Materials and Corrosion Essay Example | Topics and Well Written Essays - 1750 words

Materials and Corrosion - Essay Example Crevice Corrosion Corrosion occurring within or adjacent to crevices, which are commonly left at joints, due to small volumes of stagnant corroding fluids is known as crevice corrosion. The most important feature of this type of corrosion is the contact with stagnant solution which takes place in interstices, near seals and in cervices made for nuts and rivet heads. The metals and alloys used in chemical plants and other industrial applications are covered with passive films of protective coatings in order to prevent contact with high concentrations of Cl- and H+ ions. When such places are left unclean for long durations after long usages of the plant, sand and other substances also get deposited near metals and alloys which prevent the proper application of protective coatings. In such a scenario the crevices and interstices are more likely to come in direct contact with corroding media. The corroding fluids which commonly contains high concentrations of chloride ion is likely to ge t accumulated in the crevices made for nuts, rivets or any other type of hole. The prolonged contact with such chemical fluids starts the oxidation of the metals. The direct contact with aerated chloride rich media creates a differential aeration cell which destroys the passivity of the material. The oxidized metal starts dissolving into the chemical which is in contact with the metal, in the presence of oxygen and the prolonged contact can corrode the material completely. The best way to prevent crevice corrosion is to prevent crevice corrosion is to prevent crevices. This can be done by using welds in place of bolts and rivets in joints. The design of various components should be done in such a way that there is always a drainage mechanism for the accumulating fluid so that the harmful corroding liquids do not come in contact with the metals for long duration of time. Other effective means of preventing crevice corrosion is the use of corrosion inhibitors and coatings, some of whi ch are discussed below. Inhibitors 1. VpCl-337 which is a vapor phase corrosion inhibitor is also very effective for preventing crevice corrosion. The crevices are fogged by the material and thus large areas of material are coated against corrosion. 2. Ecoline 3690 which is a biodegradable and bio based inhibitor is also very effective for using for crevice corrosion prevention because of its ability to displace moisture and provide protection against aggressive environments. It is very suitable for use in marine environment and high humidity conditions. 3. VCI (Vapor Corrosion Inhibitor) Foam is also a very useful inhibitor for preventing crevice corrosion. It can be used in the form of a foam pad cut into the size of the space where it is to be used. It is very easy to apply as compared to other vapor inhibitors. 4. VCI 2000 is particularly useful in pipes as it can be applied on the crevices on pipes during fabrication. Protective Coatings 1. The most commonly used coating for cr evice corrosion is a mixture of PdO and TiO which is applied in the form of a 0.4 pm thick coating. The mixture is found effective in all kinds of conditions where there is a prolonged contact with chemical fluids. 2. Another coating which is present with a brand name of Reactive Gel (RG 2400) is also suitable for prevention of crevice

Information and Librarians in the Digitial Age Personal Statement

Information and Librarians in the Digitial Age - Personal Statement Example I have always had faith in myself and in God to do what is best for me throughout my life. I had worked for the library during my high school and college years, starting as a page. My interest in libraries began here that while I was shelving books and skimming through the pages, I discovered the love for books and reading. My longevity with one organization has taught me to work as a team player, to communicate constructively, exhibit flexibility, handle problems and show commitment. Some strength I possess is that I am an energetic, highly motivated person which I think can make me survive the rigors of graduate work. I am a self-starter, who is able to take on new challenges. In order to achieve common goals, I am able to work well with others. My short-term goal is providing the best care for my son, Nasir. My family is very supportive of my going to graduate school, especially since I will be the first female from either side to attain a master's degree. My long-term dream has been to pursue a Master's degree in the Library field. My goal has been to learn a lot from my supervisors and co-workers on how libraries work throughout the years. I have always felt I would be a good leader and teacher. I have worked in the library field for eights years. I have loved libraries since I was a little girl, always looking up information. This love continued in college, where I worked as a page at DeKalb County Public Library, Decatur, Georgia. I wanted to be around books as much as possible. I enjoy library work because I have access to all the information in the world at my fingertips, in both print and electronic form. I learn something new every day, and Iinteract with people of all ages and from all walks of life. I use my interviewing and teaching skills, and I have learned indispensable computer skills as a bonus. Librarianship has been a good fit for me. What I like best about being a librarian is helping people use the library resources. I try to be outgoing by establishing eye contact with patrons and asking them if they need assistance. There is so much to teach the public about libraries, and there are so many resources available. From finding a book on the shelf to using the Internet, people need help, but they often don't ask for it. The librarian has to be outgoing. As I am a graduate of Bachelor of Science Degree in Computer Information Systems, I discovered that working in a library is a lot of fun. My job gives me an opportunity to use my information seeking skills as well as to indulge my web publishing and instruction interests. I feel now is the right time to pursue my degree. I want to develop my educational background and continue working in the library field. In order to move ahead in my career, I would need to obtain a degree to reflect my skill in working in this field. If in order, the program at UNT will provide me with the comprehension I need to become a librarian. If admitted into the UNT program, I would like to pursue administration. The librarian of today is not like the librarian of yesterday due to the impact of technology that has transformed the profession. Where before there were just printed materials in the library, now information highways through the use largely of the Internet is largely what the student has to deal with. Public libraries are busy, vibrant community centers that are open days, nights, weekends and even some holidays.

Marketing research proposal Essay Example | Topics and Well Written Essays - 2000 words - 1

Marketing research proposal - Essay Example It appears that this group is consuming other soft drinks in large quantities and is attracted to buying drinks for reasons other than quenching thirst. This report will outline how Pepsi-cola should conduct their research using qualitative and quantitative techniques in order to understand the current market trends. This will enable the brand to capture a larger share of the market. In Australia Pepsi competes with its main rival Coca Cola for a share of approximately $3.8Billion. It is estimated that market will continue to compound annually until 2016 by 2.5 percent. More recently market dynamics has changed with the introduction of a number of new healthier and trendy beverages. People are shifting to water and fruit drinks since these are perceived as healthier drinks. Energy drinks on the other hand are gaining popularity due to increase in their advertisement as alternative drinks. These lifestyle and behavioral changes where people are gradually shifting to taking drinks that they perceive to be healthier and trendy have adversely affected the overall sales of the Pepsi cola soft drink product line as illustrated in figure 1. As illustrated in figure 2, the largest consumer group for Pepsi is the 35-50 year old segment, however over the last ten years this group has declined, while the 50-60 year old group is showing increases. On the other hand the 18-35 year old segment has steadily declined. In other words Pepsi’s customer base is declining because of poor adoption rates in the youngest group and changes in the older group’s consumption behaviour. The question that Pepsi’s management faces is on how to reverse the decline in sales. Is it to change the advertising/communication strategy or to develop a new product that will capture the market change, that is, to produce a drink that people will perceive as healthy and

Different Types of Database Management System Essay Example for Free

Different Types of Database Management System Essay A database can be a set of flat files stored on computer tape or disk or it could consist of database tables that are managed by a Database Management System (DBMS). There are different types of DBMS products: relational, network and hierarchical, multidimensional, object. The most widely commonly used type of DBMS today is the Relational Database Management Systems (RDBMS). Database management systems (DBMS) are designed to use one of five database structures to provide simplistic access to information stored in databases. The five database structures are: the hierarchical model, he network model, the relational model, the multidimensional model, and the object model. Inverted lists and other methods are also used. A given database management system may provide one or more of the five models. The optimal structure depends on the natural organization of the applications data, and on the applications requirements, which include transaction rate (speed), reliability, maintainability, scalability, and cost. Hierarchical Model The hierarchical data model organizes data in a tree structure. There is a hierarchy of parent and child data segments. This structure implies that a record can have repeating information, generally in the child data segments. Data in a series of records, which have a set of field values attached to it. It collects all the instances of a specific record together as a record type. These record types are the equivalent of tables in the relational model, and with the individual records being the equivalent of rows. To create links between these record types, the hierarchical model uses Parent Child Relationships. These are a 1:N mapping between record types. This is done by using trees, like set theory used in the relational model, borrowed from maths. For example, an organization might store information about an employee, such as name, employee number, department, salary. The organization might also store information about an employees children, such as name and date of birth. The employee and children data forms a hierarchy, where the employee data represents the parent segment and the children data represents the child segment. If an employee has three children, then there would be three child segments associated with one employee segment. In a hierarchical database the parent-child relationship is one to many. This restricts a child segment to having only one parent segment. Hierarchical DBMSs were popular from the late 1960s, with the introduction of IBMs Information Management System (IMS) DBMS, through the 1970s. The hierarchical structure was used in early mainframe DBMS. Records’ relationships form a treelike model. This structure is simple but nonflexible because the relationship is confined to a one-to-many relationship. IBM’s IMS system and the RDM Mobile are examples of a hierarchical database system with multiple hierarchies over the same data. RDM Mobile is a newly designed embedded database for a mobile computer system. The hierarchical structure is used primarily today for storing geographic information and file systems. Network Model The popularity of the network data model coincided with the popularity of the hierarchical data model. Some data were more naturally modeled with more than one parent per child. So, the network model permitted the modeling of many-to-many relationships in data. In 1971, the Conference on Data Systems Languages (CODASYL) formally defined the network model. The basic data modeling construct in the network model is the set construct. A set consists of an owner record type, a set name, and a member record type. A member record type can have that role in more than one set, hence the multiparent concept is supported. An owner record type can also be a member or owner in another set. The data model is a simple network, and link and intersection record types (called junction records by IDMS) may exist, as well as sets between them . Thus, the complete network of relationships is represented by several pairwise sets; in each set some (one) record type is owner (at the tail of the network arrow) and one or more record types are members (at the head of the relationship arrow). Usually, a set defines a 1:M relationship, although 1:1 is permitted. The CODASYL network model is based on mathematical set theory. The network structure consists of more complex relationships. Unlike the hierarchical structure, it can relate to many records and accesses them by following one of several paths. In other words, this structure allows for many-to-many relationships. Relational Model (RDBMS relational database management system) A database based on the relational model developed by E. F. Codd. A relational database allows the definition of data structures, storage and retrieval operations and integrity constraints. In such a database the data and relations between them are organised in tables. A table is a collection of records and each record in a table contains the same fields. Properties of Relational Tables: Values Are Atomic Each Row is Unique Column Values Are of the Same Kind The Sequence of Columns is Insignificant The Sequence of Rows is Insignificant Each Column Has a Unique Name Certain fields may be designated as keys, which means that searches for specific values of that field will use indexing to speed them up. Where fields in two different tables take values from the same set, a join operation can be performed to select related records in the two tables by matching values in those fields. Often, but not always, the fields will have the same name in both tables. For example, an orders table might contain (customer-ID, product-code) pairs and a products table might contain (product-code, price) pairs so to calculate a given customers bill you would sum the prices of all products ordered by that customer by joining on the product-code fields of the two tables. This can be extended to joining multiple tables on multiple fields. Because these relationships are only specified at retreival time, relational databases are classed as dynamic database management system. The RELATIONAL database model is based on the Relational Algebra. The relational structure is the most commonly used today. It is used by mainframe, midrange and microcomputer systems. It uses two-dimensional rows and columns to store data. The tables of records can be connected by common key values. While working for IBM, E. F. Codd designed this structure in 1970. The model is not easy for the end user to run queries with because it may require a complex combination of many tables. Multidimensional structure The multidimensional structure is similar to the relational model. The dimensions of the cube-like model have data relating to elements in each cell. This structure gives a spreadsheet-like view of data. This structure is easy to maintain because records are stored as fundamental attributes in the same way they are viewed and the structure is easy to understand. Its high performance has made it the most popular database structure when it comes to enabling online analytical processing (OLAP). Object/Relational Model Object/relational database management systems (ORDBMSs) add new object storage capabilities to the relational systems at the core of modern information systems. These new facilities integrate management of traditional fielded data, complex objects such as time-series and geospatial data and diverse binary media such as audio, video, images, and applets. By encapsulating methods with data structures, an ORDBMS server can execute comple x analytical and data manipulation operations to search and transform multimedia and other complex objects. As an evolutionary technology, the object/relational (OR) approach has inherited the robust transaction- and performance-management features of it s relational ancestor and the flexibility of its object-oriented cousin. Database designers can work with familiar tabular structures and data definition languages (DDLs) while assimilating new object-management possibi lities. Query and procedural languages and call interfaces in ORDBMSs are familiar: SQL3, vendor procedural languages, and ODBC, JDBC, and proprie tary call interfaces are all extensions of RDBMS languages and interfaces. And the leading vendors are, of course, quite well known: IBM, Inform ix, and Oracle. The object oriented structure has the ability to handle graphics, pictures, voice and text, types of data, without difficultly unlike the other database structures. This structure is popular for multimedia Web-based applications. It was designed to work with object-oriented programming languages such as Java. Object-Oriented Model Object DBMSs add database functionality to object programming languages. They bring much more than persistent storage of programming language objects. Object DBMSs extend the semantics of the C++, Smalltalk and Java object programming languages to provide full-featured database programming capability, while retaining native language compatibility. A major benefit of this approach is the unification of the application and database development into a seamless data model and language environment. As a result, applications require less code, use more natural data modeling, and code bases are easier to maintain. Object developers can write complete database applications with a modest amount of additional effort. The object-oriented database (OODB) paradigm is the combination of object-oriented programming language (OOPL) systems and persistent systems. The power of the OODB comes from the seamless treatment of both persistent data, as found in databases, and transient data, as found in executing programs. In contrast to a relational DBMS where a complex data structure must be flattened out to fit into tables or joined together from those tables to form the in-memory structure, object DBMSs have no performance overhead to store or retrieve a web or hierarchy of interrelated objects. This one-to-one mapping of object programming language objects to database objects has two benefits over other storage approaches: it provides higher performance management of objects, and it enables better management of the complex interrelationships between objects. This makes object DBMSs better suited to support applications such as financial portfolio risk analysis systems, telecommunications service applications, world wide web document structures, design and manufacturing systems, and hospital patient record systems, which have complex relationships between data.

Quality Life For Older People: Dementia

Quality Life For Older People: Dementia There is no mental disorder that is inevitable in old age. Older people describe their overall well-being as good. Hence there is such a thing as normal ageing in terms of mental (as well as physical) health. Nevertheless, as in all age groups, mental disorder is not uncommon in older people and there are some disorders that become more prevalent as age increases. Mental disorder in old age can be divided into two broad categories: à ¢Ã¢â€š ¬Ã‚ ¢ Organic disorders These are characterized by confusion, which may be acute (i.e. delirium) or chronic (i.e. dementia); à ¢Ã¢â€š ¬Ã‚ ¢ Functional disorders Such as depression, anxiety and panic; but also psychotic disorders, such as late-onset schizophrenia (formerly known as late paraphrenia) In addition, drug and alcohol misuse and dependence can (like many disorders) continue into old age, or emerge for the first time when the person is older. Similarly, it should not be forgotten that personality difficulties do not necessarily disappear with ageing. (Wolstenholme et al, 2002) Epidemiology The prevalence of mental disorder in elderly people depends on exactly which age group is examined and where they are living. In community surveys of all people aged over 65 years, approximately 5% are found to have severe organic brain disorders (mainly dementia) and a further 5% to have mild symptoms of forgetfulness. 2.5-5% will have depression severe enough to warrant treatment with a further 10% complaining of minor depressive/anxiety symptoms. Late onset schizophrenic illnesses are much less common, perhaps 0.5-1.0%. (Landau et al, 2008) If one looks at the very elderly (greater than 80 years) the rates of organic disorders, mainly dementia, are much increased, (e.g. 20%) whereas other diagnoses may occur less frequently in other words organic disorder is (as one might expect) a disorder associated with increasing age. In residents in local authority homes, hospitals or other institutional care, the rates for both organic and functional disorder (particularly depression) are much increased about 30% for each type. It is probable that mental disorder will have contributed to the person entering the institution, e.g. dementia making them unable to survive safely in their own home but the combination of losing ones home and familiar surroundings can also aggravate existing confusion and/or depression. (Landau et al, 2008) Ethics and Law The main ethical concern in older people relates to the issue of capacity. In some jurisdictions (e.g. Scotland) there are now laws around incapacity. Capacity legislation will appear shortly in England and Wales. Irrespective of the legislation, however, the need to maintain the older persons ability to make autonomous decisions is clearly of ethical importance. Autonomy can be undermined by both professionals and families for both benign and malignant reasons (Colin, 2008). The presumption should always be that the person has the capacity to make a particular decision. Judgements about capacity should always be made with respect to a specific ability: a person may not be able to drive, but may still be able to run his or her own finances. Having a particular capacity (or competence) means that the person can recall and understand the relevant information and that the person shows evidence of weighing up the information as he or she makes a decision (which need not be the decision t hat the person assessing capacity would have reached). (Colin, 2008) If the person lacks capacity, those involved must act in the persons best interests. These have to be understood broadly. The criteria for assessing a persons best interests should include: taking account of what the person has said or stipulated (e.g. on an advance directive or living will) in the past; taking account of what the person now says when enabled to participate in the decision; taking account of the views of all those other people involved in the persons welfare, insofar as this is practicable, especially as regards what they think the persons wishes would have been under the present circumstances if the person had been able to express his or her wishes; making sure that the least restrictive course of action is taken. There are particular procedures to be followed if the person lacks certain capacities. For instance, there is a variety of steps to be taken (involving the Court of Protection) when the person cannot manage his or her finances; and if the person lacks the capacity to drive, the requirements of confidentiality may be put aside in the interests of public safety. Having said this, however, the doctors duty is to be on the side of the patient and it is an affront to the persons standing as an autonomous individual if his or her abilities are undermined without due cause. The General Medical Council offers advice on such issues. (Van, 1996) The Aging Population The table (based on 1991 projections) shows the age structure of the UK population for the years 2001 to 2041. The increase in the proportion of elderly people is in the 75-84 year group (+39%) and more particularly in those 85+ years (+55%). Meanwhile, the numbers of younger people changing little. The vast majority of these older people live at the present time in their own homes, only 6% being in institutional care (residential homes or hospital). The over-85 group are predominantly women, the majority widowed and living alone. The very elderly group have high consultation rates with general practitioners, with many more home visits and occupy up to 50% of all NHS beds (medical, surgical and psychiatric). They are more likely to have complex combinations of physical, psychological and social difficulties, which require multidisciplinary assessment and treatment. (Birk and Harvey, 2006) Dementia About 5% of the general population over 65 years suffer from severe cognitive impairment with further 5% showing mild changes, which may progress with time. Dementia refers to a global impairment of mental function which follows a chronic and progressive course. The symptoms and signs have usually been present for at least 6 months (Birk and Harvey, 2006). The impairment of mental function is commonly associated with deterioration in emotional control, social behaviour, motivation and the ability to perform activities of daily living (ADLs). These non-cognitive features of dementia, which are often the most upsetting aspects for family carers and friends, tend now to be referred to as Behavioural and Psychological Symptoms in Dementia (BPSD). Dementia is related to progressive cerebral degeneration, which may be caused by a variety of pathological processes, such as Alzheimers disease, vascular dementia and dementia with Lewy bodies. Post mortem changes found in the brains of people with dementia suggest the following diagnoses (approximate figures): Alzheimers disease 50% Vascular dementia 15% Dementia with Lewy bodies 15% Mixed vascular/Alzheimers disease 15% Other causes 5% Alzheimers disease Alzheimers disease is characterised by a gradual insidious onset and progressive course, often beginning with memory failure before other cognitive functions (e.g. language, praxis) become affected. Non-cognitive features (depression, psychosis, wandering, aggression, incontinence) are common. Physical examination is often normal, as are routine blood investigations. (Farrer, 2001) Computerized tomography (CT) scans may be normal or show generalised atrophy and dilatation of ventricles. CT scans also play a role in excluding other possible causes of confusion (e.g. space-occupying lesions, haemorrhages). Angled CT scans afford better views of the medial temporal lobes, which can show marked atrophy. However, this is not specific for Alzheimers disease. Hippo-campal atrophy is also seen with magnetic resonance imaging (MRI) scanning. Single photon emission computerized tomography (SPECT) provides information on how the brain is functioning, usually by tracing blood flow using radio-labelled technetium. In Alzheimers disease SPECT scanning can show a generalized decrease in blood flow, or biparietal and bitemporal hypo-perfusion. However, the diagnosis must always be made on the basis of the overall clinical presentation rather than solely on the appearance of scans. (Farrer, 2001) Dementia with Lewy bodies Dementia with Lewy bodies is characterised by the triad of fluctuating cognitive impairment, recurrent visual hallucinations and spontaneous Parkinsonism, though not all occur in every patient. As with Alzheimers disease, onset is insidious and may begin with cognitive problems, Parkinsonism, or both. Cognitive impairment initially affects attentional and visuo-spatial function, with memory initially relatively spared. As with Alzheimers disease, non-cognitive features are common. Parkinsonism consists mainly of bradykinesia rather than tremor and, once again, routine blood investigations are normal. CT scan may be normal or show generalised atrophy and dilatation of ventricles, with less temporal lobe atrophy than in AD. Blood flow SPECT can show similar changes to those seen in Alzheimers disease, though DLB is more likely to be associated with occipital hypoperfusion than Alzheimers disease, a finding which may relate to the hallucinations and visuospatial disturbance. Parkinsonis m in DLB is associated with nigrostriatal degeneration, similar to that seen in Parkinsons disease. It is possible to image nigrostriatal degeneration using SPECT scanning with a ligand for the dopamine transporter (FP-CIT or DaTSCAN imaging) which can be helpful in assisting with the diagnosis of Parkinsons disease. In the future it is hoped such imaging methods may be helpful in diagnosing DLB as well. (Mo Ray, 2009) Vascular dementia In contrast, vascular dementia usually has an abrupt onset, often in association with a recognised stroke, and is associated with a fluctuating course, a stepwise decline and often reasonable insight at least in the early stages of illness. An exception to this course is subcortical vascular dementia, which may cause some 20% of all vascular dementia, when sudden onset and a stepwise course may not be seen. Patients will often have risk factors for vascular disease, for example high or low blood pressure, ischaemic heart disease or peripheral vascular disease, but also diabetes mellitus and hypercholesterolaemia. Physical examination is likely to reveal focal neurology and a CT scan would be expected to show evidence of cerebrovascular disease. (Mo Ray, 2009) Other dementias Other causes include rarer degenerative processes, e.g. Fronto-temporal dementia, Huntingtons disease, in addition to alcoholic dementia, tumours, haematoma, etc. In some cases no discernible pathology is found. (Mo Ray, 2009) Clinical assessment and management By careful history taking (usually from patient and informant) and examination of both physical (particularly neurological) and mental state, it is possible to predict the likely underlying pathology in most patients with dementia. No specific diagnostic tests are yet available, but clinical diagnosis may be usefully supported by structural brain imaging methods such as CT or MRI scanning and functional imaging techniques such as SPECT (Single Photon Emission Computer Tomography) scanning. It is important to develop methods of establishing the aetiology of dementia during lifetime (Eastwood and Reisberh, 1996): à ¢Ã¢â€š ¬Ã‚ ¢ To assist in predicting course of illness and determining prognosis. à ¢Ã¢â€š ¬Ã‚ ¢ To inform management decisions; for example specific treatments are becoming available for Alzheimers disease (cholinesterase inhibitors) and vascular dementia and it is necessary to know which patients should receive which treatment. Patients with dementia usually present either because of failure to cope or with disturbed behaviour occasionally with both. They often lack insight into their illness or, in the early stages, deny it. People with dementia require: à ¢Ã¢â€š ¬Ã‚ ¢ An assessment of the cause and severity of the dementia (cognitive impairment and behavioural abnormalities); à ¢Ã¢â€š ¬Ã‚ ¢ An assessment of deficits in function and the need for care (dependency); à ¢Ã¢â€š ¬Ã‚ ¢ An assessment of the persons social situation; à ¢Ã¢â€š ¬Ã‚ ¢ Provision of treatment and care appropriate to the identified needs; à ¢Ã¢â€š ¬Ã‚ ¢ Support for carers both practical and emotional; à ¢Ã¢â€š ¬Ã‚ ¢ Review of the above points is the treatment and care appropriate and beneficial? About 50% of cases of dementia have concurrent physical health problems. The burden of care produced by a physically sick patient with dementia is greater than that of a fit one; therefore, diseases should be sought and treated where appropriate. Dementia may also be complicated by: à ¢Ã¢â€š ¬Ã‚ ¢ Emotional liability à ¢Ã¢â€š ¬Ã‚ ¢ Depression à ¢Ã¢â€š ¬Ã‚ ¢ Psychotic features (i.e. delusions and hallucinations) à ¢Ã¢â€š ¬Ã‚ ¢ Behavioural disturbances (i.e., wandering, aggression, incontinence) These may be helped by pharmacotherapy, counselling and explanation and support to relatives. Such patients may respond either to antidepressants for liability and depression, or antipsychotic agents for psychotic features and some behavioural disturbances. Patients with dementia are often sensitive to side effects of psychotropic drugs and so it is important to begin therapy with very low doses of medication and monitor carefully for side-effects, particularly extra-pyramidal problems. In 2004, the two drugs Risperidone and Olanzapine were recommended not to be used for the control of agitation and disturbed behaviour in dementia because of the risk of stroke. The use of antipsychotic medication to control agitation and other difficult behaviours in moderate to severe dementia remains common but controversial. (Birk and Grimley, 2005) Memory Clinics The assessment of forgetfulness is often undertaken by memory clinics. These exist in a variety of forms (some being very clinically focused and others having a research basis). The aim is to provide thorough assessment (clinical history, with mental state, neuropsychological and physical examinations and appropriate investigations e.g. blood tests and neuro-imaging) in order to arrive at an accurate diagnosis. Some clinics then initiate and monitor the use of medication (e.g. the cholinesterase inhibitors for Alzheimers disease). Increasingly, memory clinics are seeing people with milder symptoms, many of whom will be anxious about the possibility of dementia. Some such patients will have other conditions, such as depression (i.e. pseudo-dementia) or other physical illnesses. (Seltzer et al, 2004) The diagnosis of mild cognitive impairment (MCI) is now sometimes made in people who present with forgetfulness but who do not satisfy the criteria for even a mild dementia (because, for instance, their everyday activities are not impaired). A proportion of people given the diagnosis of MCI will progress to develop dementia on followed-up. Identifying MCI may, therefore, open up the possibility of early treatment. But MCI is not uncontroversial, because some people given this label will show no such progression of symptoms and might be more properly regarded as normal. (Seltzer et al, 2004) Acute Confusion (Delirium) Elderly people seem particularly likely to develop confusion in response to a wide range of stimuli either physical insults or sudden social change. This presumably reflects the reduced ability of the aged brain to cope with such events, particularly if it is additionally damaged by a dementing process. An acute confusional episode may sometimes be the first evidence of an underlying dementia. Elderly patients with acute confusion are seen throughout medical practice, e.g. 20% of all acute medical ward admissions are found to be acutely confused. In elderly people apathy, under-activity and clouding of consciousness are more common presentations of delirium than the florid, overactive restless, hallucinating states usually described in relation to younger patients. Causes include (Birk et al, 2006): à ¢Ã¢â€š ¬Ã‚ ¢ Intercurrent physical ill-health à ¢Ã¢â€š ¬Ã‚ ¢Adverse reaction to a prescribed drug or drugs à ¢Ã¢â€š ¬Ã‚ ¢Catastrophic social situations, e.g. a move into residential care Acute confusion should be regarded as indicative of underlying disease and investigated medically. Untreated it has a 40% mortality rate. The clinical approach is to complete a full physical examination looking for evidence of infection, stoke, MI or other illness. A review of medication should focus on drugs started or stopped recently. Until the underlying cause is determined and treated, a small dose of an antipsychotic agent may reduce the severity of delirious episodes. (Birk et al, 2006) Functional Disorders Depression This is the most common psychiatric disorder found in old people (if milder cases are counted) and the second commonest single underlying cause for all GP consultations for people over 70. The majority of depressive syndromes are of mild to moderate severity. About one fifth of cases are severe and carry the risk of suicide especially in men, in those which fail to remit within 6 months of onset and in those who feel physically ill (hypochondriacal) especially if they have the delusional belief that they suffer from cancer. Depression in old age may be precipitated by adverse life circumstances: bereavement; loss of health; threat of bereavement or loss of health in a key figure. As with younger patients, those who suffer from depression may have vulnerable personalities (i.e. they may be anxious and obsessional by nature) or they may have no close confidantes (i.e. they may be socially isolated). More recently evidence has emerged suggesting that depression occurring for the first time in later life may be associated with subtle brain abnormalities, such as an increase in white matter lesions (detected on neuroimaging), which may reflect hidden or undetected cerebrovascular disease. (Rands et al, 2006) Depressive illness in old people shows a wide range of clinical presentations. The typical picture of low mood, anhedonia and vegetative disturbance of sleep and appetite seen in younger people may predominate. Some patients become apathetic, withdrawn and appear to lose their cognitive abilities (this is called depressive pseudo-dementia as cognitive impairment may be so marked as to mimic organic dementia). Others may present with a picture of severe agitation and restlessness, accompanied by delusions of ill health or poverty, e.g. that they are dying of a brain tumour, that their bowels have stopped working and are rotting inside them, or that they are unable to pay for their hospital treatments. The clinical approach with mild cases of depression is unlikely to involve the Old Age Psychiatry Service, since they will be treated by the Primary Health Care Team. Support and counselling may be supplemented by the use of antidepressants. More severe or persistent cases are likely to be referred for specialist assessment and treatment. The majority of cases respond as well to treatment as younger patients perhaps even better! Poor outcome is often the consequence of inadequate treatment. The older tricyclic antidepressants are often not well tolerated, postural hypotension, urinary and gastrointestinal side effects being prominent. (Rands et al, 2006) Dosage should be titrated to the maximum tolerated, starting doses generally being 1/3 1/2 of those for younger patients. Newer antidepressants such as SSRIs have a particular place in the treatment of the elderly. Delusional depressions require the addition of neuroleptics for unresponsive or severe depressions ECT is a safe and effective treatment. Lithium carbonate has a valuable place in prophylaxis of recurrent episodes and is also effective in potentiating or augmenting the antidepressant actions of tricyclics. Many elderly depressed patients have previous or current physical illness. Not only must this be taken into account during treatment (e.g. tricyclic antidepressants are usually avoided in a patient with ischaemic heart disease and, in patients with a high risk of bleeding, SSRIs should be used with caution), but also physical illness must be treated in its own right to maximise the patients chances of recovering from the depression. (Rands et al, 2006) Anxiety Disorders Anxiety disorders do occur in old people, about half of it persisting from early life and half coming on for the first time in response to the stresses of ageing. A common precipitant stress is that of failing physical health, e.g. developing an acute phobic state after a fall from a bus, leading to a fracture and a period of reduced mobility. Behavioural methods of treatment may be effective. Diffuse anxiety and loss of confidence, even if precipitated by an adverse event, may indicate an atypical form of depression. Such patients respond better to antidepressant, rather than anxiolytic, drugs. (Rands et al, 2006) Paranoid States It appears to be a normal feature of ageing that individuals become rather more inflexible in their attitudes and fearful of adverse influence by the outside world. Elderly people are often not only physically and financially disadvantaged, but they enjoy relatively low social status and are often the victims of attack or deception. It is, therefore, perhaps not surprising that persecutory ideas (which we tend to lump together as paranoid symptoms) often emerge. The main conditions in which paranoid persecutory symptoms occur are as follows (Corey-Bloom, 2000): Late onset schizophrenia/delusional disorder This was formerly known as paraphrenia. The typical subject is an elderly spinster, with sensory impairments (deafness or visual impairment), living alone and isolated. Her self-care skills are good and she is apparently normal apart from the possession of a complex delusional system in which she believes she is the victim of a conspiracy (usually to defraud her). She hears third person auditory hallucinations, may smell odours, which she interprets as poison gas pumped into her room and misinterprets chance occurrences as having special significance. This psychotic illness, similar to schizophrenia in younger life, responds to antipsychotic drugs if the patient can be persuaded to take them. The delusions, however, seldom completely disappear but instead become encapsulated: the patient is no longer bothered by them although he or she never gains full insight into their delusional nature. A depot injection given by a Community Psychiatric Nurse is often a useful vehicle which improv es compliance with medication and provides regular contact with the patient. (Corey-Bloom, 2000) Acute confusional state/delirium Paranoid symptoms are common during delirium, the patient misinterpreting events because of his/her altered level of consciousness. The management of these symptoms has already been described neuroleptic medication may help to reduce agitation and behavioural disturbances. Paranoid Reactions to Forgetfulness These usually occur in independent old people who explain their experience of forgetting where things have been placed by accusing others of stealing them. Objects stolen are usually everyday ones, e.g. cups, teapots, pension book, money or glasses. Stolen objects often are returned or reappear in the usual place. The most likely cause of forgetfulness and paranoid misinterpretation is, of course, a dementing process. Neuroleptic medication is seldom of benefit in these circumstances. (Corey-Bloom, 2000) Assessment Procedures Clinical diagnosis of dementia includes identifying the cause of the cognitive impairment, which may be a treatable non-dementing process, delirium, or depression (Rockwood et al., 2007). When an illness that is associated with dementia is identified, the severity and character of cognitive impairment is commonly assessed in conjunction with the degree of illness and the potential for other psychiatric disorders such as depression (APA, 2000). Diagnostic assessments include a review of the patients medical history, a physical exam, and evaluation of depression, delirium, and cognitive status (Beck, Cody, Souder, Zhang, Small, 2000). Physical assessment results may identify treatable physiological imbalances that affect cognition (Freter, Bergman, Gold, Chertkow, Clarfield, 1998). Referral to neurology, neuropsychiatry, or a geriatric specialist in dementia has been stated as an important element in diagnostic assessment (Beck et al., 2000). Other elements in the assessment process commonly include neuro-imaging that can support the findings of assessments, and over time, the progression of the disease (Van Der Flier et al., 2005). Studies have also indicated that research using electroencephalography (EEG) might be an inexpensive tool that could contribute to the differentiation of dementias. Another important set of tools for assessment of cognitive deficits is neuropsychological testing (Sano, 2007). Neuropsychological assessments include testing for deficits in cognitive abilities such as current intellectual functioning, orientation, attention, verbal and non-verbal memory, verbal fluency, naming of items, and executive functioning (Petersen Lantz, 2002). Neuropsychological testing has been suggested as providing a contribution to clinical data in diagnostic assessment for dementia, differentiating between different types of dementias, early detection of cognitive loss, and identifying potential interventions (Sano, 2007; Savla Palmer, 2005). The diagnosis of dementia, even with the use of diagnostic tools, remains primarily based on observational data and judgment of the combined clinical data. The process involved in dementia assessment and diagnosis can be overwhelming and has been reported as one reason for delaying diagnosis (Sternberg, Wolfson, Baumgarten, 2000). There is also evidence that suggests that differentiating between MCI that can precede AD, and memory loss that does not have emerging pathology, poses difficulty and hesitation in requests for formal assessment (Shah, Tangalos, Petersen, 2000). The literature also suggests that there is a strong need for individuals and families to bring their concerns forward to a physician for assessment as often the first indication that an older adult is experiencing cognitive problems occurs during a crisis situation (Boise, Neal, Kaye, 2004; Borson, Scanlan, Watanabe, Tu, Lessig, 2006). In AD, memory loss has been described as insidious and can include a period of concealment preceding diagnostic investigation related to a need to preserve feelings of self-worth, identity and control (Keady Gilliard, 1997, p. 245). A diagnosis of dementia coinciding with a health crisis (e.g., stroke leading to vascular dementia) or with a progressive neurological disease (e.g., Parkinsons disease) are reported more frequently because of a higher associated incidence and known relationship with these disorders (Lindsay, Hebert, Rockwood, 1997; Wientraub, Moberg, Duda, Katz, Stern, 2004). The most common impetus for diagnostic evaluation is a realization of memory problems by the individual, or their family and social contacts, or associated with upsetting behaviour in social situations. Thomas and OBrien (2002) described behavioural changes that have been reported in dementia categorized as psychotic symptoms or possible alterations in mood or motivation. Psychotic symptoms include delusional ideas and beliefs (e.g., believing that misplaced articles have been stolen), hallucinations (e.g., seeing and speaking to people who are not physically present in a room), and misidentification of individuals (e.g., mistaking a son for a husband). Subtle changes in mood or motivation that may initially go unaddressed but increase in level of concern include apathy (e.g., lethargy), agitation (e.g., wandering, repeated dressing and undressing), aggression (e.g., verbal and/or physical, or increasing frustration with common tasks), sleep disturbances (e.g., up during the night related to distortions in sleep cycles), changes in eating habits (e.g., progressing to dependency for awareness of meal times) and personality changes (e.g., depression or unsubstantiated suspiciousness of motives of family members). Dementia and depression have been reported as the two most common medical problems in older adults (Leplaire Buntinx, 1999). However, the ass ociation between depression and dementia severity has not been confirmed, and in some instances depression has been misdiagnosed as signalling cognitive impairment (Maynard, 2003). Diagnostic Procedures These are of primary importance and include both psychiatric and medical history-taking together with physical examination and mental state assessment (including cognitive examination). Investigative procedures, e.g. EEG, blood tests, CT, MRI or SPECT scans are used as necessary. There are now operational criteria or consensus statements for the diagnosis of the main types of dementia (e.g. Alzheimers, Lewy body, vascular and fronto-temporal dementias), as well as for functional disorders. Many of the investigative procedures used in old age psychiatry are aimed at excluding other conditions in order to satisfy accepted international diagnostic criteria (e.g. the International Classification of Diseases, Tenth Edition, and ICD-10). Thus, the diagnosis of Alzheimers disease requires that other systemic or brain disease[s] should be absent. This suggests the importance of blood tests (e.g. to exclude amongst other things vitamin B12 or folate deficiency) and brain scans (e.g. to rule out the possibility of tumours or haematomas). On the other hand, some diagnoses can be clinched by a particular finding on investigation (e.g. the finding on CT of multiple cerebral infarcts in a person whose history is in keeping with a diagnosis of vascular dementia). A functional scan, e.g. SPECT, might be a useful means to confirm a diagnosis of fronto-temporal dementia in someone where the anatomical scan (e.g. CT) only shows very mild frontal lobe atrophy. Such a scan might then be used to explain this bewildering and distressing condition to the family. Illnesses in old age are commonly multiple, so that patients often suffer from several disorders simultaneously. Investigations become important, therefore, in functional illnesses too, not only because certain conditions need to be excluded (e.g. hypothyroidism in depression), but also because other physical conditions might make some psychiatric symptoms worse, or might preclude the use of certain medications. For example, chronic obstructive pulmonary disease, if not optimally treated, might exacerbate anxiety and panic; or a bleeding disorder or ulcer might limit the use of SSRIs. Disorder of Function Diagnosis alone does not tell you how severely disabled someone is. Two people with the same condition may behave very differently, e.g. dementia due to Alzheimers disease may render one person unsafe for independent living, but simply slow the other one down in the time taken to complete the daily crossword. It is important therefore to assess the functional disability that an old person suffers from and decide whether it can be relieved. Occupational Therapists and Physiotherapists play an important part here, but the doctor needs to be aware of this aspect of illness when he/she is taking a history. No

Just Mercy by Bryan Stevenson Review

Just Mercy by Bryan Stevenson Review Beacon Lights Book Review Just Mercy by Bryan Stevenson Every once in a while a book comes along that makes you think and even changes the way you have previously looked upon a subject. Just Mercy is such a book. This is the true story of a young lawyers fight for justice on the part of many on death row. The author, Bryan Stevenson battles racial injustice and represents many poor, non-white, mentally ill and young offenders. Their stories are interspersed throughout the book as he recounts his defense of Walter McMillian, a black man on death row. The memoir reads like a legal thriller, juxtaposing his many triumphs and failures. Bryan Stevenson grew up poor in Delaware. His great-grandparents had been slaves in Virginia and this legacy of slavery influenced the way his grandparents raised their children and grandchildren. They particularly emphasized the importance of faith and education. Stevensons faith was cultivated in the African Methodist Episcopal Church where he played the piano and sang in the choir. Stevenson attended Eastern College, a Christian institution outside Philadelphia, and then Harvard Law School. His focus to defend the poor began during college when he took an intensive class on race and poverty litigation. He was required to spend a month with an organization doing social justice work. They sent him to Georgia to work with the Southern Prisoners Defense Committee where his first case required him to meet with a condemned man on death row. In the late 1980s, Stevensons legal firm first took up the cause of Walter McMillian, who was wrongfully convicted and sentenced to death for the murder of a white woman. The states case had many inconsistencies. They manufactured stories from witnesses who said they were with Walter when he committed the crime and disregarded accounts from many eyewitnesses who said they were with Walter at a church fundraiser. The legal system was determined to find someone to convict for this murder and decided Walter would be prosecuted because of his affair with a prominent white woman (a crime during this time period). The exposition of this case opened my eyes to the unfortunate fact that since prosecutors and police have legal immunity they can do considerable harm to innocent citizens when they are on the hunt for justice. A large portion of this book deals with the cases of poor black children sentenced to adult prisons and serving life sentences. Stevenson tells these stories very convincingly and sympathetically. He challenges their sentences because he says they are juveniles and his firm recognized the incongruity of not allowing children to smoke, drink, drive à ¢Ã¢â€š ¬Ã‚ ¦ because of their lack of maturity and judgement while simultaneously treating some of the most at-risk, neglected, and impaired children exactly the same as full-grown adults in the criminal justice system. Circumstances that would bring a youth to be put in a situation where he felt his only option was to kill someone because he is not aware of his other options, should be recognized upon sentencing. One example is a young boy who shoots his mothers abuser. Yes, punishment needs to occur, but placing a young child in an adult prison is not always appropriate justice. Stevenson also defends many poor white women who have been convicted of the murder of their spouse or stillborn child. He tells the stories of pregnant women who are too poor to see a doctor or go to the hospital, and then unfortunately during labor deliver a stillborn child. These women are then arrested and charged with capital murder which is punishable by the death penalty. Not all of the characters in Stevensons book are sympathetic and his defense of them does not always seem to be justified. As a defense lawyer his heart may sometimes get in the way of seeing their crimes objectively. In particular, he unsuccessfully defends a prisoner who commits the heinous act of killing a child with a bomb meant for a neighbor. While justice has been denied for a large portion those in the prison system, the authors faith in both the power of redemption and justice, underlines his continued hope in the possibility of change. The true measure of our character, Stevenson writes, is how we treat the poor, the disfavored, the accused, the incarcerated, and the condemned à ¢Ã¢â€š ¬Ã‚ ¦ we all need mercy, we all need justice, and perhaps we all need some measure of unmerited grace.

Down Syndrome :: Pregnancy Children Disorder Health Essays

Down Syndrome Although many theories have been developed, it is not known what actually causes Down syndrome. Some professionals believe that hormonal abnormalities, X-rays, viral infections, immunologic problems, or genetic predisposition may be the cause of the improper cell division resulting in Down syndrome. It has been known for some time that the risk of having a child with Down syndrome increases with advancing age of the mother; i.e., the older the mother, the greater the possibility that she may have a child with Down syndrome. However, most babies with Down syndrome (more than 85 percent) are born to mothers younger than 35 years. Some investigators reported that older fathers may also be at an increased risk of having a child with Down syndrome. It is well known that the extra chromosome in trisomy 21 could either originate in the mother or the father. Most often, however, the extra chromosome is coming from the mother. Description People with Down syndrome are first and foremost human beings who have recognizable physical characteristics and limited intellectual endowment which are due to the presence of an extra chromosome 21. The estimated incidence of Down syndrome is between 1 in 1,000 to 1 in 1,100 live births. Each year approximately 3,000 to 5,000 children are born with this chromosome disorder. It is believed there are about 250,000 families in the United States who are affected by Down syndrome. The vast majority of children with Down syndrome (approximately 95 percent) have an extra 21 chromosome. Instead of the normal number of 46 chromosomes in eachcell, the individual with Down syndrome has 47 chromosomes. This condition is called trisomy 21. The second type is called translocation since the extra 21 chromosome is attached or translocated on to another chromosome, usually on chromosome 14, 21 or 22. If translocation is found in a child with Down syndrome, it is important to examine the parents’ chromosomes, since in at least one-third of the cases, a parent may be a carrier of the translocation. This form of chromosome error is found in 3 - 4 percent of the individuals with Down syndrome. Diagnosis The child with Down syndrome is in need of the same kind of medical care as any other child. The pediatrician or family physician should provide general health maintenance, immunizations, attend to medical emergencies, and offer support and counseling to the family. There are, however, situations when children with Down syndrome need special attention. Down Syndrome :: Pregnancy Children Disorder Health Essays Down Syndrome Although many theories have been developed, it is not known what actually causes Down syndrome. Some professionals believe that hormonal abnormalities, X-rays, viral infections, immunologic problems, or genetic predisposition may be the cause of the improper cell division resulting in Down syndrome. It has been known for some time that the risk of having a child with Down syndrome increases with advancing age of the mother; i.e., the older the mother, the greater the possibility that she may have a child with Down syndrome. However, most babies with Down syndrome (more than 85 percent) are born to mothers younger than 35 years. Some investigators reported that older fathers may also be at an increased risk of having a child with Down syndrome. It is well known that the extra chromosome in trisomy 21 could either originate in the mother or the father. Most often, however, the extra chromosome is coming from the mother. Description People with Down syndrome are first and foremost human beings who have recognizable physical characteristics and limited intellectual endowment which are due to the presence of an extra chromosome 21. The estimated incidence of Down syndrome is between 1 in 1,000 to 1 in 1,100 live births. Each year approximately 3,000 to 5,000 children are born with this chromosome disorder. It is believed there are about 250,000 families in the United States who are affected by Down syndrome. The vast majority of children with Down syndrome (approximately 95 percent) have an extra 21 chromosome. Instead of the normal number of 46 chromosomes in eachcell, the individual with Down syndrome has 47 chromosomes. This condition is called trisomy 21. The second type is called translocation since the extra 21 chromosome is attached or translocated on to another chromosome, usually on chromosome 14, 21 or 22. If translocation is found in a child with Down syndrome, it is important to examine the parents’ chromosomes, since in at least one-third of the cases, a parent may be a carrier of the translocation. This form of chromosome error is found in 3 - 4 percent of the individuals with Down syndrome. Diagnosis The child with Down syndrome is in need of the same kind of medical care as any other child. The pediatrician or family physician should provide general health maintenance, immunizations, attend to medical emergencies, and offer support and counseling to the family. There are, however, situations when children with Down syndrome need special attention.