Non Medical Independent And Supplementary Prescribing V300 Nursing Essay

Non Medical Independent And Supplementary Prescribing V300 Nursing Essay This essay discusses the evolution of nurse prescribing in the context of legislation and political element, with the consideration of how this has changed and assisted the clinical nurse specialist role, with particularly emphasis on Heart failure. The pathophysiology of heart failure will be discussed and integrated into the relation of drug actions with particular interest into Diuretics. Alongside this; the importance of effective history taking, assessment and consultation skills to treat the patient accurately and at a high standard and quality is discussed. The decision making process and the importance of a shared approach in relation to heart failure is highlighted incorporating the importance of compliance in the maximising the treatment of heart failure. Sources of information and decision support systems that are available will be highlighted with a discussion on the importance of these in principles. Demonstration of ability to prescribe safely, rationally, cost effectively, and in consideration of the public health issues around medicine use are discussed and finally clinical governance through quality assurance and audit of prescribing practice is considered. For the purpose of the essay the following learning outcomes are discussed: Evaluate understanding and application of the relevant legislation and political context of the practice of non-medical prescribing Critically appraise sources of information/advice and decision support systems in prescribing practice and apply the principles of evidence based practice to decision making. Integrate and apply knowledge of drug actions in relation to pathophysiology of the condition being treated Demonstrate the ability to prescribe safely, rationally, cost effectively, and in consideration of the public health issues around medicines use Integrate a shared approach to decision making taking account of patients/carers wishes, values, religion or culture Evaluate effective history taking, assessment and consultation skills with patients/clients, parents and carers to inform working /differential diagnosis. Contribute to clinical governance through quality assurance and audit of prscribing practice and regular continuing professional development The controls of medicines in the UK has undergone a number of regulatory changes since the end of 1800s, climaxing in the Medicines Act (1968). Prior to 1992, doctors, veterinary surgeons and dentists were the only professions legally permitted to prescribe. This situation made the medical profession gatekeepers for medicines, certainly the case for those medicines considered more likely to cause harm or abuse such as controlled drugs i.e. morphine. Cumberledge Report (1986) identified the need for community nurses to prescribe, The Crown Report (1989) published findings of a review to determine the circumstances in which non-medical health professionals could undertake new roles with regard to prescribing, supply and administration of medicines and led to the development of protocols which we now know as Patient Group Directives (PGDs). The Crown Report (1999) recommended that legal authority to prescribe should be extended to include new groups of healthcare professionals, this also bought about the differentiation between Independent and Supplementary prescribers. This report noted that a doctor often rubber stamps a prescribing decision taken by a nurse, which is demeaning to nurses and doctors. (Cooper et al,2008) The Medicinal Products Act (1992) permitted qualified District Nurses and Health Visitors to independently prescribe, and this was only a limited number of medicines from a Community Practitioners Formulary. Over the next few years legislative changes occurred which involved, non community qualified nurses to train as prescribers, together with an increase in medications added to the Nurses Formulary. In 2003, nurses and Pharmacists were permitted to prescribe from the whole of the British National Formulary (BNF) as supplementary Prescribers, except controlled and unlicensed drugs. Controlled Drugs were prescribable by nurses and pharmacists using supplementary prescribing from 2005. During this time other allied Healthcare professionals such as physiotherapists, Radiographers, Podiatrists and optometrists were also able to become supplementary prescribers. (DOH, 2005) These rapid changes in the development of non medical prescribers in the United Kingdom were a contrast to the gradual introduction to prescribing rights in the United States of America. (Armstrong,1995). The UK now has the most extended non medical prescribing rights in the world. (Armstrong, 1995) In 2006, DOH (2006) permitted trained nurses and pharmacists to independently prescribe all medicines within their clinical competence. The most recent changes have occurred to the Misuse of Drugs Regulations (2012) which now means that appropriately qualified nurses and pharmacists will be able to prescribe controlled drugs like morphine, diamorphine and prescription strength co-codamol. Currently there are more than 50,000 Non medical prescribers in the UK, around 19,000 nurses and almost 2,000 pharmacists are qualified as Independent and/or supplementary prescribers (Carey, 2011) The changing legislation of Non medical Prescribers has changed alongside with the environment of the NHS services. This is recognised in the guide produced by NMC (2010) stating that the services delivered by the NHS become more challenging and complex as there is an ever increasing need for improved productivity without the compromising of quality. Coronary Heart disease, puts great pressure and demands on the National Health Service (NHS). Hospital admissions for Chronic heart failure have increased markedly, chronic heart failure accounts for about 5% of all medical admissions and approximately 2% of total health care expenditure. Despite improvements in medical management, under treatment for heart failure is still common. (Mcmurray et al, 2002) In 2002, The British Heart Foundation (BHF) piloted a scheme and funded with the help of Big Lottery Fund ninety two Heart failure nurses throughout the United Kingdom. The results were shown in the final report BHF (2008) showing an average reduction in heart failure admissions of 43% and an average estimated saving, per heart failure patient of  £1, 826. Increasing the role of the Non medical prescribers therefore increasing the skills and knowledge of nurses/pharmacists only enhances the vital role within the field these nurses have in todays current fight to provide the highest quality care possible. It has been shown that registered nurses are extending their roles and responsibilities to work in new ways (Furlong + smith, 2005). Crowther et al (2003), Gattis et al (1999), Paniagua (2011) Lambrinou et al (2012) and Jaarsma (2010) have all shown that Heart failure nurse specialists are optimal providers to assist physicians with Heart failure care for this complex and time-consuming patient population. The management of heart failure is complex involving both pharmacological treatments and strategies to improve patients functional status and quality of life (Palmer et al, 2003) Heart failure can be defined as an abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues. (ESC, 2012) Clinically patients present with typical symptoms; breathlessness, ankle swelling and fatigue. And signs; elevated JVP, pulmonary crackles and displaced apex beat. Diagnosis of heart failure relies on a detailed history and accurate physical examination (NICE, 2010). These symptoms can be related to either a reduction of cardiac ourput (fatigue) or to excess fluid retention (dysapnea, orthopnea and cardiac wheezing) fluid retention also results in peripheral oedema and occasionally an increasing abdominal girth secondary to ascites. Symptoms and signs are often non-specific and could be related to other conditions. Knowledge on the use of other diagnostic services is necessary: Echocardiography, Electrograph, Chest Xray, Blood tests all contribute to the confirmation of diagnosis. Case study One demonstrates a typical presentation of a patient presenting with first presentation of heart failure symptoms; typically compromised and in need of expert medical treatment; Pharmacological and non pharmacological therapies. This patient presented with clear signs of congestion and volume retention of which a diuretic therapy plays a central role in the treatment (Felker and Mentz, 2012) As the heart fails, there is a reduction in both blood pressure and cardiac output, in response to this the body conserves water which results in oedema. Diuretics act at different sites of the kidneys, they then eliminate sodium and water through enhanced excretion from the kidneys so are able to relieve the symptoms of fluid congestion. Different classes of diuretics work at different points within the kidney tubules. (Davies et al, 2000) Appendix two shows the diuretics available. This patient was treated with Furosemide intravenously (IV), most patients receive a loop diuretic as first line treatment for heart failure (Faris et al, 2012.) Loop diuretics are the most frequently used diuretic in treatment of Chronic heart failure despite their unproven effect on survival, their indisputable efficacy in relieving congestive symptoms makes them first line therapy for most patients. (Bruyne, 2003) Appendix three shows how loop diuretics work. As already stated first line treatment for acute decompensated heart failure is intravenous diuretic therapy either as a bolus or via continuous infusion. Despite being available for decades, few randomized trials exist to guide dosing and administration of this drug. In 2011, the Diuretic Optimization Strategies Evaluation (DOSE) trial used a prospective, randomized design to compare bolus versus continuous infusion of IV furosemide, as well as high-dose versus low-dose therapy. The study found no difference in the primary end point for continuous versus bolus infusion. High-dose diuretics were more effective than low dose without clinically important negative effects on renal function. Although no difference was found between IV and bolus dose there are benefits to both elements so clinical judgement would be made on the specific patient needs and requirements, for example, immobilization, duration of therapy requirements, haemodynamic status. The aim of using diuretics is to achie ve and maintain euvolaemia (the patients dry weight with the lowest achieveable dose. (ESC, 2012). Case study two identifies a patient whom is another example of heart failure but offers a different presentation; this accentuates the importance of a careful physical examination and valuable accurate history taking. The absent breathe sounds over the right base of lung field along with the history was an indication of pleural effusion and initiated the prescription of a radiograph chest to be performed. Absent or diminished breath sounds strongly suggest an effusion (Kalantri et al, 2007) unfortunately Congestive heart failure is the most common cause of a pleural effusion. (Enrique, 2008) Again, Pleural effusions from heart failure are managed with diuretic therapy, initially with a loop diuretic, intravenously titrated in response to clinical signs, daily weights and renal function to avoid excessive volume depletion. (Light, 2002) Non-compliance in patients with heart failure (HF) contributes to worsening HF symptoms and may lead to hospitalization. (Van der wal, 2006). Using skills that were taught during basic nursing training is imperative in conducting a beneficial and effective clinical examination, these interpersonal skills may dictate how the patient and carers perceive and acknowledge there diagnosis and may have an influence on the approach the patient has on his/her own health. Over the past 3 decades, the biopsychosocial model of health has become increasingly important in the effective practice of medicine. Central to this model is an emphasis on treating the patient as a whole person, including the biological, psychological, behavioral, and social aspects of their health (Engel, 1980). The American Heart Association (AHA) in collaboration with other professional societies has issued a new scientific statement for the management of patients with advanced heart failure. It emphasizes shared decision making and is designed to help physicians and other health professionals align medical treatment options with the wishes of the patients. Allen (2012) recognises the complexity of heart failure and complexity of the treatment options can be a barrier to shared decision making, but this only emphasizes why such a patient-centred approach should be undertaken in Advanced heart failure. Shared decision making has received particular emphasis in relation to the pre scribing of drug treatments. Traditionally, studies have identified 50% of patients with chronic conditions do not take their treatment as prescribed, with major reasons being because they do not share the doctors views, or they are worried about side effects. (REF QUOTE?) Therefore the aim is to explore these issues by adopting a shared decision making approach and reach a concordance between doctor and patients. Therefore getting patients involved in the planning and management of care, being sensitive to the individuals need, spending time figuring out what is important to them, will hopefully reduce some of the confusion and complexities concerning heart failure. Although knowledge alone does not insure compliance, patients can only comply when they possess some minimal level of knowledge about the disease and the health care regimen. (Van der wal, 2006). The National Prescribing Centre (2012) designed a competency framework which can be seen in appendix 3. One of the three domains is the consultation which highlights three areas of importance 1; Knowledge; pharmacological and pharmaceutical. 2; Options; concerning the diagnosis and management 3; Competency; involving shared decision making with parents, patients and carers. The data is clear that for the benefit of the patient and success with the treatment regimen it is vital to consider wishes of the patient/carer, ethical, cultural opinions, lifestyle of the patients. Also contributing factors which may cause non-complicance whether intentional or not for example: polypharmacy, complicated dose regimens, unpleasant side effects, and cognitive problems or physical disability preventing the patient taking the medicines. A large number of factors need to be incorporated into the thought process prior to getting to the point and writing a prescription. Surrounding issues that directly and indirectly support patient orientated prescribing Sources of information are on number of levels. In a hospital ward, for example, immediate sources of information include the British National Formulary (BNF) and ward pharmacist. The role of both is, at least in part, to assist in ensuring that, for any prescription, the correct dose and timing of administration are correct and appropriate for the indication. The BNF is widely available and accessible and can and should be used to assist in prescribing whenever there is any doubt about dose and timing. The Pharmacist provides an additional safety netting, by checking prescriptions before providing the medications. In addition, the pharmacists role includes ensuring that medications prescribed are available for administration. Further afield, but still within the hospital, local policies give guidance on what drugs are available and recommended for a particular indication. These policies may be produced by the hospital or by regional bodies, including SHA, Network PCTs, for example, local arrangement may mean that a particular statin is used for primary prevention of coronary heart disease, due to local procurement agreements or cost effectiveness analyses. Beyond the hospital setting, a number of sources provide guidance on what should actually be prescribed, or considered, for a given condition. Such sources might include national bodies, in particular National institute of clinical excellence (NICE) and specialist societies. The latter may be national and or international. For example, in the field of heart failure, NICE has given guidance on what medications should be administered and at what stage of the disease and symptoms. For all patients ACEI: should be given. There are many different ACE I. The guidelines recommend using only those which have actually been proven to be of benefit in heart failure; these [emailprotected]@@@@@@. For those who are intolerant of ACE; ARB should be used. Again, NICE recommends thoses that have shown efficacy in clinical trials, and these [emailprotected]@@@@@@. Beta-blockers are recommened but not any betablocker. Only those with proven @@@ in heart failure should be used; these are Aldosterone A ntagonists should also be used for patients with advanced heart failure (NYHA III/IV). Guidance recommends spironolactone, or eplernone if not tolerated (most usually due to gynaenomastia in men) From the above, it may be seen that the National guidance indicates which drugs from each class should be considered for each purpose. This leaves room for local policies and prescribers to decide which of the available agents is suitable for a particular individual. Pursuing the example of heart failure further, international guidelines are issued by a number of bodies. The principle of these is the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) and the American Heart Association (AHA). Of these, the ESC guidelines are most applicable to the United Kingdom. Societal guidelines tend to focus more on a particular disease and the available evidence to provide best treatment, whereas NICE guidelines have greater emphasis on appraisal of cost-effectiveness, which is of greater relevance to the local health economy in the UK. Furthermore, ESC guidelines give a strength of recommendation for a particular treatment (Class I, IIa, IIb) and an indication of the level of evidence behind the recommendation. (A, B, C) Ultimately, the source of information which informs societal guidelines comes from research, in the form of clinical trials, performed on the back of pre-clinical research. Therefore, the doses of drugs which are recommended for use usually reflects the dose and frequency of a drug or used in a clinical trial which demonstrated benefit. There are therefore numerous levels of information and advice which support prescribing practice. For many conditions, these are ultimately based on evidence derived from clinical trials, in some areas these will be the gold standard RCT. However, some trials provide softer evidence, such as observations data or even anecdotal. Understanding of these various trials and guidelines is important to understanding how local guidelines and daily prescribing practice come about and are supported by evidence. The trials/guidelines all mentioned above have provided convincing evidence that clinically significant improvements can be achieved in heart failure by appropriate drug treatment. Moynihan et al (2002) recognises that the adoption of more effective and/or safer drugs, new technologies are usually more expensive, aging of the population leads to increased morbidity and drug therapy, all play a role in increasing drug expenditure. Medicines are regarded an expenditure, but can also be an investment, if they are used rationally. Rational prescribing means cost effective use of safe and effective drugs. Specialist clinics for heart failure are a tool for delivering care according to clinical guidelines and providing diagnostic treatment. They provide optimal management of the condition, education of patient and carers about the signs and symptoms of worsening disease and medication compliance. Advances in medication and technology for heart failure are vast, which again strengthens the need and importance of such clinics to enable patient treatment to change accordingly and appropriately. Studies have shown that if patients are treated by Cardiology clinicians or Heart failure specialist nurses, clinical guidelines are more likely to be followed and readmission rates are lower for these patients. (Reis et al, 1997) An example of prescribing within heart failure is an investment for the patient and the NHS is the use of Angiotensin-converting enzyme inhibitors (ACE I). These have been shown to improve symptoms, survival and slow progression of heart failure. (Luzier et al, 1998). ACE I are one of the essential therapies for all heart failure patients, if tolerated. Treatment should be maximised and in maximising the dose quite often you can reduce or stop the use of loop diuretics due to improved symptoms and clinical signs. (Hoyt et al, 2001) Therefore patients who are appropriately treated and titrated to maximal therapy therefore benefit clinically, may reduce other medicines and they can overall reduce the chances of hospital admission with decompensated heart failure which is beneficial to the patient and the NHS finances. A recent study by Dharmarajan et al (2013) covering three million hospitalizations showed that more than a third of readmissions (within 30 days of discharge) were for heart failure. Their thought was that many of these could have been preventable, with greater input from pharmacists, physicians, nurse specialists, and greater consideration to social elements; reducing readmission also reduces other risks involved in exposing patients to hospitalization. The National Heart failure Audit (2012) conducted by NICOR is an audit to monitor progress, clinical findings and patient outcomes of patients with heart failure. It is an essential audit for each NHS trust to comply and complete. ++. It provides critical information on management and outcomes which then provides data essential to drive future improvements. Conclusion: CASE STUDY ONE Description of clinical setting: Patient was an inpatient on the Cardiology ward; he was admitted the day before and had been referred to Heart failure clinical nurse specialist for review. Case history: An 84 year old retired postman was admitted from home with progressive worsening shortness of breath over the last 6 weeks. He had been to see the General Practitioner two weeks ago who treated him for a chest infection with a course of oral antibiotics (Amoxycillin). He denies any chest pain, however he complains of palpitations at times of exertion and a productive cough. Patient had not experienced any syncope, dizzy spells; only other complaint was loss of appetite and poor quality sleep. Patient has been sleeping with 4 pillows, waking regularly due to struggling for breathe and resulted to sleeping in the chair downstairs. Exercise tolerance had drastically reduced to 50 metres before having to stop due to breathlessness. On examination the patient was tachypnoeic, pulse was 95 and regular, sitting blood pressure was 110/62 standing 105/55. Weight 97kg. Oxygen Saturations on air 94%. Inspiratory crackles were clearly heard on both lung bases, no heart murmur could be auscultated and apex beat was misplaced to the anterior auxiliary line. JVP was raised +4. Pitting peripheral oedema up to thighs and a large distended abdomen, which was soft and not tender on palpation. ECG confirmed Sinus tachycardia with Q waves in antero lateral leads. Chest x-ray also confirmed cardiomegaly and interstitial oedema. Drug treatment pre admission: Aspirin 75mg once a day (OD) Blood pressure control Past medical history: Anterior lateral Myocardial infarction 7 years ago (2005) followed by Angioplasty to the right coronary artery. No further operations or admission to hospital. Blood results: Chemistry: Sodium 128mmol/l, Potassium 4.8 mmol, Urea 9 mmol/l, Creatinine 145 mmol/l, LFTs, HB and clotting was all unremarkable. Echo: severe left ventricular dysfunction, with minor tricuspid regurgitation. Social background: Patient lives with wife in a two bedroom bungalow, they are both normally well and independant. He has no allergies and takes no over the counter medications or recreational drugs in the past or present. Drug chart to date in hospital: Aspirin 75mg OD Frusemide 80 mg OD Ramipril 2.5 mg OD Discussion: Patient was fortunate enough to have had Echocardiography that morning, which offered me the definitive diagnosis. This gentleman presents with a common clinical presentation of progressive systolic dysfunction of an ischemic cause. The patient was comfortable and stable enough for a steady and methodical examination and history taking. On construction of a management plan for this patient, clearly first line treatment is diuretic therapy, T Effective dieresis and consequent adjustment of the loading conditions of the failing heart is generally regarded as essential (Raftery, 1994) This patient went on to be prescribed Intravenous Diuretics, instructions for Daily weights, Fluid balance, advice and rehabilitation for heart failure. Then longer term plan for titration of Heart failure medications to achieve maximum therapy suitable for this patient. Allen, L.A., Stevenson, L.W., Grady, K.L., Goldstein, N.E., Matlock, D.D., Arnold, R.M., Cook, N.R., Felker, G.M., Francis, G.S., Hauptman, P.J., Havranek, E.P., Krumholz, H.M., Mancini, D., Riegel, B. and Spertus, J.A., for the American Heart Association; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia, 2012. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), pp.1928-1952. Armstrong, P., McCleary, K. J. and Munchus, G., 1995. Nurse practitioners in the USA their past, present and future. Some implications for the health care management delivery system. Health Manpower Management, 21(3), pp.3-10. Avery, A.J. and Pringle, M., 2005. Extended prescribing by UK nurses and pharmacists. British Medical Journal, 331, pp.1154-1155. Bruyne, L.K., 2003. Mechanisms and management of diuretic resistance in congestive heart failure. Postgraduate Medical Journal, 79(931), pp.268-271. Carey, N. and Stenner, K., 2011. Does non-medical prescribing make a difference to patients? Nursing Times, 107(26), pp.14-16. Cooper, R., Guillaume, L., Avery, T., Anderson, C., Bissell, P., Hutchinson, M., Lynn, J., Murphy, E., Ward, P. and Ratcliffe, J., 2008. Non medical prescribing in the United Kingdom: developments and stakeholder interests. Journal of Ambulatory Care Management, 31(3), pp.244-252. Crowther, M., 2003. Optimal management of outpatients with heart failure using advanced practice nurses in a hospital-based heart failure centre. Journal of the American Academy of Nurse Practitioners, 15, pp.260-265. Davies, M.K., Gibbs, C.R. and Lip, G.Y., 2000. ABC of heart failure. Management: diuretics, ACE inhibitors and nitrates. British Medical Journal, 320(7232), pp.428-431. Department of Health and Social Security, 1986. Neighbourhood nursing a focus for care (Cumberledge report) London, HMSO. Department of Health, 1989. Report of the Advisory Group on Nurse Prescribing (Crown report) London, HMSO. Department of Health, 2000. National Service Framework for Coronary Heart Disease. London, HMSO. Department of Health, 2005. Supplementary prescribing by nurses, pharmacists, chiropodists/podiatrists, physiotherapists and radiographers within the NHS in England. A guide for implementation. London, HMSO. Department of Health, 2006. Improving patient access to medicines: A guide to implementing Nurse and Pharmacists independent prescribing within the NHS in England. London, HMSO. Dharmarajan, K., Hsieh, A.F., Lin, Z., Bueno, H., Ross, J.S., Horwitz, L.I., Barreto-Filho, J.A., Kim, N., Bernheim, S.M., Suter, L.G., Drye, E.E. and Krumholz, H.M., 2013. Diagnosis and timing of 30 day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Journal of American Medical Association, 309, pp.355-363. Diaz-Guzman, E. and Budev, M., 2008. Accuracy of the physical examination in evaluating pleural effusion. Cleveland Clinic Journal of Medicine, 75(4), pp.297-303. Faris, R.F., Flather, M., Purcell, H., Poole-Wilson, P.A. and Coats, A.J., 2012. Diuretics for heart failure. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD003838. DOI: 10.1002/14651858.CD003838.pub3. Felker, G.M., Lee, K.L., Bull, D.A., Redfield, M.M., Stevenson, L.W., Goldsmith, S.R., LeWinter, M.M., Deswal, A., Rouleau, J.L., Ofili, E.O., Anstrom, K.J., Hernandez, A.F., McNulty, S.E., Velazquez, E.J., Kfoury, A.G., Chen, H.H., Givertz, M.M., Semigran, M.J., Bart, B.A., Mascette, A.M., Braunwald, E., OConnor, C.M., for the NHLBI Heart Failure Clinical Research Network, 2011. New England Journal of Medicine, 364(9), pp.797-805. Felker, G.M. and Mentz, R.J., 2012. Diuretics and ultrafiltration in acute decompensated Heart failure. Journal of the American College of Cardiology, 59(24), pp.2145-53. Furlong, E. and Smith, R., 2005. Advanced nursing practice. Policy, education and role development. Journal of Clinical Nursing, 14, pp.1059-1066. Gattis, W.S., Hasselbied., V., Whellan, D.J. and OConnor, C.M., 1999. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team. Archives of Internal Medicine, 159, pp.1939-1945. Hawkins, N.M., Petrie, M.C., Jhund, P.S., Chalmers, G.W., Dunn, F.G. and McMurray, J.J., 2009. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. European Journal of Heart Failure, 11, pp.130-139. Hoyt, R.E. and Bowling, L.S. 2001. Reducing readmission for congestive heart failure American Family Physician, 63(8), pp.1593-1598. Hunt, S.A., Baker, D.W., Chin, M.H., Cinquegrani, M.P., Feldman, A.M., Francis, G.S., Ganiats, T.G., Goldstein, S., Gregoratos, G., Jessup, M.L., Noble, R.J., Packer, M., Silver, M.A., Stevenson, L.W., Gibbons, R.J., Antman, E.M., Alpert, J.S., Faxon, D.P., Fuster, V., Gregoratos, G., Jacobs, A.K., Hiratzka, L.F., Russell, R.O. and Smith, S.C. Jr; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure); International Society for Heart and Lung Transplantation; Heart Failure Society of America, 2001. ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: Executive Summary. 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Comparison Of Tones Used By Ph :: essays research papers

Two of the most well known black writers that were for the abolishnist movement in America were Frederik Douglass and Phillis Wheatley. At a time when a literate Negro would have only existed in a nightmare and when even the majority of the white women in the country were illiterate, these two authors of distinguished valor managed to write literature and recite speeches that inspired some of the most impenetrable minds to change their ways of thinking. Wheatley would move her readers with her subtle, yet powerful literature while Douglass would do the same with his powerful use of words. Phillis Wheatley was one of the more passive abolishionist writers. Because she was a slave and she was aware of her position in society as opposed to the whites, she knew that enfuriating her audience was the wisest thing to do. When criticizing slavery she chose her words very wisely. In her poem â€Å"On Being Brought from Africa to America,† for example, she does not blatantly protest about slavery and call her readers savages like Douglass would do. Instead she and realized has realized her position in serialized her position in society as a slave and In her literature she criticizes slavery through rli Although, Phillis Wheatley was an abolishnist writer, she passive than a lot of her literature didn’t always reflect. At first glance it would For a man going against a legion of non-followers, Frederik Douglass held nothing back. Wheatley, Unlike unFor an abolishnist writer, one must and Although they both took very diifrent approaches very, but also managed to get their works published. Wheatley would move the crowed inspire authors wrote poetry ab it was a forbidden for a Negros to learn how to read black to learn how to read andbeing literate being illeterate was law for blacks, and women ere being illetarate for Wheatley and Douglass wroteAt a time where it was forbidden for a Negro to learn how to read and even majority of the white women couldn’t read, Phillis and Wheatley were writing verses that were so powerful wthese two authors, managed to recite speeches and write sonnets to get to

Starbucks Internationalization in Recent Years

With the first coffee shop opened in Sydney CBD, Starbucks entered into Australian market in July of 2000 and then expanded rapidly to 85 coffee shops in the following years. However, in August of 2008, Starbucks Coffee Company Australia announced to shut down more than 60 of its 85 coffee shops and to date it has scaled down to 22 opened in Sydney, Brisbane, the Gold Coast, the Sunshine Coast and Melbourne (Starbucks 2010).This writing will focus on the analysis on the attributes of Starbucks’ products and marketing, and identify the opportunities and threats facing the Starbucks Australia. The second part of the analysis also draws attention to the changes in social economy, competitors’ move and the main trends in the hot drink market. Based on the findings, recommendations are offered, aiming to help Starbucks gain competitive advantages in Australian marketplace and long run sustainability in a larger social context.In terms of coffee products and service quality, the cafe market in Australia is extremely mature and competitive. It is understandable that consumers’ expectation towards the newly-introduced coffee brand has been exalted high, especially when they are charged with premium price (Marketing Lessons 2010). However, the exotic coffee brand does not bring specialty to the local coffee culture as expected, the consuming experience stay mediocre. Meanwhile, products do not suit Australians' coffee tastes (Marketing Lessons 2010).Starbucks’ positioning in Australian cafe market has departed from the consuming needs and patterns of the local customers. Dismantled with the uniqueness it possessed and its success in the US and other Asian countries, Starbucks Australia seems to be as ordinary as one of the numerous choices for customers in Australia (Coffee Break and review 2008), and people never genuinely felt the necessity to go to a Starbucks shop. Evidently, Starbucks overestimates its points of difference, as well as th e customer-perceived value of its services (Marketing Lessons 2010).To compete out in Australian Cafe market, Starbucks needs to find new ways of creating competitive advantage to differentiate itself from local market competitors. What could make Starbucks special? It could be the menu including items catering customers’ special needs in coffee tastes, or the store environment which makes customer feel comfortable to sit in and enjoy the time, or the excellent service offered by people. Or it could be the combination of all the specialties makes the consuming experience unique.Datamonitor (2010) points out that the core competence of Starbucks is the quality of products. However, it is far from enough, because the best coffee and best equipment in the world could only make 20 percent of success, just as Ed Charles (2007) describes that success of product and service is 80 percent due to the performance of staff, and they must be trained to perform at their best both on produ cts and service to maximize the perceived value of customer.More specifically, customers’ perceived value is related to both tangible benefits such as price, product quality, service, convenience and price, as well as intangible benefits concerning reputation, aesthetics, social and emotional needs like self-enhancement and sensory pleasure needs. Quality service performed by staff could highlight both tangible and intangible benefits of customers. The attributes of the quality service in coffee shop can be demonstrated by thinking of the best consuming experience you could ever imagine.When entering a clean, well-furnished coffee shop with attractive decoration and cozy ambience, customers are recognized by friendly employees and greeted by own names. Order is made in an attentive manner, and fulfilled accurately and timely. Coffees with appealing aroma are served at moderate temperature and they are great and unique in taste. Market players could acquire some of the attribu tes depicted in the scenario to survive in the marketplace and their service quality varies depending on the competency of the service staff.What customers need is consistent quality services, which is discovered in the report by Chen and Hu (2010) that if customers feel confident that they can have a consistent quality consumption experience each time they come, they tend to choose the same coffee shop to enjoy their coffee. And such favorable attitude towards the service they have received could evolve into customer loyalty, since the essence of customer loyalty is, as Barnes (2001) depicts, â€Å"all about how you make them feel†, vice versa.Customer loyalty may result in consistent purchasing behavior of the brand over time. Therefore, it could be concluded that the all-round quality service performed by staff with high consistency could be the competitive advantage of Starbucks, which can make it special and achieve long run sustainability in Australian market. In light of this finding, Starbucks Australia should devote more efforts to human resources management. More specifically, a series of human resource practice could be designed and implemented to strategically improve employees’ competency and working attitude.For example, staff training could help them be more competent to perform all tasks involved up to standards and with high consistency and staff motivation could boost morale and let them know what is expected of them in a quite specific way. Both staff training and motivation could increase employees’ satisfaction to the extent that they are willing to exert effort to perform the service well and taking initiative to improve the service quality. It is supported by a study that a 5 percent increase in staff satisfaction can result in 1. 3 percent increase in customer satisfaction (Kleinman 2007).By improving the service performance of each staff, which is as Kleinman (2007) defined ‘employee-centered outcome’, Starbucks could achieve higher customer satisfaction, which is ‘organization-centered outcome’, and as the customer satisfaction accumulated and boosted, Starbucks would successfully deliver its positioning as ‘best coffee with premium service’ to the Australian market. And the company’s competitive advantage lies in its human resource management which includes a combination of human resource practice to increase employees’ competency and willingness to render consistent quality service to customers.Compared with the strategies which focus on price, menu and store environment, strategies on HRM would be less susceptible to imitation, since it is intangible and tacit and it is hard for competitors to know the exact HRM practices which could be replicated Additionally, the human resource management (HRM) practices should be facilitated with other non-HRM measures. For example, particular resources related to improving the service quality should be prioritized and allocated by the management to enhance the service performance.If Starbucks managed to acquire the quality service and achieve high customer satisfaction and loyalty through its competitive advantage in human resource management, it could have stayed profitable even during tough social economic condition and keep competitors away from its marketing territory. Since 2007, customer’s consuming confidence was dramatically decreased due to the economic recession and they spent money with more discretion as a result of or threatened by unemployment, bankruptcies and degraded credit. The decreased confidence of consuming caused the curbed spending which in turn resulted in pressure on the company's margins’ (Datamonitor 2010). Such tightening of consumers’ spending has encouraged defection. McDonald's, for instance, has already made small forays into providing decent coffee, and achieved some successes (Economist 2008). To retain customer, Starbuck s need to stress on premium service quality to achieve high customer satisfaction and further differentiate its products and service from McDonald’s, so that existing customers feel attached to the unique consuming experience in Starbucks and reluctant to defect.Although McDonald’s could offer decent coffee with a reasonable price, the premium consuming experience and series of HRM practice behind the strategy will be the major barriers for McDonald’s. Like most other coffee products, Starbucks' products contain caffeine, dairy, sugar and other active compounds. It is proved by public research that excessive consumption of these ingredients may lead to variety of health hazardous. The health issues are increasingly calling for public awareness and the public are suggested by doctors and experts to choose foods with discretion and reduce the frequency or quantity of intake.Such trends of food choice will reduce the demand of Starbucks’ beverage and food pr oduct (Datamonitor 2010). Noticeably, despite the threats from the health issues against the coffee products, a report by Parker (2005) reveals that the coffee demand in Australia will keep increasing from USD268. 57 million in 2006 to USD307. 13 million in 2011. This can be partly explained by the research (Luciano et al. 2005) that people’s preference to coffee beverage is genetic in Australia, and it is different from their preference to tea which is affected by the environment.It is understandable that although people’s consuming concept is becoming increasingly health-oriented, they still maintain their coffee-drinking habit. In this sense, Starbucks could retain the coffee demand by adding more decaffeinated coffee beverages and other coffee products incorporated with healthy components. The overall increase in coffee market could be seized if Starbucks manage to tune in the market trend by adjusting their coffee product structure.According to the research by Che n and Hu (2010), one of the attributes of the coffee industry is that it is highly competitive and homogenous in terms of services and products, and the availability of alternatives to the customers can be considered as an important attribute in decision making of purchasing. Therefore, Starbucks could offer a wide range of selection of coffee products as well as other beverages like tea and juices. This proposal of strategy could be justified by the finding that Wong (2010) mentions in her report.The culture of hot drinks in Australia has been evolved towards heath, and consumers are becoming mature while choosing the beverage in better taste as well as showing their preference toward premium products in both coffee and tea categories. The estimation by Datamonitor (2010) of the overall growth in the hot drink market in the next five years is 9. 1 percent, which will increase from AUD1350 million in 2008 to AUD1473million in 2013. Noticeably, the emerging tea market will increase b y 8. 1 percent, from AUD437million in 2008 to AUD473million in 2013.To optimize the profits, Starbucks could bank upon such trend and launch new products featured in tea category. Tea product can serve its market among the health conscious Australian consumers well in the next few years, due to its healthy and medicinal benefits. There is another marketing feature draws our attention. As discovered in the research by Luciano et al. (2005), women consume more beverages than men and show a lower preference for coffee than men, but higher preference for tea, which implies that the primary driving force for tea consumption is its appeal to women.This feature drives Starbucks to develop more tea products to cater for women’s preference in taste. By adding ingredients in women’s favor and making the beverage attractive in color and design, Starbucks just launched a series of tea products (Starbucks 2010) to attract more female customers. At the same time, Starbucks has creat ively combined the tea with coffee (Starbucks 2010) to create a product with specialty, which introduces a different way of enjoying coffee and tea product and also is an effective ay to surprise and delight their customers continuously. To be successful in the competitive Australian market, it is necessary for Starbucks to focus more on the human resource management practices to achieve sustainable and competitive advantages, which make their staff more capable and motivated to perform outstanding services with high consistency, so as to restore brand specialty in the marketplace. It is also important for Starbucks to be alert to all the changes in the market, as customers’ consuming habits and preferences in taste are always changing.The product structure, according to the market trends and new marketing strategies, should be adjusted to seize the opportunity facing the company. Just as Cairns put it in the report Starbucks (2008), the company needs to put the specialty to the market and grows with its customers. The winner could even proactively guide the market trends and foster the new consuming needs of customer to boost profitability. This requires the market player to be consistent in quality service performance but active and creative in marketing changes.

Definition and Examples of the Amelioration of Words

Illegal Street Racing - 1684 Words

Illegal Street Racing At least once a week, we hear on the news about someone dying as a result of illegal street racing. Sometimes, its the driver or passenger of the car that is racing who gets killed, but often times its innocent bystanders or drivers of other cars who are killed by the reckless teens who engage in a highly dangerous activity. First of all, what is illegal street racing, think Fast and the Furious, and second, what can be done to stop this from happening or at least reduce the amount of deaths that occur each year as a result of illegal street racing? This final paper will explore these questions and provide one possible solution to this on-going problem. Street racing has been around since the early 1930s†¦show more content†¦In fact, increasing the penalties may only encourage illegal street racers to try harder to evade police, since they would be arrested regardless of whether they tried to escape. Stiffer penalties and fines cannot be the only solution to this ever increasing problem. Instead, the better approach to curbing illegal street racing would be to provide young people with an out for racing that is safe, such as a racetrack. Racetracks give people the opportunity to show off their cars, race, socialize with other racers and satisfy need for speed without jeopardizing their life or the lives of others. Our Hawaii legislatures have recognized the need for a controlled environment for people to race their cars which is why they recently passed legislation that mandates the State to find locations within the State of Hawaii that can be used as sanctioned racetracks. The idea is that by opening racetracks, you make it easier for people who might otherwise engage in illegal street racing and endanger the lives of others. Another positive thing that can be done is for local organizations to get involved and help sponsor different types of racing events. In California, Race Legal holds events throughout Southern California to help get young kids that participate in dangerous illegal street racing off of the streets and gives them a safe and legal place to race. Once the racers are provided with adequate places for racing, there should be no excuse for to engage inShow MoreRelatedIllegal Street Racing1598 Words   |  7 PagesIllegal Street Racing It would seem that the import car scene is becoming one of the largest trends in the automotive industry since the introduction of the assembly line. Nearly every manufacturer of vehicles has a sport compact car in the market. Teenagers and other young adults are customizing and â€Å"souping† these cars up for purposes that no car was intended for, illegal street racing. These speed contests on public roads are a danger to anything and everything on the roads, including the driverRead MoreIllegal Street Racing1919 Words   |  8 PagesIntroduction Street racing has been identified as a threat to civil society with significant social and economic impact . Street racing is illegal in Malaysia , as reckless stunts on public roads endanger the lives of many . One of Malaysia ’ s subcultures include the ‘ Mat Rempit ’ biker gangs , estimated to be over 200,000 which comprise of bikers who either take to illegal racing in large numbers or perform extremely dangerousRead MoreIllegal Street Racing2878 Words   |  12 PagesOne of the fastest growing sports in the world is racing. Racing in general can consist of many different types such as: Drag Racing, NASCAR, Indy, Motor Cross, Truck Rally. The topic of racing that I am chose was street racing. Street racing originated from drag racing on the quarter-mile strip. The concept of drag racing is when two racers in different cars would line up at a white line, and in the middle of the two cars would be a light post, called the Christmas tree for its red, yellow and greenRead MoreThe Problem Of Illegal Street Racing881 Words   |  4 Pagescreated, Americans have been obsessed with speed. Illegal street racing became popular in the 1950s with the evolution of the motor vehicle. â€Å"In the ’50s and ’70s, Hollywood romanticized the activity in movies like â€Å"Rebel Without a Cause† and â€Å"American Graffiti.† (Petrocelli, 2007) The need for speed grew as vehicles became more powerful and faster. But, speed and racing did not come without great consequence. Statistics show in 1999 street racing involved deaths, but was not a giant issue at theRead More Illegal Street Racing Essay1818 Words   |  8 PagesIllegal Street Racing Vivid moonlight, dim city, slight overcast on the noxious night. Cool breeze blows over your sweltering body. Heart racing, sweat pouring, adrenaline pumping through the body like gas through the engine of a car. Body trembling, hands shaking, eyes twitching, foot uneasy as beady eyes observe your every move. Thunderous noise coming from the crowd, situation getting heavier the closer you get to the line. Tension raised to the max as time draws nearer†¦.5-0 no whereRead More Illegal Street Racing Essay examples2781 Words   |  12 Pages One of the fastest growing sports in the world is racing. Racing in general can consist of many different types such as: Drag Racing, NASCAR, Indy, Motor Cross, Truck Rally. The topic of racing that I am chose was street racing. Street racing originated from drag racing on the quarter-mile strip. The concept of drag racing is when two racers in different cars would line up at a white line, and in the middle of the two cars would be a light post, called the Christmas tree for its red, yellow andRead MoreEssay The Thrill That Kills980 Words   |  4 PagesThe Thrill That Kills Street racing has become a very dangerous sport in the 20th century. In the article The Thrill That Kills by Paul-Mark Rendon, he describes the dangers and consequences of illegal street racing. This article was published Sept. 17, 2001 in MacLean’s. This is an article that tries to reach out to street racers and also anyone interested in knowing more about street racing and its dangers. The article discusses how for the driver, racing is an exciting adrenaline rush,Read MoreShort Term Effects of Street Racing599 Words   |  2 PagesEver wondered what the short and long term effects on street racing were? Street racing has more risks and consequences than you would think. Many consequences range from a simple ticket to an accident that can haunt you or someone else for many more years. Street racing laws should include opening up drag strips so people can go race legally, and the city can make some money. Street racing can have many consequences, long term or short term for either the people you love, the people who love youRead MoreEssay on Street Racing1529 Words   |  7 PagesStreet Racing   Ã‚  Ã‚  Ã‚   The intricacies that are involved in turning a regular car into a â€Å"Street Racer† are many; and racers pour their souls into these magnificent machines. After seeing â€Å"the Fast and the Furious† many people have or wanted to become involved in street racing. They do not realize that this is a sport that takes knowledge, hard work, and nerve. Many of these racers have spent their lives under a car, learning the trade and improving upon it. As I have learned, this is not just aRead MoreThe Importance Of Racing Within The Car Industry1893 Words   |  8 PagesThe importance of racing within the car industry So for years now, the car industry has been evolving. While it is getting bigger and bigger, it is also branching off to many other sub-industries. Among those industries, one of the most popular is the racing one. It has been evolving since it has started. And to say that it is very popular in this generation would be a huge understatement. Even while it is an industry of its own (Racing industry), it still has many different branches. For instance

Margaret Atwoods The Handmaids Tale Essay - 962 Words

Margaret Atwoods The Handmaids Tale The Historical Notes are important in the way we perceive the novel as they answer many important questions raised by the novel and also enhance some of the novels main themes. The first question it answers is the one raised at the end of the novel; that is whether Offred is stepping up into the,darkness, or the, light. The reader finds out that Offred escaped Gilead, presumably into Canada, with the help of the,Underground Femaleroad. The reader also learns that it was Nick who orchestrated her escape, using his position as a member of the Eyes. This is important to the novel as it means that the novel can feasibly be a transcript of her story, a story she could not have told if†¦show more content†¦This again demonstrates to the reader the flaws Atwood perceives in modern society, and that what happened in Gilead could happen in our world. The Historical Notes are also important in that they show the reader that Gilead has finished, and that it had its problems, purges and internal upheavals. This provides one of the few messages of hope in the novel, that no matter how severe, not all totalitarian rule lasts forever. This is reminiscent of other rules in the past such as Nazi Germany or Modern day Russia under the rule of Stalin. This also again places the events of the novel firmly in our time period and demonstrates that Gilead is not the first totalitarian society. Another reference to, the time before, comes when the Handmaids uniforms are compared to those which were worn by, German Prisoners of War, again helping to root the novel firmly in our time. Another important effect of the Historical notes is that it demonstrates how people studying The Handmaids Tale perceive it, as a nice story, but something that couldnt happen in this day and age. The fact that Piexto states that, we are happily more free, from the problems contained in Offreds account demonstrates that many people, in theShow MoreRelated Margaret Atwoods The Handmaids Tale Essay1246 Words   |  5 PagesMargaret Atwoods The Handmaids Tale In The Handmaids Tale, Margaret Atwood tells a saddening story about a not-to-distant future where toxic chemicals and abuses of the human body have resulted in many men and women alike becoming sterile. The main character, Offred, gives a first person encounter about her subservient life as a handmaid in the Republic of Gilead, a republic formed after a bloody coup against the United States government. She and her fellow handmaids are fertile women thatRead MoreEssay on Margaret Atwoods The Handmaids Tale1419 Words   |  6 PagesMargaret Atwoods The Handmaids Tale Love of God replaces love of humanity in Margaret Atwood’s, The Handmaid’s Tale. Offred’s recollections of her past life, especially of her husband, are ones filled with passion and happiness as she remembers his tenderness towards her. Much more emphasis is put on the physical human form in her memories; she often remembers lying with her husband while she wears little or no clothing. Appreciation of the human form is an essential component of loving humanityRead MoreEssay on The Dystopia in Margaret Atwoods The Handmaids Tale1098 Words   |  5 PagesThe Dystopia in Margaret Atwoods The Handmaids Tale Offred is a Handmaid in what used to be the United States, now the theocratic Republic of Gilead. In order to create Gileads idea of a more perfect society, they have reverted to taking the Book of Genesis at its word. Women no longer have any privileges; they cannot work, have their own bank accounts, or own anything. The also are not allowed to read or even chose who they want to marry. Women are taught that they should be subservientRead More Representation of Colors in Margaret Atwoods The Handmaids Tale1774 Words   |  8 PagesRepresentation of Colors in Margaret Atwoods The Handmaids Tale Imagine if you can, living in a world that tells you what you are to wear, where to live, as well as your position and value to society. In Margaret Atwoods novel, The Handmaids Tale, she shows us the Republic of Gilead does just that. Offred, the main character, is a Handmaid, whose usefulness is her ovaries. Handmaids are ordered to live in a house with a Commander, his wife, and once a month attempt to become pregnant byRead MoreEssay on Feminism in Margaret Atwoods The Handmaids Tale1096 Words   |  5 PagesFeminism in Margaret Atwoods The Handmaids Tale In The Handmaids Tale, Margaret Atwood explores the role that women play in society and the consequences of a countryà ­s value system. She reveals that values held in the United States are a threat to the livelihood and status of women. As one critic writes, â€Å"the author has concluded that present social trends are dangerous to individual welfare† (Prescott 151).   The novel is set in the near future in Gilead, formerly the U.S., at a time whenRead MoreEssay on Feminist Ideas in Margaret Atwoods The Handmaids Tale1199 Words   |  5 PagesFeminist Ideas in Margaret Atwoods The Handmaids Tale For this essay, we focused strictly on critics reactions to Margaret Atwoods The Handmaids Tale. For the most part, we found two separate opinions about The Handmaids Tale, concerning feminism. One opinion is that it is a feminist novel, and the opposing opinion that it is not. Feminism: A doctrine advocating social, political, and economic rights for women equal to those of men as recorded in Websters Dictionary. This topic is prevalentRead MoreFeminism Lost in Margaret Atwood’s A Handmaid’s Tale Essay1527 Words   |  7 PagesIn Margaret Atwood’s A Handmaid’s Tale, the human spirit has evolved to such a point that it cannot be subdued by complacency. Atwood shows Gilead as an extremist state with strong religious connotations. We see the outcome of the reversal of women’s rights and a totalitarian government which is based on reproduction. Not only is the government oppressive, but we see the female roles support and enable the oppression of ot her female characters. â€Å"This is an open ended text,†¦conscious of the possibilitiesRead MoreEssay Romantic Love in Margaret Atwoods The Handmaids Tale1385 Words   |  6 PagesRomantic Love in Margaret Atwoods The Handmaids Tale In her novel The Handmaids Tale, Margaret Atwood addresses the concept of different expression of romantic love through the eyes of Offred, a woman who has lost almost all her freedom to a repressive, dystopic society. Throughout her struggle against oppression and guilt, Offreds view evolves, and it is through this process that Atwood demonstrates the nature of love as it develops under the most austere of circumstances. The firstRead More Margaret Atwoods The Handmaids Tale: Novel and Film Essay2075 Words   |  9 PagesMargaret Atwoods The Handmaids Tale: Novel and Film The Handmaids Tale, a science-fiction novel written by Margaret Atwood, focuses on womens rights and what could happen to them in the future. This novel was later made into a movie in 1990. As with most cases of books made into movies, there are some similarities and differences between the novel and the film. Overall the film tends to stay on the same track as the book with a few minor details changed, and only two major differences. Read MoreThe Satire of Margaret Atwoods The Handmaids Tale Essay example497 Words   |  2 PagesThe Handmaids Tale has been described as a scathing satire and a dire warning! Which elements of our own society is Margaret atwood satirising and how does her satire work ? Atwood tries to open our eyes by satirising our society with a brilliant contrasting novel. Dystopian in every way, the reader encounters a world in which modern values of our society seem/ are replaceable. Showing the worst of all possible outcomes, she demonstrates that our primarily heartless, just economical thinking

Secret life of the brain free essay sample

Neurons travel everyday in millions to carry out different task. It’s fascinating how they travel as if they are traveling across the country. They’re following cues along the way that are telling them exactly where to go. Evidence shows that young neurons have an idea about where they migrate to and can recognize their position within the brain. Neuroniologist Susan McCnell devised a series of experiment to track the destiny of a migrating neuron. Dr. McCnell found that the fate of the soon-to-become neuron was determined by his neighbor neuron. It travel beside its neighbor and took on the same function they did. The new neuron then goes on its own path, and takes on an entirely different function from the cells surrounding it. The Child’s Brain: Syllable From Sound Explain how the child’s brain is able to take a â€Å"great leap† and learn to master language? A young child has twice as many neurons than adults. We will write a custom essay sample on Secret life of the brain or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The child brain is plastic, a magnificent and flexible engine for learning. Children learn to crawl, reason, pay attention and remember. They learn to make friends, but nowhere is learning more dramatic than in the way a child learns to master language, the great leap that the brain makes that is nothing short of a miracle. I can relate being the eldest of my siblings’ language development represents one of the most profound mysterious changes. The Aging Brain: Through Many Life Explain how age affects mental performance? The lab at the University of Michigan studies shows how age affects mental performance. Its director, psychologist Denise Park, gathers evidence that presents a new view of brain aging. Aging begins in our 20s, as soon as we reach maturity, our data show clearly as we age from twenty to thirty, we get a little bit slower. We process information not quite fast. Then suddenly we turn seventy and start noticing that these continuous declines have aggregated our memory. The more unfamiliar the information, the more trouble we’re going to have remembering. We will also forget simple things such as where did I park my car. Explain the job of the hippocampus on brain activity? The hippocampus is a major component of the brain.. It plays important roles in long-term memory and spatial navigation. Like the cerebral cortex, with which it is closely associated, it is a paired structure in the left and right sides of the brain. The hippocampus is located inside the medial temporal lobe, beneath the cortical surface. In Alzheimers disease the hippocampus is one of the first regions of the brain to suffer damage; memory problems and disorientation appear among the first symptoms. Damage to the hippocampus can also result from oxygen starvation (hypoxia), encephalitis, or medial temporal lobe epilepsy. People with extensive hippocampal damage may experience amnesia which is the inability to form or retain new memories. What goes wrong in the brain to cause depression? The human brain operates, much like your automobile, on fluids called neurotransmitters. Just as your automobile have brake fluid, antifreeze, transmission fluid, and oil your brain runs on these neurotransmitters. Some give us energy, like those related to adrenalin, some control body movements (dopamine as an example), and some control mood. The brain neurotransmitter often associated with depression is called serotonin. Serotonin is the brains oil, a rather slow-acting neurotransmitter that is associated with sleep, appetite, energy, alertness, and mood just to name a few. Using the automobile as an example, if we drive our car to California at a speed of 120 mile per hour, running the engine hot for a long time, it would obviously use more oil. As long as we provided gas, however, it would continue to run. Now suppose in our trip that for every two quarts of oil we burn, we only replace one quart. By the time we reached California wed be several quarts low and our engine would be obviously overworked and overheated causing it to slow down.