Extension 2 English Proposal Essay Example for Free

Extension 2 English Proposal EssayThe audience of my major work testament be firstly incurd English teachers for marking. The story itself lead be aimed however at an audience of teen years and above, preferably interested in modern history. Any readers of a younger age may lack the necessary understanding of the context of my piece, and thus may not be equal to understand the decisions and tone of voiceings of fonts in the piece. The story will aim to incite passionate questions of the actions and experiences of my characters in the mind of the reader, as well as an emotional response establish on the life and personal experiences of the reader. For instance, if they find experienced the death of a family member, they may identify with the emotions of my characters. Purpose/Statement of Intent After much deliberation, I propose to compose a prose fiction short story based on the experiences of fictional guard in Dachau soaking up camp during WWII. I came crossways this idea when studying for the text Romulus, My father from the English Advanced course. Part of this text describes the main character Romulus and his lover Christina living in Nazi Germany, and I was reading through articles on the Internet regarding various attractions of the regime.This led me to reading letters between various concentration camp officials and Heinrich Himmler, the then leader of the SS, and high-ranking Nazi general. The writing is so simply put that it somewhat m asks the cruel and indifferent intention of the letters. After reading through these letters, I came to ask myself How does a human being come to take these attitudes, and how could a person become seemingly so cruel and twisted, without any apparent conscience? What split of life has this person lived, and what are their thoughts? Did they ever face struggle in their minds for the decisions they made? From this, I devised a perspective for a piece the perspective of a male guard in a concentration camp . But not just any ruthless guard. I want to write about a quite a troubled guard. A complex character that over the course of the piece actually begins to question the morality of his actions and thoughts. I want the reader to feel both anger towards the actions of this beast, but also at different times sympathy for his predicament. I want the reader to question their understanding of morality, and to put themselves in the shoes of this man. ConceptThe form will be fictional short story, in prose. However, I plan to include real correspondence between military officials of the camp from the time. I wanted to use this idea to give the story some real meaning, and to remind the audience that people just like my character did exist. Most of the piece will be in third person, but I will include monologues of the characters thought processes. During scenes of increased tension, for example when the man is consistent to shoot a prisoner, I will include in between the dialogue the tho ughts of the guard himself.This will hopefully engage the reader in the scene, rather than the reader being a fly on the wall, which would leave a wall between the reader and the characters. I would like to vary the style of voice communication used, from short and punchy for tension and emotion to long and reflective for the monologues. Inspiration I chose to write a story on the holocaust because it is something that I would enjoy researching in detail, absorbing e precise scrap of information, and also I think it would be challenging to confront on my own terms.Reading the information I down already come across, I cant help but feel so lucky to live in a free country, and in such a privileged life. A life where I am free to do what I choose, including writing this piece. I fancyed Dachau concentration camp in 2003, and this experience had a great effect on me. The feelings of disgust and general confusion as to how this could happen has probably lead me to be so interested in studying the topic today. I will use this experience to describe the surrounds of the setting, and some of the experiences of the prisoners.The following is an extract of a speech given by Himmler regarding the settlement of the Jews. Reading it today, I find it strange and foreign. To better understand why Himmler would take this approach to the extermination of a whole race, I will have to research the culture and attitudes of his time in-depth. Also, the ideas held by this quote is what I want to base my characters questioning on. I also want to mention a very difficult subject before you here, completely openly.It should be discussed amongst us, and yet, nevertheless, we will never speak about it in public. I am talking about the Judaic evacuation the extermination of the Jewish people. It is one of those things that is easily said. The Jewish people are being exterminated, every Party member will tell you absolutely clear, its part of our plans, were eliminating the Jews, ex terminating them, ha , a small matter. -Heinrich Himmler, 4 October 1943 Links to Advanced ExtensionThe idea for my piece came from researching the text Romulus, my father, in the Advanced course. The piece will specifically tie-in with the concept of belonging in many ways. For example, my main character will be in a position where he is pressure to belong to the regime, and to his position and rank. If he chooses to disagree with his superiors, or the regime itself, he will be shot. Also, nature of the holocaust relates directly to belonging, as anyone who belonged to the Jewish religion, was a gypsy or was disabled was persecuted and often killed by the Nazi regime.The regime aimed to wipe-out all those who, in the eyes of the officials, did not fit the requirements of a pure nightclub based on the Aryan legend. However, the piece does not necessarily link to the topic of crime writing in the Extension 1 course in any way. Research I have read many articles and letters on var ious websites, which have been very detailed and very helpful in giving me a broad account of events and people surrounding the Nazi regime.However, I will need to continue to research further in-depth into the holocaust and in particular the events and nature of the Dachau camp. I also plan to read Anne Franks Diary of a girl, to further understand the experience of life in a concentration camp. This text should provide the experience of a prisoner, with which I can use to contrast the ideals and experience of the guard. Over the holidays I will make a visit to the state library to find historical diaries and personal accounts of experiences in concentration camps.

Great Ormond street hospital Essay Example for Free

Great Ormond street hospital EssayThis is because we all concur that we would be keen to make money for this bounty. This charity raises money for the hospital to provide exceptional cargon for young patients and to discover new treatments and cures for their illnesses. Before deciding this charity, we looked on their website (www. gosh. org) to see exactly where our contribution would go, and how it would profit the charity. They state that donations help fund the most up-to-date medical equipment, refurbish the hospital, support the research of developing break-through treatments and provide accommodation and support for children and their families. In sum total when looking up this schooling, we rig Fundraising Guidelines that GOSH supplied for plenty running fundraising grammatical cases. We read the guidelines and found them extremely helpful for running our first event. These guidelines can be found in addition -. Other events that were creation contemplated are l isted below Formal spend Ball Halloween uninfected Car Boot Sale A Cake amusement park However, these ideas were non taken further as it was believe they would not be as thriving as holding a Christmas Fair.This is because a Formal Winter Ball subjects to only couples, and would find people being uncomfortable if they had no date, this convey our amount of attendees would be smaller which would not bring as oft profit. Our Christmas fair is open to all of the public, an event that you can go to with family, friends or partners. There is no limit to amount of people helping our chances of greater profit. subsequently discussing a Halloween event, we concluded it would not be as successful because not everybody celebrates Halloween in great detail, and usually only celebrate with kids, alike narrowing our attendees.Further more(prenominal), we agreed that we would not be able to organise ourselves in enough time, whereas we had more time to prepare to hold the Christmas Fair because of seasonal timings. Also a, Cake Fair is too limited, and finding stallholders who would want to attend would be limited as there would be too much competition for them narrowing the chances of selling cakes. in conclusion we decided against a Car Boot Sale as not many of us were enthused by the idea, and felt a Christmas Fair would get people in a good mood before the celebrations begin.A copy of our research for these events and our Christmas Fair research can be found in Appendix 4. We chose the Christmas Fair to be our event as it can appeal to a large amount of people and therefore has a wider target demographic. By creating an event that appeals to a wide ramble on of people pull up stakes reduce the risk of not make a profit. This will help the success of an event, rather than a failed attempt. With more customers open to the event, means there is more potential for the event to be profitable. Also due to the Christmas season being celebrated by many, more people will be willing and interested to participate.The day will be full of excitement and entertainment for all members of the community to attend and bed them. It also seems relevant, as Christmas is an extremely popular annual holiday which dominates the end of November all the way through to December 25th. Being able to work in a team is essential in planning any event and also quite important to many businesses and therefore seems a skill that should be taken professionally. As the Christmas Fair was open to the public, it is even more important that the team work well together.Therefore it was the best event to stage in magnitude to improve our skills. The event is also to raise money for Great Ormond way Hospital, which suggests that more people are likely to attend and support our give less(prenominal)ons to raise money for a great charity. The target areas that we created used SMART, in order to help the day become a success. SPECIFIC MEASURABLE ACHIEVABLE germane(predicate ) TIMES These are our objectives 1. Have over 100 attendees and supply great customer service. The objective is to have over 100 attendees this will allow us to see how well our advertising techniques were used.In addition it is imperative to have good customer service throughout the function. Without customer satisfaction, people are less likely to buy products or help to arrive at our aim of producing an enjoyable festive event. Without customer satisfaction could also relate to a negative pestle of our school, and making stallholders look bad too as they are associated with our event. This objective is more than achievable and sensible when creating an enjoyable day for families. The amount of profit and products being sold could also measure the rate of customer satisfaction.This is because, if people are not happy with the service they are getting less raffle tickets are likely to be sold, as well a the amount of people in the event. 2. Diverse Target Market The objective is to have leaflets given to unalike schools, and areas of Royston by 2nd November. By appealing to a wide target market means that the day has more chance of being successful and making a maximum profit. If the day only appealed to a limited audience, less profit is likely to be made. The wide target market also helps to achieve the aim of making a profit.This is very achievable and sensible in order to create a profitable day, as the amount of people that will enjoy the day is not limited. By creating a day for all ages means it is appealing to the maximum amount of people possible and therefore not leaving anyone out voluntarily. It is achievable by aiming stall, activities and prizes to a wide range of ages, and personalities. 3. A diverse amount of stalls Another objective of ours is to have 15 stalls by 15th September. By offering diverse stalls means it more likely that people will buy more products.It also helps produce a day for families by targeting all ages within the stall s taking part. Offering a wide classification of stalls also means that more money is likely to be made and therefore increases the chance of making a profit overall. If there were not a wide variety of stalls, less products will be sold as there will be a limited target audience. This could be measured through the range of ages, as well and products and prizes on the day. 2. Research Primary Primary research is the technique of collecting data yourself.It is the process of collecting completely new and authoritative information. These techniques include questionnaires, interviews, and surveys. The form of primary research used to collect information concerning the Christmas Fair was a questionnaire. This included relevant questions aimed at all ages in order to make the day as successful as possible and make it as easy as possible to reach the aim of the event. A questionnaire is not a very time consuming method of primary research and also means a lot of different information is found from a variety of different people.A questionnaire allows people to create questions that fit the audience, in this case, families and allows you to ask relevant specific questions to fit the purpose. A questionnaire also means plumb reliable answers are received. We asked a large variety of people that live in our surrounding area. A large variety of people including young children, teenagers, adults and ancient people were asked in order to get a wide variety of results and to ensure that our aim can be reach with this type of event.This is because, if the event is aimed at families, it is important to create an event that will appeal to all ages. Also, a total of 100 people were questioned, as it is easier to summarise and accurately measure. This means breach results will be found. A copy of the questionnaire and the results can be found in Appendix 1 2. The results of the questionnaire show that we will benefit from including aspects such as having a raffle refreshm ents and childrens stall such as painting as some of the activities and choices, in order to please the customers and meet the customer service objective created.The Santas Grotto and a chance to have a photo with Santa are also expert and would help raise more money for Great Ormond Street Hospital as well as meeting the requirement of younger children and parents. The majority of the responses was positive and therefore shows that a Christmas Fair would be extremely beneficial to stage. This means there is no reason to dispute over any other events as them Christmas Fair has a high chance of being successful due to all of the positive feedback.We also went to a surrounding areas annual Fate on the 19th June and asked stallholders if they would be interested in our Christmas Fair at the end of the year. We created a slip on Word Processor that they could fill out with their name, business name, number, e-mail address and nature of stall so that we would fulfil them in the near fu ture. It also gave us an advantage to see what activities and layout that they had to use for our Christmas Fair. A copy of our information collected from Therfield Fate can be found in Appendix 4. Secondary.Secondary research is information conducted and found by someone else used as part of your market research. This could be any information you see useful or need to find out information of your own, for example a school website with information of their Christmas craft fairs. There are a number of benefits and drawback to using secondary research. It is a very cheap method of collecting data as no effort or money has to be spent on creating, conducting or analysing of the results and source. As secondary research we looked at a variety of websites to find information about surrounding schools craft fairs such as dates and times.

Management Of Minor Injuries

Management Of Minor InjuriesIntroduction As part of this minor injuries course we have been asked to provide a 3000 word assignment utilising a case method as means of researching a uncomplaining scenario we experienced during clinical practise.Case study method enables a researcher to investigate an individual(a) and evaluate these findings and relate this evidence to clinical practice ( REFERENCE 1) Case studies are also often subjective and shewd around a personalized experience or memorable patient (REFERENCE 2), whilst identified by (REFERENCE 3) that these case studies do not provide a great amount of empirical and statistical evidence, (REFERENCE 4) highlights that case study methods stimulate critical thinking and help practitioners apply theory to clinical practice.For this case study I have chosen a patient who I treated for an Achilles muscle rupture. This assignment go out aim todocument the assessment of a patient in the acute stage of staindiscuss the initial mana gement of the injurydiscuss the intervention plans availableconclude how this case study has impacted on my clinical practiseThe Achilles tendon is given its name by Greek hero Achilles as the largest and strongest tendon within the human body, Patel and Haddad (2006). It connects the calf muscle (gastrocnemius) to the heel bone (calcaneus) and is located downstairs the skin at the back of the mortise-and-tenon joint.(reference needed) As the calf muscle contracts it provides it enables the foot to be pointed downwards (plantar inflection) It is this action that enables us to walk, run, jump and to stand on our toes.(reference needed) condescension great forces applied through this tendon it is vulnerable due to its hold in blood supply, the least vascularised area being 2 to 6 cm to a higher place the calcaneum. This diminished blood supply predisposes this region to chronic tendonitis and electromotive force rupture. (reference 5)Kerr (2005) suggests three main attributing factors are leading to an increase in rupture.Increased sedentary lifestyleRising popularity of recreational sports especially in older menAn increasing proportion of people are overweight75% of Achilles injuries occur during fair activities, and research indicates this is occurring with patients who describe themselves as novice or beginners (Josza et al, 1989). As ENPs it is important that we are able to differentiate between an acute tendon injury and opposite complaints i.e. gastrocnemius tears in pitch to treat, advice and refer appropriately. Misdiagnosis or delay in treatment can lead to gait dysfunction and chronic vexation.The adjacent case study is a true stock-stillt of a patient I assessed during my clinical placement. To maintain the patients confidentiality he will be referred to as Mr Smith. graphic symbol STUDY 68 year old retired gentleman, no drug allergies, no significant past or ongoing medical problems. Mr Smith attended the want part at 10.00 and was bo oked in with a limb problem. I greeted Mr Smith, explained my role as a training Emergency Nurse Practitioner (ENP) and gained take for his assessment.Mr Smith had been aside dancing the previous night and thought he had been kicked in the back of his right lower leg. Since, he had described difficulty walking and not been able to bend his foot as normal. Despite walking tentatively Mr Smith manoeuvred himself onto the mental test couch. From his facial expression he appeared comfortable and his pain had been reduced having taken his own paracetamol and ibuprofen. The worst pain had been last night and the patient described an ache this morning. Further analgesia was offered but declined by the patient.Physical examinationThis was broken down into 5 key areas described by Guly (2002)Look (inspection)Feel (palpation)MovementSpecialist testsFunctionDuring our course we have assessed neurovascular function as a separate examination. This will be assessed between movement and specia liser tests.Look Mr Smith was examined in a private cubicle. His trousers removed in order to expose both lower limbs for comparison. Mr Smith had no provokes, no obvious deformity, no erythema /cellulites and no bruising noted. There was noticeable swelling around the base of the calf in the soleus region on the medial aspect of the limb. Both limbs were of equal colour and warmth. No surgical scarring was observed on all limb.Feel Palpation of lower leg then took place. In accordance with Gully (2002) this should take place from the vocalise above to the joint below. Palpation started from the knee joint downwards. From the examination of the knee joint no pain over bony land marks was elicited by the patient. The palpation moved distal towards the ankle, no bony tenderness was identified. The ankle was examined for bony tenderness. No tenderness was found at the posterior edge or tip of both the medial and sidelong maleolus, the base of the 5th metatarsal or the navicular b one. Using Ottawa ankle rules (Hopkins, 2010) at that place was no indication to xray the ankle. Mr Smith was then asked to go into the attached position, this enabled a good comparative view of both limbs mainly the gastrocnemius muscles and the Achilles tendons. The gastrocnemius muscle was then palpated although uncomfortable towards the distal muscle a item tender point was not identified. The Achilles tendon was then palpated this gave a specific origin for the pain. There was also bogginess (palpable tincture) in the lower third of the Achilles. Although a step was palpable Kerr (2005) indentified that not all ruptures have a palpable step, the cause of this unknown.Movement Ankle movements were examined both active and passive. Mr Smith had good active dorsi flexion and normal plantar flexion of both ankles. However when examined with passive resistance there was a marked deficit on his right ankle. Sterling (2001) highlighted that even though normal range of motion is wi tnessed during active movement it is essential passive movement is carried out, and assumptions should not be made to the integrity of the Achilles tendon. Both medial and lateral ligaments were stressed with no laxity and good end feel. Finally an anterior draw test was performed, the ankle was stable.Neurovascular status Mr Smith had normal superstar of his first web space, dorsum of foot and anterior and lateral aspect of lower leg. Mr Smith was able to dorsiflex and had normal toe plantar mechanism. Pedal shiver was also present.Specialist tests Mr Smith was then asked to kneel onto the trolley and support himself using the wall. A Thompson- Simmons (calf squeeze) test was then performed. At this time Mr Smith had no plantar flexion movement. Johnson and Morelli (2001) details this is highly suggestive of a ruptured Achilles tendon. Prior to undertaking this assignment I was not aware of any other specialist tests other than ultrasound. These shall be discussed later.Function Guly (2002) states the examination of a joint should include its functionality. Mr Smith was then asked to perform a calf heel raise (stand on tip-toes). He was unable to perform this task. Sterling et al (2001) summarised that a patient whose other plantar flexors are still functioning will not be able to perform this task if their Achilles is ruptured.Treatment Mr Smith was diagnosed and treated as an Achilles tendon rupture. He was placed in an equinas cast and was given crutches to mobilise with, which he did very well. A referral was then made to our fracture clinic where he would be followed up with the orthopaedic team. Take home analgesia was offered but declined by the patient. Mr Smith asked close to the long term plan of action, would he need surgery to repair his tendon. I answered honestly and stated I didnt know but endeavoured to find out from one of my colleagues. It was this lack of follow on care knowledge that has been one of the focuses for this case study. Hav ing an extended knowledge base would further enable a holistic approach to care not only in the acute care environment but to also provide accurate information about the care the patient should expect to receive. This sharing of knowledge will hopefully enable the patient to make an informed choice about how they would like to proceed. The follow on from acute injury to referral to fracture clinic is currently within 3 days. The patient will be presented if suitable with two options surgical repair or buttoned-up management. From reviewing the literature contributing towards this assignment it is clear the orthopaedic world is divided over these two strategies of care. However the common goal summarised by Patel and Haddad (2006) is a coming back of the normal length and tension of the Achilles tendon, allowing patients to regain their functional and desired level of activity. Fotiadis et al (2007) supports this and further discusses the importance of restoring length as this will preserve potence of the gastrocnemius and the soleus muscles, again improving functionality.Surgical repair the procedure involves making a longitudinal incision on the medial aspect of the Achilles tendon. ordinarily the incision is between 8 and 10cm, the ends of the tendon are then sewn together using non-absorbable suture. Two types of stitch are favoured, Krackow or Bunnell. (see appendix A) Kerr (2005) highlights the advantages of surgical repair asIncreased strengthReduced calf atrophyLess likely hood of re-ruptureFaster return to sporting activities.However with any invasive procedure there will be a risk offDeep wound infectionDeep vein thrombosisDelayed wound healingScar adhesionsHyperesthesia or numbness of the skinAfter surgery the limb is immobilised with an equinas plaster or brace for between 6 to 8 weeks followed by physiotherapy.Non Surgical Management Johnson and Morelli (2001) outlines that conservative management involves the patient being placed initially in an equinas cast. The immobilisation of the ankle plantar flexed between 40 and 60 enables the tendon to be stress free promoting the unification of the uncomplete tear or rupture tendon. Having discussed the current treatment guidelines with my orthopaedic colleagues at the hospital the patient would be expected to return to fracture twice over a 6 week period. This would be to have a new POP distributively time and gradually have the degree of plantar flexion increase. The patient would remain on crutches, non weight bearing on the affected limb, to reduce the potential stress placed on the tendon.Having presented the case study and outlined initial management and expected follow up care, I would now like to allege new methods of assessing for Achilles tendon rupture as stated on page 3.Matles Test The patient is laid in the devoted position with knees flexed at 90. Both feet and ankles are observed for plantar flexion. The diagram below indicates the there is an increase in do rsi-flexion on the injured limb (right)Source foot and ankle hyperbook (2011)The OBrien test the patient lies in the prone position knees flexed at 90. A small gauge needle is then inserted 10cm form the superior adjoin of the calcaneus into the Achilles tendon. Passive dorsiflexion and plantar flexion movements are applied absence of movement indicates a potential rupture.The Copeland test the patient is laid in prone position with knees flexed at 90. A sphygmomanometer is placed around the bulk of the calf and the pressure raised to 100mmHg with the ankle plantar flexed. When the ankle is dorsiflexed, in a non- injured Achilles tendon, pressure increases to 140mmHg. Where the Achilles is ruptured the pressure remains the same (Sterling et al, 2000).Other specialist diagnostic procedures can be performed i.e. ultrasound or MRI. These have been highlighted by Patel and Haddad (2006) as more accurate at detecting partial tears. Ultrasound is operator dependent and requires an experi enced technician and radiologist and MRI carries a high cost and limited clinical value of what has already been diagnosed clinically.Differential diagnosis During the initial history taking it is paramount an accurate detail history is taken leading up to the events. Majewski et al(2008) outlines 44% of Achilles injuries are misdiagnosed as ankle sprains or gastrocnemius injuries and advocates the use of the two specialists test previously identified the calf squeeze test and the Maltes test. Majewski et al (2008) concludes along with proficient palpation of the Achilles tendon two positive tests is good evidence of a rupture. However reinforces the need for sonography (ultra-sound) to differentiate between partial and full tears.As ENPs we are usually the first clinician patients see with an acute injury. We have a vital role in demonstrating accurate history taking, assessment, treatment and referral to the appropriate speciality. Despite the patient having an injury it is import ant that we can provide the patient with accurate education and health promotion advice. It is recognised within our department that weekends have a high increase is sporting injuries who attend the emergency department. The main sports are rugby league and football. We have a great opportunity to impart knowledge to patients with injuries in order to hopefully reduce the incidence of new or re-occurring injury. In relation to Achilles injury or Achilles tendonitis perambulator (2005) promotes warm up techniques, the benefits includeIncreased blood flow to working musclesIncreased range of movementsImproved speed of contractionIncreased temperature and hence increased elasticityImproved oxygen saturationAs previously identified there is reduced vascularisation to part of the tendon, Henry et al (1986) concludes that warming up increases the flexibility of the joint involved and best results occur from static stretching.Another important factor to advice patients about is footwear. If possible hard backs of shoes should be overstate as identified by Milroy (1994) these areas nudge the Achilles, often at the site of injury and wherever possible heels should be slightly raised to shorten the Achilles resulting in less injury from sudden lengthening.It is this information that I will be now documenting i.e. did they warm up prior to exercise and also conveying this to patients in order to reduce further injuries.ConclusionAs identified there is an increase in Achilles tendon rupture injuries hence more people will be attending the Emergency Department through direct referral from General practitioners and Walk in Centres/ Minor injuries units or from self presentation. From reviewing literature it is evident there is a significant number of misdiagnosis occurring around the area of injured Achilles tendons. Despite Mr Smiths diagnosis seeming straightforward I now have a greater appreciation of differential diagnosis and the effects misdiagnosis or delay in tre atment can have on the short an

Diagnosis of Middle Ear Disorders Using Wideband Energy

Diagnosis of Middle Ear Disorders Using wideband EnergyCLINICAL DIAGNOSIS OF shopping m all EAR DISORDERS exploitation WIDEBAND ENERGY REFLECTANCEA Doctoral Thesis Presented to The Graduate College of Missouri State University In Partial fulfillment Of the Requirements for the DegreeCopyright 2008 by Alaaeldin ElsayedCLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCECommunication Sciences and DisordersABSTRACTAccurate diagnosing of midst auricula atrii disorders in adults and children is a challenging task because of the complexity of disorders. Wideband ability reflection (WBER) technique provides simplicity and accuracy in diagnosing centerfield spike heel disorders across wide frequence range. This res pinnulech is expanding the studies of WBER to investigate the nerve atrial auricle situation in blueprint and pathological conditions of the shopping centre head in adults and children. Findings showed that WBER not whole can distinguish ab linguistic rule from normal midsection spindle function but also can characterize disparate essence head disorders in adults and children. Several specific WBER prototypes were established in a variety of nitty-gritty auricula atrii disorders among adults and children that will help in pinnulely diagnosis of such pathologies. The ER pattern was including significant high-pitcheder ER in the children control group than the adult control group at 0.5 kHz and 1 kHz, abnormally high or shallower in otosclerotic ears, abnormally low in ears with TM perfo balancen and abnormally low ER with deep notch in ears with hypermobile TM. In presence of cast divulge middle-ear impel, elevated ER at ambient compel is also expected. Results also showed that standard tympanometry was slight bare-ass in diagnosing middle ear disorders when comp ard to WBER specially in otosclerotic cases. Further studies are still required to validate the clinical use of ER in badr number of individ uals with confirmed middle ear disorders.KEYWORDS wideband sinew reflectance, otosclerosis, otitis media with effusion, eustachian tube dysfunction, tympanometry.This abstract is approved as to form and contentWafaa Kaf, MD, MS, PhDCh production lineperson, Advisory CommitteeMissouri State UniversitCLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCETITLE OF THESISByAlaaeldin ElsayedA Doctoral Thesis Submitted to the Graduate College Of Missouri State University In Partial Fulfillment of the Requirements For the Degree of Doctorate, AudiologyACKNOWLEDGEMENTSI would like to thank so many who encouraged me along this dissertation. First and foremost, I am thankful to God for all his blessings.I am very acceptable to Dr. Neil DiSarno for all his support and kind caring doneout my graduate school education.Further, I am indeed grateful to Dr. Wafaa Kaf, my doctoral advisor, for her guidance, encouragement, and support throughout this work.In addition, I would like to show appreciation to my committee members for their helpful comments and direction for this dissertation. Special thanks also to the capability and secretarial staff of the Department of Communication Science and Disorders.Thanks to Dr. Walid Albohy, and Dr. Ahmad Alhag for their help in collecting data for this reflect.Special thanks and appreciation for my wife Enass and my children Mohamed and Nada, your lamb and delightful spirits has kept me going forward.DEDICATIONThis work is dedicated To My dear parents,My beloved Enass, Mohamed, and Nada,Who made all of this possible, for their endless encouragement and patience.REVIEW OF THE litHearing mechanism and the middle earSound contagion. The hear process accepts the transmission of gruelling energy through the auditory channel to the tympanic tissue layer (TM). This sound recording energy results in vibration of the TM with an equal atmospheric pressure on dickens sides of the TM. The mechanical vibrations are, then, transmitted from the TM to the air-filled middle ear space and ossicles (malleus, incus and stapes), which further amplify the sound energy and transmit it, via oval window, to the roving-filled inner ear. At the inner ear, the mechanical vibration is reborn into electric waves and transmitted as nerve signals that are interpreted by the brain as sounds.Mechanical properties of middle ear. The middle ear is an air-filled fossa that connects the outer ear canal to the labyrinth of the inner ear. This connection is established through the middle ear ossicels-malleus, incus and stapes. The malleus is attached to the TM by its handle the incus jam lies in the middle surrounded by the malleus and the stapes while the footplate of the stapes is attached to the oval window of the inner ear. The middle ear cavity is also connected to the nasopharyngeal cavity through the Eustachian tube (Musiek and Baran, 2007). The Eustachian tube is important in maintaining an equal pressure on both sides of the TM and ventilation of the middle ear cavity. The tube also drain the middle ear into the nasopharynx (Channell, 2008). Figure 1 demonstrates schematic representation of the anatomy of the ear.When the sound pressure moves the TM the mallus and incus consequently move together as one unit a flesh out a pivotal point. In doing so, both get up act as a lever the lever arm formed by the manubrium of the malleus is slightly longer than that of the incus ( somewhat 11.3 ratio). In turn, the rotation of the long process of the incus around its pivotal point leads to the back and forth (piston-like) private road of the stapes footplate in the oval window of the inner ear. The movement of the stapes footplate is directly proportional to the frequency and amplitude of the sound waves. This route of sound transmission is called the ossicular route. acoustical route is another way of transmittal sound waves directly from the TM and the oval window to the cochlea. The dir ect acousticalal stimulation of the oval and round windows, by passing the ossicles (acoustic route), plays a part in sound transmission In normal ears both routs are functioning but the upper hand is for the ossicular route (Voss, Rosowski, Merchant, and Peake, 2007).From the to a higher place study, it appears that the middle ear plays important role in the auditory modality process. The middle ear mainly helps to correct the immunity mismatching between the air-filled middle ear and the fluid-filled cochlea and to transform the acoustic energy at the TM into mechanical energy that will eventually be transferred to the inner ear. The resistor matching function of the middle ear is carried out by tercet mechanisms the lever action of the ossicles of the middle ear, the area difference between the TM and the area of the stapes footplate, and the buckling of the curved TM. An outcome of these mechanisms is that the vibration obtained from the large area of the TM is focused to the much smaller oval window of the inner ear (211 area ratio), resulting in a differential pressure between the oval window connected to scala vestibuli and the round window connected to the scala tympani. This pressure differential is critical in maximizing the flow of sound energy and activation of the cochlear structures (Cummings, 2004). Accordingly, middle ear disorders are expected to affect the normal transmission of sound, resulting in conductive hearing discharge (discussed down the stairs).An illustration of the anatomical structure of External, Middle and Inner ear. Modified from Medline Plus Medical Encyclopedia Ear anatomy.In addition to correcting the impedance mismatch between the air-filled middle ear and the fluid-filled cochlea, the middle ear also protects the inner ear from loud sound via the acoustic reflex. This mainly occurs as a result of reflex condensation of the two middle ear muscles, the tensor tympani and the stapedius, in response to loud sound le ading to addd rigor of the oscicular set up, and hence diminished sound transmission (Allen, Jeng, and Levitt, 2005). Given that the acoustic reflex mainly decreases the transmission of low frequency sounds thus, it improves speech discrimination in loud, low-frequency noisy environments. Unfortunately, the reflex does not protect the ear against impulsive sounds as gun shots collect to prolonged latency in muscle contraction (Lynch, Peake, and Rosowski, 1994).Pathophysiology of middle ear disordersTo further understand the pathology of middle ear disorders, it is important to consider the middle ear body as a vibrating mechanical system. Such a system is composed of three elements mass, stiffness, and friction. When the mass and stiffness components are equal, so-called evocative frequency of the middle ear, it is expected that the amplitude of vibration of the middle ear is at maximum. On the other hand, when there is an increase in the mass without change in stiffness or fr iction the resonant frequency is lowered and the amplitude of vibration is lowered at frequencies above the resonant frequency. In contrast, when there is an increase in the stiffness component of the middle ear the resonant frequency increases and the magnitude of vibration reduces for frequencies below the resonant frequency (Roeser, Valente, and Hosford-Dunn, 2000).Middle Ear Disorders are a variable group of pathological conditions that includes, for example, middle ear infection (Otitis Media with Effusion OME), chronic otitis media with perforation of the TM, Eustachian Tube disfunction (ETD), ossicular disruption or dislocation and or/ otosclerosis. Such middle ear disorders may lead to conductive hearing loss due to their consequenceuate on mass, stiffness, and/or friction elements of the normal middle ear.Perforated TM is induced by chronic otitis media or trauma to the ear. As a result, the normal structure and the function of the TM are altered. The degree of hearing l oss is directly related to the size of the perforation (Voss et al., 2000) The perforation leads to equalization of pressure on both sides of the membrane which consequently leads to disturbance of the ossicular route and hearing loss (Voss et al., 2000). Normally the inward movement of the stapes is followed by an outward movement at the round window (push and pull mechanism). In the presence of TM perforation, this push and pull mechanism of the ossicles is disturbed and the sound waves energy reaching the oval window is reduced.ossicular dislocation normally follows a violent trauma to head or as a consequence of chronic otitis media and/or cholesteatoma. Disarticulation of the incudostapedial joint due to concern accident was the most common pathlogy of ossicular disruption(Yetiser s, 2008). With the exception disruption due to chronic otitis media, the dislocation of the ossicles may or may not be attended by TM rupture. The injury results in loss of the impedance matching me chanism of the middle ear and a conductive hearing loss of most 40-60 dB (Merchant, Ravicz, and Rosowski, 1997).Otosclerosis is a progressive disease of bone resorption and reformation that affects bones derived from the otic capsule. The etiology of the disease is not fully understood. The disease leads to osteodystrophy and retroversion of the stapes in the oval window. Among the most accepted eatiological factors is genetic factors and viral infection. Otosclerosis is characterized clinically by progressive hearing loss, tinnitus and vertigo (Menger and Tange, 2003). Both conductive and sensational neural hearing loss has been reported in otosclerotic patients (Ramsay and Linthicum, 1994). Otosclerosis may affect the cochlea and other parts of the labyrinth as well (Menger and Tange, 2003). The resulting fixation of the footplate of the stapes leads to change magnitude stiffness of the ossicular chain early in the disease. Increased stiffness of the middle ear affects the tra nsmission of low frequency sounds. At later stages of the disease, the bone starts to grow adding a mass effect. This increase in mass of the middle ear affects the transmission of high frequency sounds as well (Shahnaz and Polka, 1997).More disorders include inflammatory conditions of the middle ear such as otitis media (OM) and media with effusion (OME), chronic otitis media, and cholesteatoma. OM usually results from upper respiratory infections or allergies that lead to obstruction of the Eustachian tube (Channell, 2008). As a consequence, negative pressure develops in the middle ear resulting in otalgia due to stretching of the TM and mild hearing loss due to the increased stiffness of middle ear transmitting mechanism. If the negative pressure inside the middle ear is not relieved, a transudate accumulates inside the middle ear. The condition is then called OME. The hearing is further affected by the mass- friction effect. The degree of hearing loss depends on the lawsuit and the amount of the transudate. The combination of fluid and pressure in the middle ear was frame to reduce TM movement at the umbo by 17 dB over the auditory frequency range (Dai, Wood, and Gan, 2008).Middle ear function bank notesTuning secernate rendering. The tuning fall apart interrogation is one of the traditionally used qualitative hearing sieves. They are used to examine the conductive component of hearing loss (external or middle ear pathology). Several interrogations have been descried including Rinne, Schwabach, Bing, and Weber tests.For Rinne test, the vibrating tuning fork is held against the skull, usually on the mastoid process bone behind the ear to cause vibrations through the bones of the skull and inner ear. To cause vibrations in the air next to the ear, the vibrating fork is then held next to, but not touching, the ear. In the test the patient is asked to determine if the sound heard through the bone is louder or that heard through the air. The results of the test are categorized as optimistic, negative, or equivocal. A negative Rinne test is indicated when the sound is heard louder by bone conduction than by air conduction which suggests a conductive component of the hearing loss. Although Rinne test was found to be highly specific in one study the same designer has suggested that it should be carried out only as a pack up test for pure tactile sensation audiometry in audiological evaluation of hearing loss (Browning and Swan, 1988 Thijs and Leffers, 1989). The Schwabach tuning fork test compares patients bone conduction to the normal examiner. Bing tuning fork tests determines the presence or absence of the occlusion effect. Weber tunning fork test determines the type of a unilateral hearing loss. While Rinne test compares air conduction to bone conduction in the same patient.Although the tuning fork testing is easy and reliable it is still a subjective test that depends on the response of the patient and the degree of hearing loss. Additional drawbacks are that tuning fork testing is a qualitative and not a quantitative test, and does not diagnose the etiology of the conductive hearing loss.Pure-tone Audiometry. Pure-tone Audiometry is a behavioral test that measures hearing threshold. The test has been used to diagnose type and degree of hearing loss for more than one hundred years.During test setting, the patient is subjected to different tones to test the hearing mechanisms via air-conduction and bone conduction. Typically, the normal level of pure tone audiogram air and bone conduction will lie between 0-15 dB HL for children and 0-25 dB HL for adults. According to Northern and Downs (1991), the degree of hearing loss can be classified in adults as (0-25 dB HL) within normal limits, small (26-40 dB HL), Moderate (41- 55 dB HL), Moderate-Severe (56-70), Severe (71-90 dB HL) or Profound (91 + dB HL) hearing loss. In children it is classified as normal (0-15 dB HL), Slight (15-25 dB HL), Mild (25-30 d B HL), Moderate (30-50 dB HL), Severe (50-70 dB HL), Profound (70 + dB HL) hearing loss. This classification is applied to PTA of 500, 1000, and 2000 Hz (Roeser et al, 2000). contrasting types of hearing loss are interpreted by comparing air conduction thresholds to bone conduction thresholds. When the air conduction threshold elevated to a maximum around 60-70 dB HL in the presence of normal bone conduction threshold, this type of hearing loss is called conductive hearing loss. In sensorineural hearing loss the pure tone audiogram shows both air and bone conduction thresholds are elevated and with a 10 dB HL or less in between. Mixed hearing loss displays elevation in both air and bone conduction thresholds, but with the bone conduction threshold at better intensities than the air conduction by 10 dB HL or more. In both conductive and mixed hearing loss, the difference in air and bone conduction thresholds is called air-bone gap and it represents the amount of conductive hearing lo ss present (Roeser et al, 2000).The use of pure-tone audiometry provides quantitative information regarding the degree and type of hearing loss. However, it does not diagnose the cause of hearing loss and cannot be used in infants, young children, and difficult-to-test subject. Mannina (1997) reported that the diagnosis of middle ear disorders in school-aged children is less efficient when using pure-tone audiometry alone. To improve the diagnosis of middle ear disorder, Yockel (2001) demonstrated that the addition of tympanometry to audiometry does improve the diagnosis of OME than using audiometry alone.Assessing Middle ear function is a very important step in early diagnosis and treatment of conductive hearing loss. Since the usually used subjective tests, the tuning-fork and pure tone audiometry, cannot identify the etiology of underlying middle ear disease, other objective measures such as acoustic immittance are needed for differential diagnosis and accurate diagnosis of spec ific middle ear disorders.Acoustic Immittance. Several objective measurements of middle ear function have been developed over the last four decades. Various anatomical structures of the middle ear represent complex network system that affects the sound presented to the ear. not all the sound represented to the middle ear is delivered to the cochlea, but some of the power is absorbed by the bony structure of the middle ear (Zwislocki, 1982). Acoustic Immittance using tympanometry assess the middle ear status by measuring the transmitted sound energy to the middle ear.Acoustic Immittance provides objective information about the mechanical transfer function in the outer and middle ear. Acoustic Immittance is defined, as the velocity with which an objects moves in proportional to an applied force, while Acoustic Impedance (Za) is the opposition offered by middle ear and the TM to the flow of energy. Mathematically acoustic admittance (Ya) of a system is the reciprocal of impedance. Acou stic Immittance refers collectively to acoustic admittance, acoustic impedance or both (Tympanometry. ASHA Working Group on Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation, 1988). Investigators have found that abnormalities in the middle ear transmission might be reflected in the acoustic condition of the TM (Allen et al, 2005). Acoustic Immittance can be measured to individual probe-tone frequency (single frequency tympanometry) or to series of multiple probe frequencies (multifrequency tympanometry).Single frequency tympanometry. Tympanometry is one of the earliest objective methods used to evaluate middle ear function. Tympanometry measures the acoustic immittance of the middle ear as a function of changing the air pressure in the ear canal. A single probe tone tympanometry is the ceremonious measure of middle ear function in response to low frequency probe tone, 226 Hz, under varying static air pressure. Evaluation of the acoustic immittance of normal and different middle ear disorders was done by Otto Metz, 1946, and confirmed later by Feldman, 1963 (Katz, 2009)In 1970, James Jerger began to incorporate immittance measurement into the routine audiological evaluation. Jerger classified tympanograms as type A, B, or C depending on the shape of the tympanogram (with or without peak) and location of the peak when present. shell A is the normal tympanogram with the peak at or near the atmospheric pressure (+25 to -100 daPa). Type A is further divided into subtypes Ad and As for high and low peaked type A tympanograms respectively (Feldman, 1976). Type B tympanogram has no peak and relates to middle ear effusion, infection with normal ear canal volume, or due to large TM perforation with large ear canal volume. Type C is a negatively shifted tympanogram that reflects Eustachian tube dysfunction, a precursor of serous OM, mostly evolved from type B (Katz, 2009).Since 1970, single frequency Tympanometry is the conventional clinical mi ddle ear measure because it is a non-invasive, objective, and cheap indicator of many middle ear pathologies in children and adults. Unfortunately, low frequency probe tone tympanometry has high false negatives in infants younger than seven months (Holte, Margolis, and Cavanaugh, 1991). This is explained by the movement of the infants ear canal wall with pressure changes in the external ear canal due to immaturity of the bony part of the external auditory canal. In addition, tympanometry was found to be relatively insensitive to many lesions that affect the ossicular chain of the middle ear (Lilly, 1984). Furthermore, Keefe and Levi (1996) reported false positive tympanometry results compared to energy reflectance, a recent middle ear function measure. They found normal middle ear energy reflectance at higher frequencies in infants with flat low probe tone tympanometry.Multifrequency tympanometry. Multifrequency Tympanometry (MFT), which was first introduced by Colletti in 1976, mea sures middle ear impedance using multiple frequency probe tones ranging from 226-Hz to 500 Hz and up to 2000 Hz (Colletti,1976) . Similar to previous discussion about the three elements of the mechanical system of the middle ear, admittance of the middle ear has three components stiffness (compliant susceptance), mass susceptance and conductance (resistance).A tympanometric pattern was developed by Vanhuyse and colleagues in 1975 that helped in interpreting the underlying middle ear pathology using MFT. The Vanhuyse tympanometric pattern is based on the assumption of the shapes and locations of reactance (X) and resistance (R) tympanograms. Using a conversion equation the model can send for the shapes of susceptance (B) and conductance (G) tympanograms. Vanhuyse et al proposed four normal patterns 1B1G, 3B1G, 3B3G, and 5B3G as shown in Figure 2. 1B1G pattern is the normal tympanogram with a one susceptance (B) and one conductance (G) peak. It occurs when reactance (X) is negative a nd its absolute value is great than resistance (R) at all pressure used (the ear stiffness is controlled). As the probe frequency increases the curve becomes more complex and notched. 3BIG model has three peaks of susceptance (B) and one conductance (G) peak. It represent negative reactance (X) with an absolute value greater than resistance (R) at low pressure and smaller than resistance (R) at high pressure. The trinity model (3B3G) appears when the ear is mass-controlled. In 3B3G model the reactance is positive and less than resistance (X R) at low pressure and becoming negative at high pressure (Margolis, Saly, and Keefe, 1999). Figure 2.A graphic presentation of the model presented by Vanhuyse, Creten and Van Camp (1975). The resistance (R) , negative resistance (-R) and the reactance (X) tympanograms is shown in the upper left recessional of each panel. Negative R is shown to compare the magnitude of the reactance X. The corresponding admittance (Y), (lower left corner), su sceptance (B), (upper right corner) and conductance (G), (lower right corner) are also shown in each panel. four patterns are presented and classified according to the number of extrema in the susceptance B and conductance G tympanograms. The pattern (1B1G) in panel one shows both susceptance and conductance have single extrema and reactance is negative. The pattern (3B1G) in panel two shows conductance G is single peaked with three extrema in susceptance B, reactance X is still negative but its absolute value is greater than resistance at high pressure. The pattern (3B3G) in panel three shows three extrema in susceptance B, conductance G, and admittance Y tympanograms, reactance Y is positive but less than resistance R . The pattern (5B3G) in panel four shows five extrema in susceptance B tympanogram and three extrema in conductance G, and admittance Y tympanograms, reactance Y is positive and greater than resistance R at low pressure.Because of the use of measuring middle ear fun ction to several probe tone frequency, MFT is considered superior to single frequency tympanometry in detecting high impedance pathological conditions of the middle ear such as middle ear effusion, otosclerosis, and cholesteatoma. Such pathological conditions were not detected by conventional tympanometry (Colletti, 1976, Keefe and Levi, 1996, Shahnaz et al 2009). Several studies have shown that MFT has higher sensitivity and specificity in detecting middle ear pathologies such as TM mass or adhesions (Margolis, Schachern, and Fulton, 1998). Also, MFT is more sensitive than single frequency tympanometry in identifying normal and abnormal middle ear condition in neonates (Shahnaz, Miranda, and Polka, 2008). However, MFT is of limited clinical use for several reasons long testing time, limited frequency range, and unreliable data above 1000 Hz (Allen et al, 2005). The use of wideband energy reflectance is shown to address the above limitations of MFT.Wideband energy reflectance. The w ideband energy reflectance (WBER) is a new technique that has been introduced recently to evaluate middle ear dysfunction (Keefe, Ling, and Bulen, 1992). Simply the idea of WBER is that incident sound to the ear is transmitted through the ear canal and TM, some of this sound energy is absorbed through the middle ear and cochlea and part of it is reflected back (Figure 3). The energy reflectance (ER) is defined as the square magnitude of pressure reflectance R(f) 2, which represents the ratio of the sound energy reflected from the TM to the incident sound energy at frequency (f). ER ratio ranges from one to zero (1.0 = all incident sound energy is reflected, and 0.0 = all sound energy is absorbed) (Allen et al, 2005). ER is an indicator of the middle ear power to transfer sound (Feeney, Grant, and Marryott, 2003).Energy reflectance (ER) measurers middle ear function over a wide band of frequencies (0.2- 8 kHz). ER is the ratio of the reflected energy (red arrow) to the incident energ y (yellow arrow). When all incident sound energy is reflected back ER ratio equals one. When all incident sound energy is absorbed ER equals zero. Red arrow represents reflected sound energy yellow arrow represents incident sound energy green arrow represent absorbed sound energy. Modified from Medline Plus Medical Encyclopedia Ear anatomy.WBER measures middle ear function using a chirp stimulus at 65 dB SPL over a wide frequency range, typically 0.2 to 8 kHz and at fixed ambient pressure (Feeney et al, 2003) . Normative data has shown that most incident acoustic power is reflected back to the ear canal (ER ratio closes to 1) at frequency range below 1 kHz or above 10 kHz that also show poor hearing threshold or at frequencies below 1 kHz and above 4 kHz (less efficient middle ear function) (Keefe, Bulen, Arehart, and Burns, 1993). More specifically, 50% of the acoustic power is transmitted to the middle ear between 1-5 kHz frequency range, indicating that the most effective middle ear transfer function (ER is at its lowest values, closer to one) occurs around 1-5 kHz (Allen et al, 2005 Keefe et al, 1993 Schairer, Ellison, Fitzpatrick, and Keefe, 2007).WBER has been used in measuring normal middle ear function and middle ear disorders using ambient pressure (Allen et al, 2005 Feeney et al, 2003 Shahnaz et al., 2009). In other studies the researchers used pressure to measure the acoustic stapedial reflex (Feeney and Sanford, 2005 Schairer et al, 2007). Development of the middle ear in infants was also investigated using WBER (Keefe and Abdala, 2007 Keefe e al, 1993 Keefe and Levi, 1996).Wideband energy reflectance in neonatal displayKeefe et al. (1993) and Keefe and Levi (1996) reported that the acoustic response properties of the external and middle ear varies significantly over the first 2 years of life. These changes, mostly physical changes, are accountable for the mass-dominant infants middle ear system with lower resonant frequency. The main components of this mass-dominant effect is the pars flaccida of the TM, ossicles, and perilymph in the cochlea (Van Camp, Margolis, Wilson, Creten, and Shanks, 1986). The mesenchyme in infants middle ear may add to the mass effect (Meyer, Jardine, and Deverson, 1997). This is completely in contrast to adults middle ear, which is a stiffness-dominant system at low frequency (Holte et al, 1991 Keefe and Levi, 1996). The TM, tendons and ligaments, the space between the mastoid and the middle ear cavity, and the viscousness of the perilymph and the mucous lining of the middle ear cavity constitute the stiffness component of the middle ear (Van Camp, Margolis, Wilson, Creten, and Shanks, 1986).Recently, Shahnaz (2008) have compared MFT and WBER findings between normal adults and normal-hearing neonates in the neonatal intensive care units (NICU), who passed the neonatal hearing screening test. The researcher found maximum absorption of the incident energy at narrower range of frequencies (1.2 2.7 kHz) in normal babies compared to adults (2.8 4.8 kHz) (Shahnaz, 2008 Shahnaz et al, 2008). This preliminary normative data from 49 neonatal ears reflects the potential diagnostic benefits of the WBER test in detecting middle ear effusion in neonates.Wideband energy reflectance in otosclerosisAlthough the main definitive diagnosis of Otosclerosis is during surgery, an accurate preoperative audiological diagnosis is very important indication for surgery. Still, pure-tone audiometry has its own limitations that sustain accurate diagnosis of otosclerosis. Also, standard 226 Hz tympanometry is usually within normal type A tympanogram in most otosclerotic patients (Jerger, Anthony, Jerger, and Mauldin, 1974). While multiple frequency tempanometry may be helpful in diagnosing otosclerosis, it adds little information to the diagnosis (Probst, 2007). On the other hand, the WBER responses in three ears of otosclerosis fell outside the 5th to ninety-fifth percentile of the normative data a nd presented a distinctive pattern for the disease (Feeney et al, 2003) which suggests that WEBR is a sensitive middle ear measure. In a recent study WBER was found to be helpful in distinguishing 28 otosclerotic ears from normal and/or other causes of conductive hearing loss. A significantly higher ER was found in otosclerotic ears at frequency range of 0.4- 1 kHz as compared to normal ears. In the same study WBER was found to be more sensitive in diagnosing otosclerosis than the conventional 226 Hz tympanometry and the MFT (Shahnaz et al., 2009).Wideband energy reflectance in other middle ear pathologyHunter and colleagues (2008) found higher sensitivity of WBER in detecting otitis media in infants and children with cleft palate (Hunter, Bagger-Sjoback, and Lundberg, 2008). Feeney and colleagues in 2003 studied WBER at ambient pressure in 13 ears with different middle ear disorders and comparative normal. Different middle ear disorders were involved in this study included four ear s with OME, one ear with ossicular discontinuity, two ears with otosclerosis, two ears with hypermobile TM, two ears with perforated TM, and one participant with bilateral sensorineural hearing loss. The results suggested a distinctive WBE

Merits and Demerits of Devaluation

Merits and Demerits of De valuationBackground and HistoryPakistan has unusual history of successive devaluation. The rupee was first cheapen in 1950 in response to a similar move by India. Later in 1972, Z.A. Bhuttos regime massively libertine the rupee by 133%. The rupee was moreover de appraised in early 1980s during General Zia regime. Moeen Qureshis c artaker giving medication in 1993 as well devalued the rupee by 7%.After that it was Benazir Bhuttos government that further devalued the rupee and finally same measure ar cosmos taken by the present government of Prime Minister Mian Muhammad Nawaz Sharif.Pakistan has been on a corpse of managed float since January 8, 1982. For most of the past decade the rupee had been fixed in relation to the US dollar at the come out of Rs 9.9= US$1. The new put back regime commenced with an official nominal derogation of 5 percent in the month of January, and a cumulative 30 % for the year 1982. This was accompanied by the giving u p of the fixed peg to the US dollar and its replacement by a flexile basket peg whereby the authorities manage the nominal substitution rate actively. The stand in rate system has remained unlettered up to the present and the establishment has periodically re-affirmed its commitment to this flexible management in stabilization and adjustment programs negotiated with the IMF. Since the entre of the new system on that point has been a continuous down slide in our exchange rate. At present the rate of Pak RS in 2010. This represents a disparagement of 260 percent sinceDevaluation and its functionDepreciation or devaluation refers to the downward apparent motion of the rate at which the home bills exchanges against the contrasted currency or an amplify in the domesticated cost of wiz unit of the international currency. Depreciation is the name given to this drop when it occurs in a free market devaluation is the same social occasion resulting from government actions in a m arket that is not free. Since 1973 most of the currencies are on the floating currency system, through the system of dirty floating unperturbed al woefuls government/ central banks to interfere to some extent. The question of devaluing the external value of the currency is mavin of the hotly debated issues in humanity insurance discussions. On the one hand, the IMF and the World Bank supports devaluation as an important component of their recommended policy package for less developed countries (LDCs). On the former(a) hand m whatsoever economist and stinting policy makers are strongly opposed to devaluing currencies has become a dirty word in many countries.Technically, devaluation of a currency is the move resort when other fiscal and monetary measures like demand management , financial incentive, trade restrictions have proved to be less effective in solving puzzle of balance of payment, by boosting the pastorals exports and decreasing imports.In countries like Pakistan wher e major economic occupation is lack of growth, exports are get-go because of poor quality of goods quite a than the value of the currency. The mechanism of the open market keeps on adjusting exchange rate automatically and has made devaluation obsolete.Balancing MechanismBasically devaluation is a measure to correct a fundamental disequilibrium in countrys balance of payments. Equilibrium in a countrys balance is a result of restraint on imports and foreign payments of all sorts and an expansion of exports and foreign exchange earning of all sorts. The restraint on import cannot be achieved through appeals. It has to be through through direct restriction and/or through operating theater of the damage mechanism, that is to say through making imports costlier by operating on import duties, and this in fact has been extensively done in many growth countries, including Pakistan. However, this is open to some objections and limitations so a simple way of making imports costlier is n ot adjustment of the exchange rate. The entire burden of making imports costlier is not primarily placed on the exchange rate mechanism. It is shared by the device of import duties and also quantitative regulations. The import duty mechanism can also be used to make transition to the new exchange rate and to give a certain amount of discretionary treatment to individual items of import.The price FactorThe other major objective of devaluation is to promote export. It should be noted that what is contemplated is an increase in exports in foreign exchange in term of domestic currency. Exports on the whole exit have to increase by more than the percentage of devaluation. Expansion of exports depends upon a number of factors, the elasticity of supply in devaluing country and of demand for the outputs of that country abroad. Much depends on the prices at which the devaluing country is able to offer its goods.Contractionary ImpactReluctance to adjust the exchange rate in downward direc tion is due to its possible contractionary impact on output and employment, re-distribution of income from wages earner to property owners, cost-push inflationary pressure and the initial approbative effect on the balance of payment. All of the above forget eventually reserved through a process of domestic inflation and larger imports. When quantitative controls on imports duties are reduced along with the devaluation, imports and exports are not particularly sensitive to price changes especially in the short run. This is particularly applicable in the case of UDCs whose imports are often consist of essential capital goods, intermediate inputs including fuel and fertilizer and sometimes basic consumer goods like food grains, edible oils etc. There is exact scope for cutting down these imports. The exports of UDCs on the other hand mainly consist of primary commodities and processed materials whose supply elasticity are rather low in short run. If devaluation has to improve the ba lance of trade in short run, it should come through a reduction in the level of output and changes in the distribution of income towards high saver which would reduce the demand for imports and generate a bigger exportable surplus. Recession, unemployment and unequal distribution of income are the cost of a self-made devaluation.Inflationary PressureThe ineffective of exchange rate adjustment in securing improvement in the external balance primarily comes from the fact that changes in costs arising from exchange rate movements feed through quickly and extensively into the economy and contribution to the accerlation of prevailing inflationary pressure associated with an improvement of the monetary conditions. The rigid put on in price over a long period has stimulated defensive inflationary responses amoung industrialists, agriculturalist, business mens, and wage earner and has nullified the impact of exchange rate adjustments on the international competitiveness of our exports. I t should be taken into account that devaluation corrects the past inflationary and other economic development that led to adverse movement in the balance of payment. This does not protect the balance of payments against further inflationary and other adverse developments. Frequent devaluation of a currency is undesirable. It stimulates speculation and results in torment in income, consumption, industrial growth and public finance. This also erodes the confidence in the currency.DEMAND ManagementUnfortunately, for keeping our external accounts disequilibrium within sustainable limits, we have relied rather heavily on exchange rate adjustment and not paid attention to the efficiency dimension of our economic system. Economic efficiency at the large and micro levels requires high productivity, technological efficiency, high evaluate of saving and investment, and incomes policy that does not lead to cost-push inflation and fiscal-monetary policy that provides a stable environment for minute demand management. These are the simple and inflexible economic laws that were recognized and grasped. Neither nix controls nor artificial stimuli like frequent depreciation of external value of the currency with help except a little and temporarily.International trade and DevaluationGlobalization is the strategy of todays world. The concept of information sharing has reinforced the process of globalization passim the world. The consultant and analysts are, therefore, working on the integration of the entire system to run smoothly without any hindrances. Looking at the economic activity in this scenario, there is two major classifications, good and services. The globalization of goods can be seen in the prospective of international trade. By international trade we mean exchange of goods betwixt the nations. Looking at the economies of the world we find that the states are broadening their activities by offering investors to share their share of excellence and encouraging their local anesthetic manufacture to research the possibilities of selling their goods in the foreign markets. International trade is really important in terms of increase the foreign exchange of the country which ultimately prospers the people.The Government of Pakistan has liberalized its trade policy with devaluation of Pak rupee and encouraged the manufacturers to export their goods and invited foreign companies to compete in the local market.The key reason for international trade is provided by the system of Comparative costs importance of relative cost saving in the outturn of one item over the other. Obviously it would be better to corrupt a product from china at the price of Rs 1/= instead of producing it at the cost of Rs. 2/- that can be ultimately be interchange for Rs 2.50 in the market.There are various other reasons which strongly support the trading among the countries, few of which areDecreasing costConsumption of excess productionDifference in tasteForeign E xchange rateFrom international trade, we mean buying and selling the goods among nations. The deal cannot, of-course, be taken place without accessibility of currency to be accepted by the seller, on the other hand an exporter/importer would definitely like to know how the exchange rate of Pakistan rupee into dollar is being fixed, and how can her benefit from it?. At present in Pakistan we have managed float of currency to determine exchange rate as an independent policy instrument.We use up some criteria to fix the exchange of currency amoung the countries. It is important to note that only a favourable exchange can really benefits the nation and by favourable exchange, we mean, getting more foreign currency by paying less local currency. Theoretically there are two type of exchange ratesStable Exchange rateAltough stable exchange rate has no pratical value now a days, yet it helps in understanding the determination of exchange theory. A stable exchange rate was set by the value of gold. However, with passage of time, the limitation and deficiencies of gold standard blended emerging. Few of these were carrying inconvencies, remelting of gold, shipment of gold, different valuation of gold by different countries, and unavailability of sufficient gold to meet with the heavy demand. That is why the gold system was found inadequate ans was replaced with the flexible exchange rate.Flexible or floating exchange rateFlexible exchange rate is set by the interaction of demand and supply muniment for foreign exchange indepently. The optimum level in demand and supply teory is set at the point where supply equal to the demand. So if a person want to buy electric equipment from the States worth $ 100000/- and an American in contrast wants to buy cotton and the parity betwixt US$ and Pak rupee is 11, the equation leave be somehow similar to as followsDemand for US$ by Pakistan 100,000Demand for Rs. By America 50,000Pakistan is demanding more dollars than America wa nts to supply. The demand and supply are not in balance, consequently Pakistan shall have to refix the parity between $ and rupee at a level where our demand for $ will become equal to the supply of $. Now if we reduce the price of our goods by half of the existing priceDemand for US$ by Pakistan 100,000Demand of Rs by America 25,000This reduction price will have dual effectsDollas will become more expensive, the American goods will become more costly.Pakistani Rupee will become more cheaper, our goods will become cheaper and as a result the demand for our goods will increase.From the above it can be include that demans for imports should be in line with supply of exports. Total value of imports and exports of a country can also help manufacturers to design their plans for future expansion. With an expensive foreign currency, export may be increased with relatively low price supply of goods and quality production within the country. At the same time with a cheap currency investment can be made in foreign countries to utilize the cheap resources and ultimately increases the value of the firm.DEVALUATION its effects on ExportsAs the reason for the devaluation has been to strengthen the countrys balance of payment by stimulating exports, curtailing imports and by encouraging overseas Pakistanis to remit their earning through banks by narrowing the wedge between the official exchange rate and the kerb rate in the open market. It is universally accepted concept that the exchange rate mechanism is used to wee-wee a balance between the imports and exports but what is lesser known fact is that this mechanism need to be implemented at the overcompensate time and for the right economic reasons to be fully effective in achieving the desired purpose.Advantages and Disadvantages of DevaluationAdvantages of DevaluationDevaluation helps in obtaining international market demand perfection in quality and reduction in price up to a competitive level. As both developed and un derdeveloped countries function in one international market therefore, it is not motiveless for Pakistan to sell a product which is also produced by France, Germany or Holland if the prices are high. However, we are competing with the underdeveloped countries, it is, therefore, very necessary for us to adjust our prices with the prices of our competitors to serve in the market.Every new product has four stages, out of which the first stage is introduction stage. An introduction stage demands lot of efforts to promote the product and create sentiency among the buyers. At this stage it is vital to sell it at even below the cost. That is why the government provides certain duty drawbacks for a specified period, until that time when the product is self-sufficient.Each country maintains an account for its total imports exports schedule along with balance of payment chart. At times when its imports increase from its exports and the balance of payment deteriorates it becomes vital to inc rease its exports immediately. The reduction in prices is one of the quickest ways of increasing the exports.At times when people tend to buy imported goods and local industry start suffering, it is necessary to discourage the people so that they cut down their expenditure towards foreign buying and direct towards local goods. Devaluation is one of the techniques to reduction imports and encourage the local industry.Reduction in price through devaluation has long term effects, which can be seen over a period of time.All the above conditions are presently prevailing in Pakistan. However the question arises as to why all these conditions have comparatively more drastic affects on our economy. The answer to this question relates to our policy of income projection and receipt from foreign donors and countries. In the past, we were used to manage our budgetary gaps with the help of aids and debts. But this time the situation is different we could not did any foreign source of income. T he IMF was used to extend loans for our development programs in the past. However, during the current year the IMF had stopped its $300 million trench of its ESAF credit. The result is quite evident devaluation and imposition of new duties/taxesDisadvantages of DevaluationDevaluation with all its disadvantages has become an irregular policy. It is rater an ad-hoc arrangement for less demand. Instead imperfect planning is essential to forecast the future when the original price level will be maintained again.Devaluation involves high risk of inflation with the country for e.g if the exports do not increase as the result of decrease of price the country will suffer losses due to increase cost of all imports as well as local imports. Loss resulted due to decrease in prices in international market.Devaluation automatically increases the value of external debts and correspondingly the amount required for debt servicingDevaluation of a currency is considered as a last step to be taken af ter failure of all other fiscal and monetary measures.Before devaluing currency to boost economy through increasing exports, other factors need to be evaluated, for example, lower exports may be because of poor quality of goods, trade barrier, lower value added goods, unavailability of export items e.t.cContinued depreciation of currency may result in unlawful import of goods within the country. Such unlawful import and export may creat unlawful parallel economy within the country, which will be completely out of the control of the government.Devaluation is always supported by special incentive package to reduce the internally produced items for export.By critically analyzing all the above referred factors, it is proposed that the following necessary action should be taken to improve the situationTax Network should be enhanced bya) levying tax on agriculture,b) improving collection procedure,c) bringing small businessmen under tax nutshell etc.Imports should be discouraged by encour aging locally produced quality goods.Export of value added items should be increased instead of increase of low value exports to compete with the other developing countries.Needless to say that government should reduce drastically its own expenditure. It is vital for government to build up its creditability through investing money in public projects very honestly.The proceed from privatization of public sectors should be utilized to pay off our external as well as internal debts. Rescheduling of the debt should also be requested from the lenders.In case of our low priced items in the international market, we should prove that the reason of our low price quality items is not government support but cost efficiency. This can be done only with the help of very competent professional people i.e management accounts, engineers and managers.With the current devaluation, it is vital that necessary incentives must be given to industry and fixed income group for their survival and to reap the benefit of devaluation.The government should build capacity to deal with economics problems on both macro and micro level. It is generally believed that the government does not possess necessary capabilities, out of elected representative and bureaucrats to deal with it. That is why most of our key position holder is either current of Ex World Bank/IMF officials.It is also suggested that major businessmen and industrialist should be taken into confidence before any major decision.Effectiveness of price control committees very necessary. In countries like Pakistan where every individual has the power to determine the price of his own product, inflation is automatically multipliedConclusionsClearly, devaluation has not been the answer. It has rather contributed to a further increase in the trade gap. The important consequences of devaluation are the burden it is putting on the repayment of the foreign debts. The ensuing depletion of reserves has such a negative effect that the positi ve impact, if any, is more than wiped out by the increased foreign exchange burden.Reviewing the policy of devaluation by successive governments in the last 50 years, one finds that devaluation has miserably failed to resolve any problems or improve the macro or micro economic conditions in the country. Rather, devaluation has been counterproductive. In the existing scenario of the forces of demand and supply, the rupee is evaluate to continue with its downward trend. If the counter measures through cost cutting and efficiency management are not taken to check the inflation, which is already running in double digit, the advantages of devaluation will be offset as in the past, leaving adverse impacts as our economy which mainly depends on imported raw-materials, fuels and capital goods. That will certainly bring more hardships for common Pakistani people because our industry has substantial imported inputs in a wide range of locally produced goods and will also retard the process of industrialization in the country. Similarly defense budget and debt servicing will cost more due to costlier dollar.Our main problem is still uncontrolled i.e. the rise in non-development expenditures, which has given rise to the culture of living beyond means. This can be countered by adoption of practical rasping measures by the government especially at the top level to set the example for the whole nation.

Northern Ireland Essay examples -- History, Reuniting Ireland

Diplomacy does not happen everywherenight, and the true tale of hardship and dither over Northern Ireland is proof of that. Ireland and England failed to agree on who held the power of Northern Ireland for over 30 years until the Good Friday Agreement, a form of diplomacy surrounded by the countries, took place. Before that time, many soldiers and innocent citizens of Northern Ireland lost their lives. Religious fights broke out between Catholic and Protestant residents. Political figures from countries like Wales and the United States came in concert to help put an end to the bitter relations of the European countries (Delaney). After many years of hard feelings and failed attempts at bringing peace to Ireland and England, the countries came together to deform to work things out. Slowly, Northern Ireland created its own identity, and the troubles started to fade away. The troubles refer to the age-old disputes over the control of Northern Ireland. Even though the argu ments lasted for several centuries, things did not turn highly violent until the 1960s (Delaney). Many terrorists entered Northern Ireland during that time. Terrorists who entered the expanse were said to be okay, and there was nothing wrong with them. Letting the terrorists slip by without stopping them had precise deadly consequences. Thousands of people died because of the terrorists invading Northern Ireland. Very few tried to stop the terrorists from coming into Northern Ireland (Graham). Those who did attempt to stop the terrorists were unsuccessful (De Breadun). The Irish and British governments fought for many years over the ownership of Northern Ireland. Britain had main control over Northern Ireland, and Ireland did not think that was fair. Be... ...oodshed, Northern Ireland finally received many relief. The Good Friday Agreement brought the diplomacy needed to the country. Northern Ireland is to this day still home to many religious disputes but nothing as severe as the disputes from several decades ago. Residents are now free to be considered citizens of either or both countries, and the countries are able to work together without any deadly and inessential controversy. Hundreds of innocent people are spared their lives every year because the preventable religious and governmental fights have dwindled. Ireland may not have the most control over Northern Ireland, and religious disputes still arise, but the country has come a long way from the way things were. Things may never be perfect for the country of Northern Ireland, but there is no doubt that diplomacy was a great decision for the country as a whole.

Impact of Childhood Attachment and Separation Experiences upon Adult Re

Impact of Childhood Attachment and Separation Experiences upon Adult RelationshipsAbstractThis qualitative research was conducted to ascertain if the attachment style a person has as an adult is created or influenced by his/her interactions with early childhood experiences. The research was carried out by means of a thematic analysis of an audience of a married middle-aged couple. The interviews bought the themes of Work, Childhood and Relationships to the foreground and these were analysed to establish if there is a connection in our childhood attachments and those we make as adults. It can be seen that there are similarities to the attachment types of infants compared to those that emerge as adults although individual differences and life experiences also have a part to play in our capacity to excogitate secure adult attachment relationships.IntroductionThe general principle behind attachment theory is to describe and explain peoples stable patterns of relationships from give to death. Because attachment is thought to have an evolutionary basis, these social relationships are formed in order to encourage social and cognitive growing, and enable the child to stimulate up to become socially confident in adulthood.The assumption in attachment research on children is that sensitive responses by the parents to the childs inescapably result in a child who demonstrates secure attachment while lack of sensitive responding results in insecure attachment. John Bowlby who attempted to understand the straiten infants experience during separation from their parents originally developed this research. Bowlby saw attachment as being crucial to a childs personality developing and to the development of relationships with others later in life. This theory has its foundation in vertical relationships i.e. Primary Care Giver/Child, while on the other hand in The sustain Assumption, Judith Rich Harris (1999) suggests that it is the peer groups that have the strongest contr ol in shaping how that child will grow up and that parents have very little influence everywhere the matter, this is known as a horizontal relationship. In developing and classifying infant behaviour Mary Ainsworth who worked with Bowlby for a number of years developed a mode of gauging attachment in infants, in an experiment known as the other Situation. This involved observations in la... ...ng to see Jo smile and raise her eyebrows when Tony says at the inauguration of the first interview he is Fairly easy going. It led me as a researcher to think that perhaps this was not actually the case, in Jos opinion. Actions like this give the interview a complete different angle, and can add tremendous information to the final interpretation of what is said.ReferencesWood C, Littleton K & Oates J, Lifespan development, Chapter 1 in Challenging Psychological Issues by Cooper T and Roth I (eds) The Open University, Milton Keynes, 2002.Ainsworth, M.S., Blehar, M.C., Waters, E. and Wall, S. (1978) Patters of Attachment A Psychological Study of the Strange Situation, Hillsdale, NJ, ErlbaumGoodley D, Lawthom R, Tindall C, Tobbell J, Wetherell M, (eds) (2003) Methods Booklet 4 Understanding People Qualitative Methods. Open University Press.Banister P, (ed) (2003) Methods Booklet 5 Qualitative Project. Open University Press.Harris, J.R. (1999) The Nurture Assumption, London Bloomsbury.Research Methods in Psychology DSE 212 Video 1 Part 4 Interviewing, Milton Keynes, The Open University.AppendixAppendix A -Annotated copy of transcript.