Placement Test Beginning in the Next 15 Minutes The more practice you've got, the better you will end up. You have to practice a number of mock tests in order to acquire the feeling of the time constraint during the exam. Having illustrated diagrams for electrode placement is also practical for patients who purchase home units and wish to use their TENS unit by themselves. Placement test scores are valid for a couple of years, in accord with state guidelines. With the diverse therapy applications of a TENS unit, it's the ideal addition to numerous rehabilitation regimens. One of the principal goals in pain management in physical therapy is to get a modality that's non-invasive and productive. Patient will truly feel a little tingling feeling. The term that you want to use is misalignment. The Advantages of Essay Topics for Placement Test In case you are unable to disprove the cheating charges, colleges will just find your scores are canceled, without access to additional information regarding why it happened. An mba essay will be supplied. You might also be informed that you've been accused of cheating after the test. A small review may create a difference. If you are flagged as a result of a substantial score improve, the testing agency will typically request that you retake the test, at no cost, in a more controlled setting. The intention of the placement test is to set the course that's best suited to your writing needs.

Alcoholism And Rehabilitation Free Essays

Alcoholism, also known as alcohol dependence, is unfortunately a widespread ailment which spans people of all age groups and socioeconomic levels. The health risks of this disease, and alcoholism is a disease, are as widespread as the individuals who contract it. In addition to these health risks, alcoholism is also an influencing factor in another problem plaguing societies, domestic violence. We will write a custom essay sample on Alcoholism And Rehabilitation or any similar topic only for you Order Now Thus, alcohol and anger create a sometimes fatal combination. As a result, rehabilitation success rates are vital in the ridding alcoholism and its negative effects from society. Alcoholism is a disease which can be described by degree. Alcohol dependence describes individuals who have developed a â€Å"maladaptive pattern† of alcohol consumption which is characterized by a developing alcohol tolerance, withdrawal symptoms, or hangovers, and the inability to stop drinking. It doesn’t stop there People with alcohol dependence may progress to alcohol abuse which can significantly interfere with their social lives, their work or their interpersonal relationships. In addition, this abuse can also cause a host of related issues including â€Å"major depression, dysthymia, mania, hypomania, panic disorder, phobias, generalized anxiety disorder, personality disorders, any drug use disorder, schizophrenia, and suicide† (Cargiulo 2007). According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), drinking up to 14 drinks in a week for men or seven drinks per week as a woman could indicate alcohol dependence. In addition, the NIAAA estimates that up to nearly 18 million Americans could be considered alcoholics (Lauer 2006). That amounts to way too many individuals who are addicted to a drug that is both physically and mentally harmful, not to mention the effects on society as a whole. Despite the many mental and physiological problems that are associated with alcoholism, some of the most frightening are the health problems associated with the brain. Evidence exists that shows the damage that alcohol consumption does to the brain. Brain imaging studies have revealed that people with alcoholism have significant differences in parts of their brains than those without alcoholism. The brain volume is reduced in alcoholics as well as the blood flow to the brain. The reduced blood flow has been linked to a lowering of inhibitions and memory, impaired cognitive function in general and even damage to the corpus callosum (Cargiulo 2007). Thus, alcoholism can directly translate to serious problems with the mind. These problems can lead to long term brain damage. Lesions in the brain form in those with long term patterns of alcohol abuse. This can translate into Korsakoff’s disease which is characterized by motor impairment and thinking impairments which can affect a person’s ability to care for himself. In the end, the individual may have to be cared for institutionally. Alcohol affects the neurotransmitters in the brain. As the disease progresses to chronic status, the brain cells begin to adapt to the alcohol that seems to reside permanently in the brain. As a result, the brain becomes reliant on the alcohol to work. If alcohol is removed, the symptoms of withdrawal take longer and longer to subside. Ultimately, the brain tissue will rebel, in a way, and the withdrawal symptoms can be severe, even fatal. Once the cells in the brain die, they cannot be regenerated (Shoemaker 2003). These effects seem to affect males to a greater degree than females. This fact can be explained by differences in drinking patters, choice of alcoholic drinks, rate of alcohol metabolism and the protective effects of hormones such as estrogen (de Bruin, 2005) As such, alcohol dependency and abuse is three times more prominent in men as it is in women even though evidence suggests that for both genders, the numbers are underreported (Cargiulo 2007). As if the physical effects on the body were not bad enough, the behaviors of individuals who are addicted to alcohol are also quite dangerous. The drinkers find themselves to be less inhibited and more willing to engage in risky behaviors. Many of these behaviors can be characterized as aggressive and violent. In addition to the money that society has to pay for the medical care, it is also very costly to sort through all the social issues that alcoholism may create. Galvani (2004) gives several possible reasons why this risky and damaging behavior may occur in drinkers. Physiological theories argue that ethanol, the drug in alcohol increase aggression biologically. A theory known as Disinhibition Theory notes the earlier link between alcohol and cognitive function, specifically the portion of the brain mentioned above that regulates levels if inhibition. The Deviance Disavowal theory argues that the abusers use alcohol as a reason for their behavior and consciously drinks so that they can blame the alcohol for their actions. Social Learning theories explain that people will act in a way based on their experiences around others. Therefore, parents and societal expectations can lead to alcoholic abuse and abusive behaviors (Galvani, 2004). As with many ailments, more than one option for treatment exists. Many of these options can occur in conjunction with others. For years, behavior modification such as one might find in various 12 – Step Program or other similar programs have been the way of choice. These programs focus on the addicts significantly changing the way they behave in society including the people with whom they associate. Either a professional or a group of individuals led by a former addict facilitate the alcoholic’s recovery. Alcoholics Anonymous (AA), is an organization most known for its success rates for alcoholics’ recovery. It is available to anyone who desires its services. Lately increasing research evidence has found that a 12-step program affiliation is not only effective on its own, but even more effective along with professional, medical treatment, including residence based programs. The truth is, â€Å"Involvement with AA is consistently and positively associated with improved drinking outcomes, replicated across a large volume of studies using a variety of treatment methods† (Cloud, Zeigler and Blondell, 2004). The reason for this success is the three core items of AA: identification of self as a member, the number of steps completed, and the quantity of meetings attended (Cloud, Zeigler and Blondell, 2004). It can be a tiring process for an already worn individual. Because so many of these types of programs rely on frequent attendance by the alcoholics. One study sought to find the correlation, if any, between the duration of treatment and the level of intensity of the treatment. Moos and Moos (2003) conducted a study of 276 alcoholics who began formal treatment for alcohol abuse. These patients were involved with out-patient programs, residential programs, or a combination of the two. The average length of treatment was 20. 7 weeks, and the average intensity, or number of contacts, was 2. 8 contacts per week. These researchers first note that the individuals who had longer duration of treatment usually had less intense treatment. They found that patients who had a short treatment duration, which is considered 1-8 weeks, were more likely to abstain from alcohol than those who received no help whatsoever. If the treatment lasted for nine weeks or more, then the patient was even more likely to abstain from alcohol. This seems to suggest that the longer the treatment duration, the better the individual may respond to the treatment (Moos and Moos, 2003). However, recently the question has arisen as to whether or not recovering alcoholics must completely abstain from alcohol or not. Most programs, such as AA, or other groups perhaps affiliated with churches or in-patient and out-patient residential programs, build potential and motivation for success on complete life changes. These changes includes huge behavior shifts which focus on completely eliminating alcohol. Unfortunately, many people do not seek treatment because they don’t want to completely give up the occasional beer or social glass or wine. Humphries, Weingardt, and Hoyst (2005) agree and have encouraged programs like Moderation Management which do not force individuals to part with alcoholic beverages forever. Allowing a choice of goal may be one effective way to increase the numbers of people willing to enter alcohol treatment. It is estimated that as few as 10% of individuals with alcohol use disorders attend treatment; more flexible goals may appeal to a wider range of these people. There is also evidence that therapy can move people toward choosing a realistic drinking goal for themselves (Humphries, Weingardt, and Hoyst, 2005). On one side of this debate are those that argue in favor of abstinence. They say that the disease controls the individual and that this person will definitely lose control of they are exposed to alcohol, even a small amount . (Humphries, Weingardt, and Hoyst, 2005). Never drinking again is the surest way to â€Å"cure† this disease. Alcohol recovery patients are constantly reminded that they are and always will be an alcoholic, just like a diabetic always will be a diabetic. Opponents to the abstinence-only argument argue that people and their problems with alcohol are all different with different times of drinking and different levels of drinking. The researchers use the common phrase â€Å"different strokes for different folks† in describing this philosophy. While they agree that some problems require abstinence, but they allow that other individuals could moderate their drinking and still improve. They call this a â€Å"harm-reduction orientation toward alcohol problems† which â€Å"focuses less on the amount of alcohol consumed and more on helping individuals decrease the harms related to alcohol use. Although abstinence may be desirable, it is not the primary measure of successful outcomes† (Humphries, Weingardt, aned Hoyst, 2005). Some of the personal demographics of individuals who are more likely to experience success on non-abstinent programs include younger people, those with social and psychological stability, those who are regularly employed, and those who believe that they can seriously manage a moderate drinking program. However, if the patients are pregnant, experiencing liver problems, or are in the advanced stages of alcoholism, they may be forced to consider only the abstinence route (Humphries, Weingardt, and Hoyst, 2005). Another reason that some people avoid seeking treatment for alcoholism is their reluctance to commit to residential or in-patient treatment. Luckily, recent studies have indicated that outpatient treatment is effective in treating alcoholic dependency. Studies of this type have reported abstinence rates of 34-59% for 6 months post-treatment, 48 % for 19 to 24-month post-treatment and 52% for the 49-month post-treatment mark. In Bottlende and Soyka’s study of 2005, their rates were slightly higher for the six month mark at 64% abstaining, and 14 % significantly reducing their alcohol intake with a 22% rate of serious relapse. Perhaps, if people understood that they could get good results with a outpatient program, they would be more inclined to seriously consider treatment. Additionally, alcoholics do not need lengthy terms of treatment. Perhaps a brief commitment would do the trick for many with alcohol problems. â€Å"Brief interventions targeting alcohol consumption have been found to be very effective in changing clients’ consumption levels† (Roche and Freeman, 2004). One study cited by these researchers noted that heavy drinkers were likely to reduce the amount of alcohol they consumed six and twelve months after a brief intervention as compared with similarly heavy drinkers who received no interventions whatsoever: A WHO study conducted in eight countries involving over 1600 participants found that brief interventions reduced daily alcohol consumption on average by 17% and intensity of drinking by 10%. Brief interventions also reduce the number of alcohol-related problems, health-care utilization and associated treatment costs and the number of emergency department admissions. Brief interventions are also highly cost-efficient due to the minimal cost of the intervention and the breadth of scope for prevention of more serious and more costly problems (Roche and Freeman, 2004). However, the same benefits were not noted for women or for low consumers of alcohol who occasionally drank at very hazardous levels, also known as binge drinkers. Evidence suggests that â€Å"the majority of alcohol-related harms† affect these moderate to low drinkers who binge (Roche and Freeman, 2004). This study just shows that people do react differently to alcohol. One huge area of research in alcohol rehabilitation right now is in the area of gender. The above study mentioned that women do not receive the same level of benefits from brief interventions as men receive. This has led many researchers to fill the research gap between studies that focus on only males or on mixed genders and females. While women have a lower rate of substance abuse, those that are alcoholics suffer just as men do. In fact, women actually suffer more severe effects in some cases than men do. For example, women have more alcohol related health issues, â€Å"mental disorders, death rates, quicker addictions and greater social isolation and stigma† (Najavits, Rosier, and Nolan, 2007). This is unfortunate because women have become increasingly more addicted to alcohol at younger and younger years of age. However, studies also indicate that while in treatment, women show more rapid improvement and are more able to control impulsive behaviors that are so problematic for men (Najavits, Rosier, and Nolan, 2007). Of course, one rehabilitative method that is often overlooked in the search to rehabilitate alcoholics is the pharmacological method. While drugs are frequently use to aid in helping alcoholics avoid painful and dangerous withdrawal symptoms, others are now being marketed as treatment methods themselves. One such drug is Acamprosate which is a synthetic compound with a similar structure to that of the neurotransmitter GABA and the neuromodulator Taurine† (Scott, Figgitt, and Keam, 2005). Once the patient is detoxified, Acomprosate helps the patient maintain abstinence in the place of rehabilitation programs. This way, individuals can maintain his social and professional life. Several studies found this to be true a year after use had begun â€Å"irrespective of disease severity or the type of psychosocial support† (Scott, Figgitt, and Keam, 2005) the patient received. Also, the drug appears to pose few tolerance issues such as nausea, diarrhea or the like. A second prescription medication is available for the treatment of alcoholism. Naltrexone has also produced very positive results in promoting abstinence among recovering alcoholics. This drug has also had several positive research trials and works better in conjunction with behavioral therapy. One way this drugs works is to result in a reduced urge to drink and negative physical side effects if it is taken in conjunction with alcohol (Rohsenow, 2004). Alcoholism is a horrible, addictive disease that leads not only to medical problems such as brain and liver problems, but also to psychological problems, social problems and even violent behavior. The disease affects individuals differently, and new approaches are always being considered to treat each sufferer. While abstinence only and residential programs seem to have prevailed in the past, the new approaches are leaning to more brief, outpatient programs and interventions that support both abstinence and moderation when it comes to alcohol consumption. These new programs also take into account differences that result from race and gender. With hope, this disease will soon be tamed, or even eradicated, with better and better rehabilitation programs. . References Bottlender, M. Soyka, M. (2005). Efficacy of an Intensive Outpatient Rehabilitation Program in Alcoholism: Predictors of Outcome 6 Months after Treatment. European Addiction Research 11 (3): 132-137. Cargiulo, T. (2007). Understanding the health impact of alcohol dependence. American Journal of Health-System Pharmacy 64: S1-S17 Cloud, RN, Ziegler, CH, Blondell, RD. What is Alcoholics Anonymous Affiliation? Substance Use Misuse 39(7), 2004: 1117-1136 Galvani, S. (2004). Responsible disinhibition: Alcohol, men and violence to women. Addiction Research Theory 12 (4): 357-371 Humphreys, K, Weingardt, KR, Horst, D. Prevalence and predictors of research participant eligibility criteria in alcohol treatment outcome studies, 1970-98. Addiction 100(9), Sep 2005: 1249-1257 Moos, RH Moos BS. Long-term influence of duration and intensity of treatment on previously untreated individuals with alcohol use disorders. Addiction 98 (3), March 2003: 325-337. Najavits, LM, Rosier, M, Nolan, AL. (2007). A New Gender-Based Model for Women’s Recovery From Substance Abuse: Results of a Pilot Outcome Study. American Journal of Drug and Alcohol Abuse 33(1), 2007: 5-11 Roche, AM Freeman, T. (2004). Brief interventions: Good in theory but weak in practice. Drug and Alcohol Review 23(1):11-18. Rohsenow, Damaris J. (2004). What Place Does Naltrexone Have in the Treatment of Alcoholism? CNS Drugs 18(9): 547-560. Scott, LJ, Figgitt, DP, and Keam, SJ. (2005). Acamprosate: A Review of its Use in the Maintenance of Abstinence in Patients with Alcohol Dependence. CNS Drugs 19(5): 445- 464 Shoemaker, W. (2003). Alcohol’s Effects on the Brain. Nutritional Health Review: The Consumer’s Medical Journal 88: How to cite Alcoholism And Rehabilitation, Papers

Rugby School Essay Example

Rugby School Paper Salman Rushdie was born in Bombay, India to a Muslim family. At the age of fourteen Rushdie was sent to Rugby School in England. In 1964 Rushdies parents moved to Karachi, Pakistan. During this time there was a war between India and Pakistan, and the choosing of sides. Rushdie wrote his novel East, West based on the cultural similarities and difference and the relationship between east and the west. The theme of his work shows many connections, disruptions, migrations and shows the contrast between the religion, influence and identity between the Eastern and Western world. The first three stories are set in India; they involve the section titled East. In the short story The Free Radio Rushdie shows a comparison between the Indian society, its classes and its backwardness. The main priority of the Indian lower caste people being wanting to rise above all even if it means giving up their manhood. The story is about, a young boy, Ramani(symbolizes the Indian people) who is characterized as a teenage boy, and gets married to a thiefs widow(Indira Gandhi), who looks only for his downfall. Ramani, who is uneducated and is from the lower caste society, gives up his manhood in order to get a free radio which was promised, but never arrives. During the time of the Emergency (1975-1977) the basic rights and freedoms were taken away from the people. India had problems with over population hence, men were forced to give up their manhood (vasectomy) if not voluntarily then they will be forced to do so. We will write a custom essay sample on Rugby School specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Rugby School specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Rugby School specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Ramani in this case who did this voluntarily showed that the lower caste society would do anything for a little money or satisfaction, they also dont think about their actions and consequences and does things willingly and not ready to accept what they did was wrong. This proves that Indira Gandhi was trying to destroy the lower caste society since they werent of much use. This is an image of no unity among the people of India they did what they thought was best for them. They were so driven by the idea of having a free radio that didnt exist. The radio could also be a symbol of the unity of India. Since thats the only medium in which they can communicate. Since it wasnt possible to get the free radio it meant that it was never possible to achieve unity among the people. Ram always had the rare quality of total belief in his dreams, and there were times when his faith in the imaginary radio took us in, so that we half-believed it was really on its way, or even that it was already here, cupped invisibly against his ear as he rode his rickshaw around the streets of the town. (Rushdie. East, West. 27). This meant that there was a dream that was believed by everyone but for the benefit of one person everything could be destroyed. The tone of this story is like of a fable. He uses this tone because it was a way of showing what happened in India was wrong and it didnt do much good to people or the nation. And it is written in a way that he lets you decide if what happened was right or wrong. The diction and syntax in the stories of the east is that of an Indian lower class English that was influenced by the british and many words are derived from hindi/Arabic or Sanskrit like pukka.

Free Essays on Oil Changing For Dummies

Oil Changing for Dummies So, you have decided to do a little maintenance on your vehicle, and change the oil yourself? Great! You don’t know where to start? Let me tell you and hopefully you will be able to successfully change the oil and save a few dollars at the same time. First and foremost is safety. It is very important that you have all the safety equipment, properly working tools, and an extra adult around to call for help or just as an extra set of hands. Safety equipment should include the following: safety goggles, gloves to protect your hands from excessive exposure to the hot oil, shop rags, the proper oil collection pan, and container(s) that can be taken to your local oil recycling center or service station. You want to save both yourself and the environment for another day. Your tools should be clean, free from rust and other damage. Also, your work area should also be clean and on level ground; cement is preferable rather than gravel, as you will be lying on it. Secondly, assemble all the tools and parts you’ll need, as well as having your owner’s manual on hand to be able to find the engine and oil pan components that you’ll be working on. Tools that are recommended are the following: car ramps, oil filter wrench, socket wrench that fits the oil plug, a â€Å"Jeepers Creeper† shop cart to roll around on when you do the undercarriage work, and clean shop rags. You will need to have the manufacturer’s recommended weight of oil and enough quarts of that weight for your vehicle. You’ll need the correct size of oil filter, as well. Your local car parts store will be happy to help if you cannot find the information in your manual. Now, with your partner’s assistance, carefully place the car ramps in front of the automobile and slowly drive up them. Keep in mind, though, that the more the engine has run, the hotter the oil. You may want to let it cool for a few moments and let all the oi... Free Essays on Oil Changing For Dummies Free Essays on Oil Changing For Dummies Oil Changing for Dummies So, you have decided to do a little maintenance on your vehicle, and change the oil yourself? Great! You don’t know where to start? Let me tell you and hopefully you will be able to successfully change the oil and save a few dollars at the same time. First and foremost is safety. It is very important that you have all the safety equipment, properly working tools, and an extra adult around to call for help or just as an extra set of hands. Safety equipment should include the following: safety goggles, gloves to protect your hands from excessive exposure to the hot oil, shop rags, the proper oil collection pan, and container(s) that can be taken to your local oil recycling center or service station. You want to save both yourself and the environment for another day. Your tools should be clean, free from rust and other damage. Also, your work area should also be clean and on level ground; cement is preferable rather than gravel, as you will be lying on it. Secondly, assemble all the tools and parts you’ll need, as well as having your owner’s manual on hand to be able to find the engine and oil pan components that you’ll be working on. Tools that are recommended are the following: car ramps, oil filter wrench, socket wrench that fits the oil plug, a â€Å"Jeepers Creeper† shop cart to roll around on when you do the undercarriage work, and clean shop rags. You will need to have the manufacturer’s recommended weight of oil and enough quarts of that weight for your vehicle. You’ll need the correct size of oil filter, as well. Your local car parts store will be happy to help if you cannot find the information in your manual. Now, with your partner’s assistance, carefully place the car ramps in front of the automobile and slowly drive up them. Keep in mind, though, that the more the engine has run, the hotter the oil. You may want to let it cool for a few moments and let all the oi...

Joseph Michael Swango, Serial Killer Profile and Biography

Joseph Michael Swango, Serial Killer Profile and Biography Joseph Michael Swango is a serial killer who, as a trusted doctor, had easy access to his victims. Authorities believe he murdered up to 60 people and poisoned countless others, including co-workers, friends and his wife. Childhood Years Michael Swango was born on October 21, 1954, in Tacoma, Washington, to Muriel and John Virgil Swango. He was the middle son of three boys and the child that Muriel believed was the most gifted. John Swango was an Army officer which meant the family was constantly relocating. It was not until 1968, when the family moved to Quincy, Illinois, that they finally settled down. The atmosphere in the Swango home depended on whether or not John was present. When he was not there, Muriel tried to maintain a peaceful home, and she kept a strong hold on the boys. When John was on leave and at home from his military duties, the home resembled a military facility, with John as the strict disciplinarian. All of the Swango children feared their father as did Muriel.  His struggle with alcoholism was the main contributor to the tension and upheaval that went on in the home. High School Concerned that Michael would be under-challenged in the public school system in Quincy, Muriel decided to ignore her Presbyterian roots and enrolled him in the Christian Brothers High School, a private Catholic school known for its high academic standards. Michaels brothers attended the public schools. At Christian Brothers, Michael excelled academically and became involved in various extracurricular activities. Like his mother, he developed a love of music and learned to read music, sing, play the piano, and mastered the clarinet well enough to become a member of the Quincy Notre Dame band and tour with the Quincy College Wind Ensemble. Millikin University Michael graduated as class valedictorian from Christian Brothers in 1972. His high school achievements were impressive, but his exposure to what was available for him in selecting the best colleges to attend to was limited. He decided on Millikin University in Decatur, Illinois, where he received a full music scholarship. There Swango maintained top grades during his first two years, however, he became an outcast from social activities after his girlfriend ended their relationship. His attitude became reclusive. His outlook changed. He exchanged his collegiate blazers for military fatigues. During the summer after his second year at Millikin, he stopped playing music, quit college and joined the Marines. Swango became a trained  sharpshooter for the Marines, but decided against a military career. He wanted to return to college and become a doctor. In 1976, he received an honorable discharge. Quincy College Swango decided to attend Quincy College to earn a degree in chemistry and biology. For unknown reasons, once accepted into the college, he decided to embellish his permanent records by submitting a form with lies stating that he had earned a Bronze Star and the Purple Heart while in the Marines. In his senior year at Quincy College, he elected to do his chemistry thesis on the bizarre poisoning death of Bulgarian writer  Georgi Markov. Swango developed an obsessive interest in poisons that could be used as silent killers. He graduated  summa cum laude from Quincy College in 1979. With an award for academic excellence from the American Chemical Society tucked under his arm, Swango set out to get accepted into medical school, a task that was not so simple during the early 1980s. At that time, there was fierce competition among a massive number of applicants trying to get into a limited amount of schools throughout the country. Swango managed to beat the odds and he got into Southern Illinois University (SIU). Southern Illinois University Swangos time at SIU received mixed reviews from his professors and fellow classmates. During his first two years, he earned a reputation for being serious about his studies but was also suspected of taking unethical shortcuts when preparing for tests and group projects. Swango had little personal interaction with his classmates after he began working as an ambulance driver. For a first-year medical student struggling with tough academic demands, such a job caused great stress. In his third year at SIU, the one-on-one contact with patients increased. During this time, there were at least five patients that died after they had just received a visit from Swango. The coincidence was so great, that his classmates began to call him Double-O Swango, a reference to the James Bond and the license to kill slogan. They also began to view him as incompetent, lazy and just strange. Obsessed With Violent Death From the age of three, Swango showed an unusual interest in violent deaths. As he got older, he became fixated on stories about the  Holocaust, particularly those that contained pictures of the death camps. His interest was so strong that he began to keep a scrapbook of pictures and articles about fatal car wrecks and macabre crimes. His mother would also contribute to his scrapbooks when she came across such articles. By the time Swango attended SIU, he had put together several scrapbooks. When he took the job as an ambulance driver, not only did his scrapbooks grow, but he was seeing firsthand what he had only read about for so many years. His fixation was so strong that he would rarely turn down the chance to work, even if it meant sacrificing his studies. His classmates felt that Swango showed more dedication to making a career as an ambulance driver than he did for getting his medical degree. His work had become sloppy and he often left unfinished projects because his beeper would go off, signaling him that the ambulance company needed him for an emergency. The Final Eight Weeks In Swangos final year at SIU, he sent off applications for internships and residency programs in neurosurgery to several teaching colleges. With the help of his teacher and mentor, Dr. Wacaser, who was also a neurosurgeon, Swango was able to provide the colleges with a letter of recommendation. Wacaser even took the time to write a handwritten personal note of confidence on each letter. Swango was accepted in neurosurgery at the University of Iowa Hospitals and Clinics in Iowa City. Once he nailed down his residency, Swango showed little interest in his remaining eight weeks at SIU. He failed to show up for required rotations and to watch specific surgeries performed. This astounded Dr. Kathleen OConnor who was in charge of overseeing Swangos performance. She called his place of employment to schedule a meeting to discuss the matter. She did not find him, but she did learn that the ambulance company no longer permitted Swango to have direct contact with patients, although the reason why was not disclosed. When she finally did see Swango, she gave him the assignment to perform a complete history and examination on a woman who was going to have a  cesarean delivery. She also observed him entering the womans room and leaving after just 10 minutes. Swango then turned in a very thorough report on the woman, an impossible task given the amount of time he was in her room. OConnor found Swangos actions reprehensible and the decision to fail him was made. It meant that he would not be graduating and his internship in Iowa would be canceled. As the news spread about Swango not graduating, two camps were formedthose  for and those against SIUs decision. Some of Swangos classmates who had long decided that he was not fit to be a doctor used the opportunity to sign off on a letter describing Swangos incompetence and poor character. They recommended that he be expelled. Had Swango not hired a lawyer, it is likely that he would have been expelled from SIU, but shrinking from the fear of being sued and wanting to avoid the costly expense of litigation, the college decided to postpone his graduation by a year and give him another chance, but with a strict set of rules that he had to follow. Swango immediately cleaned up his act and refocused his attention on completing the requirements to graduate. He reapplied to several residency programs, having lost the one in Iowa. Despite having an extremely poor evaluation from the dean of ISU, he was accepted into a surgical internship, followed by a very prestigious residency program in neurosurgery at Ohio State University. This left many who knew Swangos history completely dumbfounded, but he apparently aced his personal interview and was the only student out of sixty accepted into the program. Around the time of his graduation, Swango was fired from the ambulance company after he told a man having a heart attack to walk to his car and have his wife drive him to the hospital. Deadly Compulsion Swango began his internship at Ohio State in 1983. He was assigned to the Rhodes Hall wing of the medical center. Shortly after he began, there was a series of unexplained deaths among several healthy patients being cared for in the wing. One of the patients who survived a severe seizure told the nurses that Swango had injected medicine into her just minutes before she became critically ill. Nurses also reported to the head nurse their concerns about seeing Swango in patients rooms during odd times. There were numerous occasions when patients were found near death or dead just minutes after Swango left the rooms. The administration was alerted and an investigation was launched, however, it seemed as if it was designed to discredit the eyewitness reports from the nurses and patients so that the matter could be closed and any residual damage curbed. Swango was exonerated  of any wrongdoing. He returned to work, but was moved to the Doan Hall wing. Within days, several patients on the Doan Hall wing began to die mysteriously. There was also an incident when several residents became violently ill after Swango offered to go get fried chicken for everyone. Swango also ate the chicken but did not get sick. License to Practice Medicine In March 1984, the Ohio State residency review committee decided that Swango did not have the necessary qualities needed to become a neurosurgeon. He was told he could complete his one-year internship at Ohio State, but he was not invited back to complete his second year of residency. Swango stayed on at Ohio State until July 1984 and then moved home to Quincy. Before moving back he applied to get his license to practice medicine from the Ohio State Medical Board, which was approved in September 1984. Welcome Home Swango did not tell his family about the trouble he encountered while at Ohio State or that his acceptance into his second-year residency had been rejected. Instead, he said he did not like the other doctors in Ohio. In July 1984, he began working for Adams County Ambulance Corp as an emergency medical technician. Apparently, a background check was not done on Swango because he had worked there in the past while attending Quincy College. The fact that he had been fired from another ambulance company never surfaced. What did begin to surface was Swangos weird opinions and behavior. Out came his scrapbooks filled with references to violence and gore, which he doted on regularly. He began making inappropriate and strange comments related to death and people dying. He would become visibly excited over CNN news stories about mass killings and horrific auto accidents. Even to hardened paramedics that had seen it all, Swangos lust for blood and guts was downright creepy. In September the first noticeable incident that Swango was dangerous occurred when he brought doughnuts for his co-workers. Everyone who ate one ended up becoming violently ill and several had to go to the hospital. There were other incidents where co-workers became ill after eating or drinking something Swango had prepared. Suspecting that he was purposely making them ill, some of the workers decided to get tested. When they tested positive for poison, a police investigation was launched. The police obtained a search warrant for his home and inside they found hundreds of drugs and poisons, several containers of ant poison, books on poison, and syringes. Swango was arrested and charged with battery. The Slammer On August 23, 1985, Swango was convicted of aggravated battery and he was sentenced to five years behind bars. He also lost his medical licenses from Ohio and Illinois. While he was in prison, Swango began trying to mend his ruined reputation by doing an interview with John Stossel who was doing a segment about his case on the ABC program,? 20/20. Dressed in a suit and tie, Swango insisted that he was innocent and said that the evidence that was used to convict him lacked integrity. A Cover Up Exposed As part of the investigation, a look into Swangos past was conducted and the incidents of patients dying under suspicious circumstances at Ohio State resurfaced. The hospital was reluctant to allow the police access to their records. However, once the global news agencies got wind of the story, the university president, Edward Jennings, assigned the dean of Ohio State University Law School, James Meeks, to conduct a full investigation to determine if the situation surrounding Swango had been handled properly. This also meant investigating the conduct of some of the most prestigious people in the university. Offering an unbiased assessment of the events that had occurred, Meeks concluded that legally, the hospital should have reported the suspicious incidents to the police because it was their job to decide if any criminal activity had occurred. He also referred to the initial investigations performed by the hospital as superficial. Meeks also pointed out that he found it astounding that the hospital administrators had not kept a permanent record detailing what had occurred. Once full disclosure was obtained by police, the prosecutors from Franklin County, Ohio, toyed with the idea of charging Swango with murder and attempted murder, but due to a lack of evidence, they decided against it. Back on the Streets Swango served two years of his five-year sentence and was released on August 21, 1987. His girlfriend, Rita Dumas, had fully supported Swango throughout his trial and during his time in prison. When he got out the two of them moved to Hampton, Virginia. Swango applied for his medical license in Virginia, but because of his criminal record, his application was denied. He then found employment with the state as a career counselor, but it was not long before weird things began to happen. Just like what happened in Quincy, three of his co-workers suddenly experienced severe nausea and headaches. He was caught gluing gory articles into his scrapbook when he should have been working. It was also discovered that he had turned a room in the office building basement into a kind of bedroom where he often stayed for the night. He was asked to leave in May 1989. Swango then went to work as a lab technician for Aticoal Services in Newport News, Virginia. In July 1989, he and Rita got married, but almost immediately after exchanging vows, their relationship began to unravel. Swango began ignoring Rita and they stopped sharing a bedroom. Financially he refused to contribute to the bills and took money out of Ritas account without asking. Rita decided to end the marriage when she suspected that Swango was seeing another woman. The two separated in January 1991. Meanwhile, at Aticoal Services several employees, including the president of the company, began suffering from sudden bouts of severe stomach cramping, nausea, dizziness, and muscle weakness. Some of them were hospitalized and one of the executives of the company was nearly comatose. Unphased by the wave of illnesses going around the office, Swango had more important issues to work out. He wanted to get his medical license back and start working as a doctor again. He decided to quit the job at Aticoal and started applying at residency programs. Its All in the Name At the same time, Swango decided that, if he was going to get back into the medicine, he would need a new name. On January 18, 1990, Swango had his name legally changed to David Jackson Adams. In May 1991, Swango applied for the residency program at Ohio Valley Medical Center in Wheeling, West Virginia. Dr. Jeffrey Schultz, who was the chief of medicine at the hospital, had several communications with Swango, mainly centering on the events surrounding the suspension of his medical license. Swango lied about what had happened, downplaying the battery by poisoning conviction, and said instead that he was convicted for an altercation he was involved in at a restaurant. Dr. Schultz opinion was that such a punishment was far too severe so he continued to try to verify Swangos account of what happened. In return, Swango forged several documents, including a prison fact sheet which stated that he had been convicted of hitting someone with his fists. He also forged a letter from the Governor of Virginia stating that his application for Restoration of Civil Rights had been approved. Dr. Schultz continued to try to verify the information that Swango had provided to him and forwarded a copy of the documents to the Quincy authorities. The correct documents were forwarded back to Dr. Schultz who then made the decision to reject Swangos application. The rejection did little to slow down Swango who was determined to get back into medicine. Next, he sent an application to the residency program at the University of South Dakota. Impressed by his credentials, the director of the internal medicine residency program, Dr. Anthony Salem, opened up communications with Swango. This time Swango said the battery charge involved poison, but that coworkers who were jealous that he was a doctor had framed him. After several exchanges, Dr. Salem invited Swango to come for a series of personal interviews. Swango managed to charm his way through most of the interviews and on March 18, 1992, he was accepted into the internal medicine residency program. Kristen Kinney While he was employed at Aticoal, Michael had spent time taking medical courses at the Newport News Riverside Hospital. It was there that he met Kristen Kinney, to whom he was immediately attracted to and aggressively pursued. Kristen, who was a nurse at the hospital, was quite beautiful and had an easy smile. Although she was already engaged when she met Swango, she found him attractive and very likable. She ended up calling off her engagement and the two began dating regularly. Some of her friends felt it was important that Kristen know about some of the dark rumors they had heard about Swango, but she did not take any of it seriously. The man she knew was nothing like the man they were describing. When it came time for Swango to move to South Dakota to begin his residency program, Kristen immediately agreed that they would move there together. Sioux Falls At the end of May, Kristen and Swango moved to Sioux Falls, South Dakota. They quickly established themselves in their new home and Kristen got a job in the intensive care unit at the Royal C. Johnson Veterans Memorial Hospital. This was the same hospital where Swango began his residency, although no one was aware that the two knew each other. Swangos work was exemplary and he was well liked by his peers and the nurses. He no longer discussed the thrill of seeing a violent accident nor did he exhibit the other oddities in his character that had caused problems at other jobs. Skeletons in the Closet Things were going great for the couple until October when Swango decided to join the American Medical Association. The AMA did a thorough background check and because of his convictions, they decided to turn it over to the council on ethical and judicial affairs. Someone from AMA then contacted their friend, the dean of the University of South Dakota medical school, and informed him of all of the skeletons in Swangos closet, including the suspicions surrounding the death of several patients. Then on the same evening, The Justice Files television program aired the 20/20 interview that Swango had given while he was in prison. Swangos dream of working as a doctor again was over. He was asked to resign. As for Kristen, she was in shock. She was completely ignorant of Swangos true past until she watched a tape of the 20/20 interview in Dr. Schultz office on the day Swango was being questioned. In the following months, Kristen began to suffer from violent headaches. She no longer smiled and began to withdraw from her friends at work. At one point, she was placed in a psychiatric hospital after the police found her wandering in the street, nude and confused. Finally, in April 1993, unable to take it anymore, she left Swango and returned to Virginia. Soon after leaving, her migraines went away. However, just a few weeks later, Swango showed up on her doorstep in Virginia and the two were back together. With his confidence restored, Swango began sending out new applications to medical schools. Stony Brook School of Medicine Incredibly, Swango lied his way into the psychiatric residency program at the State University of New York at Stony Brook School of Medicine. He relocated, leaving Kristen in Virginia, and began his first rotation in the internal medicine department at the VA Medical Center in Northport, New York. Again, patients began to mysteriously die wherever Swango worked. Suicide Kristen and Swango had been apart for four months, although they continued to talk on the phone. During the last conversation that they had, Kristen learned that Swango had emptied out her checking account. The next day, July 15, 1993, Kristen committed suicide by shooting herself in the chest. A Mothers Revenge Kristens mother, Sharon Cooper, hated Swango and blamed him for her daughters suicide. She found it inconceivable that he was working at a hospital again. She knew the only way he got in was by lying and she decided to do something about it. She contacted a friend of Kristens who was a nurse in South Dakota and included his full address in the letter stating that she was glad that he could not hurt Kristen anymore, but she was afraid of where he was working now. Kristens friend clearly understood the message and immediately passed along the information to the right person who contacted the dean of the medical school at Stony Brook, Jordan Cohen. Almost immediately Swango was fired. To try to prevent another medical facility from being duped by Swango, Cohen sent letters to all the medical schools and over 1,000 teaching hospitals in the country, warning them about Swangos past and his sneaky tactics to gain admission. Here Come the Feds After being fired from the VA hospital, Swango seemingly went underground. The FBI was on the hunt for him for falsifying his credentials in order to get a job in a VA facility. It was not until July 1994 that he resurfaced. This time he was working as Jack Kirk for a company in Atlanta called Photocircuits. It was a wastewater treatment facility and frighteningly, Swango had direct access to Atlantas water supply. Fearing Swangos obsession over mass killings, the FBI contacted Photocircuits and Swango was immediately fired for lying on his job application. At that point, Swango seemed to vanish, leaving behind a warrant for his arrest issued by the FBI. Africa Swango was smart enough to realize that his best move was to get out of the country. He sent his application and altered references to an agency called Options, which helps American doctors find work in foreign countries. In November 1994, the Lutheran church hired Swango after obtaining his application and falsified recommendations through Options. He was to go to a remote area of Zimbabwe. The hospital director, Dr. Christopher Zshiri, was thrilled to have an American doctor join the hospital, but once Swango began working it became apparent that he was untrained to perform some very basic procedures. It was decided that he would go to one of the sister hospitals and train for five months, and then return to Mnene Hospital to work. For the first five months in Zimbabwe, Swango received glowing reviews and almost everyone on the medical staff admired his dedication and hard work. But when he returned to Mnene after his training, his attitude was different. He no longer seemed interested in the hospital or his patients. People whispered about how lazy and rude he had become. Once again, patients began mysteriously dying. Some of the patients that survived had a clear recall about Swango coming to their rooms and giving them injections right before they went into convulsions. A handful of nurses also admitted to seeing Swango near patients just minutes before they died. Dr. Zshiri contacted the police and a search of Swangos cottage turned up hundreds of various drugs and poisons. On October 13, 1995, he was handed a termination letter and he had a week to vacate hospital property. For the next year and a half, Swango continued his stay in Zimbabwe while his lawyer worked to have his position at the Mnene hospital restored and his license to practice medicine in Zimbabwe reinstated. He eventually fled Zimbabwe to Zambia when evidence of his guilt began to surface. Busted On June 27, 1997, Swango entered the U.S. at the Chicago-OHare airport while in route to the Royal Hospital in Dhahran in Saudi Arabia. He was promptly arrested by immigration officials and held in prison in New York to await his trial. A year later Swango pleaded guilty to defrauding the government and he was sentenced to three years and six months in prison. In July 2000, just days before he was to be released, federal authorities charged Swango with one count of assault, three counts of murder, three counts of making false statements, one count of defrauding by use of wires, and mail fraud. In the meantime, Zimbabwe was fighting to have Swango extradited to Africa to face five counts of murder. Swango pleaded not guilty, but fearing that he could be facing the death penalty on being handed over to the Zimbabwe authorities, he decided to change his plea to guilty of murder and fraud. Michael Swango received three consecutive life sentences. He is currently serving his time at the supermax U.S. Penitentiary, Florence ADX.

Rwandan genocide Essay Example | Topics and Well Written Essays - 3750 words

Rwandan genocide - Essay Example They made a clear explanation that this was meant for ethnic distinction. In most cases, they considered the Tutsi to be superior to the rest of the population and replaced the Hutu leaders with the Tutsi. Later in1950s, the Belgians altered their support for the Tutsi elites; they opted to support the Hutus who were the majority. These changes came as a result of several events, it included influential priests who were active politically and were supporting revolution. The second event was the movement of liberation in the Africa and European colonies. The third event was the rebellion from the Tutsi dominated National Rwandese Union (Union Nationale Ruandaise, UNAR). They were against the Belgian rule and supported the monarchy rule. They wanted an immediate independence from the foreigners. The Belgians chose to support the PARMEHUTU (The Party for the Emancipation of the Hutus). In 1959, the Tutsi leader Mwaami Rudahigwa died immediately, the Hutus rose in rebellion killing sever al Tutsis. Those who died were estimated to be ten to one hundred thousand. However, Belgians did not intervene. Several refugees fled the country. In 1961, the Belgians pushed for elections and Gregoire Kayibanda, the leader of PARMEHUTU, came to power as the first president of Rwanda. In the same year, the country was declared independent, and it was granted formally in 1962. In an attempt to regain power, the Tutsi refugees from the neighboring countries organized major attacks between 1961 and 1964. Each attack resulted in a massacre of Tutsis who were still in the country. In 1973, Kayibanda was overthrown by Juvenal Habyarimana, the then Major General of the Army through a military coup. Kayibanda had ruled unfairly and favored Hutus from the southern Rwanda where he came from. This created the difference between the Hutus of the south and those of the northwest. Habyarimana came from the North West. He introduced a quota system in several institutions which included education and the government in an attempt of â€Å"fairness†. He decreed that the Tutsi’s percentage in schools, government offices and military should not be more than the percentage of the Tutsis population which was 9%. A census was organized for the definition of this percentage, and identity cards were re-issued indicating one’s ethnicity. The identity cards were vital tools used during the genocide. In 1990, Rwanda was attacked from the north by rebel group which known as the Rwandan Patriotic Front (RPF). Its composition was several refugees from the Uganda, Burundi, Tanzania, and Zaire. Fred Rwigyema who was the rebel’s group leader died and was replaced by Paul Kagame who was his close ally from the Ugandan National Resistance Army. Even though most members of the group died due to harsh conditions, the rebels who were disciplined and had appropriate training were a significant threat to the government. According to Lemarchand (2009), the most extreme el ements of the Hutu elite formed Coalition for the Defense of the Republic (CDR). It comprised of the akazu a group that surrounded Habyarimana’s wife Madame Agathe Kanziga. The majority were close family members and friends from Ruhengiri and Gisenyi. They formed civilian militias known as the interahamwe. They had extreme racist ideas and increased fear among the Tutsi. According to Jones, (2010), the Hutu manifesto was published in December 1990 in Kangura newspaper that belonged to

Health Care Provider and Faith Diversity Essay Example | Topics and Well Written Essays - 1000 words - 1

Health Care Provider and Faith Diversity - Essay Example There are numerous similarities and differences among all religions. Religions portray some sort of symbol or icon which they worship but cannot see. Every religion teaches non-violence as well as sacred beliefs. They all entail beliefs in a god or gods and that they all have a final destination. This paper will research three diverse faiths and compare the viewpoint of providing healthcare from the perception of each of these faiths with that of the Christian perspective and my own personal perspective. Health Care Provider and Faith Diversity Introduction Healing is thought as something that originates from medical science, but many religions are now looming on different spiritual or religious beliefs to cater for the healing process of their faithful (O’Brien, 2011). For individuals in the health care industry, it is essential to understand basic spiritual and religious beliefs because they offers more insight into how patients process and perceive their diseases or illness es. Christianity There are numerous religious practices and beliefs depending on an individual, denomination or church. In spite of the varying principles, there are numerous common practices among Christians today (O’Brien, 2011). A majority of Christians are baptized and take the Holy Communion. These are sacred beliefs, which a majority of Christians practice. ... Through asking for forgiveness and God’s intervention, Christians believe that the illness will disappear. Many Christians will first attempt spiritual healing prior to trying surgery or medical healing. Even though Christians opt for divine intervention when dealing with illnesses, they also consider medical intervention as a vital tool for healing (O’Brien, 2011). Christianity has a significant influence throughout the globe. Christianity is also one of the most dominant religions currently. Health care providers, therefore, need to understand the beliefs and doctrines of Christians. Buddhism Buddhism, just like numerous other religions, has different traditions. However, there are several principles that are shared by Buddhists and other religions. Buddhists strive for peace, love and fullness throughout their lives (Bloom, 2011). They use prayers as a tool of regaining mental stability and healing. When Buddhists pray, they must attach four points of their body to t he ground. A majority of Buddhists, for instance, attach the knees and the elbows to the ground when saying their prayers. The touching of the ground with four points symbolizes the heroes in the Buddhists religions. The first and foremost priority in their life is God. The second one is conceding to their ancestors. Their third priority is paying respect to their parents and guardians. Finally, their fourth priority is paying tribute to any teacher in their lives. Buddhists do not believe in evil things (Bloom, 2011). Normally, they are satisfied but do not consider whether a person has done a good or evil thing during his/her lifetime. Buddhists consider healthcare workers to be second to God. Healthcare providers are, therefore, widely respected in the Buddhist spiritual world and religion.

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