Reflection on skills Essay Example | Topics and Well Written Essays - 2000 words

Reflection on abilities - Essay Example People increase various sorts of abilities and information in their courses of life encounters and formal learning. What is most significant is the thing that remaining parts and is held for motivations behind applying it in the working environment. This article is a clarification of the aptitudes and information I have gained previously and at present as a human asset understudy in our college class and an utilization of all these in working environment. A significant information I have procured in the college is a comprehension of initiative elements with regards to an association. Numerous different things in an association experience change after some time as are the organisation’s authority expected to change.  The move from being static to dynamic/alterable is persuaded by the need to accomplish better execution while the push for better execution in numerous associations is driven by the current rivalry. This requires the conveyance of value administrations or creatio n of value items. This goal is typically all around accomplished through consistent advancement and innovativeness in the association. Agbor (2008) clarifies that pioneers in associations are sources and impetuses to development and imagination. An organisation’s initiative can have the option to drive imagination by empowering and overseeing decent variety. This implies the pioneers should start an adjustment in the organisation’s culture. As per Zaccaro (2001), the authority structure of an association ought to be one that can bolster and support development process in the association. This implies important changes ought to be made to this structure. As indicated by Zaccaro (2001), the factor of time is significant for pioneers and this implies pioneers of an association need to pick carefully their time-direction. This choice is significant thinking about the constrained asset in numerous associations. For instance, long haul authority points of view are focused on long haul success. Momentary direction is significant while focusing on quick outcomes and settlements. This generally turns into a decent alternative if the association works under social frameworks that are mind boggling and shaky. In any case, authority elements requires that organisation’s pioneers ought to have the option to adjust to the two viewpoints since one point of view abuses the assets of the association. As an associate administrator, I had the option to utilize time direction ability in settling on long haul and transient choices in the shoe organization in light of existing organisation’s needs. I needed to make a thought of the accessible assets. As per Dyer (1999) capabilities allude to setting explicit practices that characterize achievement in a specific setting. I have come to procure information on various expert and individual HR capabilities through this course. These capabilities are assembled into center, job explicit and job authority and t he board abilities, and individual traits. The center HR proficient capabilities incorporate consistence, stewardship, training and counseling , client center, innovation ability, ability, seller and information the board, virtual collaboration, representative promotion and , evaluation and estimating aptitudes (Brockbank and Ulrich, 2003).  According to Ramlall, (2006), individual properties/capabilities incorporate outcome direction, nonstop initiative, duty, and trustworthiness and respectability. Authority and the executives abilities incorporate vision arrangement, vital reasoning, asset the executives, organizing, process greatness, collaboration, objective setting and execution advancement (Brockbank and Ulrich, 2003).  As a manager in a brew processing plant, I used the HR capabilities I had obtained during my past learning and online exploration to react to client needs. I did this such that increases the value of the association while creating noteworthy consumer loya lty. I additionally ensured that I took care of representative issues such that it kept or expanded their inspiration regardless of the circumstance. I am additionally learned on the significance of handy and imaginative deduction abilities corresponding to HR. HR require

What Are the Ivy League Schools Should You Go to One

What Are the Ivy League Schools Should You Go to One SAT/ACT Prep Online Guides and Tips At the point when we hear the expression â€Å"Ivy League†, the majority of us most likely consider rich individuals who tie sweaters around their necks. In all honesty, there’s much more to it than that. The Ivy League is a gathering of first class universities that have a long history of great accomplishments and striking graduated class. Yet, how did this come to fruition? What's more, how are these schools truly? Peruse on to study the arrangement of the Ivy League, its part schools, and whether you ought to consider applying. A Brief History of the Ivy League The Ivy League comprises of eight of the most seasoned and most renowned colleges in the United States.These schools initially framed an association dependent on their normal advantages in the two scholastics and sports. The Complete List of Ivy League Schools: Earthy colored University (established 1746) Columbia University (established 1754) Cornell University (established 1865) Dartmouth College (established 1769) Harvard University (established 1636) College of Pennsylvania, AKAUPenn (established 1740) Princeton University (established 1746) Yale University (established 1702) Despite the fact that the schools themselves go back to a long time before the American Revolution, the term â€Å"Ivy League† has been around for a shorter time than you may might suspect. The most well known inception story is that the term wascoined in the mid 1930s by a sportswriter for the New York Herald-Tribunewho grumbled about covering a football match-up among Columbia and UPenn rather than a game highlighting his place of graduation, Fordham University. He to some degree scornfully alluded to Columbia and UPenn as old ivy-shrouded schools and was the first to utilize the expression Ivy League in the article that followed. The name didn't get official until 1945, when the leaders of the eight schools got together to frame an understanding â€Å"for the reason for reaffirming their goal of proceeding with intercollegiate football so as to keep up the estimations of the game, while keeping it in fitting extent to the principle motivations behind scholastic life.''Essentially, they made it their strategic work together to adjust games and scholastics at the universities (initially just football, yet later reached out to different games). They would consider themselves the Ivy League. The Ivy League is somewhat similar to the Justice League, aside from back when it was initially shaped just rich white fellows could be a piece of it. All things considered, I surmise that is generally valid for the Justice League as well. Presently I'm discouraged. Two between college advisory groups were framed, one that implemented the guidelines of qualification for Ivy League sports (for the most part contained school senior members) and one that set up general athletic arrangements (involved athletic directors).Starting in the mid-1950s, these schools started to sort out rivalries among one another in an assortment of sports.The Ivy League later included boards for affirmation and budgetary guide as the association took on an increasingly scholarly core interest. Despite the fact that the making of the Ivy League was established in games, these days these schools are known for their scholastic esteem and well known alumni.All the Ivy League collegeshave huge blessings that are the result of rich graduated class commitments over the years.Ivy League schools are regularly observed as images of elitism since they pull in understudies who originate from heritages of riches, however they offer some extraordinary money related guide bundles to impeded understudies on account of their enormous gifts. They speak to the absolute generally particular and notable schools in the country.The schools of the Ivy League have had additional time than most different schools to develop their notorieties through the aggregation of profoundly effective graduates.In option to serious undergrad programs, Ivy League universitiesoffer probably the best proficient projects for law and medication. Hammer Banging 101 is by a long shot the best graduate school class, however the finals can be somewhat tumultuous. Ivy League Schools: The Specifics For every one of the Ivy League universities, I’ll list enlistment, confirmations, and educational cost insights so you can improve thought of how they contrast from each other: School Area Student Enrollment Concede Rate Yearly Cost US News Rank Earthy colored Provision, RI 6,320 9% $62,046 14 Columbia New York City, NY 8,613 6% $68,825 4 Cornell Ithaca, NY 14,315 14% $67,613 out-of-state; $50,869 NY inhabitants 15 Dartmouth Hanover, NH 4,289 10.5% $66,174 12 Harvard Cambridge, MA 6,700 5.2% $60,659 2 UPenn Philadelphia, PA 10,406 9.4% $63,526 9 Princeton Princeton, NJ 5,275 6.5% $63,690 1 Yale Hartford, CT 5,477 6.3% $63,970 3 Are Ivy League Schools Really Better Than Other Universities? The individuals from the Ivy League might be probably the most renowned universities in the nation, yet will they really give you superior training than different schools with comparable acknowledgment rates? The primary explanation an Ivy League school may be better than some other top-level college is because of name acknowledgment. Adiploma from an Ivy League collegemay open entryways for you since managers and graduate school confirmations officials will know promptly that you went to an amazingly serious school.Ivy League universitieshave extraordinary worldwide notorieties that very few different schools can claim.You’ll additionally get the chance to coordinate with exceptionally fruitful and compelling graduated class. All things considered, you should remember that there are significant contrasts between schools inside the Ivy League as far as notoriety. The customary top three, Harvard, Yale, and Princeton, are viewed as fairly more amazing than less specific Ivies like Cornell or Dartmouth. They're all around regarded schools, however getting into one Ivy League school isn't equivalentto getting into every one of them. For this and different reasons, it's unsafe to expect that Ivy League graduates will wind up more â€Å"successful† in general than different understudies. Achievement ismore about a student’s inalienable drive and capacity than which school the person in question winds up attending.One study found that â€Å"the better indicator of profit was the normal SAT scores of the most specific school an adolescent applied to and not the regular scores of the foundation the understudy attended.†In different words, understudies who applied to Ivy League-bore schools yet wound up going to less particular universities fared no more terrible than their first class school partners. Aspiration is one of the most significant factors in progress. It's additionally a smart thought to convey an overwhelming folder case consistently. Individuals are bound to employ you in the event that you have one excessively solid arm. In all actuality Ivy League collegesdon’t consistently have the highest caliber of guidance for college understudies. Generally speaking, they will in general be exceptionally centered around doing scholastic research to keep up their situation at the bleeding edge of academia.Professors might be less keen on instructing than they are in their own projects.You could wind up with a superior learning involvement with a little, profoundly specific school that only selects college understudies in light of the fact that the educators are there basically to instruct. Ivy League collegesalso aren’t the main schoolswhere you’ll get motivation from the astounding things the understudies around you are doing.There are numerous particular schools and colleges around the nation that pull in profoundly energetic understudies and have learning situations that will challenge you.Though the Ivies have high centralizations of serious understudies, they certainly don’t have an imposing business model on undergrad ability. In outline, here's a diagram that subtleties how various sorts of non-Ivy colleges contrast with Ivy League schools. An or more sign demonstrates that this sort of school is apparently better than Ivy League schools in the class indicated on the left. A short sign demonstrates that it's not exactly as great. An equivalents sign shows that the sort of school is practically identical to the universities of the Ivy League. Top Tier Research Universities (Stanford, MIT) Top Tier Small Teaching Colleges (Amherst, Pomona) Somewhat Lower RankedUniversities (16-30 US News) Notoriety (National and International) = - - Undergrad Teaching = + = Research Opportunities = - = Graduate School Potential = = - Bore of Students = = - Would it be advisable for you to Apply to Ivy League Schools? The possibility of heading off to an Ivy League universitymight sound incredible, however before you choose to apply, you should take a couple of various variables into thought. This is what you have to do before sending in an application. Check Your Qualifications For it to merit applying to any of these schools, you ought to perform at an elevated level academically.Even at the Ivies with acknowledgment rates over 10 percent (Cornell, Dartmouth, UPenn), genuine candidates have amazing secondary school transcripts and test scores.At Cornell, for instance, the normal SAT score for conceded understudies is a 2170. In the event that you need to have a solid possibility of affirmation at the vast majority of the Ivies, you should go for at any rate a 2200 SAT score or a 33 ACT score.The GPAs of most understudies who are acknowledged to Ivy League universitiesare at or near a 4.0. It’s expected that you will have taken the hardest courses in secondary school and be in any event in the main 5-10 percent of your group. As you would know, Harvard, Yale, and Princeton are the most famously specific of the Ivies (despite the fact that Columbia has snuck up on them in ongoing years).To get into these schools, you ought to have incredible grades and grades in addition to other noteworthy and one of a kind achievements that will recognize your application.This could be anything from winning a national science reasonable rivalry to going into business to composing a novel.Read this article to

10 Interesting Facts About New Orleans

10 Interesting Facts About New Orleans New Orleans is the biggest city in the United States territory of Louisiana with a 2008 populace of 336,644 individuals. The New Orleans Metropolitan region, which incorporates the urban areas of Kenner and Metairie, had a 2009 populace of 1,189,981 which made it the 46th biggest metropolitan territory in the United States. Its populace dropped drastically after Hurricane Katrina and the resulting extreme flooding hit the city in 2005.The City of New Orleans is situated on the Mississippi River in southeastern Louisiana. The huge Lake Pontchartrain additionally exists in as far as possible. New Orleans is most notable for its unmistakable French design and French culture. It is acclaimed for its food, music, multicultural occasions and the Mardi Gras celebration held in the city. New Orleans is otherwise called the origination of jazz.The following is a rundown of 10â important geographic realities about New Orleans. The City of New Orleans was established under the name La Nouvelle-Orlã ©ans on May 7, 1718, by Jean-Baptiste Le Moyne de Bienville and the French Mississippi Company. The city was named after Phillipe dOrlà ©ans, who was Frances head of state at that point. In 1763, France lost control of the new state to Spain with the Treaty of Paris. Spain at that point controlled the locale until 1801, at which time, it was passed back to France. In 1803 the district incorporating New Orleans and encompassing territories was sold by Napoleon to the United States with the Louisiana Purchase. The city at that point started to develop impressively with a wide range of ethnicities.After turned into a piece of the United States, New Orleans likewise started to assume an enormous job in worldwide relations as it formed into a huge port. The port at that point assumed a job in the Atlantic slave exchange yet in addition the exportation of various wares and the bringing in of universal merchandise f or the remainder of the country up the Mississippi River.Throughout the remainder of the 1800s and into the twentieth century, New Orleans kept on developing quickly as its port and angling industry stayed significant for the remainder of the nation. Toward the finish of the twentieth century, development in New Orleans proceeded yet organizers got mindful of the citys defenselessness to flooding after disintegration of wetlands and swamps. In August 2005, New Orleans was hit by the class five Hurricane Katrina and 80 percentâ of the city was overflowed after a disappointment of the citys levees. 1,500 individuals passed on in Hurricane Katrina and a great part of the citys populace for all time relocated.New Orleans is situated on the banks of the Mississippi River and Lake Pontchartrain around 105 miles (169 km) north of the Gulf of Mexico. The absolute zone of the city is 350.2 square miles (901 sq km).The atmosphere of New Orleans considered sticky subtropical with gentle winters and blistering, damp summers. The normal July high temperature for New Orleans is 91.1 °F (32.8 °C) while the normal January low is 43.4 °F (6.3 °C).New Orleans is known for its reality acclaimed design and zones like the French Quarter and Bourbon Street are well known regions for sightseers. The city is one of the main ten most visited urban communities in the U.S.The economy of New Orleans depends to a great extent on its port y et additionally on oil refining, petrochemical creation, angling and the administration area identified with the travel industry. New Orleans is home to two of the biggest private colleges in the United States-Tulane University and Loyola University New Orleans. State funded colleges like the University of New Orleans are likewise inside the city.

The Tempest and Dreams Essay Example For Students

The Tempest and Dreams Essay It is urgent to acknowledge in any case, that creative mind isn't confined exclusively to the finishes of both The Tempest and Dreams. Creative mind is required all through each piece, including myself from the earliest starting point, to end. In spite of the fact that creative mind is vital in both, each requires it for various purposes. So as to completely get a handle on The Tempest, it was fundamental for me to envision the setting all the more then I was required to in Dreams which portrayed it in expand terms. Additionally, I found that Dreams made me question certain convictions that I held, where as I acknowledged a greater amount of the principles in The Tempest. For instance, in Dreams, Everett proposes a somewhat fascinating inquiry that set off my creative mind for potential clarifications. The main spot that Kenneth Albright goes, I let you know, is in dreams, Everett said. That is the main spot past the ward into which the patient can or escapes.' (Findley, 99). A progression of inquiries emerged in myself, quickly following this thought, for example, is this extremely conceivable? Would one be able to go into anothers dreams? My creative mind was required to completely grapple with these inquiries, in which I comprehended that it was workable for Everett to encounter Kenneth, yet that Kenneth couldn't encounter Everett in the fantasy. Creative mind is accordingly, a need to value these apparently foolish and fairly unfathomable hypotheses. We will compose a custom paper on The Tempest and Dreams explicitly for you for just $16.38 $13.9/page Request now At long last, in both The Tempest and Dreams emerge two comparable characters, Mimi and Gonzalo who are depicted as the savvy ones and the defenders, while varying in the cooperation of dream versus reality subject. Gonzalo is viewed as the defender of Prospero and Miranda as he sends them off on a pontoon with food, water, and different necessities to guarantee their endurance, while he is told to kill them. He is the down to earth one in the novel, which is the reason he didn't move into the fantasy world easily. He would much rather remain in reality where things were spread out all together and the entirety of the activities of individuals could be represented. It was not by his decision to wind up on the baffling island and he doesn't especially fit into this inventive setting. He is constrained into the fantasy world, however would much rather be arranged in actuality. For the situation when Ariel gave him the admonition in his fantasies that peril was close to he arose unexpectedly and liked to stay in reality for the rest of the night. There was a clamor, that is verily. Tis best we remain upon our gatekeeper, or that we quit this spot. Lets draw our weapons. (Shakespeare, 40). He was set up to move camp and arrange elsewhere trying to get away from the fantasy world that he wound up in for a brief timeframe. Mimi shares huge numbers of indistinguishable qualities from does Gonzalo in that she is a gatekeeper figure and defender over Everett, for example, Gonzalo was over Prospero and Miranda. At the point when she found that he was unable to rest she was resolved to remain alert, so as to look out for him and direct his wellbeing. Nonetheless, she was the gatekeeper of her better half, yet in addition that of her patient Brain Bassett, as she was referred to in the emergency clinic as, Bassetts insane watchman heavenly attendant. (94). She turned out to be extremely included and appended to him, as Everett had become to Kenneth. In any case, not at all like Everett and even Gonzalo, she was substantially more ready to turn out to be separated of the fantasy world at that point was Everett or Gonzalo. She entered the fantasy world effectively trying to spare her patient, Brian and help her significant other, Everett. With Brian she went into his reality to all the more likely get him, All right, she said to Brian Bassett in her psyche, you win. (Findley, 95). .u04fa6f69970099a32a2d1a42d359c98f , .u04fa6f69970099a32a2d1a42d359c98f .postImageUrl , .u04fa6f69970099a32a2d1a42d359c98f .focused content zone { min-stature: 80px; position: relative; } .u04fa6f69970099a32a2d1a42d359c98f , .u04fa6f69970099a32a2d1a42d359c98f:hover , .u04fa6f69970099a32a2d1a42d359c98f:visited , .u04fa6f69970099a32a2d1a42d359c98f:active { border:0!important; } .u04fa6f69970099a32a2d1a42d359c98f .clearfix:after { content: ; show: table; clear: both; } .u04fa6f69970099a32a2d1a42d359c98f { show: square; progress: foundation shading 250ms; webkit-change: foundation shading 250ms; width: 100%; mistiness: 1; progress: obscurity 250ms; webkit-progress: murkiness 250ms; foundation shading: #95A5A6; } .u04fa6f69970099a32a2d1a42d359c98f:active , .u04fa6f69970099a32a2d1a42d359c98f:hover { haziness: 1; change: darkness 250ms; webkit-progress: haziness 250ms; foundation shading: #2C3E50; } .u04fa6f69970099a32a2d1a42d359c98f .focused content zone { width: 100%; position: relative; } .u04fa6f69970099a32a2d1a42d359c98f .ctaText { fringe base: 0 strong #fff; shading: #2980B9; text dimension: 16px; textual style weight: striking; edge: 0; cushioning: 0; content embellishment: underline; } .u04fa6f69970099a32a2d1a42d359c98f .postTitle { shading: #FFFFFF; text dimension: 16px; textual style weight: 600; edge: 0; cushioning: 0; width: 100%; } .u04fa6f69970099a32a2d1a42d359c98f .ctaButton { foundation shading: #7F8C8D!important; shading: #2980B9; outskirt: none; outskirt span: 3px; box-shadow: none; text dimension: 14px; text style weight: intense; line-tallness: 26px; moz-fringe range: 3px; content adjust: focus; content enhancement: none; content shadow: none; width: 80px; min-stature: 80px; foundation: url(https://artscolumbia.org/wp-content/modules/intelly-related-posts/resources/pictures/straightforward arrow.png)no-rehash; position: supreme; right: 0; top: 0; } .u04fa6f69970099a32a2d1a42d359c98f:hover .ctaButton { foundation shading: #34495E!important; } .u04fa 6f69970099a32a2d1a42d359c98f .focused content { show: table; stature: 80px; cushioning left: 18px; top: 0; } .u04fa6f69970099a32a2d1a42d359c98f-content { show: table-cell; edge: 0; cushioning: 0; cushioning right: 108px; position: relative; vertical-adjust: center; width: 100%; } .u04fa6f69970099a32a2d1a42d359c98f:after { content: ; show: square; clear: both; } READ: Olouadah Equiano EssayShe was there with him, soothing him, making one final association with him before kicked the bucket. So also she was with Everett, effectively taking an interest in his fantasy world as he battled. Im holding up here, she let him know, until we both wake up.' (Findley, 100). She imparted this fantasy to him, to solace and bolster him. While Gonzalo was significantly more fitted to this present reality, Mimi took an interest vivaciously in the illusory world to support and console the individuals who she was directing, dissimilar to Gonzalo. All in all, as you read further into both the play and short story, it turns out to be considerably more apparent that these two pieces do really share a comparative topic going through them two. Through the setting, characters and structure of the two pieces, likenesses emerge in the topic of dream versus reality. I have not had a lot of experience perusing pieces that remove you in and from various real factors, for example, The Tempest and Dreams have done. I found that I expected to peruse all the more mindfully then I in any case would, so as to recognize which world and setting I was in. I astounded myself too, in that I am typically not a tolerant individual of leaving things to enchantment, and even as a kid would censure things for not being sensible. In any case, while perusing The Tempest I later understood that I totally acknowledged the clarification that enchantment made it conceivable and that destiny drove the way. I had the option to acknowledge The Tempest as to a greater extent an anecdotal piece, at that point I could of Dreams, for I have been to Toronto ordinarily and comprehend it as a genuine spot, while an island on the Mediterranean appears to be far and removed to me, an ideal setting for an anecdotal story. While understanding Dreams in any case, I ended up accepting that Mimi and Everett were real individuals, seeing as how the setting was so genuine. Dreams too, had a particularly solid effect on me because of my own encounters as a youngster. While living in my past house when I was around age five or six, I would have a reoccurring bad dream. Consistently I could rely on a similar dream wherein I was being pursued down a school passage. When Everett wouldn't rest as a result of a reoccurring dream, I saw precisely what he was feeling and it gave me the chills as I recalled a comparable fear of resting. This, alongside the way that I continued trusting Dreams was halfway non-anecdotal, caused the short story to appear to be all the more chilling then The Tempest. While there are evident contrasts, in the two Dreams and The Tempest, numerous likenesses can likewise be found. Using setting, characters and structure the subject of dream versus the truth is passed on in an evident and alluring manner.

Pi on Pie

Pi on Pie This past Thursday on my birthday my floor BMF organized that week’s Random Hall weekly-ish study break. In honor of Pi Day Irina O. ’15 and Luisa B. ’16 baked from scratch  1.909859317102744  p pies (and I did dishes). I want to share them with you, to the extent that I can share 1.909859317102744 p pies over the internet.   (A secret: the pies are a lie. Their bottoms are excised and their insides are pudding.)     Here are the pudding pies, piedentified (joke by Irina’s boyfriend Alex). The top row is whipped creamâ€"just whipped cream (people looking for the pudding in the whipped cream was hilarious), chocolate pudding, and vanilla pudding. The bottom row is banana cream (vanilla pudding and bananas), fruit salad (fruit tart without the tart), and strawberry pudding.         Right now we’re curled up in the kitchen watching Veronica Mars, and when I’m done with this blog post I’m going to go back to grading. (“Grading” is a word which here means “falling asleep with my laptop open.”) I got in on Pi Day five years ago. In the weeks and years preceding, getting into MIT seemed like the most important thing in the world. In the years since, I have learned that happiness, to me, is books, rivers, forests, my family and friends, working hard on something I care about, walking a while, and a good night’s sleep. Regardless of whether or not you get in this Pi Day, I hope that you are happy today, and that you spend your day with people you love. Here is some advice from Irina O. ’15, my roommate, lifelong friend, and one of the lovely people who created all these p-themed pies: “Have cake ready. That way, either way, you have cake.”

Spain Unemployment demand deficient, Crisis responses - 3575 Words

Spain: Unemployment demand deficient, Global financial crisis responses (Essay Sample) Content: UNEMPLOYMENT IN SPAINStudentà ¢Ã¢â€š ¬s Name:Course:Date:UNEMPLOYMENT IN SPAINStable and low unemployment is one of the four major objectives in macroeconomics. However during periods of recessions, where there is negative growth, it is always quite impossible for governments to attain these goals. The economy of Spain has always experienced the worst unemployment rates compared to its economic partners. The crashing of the housing market as a result of poor banking controls, higher public spending and high unemployment rates provided the conditions for the collapse of the economy. The recession of the country has resulted into decreased spending and the aggregate demand of the economy. This probably means that less products will have to be produced and demand decrease for labor will lead into unemployment. In rescue of the global financial crisis, the IMF came in to offer Spain with the relevant policy frameworks that could help it survive the crisis and hence focu s on sustainable economic growth. The IMF provided Spain with appropriate guidelines that could help it revive its economy. Some of the guidelines includes; restructuring of the labor market, reduce public spending and regulate the banking system. Unemployment still remains a major issue in Spain and the country must continue in advancing the policies that will help it address the specifics of the Spanish Labor market.BackgroundSpain has been rated as the fifth largest economy in the European Union and it is also one of the countries that suffered greatly as a result of global financial crisis. Spain joined the European Union in 1994 and its unemployment rate was at 24%. Since 1980, the unemployment rate in Spain has always stood at 16%. Even in the years 2005, 2006 and 2007, when the country experienced economic growth, the unemployment rate has always been above 8 percent.[Joan Edelman, Spero and Hart Jeffrey. The politics of international economic relations. (Cengage Learning, 2009).] Spain was affected by the global economic crisis because its economy depended greatly on heavy investment in construction and housing. The dependence on toxic assets oversees and on the global economy also resulted into the global financial crisis. In the year 2007 there were about 700,000 units of housing that were going on in Spain. There are various factors that facilitated the housing market business. Some of these factors include increase in population from the incoming immigrants, home purchases by northern Europeans, the growth of middleclass, homeownership subsidies and a poor control of the banking institutions.[Ibid., 13] The global financial crisis effects began having an impact on the Spanish Economy in the first quarter of the year 2008. During this period, the real growth of GDP slowed down by about 0.9%, the domestic demand contributed about 0.1 percent in the GDP while the export growth slowed down by about 0.7 percent compared to the previous year. In the year 2009, there was a decrease in domestic demand, foreign trade and private consumption, thus leading to a decline the economic activity by about 3.6%.[Ion, Dobre, and A Alexandru. "The impact of unemployment rate on the dimension of shadow economy in Spain: A Structural Equation Approach." European Research Studies Journal 13, no. 4 (2009), 179-197.] The effect on the economy increased the rates of unemployment by about 12 points from the year 2007 to the year 2009. In the year 2008 construction sector unemployment increased from 315, 108 at the onset of the year to 607, 905 at the end of the same year. In 2009 December, there were about 4.45 million unemployed Spaniards. During the first quarter of 2011, there was a rise in unemployment from 21.3 million people to 4.9 million people.[Barbara, Petrongolo and Pissarides A. Christopher. "The ins and outs of European unemployment." (2008).] As the effects of the global economic crisis began creating devastating effects in Europe, t he financial market placed Spain as part of the PIGs, an acronym commonly used to refer to a heavily-indebted country in the European Union. However as stated earlier, Spain is considered the fifth largest economy in the European Union. Portugal is rated at fifteenth, Ireland thirteenth, and Greece eleventh. Nevertheless, in the year 2009, the output of Spain was relatively higher and it was close to that of France and Italy and below 10 percent to that of UK or Germany. Unlike Ireland or Greece, there are very low chances that Spain will receive aid from the European Union or for any state in the EU to manage its bad debt. According to Dominique Strauss-Khan, the IMF CEO, Spain does not require any kind of financial support.[Ibid., 18.] Unemployment demand deficientIf the labor market functioned appropriately, the recession would only cause average wage rate to decrease, demand for labor to decrease and quantity for demand for labor to also decrease. However, the wages are consi dered "downwards stickyà ¢Ã¢â€š ¬Ã‚ , since it is unlikely for wages to decrease as a result of worker discontent and union strength, thus leaving the average wage at a much higher rate, making the quantity of demand for labor to decrease. In Spainà ¢Ã¢â€š ¬s situation, due to the demand for labor, there was a massive decrease, thus resulting into an average decrease because the unions had to protect the jobs of their workers causing the quantity of the demand for labor to increase. Consequently resulting into unemployment gap. This kind of scenario resulted into 25% unemployment in Spain The effects has been so devastating especially on the youths who lack the required experience, thus making them more likely to get fired hence resulting into a 50 percent unemployment in the youth.[Ibid., 22.] The high unemployment had a serious effect on those directly affected by it. The effect is high on individuals who are 30 years and are educated. This is because Spain economy depends on this category to purchase housing or begin families. If these groups remains unemployed, there will be expected unemployment since there will be no jobs for individuals leaving university. Unemployment has also resulted into strained relationships since most families would break up as a result of no jobs after wedding. Because the standards of living may decrease in the future, most families are prolonging to have children. In addition, more individuals have opted to live with their parents for a longer duration in order to gain financial security. Some families have even tried to depend on the pensions of their grandparents in order to survive. However as argued by most critics, it is better for most families to rely on other families than to rely on unemployment benefits in order to survive.Global financial crisis responsesThe large deficits of the government, rising unemployment and other related challenges resulted into investor panic. The low confidence in investor had a great effect on borrowing and thus destabilized the global currency markets. According Mutual Assessment Process (MAP) Spain is facing a global financial crisis. Spain has been classified as an advanced deficit economy. In order to achieve a balanced and sustainable growth, most economies are expected to create a fiscal consolidation that is reliable, rebuild confidence in the market and bring back fiscal soundness. Additionally, it is advised that countries should establish and implement policies that address high unemployment as part of fiscal consolidation. The labor reforms should be designed in a way that its main purpose is to lower the hiring costs, reduce employment in the long-term, encourage search for jobs, mobility and matching. Fiscal consolidation along with reforms in comprehensive labor market and collaborative policy actions suggest a sustainable and balanced global growth.An emergency austerity bill was approved by the Spanish Parliament in 2010. The government allocate d 15 billion euros for the austerity bill with the aim of restoring confidence and reassuring debt markets in the economy of Europe. The bill reduced the civil servant wages by about 5 percent, the budget deficit was also cut by 9.3 percent in GDP by 2010. After 2 months, Spain passed a labor market reform. The reform was aimed at making the wages to be more responsive towards the labor market. This would later firm-particular conditions, and ease employment protection legislation for permanent workers. The steps that were taken to reduce the cost of dismissing and employing workers. In addition, the labor reform alleviated the conditions for different firms to opt out from collective higher level bargaining agreements.[JosÃÆ' Emilio Boscà ¡, , A. DÃÆ'az, Rafael Domenech, Javier Ferri, E. PÃÆ'rez, and L. Puch. "A rational expectations model for simulation and policy evaluation of the Spanish economy." SERIEs 1, no. 1-2 (2010), 135-169.] If the economy continues to experience lo w aggregate demand, the unemployed will lose morale and their expertise and skills will become deteriorated and outdated. As time moves on, the workers may not be able to fit the jobs applications that are available when the economy revives. This may cause the aggregate supply for labor to decrease, thus increasing the space between the total labor force and the supply of labor. The space between the total labor force and supply for labor represents economyà ¢Ã¢â€š ¬s unemployment and since the aggregate supply in Spain is moving inwards, the rate of unemployment is probably increasing. This is a situation referred to as structural unemployment that may cripple an economy and ...

Calculate the Expected Value in Roulette

The concept of expected value can be used to analyze the casino game of roulette.  We can use this idea from probability to determine how much money, in the long run, we will lose by playing roulette.   Background A roulette wheel in the U.S. contains 38 equally sized spaces. The wheel is spun and a ball randomly lands in one of these spaces. Two spaces are green and have numbers 0 and 00 on them. The other spaces are numbered from 1 to 36. Half of these remaining spaces are red and half of them are black. Different wagers can be made on where the ball will end up landing. A common bet is to choose a color, such as red, and wager that the ball will land on any of the 18 red spaces. Probabilities for Roulette Since the spaces are the same size, the ball is equally likely to land in any of the spaces.  This means that a roulette wheel involves a uniform probability distribution. The probabilities that we will need to calculate our expected value are as follows: There are a total of 38 spaces, and so the probability that a ball lands on one particular space is 1/38.There are 18 red spaces, and so the probability that red occurs is 18/38.There are 20 spaces that are black or green, and so the probability that red does not occur is 20/38. Random Variable The net winnings on a roulette wager can be thought of as a discrete random variable. If we bet $1 on red and red occurs, then we win our dollar back and another dollar. This results in net winnings of 1. If we bet $1 on red and green or black occurs, then we lose the dollar that we bet. This results in net winnings of -1. The random variable X defined as the net winnings from betting on red in roulette will take the value of 1 with probability 18/38 and will take the value -1 with probability 20/38. Calculation of Expected Value We use the above information with the formula for expected value. Since we have a discrete random variable X for net winnings, the expected value of betting $1 on red in roulette is: P(Red) x (Value of X for Red) P(Not Red) x (Value of X for Not Red) 18/38 x 1 20/38 x (-1) -0.053. Interpretation of Results It helps to remember the meaning of expected value to interpret the results of this calculation. The expected value is very much a measurement of the center or average. It indicates what will happen in the long run every time that we bet $1 on red. While we might win several times in a row in the short term, in the long run we will lose over 5 cents on average each time that we play. The presence of the 0 and 00 spaces are just enough to give the house a slight advantage. This advantage is so small that it can be difficult to detect, but in the end, the house always wins.

Companies That Built Success on Business Data Free Essay Example, 1250 words

The big floods of data in corporations have made evaluating and analyzing easy which has led to the advancements and has given an upper hand in various business strategies. Using an analytical way of decision making minimizes risk which leads to more profit generation (McCafferty). The market of big data is advancing and progressing as faster than ever which has led to both challenges to counter unstructured and structured one while giving numerous opportunities to make advancements like never before. It has given the opportunity to advance at corporate levels where information technology is used as a viable tool to progress and make amends in the present strategies. Data mining is a big question when it comes to it because seeking the right type of information and manipulating it accordingly is necessary. Agreeing with the point that mixing new data with old data and then utilizing it for analytical purposes will lead to far better progress at the institutional level but this can a lso have a negative impact if misused or not properly used to gain results that are incorrect. Incorrect results lead to wrong decision making which then has an impact on the organization overall and its reputation can deteriorate heavily. We will write a custom essay sample on Companies That Built Success on Business Data or any topic specifically for you Only $17.96 $11.86/page

The Slavery Of The Slave Trade - 1104 Words

The Atlantic Slave Trade was about importing and exporting of commodities such as sugar, cotton and humans beings (slaves) which would be considered the most valuable product. A slave is defined as a person being held in servitude as the chattel (property) of another; one that is completely subservient to a dominating influence.† (Merriam-Webster) According to Paul Lovejoy â€Å"slavery was one form of exploitation. Its special characteristics included the idea that slaves were property; that they were outsiders who were alien by origin, or who had been denied their heritage through judicial or other sanctions;†¦.† This â€Å"slavery† commerce became a position of wealth in the African countries among its leaders, and spread throughout Europe†¦show more content†¦People were considered as wealth and security because they labored to produce food and other goods. It was the norm for the eldest man in the founding family to be the leader and that le ader used his leadership ability to distribute resources and make the important decisions as well as commanding respect. A strong leader had people who were loyal to them. A wealthy person was also a leader, but with the ability to organize labor in order to clear out and farm the land. Polygyny was also an accepted practice in the African culture which assisted in the production of labor power. Therefore African societies were not slave societies because wealth in people was the norm in African lifestyles. Rules of slavery were more dehumanizing in the American slavery methods. African slaves held positions in administration, served in the military, sometimes positions of command, personal servants and agricultural laborers. War was a vehicle to increase slaves by taking them Captive (outsiders). War was made by African rulers and was always a way to increase wealth. Waged war by African leaders was specifically for humans. The more humans, the more power, the more wealth accumulation. They sold people who were already Captives of war. Slaves held by the owner (European or African) and not immediately sold could be used to obtain additional resources that would â€Å"strengthen the king and his administration.† West Africa traded the largest majority of slaves. TheShow MoreRelatedSlavery And The Slave Trade1436 Words   |  6 PagesSlavery has been documented and has been part of the world for a very extensive time. Slaves as well-defined by numerous of individual’s state that slaves were a group of individuals who were legally bought and soon after, became the property of an owner and were forced to obey. No one knows when slavery actually came about, but we do know that it existed. So this being said, today I will be talking about the slave trade, comparing the differences of being an African slave and American slave, asRead MoreThe Slavery Of The Slave Trade1405 Words   |  6 PagesThe slave trade, which was once a legal part of the American constitution, has for many years become a form of piracy because it takes away the basic human rights of any person. The Atlantic slave trade was originated in West Africa and became a systematic institution in American and European economies. This plague brought about an inevitable existence of the nations greatest political conflict. The slave trade evoked heartbreak, and a horror to society as the nation became split over puritan valuesRead MoreThe Slavery Of The Slave Trade1328 Words   |  6 Pagesamounts of workers for cultivation infrastructure. For this reason, American settlers began the transatlantic slave trade trade. Christianity played an important role in advocating for the morality of the slave trade (Ri chard). In order to drive the slave industry, pastors across America used the traditions and stories found in the Bible to endorse and even encourage the practice of slavery. At this time, America was seeing ever dividing sects of protestantism. There were countless institutions anywhereRead MoreSlavery And The Slave Trade1498 Words   |  6 PagesThe phenomenon of new world slavery was a well-run business and the slaves were the product. Slavery was one of the few industries in history where assets exceeded liability and owner’s equity, which is an unusual occurrence considering the equation is normally that assets equal liability and owner’s equity. Throughout this essay, the rise of slavery and the slave trade will be explained and slavery will be illustrated as the product of a domino effect. Slavery was a process and it took many peopleRead MoreThe Slavery Of The Slave Trade1310 Words   |  6 PagesThe word slave is well-defined as an individual detained in se rvitude as the chattel of another, or one that is wholly impassive to a ruling power (American Heritage dictionary of the English language, 2011). The most renowned circumstances of slavery materialized throughout the settling of the United States of America. From 1619 until July 1st 1928 slavery was acceptable within United States of America the Slavery protestors endeavoured to end slavery, which at some point; they were effective atRead MoreThe Slavery Of The Slave Trade1295 Words   |  6 Pagesyou a few examples of how Atlantic slave trade came to be. What would be significant about it is that the laws, and rules that existed for the slave trade, were slightly confusing. Example not everyone knew or would agree to slave trade, the vast argument was whether slavery was a necessity or not and who would be considered a slave. Some say that without slaves, they would not get the proper work done such as field work is an example. Also others argued that slavery was not needed. As a result of theRead MoreSlavery And The Slave Trade Essay1313 Words   |  6 Pagesuse of the domestic slave trade because of the need for slaves in the tobacco planting lands. Many landowners and planters looked towards the Chesapeake area to seek for slaves. Many slave owners started looking towards that region because the International Slave Trade had been blockaded off. The domestic slave trade began something different; where African Americans were moved to a new location either through being sold or being transferred. Because of the desperate need of slaves in order to earnRead MoreThe Slavery Of The Slave Trade1987 Words   |  8 Pagesbe complete without the mention of the interstate slave trade. This is most applicable when we talk about one aspect of the slave trade that often gets overlooked, the Atlantic Slave Trade. When mentioning the Atlantic Slave Trade, it is the fact that southerners considered reopening the trade after its dissolution in the beginning of the nine teenth century. Interestingly enough, there were movements by southerners to reopen the Atlantic Slave Trade that were in the name of southern expansion. OneRead MoreSlavery And The Slave Trade2968 Words   |  12 Pageshistory of slavery is long, documented, captured in photos and personal narratives of slaves and slave owners. There are many accounts of how slavery started, the horrific stories of transporting slaves and what they were used for throughout history. To start at the beginning you have to start with how slaves were placed in different countries and continents where they were not born. Most know about the Atlantic slave trade that effected North America, South America and the Caribbean. Slavery existedRead MoreSlavery And The Slave Trade1889 Words   |  8 PagesFor over 2,000 years, slavery has been conducted in various parts of the world. From year 1500 to year 1900, Europeans stole individuals from West Africa, West Central Africa, and Southeast Africa and shipped them to the different parts of the Atlantic. This process dehumanized them of their identity. Europeans stole husbands, wives, merchants, blacksmiths, farmers, and even children. They removed them from their homelands and gave them new names: slaves. European slaveholders never thought to take

Classical Chinese Garden Of Suzhou And Japanese Dry...

The Interpretation of Nature in Classical Chinese Garden of Suzhou and Japanese Dry Landscape Garden of Ryoan-ji Luis Barragà ¡n, the influential Mexican minimalist architect and Pritzker Prize winner once said that, â€Å"In the creation of a garden, the architect invites the partnership of the Kingdom of Nature. In a beautiful garden the majesty of nature is ever present, but it is nature reduced to human proportions and thus transformed into the most efficient haven against the aggressiveness of contemporary life.† Such design principle, with a strong emphasis on the unity of man and nature as a way to build freedom and independence in the natural environment of gardens away from the unrest social political atmosphere, has not only been seen in Western minimalist architecture, but also has been extensively utilized in Classical Asian architecture. Classical Chinese Garden of Suzhou and Japanese Dry Landscape Garden are two typical examples that demonstrate such harmonious coexistence between artificiality and nature. Thus, with a focus on a comparison between the selected examples of Humble Administrator’s Garden of Suzhou (see fig. 1) and Ryoan-ji Dry Landscape Garden (see fig. 2), this essay aims to analyze the design techniques of the two gardens and how they respond to their social political and religious environments by conveying different interpretations of nature. Garden of the Humble Administrator, which consists of numerous pavilions and bridges set among a maze of

Cancer management Free Essays

Introduction The aim of this case report is to provide a source of information regarding patients with Bulky stage 1B cervical cancer by focusing on optimum care and treatment pathway of a patient. The author aims to describe important scientific observations from clinical trials, and therefore provide insightful information to expand knowledge and new research already present. Despite a ‘well established’ UK screening programme for detecting cervical pre-invasive disease there are still approximately 2,800 cases of cervical cancer per annum and 1,000 women still die from cervical cancer each year (Cancer research UK, 2003). We will write a custom essay sample on Cancer management or any similar topic only for you Order Now The case study focuses on a patient with squamous cell carcinoma of the cervix uteri (exocervix and endocervix), poorly differentiated and staged by FIGO staging system at IB2 N1 (appendix A). The FIGO staging system (Appendix 1), is based on clinical evaluation (inspection, palpation, colposcopy), radiological examination of chest, kidneys, and skeleton, and endocervical curettage and biopsies. The FIGO staging recommendations were last revised in 1995. Stage IB (T1b) includes all invasive tumours limited to cervix larger than stage 1A2 lesions. Stage T1b occult is no longer used. Stage IB lesions (confined to cervix) were subdivided into stage IB1 clinical lesions (?4cm in size) and stage IB2 lesions (4cm in size). There were no changes in other stages, including the 1987 definitions of stages IA, IA1, and IA2 (FIGO, 1995). Brady et al (1999) acknowledge squamous cell carcinoma of the uterine cervix originating at the squamous columnar junction (transformation zone) of the endocervical canal and portio of the cervix. This lesion is frequently associated with severe dysplasia and carcinoma in situ, which has the possibility of progressing to an invasive carcinoma in 10 to 20 years. The malignant process breaks through the basement membrane of epithelium and invades the cervical stroma. If invasion was less than 3mm, the lesion was classified as microinvasive or superficially invasive (stage IA1) the probability of lymph node metastasis is about 1% (Bohm et al, 1976). Perez et al (1998) suggested incidence of pelvic node metastases to be approximately 15% in stage IB, 25% to 30% in stage IIB, and 50% in stage IIIB disease.Incidence of para-aortic node metastases was found to be approximately 5% in stage IB, 19% in stage IIB, and 30% in stage IIIB disease. Fagundes et al (1992) submitted the tumour may spread to adjacent vaginal fornices or to paracervical and parametrial tissues, with eventual direct invasion of bladder, rectum, or both. They advocated the most common metastatic sites as lungs (21%), para-aortic nodes (11%), mediastinal and supraclavicular lymph nodes, bones, and liver. Literature review criteria: The most recent form of literature available was published scientific articles in form of electronic journals. Literature found included, reviews on the subject of Cervical cancer and published clinical trials which demonstrated clinical benefits and subsequent evaluation. Journals were accessed via internet using PubMed and Science Direct databases. Papers were selected based on merit of abstract and relevant articles were extracted from reference lists. Primary search terms: ‘Cervical cancer’ ‘Squamous cell carcinoma of cervix’ ‘Cancer of the cervix’ Secondary search terms: ‘Poorly differentiated IB2 N1 Cervical cancer’ ‘IB2 N1 Cervical Cancer’ ‘Ovarian Transposition + Cervical Cancer’ ‘Phase 1 trials +Cervical Cancer’ ‘Treatment pathway + Cervical Cancer’ ‘Supportive care + Cervical Cancer’ ‘HPV + Cervical Cancer’ Exclusion criteria: Most of the references used were less than eight years old, although older articles were reviewed to note development of treatment. Patient case presentation The patient case is of a twenty two year old women (gravida 0, para 0). She had no familial history of Cervical cancer or any other type. She consumes two units of alcohol per week and is an occasional smoker with a one pack per year history. She is currently employed and works thirty-six hour per week. In November 2008, patient presented with an abnormal cytologic (Papanicolaou) smear test and some postcoital spotting. She denied any forms of vaginal discharge but remarked a feeling of heavy fatigue and pelvic pain. A general physical examination of the patient was carried out with special attention to supraclavicular (nodal) areas, abdomen, and liver. A careful pelvic examination which included a bimanual palpation of the pelvis took place. Following an abnormal smear test the patient was referred for a colposcopic examination, where high grade cervical dysplasia was discovered. The patient was consequently referred in October to her local hospital for a LLETZ (large loop excision of transformation zone of cervix) biopsy of cervix. Specimens obtained during this procedure identified an invasive, moderately differentiated squamous cell carcinoma of large cell keratinising type. Vascular invasion was not identified. The tumour was staged as IB+. November 2008, contrast MRI of abdomen and pelvis completed, which concluded a large homogenous mass being seen arising from lower end of cervix extending slightly more to the right. Cervical canal was noted to appear preserved and the endometrium and rest of uterus appeared normal. There was suspicion of extension of tumour into the upper vaginal wall. A right sided simple ovarian cyst was noted, with a normal left ovary observed. A large lymph node was seen in the right pelvic sidewall highly suspicious of being metastatic. No Para- aortic lymphadenopathy noted. Concluding staging on MRI grounds was recorded as a Stage T2b, N2 cervical cancer. Based on MRI findings, patient was referred for EUA (examination under anaesthesia) for consideration of trachelectomy, in November. Trachelectomy is a surgical removal of the uterine cervix. EUA recorded a large 5cm exophytic tumour and on looking around it on 360? no macroscopic infiltration into vagina was seen.In order to give better definition an endo-cervical coil MRI was performed in December 2008, which further confirmed a definitive 6cm exophytic cervical cancer and enlarged right pelvic lymph node. Due to this the patient was not an ideal candidate for a trachelectomy. The patient was next referred for a EUA, cystoscopy, colonoscopy, sigmoidoscopy and biopsies. Procedure was uneventful. No vaginal or parametrial involvement were identified. Cystoscopy, sigmoidoscopy and colonoscopy were normal. This gave a concluding staging of Ib/2a. The patient’s case was discussed within a MDT (multi-disciplinary team) meeting. Here it was decided that chemo-radiotherapy would be preferred treatment. The patient’s main concern was preservation of fertility due to her young age. Due to the progression of disease and quick follow through from diagnosis to treatment, the patients family, patient and partner all became very distressed, and a referral was made to a specialist gynae – nurse, where information regarding treatment, prognosis and side effects could be explained and discussed again. The oncologist referred patient to a fertility specialist in December 2008, to discuss possible options for fertility sparing prior to patient commencing radiotherapy and chemotherapy. From this meeting it was decided that the patient was to undergo ovarian transposition to exclude them from the radiation scatter effect from the proposed adjuvant radiotherapy. Within the same procedure in December, patient underwent a laparoscopic para-aortic node assessment, which subsequently defined the radiotherapy field. The results of the assessment were discussed within a MDT meeting whereby it was found that the frozen section of the suspicious right obturator node confirmed malignancy, although, the para-aortic lymphadenectomy was negative. Patients consent, height and weight were taken in order to calculate Cisplatin chemotherapy dosage needed for concomitant chemotherapy. December 2008, patient proceeded to commencing radiotherapy prescribed at 50.4Gy in 28 fractions with a four field technique at 10MV. In addition to this she commenced her first concomitant chemotherapy of Cisplatin 40MG/M2 60MG, first of four cycles. The patient was reviewed throughout her radiotherapy and chemotherapy and tolerated both well with minimum side effects. Subsequently the patient was consented for intrauterine and intravaginal high dose rate brachytherapy for February 2009. The patient was noted to be down and depressed and very tearful and expressed concerns of not coping. The patient was referred to a CLIC/Sargent social worker for support and advice in January 2009. Prior to first fraction of brachytherapy, patient underwent EUA. It showed a good regression of tumour, but was still bulky. A smit sleeve was inserted as well as intrauterine tube and ovoids. Patient was admitted for brachytherapy (16.5Gy to point A in three fractions) which proceeded without complication, patient was subsequently discharged. Following brachytherapy, an external beam pelvic side wall boost was performed at 5.4Gy in three fractions. The patient was reviewed five weeks post treatment in March 2009. She noted slight bowel changes and noticed that she was leaking small amounts of urine. This was dismissed as radiotherapy related. The patient was given vaginal dilators and provided with instructions as well as an explanatory DVD. Patient relayed her fears of being re-infected by HPV. Patient was encouraged to talk with long partner regarding HPV testing. The patient also mentioned experiencing a few night sweats and hot flushes, actioning referral for an estradiol level, FSH and LH check. April 2009, patient was given news that hormonal tests taken showed signs of menopause. Patient devastated as ovarian transposition was not successful. Patient referred for hormone replacement therapy. Three month follow up MRI scan and clinical examination revealed no sign of disease. July 2009, three months post follow up, patient seen in clinic complaining of recurrent pain in right upper quadrant. Patient was on regular analgesics, but denied any per vagina bleeding or discharge. Bowels and micturation not working properly, denied it being associated with pain. Patient sent for CT scan of thorax, abdomen and pelvis in conjunction with FBC and U and E’s. Results of patient scans discussed within an MDT in August 2009, where it showed recurrent disease in the transposed side ovary. The plan decided within MDT is to perform a diagnostic laparoscopy and removal of said ovary. Patient and family were extremely distressed and emotional on hearing this news. Final pathology of biopsies taken laparoscopicaly in September 2009 confirmed malignancy in the right ovary. Following discussion at MDM, decision made to give the patient three cycles of Carboplatin and Taxol and reassess to see if surgical excision were possible. It was noted that peritoneal washings taken at time of biopsy were positive, which implies that peritoneal disease is elsewhere. Patient was consented for further chemotherapy and was distressed about possibility of hair loss due to chemotherapy. Patient was referred to MacMillan team for assessment of grant for financial assistance. An interval CT scan was taken post 3rd cycle of chemotherapy in November 2009. This showed a response in disease with the mass having reduced slightly in size. Patient proceeded with a further two cycles of chemotherapy with G-CSF support (granulocyte-colony stimulating factor) a growth factor that stimulates the bone marrow to produce more white blood cells. After the patient had finished five cycles of Carboplatin and Taxol, patient was consented and referred for a laparotomy and exploration of lesser sac and paracolic gutter in December 2009. This showed evidence of metastatic disease in form of omentum nodules, which subsequently tested positive for metastases on frozen section. The tumour was found in right hepatic flexure and was fixed to the right para-colic gutter involving head of pancreas and infiltrating liver. From this discovery of metastatic disease, it was considered inappropriate to proceed with the proposed right hemicolectomy, cholecystectomy, resection of part of liver and excision of the Gerota’s fascia. Patient and family were understandably very distressed about intra-operative findings. They were given a psychological support referral. Family were seen by a clinical psychologist, although the patient declined the appointment, but opted to speak to a CLIC Sargent social worker. Community palliative care team were to liaise and follow up with patient and family. The patient and family were additionally put in contact with a local hospice within their catchment Based on findings the clinical oncologist felt that the Carboplatin and Taxol regime was ineffective in controlling disease progression and spread and was therefore stopped. In December 2009, next chemotherapy line suggested was Topotecan, although a request was made to consider the patient for a Phase 1 agent. Due to patients increasing pain and problems with control the patient was not a suitable candidate for Phase 1 chemotherapy. Therefore patient was commenced on fives cycles of standard palliative chemotherapy Topotecan in January 2010. Patient had extensive meetings and liaisons with social worker for young people. Macmillan nurse, from hospice arranged for home visits to assess pain medication. The patients ECOG performance was ranked as 1 (Appendix 2). Re-staging CT was performed which showed an increase in size of tumour with further encroachment onto liver, new malignant lesions were identified as well as more dilated bowel loops. Patient completed intended cycles of Topotecan but was admitted for treatment of Sepsis with IV antibiotics in March 2010. Subsequent CT scans in April 2010 displayed disease progression despite Topotecan. Patient commenced on Tamoxifen therapy due to her disease having some ER positivity. Patient’s family were seen separately from patient, advised of patient’s prognosis to be less than 6 months. Patient’s mother raised concerns of patient expressing suicidal ideation. Macmillan nurse visited patient’s home. May 2010, patients pain became difficult to control, home visit made by consultant in palliative medicine as patient became increasingly drowsy. Patient deteriorated rapidly and was commenced on the Liverpool Care Pathway.Marie curie nurse, present most evenings with patient at familial home. June 2010, patient passed away with family around her. Screening and HPV testing Since first being introduced as a screening test for cervical cancer by Papanicolaou in 1927 (Papanicolaou, 1928), the cervico-vaginal smear test has proved to be one of the most cost effective test within medicine.The American Cancer society (1997) states that according to the National Cancer Institute, mortality rate from cervical cancer has dropped 70% over the last 70 years. Currently only 30% of cervical cancers are screen detected, the majority of these cases occur in women who have never had a smear (PAP- Papanicolaou) test or regularly attend a screening programme. The patient discussed (patient A), was part of this statistic as she had never had a smear test due to the UK cervical screening age being 25. Patient A presented with symptoms aged 22. Standard practice within the UK is for women aged between 25 and 60 to be contacted every 3 to 5 years and asked to go for a cervical screening test. In patients A case, a smear test was only done due to other symptoms such as post coital bleeding. An article in ‘The Times’ (2009) confirmed that new guidance will be issued to all GP’s and practice nurses to increase awareness and management of cervical cancer, but age at which women are screened will not be lowered to 20, announced by the department of health. This decision was finalised after a review by the Independent Advisory Committee on Cervical Screening (ACCS) which found that risks for women under 25 of false positive results and premature births outweighed benefit of identifying a â€Å"few extra cases†. The ACCS found that treating women for abnormal cervical cell changes has been linked to an increased risk of premature birth. While women of all ages who are treated are more likely to give birth prematurely, benefits of screening older women outweigh this risk, the panel said. One in three women under the age of 25 will have an abnormal result compared with one in fourteen for older women, the ACCS said, meaning that there are many false positives identifying abnormal changes in cells that often return to normal without treatment. A study by Sasieni et al (2009) further confirmed the ACCS’s findings that cervical screening in women aged 20-34 is less effective than in older women. By studying the effect of screening in smaller age groups, Sasieni et al showed that efficacy of screening decreases with decreasing age, even within the age 20-34. On average, participation in the UK cervical screening programme by a woman aged 35-64 reduces her risk of cervical cancer over the next five years by 60-80% and her risk of advanced cervical cancer by about 90%. The benefit of screening for women aged 25-34 is more modest. Screening in women aged 20-24 has little or no impact on incidence of cervical cancer under the age of 30. HPV is a factor being recognized as a major risk factor in pathogenesis of squamous cell carcinoma of cervix. Any woman who is sexually active is at risk of infection from human papillomavirus (HPV). Patient A was sexually active from aged 16. De Villiers et al (2004) identified Over 100 subtypes of HPV. A significant proportion of HPV disease is attributed to four subtypes; 6, 11, 16 and 18. HPV subtypes 16 and 18 cause approximately 70% of cervical cancer cases worldwide. HPV subtypes 6 and 11 infections are responsible for genital warts (Wiley et al, 2002). Arbyn et al (2007) acknowledge that HPV is the major cause of nearly 100% of all cervix cancers. This finding rapidly led to the development of vaccines against common and aggressive virus strains causing cervix cancer, the HPV genotypes 16 and 18 (Harper et al, 2006). According to Tornesello et al (2011), the role of HPVs in the etiology of cervical cancer precursor lesions and invasive carcinoma development has been well established. Bouvard et al (2009) found that at least 12 viral genotypes of alpha genus (HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59) have been found associated with a high relative risk of cervical cancer and labelled carcinogenic to humans. Although holding different prevalence rates, HPV types 16 and 18 were the most common viral types in invasive carcinoma of the uterine cervix worldwide (Li et al 2008). Cheryl et al (2000) explain the HPV as replicating primarily within the proliferating basal cells of squamous epithelium. In order for the virus to infiltrate these cells, disturbance of the overlying epithelium must occur. Once present in the basal squamous cell, HPV early genes are expressed, which lead to viral replication and host cell duplication. Previously no specific antiviral treatments existed for HPV-associated diseases, including genital warts, cervical, vaginal and vulval dysplasia as well as cervical cancer. The development of vaccines against HPV is an attractive strategy for both prevention and therapeutic intervention against genital tract HPV infections (Sherman et al, 1998). Two HPV vaccines have been developed: Cervarix ® (GlaxoSmithKline, London, UK) a bivalent HPV (types 16, 18) vaccine and Gardasil ® (Merck Co., Whitehouse Station, NJ), a quadrivalent HPV (types 6, 11, 16, 18) vaccine. Both are prophylactic vaccines that have been shown to be effective in young women prior to HPV exposure. Following advice of the Joint Committee on Vaccination and Immunisation (JCV I) the Government and Department of Health (DOH, 2007) have introduced HPV vaccines for girls aged 12 to 13 years of age, starting from September 2008 (Garland et al, 2007). This was implemented three months after Patient A’s diagnosis. Cricca et al 2006 recognised an increased interest being focused on HPV detection in cervical lesions. They subsequently reported that detections of HPV DNA in the absence of cytological abnormalities may indicate persistent high-grade squamous lesions which may have been missed by PAP screening within the follow up of CIN3 – cervical intraepithelial neoplasia (severe dysplasia, carcinoma in situ- Dysplastic cells extend into the upper third and may occupy the full thickness of the epithelium) treated patients. A study carried out by Silvana et al (2007) found HPV testing significantly predicts disease clearance or persistence, in comparison to PAP smear whose results did not register any statistical significance. The study further suggested that after treatment women should be followed up at 6-month intervals, for a minimum of 2 years with both PAP and HPV testing being carried out. Patient A only received HPV testing after her abnormal smear test was analysed. Introducing routine HPV testing as part of screening process every three years could have had a marked impact on her prognosis. Fertility preservation Patient A’s initial main concern was preservation of fertility and a referral was made by the clinical oncologist for her to see a fertility specialist to seek advice. In women who preservation of fertility is anticipated, an alternative to simple/radical hysterectomy is a radical trachelectomy. This process requires vaginal resection of cervix, upper 1 to2 cm of vaginal cuff and medial portions of cardinal and uterosacral ligaments. The cervix is transected at lower uterine segment and a prophylactic cerclage is placed at time of surgery . Landoni et al (1997) argue that for early stage disease, surgery conserves ovarian function and avoids effects of early menopause. They further propose that less shortening and fibrosis of vagina occurs compared to radical radiotherapy which gives better results in terms of residual sexual function. Surgery was thought to be the preferred treatment option in young women excluding the presence of any contraindications. Patient A fell into the young woman classification and initially had no contraindications to surgery. Relative risks and benefits of different surgical management approaches should be thoroughly discussed with the patient on an individual basis (Shepherd, 2009). Patient A had a thorough consent process prior to each surgical procedure and was put in contact with a specialist gynaecological nurse to answer any further questions. Patient A presented with a 5cm exophytic tumour. She undertook a radical trachelectomy, although research suggests that it does not appear to increase rate of recurrence, provided tumour diameter is no greater than 2cm (Landoni et al, 2005). Safety of radical trachelectomy in women with lesions that are greater than 2cm in diameter is not known as the majority of reported cases of radical trachelectomy have been in women with tumours less than 2cm in diameter. A recent prospective multicentre study by Renaud et al (2004) of radical trachelectomy combined with laparoscopic pelvic lymphadenectomy reported three recurrences in 100 treated patients (FIGO IA1, IA2, and IB1). NICE (national institute for clinical excellence) guidelines (2010) state, that women requesting fertility conservation should be offered radical trachelectomy and pelvic lymph node dissection, providing tumour diameter is less than 2cm and no lymphatic-vascular space invasion is present. As established within the case notes, Patients A tumour presented at 5cms, which means guidelines were not properly followed. In addition to trachelectomy patient A underwent ovarian transposition. Preservation of ovarian function is an important concern in premenopausal cancer patients whose treatments include external beam radiation to pelvic structures that incorporate ovaries applicable to patient A. Ovarian transposition was developed to displace ovaries from their normal anatomic position and away from direct radiation, with goal of maintaining long-term ovarian function. Ovarian transposition is seen as 40-50% successful (Shepherd, 2009). Techniques for ovarian transposition using a laparoscopic approach depend on radiation field size and location. Tinga et al (1999) have described transposition of ovaries in a fixed position behind uterus (to lie beneath an external midline block) as well as a superior transposition to level of iliac crest. They contend that the disadvantage of midline oophoropexy (surgical fixation or suspension of an ovary) is a higher level of internal radiation scatter, as the area is generally surrounded by in-field radiation. Morice et al (1998) reported a series of 24 patients who underwent ovarian transposition to paracolic gutters, before radiation for gynecologic malignancies. Authors concluded that this procedure was a safe and effective method of preserving ovarian function. Complications in both of these reports were rare. The fact of Patients A recurrence being at sight of transposition was noted as extremely rare and was the first case experienced by the clinical oncologist. No li terature was found outlining risks of recurrence of cervical cancer with ovarian transposition. It could be noted that perhaps Patient A’s size of tumour was too large for radical fertility sparing surgery. Psychological Support Patient A and her family experienced a great deal of distress during the care pathway. In 1983 Derogatis et al acknowledged cervical cancer as having a significant psychological and psychosocial impact on the individual and felt it was important to develop strategies to deal with this. Fallowfield et al (2001) recognise psychological distress as being common in patients with all forms of cancer and advocate it as remaining undetected. Regardless of socio-demographic characteristics or clinical characteristics, the well-being of patients with cervical cancer changes during the course of their disease (Greimel et al, 2000). A study by Greimel et al (2000) of 119 patients’ newly diagnosed gynaecological cancer evaluated psychological well-being and functions of daily living before surgery, three months after surgery and one year after surgery. Greimel et al (2000) noted a decline in psychological well-being and functions of daily living scores at three months after surgery. After one year there was a significant improvement in psychological well-being and no significant difference in functions of daily living compared to before surgery. Greimel (2000) recognised that in patients treated with surgery, level of psychological distress may be related to extent of surgery. The multidisciplinary team (MDT) should routinely screen for presence of psychological distress and be aware of risk factors for very high levels of psychological distress from point of diagnosis onwards (including during follow-up review phases) (Fallowfield et al, 2001). The MDT team involved with patient A routinely screened her psychological well-being and monitored it closely due to the young age of the patient. Patient A had regular contact with a support group and social worker for young patients in a similar circumstance. She was able to discuss matters which she was unable to share with her family and partner, such as body image and sexuality issues. As illustrated by Fallowfield et al (2001), many of psychological, physical and practical challenges facing women with cervical cancer are common to all cancer patients. These include, coping with shock of diagnosis, pain, nausea, fatigue and disfigurement from surgery as well as treatment worries over practical issues such as travel costs and loss of income. These above challenges were all experienced by Patient A. MDT supported the patient through these challenges. There is evidence that providing psychological and practical support may have a positive effect on patients’ well-being (Slevin et al, 1996). Evidence identified in relation to support needs of cancer patients was from small heterogeneous studies such as Walker et al (1999) and types of help offered are very varied. No studies found were specific to patients with cervical cancer but were comparable to cervical cancer population. Interventions included structured psychological support, relaxation techniques, o rientation programmes and general psychological support. The interventions reduced anxiety levels and improved quality of life.There are many national and local support services, for example, voluntary agencies, clinical nurse specialists, liaison psychiatry, clinical psychologists, local support groups, drop-in centres and day centres. These support services may offer complementary therapy services, such as yoga, aromatherapy and reiki. Reflexology was undertaken by patient A which, was offered by one of these support services. NICE guidelines (2010) state that â€Å"Patients with cervical cancer should be offered psychological support at time of diagnosis and at intervals throughout their management. Information about local support services should be made available to patients. Carers, families and dependants should be made aware of support available including local and national organisations. Multidisciplinary teams across healthcare settings should have agreed protocols for offering support for carers, families and dependants of patients with cervical cancer.† These guidelines were adhered to in the treatment of patient A. Near the end of Patients’ A life, a MDT decision was made to commence the Liverpool Care Pathway. Over past few years a major drive has been underway to ensure that all dying patients, and their relatives and carers receive a high standard of care in the last hours and days of their life. The Liverpool Care Pathway for the Dying Patient (LCP) is a key programme within the palliative care pathway for a patient. LCP was recognised as a model of best practice in the NHS Beacon Programme (2001). It was recommended in NICE guidance on supportive and palliative care for patients with cancer (2004) as a mechanism for identifying and addressing the needs of dying patients. It was recommended in the Our Health, Our Care, Our Say white paper 2006 as a tool that should be rolled out across the country. It is recommended in the End of Life Care Strategy DH 2008. Optimal management of cervical cancer involves a multidisciplinary team as demonstrated in Patients A case. The challenge for the team is to individualise treatment. As cervical cancer commonly occurs between ages of 30 and 45, this includes offering women with early disease the option of having fertility conserving surgery, where appropriate. Patient A did not fall into common age group for occurrence of cervical cancer. Patient A presented aged 22. For those such as Patient A, with intermediate or advanced disease, aim is to minimise treatment side effects without compromising outcome. Chemotherapy and Trials Within the last ten years concomitant chemoradiation has been the standard of care for advanced cervical cancer. Patient A received Cisplatin with radiotherapy followed by Adjuvant Topotecan. Varying proposals have been made that to control occult metastatic disease adjuvant chemotherapy after chemoradiation will improve outcome. In 2009 Duenas-Gonzalez et al described results of a phase III randomized trial which compared chemoradiation with gemcitabine and cisplatin followed by adjuvant gemcitabine and cisplatin for two additional cycles VS chemoradiation with cisplatin in women with stage IIA to IVA cervical cancer. Results showed a significant survival benefit for patients receiving chemoradiation plus adjuvant chemotherapy, the results concluded a 3 year survival of 74% in the chemoradiation plus chemotherapy arm against 65% in the chemoradiation arm. In order to confirm these results future trials are imperative, Kitchener et al (2010) aim to randomise women receiving chemoradiaiton after radical hysterectomy to four additional cycles of carboplatin and paclitaxel or no additional therapy. Chemotherapy is recognised as a standard treatment for women with late stage disease and those with recurrence not eligible for chemoradiation or surgery applicable to patient A. Monk et al (2009) published results of a phase III trial which compared 4 platinum containing doublets. Patients were randomised to receive cisplatin combined with either paclitaxel (the reference arm), vinorelbine, gemcitabine or topotecan. The results showed that progression free survival and response rates were similar in all four arms. Cisplatin with paclitaxel was found to have the best toxicity profile with quality of life similar across the four arms Angiogenisis is the formation of new blood vessels that grow into the tumour, giving it nutrients and oxygen to assist its growth. As with other cancers the role of anti-angiogenic targeted agents are of interest and importance in the treatment of cervical cancer. A phase II trial of bevacizumab in women with persistent or recurrent cervical cancer concluded a median progression free and an average overall survival range 3.4 – 7.3 months thus showing favoribilty within cervical cancer (Monk et al, 2009). Leading from the results of this trial Kitchener et al (2010) constructed a phase III trial where women are randomised to one of four arms using bevacizumab with cisplatin/paclitaxel or topotecan/paclitaxel. Monk et al (2010) identified Pazopanib as a second anti-angiogenic agent usuable within the cervical cancer patient population. This agent is known as an oral tyrosine kinase inhibitor which targets the vascular endothelial growth factor receptor. It was found that patients treated with pazopanib had a median overall survival of 50.7 weeks. Patient A received topotecan as a single adjuvant agent, if combined with an anti-angiogenic agent such as bevacizumab or pazopanib she may have had a prolonged life expectancy. Funding, costing and PCT approval may have been a barrier to access. Conclusion Patients A case is a sad case. The patient underwent ovarian transposition in order to preserve fertility but unfortunately the disease recurred at this site. Perhaps if the transposition was not undertaken then she may have still been alive. Ultimately it was the patient’s choice and due to the patients young age fertility preservation was very much applicable and supported by the clinician. There is a lot of controversy surrounding the topic of lowering the age of PAP smear testing and the standardisation of HPV testing as routine. If patient A had had regular smear tests and HPV testing as research has proved beneficial her disease may have been identified earlier and put through radical treatment. The availability of anti angiogenic has not yet been standardised by some PCTs, patients A access to chemo drugs such as pazopanib may have prolonged her life further. Throughout the past years there have been many advances and discoveries in the prevention and treatment of cervical cancer, Within the next five years there are many other advcances and technologies that will possibly impact the management of this common indiscriminatory disease. Active areas of research that can change the management and practice include the use of PET/CT imaging to guide therapy and PET or high-field MRI to monitor response to treatment, combined use of hyperthermia and radiation therapy to treat locally advanced disease and the role of intensity modulated radiotherapy. Appendix 1 FIGO staging of cervical carcinomas Stage I: Stage I is carcinoma strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm. Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter. Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter. Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers. Stage IB1: Clinical lesions no greater than 4 cm in size. Stage IB2: Clinical lesions greater than 4 cm in size. Stage II Stage II is carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third. Stage IIA: No obvious parametrial involvement. Involvement of up to, upper two thirds of the vagina. Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall. Stage III Stage III is carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers. Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina. Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney. Stage IV Stage IV is carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum. Stage IVA: Spread of the tumour into adjacent pelvic organs. Stage IVB: Spread to distant organs. Source: TNM Classification of malignant tumours. L. Sobin and Ch. Wittekind (eds.), UICC Internation Union against Cancer, Geneva, Switzerland, pp155-157; 6th ed. 2002 Appendix 2 ECOG Performance Status These scales and criteria are used by doctors and researchers to assess how a patient’s disease is progressing, assess how the disease affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. ECOG PERFORMANCE STATUS GradeECOG 0Fully active, able to carry on all pre-disease performance without restriction 1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours 3Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 5Dead As published in Am. J. Clin. Oncol. :Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982 References Cancer Research UK. (2003) UK Cervical Cancer incidence statistics [online]. 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