Diagnosis and Assessment week 1 Essay Example | Topics and Well Written Essays - 1250 words

Diagnosis and Assessment week 1 - Essay Example As an example, in statistics, an abnormality may be the deviation from the average or the majority of other distributions. Intelligence is another area where there is a normal distribution of IQ scores, and then there are standard deviations that are higher or lower than the norm which can show an individual as genius (higher) or mentally retarded (lower). (Dewey, 2010). Society is structured with certain rules and controls that give people an understanding of normal. Normal in this situation is what the majority sees or does. People are expected to follow the rules and those who do not follow these rules are seen as abnormal. In other words, anything that goes against what is considered to be normal by the majority is considered abnormal. The DSM-IV-TR (2000) describes mental disorders rather than saying what is abnormal. They make a distinction between mental disorders and general medical conditions. The general medical condition is defined as any condition that is not a mental condition (American Psychiatric Association (APA), 2000). They suggest that "no definition adequately specifies precise boundaries for the concept of mental disorder" (p. xxx). The APA also defines a mental disorder as a "clinically significant behavior or psychological syndrome or pattern that occurs in an individual and that is associated with present distress" (APA, p. xxxi). The challenge in using these definitions as a way to assess clients is that clients are labeled by these definitions. For insurance purpose, the counselor must be able to make some sort of diagnosis, but in giving an abnormal diagnosis, the client receives a label that may stay with them the rest of their lives. Designating a client as normal can also create problems because the idea of normal is different for different people. Culture brings another issue to this discussion because cultures have traditions and/or customs

Large industrial facility Essay Example for Free

Large industrial facility Essay 1. Describe how the use of a tall smoke stack might improve air quality near a large industrial facility. Tall smoke stacks built 500 ft or taller can improve air quality for a large industrial facility, by â€Å"releasing air pollutants such as sulfur dioxide and nitrogen oxides high into the atmosphere to help limit the impact† to the near by areas (Air, 2011, p. 2). The use of tall smoke stack is also believed to contribute to a wider spread of air pollutants. 2. How can topography contribute to pollution in a city or region? Topography and weather are big contributors to a city pollutions. Most cities are built in a valley and not on top of a mountain, which makes it hard for the air to circulate. This traps the pollution into an area resulting in a poor air quality. (Factors, n.d.) 3. From where do hurricanes derive their energy? What factors tend to weaken hurricanes? Would you expect a hurricane to weaken more quickly if it moved over land or over cooler water? â€Å"Hurricanes derive their energy from the warm, tropical oceans and by evaporating water from the oceans surface. Heat energy is converted to wind energy when the water vapor condenses and latent heat is released inside deep convective clouds† (Ahrens, 2014, p. 341). Hurricanes can weaken more quickly if it moves over cooler water, because they get their energy from warm tropical oceans. 4. Where is the Bermuda high located during the summer and fall? How might the path of a hurricane, moving toward the west from Africa, be affected by the Bermuda High as the hurricane approaches the United States? During the summer and fall the Bermuda high forms over the Atlantic Ocean. Hurricanes moving toward the west from Africa may increase its intensity as it approaches the United States. The Bermuda High â€Å"not only heats up summer-time temperatures in the East, but the Bermuda High can affect the  intensity of tropical storms and hurricanes† (Bermuda, 2013). 5. How do you think pollutants are removed from the atmosphere? Does this occur quickly or slowly? Pollutants in the atmosphere can be removed by trees and plants. The trees and plants absorb CO2 and other pollutants, then produce oxygen for the atmosphere. The removing of pollutants in the air is a slow progress and some pollutants never go away. Ahrens, C. D. (2014). Essentials of Meteorology: An Invitation to the Atmosphere, 7th Edition. [VitalSource Bookshelf version]. Retrieved from http://online.vitalsource.com/books/9781305439733/id/ch11-L3-5 Air quality. (2011). GAO. Retrieved from http://www.gao.gov/new.items/d11473.pdf Bermuda high is cause of most east coast summer heat. (2013) Weather Bug. Retrieved from http://weather.weatherbug.com/weather-news/weather-reports.html?story=8263 Factors affecting air quality. (n.d.) BC Air Quality. Retrieved from http://www.bcairquality.ca/101/air-quality-factors.html

Humorous Wedding Speech by an Old Roomate (Flatmate) :: Wedding Toasts Roasts Speeches

Humorous Wedding Speech by an Old Roomate (Flatmate) Well, congratulations to Herman and Connie. I assume that you are now expecting me to have a bit of fun at Herman's expense. Well, the only trouble is, Herman's expenses have been so high today that I’m not sure how much more he can take. Herman and I have been great friends (mates) for a long time now, and inevitably we've shared many things over the years: football; college; my driving license when Herman didn't have one - and now, a wedding table. Who'd have thought it? We also shared an apartment (a flat) for a short time. Not long after finding a place together I realised his biggest hate in life – housework! And why? Because you have to make the beds and do the dishes. Then six months later you have to start all over again. But we had a good understanding and split everything down the middle. It was my job to get the take-out, Herman’s job to get the beer, my job to clean the bath room, Herman’s job to clean the kitchen. And I’m not joking, when Herman was done with the kitchen you could eat of that floor †¦ there was lots of food still down there. On the whole, though, living with Herman was a pleasurable experience. Having said that, there weren’t any books in our flat, so when the Satellite dish stopped working we actually had to talk to each other. Now, I'd like to think I taught Herman a thing or two before he got a place of his own, especially about women. Imagine the shock I got when out of the blue he called me to say that he had got engaged, the things that go through a best friend’s mind. Mostly about mail order brides, one-way tickets from Thailand and subscriptions to Gay Connections Monthly. Then when I heard that it was Connie, I was filled with much relief and happiness. Because when it came to finding a wife, Herman couldn't have been luckier. Connie is a fantastic person and, as I'm sure you will all agree, looks stunning today. I have a great deal of respect and admiration for her. And, being a nurse, she has the added bonus of already being familiar with dealing with incontinence and impotence on a daily basis. Since Herman met Connie, I have seen a change in him.

Continuity and Change in the Willamette Valley Essay -- United States

Continuity and Change in the Willamette Valley From the 1830s until the turn of the twentieth century, the Willamette Valley in Oregon was populated by people who migrated there from throughout the United States and the world. One group that came in large numbers was the yeoman farm families of the Midwest, who migrated to the Willamette Valley during the 1830s and 1840s seeking new land and continuity in their way of life. Another group that came in large numbers were Chinese migrant workers who came to the Willamette Valley after the Civil War, who came seeking work and continuity in their way of life. As the two groups pursued their own goals, interacted with each other, and tried to preserve their ways of life, both groups were changed forever, and a new culture was formed. During the late 1830s and early 1840s, the people living in the river valleys of the midwestern United States experienced an economic depression, floods, and the spread of diseases such as influenza and malaria. At this time, newspapers, pamphlets, lectures, and sermons had begun to spread word of the rich soil and healthful climate of the Willamette Valley in western Oregon (Jeffrey 27). As "Oregon fever" spread, it was the lure of the land that drew many yeoman farm families to travel 2,000 miles for a fresh start in Oregon. These small, independent farmers desired not land for land's sake, but land as a place to establish and provide for themselves and their families for generations (May 24). Yeoman culture was family-centered and the roles of men and women were distinct and interlocking. Husbands and wives were determined to carry their culture and ideology to Oregon and to recreate the world of their parents as they established a new... ...d, and society in the American West. New York: Cambridge University Press, 1994. McClellan, Robert. The Heathen Chinese: A Study of American Attitudes toward China, 1890-1905. Columbus: Ohio State University Press, 1971. Pan, Lynn. Sons of the Yellow Emperor: A History of the Chinese Diaspora. Boston: Little, Brown and Co., 1990. Scott, H. W. History of Portland Oregon. Syracuse: D. Mason and Co., 1890. Seward, George F. Chinese Immigration: Its Social and Economical Aspects. New York: Charles Scribner’s Sons, 1881. Steeves, Sarah Hunt. Book of Remembrance of Marion County, Oregon, Pioneers, 1840-1860. Portland: The Berncliff Press, 1927. Takaki, Ronald. Strangers from a Different Shore: A History of Asian Americans. Boston: Little, Brown and Co., 1989. Whitney, James A. The Chinese and the Chinese Question. New York: Tibbals Book Company, 1888.

Lessons On How To Use Pendulums Environmental Sciences Essay

Throughout history, pendulums have been used for many different things. They have been used as tools for turn uping H2O, gold or other minerals ; they have aided in medical diagnosing or foretelling the gender of an unborn babe ; they have been used in combination with maps in turn uping points or people ; and have been used to reply inquiries or predict the hereafter. Dousing rods predate pendulums in use for some of the above mentioned countries. Dousing rods are normally either L-shaped metal rods or even a Y-shaped subdivision from a tree. Some water witchs prefer one signifier over the other when dousing for H2O, oil, gold or other minerals. However, they can non be used in such a broad spectrum as a pendulum nor are they as easy portable. Let ‘s go back to late 300 CE merely as an illustration of how far back in history there is recorded grounds of pendulum use as a divination technique. It is here that a adult male by the name of Ammianus Marcellinus was known as a baronial Roman historiographer. Among the tonss of texts he wrote on the current occurrences of his clip, you will happen a really interesting blend of heathen enigmas. He tells of many users of â€Å" the black humanistic disciplines † ; of swayers seeking the advocate of diviners who scryed for messages through H2O and fire ; you will besides happen some devising anticipations through astrological agencies. Amongst these recorded historical narratives, you will besides happen Marcellinus state the narrative of a group of plotters. This group non merely plotted the blackwash of a Roman emperor but they besides made usage of a pendulum-like device to happen the name of the following emperor. They did this by suspending a ring on a piece of yar n and utilizing it much like an Ouija board. Interesting, huh? You do n't happen excessively many narratives like that in the wars and events go oning in the universe as we know it now. However, shortly you will detect other interesting events that have happened even in our ain timeline ( or the timeline of our parents ) of pendulum usage. As I mentioned, pendulums are a much more moneymaking tool for the diviner because they can embrace so much more than the capablenesss of a dowse rod. Whether you believe the pendulum is replying a inquiry for you and is playing on your subconscious or if you believe the pendulum is being affected through religious agencies, no one truly knows for certain. All that is known is that it can and does work rather efficaciously. There are many interesting facts and narratives contained in an online book called Pendulums and Dowsing Rods that can be read here: hypertext transfer protocol: //brianstalin-pendulum.blogspot.com/ . Please read through this short but really interesting book! With a spot of diging into history, you will happen the narratives of the Inquisition and the accusals of witchery associated with it. You may besides happen recorded spots of swayers trusting on diviners or visionaries to help them in conflict or in doing determinations of province. You may besides happen the narratives of the alchemists and the hunt for the elusive philosopher ‘s rock. While you ‘re happening all this – you will besides happen assorted in between all those celebrated narratives, the narrative of the water witchs or H2O enchantresss. Sometimes you may even read about gypsy trains and the anticipations made with a ring on a twine. Seek and you shall happen sometimes in obvious topographic points and sometimes in the most pathetic of topographic points, spots and pieces of pendulum history. Assignments Post to Discussion Board Please portion with a few sentences what drew you in to taking this category. In the on-line book Pendulums and Dowsing Rods, name one individual stated in history who used a pendulum that you found interesting and what they used it for. What drew you to this individual? Minimum of 150 word essay ( it ‘s merely a large paragraph – do n't acquire scared ) . Post below Write a 300-500 word essay on pendulum usage in history. It can be on the same individual you wrote about for # 1 or a general â€Å" pendulum usage in history † essay. Please mention your beginnings for this assignment. LESSON TWO Terminology There are several different footings used for the different countries a pendulum can be used. A twosome of the footings most frequently used and will be used here are â€Å" pendulum dowse † and â€Å" pendulum divining. † Pendulum dousing refers to when a pendulum is used to seek for a specific mark or thing such as H2O, gold, or other minerals. Pendulum divining is the proper term when utilizing a pendulum to foretell the hereafter or supply information. Pendulums can besides used for dowse and radiesthesia. Both of these footings refer to dousing with a pendulum or divining rod. While they hold that in similarity, what the diviner is dousing for is rather different. Dowse is the proper term for dousing for concealed objects. These concealed objects can be H2O, minerals or other cherished artefacts. It can be lost points or even locating people. The of import thing to retrieve is this: dowse is the term used to happen things. Radiesthesia is besides used to â€Å" happen things † . It ‘s merely those things it is happening are of a much more delicate nature than that of person utilizing dowse. Radiesthesia can mention to all signifiers of dousing but it normally refers to medical dowse. It gets its name from the theory that all life organisms emit some sort of radiation or other emanation and it is this that can be detected through dowse. In order to utilize a pendulum for medical diagnosing, the diviner holds the pendulum above the patient and easy moves it about above the patient ‘s organic structure. The theory of how this works is this – when the pendulum is above a morbid portion of the organic structure, the pendulum is so repelled from the disease which causes the pendulum to swing or curve to maintain itself off from the illness inside the patient. The larger the cringle the pendulum makes, the more morbid that organ or country of the organic structure. In other words, ra diesthesia is for turn uping medical jobs while dowse is for turn uping objects. What is a pendulum? A pendulum is an object that has many different utilizations as you will larn through these categories. It can be for your ain personal energy work and can be used in enchantment work. It is a tool that can be used efficaciously to link to your subconscious, the spirit universe and for divination. Pendulums come in many different forms and can be made from different stuffs. You can buy a really fancy one or do a really simple one. A pendulum can be an elaborately carven rock or crystal wrapped in a beautiful wire design or merely consists of a stone on the terminal of a yarn. You can besides utilize a watchband with a appeal on the terminal or even a necklace with a pendent. Equally long as it is something that can freely travel, it can be used as a pendulum. I have even heard of person utilizing an ear bud when there was nil else available†¦ and it worked! The chief thing a pendulum consists of is a somewhat weighted object normally at the terminal of a short spot of concatenation that is able to travel freely and is able to swivel. The concatenation can be of varied lengths but the length a individual by and large wants in a pendulum is one where the pivot terminal is held with fingertips, your elbow remainders on a tabular array and the leaden terminal does non make the top of the tabular array thereby leting the weight to swing freely and of its ain agreement. As you can see, the varied lengths of pendulums that can be purchased in a store are due to the different lengths of a individual ‘s forearm – though the concatenation is by and large 6.5-7.5 inches long. If you find utilizing the pendulum works better with the concatenation at a shorter length, you can garner some of the concatenation in your fingers and keep the concatenation closer to the pendulum terminal. Another thing, if you are adept at working with jewell ery, you can shorten your concatenation by taking some links from the concatenation. However, I have seen pendulums for dousing much larger and used for standing instead than in a sitting place. There are besides times the concatenation is somewhat shorter every bit good. It is the ability for motion that is most of import. Assignments Below are the footings and definitions you will necessitate to retrieve to finish the assignment for this category. Radiesthesia – dowse to name medical issues Rhabdomancy – dowse to turn up points Dousing – the pattern of turn uping H2O or other concealed points Divining – the art of seeking to announce future events or detect hidden cognition Pendulum – a leaden object that is suspended from a fixed point yet is able to swing freely ; a tool that can be used to link to the subconscious, the spirit universe and for divination. LESSON THREE Choosing a Pendulum There are several different types of pendulums to take from if you decide to buy one. There is no specific type that is the â€Å" best † to acquire. Travel with what you are drawn to. It may be one made of wood or metal. It may be a pendulum that is a merely cut semi-precious rock. It may be a combination of all of the above or even none of the above. You may even make up one's mind to do one yourself if you are so cunningly inclined. However it happens, you need to acquire to cognize your pendulum merely as you would any other divination object. If you are familiar with the belongingss of rocks and crystals, this can assist you out in taking the right rock for you or for what it is you hope to carry through with your pendulum. If you are non familiar, so get down looking at what pendulum attracts your attending. Make note of what type of rock it is ( if it is made of a rock or crystal ) and look up the belongingss of that peculiar rock. If you happen to be shopping in a metaphysical shop, ask! Opportunities are the individual who works there will either cognize the reply or will cognize where to look it up and can assist steer you to do a terrific purchase! Making your ain pendulum is a really personal experience. It is besides non really hard if you have merely a few little tools and the inspiration. You can utilize either a spot of strong yarn, all right rope or a little concatenation ( this can be from a watchband, necklace or found in the jewelry-making subdivision of your favourite trade shop ) . You will necessitate something with a small spot of weight – it does non necessitate to needfully be heavy – merely heavier than your concatenation so that it will be able to utilize this weight to travel. Anything that weighs between 0.5-2 ounces is perfect. Traditionally, the pendulum is an object that comes to a point that hangs down. However, I have had merely every bit much fortune with a wire-wrapped semi-precious rock or a unit of ammunition ball form. The form and the stuff does non count every bit much as it being something that entreaties to you. You can utilize a bead at the top of the concatenation or a knot at th e top of the rope as a â€Å" grip † for your pendulum. I have made a pendulum by utilizing a hematite ring, set and distorted my ain concatenation utilizing a thin Cu wire and so wire-wrapped a ruddy tiger ‘s oculus rock at the terminal. I have besides made some pendulum watchbands which are nil more than a little spot of concatenation, a rock attached with a bond glued to the top and a clasp so you can have on it and ne'er be without your pendulum. I have used my pentagram necklace as a pendulum at times – I merely need to keep the concatenation in my custodies so it is non excessively long. An old household tradition of mine is to do a pendulum from a nuptials ring and a spot of yarn to foretell the gender of a babe. That was more of a â€Å" goad of the minute † pendulum and besides a reasonably common common people tradition. As you can see, there are many different ways one can be created. Sometimes the rock that you hold at the tip of the concatenation will be different than the leaden rock of the pendulum itself or merely as likely it will be a little rock to keep that is the same as the pendulum. You may besides come across metal or wood pendulums. Do n't dismiss the effectivity of these! Forests and metals have belongingss merely every bit good as different rocks and crystals. The best stake is to seek before you buy. However, if you are unable to be â€Å" in individual † and alternatively make some online shopping – cognition about what you are buying is ever the best stake. Whether you have made, purchased or been gifted a pendulum, delight retrieve to cleanse and bear down your pendulum merely as you would any of your other charming tools. Assignments Post to Discussion Board: Purchase or do a pendulum if you do non already have one. Describe how your pendulum looks. What drew you to this pendulum? How does it experience? How did you cleanse and bear down your pendulum? What do you experience is the most advantageous belongings associated with the stones/metal/wood that makes the leaden point of your pendulum? If there is a rock at the terminal of the concatenation that you hold, what rock is this and make you experience it has belongingss that besides help the pendulum move? Lesson Four Geting to Know Your Pendulum In the past few lessons you have learned a spot about the pendulum, it uses throughout history and you have one in your ownership – it is clip for you and your pendulum to acquire acquainted. This lesson and the undermentioned lesson will concentrate on the relationship edifice between you and your pendulum. You will go familiar with its motions and it will go familiar in reacting to your bids. The undermentioned lessons of exercisings will be important to fostering lessons and working with your pendulum in many different countries so acquire familiar with it and hold merriment! The first thing we have to make to acquire ready is to ready ourselves and our manner of thought. Most of us go through our day-to-day lives utilizing the left side of our encephalon – the analytical side. In order to tap into any kind of divination work ( and this goes for any kind – good beyond pendulums ) we need to cognize how to wake up and exert the right side of our encephalons – the originative and intuitive side. This intuitive side of our encephalon is how we can link to our subconscious, to the spirit universe and to the Godhead. Meditation is normally a good index on exerting this country of the encephalon. Particularly if your speculation pattern is non the â€Å" all must be stillness and quiet † sort but is, alternatively, the kind of speculation chapeau allows for ideas, images and whatever else flow approximately. Using a pendulum can really assist with this by giving the analytical side of your encephalon something to make ( a physical ob ject on which to concentrate ) go forthing the intuitive side of your encephalon to get down to stretch and work its admirations through your pendulum. Using a pendulum is portion you, portion pendulum and can besides include other parts ( liquors, the Godhead, etc. ) which we will discourse much later. Right now it ‘s all you, your subconscious and your pendulum. Subsequently in this series of categories, we will larn how to utilize the pendulum for spirit contact and even reach with the Divine. Many believe that each object, populating or otherwise, gives off electro-magnetic quivers. These â€Å" vibraphones † are what you will be experiencing or turn uping or tapping into along with the spirit world/subconscious/divine when making any pendulum work. Talk to your pendulum. State it you are its new proprietor ; you will maintain it safe and in return it can help you. The first manner it will help you is to let the two of you to acquire to cognize each other. You can even pet it and love it and call it if you like. Some people do call their pendulum because they set up rather an confidant relationship with this little and fantastic tool. Working with Your Pendulum Get yourself in a relaxed province. If you are in a fidgety temper so the pendulum and any exercisings will non work suitably for you. You need to be in a unagitated province. Your energy degree can be high but your organic structure and head can non be all jumpy. Meditate if demand be for a few minutes. Rather than speculation, you can besides take a few proceedingss to merely take a breath ( this works truly good for me ) . Just acquire your ego comfy and think of nil but your breath. Take in a deep breath, easy make fulling your lungs and your tummy. Keep it for a minute and so easy exhale. Breathe in the composure by easy inhaling that composure and so expire the heebie-jeebiess or excitedness or whatever has got you in a non-relaxed temper. Continue this slow deep external respiration. I am normally relaxed after making three good long deep breaths. It may take more for you or less – it is different for different people but as a general regulation, three is reasonably goo d. Keep the terminal of the concatenation between your pollex and index leting the concatenation to swing down with the leaden terminal hanging free and your cubitus resting on the border of a tabular array to maintain you stabilized. Keep the terminal steadfastly but slackly leting freedom of motion for the pendulum and maintaining yourself relaxed. If need be, utilize your other manus to calm the pendulum because you will desire it to be held still and non traveling at this clip. If there is a little shudder, that is all right but do maintain note that a little shudder in the pendulum is non an existent motion. Any motions your pendulum will do will be clear and concise motions whether they are singing or round motions. The little shudder is normally your ain motion impacting the pendulum somewhat. If this is your first clip in utilizing a pendulum or if it has been some clip since utilizing one, you will necessitate to pattern a few exercisings foremost to â€Å" acquire in form † . Practice these exercisings at least one time a twenty-four hours for the following hebdomad. You may go on to pattern these exercisings for longer, every bit long as you feel you are acquiring good responses from your pendulum and you are confident in the motions. Keep your pendulum as instructed antecedently and mentally inquire your pendulum to do clockwise circles. You can voice your bid every bit good if you feel comfy but this is non necessary. Since you are exerting the intuitive country of your encephalon, will the pendulum to make your command. It may non react right off. You may necessitate to wheedle it by gently utilizing your manus to swing it in that round gesture. Then halt it and once more will the pendulum to travel in a clockwise circle. Once the pendulum is responding decently, state it to halt and it should halt. You may necessitate to halt it yourself but so will it to swing once more and acquire it to listen to your mental stop bid. Once this is working satisfactorily, you can so get down to play with it holding it swing in smaller or larger circles and halting. After you ‘ve got the clockwise gesture down-pat, travel onto counter-clockwise circles in the same mode. Again, doing bigger and smaller circles and halting in a counter-clockwise gesture. When you have become successful at holding your pendulum create the round motions, so it is clip to seek a back and forward swing and so to swing from side to side. Use the same mental bids, halting between each new bid and get downing once more as you did when making circles. You can besides do it swing faster and wider or slower and smaller. This might look silly at first, but it is assisting to make a connexion between you and your pendulum. It is besides assisting to exert that right side of your encephalon and acquiring that intuitiveness fluxing good before traveling on. This will besides assist you at a ulterior clip when you will get down inquiring your pendulum inquiries. How so? Because you will cognize what a commanded swing feels like and when it is a gesture you did non command, but one that comes from another beginning ( your deep subconscious, liquors or the Godhead ) you will be able to experience the difference. It is that â€Å" feeling † that turns it into a â€Å" knowing † . Assignments Post to Discussion Board Practice the exercisings from the lesson with your pendulum at least one time a twenty-four hours every twenty-four hours for at least a hebdomad and maintain path of your consequences. How did you experience when first acquiring acquainted with your pendulum? Did you experience silly or were you comfy? Did you call it and if so, what name did you give it? How many times did you have to try the round exercising before your pendulum responded? Did you have any troubles? How long did it take your pendulum to react to the vacillation exercisings? Did you have any troubles? Which exercising do you experience was easier to finish – circles or swings? Why do you believe that is? Lesson Five More Exercises In the old lesson we got familiar with our pendulums and were able to command their motions. In this lesson there will be more motion bids but these will be done somewhat otherwise and you do n't necessitate excessively many particular tools. What you are traveling to necessitate is yourself, your pendulum, a tabular array or other level surface to work on, three coins and three cups. Two of the coins must hold the same day of the month and they should all be of the same denomination ( pennies are normally truly good for these exercisings ) . Take the two coins that are the same denomination and day of the month. Put them about a manus width apart on your surface. Keep your pendulum as you were taught antecedently with the pendulum hanging over the infinite between the coins. Now, here is the cockamamie inquiry you askaˆÂ ¦ Ask your pendulum to state you which coins are the same. Yes, it is silly but it will do sense shortly. Your pendulum will either swing over the two coins or it will do a round gesture over the two coins. Once it has answered your inquiry right, state it to halt. Following, topographic point three coins on the surface about a custodies width apart in a triangular form. This clip two of the coins must be the same and the 3rd coin is different. It can be a different day of the month or denomination -that does n't count. It merely needs to be different. Again, inquire your pendulum to demo you the two coins that are the same. The pendulum will swing between the two coins that are the same. When it has completed this undertaking successfully, state it to halt. It truly is first-class pattern to acquire into this wont after each and every bid or inquiry. You can go on exchanging out coins and proving your pendulum in this manner until you are satisfied your pendulum is working in this mode decently. The following measure is to convey out the cups and maintain one coin. Put the coin on the surface and topographic point a cup inverted over the coin. Put the other cups inverted on the surface every bit good. Skid the cups around the surface blending up their order until you are diffident which cup has the coin underneath. Now, with your cups in a line and keeping the pendulum so it dangles in forepart of the line of cups but besides doing certain it is several inches off. You will necessitate room for its motions. Ask the pendulum to indicate to the cup with the coin underneath. This is a small trickier and it may take a small while before your pendulum begins acquiring the right reply. Do n't give up! It is a larning procedure non merely for your pendulum but besides for your ego and your right encephalon! Normally, I would state you that your pendulum is a serious divination tools and to non utilize it for playing game. Seriously, it is. You would non utilize your tarot cards to play fire hook, right? Or your set of runic letters for a different kind of balls and knuckleboness game, right? The same holds true for your pendulum. These â€Å" games † we are playing now are exercisings for you and your new tool. They are to be used to better aid you along in farther usage with your pendulum. This will go apparent when we get to that lesson. Your pendulum is a serious tool and should be treated as such. It is non to be used for parlour fast ones. Practice these exercisings every bit frequently as you can or necessitate to in order to set up a good working relationship with your pendulum. These are a little more hard and may necessitate a little more clip – particularly the last exercising. Do non give up hope! You can make it! Assignments Post to the Discussion Board Truthfully, how silly did you experience inquiring your pendulum to demo you the two indistinguishable coins when there truly was merely two indistinguishable coins? Did you have any troubles with any of the exercisings? How many attempts did it take before you and your pendulum were able to right place the coin under the cup? What do you believe these exercisings will take to in making different divining techniques in the hereafter? Lesson Six Divining with Yes/No Questions In the past few lessons you have learned a spot about the pendulum, it uses throughout history, you have one in your ownership and the two of you have gotten a small acquainted. Now it is clip for you and your pendulum to acquire down to some merriment material and a small divination type of work larning the most common manner people use this tool for divination – replying yes and no inquiries. Keep the terminal of the concatenation between your pollex and index leting the concatenation to swing down with the leaden terminal hanging free and your cubitus resting on the border of a tabular array to maintain you stabilized. If need be, utilize your other manus to calm the pendulum because you will desire it to be held still and non traveling at this clip. Ask it â€Å" Show me Yes † . It may non react instantly but it will react. If needed repetition the inquiry. You want it to set up a definite swing and non merely a little small frisson. It does non hold to swing so far or fast that it threatens to take out an oculus – but it does necessitate to demo you a definite motion so you can set up a on the job form. Remember which manner it was singing ( right-to-left or back and frontward ) because this will be established as the reply â€Å" Yes † to a Yes/No Question you ask it. â€Å" No † should swing the opposite manner of â€Å" yes † . In other words, if â€Å" yes † was right-to-left so â€Å" no † will be normally be back and frontward. Be certain to state the pendulum â€Å" Stop † between each different motion and bid. It is good to acquire in this wont now because it is one that will be used ever when working with your pendulum. Sometimes, and this juncture seems pretty rare, a pendulum will travel doesil and widdershins for â€Å" yes † and â€Å" no † . This could even go on for â€Å" possibly † or â€Å" do n't cognize † . However, it will non go on for both or all. Each answer the pendulum will give you is alone to the pendulum but is besides ever the same. If â€Å" yes † is back and forward it will ever be back and frontward. Likewise, â€Å" no † will ever be left-to-right and so on nevertheless your pendulum has made this clear. You can even set up â€Å" possibly † and â€Å" do n't cognize † in the same manner. Be certain between each clip you tell your pendulum â€Å" Stop † . We need to set up these replies of â€Å" possibly † and â€Å" do n't cognize † every bit good because sometimes the reply is non unequivocal. Many times, people will make a board to transport with their pendulum to reply merely such inquiries. The board can be every bit simple or every bit fancy as you want it. It can be a board with the waies painted or wood-burned into the surface ; a piece of cloth with the waies drawn, stitched or painted on ; or even a piece of paper. Here is an illustration of what your board may look like: Establishing this good working relationship with your pendulum will profit you as a novitiate pendulum diviner and will still be a endowment you will go on to utilize as a maestro diviner. You may even go so familiar with the motions of your pendulum that you will no longer necessitate your Yes/No board. Whether or non this is true, the manner your pendulum moves in reply to the inquiries will ever be the same. This holds true whether you are tapping into your ain subconscious ideas and feelings ( as we are with this lesson ) or whether you are working with the spirit universe and the Godhead ( in subsequently categories ) . Be certain when you are inquiring your pendulum yes/No inquiries that you are non concentrating on a specific reply because you will it to be so. If you do this, so your pendulum will either respond to the mental bid you are giving it or it will be confused and non respond at all. Alternatively, inquire the inquiry with an attitude of â€Å" I wonder what the result will be? † Besides, maintain in head the reaction of the reply the pendulum gives you. If it is a full and good swing so you answer is rather definite. If it is a more halfhearted swing, so the reply could be â€Å" yes † ( or whichever manner the pendulum was singing ) but a â€Å" yes † that could be more unequivocal with other factors in topographic point. Another thing, if your pendulum does non travel it could be due to a refusal to reply the inquiry you asked. paraphrase it and see if you can acquire an reply so. Last, stick to your ain ethical motives and codification of moralss. If it is again st your beliefs to be glancing in on others, so make non make it with your pendulum either. Stick to your ain comfort zone and boundaries in ethical motives and moralss merely as you would in any other divination or magickal state of affairs. Assignments Post in the Discussion Board: Print out and/or create a pendulum board ( click nexus below for image with words to cut out if inclined to make so & A ; topographic point in countries ) so you can hold a paper one OR you can acquire more originative and do your ain out of another stuff. Describe how you made your pendulum Yes/No board and the swing of your pendulum swings for each way. PENDULUM BOARD TO PRINT Post below: Ask your pendulum a series of inquiries ( 3-5 inquiries ) . Record the inquiries and replies here. Do you experience your pendulum gave you accurate replies to your inquiries? Lesson Seven Personal Energy Work Now that you have a pendulum and you ‘ve established a good yes/no/maybe/do n't cognize relationship, allow ‘s travel on to research other ways you can work with your pendulum. These following few exercisings in this lesson will assist steer you into making some energy work with your pendulum. As a magickal practician of any kind, you should already cognize that there is energy all around you and within you. This energy is what you use when directing out any kind of enchantment work. There is besides energy within you and environing your organic structure. This is called your energy field. If you have of all time had an aura reading done or an aura image taken, this is the energy the camera or reader is sing – the energy that surrounds your organic structure. When you raise energy either through enchantment work, ritual work or even heightened emotions this energy field is besides raised and spreads out farther from your organic structure. In this first exercising, you are traveling to utilize your pendulum to observe the energy field around you. State your pendulum, â€Å" Show me my energy field. † Remember to utilize a steady manus, rest your cubitus on a tabular array border if need be and let your pendulum freedom of motion. It will get down to swing about in either a doesil ( clockwise ) or widdershins ( counter-clockwise ) gesture. Whichever manner it swings, does n't intend anything. It is the act of the motion itself that you ‘re concentrating on. If your energy field is high, the round gesture of the pendulum will be fast and broad. If your energy field is low, so the round gesture of the pendulum will be little and slower. In this following exercising, we are traveling to concentrate on raising and take downing your energy field through the usage of your pendulum. When your energy field is high and you are holding problem foundation, this simple act can really assist you to anchor. As the pendulum does its round gesture of fast and big, state it to decelerate down. State it to assist convey in your energy field. Sometimes, this will take a few proceedingss and sometimes it is a affair of minutes but finally the pendulum will decelerate down and the round gesture will acquire smaller. Continue with this exercising until you feel the pendulum has helped you to acquire your energy degree to a more manageable province and so state the pendulum â€Å" Stop † . Similarly, you can use your pendulum to assist raise energy if it is low. This is done in precisely the opposite manner of take downing the energy field. You do this by stating your pendulum you want your energy raised. Depending on how low your energy degree was to get down with will depend on how easy your energy degree is raised. Another blocker in either instance will be either your willingness to let the energy field to be raised or lowered. You truly necessitate to be in a province of head of credence of this happening so that you do non acquire discouraged. The elevation of an energy field can sometimes be a small more hard than take downing it. Once your energy field is raised, state the pendulum â€Å" Stop. † Repeat the procedure of take downing your energy field by utilizing your pendulum until you are at a manageable energy province once more and once more state the pendulum to â€Å" Stop. † This will assist you in larning another manner to maintain your en ergies in balance. Continue with this pattern until you are comfy in acknowledging your energy field every bit good as raising and take downing your energy field. Then finish the assignments below. Assignments – Post to Discussion Board When you foremost used your pendulum to observe your energy field, what was the consequence? Was your energy high or low? Make it observe it right or make you experience the pendulum did non accurately observe your personal energy field? Raise your energy field by utilizing your pendulum. How long did it take to carry through this? How does it do you experience? Now lower your energy field to a manageable or comfy degree. How long did it take to carry through this? How do you experience now? Do you experience comfy utilizing your pendulum in this pattern for your ain energy field? Lesson Eight More Energy Work The old lesson we learned how to make balance in the energy field for ego by raising and lowering/speeding up and decelerating down the round gesture of the pendulum. This was accomplished through many different channels. It was through your bid of the pendulum and its motions. It was besides through utilizing your right encephalon and tapping into your subconscious to command your energy field. I told you that those earlier gestures lessons were traveling to stop up paying off – and we have hardly even scratched the surface! These following energy field exercisings will necessitate the cooperation of another individual. For this following 1 we will be turn uping border of another ‘s energy field/aura. First, you ( the diviner ) will stand following to another individual. Right following to them. Keep out your pendulum and inquire it to demo you their energy field. Your pendulum should get down to swing broad and fast or travel in a big round gesture. As you slowly travel off from your spouse, the pendulum ‘s swing should decelerate until it becomes smaller and Michigans when you are at the border or merely outside the boundary of their energy field. If you take a measure near them once more, the pendulum should so pick up its impulse once more. Try this either with different people or with different degrees of energy. Emotions can play a big portion in the size of a individual ‘s energy field. Angry emotions tend to be held tighter and closer to a individual as do feelings of apprehensiveness. Happiness tends to make big nergy Fieldss around a individual. Have some merriment and laugh, so seek this exercising once more. If your spouse is a practician of the trade, they can seek some things as you approach or travel off with your pendulum. They can seek to screen themselves and see how that affects your pendulum. They can seek to raise energy in other ways ( similar to raising energy during ritual or for spell work ) and see how that affects your pendulum and how it reacts to their energy field. In this following exercising, you ( the diviner ) will hold your dorsum to your spouse. Keep your pendulum out in forepart of you. Now have your friend move easy and softly towards you but you truly necessitate to be incognizant of their propinquity to you. If need be, someway hold your ears plugged so you can non hear their attack. At the beginning of this exercising, state your pendulum it is to travel when your spouse stairss into your energy field. When your spouse comes to the border and/or crosses the boundary line line of your energy field, your pendulum should swing to alarm you of their attack. This exercising can be a spot more hard and sometimes does non work ab initio. A batch depends on the working relationship you have established with your pendulum. Stick with it and shortly you can go an unstoppable divinatory brace! Decision This full category is a basic lesson in how to run your pendulum, use it for some simple energy work and some really basic divination techniques you can make by inquiring yes/no type inquiries. Those types of inquiries can truly pay off in the long tally. You merely necessitate to inquire several of them and through the different replies you can find a batch. You can even believe of it as a game of â€Å" 20 Questions † where you need to inquire a batch of inquiries in order to come to a decision. Working with your pendulum in this mode can be rather good in many different ways – far excessively many to even get down to advert here. I hope you have enjoyed this category and in going acquainted with your new tool and friend! Assignments Post to the Discussion Board How good did the energy exercises with a spouse work for you? What difficulties did you face, if any? What ways can you believe of to utilize a pendulum in working with energy that was non mentioned in this category? How frequently do you believe you will now be utilizing your pendulum? Did you bask this category? What is so far your favourite portion of utilizing your pendulum? What was your favourite exercising? LESSON ONE – Mentions: hypertext transfer protocol: //penelope.uchicago.edu/Thayer/E/Roman/Texts/Ammian/29*.html hypertext transfer protocol: //www.pendulums.com/history.htm The Little Big Book of Magick by DJ Conway LESSON TWO – Mentions: hypertext transfer protocol: //www.experiencefestival.com/radiesthesia hypertext transfer protocol: //www.pendulums.com/dowsing.htm hypertext transfer protocol: //www.azuregreen.net/Pendulums/products/85/ hypertext transfer protocol: //www.merriam-webster.com/dictionary LESSON FIVE – Mention: The Big Little Book of Magick by DJ Conway

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School of Social Science and Public Policy. Case Studies in Policy Decision - Essay Example Inter-American Development Bank (2010, p.203) explains that the integrity, adaptability, sustainability and applicability of public policy depends on how the policies are presented, debated and implemented. Policies go through the stages of formulation, implementation and effect (Wilson, 1997, p.12). For successful outcome policies must put into consideration four aspects; needs of the population, the opportunities available, challenges and applicability within a given environment. These issues are better conceptualized by learning through case studies. Case studies bridge the gap between theory and practice and allow students to simulate the processes of policy formulation, implementation and effect and some to the challenges and gaps that might be encountered. 2.0 English Smoking Ban The English Smoking ban was introduced after studies revealed that passive smokers were at risk of developing lung cancer just like first hand smokers. The policy issue in this case was that non-smokers were continually being placed at a risk of developing health problems as a result of passive smoking (Institute of Medicine (U.S.). Committee on Secondhand Smoke Exposure and Acute Coronary Events, 2010, p.32). The problem became a policy issue and there was a dire need to protect non-smokers from the dangers of passive smoking. For instance, studies by Hirayama 1984 and Trichopoulos in 1981 established that there were serious health risks associated with passive smoking (Lippmann, 2011, p.723). ... According to Gerston (2010, p.3), the politics accompanying the process of policy formulation is mostly characterized by â€Å"confusion, contradictions and consternation.† Other aspects that impact on policies are issues such as advocay, path dependency and bureaucracy. Inter-American Development Bank (2010, p.203) explains that the integrity, adaptability, sustainability and applicability of public policy depends on how the policies are presented, debated and implemented. Policies go through the stages of formulation, implementation and effect (Wilson, 1997, p.12). For successful outcome policies must put into consideration four aspects; needs of the population, the opportunities available, challenges and applicability within a given environment. These issues are better conceptualized by learning through case studies. Case studies bridge the gap between theory and practice and allow students to simulate the processes of policy formulation, implementation and effect and some to the challenges and gaps that might be encountered. 2.0 English Smoking Ban The English Smoking ban was introduced after studies revealed that passive smokers were at risk of developing lung cancer just like first hand smokers. The policy issue in this case was that non-smokers were continually being placed at a risk of developing health problems as a result of passive smoking (Institute of Medicine (U.S.). Committee on Secondhand Smoke Exposure and Acute Coronary Events, 2010, p.32). The problem became a policy issue and there was a dire need to protect non-smokers from the dangers of passive smoking. For instance, studies by Hirayama 1984 and Trichopoulos in 1981 established that there were serious health risks associated with passive smoking (Lippmann, 2011, p.723).

Trip Report Essay Example | Topics and Well Written Essays - 750 words

Trip Report - Essay Example The plant should introduce "advance notice" procedures and indicate the exact time of arrival for each truck. (b) Also, it is possible to focus on activity scheduling, which is concerned only with activities directly related to the function: for instance, time of arrival, loading, lab reports, etc. The timing of such activities may have a significant impact on resource utilization and customer service (Chase, Jacobs 2003). The main problem of Quality Control Laboratory is a slow report procedure and work overload. The Quality Control Laboratory can be divided into several sub-units responsible for certain reports. It can increase costs, but it will reduce time and improve service provided. For instance, the laboratory can have the following units: (a) for incoming raw materials to verify the identification and specifications are correct, (b) for WIP and any special request from any production department, and (c) for outgoing shipment. If there is no much work to do, one of the groups could help another one with analyses for outgoing shipment. Again, if the time is stipulated, the trucks will not wait for a long time to test results. The main problems of this level involve (1) product shortage caused by inefficient production ... (a) The assessment of the nature and level of demand for products and services must be accurate, if economic resources are not to be misused. (b) The department should find out, as accurately as possible, present and future customers requirements. (c) Records must be up to date and quickly accessible, particularly where demand fluctuates rapidly. (d) Facility decisions are concerned with how many warehouses and plants Denver should have, and with where they should be located in order to optimize the customer service/cost equation. For the majority of companies it is necessary to take the location of existing facilities as given in the short term. Thus, managers can consider the inventory management problem to be a part of a wider operations scheduling problem. (e) Capacity management decisions will provide a context within which inventories and activities are be both planned and controlled. They will to some extent reflect operating policy decisions, while inventory and scheduling pr oblems might be considered as more tactical issues (Vonderembse, White 2003). Production units and operational departments should be better coordinated according to their functions and performance. It is the task of the department manager and plant manager to coordinate and control production procedures. For instance, an employee on a golf cart can help to coordinate activities on all shifts informing various operators about current changes and procedures. Product Loading Facilities and Operations Poor time management leads to queues and incorrect loading facility. Primarily, the right levels of stock must be fixed. Most firms carry too high levels of stock and any firm which is attempting to reduce stocks must note the factor dealt with under stock or inventory problems. For

School of Social Science and Public Policy. Case Studies in Policy Essay

School of Social Science and Public Policy. Case Studies in Policy Decision - Essay Example Inter-American Development Bank (2010, p.203) explains that the integrity, adaptability, sustainability and applicability of public policy depends on how the policies are presented, debated and implemented. Policies go through the stages of formulation, implementation and effect (Wilson, 1997, p.12). For successful outcome policies must put into consideration four aspects; needs of the population, the opportunities available, challenges and applicability within a given environment. These issues are better conceptualized by learning through case studies. Case studies bridge the gap between theory and practice and allow students to simulate the processes of policy formulation, implementation and effect and some to the challenges and gaps that might be encountered. 2.0 English Smoking Ban The English Smoking ban was introduced after studies revealed that passive smokers were at risk of developing lung cancer just like first hand smokers. The policy issue in this case was that non-smokers were continually being placed at a risk of developing health problems as a result of passive smoking (Institute of Medicine (U.S.). Committee on Secondhand Smoke Exposure and Acute Coronary Events, 2010, p.32). The problem became a policy issue and there was a dire need to protect non-smokers from the dangers of passive smoking. For instance, studies by Hirayama 1984 and Trichopoulos in 1981 established that there were serious health risks associated with passive smoking (Lippmann, 2011, p.723). ... According to Gerston (2010, p.3), the politics accompanying the process of policy formulation is mostly characterized by â€Å"confusion, contradictions and consternation.† Other aspects that impact on policies are issues such as advocay, path dependency and bureaucracy. Inter-American Development Bank (2010, p.203) explains that the integrity, adaptability, sustainability and applicability of public policy depends on how the policies are presented, debated and implemented. Policies go through the stages of formulation, implementation and effect (Wilson, 1997, p.12). For successful outcome policies must put into consideration four aspects; needs of the population, the opportunities available, challenges and applicability within a given environment. These issues are better conceptualized by learning through case studies. Case studies bridge the gap between theory and practice and allow students to simulate the processes of policy formulation, implementation and effect and some to the challenges and gaps that might be encountered. 2.0 English Smoking Ban The English Smoking ban was introduced after studies revealed that passive smokers were at risk of developing lung cancer just like first hand smokers. The policy issue in this case was that non-smokers were continually being placed at a risk of developing health problems as a result of passive smoking (Institute of Medicine (U.S.). Committee on Secondhand Smoke Exposure and Acute Coronary Events, 2010, p.32). The problem became a policy issue and there was a dire need to protect non-smokers from the dangers of passive smoking. For instance, studies by Hirayama 1984 and Trichopoulos in 1981 established that there were serious health risks associated with passive smoking (Lippmann, 2011, p.723).

Writing Assignment #2 Essay Example | Topics and Well Written Essays - 500 words - 4

Writing Assignment #2 - Essay Example Products in oligopolistic market structures will usually have very few or no substitutes as in the case of oil. The automobile industry in the world also evidences oligopolistic tendencies with a few large car manufactures selling similar auto models across the world. In most cases, players in such industries are torn between competing separately to win the market and coming together to create a monopolistic situation. Normally, the latter case never works as most companies rebrand constantly to differentiate themselves from their competitors. This is clearly seen in the automobile industry where different auto makers are customizing their brands to suite specific categories of people in the market. In a duopoly market structure, where the market players are limited to two, the common situation is normally cooperation between them so as to limit output to the monopoly style (Perloff 78). In such a case, profit is maximized as the price becomes much greater than the marginal cost. A case in point lies in the operation of Coca-Cola and Pepsi cola which operate in a duopoly situation. Most duopolies are created out of collusion between two or more players who agree to jointly set the price and manage output. Production in that is usually more than in a monopolist but less than in the in the completive market. In the same vein, some duopolies operate as cartels where strict cooperation is the order of the day. Price determination in oligopolistic market environments is always the prerogative of the market players. This arises since these players are normally big enough to influence prices in the market unlike in competitive market environments. In any case, prices in such markets are not determined by the interaction of supply and demand but are a function of the cooperation between the competing firms. Such a pricing strategy is known to create myriad inefficiencies in the market as usually evidenced in the oil industry where the need to rake in more profits

Legalizing gambling Essay Example for Free

Legalizing gambling Essay Gambling is legal in many places, its not either a criminal or dangerous activity provided it is done responsibly, and in accordance with the law. Have you ever wagered on a game? If so you were gambling and should have been fined. Lawmakers have decided that it is evil to gamble, they have justified it as a means to scam billions from citizens in order to compensate for their mismanagement of tax revenue. They pass laws that could put a taxpayer in jail for placing a single dollar wager on a pool game. Legalizing gambling nationally could potentially benefit our economic situation. All gambling was once legal. Looking back only 75-100 years ago most of our states had lotteries in place. Over the past century, as a result of abuse and moral fervor the majority forms of gambling have been prohibited. The history of gambling in the United States evolved from Europe. The Puritans and Quakers took little time to create first laws against gambling in 1638. Casino gambling is becoming increasingly popular especially in southern states. Native Americans are allowed to establish bingo parlors and casinos on their reservations, although Las Vegas and Atlantic City remain gambling tourist top destination choice. Many states allow horse and dog racing tracks and then there’s the people who bet on sporting events, card games, and almost anything you can imagine in the privacy of their own home. The first thing to do is to regulate gambling, both land-based and online. After the legislative base is created and regulation covers every aspect of the gambling industry, its half way to being legalized. I don’t see why we should lose a couple dollars to a pool hustler, when we could be hustled legally by the state. Gambling offers individuals the adrenaline rush that greater opportunity lies within their own hands. People should not be denied an activity that they enjoy partaking in. Government can earn revenues from legalized gambling which can be diverted towards bettering our society. Legalizing gambling would increase employment opportunities in society which could help to reduce the amount of working capable people out of a job. Gambling establishments have shown to increase employment opportunities as well as improve tourism in the right areas. The presence of gambling establishments is also beneficial to society because they can contribute the revenues to local governments which then could use the profits for social programs that would benefit both gamblers and non gamblers. Legalized commercial gambling is becoming an increasing controversy within our state governments. There is no doubt that many different forms of legalized gambling has exploded in the region and around the country, if the government gives full support of legalization they will be doing all US citizens a favor. Some argue that gambling is an addiction, one that can become dangerous and harmful to the general public. The truth is that like all other influenced jobs it can be a way of making a living for yourself and your family. Though there are a lot of people that struggle with an addiction to gambling, there are probably just as many people who are responsible gamblers and have enough self control to moderate there wagering hobbies. Legalizing gambling nationally will help stimulate our struggling economy in many ways. If our government would be willing to try to implement new laws to legalize and regulate it theres no way a short time period of testing these ideas would leave any permanent damage on our nation.

Nebulized L-epinephrine in Post -Bronchoscopy Croup

Nebulized L-epinephrine in Post -Bronchoscopy Croup Safety and Efficacy of Nebulized L-epinephrine in Post -Bronchoscopy Croup in Children, Anesthesia Consideration Dr Asma Aref Idamat, Pharmacist Dr Hussein Khraysha, Senior Specialist Anesthetist Dr Najeh Alomari, Consultant Pediatric Surgeon Amman-Jordan ABSTRACT OBJECTIVE: To assess the value of bronchodilator effect of nebulized epinephrine post bronchoscopy in children and to compare the effectiveness and side effects of nebulized L-epinephrine (NLE) 1/1000 at a dose of 0.1 mL/kg versus 0.5 mL/kg in the treatment of post-bronchoscopy croup and upper airway obstruction . MATERIAL AND METHOD: Between April1998 and April 2002, 120 children, who developed signs and symptoms of upper airway obstruction (UAO) after bronchoscopy, were randomized to receive either 0.1 mL/kg or 0.5 mL/kg of nebulized L-epinephrine (NLE). Age group ranged from 4months to 14 years, mean of 4.6 years, male /female ratio 4:1. UAO scores, vital signs (VS) ,oxygen saturation (O2 Sat)and side effects if present were recorded before ,at 15 minutes , 35 minutes and 45 minutes after the treatment. The treatment was accomplished in the recovery room under the care of the anesthetist and pediatric surgeon. All patients were reviewed carefully prior to discharge from recovery room. RESULTS: Sixty children were allocated to the 0.1mL/kg (NLE) and sixty children to the 0.5 mL/kg (NLE).. The (NLE) was mixed with 2ml of normal saline. Both groups showed improvements in UAO scores and Oxygen saturation over time. There were no significant differences in UAO scores and VS between the groups at all time points. There were no side effects of epinephrine during the observation. CONCLUSION: The administration of nebulized L-epinephrine is safe and effective in reliving croup and upper airway obstruction (UAO) post-bronchoscopy in children. NLE at the dose of 0.1 mL/kg results in similar improvements in the UAO scores, compared with the dose of 0.5 mL/kg. No complications were seen in either dose and we recommend the routine use of 0.1ml/kg (NLE) post –bronchoscopy in children. Key words: Bronchoscopy, Bronchodilators, L-adrenaline, croup, children Introduction Croup or subglottic edema post bronchoscopy and post intubation is a well known entity. Children are more vulnerable to develop croup after such procedures than adults due to well known differences in the anatomy of upper airway and tracheo-bronchial tree with narrower laryngeal and tracheal lumens with the result of obstruction more readily by to mucosal edema due to different causes, like viral and bacterial infections as well as allergic manifestations. The narrowest part of upper airway is that at the level of cricoid cartilage which makes the internal tracheal injury by endo tracheal tube or bronchoscope sheath more prone at the narrow subglottic area even after easily passage through the vocal cords. Bronchoscopic removal of aspirated foreign bodies in children is a common procedure in Jordan and many other countries worldwide. The procedure is performed under general anesthesia using rigid bronchoscopic device through which the ventilation is maintained. Foreign bodies are usu ally successfully removed using forceps, wash out with saline and suction tube. In many cases repeated bronchoscopic intubation may be necessary to assure complete removal of foreign bodies with the result of significant irritation and edema to the tracheo-bronchial tree with the sequel of croup, wheezy chest and features of upper airway obstruction (UAO) which may lead to significant morbidity and prolonged hospitalization. The incidence of post intubation croup in children was reported to be between 1 to 6 % (1,2). The medical treatment of postintubation croup is the same as that for infectious croup, including corticosteroids and nebulized epinephrine. The vasoconstrictive effect of epinephrine decreases the degree of subglottic edema, resulting in clinical improvement. Traditionally recemic epinephrine has been used as a non-selective adrenergic agonist of choice in children due to its supposedly fewer side effects than the more active and more readily available natural laevorot atory form of epinephrine. However, there seems to be no pharmacological basis for this belief (3-5) and subsequent trials have shown the L-epinephrine which we use for resuscitation, to be safe and effective in both infectious and postintubation croup(6,7). In addition, L-epinephrine is readily available in all countries while racemic epinephrine is not. Even in countries where both forms are available the racemic form is much more expensive(8 ).It was noted that the doses of L-epinephrine used in those trials were 2.5 and 5 mL of 1:1000 solution for all recruited children, regardless of weight. As a result, the dose of L-epinephrine in the treatment of croup has been suggested to be 0.5 mL/kg, with a maximum dose of 2.5 mL and 5 mL for children younger and older than 4 years, respectively (9). So far there have been very few reports that have studied the efficacy L- epinephrine in the management of post bronchoscpy croup and (UAO) in children. This study was designed for tow purpo ses of: (a) ascertaining the effectiveness of L-epinephrine in the management of croup and weezy chest post bronchoscpy in children or not; and (b) comparing the efficacy of a nebulized L-epinephrine at the dose of 0.1ml/kg versus 0.5ml/kg for the treatment of the above conditions and finally to recommend the routine use of L-epinephrine at the dose of 0.1ml/kg as protocole for the management croup and (UAO) post bronchoscopy in Children Material and Methods Between April1998 and April 2002, 120 children, who developed signs and symptoms of upper airway obstruction (UAO) after bronchoscopy such as severe irritative cough, wheezy chest, stridor and hoarseness of voice were randomized to receive either 0.1 mL/kg or 0.5 mL/kg of nebulized L-epinephrine (NLE) with maximum of 2mL for patients below 5 years of age and 4mL for patients above 5 years of age. Two mL of normal saline were added to the dose of L-epinephrine. Age group ranged from 4months to 14 years, mean of 4.6 years, male /female ratio 4:1. We used L-epinephrine because racemic epinephrine in not available in our hospital and it is expensive. The treatment was accomplished in the recovery room under the care of the anesthetist and pediatric surgeon using facemask with 100% oxygen at 6 liters/minute. The main parameter that evaluated was the change of the (UAO) scores (Table 1) and the other parameters that evaluated were changes in the respiratory rate, heart rate, blood pressure and oxygen saturation observed by pulse oxymeter. All parameters were evaluated at 15 minutes, 35 minutes and 45 minutes after the treatment, side effects of nebulized epinephrine, if present such as tremor, arrhythmia, and pallor were recorded at the same time. The management was repeated after 2 hours whenever clinically indicated if the results were not satisfactory. All patients were reviewed carefully prior to discharge from recovery room. RESULTS One hundred and twenty children post bronchoscopy for foreign body aspiration (FBA) were enrolled in this study. Sixty children were allocated to the 0.1mg/kg (NLE) and sixty children to the 0.5 mL/kg (NLE). The (NLE) was mixed with 2ml of normal saline. Both groups had the same baseline characteristics (Table 2) and both groups had initially moderate upper airway obstruction. Both groups showed clinically significant improvements and reduction in UAO scores and Oxygen saturation at 15, 35 and 45 minutes(Table 3) compared to that prior to (NLE) at time 0. There were no significant differences in UAO scores and VS between the groups at all time points and none required immediate intubation or re-bronchoscopy. Side effects of epinephrine including pallor, arrhythmia and tremor were not observed. Table 1: Upper airway obstruction score (15)** Score 0 1 2 Cough Stridor Retraction Inspiratory breath sounds Cyanosis* None None None Normal None Hoarse cry Inspiratory Suprasternal Harsh with rhonchi In room air Bark Inspiratory +expiratory Suprasternal+ substernal +intercostal Delayed In 40% oxygen *Cyanosis was modified and defined as oxygen saturation ** Downes JJ, Raphaely RC. Pediatric intensive care. Anesthesiology 1975; 43: 238-50. Table 2: Patient characteristics of our study groups 0.1mL/kg 0.5mL/kg Number of patients 60 60 Mean age (years) 3.4 5.8 Gender (M/F ratio) 4:1 4:1 UAO score immediately after bronchoscopy ( Mild ( Moderate 4-7) n, % (Severe > 7) n, % 12 (20%) 42 (70%) 6 (10%) 15 (25%) 38 (63.33%) 7 (11.66%) Table 3: The outcome variables in our study groups Time Time 0 15 Minutes 35 Minutes Nebulized L-epinephrine / Dose Number of patients 0.1mL/kg 0.5mL/kg 60 60 0.1mL/kg 0.5mL/kg 60 60 0.1mL/kg 0.5mL/kg 60 60 Upper airway obstruction score (Mean) 5 (1-8) 5 (1-7) 3 (1-6) 2 (0-5) 2 (0-5) 1.4 (0-5) Respiratory rate/minute (Mean) 28 30 32 33 29 28 Heart rate /minute (Mean) 126 128 130 128 125 123 Systolic blood pressure :mmHg (Mean) 95 100 102 106 97 103 Diastolic blood pressure: mmHg (Mean) 55 61 58 63 56 62 Oxygen saturation % (Mean) 93 94 96 97 98 98 Discussion Post bronchoscopy croup and respiratory distress is know entity in pediatric age group, especially when there is a need for repeated bronchoscopic trials for retrieval of long standing foreign bodies. In such conditions, severe inflammatory process of tracheo-bronchial tree is almost present from certain foreign bodies like peanut and other seeds that elaborate severe irritative substances leading to infection and granulation of bronchial tree that aggravate the respiratory distress, bronchospasm and croup post bronchoscopy. The main aim of the clinician in such conditions is to provide relief of respiratory distress by decreasing upper airway irritation and improving air entry. The present study has attempted to verify the safety and efficacy of bronchodilator effect of (NLE) and to prove that a dose of 0.1mL/kg is at least as effective as the dose of 0.5mL/kg in the treatment of croup and (UAO) post bronchoscopy in children. Many studies have tested the value of racemic epinephrine compared to placebo (10) and to nebulized salbutamol (11-13) and the results showed superior value of racemic epinephrine in the treatment of bronchiolitis. It seems no pharmacological basis for the belief that racemic epinephrine is safer than L-epinephrine (3-5) and racemic epinephrine is not available in Jordan and is thus difficult to obtain and expensive, making L-epinephrine a more viable option. Sumboonnanonda (14) used (NLE) at the dose 0.05mL/kg (maximum 0.5mL) in the treatment of infectious croup. They found a clinically significant improvement in (UAO) scores at 24 and 48 hours after admission, even in the placebo group without dexamethasone treatment .The present study found similar results at average 30 minutes in children with post-bronchoscopy croup and wheezy chest. The maximum dose of (NLE) in this study was 2mL for patients less than 5 years of age and 4mL for patients more than 5 years. In our study we confirmed the safety and efficacy of (NLE) in the treatment o f post intubation croup (6) and infectious croup (7), when Nutman (6) used 0.25mL of 1% L-epinephrine (2.5mg) regardless the weight, for children post-intubation croup and found significant reduction of stridor score within 20 minutes, the same we observed in our study which continued at least over the next 4 hours post –bronchoscopy. Waisman (7) used 5mL of 1/1000 L-epinephrine (5mg), regardless the weight, in children with infectious croup when he found a significant reduction of croup score, reaching its maximum at 30 minutes. The majority of our patients required one section of (NLE) to achieve these results and in very few of them who had long standing foreign bodies and repeated trials of bronchoscopy and bronchial wash out, another session of (NLE) required over 24 hours on 6 hourly interval. The present results suggest that nebulized L-epinephrine, at a minimal dose of 0.1 mL/kg, is at least as effective as the dose of 0.5 mL/kg in the treatment of post-bronchoscopy c roup. Both doses temporarily alleviated airway obstruction without undesirable side effects. The dose of 0.1 mL/kg is much less expensive. We would suggest that the dose of 0.1 mL/kg is also efficacious in the treatment of children with post-bronchoscopy croup. This dose may be adequate to diminish mucosal edema of the upper airway by stimulating alpha-adrenergic receptors and producing vasoconstriction (4). In conclusion, the presented data suggest that administration (NLE), at the dose of 0.1 mL/kg is safe and effective and results in a similar reduction in upper airway obstruction scores, compared with the dose of 0.5 mL/kg, in children with post-bronchoscopy croup. Neither dose was associated with any adverse side effects and we recommend the routine use of 0.1mL/kg (NLE) post –bronchoscopy in children. Taking in consideration the comparable efficacy of both doses, the use of a small dose in clinical practice would save the medication expense and, theoretically, have a lower risk of developing side effects that are mostly dose dependent. Future studies should consider the use of (NLE) at the dose of 0.1 mL/kg in children with post bronchoscopy croup, which has a pathophysiology resembling infectious croup. Further studies examining the optimal dose and frequency of (NLE) in children with croup due to different pathologies including post-bronchoscopy croup seem warranted. Acknowledgment to DR Mohamad Al-Sukar, Chair of Anesthesia Department –Royal Medical Services,Dr Kassem Khamaeseh,MD, Anesthesia Intensive care for their support and review of this manuscript. References 1. Borland LM, Colligan J, Brandom B.W. J Clin Anesthesia Koba BV, Jeon IS, Andre JM, MacKay I, Smith RM. Postintubation croup in children. Anesth Analg 1977; 56:501-5 Holbrook PR, Issues in airway management -1988. Critical Care Clin 1988;4:789-802 Remington S, Meakin G. Nebulized adrenaline 1/1000 in the treatment of croup. Anesthesia 1986;41:923-946 Tabachilk E, Livensopn H. Clinical application of aerosols in pediatrics. Am Rev Respir Dis 1988;122:97-103 Waisman Y, Klein BL, Boeinning DA, Young GM, Chamberlain JM, O’Donnell R, et al . Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosol in the treatment of laryngotracheitis (croup). Pediatrics 1992;89:302-6 Nutman J, Brooks LJ, Deakin KM, Baldesare KK, Witte MK, Reed MD. Racemic versus L-epinephrine aerosol in the treatment of postextubation laryngeal edema : Results from a prospective ,randomized double-blind study .Crit Care Med 1994;22:1591-4 Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 1995;126:1004-1007 Siberry GK, Lannone R. The Harriet Lane Handbook 15th Edition .St Louis : Mosby-Year book,2000:705-6 Kristjansson S, Lodrup KC, Wennegren G, Strannegard I-L, Carlsen KH. Nebulized racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child 1993;69:650-54 Wennegren G, Holmgren D, Engstrom I, Sten G, Bjure J. Using transcutaneous blood gases to evaluate treatment effects on acute asthma in young children. Scand J Clin Lab Invest 1988;48(supp 189:41-44 Sanchez I, Dekoster J, Powell RE, Walstein R, Chernik V, Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infant with bronchiolitis . J Pediatr 1993;122:145-151 Reijonen T, Korpi M, Pitkakangas S, Tehhola S, Kyllikki R. The clinical efficacy of nebulized racemic epinephrine and albuterol in acute bronchiolitis. Arch Pediatr Adolosc Med 1995;149:686-692 Sumboonnanonda A, Suwanjutha S, Sirinavin S. Randomized controlled trial of dexamethasone in infectious croup. J Med Assoc Thai 1997;80:262-5 Downes JJ, Raphaely RC. Pediatric intensive care. Anesthesiology 1975; 43: 238-50.