Essay on Compare Mill and Kant’s Ethics - 862 Words

Kant’s Ethics may best apply to modern business. Kant said right action based on a set of moral rules, and the right action is supposed to be the one that conforms with these rules, whereas certain other types of action are morally forbidden. He also suggests that people should be treated with respect and as ends in their own right, not solely as means to others ends. On the contrary, Mill’s ethics only concern about the happiness of majority instead of duty itself. Thus, the question how could Kant’s â€Å"austere† system do better for business needs than Mill’s flexible business ethics. I would say that although Mill’s Ethic is a functional system of moral analysis, but the decision is easily changeable when the consequence change and in†¦show more content†¦However, a Kantian doctor will say that is immoral and he should tell the truth about the person’s diagnosis. It is the duty of the doctor to be honest to his/her patien ts. Also, we should respect a patient’s own right to decide for his/her life. We cannot use the patient as mean to achieve other ends which is the greatest happiness of the people involved. One may argue that utilitarian consider long term consequences if doctor lie. Although this is true, we must not forget sometime long term consequence is not uncovered. When long term consequences are not known, we cannot make a moral decision, where as Kant’s approach concern about the duty of doctor instead of outcome of the action. Another scenario, suppose a doctor sees the test data showing that the person has a disease that is curable and have survive rate of greater than fifty percent. What will the doctor do? A utilitarian doctor will say telling the truth there will be a great deal of pleasure to all. The person will be happy, their family will be happy, the doctor will be happy in informing the ill person that there is treatment to alter his/her condition. So the ethical s olution will be to tell the truth, which is different from the first scenario. The Kantian doctor would make the same decision as the decision he made in the first scenario, no matter how the outcome changes. The two cases show that, although the doctors using different ethical approach, they may end up making the sameShow MoreRelatedPsychological and Ethical Egoism, Mill vs Kant, and Ethical Relativism904 Words   |  4 PagesTopic 1 Distinguish between psychological and ethical egoism and subject each to critical scrutiny in detail. Compare and contrast ethical egoism with virtue theory. Egoism is a view that states that what a person wants is somewhat relevant to what humans actually do. There is two main types of egoism: psychological and ethical. These two views are very similar; because of this they can easily be interchanged. It is important to be able to recognize the dissimilarity of these two views. PsychologicalRead MoreKant : Kant s Ethics1293 Words   |  6 PagesKhaled AlMarwani Philosophical Ethics PHL270 Dr. Elizabeth F. Cooke Question # 1: Kant’s Ethics According to my humble reading, Kant is considered the hardest to read, grasp and understand among the philosophers that we came across studying ethics. According to Kant, nothing could be called good without qualification except a good will. And the good will is the desire or the tendency to do your duty because it is your duty, not anything else. Thus, nothing can be gained out of an actionRead MoreEthics And Ethics Of Ethics Essay1491 Words   |  6 Pagesemployees that the work place ethics code forbids using work-place resources for personal financial profit. To make ethically right decision in this ethical dilemma, I will focus on the philosophers’ standpoint and reasoning of ethics of care, ethics of justice, utilitarian ethics and universal principle to analyze the situation. In this tough situation, my conclusion is that I will not report this action to the higher authority although she is violating work place ethics code. I will provide my reasoningRead MoreThe Ethics Of Virtue Ethics925 Words   |  4 PagesVirtue ethics is a normative theory whose foundations were laid by Aristotle. This theory approaches normative ethics in substantially different ways than consequentialist and deontological theories. In this essay, I will contrast and compare virtue ethics to utilitarianism, ethical egoism, and Kantianism to demonstrate these differences. There is one fundamental aspect of virtue ethics that sets it apart from the other theories I will discuss. For the sake of brevity and to avoid redundancy, I willRead MoreAnalysis Of The Book Justices : What Is The Right Thing Essay1540 Words   |  7 Pagesand beneficial to generate the greatest happiness for the greatest number. Both Jeremy Bentham and John Stuart Mill support different type of utilitarianism. While Bentham supports the act utilitarianism where â€Å"highest principle of morality is to maximize happiness, the overall balance of pleasure over pain† (23). Bentham foc uses on the act in order to see if it promotes pleasure, while Mill supports the rule utilitarianism because rules and laws can help promote happiness. For example, if a hungryRead MoreMorals, Ethics, And Modern Thinking Essay1367 Words   |  6 PagesMorals, Ethics, and Modern thinking Morality is the social practice of what we define as right and wrong. Rules, policies, customs vary all over the world in all kinds of settings. Some think that if you â€Å"use your good judgment† or â€Å"let your conscience be your guide† you are promoting good morality. When we disagree about what is good morality, is there a theory out there that will resolve the disagreement? Factual information of income inequality shows a divergence from moral ethics and the consequencesRead MoreJohn Stuart Mill And Immanuel Kant Essay1805 Words   |  8 PagesKant and Mill, to determine whether or not torture is ever ethical. John Stuart Mill and Immanuel Kant, both proposed different philosophies, using deontological and teleological theories in ethics. John Stuart Mill used a teleological theory, which prioritized the end result of an action, based off the moral nature of the action itself, compared to the deontological theory proposed by Kant, which presented actions as o bligations of an individual, leading them to act in a certain way. Mill used a codeRead MoreKant And Mill On Animal Ethics Essay1365 Words   |  6 PagesIn this essay I will begin by explaining the overall views of Immanuel Kant and John Stuart Mill, then compare and contrast the ideas and philosophies of Kant and Mill on Animal Ethics. I believe that Kant, the deontologist, will not care as much about the duty/responsibility between humans and animals as Mill, the utilitarian, who will see the extreme importance of animal ethics. After studying and explaining the views and teachings of these two philosophers I will see if my thesis was correct,Read MoreComparing Aristotle And John Stuart Mill1130 Words   |  5 PagesKearney PHIL 231: Ethics 28 April 2015 Essay 2 Comparisons on Pleasure in Morality The role of pleasure in morality has been examined thoroughly throughout the beginning of philosophy and continues to be a questionable issue. With these in-depth examinations, some similar outlooks as well as differing views have been recorded. Many philosophers have dissected this important topic, however I intend to concentrate of the famous works of Aristotle, Immanuel Kant, and John Stuart Mill. After meticulouslyRead MoreThe Case Of Frank Van Den Bleeken1672 Words   |  7 Pagesand John Stuart Mill would reach an agreement in which Van Den Bleeken should be restricted his right to physician assisted suicide. The three philosophers had various epistemological thought processes and ethical theories applied in determining what was moral. Whether it was the individual’s duty to stay in jail, the best option for the most people involved, or simply the rule, Frank Van Den Bleeken should have to live out his full sentence. Part A: Kantian Ethics Kantian ethics does not look at

Encourage Foreigners to Invest in Philippine Real Estate Market Free Essays

Topic: Encourage Foreigners to Invest in Philippine Real Estate Market Real estate business is a very lucrative and capital intensive venture. It is not for just any one, but only for those who have financial capacity and willingness to buy real properties. Real property may come in the form of buy and sell, or merely renting and make money out of it. We will write a custom essay sample on Encourage Foreigners to Invest in Philippine Real Estate Market or any similar topic only for you Order Now Known as one of the most vibrant real estate markets in Asia, the Philippines growing economy consistently sustained its growth despite the global economic recession. The country’s real estate industry has been receiving positive remarks from various analysts across the globe. The reflection of its success, mainly rooted to the country’s excellent financing services, good capitalization and pro-business climate drives every real estate investors to provide the best real estate solutions for needs of the market. The real estate industry has been increasing year on year and this is characterized by the dynamic growth and upsurge of condominium development across Metro Manila. This growth is fuelled by the increasing overseas Filipino workers remittances as well as new investors who take advantage of the benefits of the low interest rates in the housing market. The influx of condominium development across Metro Manila also validates the soaring demand for residential options, which is between renting an apartment and owning a home in the city. Various innovative unit designs and concepts are being offered in the market to suit current trends in housing and lifestyle preferences of today’s market. This increasing realtors’ confidence to Philippine real estate industry is brought by the improving economy, implementation of good governance among private and public sectors, and the reform inspired government of the new administration. Presently, the real estate market is banking on two major components: (1) remittances of overseas Filipino workers and (2) continuous growth demand by the expanding business process outsourcing industry in the country. Aside from having an investment that never depreciate, investing in real estate in the Philippines would give foreigners additional investment portfolio in a much lower cost compared if they invest it in their own land. The cost of living in the Philippines is relatively lower compared to other nations, and therefore, foreigners can have more value for their money, which in turn increases their investment opportunities. That would be considered â€Å"hitting two birds with one stone†. The economic outlook on the Philippine real estate market is seen to be growing, and it will continue to grow in the next five to ten years brought by the ensuing business process outsourcing industry. BPO is becoming one of the primary sources of income of the young working population in the country today. Owning/Investing Options for Foreigners Any foreigner can lease, buy and own with 100% ownership rights on condominium units only. As far as the law is concerned, every piece of land of the Philippines is for the Filipino only. For investment purposes, foreigners may also lease or buy building offices for business purposes, like those being rented out to others. In as much as there are limitations being followed by foreigners when investing the Philippine real estate market, there are also ways on how they can easily own one. (1) Lease a property – foreigners can lease a property from short to long-term as long as both parties to contract mutually agree. Leased properties may be subleased to other tenants. This form of business operation may be considered as legal operation and foreigners can take advantage of. (2) Be married to a Philippine citizen – once a foreigner is married to a Philippine citizen, the rights to own a land becomes a conjugal. It may seem to be the fastest and least cost among other options. (3) Inherit the property from a deceased Philippine spouse – once married, but suddenly the Philippine citizen spouse died. In this situation, the foreigner spouse together with the other surviving heirs; will be the immediate heir and owner of the property left behind. 4) Purchase land as Balikbayan – some Filipinos who have stayed abroad and eventually availed of another citizenship, may still buy and own properties. It is also possible to own property if the parents or relatives wanted to transfer their property ownership to a Balikbayan. (5) Buy condominium units – foreigners can buy condominium units, in the same way as a Philippine citizen acqu ires condominium unit. Some foreigners can also do trading of condominium units. They can do buy and sell business operation, wherein they will buy a barely finished unit, dress it up and fill with furnitures, and sell at a premium or lease it out. 6) Form a corporation – this option opens the opportunity for foreigners to invest in land, but, it is a must, that the corporation be composed of at least 60% Filipino and only 40% for foreigners. The majority stakeholder should still be Filipinos. After enumerating the ways on how foreigners can invest in the Philippine real estate market, it is imperative for them to know the basic information and obligations when investing in real property. First thing is the preparation for tax obligations. Non-resident foreigners who acquire property may be assessed with 5% – 32% of taxes, depending on the nature of the transaction. Another consideration is the documentary requirements necessary for the processing of transferring of ownership to a foreign national. There are documents that need to be authenticated by the Philippine Consulate from their country. Overview of the Real Estate Investment Trust (REIT) The efforts of passing the REIT Law will open another medium for foreigners’ opportunity to invest in the Philippine real estate market. REIT is defined as a corporation engaged in business whose income will be generated from owning or managing real estate. Through this REIT, the country will be given a better and bigger opportunity to join the global market of real estate investment markets, and foreigners can take their part in. Since it is not yet passed as law, the regulations, rules and limitations are still unknown. Another positive contributor to success of the real estate sector is the proliferation of establishment of special economic zones across the country. The government provides incentives to companies who patronize economic zones, and this attracts more foreign corporate clients and brings their business process outsourcing facilities here. How to cite Encourage Foreigners to Invest in Philippine Real Estate Market, Papers

The Dress free essay sample

â€Å"The Dress† is a short story about a dysfunctional family, consisting of two sisters, Flora and Rachel, and their mother. Flora has stolen Rachel’s dress, spilled a drink upon it and afterwards buried it in the garden. The conflict erupts during their mother’s birthday meal at a restaurant. Once at home again from the restaurant the crisis results in both girls leaving the house – leaving their mother behind, alone, with a glass of wine. The setting of the story is not distinctly described as it is not crucial for the understanding of the story. The story only features three characters: Flora, Rachel and their mother. Rachel comes across as the bigger sister, frustrated with Flora’s carelessness. Her rage against Flora for stealing the dress is unusual keen, concerning the fact that it is only a dress – â€Å"only a scrap of material†, as Flora at some point exclaims. As a reader you immediately get a sense of a smouldering danger just beneath the surface. We will write a custom essay sample on The Dress or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Something undefined, yet ominous. Flora is obviously conscious that what she is doing is wrong. But while she understands that her sister will not be pleased with her stealing the dress, she could not possibly imagine the hatred it would release. Flora is ignorant and careless, but she is only immature – not vicious. Their mother is a bereavement counsellor, but despite this she is unable to deal with the daughters constant intrigues. When she is at home she has a need to distance herself from her professional work, and therefore she only wishes to be in a loving and caring environment. This results in a neglection of her daughters, which has obviously had an effect on the two sisters. Rachel depresses her feelings, and is unable to handle them: â€Å".. Rachel knew that she would have to be pleasant, to forget about her stolen dress, wear something else, and smile. † , and Flora is desperately trying to get her mother’s attention. The mother feels unsafe about facing serious problems in real life: â€Å"She (the mother) liked emotions to be explored in safe rooms, with a clock. † She is rather ignorant about the serious crisis between her daughters, and would like them to make an effort to behave nicely, and hide away their problems. The relationship between the two sisters is tensed. Flora is dangerously jealous of Rachel, and secretly wishes to be just like her: tall, brave and clever. The dress represents everything that Flora wants to be – and everything that Rachel is. But the other way around Rachel seems to feel jealousy towards Flora too. When she realises her dress has gone, and she imagines how Flora would be sitting at a cafe wearing it, Flora is described rather incredible. As if Rachel’s perception of Flora is that she is superior. Rachel may be feeling overlooked and deprived of motherly care, as her sister desperately craves their mother’s attention. This naturally generates a fierce hate against whoever, in this case Flora, gets the attention she is deprived from. This may explain why Rachel reacts unexpectedly intense in the matter of the stolen dress. To her it is not just the dress – it is Flora steeling the attention and loving care that she, Rachel, was meant to have. The mood in this short story is the feeling of a great danger just underneath the surface. Something that is much more frightening than the superficial crisis in the mutual relations. It makes you feel like you are apathetically awaiting something unpredictable, yet inevitable. The whole story seems to me like an allegory. Nothing seems right, just as if the story is a transparent layer, covering up the real story. The dress in this story is the main symbol. It plays a central role in the relationship between the two. Between the sisters the dress is a symbol of the differences between them and the jealousy. Flora is trying to â€Å"steel† the identity of her sister Rachel. Flora is insecure, and feels like she deserves the dress (Rachel’s qualities) more. This frustrates Rachel for if Flora becomes Rachel, then who is Rachel? When flora buries the dress in the garden, it becomes a symbol of neglection of the jealousy, and her failed attempt of becoming like Rachel. The language is down to earth and everyday like. The sentences vary from very short, definite, ones when describing actions, to longer descriptive ones when describing surroundings. It creates a perception of a dull and ordinary life. The main themes are jealousy and neglection the jealousy that Flora feels for Rachel, and their mother’s neglection of them, and their emotions. The short story is about a mother’s inability to cope with the crisis between her daughters, despite the fact that she is actually a bereavement counsellor. Maybe there is a connection between the mother’s profession, and Flora’s act of burying the dress, which is rather ironic.

Styrofoam and Clam Shells as Tiles Essay Example For Students

Styrofoam and Clam Shells as Tiles Essay STYROFOAM AND POWDERED Mercanana mercanana (CLAM SHELLS) AS ALTERNATIVE TILES INTRODUCTION A. Background of the Study Our country is presently facing from economic crisis. Financial problem is one of the biggest problems of each Filipino family. People tend to budget their money wisely, it is because all the needed things which are sold in the market are all expensive which includes foods, clothing materials and etc. Waste materials like plastics and Styrofoams are scattered anywhere. People tend to throw or disposed these wastes to rivers, lakes and seas, which the results caused water pollution and diseases. Clam shells are very abundant in our locality, which are highly valued as delicacy. Clam shells contain calcium carbonate, which indicates that it can be use as a source of calcium oxide (CaO). Only the meat of the clam will be eaten and the shells are thrown away. So the researchers wants to determine if dissolved Styrofoam and powdered Clam shells can be a good component in making tiles. B. Statement of the Problem This study aims to produce tile from the mixture of dissolved Styrofoam and powdered clam shells, specifically it aim to determine; a. We will write a custom essay on Styrofoam and Clam Shells as Tiles specifically for you for only $16.38 $13.9/page Order now If dissolved Styrofoam and powdered clam shells is a good component in making tiles. . Which of the following ratios, 2:1, 3:1, and 4:1, powdered clam shells is to dissolve Styrofoam is a good tile using the durability test and water absorption test. c. If the dissolved Styrofoam and powdered clam shells tile is comparable to commercial tile. C. Statement of the Hypothesis a. If the dissolved Styrofoam and powdered clam shells is a good component in making tiles then we will try to contact the South Milandia, Inc. Ceramic and Granite Tiles, Zamboanga City) to recommend our study to them. b. If we will going to conduct the following ratios we will having a three trial test in durability test and water bsorption test so that we can identify the durability of each given ratio and to determined the difference of soaked tile (grams) with the initial weight of the tiles. c. If the dissolved Styrofoam and powdered clam shells tile is more comparable to commercial tiles then you can save mon ey and it can help to reduce the amount of Styrofoams and in our community. This research study aims to produce tile out of dissolved Styrofoam and powdered Clam shells. This research study is important in a way that it can help to minimize the amount of waste materials particularly the non biodegradable ones, which are isposed anywhere. Therefore, this can help to prevent pollution and avoid diseases. This study also helps to prevent the destruction of our environment like rivers, lakes and seas. Finally, this research study also produce useful and affordable tile that each individual can enjoy and have a comfortable houses to live in. E. Scope and Limitation The boundary of this research study is to extent the use of dissolved Styrofoam and powdered Clam Shells as tiles. This study limits only on the ratios of 2:1, 3:1 and 4:1, powdered Clam Shells and dissolved Styrofoam respectively. This study also limits on he two tests, the durability and water absorption. Three trials were conducted per test per treatment. REVIEW OF RELATED LITERATURE Tiles are similar to bricks; they differ in uses, shapes and in finishing. A brick is in the form of a block while a tile is in the form of a sheet. Both are made from the same process and materials but the tile may go through glazing can give it a smooth finish. Tiles are used for walls and flooring. Clay was used as a material in making tiles. A reserved of 41. 5 mil. Tons of clay located in Giengday ensures the production of 100 mil. Bricks and tiles for a period of ore than 100 years. Giengday clay high contents of Fe203 and Fe304 as compared to those found in other places that bricks and tiles made of this material are dark red and well-shaped, smooth and of high quality. .u6c54747b98fbee185a01d05e7a62c280 , .u6c54747b98fbee185a01d05e7a62c280 .postImageUrl , .u6c54747b98fbee185a01d05e7a62c280 .centered-text-area { min-height: 80px; position: relative; } .u6c54747b98fbee185a01d05e7a62c280 , .u6c54747b98fbee185a01d05e7a62c280:hover , .u6c54747b98fbee185a01d05e7a62c280:visited , .u6c54747b98fbee185a01d05e7a62c280:active { border:0!important; } .u6c54747b98fbee185a01d05e7a62c280 .clearfix:after { content: ""; display: table; clear: both; } .u6c54747b98fbee185a01d05e7a62c280 { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .u6c54747b98fbee185a01d05e7a62c280:active , .u6c54747b98fbee185a01d05e7a62c280:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .u6c54747b98fbee185a01d05e7a62c280 .centered-text-area { width: 100%; position: relative ; } .u6c54747b98fbee185a01d05e7a62c280 .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .u6c54747b98fbee185a01d05e7a62c280 .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .u6c54747b98fbee185a01d05e7a62c280 .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .u6c54747b98fbee185a01d05e7a62c280:hover .ctaButton { background-color: #34495E!important; } .u6c54747b98fbee185a01d05e7a62c280 .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .u6c54747b98fbee185a01d05e7a62c280 .u6c54747b98fbee185a01d05e7a62c280-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .u6c54747b98fbee185a01d05e7a62c280:after { content: ""; display: block; clear: both; } READ: Old is GOld Sample EssayGienday clay is really qualified enough to produced ceramic and chinaware, decorative bricks used in extra standard building. (Shriff, 1982) A clam shell burrows shallowly in sediments of either mud or sand. It is among the most commercially important species of invertebrate. Clams have a large, heavy shell that ranges from being a pale brownish color to shades of gray and white. The exterior of the shell, except nearest the umbo is covered with a series of growth rings. The interior of the shell is colored a deep purple around the posterior edge and hinge. METHODOLOGY A. Research Locale This study will be conducted at Tumulaks Residence at Villa Luz Drive, Tugong Road, Sta. Maria, Zamboanga City. This research is a qualitative type of research for it will compare the commercial tiles and tiles out of Styrofoam and Clam Shells. C. General Procedure Preparation of Materials Shells will be obtained from the fishponds in Zambowood, Zamboanga City. The hells will be wash and then sun-dried. The shells will be pulverized and stained to separate to bigger particles. Styrofoams will be obtained from neighbourhood and from restaurants were it was used as food packaging. The collective Styrofoam will be wash and leave for drying. Three hundred grams of Styrofoam will be dissolved to 1 L. of premium gas. Preparation of Mixtures The powdered oyster shells and dissolved Styrofoam will be mixed evenly to the following ratios, 2:1, 3:1 and . Molding and Drying The prepared mixtures will be poured into the corresponding molders made up of luminum having 4 X 4 dimensions. The molders will be kept in a cabinet and leave for air drying. The average curing period of the tile is about two to three weeks. Glazing The dried mixture will be glazed by applying lacquer on the tiles. The applied lacquer will leave for drying then second coating will be done and leave again for further drying. Continuous application of the lacquer will be done until the desired glossiness will be achieved. Testing the Tiles A. DURABILITY TEST The durability test will be done by placing the tile on the floor and a load will be drop n the tile with the respective weights of 1. kg, and 2 kgtoa height of 1 meter. Three trials will be conducted per treatment per test/load. Commercial tiles will also test using the procedure to compare its durability value. B. WATER ABSORPTION TEST The tiles will be soaked in a basin with water and left for observation for about one (1) day. There will be three trials will be conducted per ratio. Commercial tiles will measured (grams). Water absorption value will be determined by getting the difference of the soak ed tile (grams) with the initial weight of the tiles.

Mrs. Mann Essay Example

Mrs. Mann Essay Example Mrs. Mann Paper Mrs. Mann Paper The novel Oliver Twist was written in the Victorian period by the famous Charles Dickens, witch was also the period of the industrial revolution. Because the population was very high and still increasing the demand for goods also dramatically increased. With such a high demand the living conditions and goods such as food and clothing severally lacked in quality. The living conditions for the poor people in large cities where very bad, so bad in fact that familys were forced to share one room between themselves. The amendment of the poor law was introduced in 1834, this law was made to disapprove of poor people living in workhouses. Workhouses were horrible places to be, only people who had no other choices would live and work there. People who were in there would be separated according to their gender and age. This novel begins with the birth of Oliver twist, after Olivers mother had given birth she hardly had the strength to hold her own baby in her arms. She gave him one last kiss before she closed her eyes and died. Because his father or family could not be located he was put into a workhouse as an orphan. He was treated terribly, he was fed watery gruel three times a day, an onion twice a week and half a roll on Sundays. They grew so hungry they used to worry they might eat each other dickens used irony to highlight the serious neglect with that quote. The character Mrs. Mann took care of the children but did a terrible job of it. She mistreats the children, Mr. Bumble who is her superior is supposed to check on her but he puts up with her and her wrong doing. I believe that the only reason Mrs. Mann chooses to look after the children is so she can torment and bully them, to feel that she is bigger and better then them. I think that the society and Mr. Bumble should not have let her get away with such savvier wrong doings and should have let her take care of the children. I think Charles dickens chose the name Mrs. Mann because it reflected the characters personality, she is a manly and strong character. Life in the workhouse was horrible, the conditions where very poor and the children where practically starving. The boys where fed watery gruel three times a day. Oliver along with all the other children was skinny and small. The children chose between themselves who would go up and ask the master for more gruel after supper and in the end it came down to Oliver. So he went and asked, the workhouse governors were horrified at his crime so they locked him in a cell for over a week. Sum one would come in everyday and beat him. Oliver escaped to London and met a character name Jack Dawkins (AKA the Artful Dodger). He took Oliver to a place were he could stay.

Art History Essay The Breakfast Scene

The symbol of cupid presented reflects themes presented within Venus, Cupid, Folly and Time , displaying aspects of misguided love , primarily emphasizing how lust compromises the morale of individuals. That the count presented sense of obliviousness in regards to the consequences of his actions, well eventually taint his family name in regards to the infidelity committed , but also such constant self ind... ...h open composition, provides a rustic appeal in order to emphasize the working class. The portrait depicts a fisherman’s daughter , maintain her lovely complexion , in order to lure individuals , to purchase selfish that resides in a basket placed upon her head, establishing a sense of euphoria. Adopting such seductive appearance to establish a form of interest , not only to display her services , but also displays aspects of eroticism and feminism , very large breast that references aspects of fertility , but also the delicate facial features the use of blush to complement her subtle complexion. The use of contropasto, the bodily composition presents a sense of equilibrium in which the action correlates with the action depicted, in which her arm is extended in order to maintain the balance. While the other resides at her waist idealizing her feminine figure.

Marketing Essay Example | Topics and Well Written Essays - 2000 words - 6

Marketing - Essay Example Table of Contents Table of Contents 3 Introduction 4 Types of Websites 6 Comparison between B2B & C2C websites 8 Recommendation for improvements 12 Conclusion 13 Reference 14 Introduction In the year 1990 commercialization f the web began with the introduction of linking websites and the information by Tim Berners-Lee’s. With the advancement in the technological field more innovative approach came into play with the innovation of new hyper text transfer protocol (HTML). New browser was developed by the developers of them the most prominent one becomes Internet Explorer from Microsoft Corporation which gained popularity amongst the users. The major factor behind the rapid growth of the Web technology is due to the fall in price of computers and interest rate of the bank which increases the ownership of computers to great extent amongst the people. Different types of websites came into existence and increased at lightning speed from 19,000 websites to 176M websites just within a period of 18 years from 1990’s to 2008. With time and technological inventions better understanding of the web techniques and developers helped in better communication and user friendly design which created more attractiveness for the websites for different companies. ... E-commerce was introduced into web and companies carry out their business over internet for a better reach to the customer resulting in huge growth from $27M in the year 2000 to $ 139M in 2008. Figure 1: E-commerce retail sales growth 2000-2008 (Source: Cengage Learning, n.d.) This report is mainly concerned with the analysis of two kinds of websites one is Business to Business website (http://australia.cat.com/) and the other one is Consumer to Consumer website (eBay.com.au). Both these websites are based at Australia and the companies are operating their business in two different ways with the help of technologies which is needed to be evaluated in this project. Types of Websites While developing a website one of the foremost requirements for the company is to understand the types of business in which the company operates in. With proper understanding of the business process the website development team can implement the strategies and design the website for better grip in the mark et. Complying with the business model is very essential for a sustainable growth in the market for the company. For operating business online e-Commerce business model is the major tool for the companies to reach to the customers in a more convenient manner. E-Commerce technology can be implemented on several ways in different types of websites according to the business process and the product offering of the company. The different types of websites can be as follows- Business to Business (B2B) When the e-commerce transaction is taking place in between two business units and the buying and selling of goods and services are carried out for manufacturing and producing new products. In business to business process the raw

Reflective Account Essay Example | Topics and Well Written Essays - 2500 words

Reflective Account - Essay Example According to Kohenen (2004), student must be facilitated in developing reflective learning through working on beliefs, experiences and learning assumptions on their own. As a volunteer teacher working with special needs primary school children I was able to practically learn a lot of skills which I think a long way in assisting develop my professional outlook going forward. For learning to occur there must be an explicit awareness and understanding of just exactly what is to be learnt as well as why it is necessary. Learning has been defined as a process of creating new knowledge and understanding that takes place through transforming experience (Kohenen, 2004). Reflection on its parts plays a very crucial role of I the learning process by bridging the gap between theoretical conceptualisations and practical experience. There is no doubt therefore that volunteer experiential learning is an important aspect of education that will help students transit from the theoretical setting of the class to the much important practical application of knowledge. Successful transformation must include both theory and application which almost guarantees learning. Reflective experiential learning will no doubt play an important part in my development and conceptualisation of ideas. Experiential learning integrates the theory and practical aspects of learning with aim of attaining a wholesome approach and stress the importance of experience in learning. it takes various forms such as work study assignments, internships in the business world, exchange & volunteer programs in education, clinical experience and many others depending on the industry. Principles of reflective and experiential learning are applicable in both formal and informal learning settings. The most important element is the emphasis on active participation through interaction where learners get

ICT Industry And Employment Essay Example for Free

ICT Industry And Employment Essay Understanding the impact of information technology will greatly affect one’s choice of career path. In this world of computers, electronic data and the internet, it is more practical to consider jobs and careers that go hand in hand with IT. There are solid evidences that the ICT industry will soon be the biggest player in any world economies. In the healthcare industry, every patient data is going paperless. With the introduction of EMR or Electronic Medical Records, hospitals, patients and health professionals can easily exchange data in order to assess the best possible way to provide patients with the necessary healthcare. Computers and the internet play important roles in EMR. Meanwhile, the finance and banking industry are also going electronic by implementing e-commerce strategies. Many of them are now providing electronic banking and investment facilities that clients can easily access. This innovation saves them thousands of dollars, which could have been used for labor, facility, or marketing funding needs. On the other hand, engineering companies are also joining the bandwagon. They have set up their respective IT departments in order to integrate computers to their manufacturing and service sectors. With the availability of reliable data, engineering companies can easily decide on implementing their plans or relaying information across all departments, which will result to better productivity. So what do these evidences say? Information and Communications Technology will soon become the very backbone of any economic sectors. In fact, any industries (software, electronics, hardware, internet) related to IT are considered some of the most robust in the global economy (Stanley Labs). If one wishes to get a bright future, then investing on learning the techniques in IT will be the right approach.

Alzheimer’s Disease: The Importance of Public Awareness Essay -- Alzhei

Imagine greeting your grandmother and being met with a blank stare. Think about how it would feel to watch as your father forgets how to drive or dress himself. Picture your own mother crying out for her long dead parents and siblings. Try to envision the look on a loved one’s face as you tell them that they can no longer live at home alone. Now put yourself in their place-- slowly losing your freedom, your memory, and your very identity. Welcome to the world of Alzheimer’s disease. This is the reality that nearly fifteen million caregivers and over five million patients must face every day. Public awareness must be raised about Alzheimer’s disease and the people it affects. Alzheimer’s disease was discovered in 1906 by German physician Alois Alzheimer. While studying the biopsy of the brain of a fifty-five year old woman who had suffered some type of severe dementia, he noticed some aberrations in her brain structure. The brain appeared shrunken, with enlarged crevasses in the gray matter. Over a century later, we now know that Alzheimer’s is caused by a mixture of chemical and cellular brain abnormalities and the breaking down of cells in the mind. Most of the defects occur in the cerebral cortex, which is the outer gray matter of the brain and the center of most human-like brain functions like memory, language, and thought. About ten percent of the nerves in the cerebral cortex die as the disease progresses, causing the person to lose previously created synapses (connections between nerve cells). Neurofibrillary tangles, which are abnormally twisted and knotted strands within nerve cells in the cerebral cortex, also contribute to the cognitive impairment. Nerve cells in the brain lose the ability to create vita... ... a disorder that plays a huge role in the United States, and one that needs to be recognized. Public awareness of Alzheimer’s will stimulate research to increase, more support to be made available to those directly affected, financial solutions to be found, and an overall increase in understanding and compassion. By informing people about Alzheimer’s and its consequences, we can truly begin to battle this devastating disease. â€Æ' Works Cited Alzheimer's Association. 2011 Alzheimer's Disease Facts and Figures. Annual Report, Washington: Alzheimer's Association, 2011. August, Paul Nordstrom. Brain Function. New York: Chelsea House Publishers, 1988. Check, William A. Alzheimer's Disease. New York: Chelsea House Publishers, 1989. Harmon, Dan. Life Out of Focus; Alzheimer's Disease and Related Disorders. Philadelphia: Chelsea House Publishers, 1999.

Extremist Group Essay

Makenssey Brinkman Mr. Feudo English 1 Pre-AP – 6th 22 April 2010 The Dangers of The Extremes Extremist groups go above and beyond to get what they want. They go to extreme measures, even disregarding people’s safety and turning groups against each other to reach their goal. They are a great hazard to mankind. Despite the fact that people have the right of free speech and assembly, the banning of Extremist groups will better society because they promote hate and violence and turn people against each other. Topic Sentence 1) Extremist groups shower hate all over the groups of people who oppose them, and they become relentless in their attempt to do so. (Evidence 1) – â€Å"Anti-choicers harassed [George Tiller’s] patients, day in and day out. They bombed his clinic. They shot him once before. They filed lawsuit after lawsuit and even convinced local prosecutors to launch criminal investigations and trials. † (Analysis 1) – The Extremist pro-li fe group attacked the abortion doctor with hate.By harassing his patients and trying to convince prosecutors to go against him, they set a solid, horrid example for others that do not share the same views as Tiller. These hateful attacks ultimately led to Tiller’s murder by gun at The Reformation Lutheran Church. (Evidence 2) – â€Å"To recruit members and spread its beliefs, the American Front has collaborated with various neo-Nazi and skinhead groups to stage protests and rallies that demonize Jews, blacks, and other minorities. (Analysis 2) – Just to try and get members into the group, the Extremist group staged many protests and minorities put down many minor groups, They promoted hate into the people who listened to and watched them as they did so, and therefore spreading the hate all they could. (Example 3) – â€Å"Anti-Semites and racists have found video-sharing websites, such as YouTube and MySpace Video, an effective means to promote propagand a and hateful material that might not otherwise be seen by the public.Internet users who search video-sharing sites will often find anti-Semitic and racist videos when looking for information completely unrelated to the videos due to misleading tags and titles that extremists attach to the videos when uploading them to the sites. † (Analysis 3) – Extremist group are using the internet to spread hatred of other groups worldwide. By doing so, it makes it even easier for them to promote the hate and then hide the evidence if their website or video is caught. This must be stopped. Topic Sentence 2) Extremist groups use violence in reaching their goals and emphasizing the point they are trying to make. (Example 1) – â€Å"On June 10, 2009, a white supremist who believed it was â€Å"time to kill the Jews† took his gun to the Holocaust museum in Washington, D. C. , and stated shooting upon entering. † (Analysis 1) – In believing he was doing the ri ght thing, this Extremist tried to make his point by attacking the Holocaust victims museum. By attacking this museum, he made a big stand by basically showing with his violence that he supported what happened in the Holocaust. Example 2) – â€Å"[ETA (Euskadi Ta Askatasuna)] has waged a relentless campaign of violence against the Spanish state, targeting politicians, policemen, judges, and soldiers. In 1980 alone, ETA was blamed for 118 deaths, and in 1995 it nearly succeeded in assassinating Jose Maria Aznar, then leader of the opposition, now Spain’s prime minister. † (Analysis 2) – The Extremist group ETA is taking their beliefs to an extreme extent. By killing and trying to assassinate a respected leader, they are using the violence to try and scare off and weaken their opposition. Example 3) – â€Å"Since 1977, there have been at least 17 attempted murders, 383 death threats, 153 incidents of assault or battery and three kidnappings committe d against abortion providers in North America. † (Analysis 3) – These are solid facts that exemplify all of the violence that have taken place from just one Extremist group. The groups cause pain and suffering in North America, and they feel as though using violence is one of the only ways to get their point across. (Topic Sentence 3) – Along with all the hate and violence that these groups reate, Extremist groups try tearing people further apart with their actions and words. (Example 1) – â€Å"The Kach movement was most famous for its platform calling for the removal of the entire Israeli-Arab population from Israel and transferring them â€Å"elsewhere. †Ã¢â‚¬  (Analysis 1) – The Jewish Defense League is another Extremist group that prizes themselves over all people. By trying to kick the Israeli-Arab population out of their homeland so they can take over, they cause horrible tensions between the people. These tensions would almost most certainly lead to more hate and more violence. Example 2) – â€Å"One man from Brockton, Massachusetts – who told police he had learned on white supremacist websites that a genocide was under way against whites – is charged with murdering two black people and planning to kill as many Jews as possible on the day after Obama's inauguration. † (Analysis 2) – By using the internet as a source to get to people, the Extremist groups have given false information and got what they wanted from it. They scared the man into believing that he was in danger, so he decided to take action and go against the other races. (Example 3) –

Belbin’s Theory Essay

When a team is performing at its best, usually each team member has clear responsibilities . Belbin suggests that, by understanding the role within a particular team, people can develop strengths and manage weaknesses as a team member. Belbin’s 1981 book Management Teams presented conclusions from his work studying how members of teams interacted during business games run at Henley Management College. Amongst his key conclusions was the proposition that an effective team has members that cover eight (later nine) key roles in managing the team and how it carries out its work. He categorized those roles into three groups: Action Oriented, People Oriented, and Thought Oriented. Each team role is associated with typical behavioural and interpersonal strengths. Belbin also defined characteristic weaknesses that tend to accompany each team role. He called the characteristic weaknesses of team-roles the ‘allowable’ weaknesses; as for any behavioural weakness, these are a reas to be aware of and potentially improve. Belbin suggested that, in order for a team to operate effectively, it needed a balance of nine different roles. Plant: Plants are creative, unorthodox and generators of ideas. If an innovative solution to a problem is needed, a Plant is a good person to ask. A good Plant will be bright and free-thinking. Plants can tend to ignore incidentals and refrain from getting bogged down in detail. The Plant bears a strong resemblance to the popular caricature of the absent-minded professor/inventor, and often has a hard time communicating ideas to others. Multiple Plants in a team can lead to misunderstandings, as many ideas are generated without sufficient discernment or the impetus to follow the ideas through to action. Resource Investigator: The Resource Investigator gives a team a rush of enthusiasm at the start of the project by vigorously pursuing contacts and opportunities. He or she is focused outside the team, and has a finger firmly on the pulse of the outside world. Where a Plant c reates new ideas, a Resource Investigator will quite happily appropriate them from other companies or people. A good Resource Investigator is a maker of possibilities and an excellent networker, but has a tendency to lose momentum towards the end of a project and to forget small details. Chairman (1981) / Co-ordinator (1988): The â€Å"Chairman/Co-ordinator† ensures that all members  of the team are able to contribute to discussions and decisions of the team. Their concern is for fairness and equity among team members. Those who want to make decisions quickly, or unilaterally, may feel frustrated by their insistence on consulting with all members, but this can often improve the quality of decisions made by the team. Clarifies goals; helps allocate roles, responsibilities, and duties; articulates group conclusions Shaper: A dynamic team-member who loves a challenge and thrives on pressure. This member possesses the drive and courage required to overcome obstacles. Seeks patterns in group work; pushes group toward agreement and decisions; challenges others Monitor-Evaluator: A sober, strategic and discerning member, who tries to see all options and judge accurately. This member contributes a measured and dispassionate analysis and, through objectivity, stops the team committing itself to a misguided task. Analyzes problems and complex issues; monitors progress and prevents mistakes; assesses the contributions of others; sees all options; judges accurately Team Worker: The â€Å"Team Worker† is concerned to ensure that interpersonal relationships within the team are maintained. They are sensitive to atmospheres and may be the first to approach another team member who feels slighted, excluded or otherwise attacked but has not expressed their discomfort. The Team Worker’s concern with people factors can frustrate those who are keen to move quickly, but their skills ensure long-term cohesion within the team. Gives personal support and help to others; socially oriented and sensitive to others; resolves conflicts; calms the waters; serves as an in-group diplomat Company Worker (1981) / Implementer (1988): The â€Å"Implementer† is the practical thinker who can create systems and processes that will produce what the team wants. Taking a problem and working out how it can be practically addressed is their strength. Being strongly rooted in the real world, they may frustrate other team members by their perceived lack of enthusiasm for inspiring visions and radical thinking, but their ability to turn those radical ideas into workable solutions is important. Completer Finisher: The â€Å"Completer Finisher† is the detail person within the team. They have a great eye for spotting flaws and gaps and for knowing exactly where the team is in relation to its schedule. Team members who have less preference for detail work may be frustrated by their analytical and meticulous approach, but the work of the Completer Finisher ensures the  quality and timeliness of the output of the team. Emphasizes the need for meeting schedules, deadlines, and completing tasks; searches out errors Specialist (1988): Belbin later added a ninth role, the â€Å"Specialist†, who brings ‘specialist’ knowledge to the team. Single-minded, self-starting, dedicated; provides unique or rare expertise and skills Specialists are passionate about learning in their own particular field. As a result, they are likely to be a fountain of knowledge and will enjoy imparting this knowledge to others. They also strive to improve and build upon their expertise. If there is anything they do not know the answer to, they will happily go and find out. Specialists bring a high level of concentration, ability, and skill in their discipline to the team, but can only contribute on that specialism and will tend to be uninterested in anything which lies outside its narrow confines. Note that Belbin was not arguing that every team has to have a minimum of nine members. Individuals within the team may take on more than one role each. As long as all the roles are filled, the team will be more likely to be effective.

Free Essays on The Rabbits Of Watership Down

The main rabbit in the story Watership Down is Hazel. Hazel is the leader of the rabbits who leave the Sandleford warren. The word hazel means â€Å"reconciliation†. Hazel shows this quality when he tries to make amends with General Woundwort after Bigwig leads the does from the Efrafa warren. He comes up with a solution that is good for both warrens and tries to solve their problem. The plant witch hazel is occasionally used for medicinal purposes. In the book, Hazel gives medical attention to different rabbits who become injured during one of their many adventures. The word bluebell means â€Å"consistency†. In the story Bluebell shows great consistency in protecting Holly after they escape the Sandleford warren. Holly, a former captain of the Owsla, is injured and cannot move very fast. Bluebell stayed with him for the entire trip to watership down, and speaks for him when the other rabbits find them. The plant bluebell is a wild flower. In the book. Bluebell acts a little more wildly than the others by telling jokes in odd situations. Strawberry is a rabbit met at Cowslip’s warren. He becomes friends with some of the wandering rabbits and eventually leaves his warren to go with them. This is how Strawberry is similar to the plant he is named for. The typical strawberry plant has short roots; Strawberry himself has short roots because he leaves his warren without taking much time to make his decision. The word strawberry means â€Å"esteem†. Strawberry shows his esteem towards the other rabbits by listening to their opinions and trusting them from the beginning of their journey together. Holly is a captain in the Sandleford warren, but does not join the other rabbits until his warren has been destroyed and the other rabbits have reached watership down. The word holly means â€Å"foresight†. When Hazel takes the group to retrieve does from Efrafa, Holly uses his foresight and good judgment ... Free Essays on The Rabbits Of Watership Down Free Essays on The Rabbits Of Watership Down The main rabbit in the story Watership Down is Hazel. Hazel is the leader of the rabbits who leave the Sandleford warren. The word hazel means â€Å"reconciliation†. Hazel shows this quality when he tries to make amends with General Woundwort after Bigwig leads the does from the Efrafa warren. He comes up with a solution that is good for both warrens and tries to solve their problem. The plant witch hazel is occasionally used for medicinal purposes. In the book, Hazel gives medical attention to different rabbits who become injured during one of their many adventures. The word bluebell means â€Å"consistency†. In the story Bluebell shows great consistency in protecting Holly after they escape the Sandleford warren. Holly, a former captain of the Owsla, is injured and cannot move very fast. Bluebell stayed with him for the entire trip to watership down, and speaks for him when the other rabbits find them. The plant bluebell is a wild flower. In the book. Bluebell acts a little more wildly than the others by telling jokes in odd situations. Strawberry is a rabbit met at Cowslip’s warren. He becomes friends with some of the wandering rabbits and eventually leaves his warren to go with them. This is how Strawberry is similar to the plant he is named for. The typical strawberry plant has short roots; Strawberry himself has short roots because he leaves his warren without taking much time to make his decision. The word strawberry means â€Å"esteem†. Strawberry shows his esteem towards the other rabbits by listening to their opinions and trusting them from the beginning of their journey together. Holly is a captain in the Sandleford warren, but does not join the other rabbits until his warren has been destroyed and the other rabbits have reached watership down. The word holly means â€Å"foresight†. When Hazel takes the group to retrieve does from Efrafa, Holly uses his foresight and good judgment ...

Albert Nobbs (2011) Movie Review Example | Topics and Well Written Essays - 750 words

Albert Nobbs (2011) - Movie Review Example Albert worked as a hotel waiter for thirty years during which she exhibited extreme dedication, and was known for her introvert nature. The hotel appointed Joe Mackins for repairing of boilers, who soon went into a relationship with the flirtatious maid Helen Dawes. However, Joe proved to be a drunk and extremely dominating man. Albert then narrates her life story to Hubert Page who is a housepainter and a fellow transvestite. Albert had chosen her present life out of economic needs after she was gang raped at the age of fourteen. However, Albert refrains from revealing her true name since she considers herself as a man. Seeing that Hubert is married and has a wife, Cathleen who is a dressmaker by profession, Albert too dreams of having a life partner. Albert’s objective in life is to open a tobacco shop with her savings and for that she offered Helen to stay with her. In spite of her reluctance, Joe insists Helen to agree since he thought Albert would give her the money that he needed to leave Ireland for America with Helen. During this time, typhoid epidemic broke out in Dublin for which hotel business began to drop thus calling financial problems for Albert. Soon she learns that Cathleen has died of the epidemic. In memory of Cathleen, Albert and Hubert dress up as women wearing the clothes made by Cathleen. During a walk together, although they manage to overcome their initial uneasiness, Albert soon trips and falls which returns her to reality. They then revert to their old lives, i.e. playing the role of men. Immediately after this Albert learns that Helen is pregnant with Joe’s child. In response to Helen’s fear that Joe may abandon her and leave for America, Albert offers to marry her. Later that eveni ng, Helen and Joe get involved in a fight in which Albert intervened and physically attacked Joe. Joe, in a fit of rage, pushes Albert

Heteronormativity Essay Example | Topics and Well Written Essays - 2000 words

Heteronormativity - Essay Example Despite the increased visibility of gay men and lesbian women, there remains no definition of family in the public consciousness that refers to same-sex couples with children. In fact, in the not too distant past, the notions of lesbian mothers/homosexual fathers or lesbian/homosexual families would have been nonexistent. This culture of heteronormativity (Gamson, 2000) dictates that a viable family consist of a heterosexual mother and a father raising children together. Heterosexuality and heterosexual forms of relating are the norm.1 All other forms of relational experience are thus viewed in contrast. For example, the descriptive term "couples" means heterosexual couples, then, there are gay and lesbian couples. Families are nuclear and headed by two heterosexual parents, then, there are gay and lesbian families. Similarly, "woman" means a heterosexual woman, then, there is the lesbian. Heteronormativity supports the dominant norm of heterosexuality by marginalizing any relational structure that defies it.2 A review of the family therapy literature bears this out; until recently the concept of the gay/lesbian family has been virtually unheard of in the family therapy field. This fact was confirmed by two research studies. Allen and Demo3 and Clark and Serovich found that the marriage and family therapy fields generally ignored gay, lesbian, and bisexual issues. For example, Clark and Serovich surveyed 17 journals published from 1975 to 1995. Of the 13,217 articles published, only 77, or 0.006% focused on gay/lesbian issues, used a gay/lesbian sample, or included sexual orientation as a variable.4 Goodrich (2003) cited the availability of only two early texts on working with lesbian couples in family therapy as an indication of the intense homophobia in the field from the 1960s to the 1990s.5 Proceeding from the above stated, heteronormativity has determined that unless the word gay is attached, marriage implies heterosexual marriage. Heterosexuality is the norm. Indeed, as Warner (1993) pointed out, "humanity and heterosexuality are synonymous."6 This notion of heterosexuality goes far beyond the institutions that marginalize and punish any relationship viewed as other. In this vein, heterosexuality is, of itself, a social and political organizing principle.7 Intrinsically linked to the structures of male dominance, heterosexuality can be viewed as a dictatorial patriarchal institution.8 Rich described this culture of compulsory heterosexuality as a powerful cluster of forces within which women have been convinced of the inevitability of both marriage and sexual orientation toward men. Thus, there have been very few attempts to explain how an individual develops a heterosexual orientation.9 Research into the development of heterosexuality is limited by the belief that it is natural and when it focuses upon homosexuality, persistently views it as deviant. Thus, implicit in discussions about sexual orientation is the notion that heterosexuality is both normal and mentally healthy, and that non-heterosexuals are abnormal and psychologically disabled.10 In direct relation to the homosexual/heterosexual categories, Rothblum (2000) pointed out that in a categorical definition of sexual orientation behavior, desire, and identity are assumed to be congruent.11 This is disputed by research.

Exam #2 Essay Example | Topics and Well Written Essays - 500 words

Exam #2 - Essay Example By implementing this program, the company gets the following benefits: Light and modified duty program offers cost savings opportunity for the company to control workers’ compensation and disability costs. A well developed Light and modified duty program must contain the senior management’s support and cultural acceptance by the location management of the program. In addition, a well-made light/modified duty program contains a detailed job description for each task done in the workplace. Potential questions include: A). will there be a rising cost of workers’ compensation and healthcare? –the answer to this question is no, the program in conjunction with the transitional duty will manage this. Also, it is more efficient to pay an employee working at 50% as opposed to paying for workers compensations which is 0% productivity to the company. B). in case of injury, which will be responsible? The answer to this question is, the responsible individuals include the injured employee, supervisor, and program coordinator a. Family medical leave act- Only serious health conditions of the employee constitutes a modified work program. This act is only relevant in cases where the employee has a serious accident, with the approval of a medical practioner. b. The Americans with disabilities act- This act enables employers to make permanent reservations for employees who are disabled. This means that disabled employees do light duty task. If no outcome is predestined for the light duty program and the employer requests no follow up information, the employer may be sued. Although the employee may be working under the light and modified duty programs, follow up data is necessary. c. Workers compensation statutes- Actual disabilities qualify someone for this act and for a modified work program. An employer may be sued if found to make a sick or injured employee work as

History (Fifteen Year War in Asia) Essay Example | Topics and Well Written Essays - 1000 words

History (Fifteen Year War in Asia) - Essay Example This essay will address the responses of African Americans and Japanese Americans before and during the World War II. Many influential African descendants began admiring Japan after Japan’s defeat of Russia. W.E.B. Du Bois, Booker T. Washington, Marcus Garvey and Harry Dean all wrote and spoke about their high regard for the Japanese. These men considered Japanese to be a people of color. For a people of color to vanquish a country ruled by a white monarchy gave African Americans hope. If Japan could triumph over Russia, why could Japan not defeat America? Marcus Garvey believed the wind of change had started blowing. His organization the Universal Negro Improvement Association began supporting pro-Japanese causes in American and Britain. The African descendents and African Americans did not only admire the Japanese for their victory in the Russo-Japan war. The Japanese were admired for their acceptance of people of color. Many Japanese speakers in America at that time brought an African American wife or mistress to address the African Americans. In a time of Jim Crow laws to have a Japanese man affiliate himself with African Americans proved that Japan could provide a more racially equal environment than America. The thought of a society with little or no racial tension appealed to African Americans. To boost the pro-Japanese stance, Elijah Muhammad, a Nation of Islam leader, Marcus Garvey and Harry Dean, Paul Cuffe’s grandson, put forth the theory that Africans and Japanese were related by blood. A theory was put forth that Africans and Japanese were related by blood. Harry Dean, a sailor by profession, brought a tale back from Africa. This tale, the Teo Saga, claimed a chief, more Japanese than Africa, told how South Africa, Madagascar, Sumatra, Java, Korea and Japan once were connected by land. After the great flood these places were separated by water. Elijah Muhammad pointed out the

Treatment of Ankle Syndesmosis Injuries

Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as â€Å"high ankle sprain†with incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore importa nt to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis. 1.1. Anatomy The inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament. At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12). The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula [Fig. 1.1]. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) [Fig. 1.2]. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation [Fig. 1.2]. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9). Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35%; the transverse ligament, 33%; the interosseous ligament, 22%; and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability. 1.2. Biomechanics The primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus ‘‘wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion t o full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20). When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume. 1.3. Mechanism of Injury The 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30). Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in â€Å"Pronation-External Rotation† (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic cha llenge. These injuries are sometime referred as â€Å"high syndesmotic sprain† (4, 27, 34). 1.4. Diagnosis Diagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36). Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"medial clear space† is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship: (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm; (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width; (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42). 1.5. Treatment of Syndesmosis diastasis and review of literature Injuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation. Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant diff erence in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes follow ing syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group. Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation. Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67). The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire ® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the fol low-up reported in the literature is short and the number of cases are limited [Table 1]. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reporte d subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series. Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syn desmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term. 1.6. Aims and Objective The primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome. Population (P) Adult patients with acute fixation of ankle syndesmosis. Intervention (I ) Tightrope fixation of ankle syndesmosis. Comparison (C) Syndesmosis screw fixation. Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan. Chapter No. 2 2. PATIENTS AND METHODS We conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control. The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed. The inclusion criteria were as follows: adults (> 18 years) with acute ankle syndesmosis injury willing to give informed consent to participate in the study , fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria. The exclusion criteria set out for this study included: P patients with open fracture, I i ndividuals with diabet es ic or neuropathic arthropathy, M multi trauma patients and P patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control. Pregnancy was included in exclusion criteria B because of radiation exposure in this study. â€Å"pregnancy† was also mentioned as exclusion criteria. i I ndividuals unwilling to consent to the study Patients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively; and intraoperative confirmation under fluoroscopy using â€Å"external rotation stress test† and â€Å"hook test† in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"Tightrope† depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFA S) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications.   All patients were scanned supine in the axial plane with no gantry tilt.   Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx [Fig. 2.1]. This technique was adopted in order to reduce the radiation exposure to the patient without compromising th e quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond. 2.1. Outcome Variables The â€Å"accuracy of syndesmosis reduction† on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at > 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on A P radiographs and > 6 mm of tibiofibular clear space is considered abnormal, the criterion of > 2 mm would be justified.   Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function. In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses. 2.2. Data Collection and Measurements Demographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes. Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The â€Å"tibiofibular clear space† is defined a Treatment of Ankle Syndesmosis Injuries Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as â€Å"high ankle sprain†with incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore importa nt to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis. 1.1. Anatomy The inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament. At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12). The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula [Fig. 1.1]. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) [Fig. 1.2]. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation [Fig. 1.2]. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9). Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35%; the transverse ligament, 33%; the interosseous ligament, 22%; and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability. 1.2. Biomechanics The primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus ‘‘wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion t o full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20). When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume. 1.3. Mechanism of Injury The 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30). Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in â€Å"Pronation-External Rotation† (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic cha llenge. These injuries are sometime referred as â€Å"high syndesmotic sprain† (4, 27, 34). 1.4. Diagnosis Diagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36). Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"medial clear space† is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship: (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm; (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width; (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42). 1.5. Treatment of Syndesmosis diastasis and review of literature Injuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation. Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant diff erence in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes follow ing syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group. Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation. Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67). The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire ® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the fol low-up reported in the literature is short and the number of cases are limited [Table 1]. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reporte d subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series. Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syn desmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term. 1.6. Aims and Objective The primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome. Population (P) Adult patients with acute fixation of ankle syndesmosis. Intervention (I ) Tightrope fixation of ankle syndesmosis. Comparison (C) Syndesmosis screw fixation. Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan. Chapter No. 2 2. PATIENTS AND METHODS We conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control. The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed. The inclusion criteria were as follows: adults (> 18 years) with acute ankle syndesmosis injury willing to give informed consent to participate in the study , fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria. The exclusion criteria set out for this study included: P patients with open fracture, I i ndividuals with diabet es ic or neuropathic arthropathy, M multi trauma patients and P patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control. Pregnancy was included in exclusion criteria B because of radiation exposure in this study. â€Å"pregnancy† was also mentioned as exclusion criteria. i I ndividuals unwilling to consent to the study Patients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively; and intraoperative confirmation under fluoroscopy using â€Å"external rotation stress test† and â€Å"hook test† in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"Tightrope† depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFA S) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications.   All patients were scanned supine in the axial plane with no gantry tilt.   Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx [Fig. 2.1]. This technique was adopted in order to reduce the radiation exposure to the patient without compromising th e quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond. 2.1. Outcome Variables The â€Å"accuracy of syndesmosis reduction† on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at > 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on A P radiographs and > 6 mm of tibiofibular clear space is considered abnormal, the criterion of > 2 mm would be justified.   Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function. In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses. 2.2. Data Collection and Measurements Demographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes. Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The â€Å"tibiofibular clear space† is defined a