To Kill a Mockingbird Research Allusion Essay Example for Free

To Kill a Mockingbird Research Allusion Essay In To Kill a Mockingbird allusions are used throughout the book. An allusion is a passing or casual reference; an incidental mention of something, either directly or by implication. In chapter 11 Scout uses the allusion, â€Å"this looks like you,† to try to cheer Jem up. It was referring to Dixie Hall. He was an American Football player. He played college football as a halfback at the University of Alabama from 1932 to 1934 and with the Washington Redskins of the NFL in 1937. Howell was also the head football coach at Arizona State Teachers College, from 1938 to 1941 and at the University of Idaho from 1947 to 1950, compiling a career coaching record of 36–35–5 in American college football. Dixie Howell was inducted into the College Football Hall of Fame as a player in 1970. Howell was one of the best punters. Howell also had an uncredited role in the movie, The Adventures of Frank Merriwell as a football player. Scout’s allusion to Dixie Howell is to comfort Jem since he loves football. By telling him that Dixie Howell looks like him, she is telling him that he comes first and takes precedence over Dixie Howell who was a famous NFL football player and coach. This also shows Scouts deep understanding of Jem. although saying This looks like you may seem like a meaningless compliment, Scout knows that because of his love for football and how he is associated with it, this would be a major honor for him to have anything similar to one of the greatest football players at that time. That’s how the allusion is used in the book. Howell, Dixie. Dixie Howell ENotes.com Reference. Enotes.com. Enotes.com, n.d. Web. 16 Sept. 2012. .

Empirical Literature on Asthma Care

Empirical Literature on Asthma Care This brief critically considers the empirical literature on asthma care. Emphasis is on UK studies although research from the USA (and other countries) is also considered. It is argued that both environmental and genetic factors are implicated in asthma onset, based on epidemiological evidence. Deficits in care provision persist: these gaps in care may be attributable to a wide range of modifiable factors, including unsatisfactory health professional (GP, nurses) input, limited use of care plans, and patient unawareness. Overall, however, conclusive inferences about asthma care provision are hampered by: A preponderance of retrospective/correlational studies, and a paucity of randomised control trials, which demonstrate causality; A paucity of research on particular gaps in asthma care; Failure to account for third-variable moderator effects. The Office for National Statistics (2004) publishes comprehensive statistics on asthma-related mortality, morbidity, treatment, and care, collapsed by demographic categories. Data is collected from the General Practice Research Database (GPRD). Issues addressed include mortality, prevalence, time trends, patients consulting general practice, incidence of acute asthma, and hospital inpatient admissions. Research suggests that health care providers often fail to agree on the precise criteria for diagnosing asthma, whether mild or severe (e.g. Buford, 2005). Severe asthma is often defined based on pulmonary function measurements, such as forced expiratory volume in 1 second, and hospitalisation. However, neither of these indicators reliably predicts asthma severity (Eisner et al, 2005). Eisner et al (2005) evaluated the efficacy of a method for identifying a cohort of adults with severe asthma based on recent admissions to an intensive care unit (ICU) for asthma. Four hundred adults with severe asthma enrolled at seventeen Northern Carolina hospitals were surveyed. A control group of patients hospitalised without ICU unit admission was also recruited. The study examined whether admission to an ICU unit is in itself a reliable indicator of asthma severity. Asthma patients with a recent ICU admission generated higher asthma scores (based on the frequency of current asthma symptoms, use of steroids and other medications, and history of hospitalisations/intubations), and poorer quality of life, were more likely to have been hospitalised, visited an asthma specialist in the previous twelve months, been in an asthma-related emergency department, and received inhaled corticosteroids in the past year. Data analysis controlled key background variables (e.g. demographic factors), increasing confidence in the reliability of the findings. However, this study was based on quasi-experimental design and hence may be confounded by sampling bias. Trends in annual rates of primary care consultations, mortality, and hospital visits/admissions were monitored for children under 5 years and 5-14 year olds. For children aged For 5-14 year olds, weekly general practice visits rose in the early 1990s (circa 70/100,000 in 1990), showed a fluctuating pattern through the mid 1990s, but has declined steadily since 1997 (about 50/100,000 by 2000). The number of patients treated annually for asthma has risen slowly but steadily, although this increase seemed to level out by the mid/late1990s. Both mortality rates have dropped steadily since the early 1990s, from about 14 million in 1990 to circa 2 million by 2000. Annual hospital admissions has also fallen steadily, from just under 30/10,000 in 1990 to about 15/10,000 by 2000. These patterns suggest an increase in self-management (e.g. action plans) that obviates the need to visit a general practice, and that asthma care overall is having the desired effect on mortality. The prevalence of wheezing and asthma in children has generally increased during the last 40 years. Although there is a paucity of reliable national statistics, data is available from specific parts of the UK, notably Leicester, Sheffield, and Aberdeen (see Figure 1). The prevalence of wheezing increased from 12% (1990) to 26% (1998) in Leicester, and from 17% (1991) to 19% (1999) in Sheffield. The prevalence of asthma showed a similar pattern in both cities, rising from 11% (1990) to 18% (1998) in Leicester, and from 18% (1991) to 30% (1999) in Sheffield. Wheezing incidence rates for Aberdeen increased from 10% (1964), to 20% (1989), 25% (1994), and 28% (1991). Data from national birth cohorts suggests a sharp increase in the average weekly GP consultations for hay fever/allergic rhinitis from 1991 to 1992. The rates rose from circa 13/100,000 (0-4 year olds) and 40/100,000 (5-14 years olds) in 1991 to about 25/100,000 (0-4 year olds) and 76/100,000 (5-14 year olds) as 1992 approached. Trends subsequently dropped off slightly but then started to show an increase again around 1998. By the year 2000 the figures were roughly 20/100,000 (0-4 year olds), and 56/100,000 (5-14 year olds). Data from a nationally representative sample of schools across the country suggests that the prevalence of asthma was fairly even across different regions. However, Data for England suggests a higher prevalence outside big cities. The greatest proportions of wheezing was found in the South West, while the highest proportion of asthma cases was found in East Anglia and Oxford (see Figure 2). In a recent Annual Report, Asthma UK (2003/2004) noted that one child in 10 has asthma and a child is admitted to hospital every 18 minutes due to an asthma attack. Over 600 copies of Asthma in the Under Fives are downloaded from the UK Asthma website monthly and on average every classroom in the UK has at least 3 children with asthma. The impact of acute asthma can be debilitating. Around 5.2 million people in Britain are presently being treated for asthma, and asthma prevention/care costs the NHS on average almost  £900 (i.e.  £889) million per year. GPs across the country treat over 14,000 new episodes of asthma each week, and UK Asthma met almost 25,000 requests for health promotion documents and other materials. About 40% of workers who have asthma find that working actually exacerbates their asthma, and 1 in 5 asthmatic people feel excluded from areas of the workplace in which people smoke. Over 12.7 million working days in the UK are lost as a result of asthma, and it is estimated that the annual cost of asthma to the economy is  £2.3 billion. Asthma UK also states that 82% of people who are asthmatic find that passive smoking triggers their asthma, and 19% of people with asthma indicate that their medical condition makes it difficult for them to play with children in their family. One in 3 children has had their routine daily activities disrupted due to asthma and 39% of asthmatic people are badly affected by traffic fumes (which stop them exercising). About 500,000 people have asthma that is very difficult to control. In 2003/2004 over 90 researchers worked on Asthma UK-funded projects and, Asthma UK spent  £2.5 million on asthma-related research. The group funded/is funding 63 research projects. These statistics paint a rather bleak picture of asthma prevalence, incidence, and the effects on people’s lives. Numerous epidemiological studies have been published that address the etiology of asthma in population groups (International Archives of Allergy Immunology, 2000; Kitch et al, 2000; Schweigert et al, 2000; Tan, 2001; Court et al, 2002; Smyth, 2002; Weissman, 2002; Tan et al, 2003; Wenzel, 2003; Gibson Powell, 2004; Barnes, 2005; Pinto Almeida, 2005). Barnes (2005) considered evidence on the role of genetic factors in resistance to atopic asthma, Studies which focus on the role of genetic factors in resistance to tropical/parasitic diseases (e.g. malaria) overlap with genetic associations found for asthma. It was concluded that genetic factors might be implicated in the development of allergic illnesses. Pregnancy is thought to increase the probability of asthma attacks in about 4% of all pregnant women. Beckmann (2006) assessed eighteen pregnant women with asthma. The study was based on a longitudinal design. Participants were recruited from local prenatal clinics and private enterprises, and enrolled during the first trimester. Patients kept a daily log recording peak expiratory flow data until delivery. Three peak-flow assessments were recorded after which the best value was entered into the log. Asthma was diagnosed by a health professional. Participants were also required to record asthma symptoms, exacerbations, medications, and cigarette use. To increase participation, subjects were reminded by telephone to complete their log. Data analysis showed that peak expiratory flow (PEF) was variable as a function of particular trimesters. Peak air flow was highest during the second trimester, with a statistically reliable difference between the second and third trimester. Unfortunately, the small sample size limits the generalisability of the findings. However, the study was based on a longitudinal design, allowing tentative causal inferences. Schweigert et al (2000) reviewed the literature on the role of industrial enzymes in occupational asthma and allergy. Enzymes used by detergent manufacturing companies (e.g. amylases, cellulases) are toxicologically benign, with mild irritation effects on the body. However, these enzymes do affected asthma and allergy. Thus, the industry is required to adhere to exposure guidelines for these enzymes. Kitch et al (2000) considered literature on the histopathology of late onset of asthma (i.e. onset in adulthood), and whether allergic exposure and sensitivity have the same impact on asthma development in adulthood as they do in children. Epidemiological studies suggest that the prevalence of asthma in older adults aged 65years or more is between 4% and 8%. The illness appears to be more common in women, especially those with a long history of smoking, and with respiratory symptoms (e.g. cough, wheeze, shortness of breath). Asthma in adulthood often developed before the age of 40, with maximum incidence occurring around early childhood. Beyond the age of 20 years the incidence of asthma tends to remain stable through young, middle-aged, and older adulthood. Death rates in adults are generally lower than figures for children; â€Å"Mortality rates attributable to asthma among those aged between 55 and 59 years of age and 60 and 64 years of age were 2.8 and 4.2 respectively, per 100,000 people, the highest rates among all age groups† (p.387). However, as adults get older asthma is less and less likely to be identified as the main cause of death due to the increased incidence of other pathology. Epidemiological research in Japan highlights a link with air pollution (International Archives of Allergy Immunology, 2000). The prevalence of asthma among kindergarten and elementary school children has increased steadily since the early 1960s, rising from 0.5-1.2% between 1960 and 1969, to 1.2-4.5% (1970-1979), 1.7%-6.8% (1980-1989), and 3.9-8.2% (1990 onwards). By contrast, data indicates little or no change in asthma prevalence amongst adults. Figures range from 1.2% in 1950-1959 to 1.2-4.0% (1960-1969), 0.9-5.0% (1970-1979), 0.5-3.1% (1980-1989) the 1960s to 1.6-2.9% (1990 onwards) (see Figure 3). Asthma in Japanese children is more common amongst boys than girls although this gender difference has diminished noticeably since the 1960s. Asthma usually appears in infancy or early in childhood but has been known to begin across all age groups. Inherited (genetic) dispositions to allergies have been implicated in the onset of asthma. There is normally a strong correlation between asthma onset and a family history of asthma. Overall, asthma-related mortality in Japan has decreased since the mid 1990s. Delays in seeking treatment and rapid exacerbation of symptoms have been strongly implicated in asthma mortality. Unfortunately, this article offers little information about the designs of studies reviewed. Inferences regarding the possible causes of asthma morbidity and mortality may be inconclusive if much of the evidence is derived from cohort studies, rather than case control studies that more effectively eliminate alternative causes. The premenstrual period in women has been implicated in asthma exacerbation. Tan (2001) reviews epidemiological literature suggesting that female sex-steroid hormones may be significant in understanding the premenstrual-asthma link, albeit the available evidence is tenuous. The luteal phase of the menstrual cycle is associated with airway inflammation and hyper-responsiveness, and hence may explain asthma exacerbation during the premenstrual phase. However, this increase in asthma severity can still be treated effectively using the normal drugs. Studies suggest that premenstrual asthma affects the rate of hospital admissions – the majority of adults admitted are women, indicating that hormonal factors play an important role. Other evidence suggested that emergency presentations increased before ovulation. It is suggested that oral contraceptive pills or gonadotrophin releasing hormone analogues may be especially effective treatments. However, premenstrual asthma was rarely associated with serious mortality. Unfortunately, most of the studies reviewed were retrospective and questionnaire based, and hence subject to response bias. There was a paucity of randomised control trials, or pseudo experiments that may permit causal inferences. Court et al (2002) considered the distinction between atopic (extrinsic) asthma, common in younger people, and non-atopic (intrinsic) asthma, found mostly in older groups. Additionally, they also considered whether identification of asthma cases in epidemiological research should be based on a doctor’s diagnosis or self-reported asthma symptoms. Nearly 25,000 people in England were surveyed. Data was collected regarding whether participants had experienced wheezing in the past 12 months and/or had been diagnosed as asthmatic by a doctor. People with atopic asthma were more likely to have experienced wheeze and been diagnosed as asthmatic in the past, compared with the non-atopic group. Logistic regression analysis showed that gender, social class, smoking status, living in an urban/rural area, and house dust mice (HDM), were all risk factors for the presence of wheeze both with (age not significant) and without (urban/rural area not significant) a diagnosis of asthma. Wheeze/asthma was more prevalent in women, younger people, lower social classes, previous/current smoking, living in an urban area, and greater HDM IgE levels. Smoking status, social class, and age were all risk factors for wheeze in both atopic and non-atopic cases. Gender was also a risk factor for atopic subjects, and urban living for non-atopics. Other research has considered the epidemiology of severe or ‘refractory’ asthma, which is rather less well understood compared with milder forms of asthma. Wenzel (2003) reviews evidence indicating that severe asthma (defined as asthmatics requiring continuous high-dose inhaled corticosteroids or oral corticosteroids for over half of the preceding year) may account for circa ≠¤ 5% of asthma cases. Data from a large Australian-based study, which has followed a large cohort of asthmatics for over three decades, implicates childhood pulmonary problems with reduced lung function in adulthood. Data suggests that over two-thirds of severe asthmatics were afflicted with asthma in childhood. Other risk factors implicated include genetic mutations (in the IL-4 gene and IL-4 receptor), and environmental factors (e.g. allergen, tobacco exposure, house dust mite, cockroach and alternaria exposures), respiratory infections (e.g. pathogens like chlamydia), obesity, gastroesophageal reflux disease, increased body mass index, lack of adherence to corticosteroid regimes, and poor physiological response to medication. Physiological factors are also implicated, notably structural changes in airway reactivity, inflammation of the peripheral regions of the lungs. Steroids are the main form of treatment. Tan et al (2003) demonstrated the role of respiratory infection in patients with severe (i.e. near fatal) asthma, acute exacerbations, or chronic obstructive pulmonary illness (COPD). Participants had all been diagnosed as asthmatic by a physician and were undergoing treatment. All showed evidence of forced expiratory volume in 1 second (FEV1) increase of 200mL. COPD patients were suffering from chronic cough and dyspnea, with a predicted FEV1% 50%, with no ÃŽ ²-agonist reversibility. Near fatal cases were patients undergoing ventilatory support in the intensive care unit of a hospital (National University Hospital and Alexandria Hospital, Singapore) as a result of a severe exacerbation. Acute asthma subjects were characterised by non-improvement following administration of ÃŽ ²-agonists, and/or severe exacerbation judging from clinical/blood data. Analysis showed that near-fatal cases were the least likely to have the influenza A + influenza B virus, but the most prone to have adenovirus and picornavirus, compared with the other two groups (see Figure 4). This suggests that viral infection may be a risk factor for severe asthma. However, due to sampling size/bias (n= 68), and failure to control for key background variables (e.g. asthma history, smoking history, prior medication use, and outpatient spirometry), the findings can be considered tentative. Smyth (2002) reviewed epidemiological studies on asthma in the UK, and worldwide. The number of new asthma cases seen by GPs has increased noticeably since the mid 1970s. Nevertheless, asthma incidence has tended to decrease since the early 1990s, consistent with data from the Office for National Statistics (2004). By the year 2000 circa 60-70, 40-50, 20-25 new cases (per 100,000 of a given age group) were reported amongst, respectively, preschool children, 5-14 year olds, and people older than 15 years. Significant ethnic differences have been reported, with high asthma prevalence in Afro-Caribbean children. Since 1962, the number of preschool children hospitalised for asthma rose steadily, then peaked in the late 80s and early 90s, and has begun to decline since. The hospitalisation rates in 1989 were 90/10,000 (preschool children), 30/10,000 (5-14 year olds), and 10/10,000 (15 years or older). By comparison the rates for 1999 were 60/10,000, 20/10,000, and 10/10,000 respectively ( see Figure 5). The British Thoracic Society identifies specific benchmarks or ‘best practice’ which health professionals are required to meet when caring for asthma patients (BTS, 2004). These recommendations are mostly based on scientific evidence from RCTs, epidemiological studies (cohort and case-control), meta-analytic reviews, and other good quality research. The recommendations related specifically to the following topics: Diagnosis and assessment in children and adults (e.g. key symptoms, recording criteria which justified diagnosis of asthma); Pharmacological management (e.g. use of drugs [inhaled steroids, ÃŽ ²2 agonist] to control symptoms, prevent exacerbation, eliminating side effects, employing a ‘stepwise’ protocol for treatment); Use of inhaler devices (technique and training for patients, agonist delivery, inhaled steroids, CFC vs. HFA propellant inhalers, suggestions on prescribing devices); Non-pharmacological management (e.g. breast feeding and modified milk formulae for primary prevention, and allergen avoidance for secondary prevention, alternative medicines); Management of acute asthma (initial assessment, clinical features, chest x-rays, oxygen, steroid treatment, referral to intensive care) Asthma in pregnancy (drug therapy, management during labour, drug treatment in breastfeeding mothers); Organisation and delivery of care (e.g. access to primary care delivered by trained clinicians, regular reviews of people with asthma, audit tools for monitoring patient care after diagnosis); Patient education (e.g. action plans, self-management, compliance with treatment regimes). Overall, despite these guidelines, recent research suggests that patients’ treatment needs are not being met. For example, Hyland and Elisabeth (2004) report data on the unmet needs of patients. Focus groups were organised between parents, patients, and clinicians. Patients and parents reported various needs that weren’t been met including frequent exacerbations, and a preference for less complex drug regimens (i.e. with fewer drugs). Many individuals had worries regarding treatment and experienced asthma symptoms 3 or more days per week. As Levy (2004) suggests, there is a need for health professionals to address these concerns, especially in relation to the BTS guidelines. Levy, a GP and Research Fellow in Community Health, identified current deficiencies in the care of asthma victims. These comprised: Higher than expected exacerbations (42/1000 patients per year); Under-diagnosis: more patients presenting for treatment with uncontrollable asthma, who had not been diagnosed previously; Deficiencies in treatment uptake: many patients fail to collect their prescriptions; Many patients with symptoms delay presenting for treatment, until their medical situation becomes critical; Health care professionals are failing to assess patients objectively (PEF, oximetry), both pre- and post-treatment; Failure to adhere to national guidelines for the care of acute asthma (e.g. not enough oral steroids and ÃŽ ²-agonists are prescribed for patients presenting with asthma attacks. Considerable variations across GPs, NHS Trusts, clinics, and other sources of care provision: patient follow-up appointments range from a few days to six months, in direct violation of standards set by the British Thoracic Society (BTS, 2004). Levy suggests various strategies for improving asthma care including diagnosis criteria (e.g. â€Å"any patient with recurring or respiratory symptoms [cough, wheeze, or shortness of breath], or who has been prescribed anti-asthma treatment should be considered to have asthma† (p.44)), use of computerised templates, having systems or triggers in place for recalling patients (e.g. patients requesting more medication, or who have been seen out of hours), introducing more effective protocols for monitoring and informing asthma patients (e.g. using a checklist to ascertain various key information on patients status, such as effects of asthma on patients life, recent exacerbations), providing written self-management plans (e.g. how to detect uncontrolled asthma, using PFM charts), and having an agreed procedure for managing acute asthma attacks (e.g. selecting a low threshold for using oral steroids). Currently there is a lack of research testing the value of these recommendations on asthma health outcomes. However various strategies are continually being implemented in various parts of the country to improve the quality of asthma care. For example, Holt (2004) describes the effects of implementing the RAISE initiative, launched by the National Respiratory Training Centre, in a primary care setting. This scheme is designed to raise awareness of existing variations in standards of care, improve standards of care through education, support, and feedback, increase awareness and understanding of respiratory disease, use asthma as platform to demonstrate the value of shared experiences across different agencies/professionals, and augment the profile of primary care settings as the main source of asthma care and innovation. The RAISE led to various improvements, such as: The use of ‘active’ and ‘inactive’ asthma registers, to distinguish patients who currently have asthma symptoms from those who don’t. Introduction of computerised templates to improve accuracy and reliability of data recording during consultations (e.g. progressing sequentially from assessment of symptoms, to peak flow, inhaler, and advice stages). Use of symptom questionnaires (e.g. handed out with repeat prescriptions) that help patients with well-managed asthma decide whether they can opt for a telephone consultation, rather than taking the trouble to visit the practice for a face-to-face consultation. Haggerty (2005) identifies several factors paramount to effective care and management of asthma in UK patients. These comprise adequate patient education about the nature of asthma (e.g. number of asthma episodes, use of quick relief medicines, long term symptoms, restrictions on daily activities, and emergency visits), use of asthma action plans, and customised treatment plans (to achieve early control), and addressing patients own concerns and perception. Treatment for asthma is usually in the form of regular inhaled corticosteroids (ICS), oral corticosteroids (OCS), and ÃŽ ² agonists. These treatments are usually administered by a health professional when symptoms manifest and/or become severe. However, since asthma can often exacerbate rapidly, before an individual can seek medical help, it is vital that asthma patients receive the necessary care from health professionals, and also self-management skills. GPs and nurses play a critical role. Griffiths et al (2004) conducted a randomised control trial to assess the effect of a specialist nurse intervention on the frequency of unscheduled asthma care in an inner city multiethnic clinic in London. The role of specialist nurses in asthma care has been uncertain. Interventions in which specialist nurses educate patients about asthma, after hospital attendance with acute asthma, were shown to have inconsistent effects on unscheduled care. However, outreach initiatives to educate medical staff had shown no effect. Thus, an intervention was designed that combined patient education with educational outreach for doctors and practice nurses. It was suspected that such an integrated approach would benefit ethnic minority groups, especially given their higher hospital admission rates and reduced access to care during asthma exacerbation. The key research question was whether specialist nurses could improve health outcomes in ethnic minority groups. Outcome variables were the percentage of patients receiving unscheduled treatment for acute asthma during a 12 month period, and time to first unscheduled attendance with acute asthma. The study was based on 44 practices in two east London boroughs. Participants comprised over 300 patients (aged 6 to 60) who were admitted to or attending the hospital, or the out of hours GP service with acute asthma. Half the sample were classified as South Asians, 34% were Caucasian, while 16% were Caucasian. The intervention was based on a liaison model. Practices were assigned to either a treatment or control condition. Practices randomised to the treatment condition ran a nurse led clinic involving liaison with GPs and practice nurses, incorporating education, raising the profile of guidelines for the management of acute asthma, and providing on-going clinical support. In practice these practices received two one-hour visits from a specialist nurse who discussed guidelines for managing patients with acute asthma. Discussions were based on relevant empirical evidence. A computer template was provided to elicit patient information on various treatment issues, such as inhaler technique and peak expiratory flow, and offer self-management advice. By contrast, control practices received a visit promoting standard asthma care guidelines. Data analysis showed that the intervention lengthened the time to first attendance (median 194 days for intervention practices, and 126 days for control practices), and also reduced the proportion of patients presenting with acute asthma (58% treatment practices versus 68% in control practices (see Figure 6). These effects were not moderated by individual differences in ethnicity, albeit Caucasians seemed to benefit more from the intervention compared with minority ethnic groups. O’Connor (2006) noted that asthma care in the UK remains below the required standards. The majority of the 69,000 hospital admissions and circa 1400 deaths annually are attributable to poor patient adherence to treatment regimens. Nurses, it is argued, play an important role in promoting adherence. Additionally, use of a new inhaled corticosteroids – circlesonide – may also help increase adherence. Circlesonide is much easier to use than more established asthma drugs (e.g. it has a once-daily dosing). Evidence is reviewed suggesting that peak expiratory flow remains stable when patients are given circlesonide compared with a placebo. Tsuyuki et al (2005) assessed the quality of asthma care delivered by community-based GPs in Alberta, Canada. They reviewed clinical charts for over 3000 patients from 45 primary care GPs. Of this number 20% had ever visited an emergency department or hospital, 25% had evidence that a spirometry had been performed, 55% showed no evidence of having received any asthma education, 68% were prescribed an inhaled corticosteroid within the past 6 months, while a very small minority (2%) had received a written action plan. Figure 6 shows percentage of participants receiving medication. Sixty-eight percent were prescribed an inhaled corticosteroid, 11% were given an oral corticosteroid, and 80% received a short acting ÃŽ ²-agonist, while 8% were prescribed a long acting ÃŽ ²-agonist. Participants with an emergency room/hospital event were (marginally) more likely to be prescribed medication (no group differences in use of short acting ÃŽ ²-agonists). Regarding pulmonary testing, 25% had evidence of a pulmonary function test (not peak flow), 46% had peak flow monitored, 34% showed no evidence of pulmonary function tests, while 26% had an x-ray. Again individuals with an emergency room/hospital event were more likely to be tested (see Figure 7). Data about education received by patients was also evaluated. Twenty-two percent received information about environmental triggers, 20% on inhaler use, 10% on how to perform a home PEF test, 2% on written action plans, while 55% received no education at all. Those with an emergency room/hospital event were more likely to receive education. Receiving asthma education, use of spirometry, and prescription of inhaled corticosteroids, were all predicted by number of asthma-related clinic visits (4 or more) and having an emergency room/hospital event. Additionally, asthma education was predicted by cormorbidities, and absence of documentation regarding asthma triggers, while use of spirometry was predicted by being a non-smoker, and symptoms or triggers. Finally, use of inhaled steroids was predicted by symptoms. Overall, this study highlights numerous gaps in the care provided by GPs, partly echoing criticisms of GPs in the UK (Levy, 2004). For example, Levy (2004) cited ‘under

Charlie And The Chocolate Factory, 2005

Charlie And The Chocolate Factory, 2005 The 2005 Charlie and the Chocolate Factory movie promotes a dark moral lesson of the gluttony, pride, greed and ignorance. The film has undertone of consequences of good and bad behaviour in children. The analogies are visibly projected in the film of how those who characterize the hideous vice to get their comeuppance, on the contrary, those who characterize loving and caring traits eventually meet their fortune. Music numbers were incorporated to emphasize their doomed punishment. This movie draw the audience into a beyond imaginative story that shows us love and passion could still be found in our society. Charlie and the Chocolate Factory is a 2005 musical adventure film directed by Tim Burton. It is an adaption of the 1964 childrens book of the same name by Roald Dahl. Johnny Depp starred as Willy Wonka and Freddie Highmore as Charlie Bucket. The story if about a talented Willy Wonka, the eccentric owner of a chocolate factory, hid five golden tickets in his Wonka chocolate bars. The lucky finders of the golden ticket will be invited to visit the factory with one family member, and one of the five will then win a lifetime supply of chocolates and a special secret prize. All five children who win golden tickets present different personality traits and behaviour, as well as their family members. The chocolate factory is run by Oompa-Loompas, a tribe of little people from Loompaland, whom Wonka invited to work for him in return of Coca beans. Upon the journey inside the mysterious chocolate factory, the children, one by one, are eliminated accordingly to their misbehaviour. Only Charlie is spared and carries the day winning the special secret prize which turns out to be the inheritance of the factory. However, Charlie refuses because Wonka insist Charlie to leave his family behind. At last, Charlie assist Wonka to reconcile with his alienated father and Charlie, ultimately inherits the chocolate factory. Though there is not a specific time of history or place setting in the movie, the story is easily noticeable that it starts in cold snowy winter. Winter is a sign of hibernation and perseverance. But there is hidden renewed hope in the far-off distance as spring follows. Houses are lined up neatly with snow covering almost every corner of the town. Charlies old and shabby house outstands itself at the very edge of the city, and the mysterious chocolate factory at the very top center of the town. This is a symbolic imaginary of social class. Various social theories propose a hierarchy arrangement of people in society. Wonka being at the top is viewed as the elites with a great deal of power and intelligence. By contrast, Charlies family at the edge is clearly reinforced their struggle routines; with no power or worldly goods and just barely have enough to eat. About Prince Pondicherry and his Chocolate Palace Grandpa Joe later on in the movie tells Charlie about the Chocolate Palace story in order to further describe Willy Wonka. There is a scene where Willy Wonka builds a terrific palace made of only chocolate for a wealthy prince Pondicherry. Pondicherry despite Wonkas warning, insist to live in it. Soon after, on a very hot day, the palace melts and totally falls apart. Mr. Wonka indeed is a brilliant artist and he sure is someone who gives advices that should be taken seriously. This part of the movie plays a foreshadowing revelation of unpleasant consequences might follows if Wonkas advice is not taken seriously. In reality, although not too many considerable advices are deemed wise and righteous, but we should be able to differentiate from the good and evil with objective judgment. To be bent on having ones own way, one will be responsible for the consequences of their own. About the five Golden Ticket Winners There are five music numbers with stage exorbitantly choreographed sequence, set to each turning point in this movie. Danny Elfman is the composer of the music scores; he also performed the four, among the five, vocals of the songs that are sung by the Oompa-Loompas in the film. Each number with its scene returns a moral lesson of a corrupted aspect of society. They serve not only as a specially entertainment but also emphasize the storys key moments and lead the audience to the next stage of the movie. Physical appearances are believed to be an important factor in the development of social relations; however, the implications of ominous factor are often hidden in many superficial judgments. This is fully examined in the first music number played at the entrance of Wonkas factory. Mr. Wonka welcomes the five golden ticket holders and their family member to his humble factory with a cheerful mechanical welcoming show. The Wonkas Welcome Song was electronically performed by little plastic puppets with large round weighted eyes and peeled looking skin. The show is delightful, luminous and colourful. The music starts with various children laughter, and continues in jumping rhythm giving the visitors a warm cheerful welcoming; however, the show ends in small fire caused by the haywire spark of fireworks and the music ends with a hitch. The welcoming show is not pure entertainment, it implies though the chocolate factory seems bright and joyous, there are certain hidden consequential thre ats to be carefully discovered. A cursory glance and jumping to conclusion is actually as old as it is common in todays society. We are taught that objectivity is desirable, and this societal moral value is often controllable so long as conceit or negligence is not occupying too much of our ego. Otherwise, unknowable consequence might have been lining up next. This first musical number brings us into this exciting journey yet threatening chocolate factory; and shows how this prelude can form such a profound message. Apart from the first introducing number mentioned above, the later four numbers are performed by the Oompa-Loompas when each of the four repulsive children is eliminated from the contest. The songs are fetching and easy to remember, the lyrics are closely connected with each misbehaved children and summed up each lesson to be learned. The musical numbers play a recurrent motif protruding the childrens ill personality traits and at the same time demonstrating how their fatal action leads them meeting their doom. In Ausgustus Gloops character, we see gluttony. Gluttony is a disliked societal sign of greed and shows extreme voracious eating and drinking, this lack of self control leads to unpleasant consequences as we see in the film. Wonka leads the group through a long tunnel upon entering the wonderful Chocolate room, where he explains that everything in the room is edible. Here we also meet the most important performers, the Oompa-Loompas. The Oompa-Loompas are the little choco-covered people working for Wonka inside the factory. They love to sing and dance, although sometimes in a mischievous way. The Oompa-Loompas performs the second number in this room while Augustus neglect Wonkas warning, by eating himself into the chocolate river and being stuck in a tube of chocolate. The Oompa-Loompas dancing around and forms a large swimming circle sequence fitting the rhythms and music present in the song. The lyrics of the song convey Augustus character. the great, big, greedy nincompoop, August us Gloop, so big and vile. So greedy, foul and infantileà ¢Ã¢â€š ¬Ã‚ ¦ Augustus Gloop is a representation of gluttony. His overeating is one of the main reasons of his obesity and of course also a perfect example of defiance and unbalanced behaviour. The Oompa-Loompas continue, This greedy brute, this louse ear is loved by people everywhere, for who could hate or bear a grudge against a luscious bit of fudge. Gluttony might in turns appear to be desirable but this lack of self control can also occur in many other forms such as drinking, smoking or drug use other than eating. The key term is too much which leads to further horrible outcome. In this case, we see how Augustus met his doom and got almost made into fudge Violet Beauregarde shows a characteristic of Pride. Pride allows too much ego built inside a person which first leads to incorrect decision making, and eventually failure. The third number was performed in the novel Inventing room when Wonkas 3-course dinner gum serves Violet her downfall. Violet, being the gum chewing champion, claims the new invention of Wonkas as her type of gum. Mr. Wonka warns Violet that the gum has not been perfected. Violet too, like Augustus, despite Wonkas warning and throws the gum into her mouth. She describes the wondrous 3-courses dinner she tastes as she starting to transform. The Oompa-Loompas sings and dance mocking violets disgusting gum chewing habit. By repeating the chorus emphasizing her all day long gum chewing and by ending by saying they will try to save Violet before it is too late, although they are not sure that they can. It is indeed not her gum chewing that got her into trouble but her presumptuous behavior. We can see the same traits in her mother, a poor mannered lady with her pride at being the best, who encourages Violet to keep her Eyes on the prize. This competitive quality is highly established in capitalist society today. We compete at any and all levels, regardless of who we step on. The prize of being the first and the most competitive should earn us some sort of reward. It is an arrogance that misleads us to believe that we are always better than others. Pride hardens the mind and refuses the ears to hear the advice of other, consequently a big fall. Accordingly, Violets self-conceit turned herself into a giant blueberry. Veruca Salt, the queen, is a perfect demonstration of capricious greed. Greed is the root of all evil Along with gluttony and pride, greed is also morally questionable. Like gluttony, greed is a strong desire for more possession and demand, etc. than a person need, which often leads to certain unwanted lesson. In this case, the shameful Veruca Salt who got badly spoilt by her parents fully demonstrates her little heart desires is the epitome of greed. Wonka takes the group into the nut room. He tells everyone about how the amazing squirrels are trained to shell walnuts and also discern a bad nut from a good one. Wonka warn off the group not to disturb the squirrel. Veruca strongly demand to have one of Wonkas trained squirrels but Wonka refuses. She then went under the gate and reaches to grab one by herself. All the squirrels suddenly pounce on Veruca and one of them knock her on her head, discern she is a bad nut after all and unload her to the garbage chute. The Oompa-Loompas onc e again come on the stage and perform a song for the misfortunate of Veruca. They dance again in circle sequence around the hold of the garbage chute in harmonized rhythm. The lyrics remind Mr. Salt that his daughters ill-personality is indeed a result of his action by spoiling her and pandering to her every need. This number not only accentuate Verucas punishment but also emphasize who else held responsible Mr. Salt, Verucas dad, who completely spoilt her by answering to all her wishes. Poor Veruca, in this case met her demise with garbage as her new found friends. Whos next? Meet Mike Teavee, representation a variety of wicked societal behaviours which we often heard everyday. He behaves as an incessant know-it-all who righteously rebukes others with angrily manner and being such a compulsive video game fanatic who completely misses out many other happiness of being a youngster. Wonka takes the rest of the group into a blindingly white room, the television room. Wonka excitedly explains that the room is for testing television chocolate, how it can transport chocolate to every home through television. After Wonka gives a cautionary note and does a demonstration, Mike bumptiously calls Wonka an idiot and jumps into the machine and had himself teleported inside the television. Mike is shrunken down into a pint sized terror because of his inability to listen. The number takes place while an Oompa-Loompas switching channels trying to find the shrunken Mike inside the TV. The number starting with rock music then as the channel switches to a Beatles knock-off and later more violent actions, serving as a symbolic background of how selected media are unsuitable for children. The lyrics of the song prompt society how children learns from responsive media and the consequences of excessive television and video games will rots their senses and alter childrens imaginations, creates people with one track minds and rather aggressive personalities. The music numbers are a mixture of cultural cult and fad in different times. For example, Augustus Gloop numbers brassy music is like what we often hear from a Bollywood production piece; Mike Teavee is a mixture of hard rock and techno music to emphasize his crazy devotion for video games. These last four musical numbers are inserted between the light and dark moments of each turning scene during the tour. Every different room appears to be fascinating and out of the ordinary to the visitors, then soon an unpleasant child is eliminated with a darker undertone of a cautionary tale against a corrupted aspect of society, tackling a fundamental moral question. The first number was representing a Trojan horse to foreshadow importance of Wonkas warning, which all of the above four children neglected. The chocolate factory is as wonderful as it may seems, but true intentions are hidden and those refused to listen are responsible for their hideous vice. There are several scores placed in the film. Each has a different rhythm and beat to introduce the motives and themes in the scene. For example, the score played during the chocolate river cruise carries a dramatic sense of unpredictable excitement, the feeling of tossing on top of the beat and it gets stronger when the speed of the boat increases. Another example would be the score inserted during Wonks flashback of his visit to Loompaland, where the music is replete with chanting of tribal beats, which fully characterized the adventurous island. In contrast, a softer kind of music was played at the end of the story, where the theme is more complacent. Interestingly, a score is accompanied with the end credits of the film, which is the combination of the numbers but in music-only versions. This serves like a recollection of the five major moral lessons carried out in the whole film. Whos left? Charlie Bucket Willy Wonka Charlie Bucket, one of the protagonists of the story, has a warm and caring family. They are not wealthy but the family get along very well and share a strong bond of love. Charlie is a role model of a loving, caring and obedient child. The other protagonist Willy Wonka, on the other hand, is a sarcastically isolated factory owner who is estranged from his father. His chocolate factory can be seen as a reflection of his mind; it is fascinating and full of imagination but filled with perilous tricks. Charlies respectable character is in contrast to the other children in the film, it is also the grounds for making him the victor. In the film, he refuses to leave his family behind for the reward of contest. Wonka was question because he does not understand the value of a family. Charlie then helps Wonka reconciled the relationship of Wonka and his father, and at the end, Wonka and the Buckets live happily together inside the chocolate factory. The movie brings out significance of good b ehaviour and urges us to understand the importance of having a loving family. Conclusion At the ending of the film, it reveals the narrator is actually an Oompa-Loompas. He spoke in the beginning of the film and at the closing of the story. This is an example of circularity. This film and the story itself, is stunningly educational. The combination of the plot, setting and music create a mood, convey emotions and communicate not only on a level of pure entertainment, but in depth of imagery with the use of undertones so specific, yet leaves room for audience to travels beyond imaginations.

We Need Stronger Child Support Laws Essay -- Argumentative, Persuasive

The amount of child support cases in arrears would decline if a few things were changed, hopefully providing incentives to pay child support on time and regularly. There are also harsher consequences that could be carried out to prevent future mistakes. There are things being done, but is it enough? As it stands the noncustodial parent can face loss of visitation, probation, and even jail time for none payment of child support. By not enforcing court ordered child support and making examples out of those who are not in compliance, we are sending out a message that child support is more of an option than a legal obligation. Think about the ones who are really suffering here, the children involved. There are many low-income families who are not receiving court ordered child support simply because they cannot afford the legal representation and court costs to fight for what they are legally entitled to. What should be done to start helping in these cases? The Office of the Attorney General Child Support Division is set up to help parents locate non-custodial parents who have not paid their child support. This is a free service; they also help provide the custodial parent with information regarding government programs including: Medicaid, TANIF, Food Stamps, and WIC. They can help you get health insurance if the non-custodial parent is not covering those expenses. The government help is easy to obtain only requiring information that would be easily obtained like proof of income, household members, SSN, expenses, and other personnel information. Once you have filed a case with them they will send paperwork to fill out, this will consist of; the noncustodial parents full legal name , last known address, last known telephone number,... ...e best interest of their children. It’s not the amount of child support that is being paid that is important while you are doing the best you can for your children and supporting them the best way you can. Enforcing child support and having greater punishments are not just to make the nonpaying parents lives more difficult but to ensure a better life for their children. Works Cited (Texas Child Support Enforcement Resource Center, 2011) Retrieved from http://www.supportcollectors.com/resources_texas.php#stats (Huffington Post UK, 2011) Retrieved from http://www.huffingtonpost.co.uk/2011/09/02/child-support-dodgers-mos_n_946102.html#s348352&title=Ive_Become_A (Texas' child support collection data presents varied picture, 2010) Retrieved from http://www.txcn.com/sharedcontent/dws/news/texassouthwest/legislature/stories/080310dntexnuchild.2b72be0.html

short story :: essays research papers

It was one of those nights that the sky was clear and the stars were visible. I had just defeated the stress of finals and was now ready to be back in action; the late night activity of the San Francisco underground scene was calling my name. It is where a person could go and walk down one street and probably visit at least 30 clubs by doing this. There was a particular flavor I was in search of this night, something that could make me exert my body to its fullest extent. I needed to go and release some stress by dancing at a club, I needed to let loose. When my friends Mike, Christina and I arrived in San Francisco our first destination was the Cat Club. It was a seedy little place hosted the break beat and jungle music. It wasn’t much to look at it, with its dark entrance and several vagrants sleeping in the street near the entrance. A different crowd hung out there. It was a mixture of old dance party burnouts and very young ambitious club-goers. I felt confident though, I was going to go in there and knock the crowd’s socks off. I was in my best fits (outfit); I was wearing my black old school Adidas running suit with white stripes, and a black Kangol hat. The Adidas Superstar shoes that I was wearing had my white fat laces in them, to add a little flavor, but the shoes themselves looked almost war torn; they were scared from many other late nights.   Ã‚  Ã‚  Ã‚  Ã‚  As the line moved forward closer to the entrance of the club, I could feel the pulsating vibes of the music like a gust of wind every time the door was opened to allow other patrons into the club. It sounded wild in there, I was outside and I wanted to be in there so bad. Just the sound of the music and feeling of the vibration was making me more anxious then ever. I felt like a little kid waiting for Christmas. I needed to be inside, on the dance floor, just it and me. I was going to dance tonight. Suddenly, the line had stopped. What was going on? This couldn’t be happening I needed to be inside; I needed to feel weightless and sweaty from some fast paced break dancing. My legs were jittery with anticipation.

Reconstruction after the civil war

After much trial and tribulation that our exasperated country has faced, we all still gather here today in order to follow a long tradition of George Washington, a founding father and cherished president who gave and set precedent to all the new leaders who soon will follow the same path of presidency. A path followed by great accomplishments of the Grant administration, has helped to set a rolling future for the united States and now we will Improve upon the Grant administration using It as a stepping stone to once again unite the country.Now that the sure wind of war thin our country has prevailed we must continue to rebuild upon the accomplishments of the Grant Administration. We must rebuild within our trust with other human beings and rebuild within the large battered roads of this nation. Though much has been done in the last presidency, there is still ton more to accomplish. Likewise the efforts of before have helped me gain a foot on the task to better our united nation. Look ing back the last few years, already have we recovered from the tribulation of Civil War.We have started the healing process between the different races that were pitted against each other but now stand as brothers. The recent Call Rights Acts and the passing of the 1 5th Amendment have helped to guarantee and ensure the equal Civil Rights that all men will share and all able to be comprised under the glorious Constitution. Yet throughout the years we have also placed ourselves in the continued process of reconstruction in which we have rid the terrors of extremists groups but also have accomplished the first steps of reunion with the Southern states.Likewise, these efforts to heal the previous tension have been done to almost a full recovery. Many former rebels have been pardoned and owe the first steps to a unified country have put under way by the removal of many federal soldiers. The vanquishing of the post war tensions has been successful but now we must continue and move forwa rd. The reality is that all races much make the effort to live harmoniously with sympathy and empathy through the eyes of each individual.And through the government will the Constitutional rights of all men be upheld as shall the eradication of prejudice of others In order to keep this nation prosperous. In order to end the final lasting tensions of this era, we will make sure to eve the well waited autonomy of the last few southern states. We will make sure to relieve them of the pressure that federal troops have brought in the states of Louisiana and South Carolina. Through this progress we must also put in an investment to Americas' future in education.With support of the government it will be a priority to make sure education is available to everyone, for with this we can move forward and develop a bright future through the youth at the moment. Universal education and improvements in the intellectual and moral conductivity is the root to all prosperity. The interest to better so ciety Is In equality of both colored and white people, for the perseverance of everyone Is needed to make these new Improvements In equality and education. Again we have been In depression within our manufacturing and commercial Industries.For sure this will come to an end. In need we must comply that a papered currency Is unreliable and accustomed to fluctuate. Likewise the best way to back this is with a coin based currency where that I will keep as my honored predecessor, President Grant, who made sure to preserve the peace between us and foreign powers. If those countries that require aid need it, without disposition we will help in a peaceful and honorable way so we can create mutual understandings to the entire world[K] .Grieving once again to bring forward this nation I ask all of you: Farmers, lawyers, doctors, politicians, judges, and citizens to Join me in this movement to restore our country to the divine rights that we all share. To help in earnest efforts to rekindle th e unity we all share in order for every man no matter color to achieve the pursuit of happiness and without fail grasp the happiness that we all will share together.

Future Job

Just imagine this; you’re sitting in an extravagant, red chair surrounded by incredibly brilliant people like One Direction, Justin Timberlake and Taylor Swift; in a dress that was designed just for you, by Vera Wang herself. Suddenly, you are pulled back into reality as you hear your named being called as a spontaneous applause begins. You walk up to the stage as they play one of your recent hits that was sold out worldwide and you start to give your acceptance speech for winning a Grammy for Record of the Year!My dream job ever since I was little was to be a popular, legendary music artist. As nice as it sounds with money, popularity, and not to mention the thousands of fans, there have always been three key flaws of being a well-known singer; the no privacy, the work shift, and family. In the first place, becoming a celebrity, especially at a young age, would require accepting the fact that I would no longer have â€Å"alone time. † For instance, say I wanted to go o ut with my friends and have a good time.I would have simply one drink and the next day, Star magazine would accumulate rumors and it would be saying that I am an alcoholic, that my life is in chaos and I am getting drunk to compensate for this. Even working in the studio with another singer of the opposite gender and taking a lunch break together would be blown out of proportion. Correspondingly, if I was to be in a relationship, tabloids would be taking pictures of our every move and it would come out any way the paparazzi wanted the story to play out, for the enjoyment of others.It may even get to a point where if there was no interesting news at the moment, they could twist it so there would be a break up with the guy I was seeing. My private life would be public. No matter what was going on in my love life, the whole world would know. I could become an open matter for the world to judge. Consequently, the work hours may seem to be the equivalent with a majority of other jobs how ever, it comes with that and more.Knowing the music industry, I could be anywhere, possibly doing a world tour or maybe even an album promotion in LA, New York, etc. This requires a lot of adjustment to different time zones and studio work could possibly even call me to be there at six in the morning and not get out of there until later into the day. Exhaustion would be the highest factor in my life. After a while you could even get sick of it, mentally or physically. There would also be promoting the records and endorsements that would cause more inhumanly hours of work.Somehow I would likewise have to manage to fit in interviews and publicity stunts on top of all of that. Let’s not forget the myriads of charities that would be necessary for me to be getting involved in. Lastly, my family would be the third and probably leading flaw with my choice. In my life, my parents, my sisters, and all my loved ones have always been my first priority. I’m not saying that choosin g this occupation would make me lose contact with my relatives, but it would formulate a great impact on the amount of time I get with them.On the other hand, the normal holidays such as Christmas, New Year’s, and summer are a great time to get together with family but also at the same time, the perfect opportunity in a singer’s career to make public appearances. Generally speaking, the chance to grow into an immense star in the music world is wonderful but comparable to many things in life, as well comes with numerous drawbacks. Now, go back to that scene in your head where you’re just about to grasp that Grammy, all the hard work you ever did in your life leads up to this moment. As you accept that Grammy, you think to yourself, is this job the reason for your smile right now?