Improving Medication Concordance in Mental Health - Free Essay Example

Sample details Pages: 16 Words: 4690 Downloads: 3 Date added: 2017/09/21 Category Advertising Essay Type Argumentative essay Tags: Discussion Essay Did you like this example? Improving Medication Concordance in Mental Health- A Review of the Literature Where a man is against his will, that to him is a prison. Epictetus Abstract There has been much discussion on why concordance with antipsychotic medication and treatment appears to differ from other fields of medicine. Does the literature support this contention? This review aims to seek out best practice and apply the principle of informed choice in assessing concordance and using appropriate interventions to educate individuals with psychosis. Contents Abstract Introduction Compliance or concordance? Client centered therapy Administration of medicines and patient capacity Competent or non-competent? Schizophrenia in comparison with asthma and epilepsy Negotiating medication Antipsychotics- Hobson’s choice? Education the patient’s view Psychosocial treatment interventions Compliance therapy Conclusion and Recommendations References Introduction The aim of this literature revie w is to identify if possible, what simple, easily introduced refinement may be useful on an acute mental health ward, with the aim of better understanding the factors affecting concordance with both medication and treatment provisions. The review of the evidence was necessarily broad, for two reasons. Firstly, the premise that concordance is poorer with mentally ill patients (Hughes, et al. 997, Marland and Cash, 2005), compared with those suffering from physical illnesses (although acknowledging the considerable over-lap). This premise has been personally encountered whilst on practice placements. Secondly, whether any advantage might be gained from other areas of practice and applied to the chosen patient group. The literature search strategy was carried out by initially accessing the â€Å"Pub med† and â€Å"Ovid† databases, using the terms â€Å"concordance†, â€Å"compliance† and â€Å"adherence†. Attention was focused on research papers that dealt with both physical and mental conditions. Priority was given to any evaluation of techniques potentially useful in improving concordance, and research papers frequently referred to by other authors, or otherwise indicated as seminal. The review was limited to studies carried out in the UK, Ireland, and the USA. It was of course, necessary to limit the final discussion to a representative number, which aim to reflect some changing views, with emphasis on recent research. Gray, et al. (2002) note that non-compliance with antipsychotic medication is a major preventable cause of relapse in psychotic patients. The causes of non-compliance are seldom immediately clear, and the literature suggests a large number of factors interplay, and individual reasons for stopping medication can be arbitrary. Evidence-based medication management aimed at enhancing treatment concordance should include a collaborative, educational approach to working with patients, tailoring medication regim es to the patient. Gray, et al. advocate using therapeutic techniques such as compliance therapy, discussed in this review, in order to empower individuals, and preserve their right to choice. Compliance or concordance? Repper and Perkins (1998) highlighted the importance of terminology in mental health, and suggest that the use of words like compliance infer patients should be passive recipients of health-care, and should obey professionals. It has recently been proposed that â€Å"concordance† should replace the words â€Å"compliance† and â€Å"adherence†. Concordance emphasizes patient rights, and the importance of two-way decision making. More controversially, it also suggests patients have the right to make choices such as stopping medication, even if clinicians do not agree with the decision. This principle conflicts with traditional psychiatric practice, and potentially with the provision of treatment under the Mental Health Act 1983. Since this re view reflects the source literature, the three terms are retained, and may be read as synonyms, unless the context dictates otherwise. Client centered therapy Rogers (1975) Client centered therapy, described five factors affecting health behaviour; severity, susceptibility, response, self-efficacy and fear. Focusing on the latter two factors, self-efficacy has been defined as a person’s belief in his ability to accomplish a given task (Bandura, 1977, quoted by Hughes, 2004). How a person thinks an illness will affect him is determined by previous knowledge or experience, as well as fear, or threat appraisal. Belief that a change would improve coping strategies, and the person is empowered to undertake such a change, can improve considerably the ability of the patient to be more independent, and concordant with medication strategies. Administration of medicines and patient capacity The law imposes a duty of care on those that administer medication to others (Griffith, et al . 2003). Administration of medication is not without its complications. Minor prescribing errors, adverse drug reactions, interactions with food, or herbal products, overdoses (intentional or otherwise), and even possible genetic problems or death. These potential problems are reflected in the strict legal framework that regulates the prescribing and distribution of medication. There is however, still widespread concern in the UK over the administration of non-prescribed medicine and the practice of covert administration in the non-compliant (Wright, 2002). The law is clear that covert administration is only justifiable in cases of incapacity. Incapacity occurs where the patient is unable to comprehend and retain information material to the decision, or the patient is unable to weigh up the information as part of the process of an informed decision (Nys, et al. 2004). In the case of covert administration to an adult there would be a need to demonstrate that the patient is inca pable. The nurse should be able to justify the techniques of administration were in the patients best interests, and the crushing of tablets, for example, was safe. In practice this should be a multi-disciplinary team decision. The covert administration of medication observed on placement was one reason I have chosen to explore the literature, and examine any methods used that may be applied to adults who are non-concordant with anti-psychotic medication. Competent or non-competent? Levenson (2003), interviewed patients with Parkinson’s disease, and their views are quoted here for two reasons. Firstly health care professionals may tend to view patients with Parkinson’s disease in a similar manner to those with a mental illness, i. e. not competent to self-administer medication. Secondly the benefits of helping patients maximize control over their own medication are so apparent, and might well be applied to patients with other illnesses. The issue of balancing the benefits of medication against very significant unwanted effects was a major concern to interviewees. The patients had in common an understanding of the symptoms of the disease, and how their medication, particularly the timing, affected their symptoms. It was clear in one case; the doctor really listened to the needs of the patient, adjusting dosages and times accordingly. Another patient was able to use a dosset box with electronic timer as a memory aid. Some patients experienced difficulties retaining control of their medication when admitted to hospital. They found the timing of the drug rounds did not suit them. This undermined their efforts to comply with the medication. This aspect of medication administration appears to lend weight to the instrumental passivity hypothesis (Baltes and Skinner 1983, quoted in Faulkner, 2002) The argument is that hospitals and nursing homes reinforce dependent behaviour by supporting and encouraging them. The primary ethical strategy Fau lkner advocates is for staff to focus on reinforcing independent behaviour. Forms of self-medication come into this category. Melanie Baker (2003) described a scenario involving a 47 year old man suffering from bipolar affective disorder. His case typifies the interplay between physical and psychiatric health, and the patient poorly concordant with medication. Among his numerous significant medical conditions were angina, and a myocardial infarction. He also had diabetes mellitus and developed diabetic neuropathy, which was treated with carbamazepine. His mental state was coincidentally improved with the introduction of carbamazepine, but after 18 months of stability, he took an overdose, resulting in the prescription withdrawn. Prior to the 18 month period stability, the patient had a long history of decline. Psychotropic medication and his unstable angina may relate to poor adherence with cardiac medications. He was more amenable to cardiac treatment when mentally well. The consultant and Multi-disciplinary team felt that when he was mentally stable, his physical health improved in parallel, possibly due to improved compliance with both medication and lifestyle advice. He appeared to view psychiatric care as stigmatizing, contributing to poor compliance. Treatment for diabetic neuropathy was perceived as less stigmatizing. The importance of tailoring medication to each individual is highlighted in this case, as the accidental overdose of Carbamazepine led to a serious long-term deterioration. Schizophrenia in comparison with asthma and epilepsy Marland and Cash (2005) have found that the belief that non-compliance is a direct result of disease processes in schizophrenia dominates the clinical perception of non-compliance for these patients. One explanation given, was likened to a negative feedback, where a patient who stays off medication, perhaps out of a delusional feeling (â€Å"my doctor is poisoning me†), for a time feels well, which ma y have the effect of strengthening the delusion. They also demonstrated that although patient attitudes to medication change over time, the process of change is rarely well documented on an individual basis. The study objective was to compare the medicine taking decisions in people with schizophrenia to those of people with asthma and epilepsy, also both enduring, episodic illnesses. They concluded that for people taking antipsychotics, relapse was socially disadvantaging and unwelcome, particularly if it resulted in readmission to hospital. They confirm that the association between stopping medication and hospital readmission is learned eventually by many people on anti-psychotics. Interestingly people from all three diagnostic groups seemed prepared to experiment with timing and amounts of medication when well presumably as the fear of illness subsides. Patients for whom the consequences of altering medicine regimes were delayed or relatively mild were more likely to experim ent than those who experimented with medication leading to rapid or severe symptoms. Hence there was a learned ability to balance symptoms and medication side effects to achieve an optimum quality of life, whilst living with a fear of relapse. Fear of dependence was also a strong motivator for some, and exceptionally leads to complete cessation of medicine taking for long periods, even leading to frequent or severe symptoms. They conclude by confirming interventions useful in promoting therapeutic interactions with medicine in physical illness should also be appropriate in schizophrenia. They found it important to ascertain the individual’s level of understanding and insight, of the illness, medication and side effects. Negotiating medication Carder, et al. (2003) were concerned with how adults with illnesses characterized by repeated flare-ups, or instability, resulting in temporary inability to manage tasks of daily living, negotiated their medication needs. They incl uded sufferers of multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosis, along with those with schizophrenia and bipolar disorder. They described how these individuals with chronic illnesses made on-going negotiations with health-care practitioners, balancing health and illness with a preservation of self-identity. Many of those interviewed described on-going efforts to find the right medication or combination of medications. In addition, a third of participants described the use of alternative medications, such as vitamins, Chinese herbal tablets, and naturopathic remedies. It was found the necessity of taking daily medication did not always square with the individuals self-identity (â€Å"I am not ill†), so adaptation was stressed. The psychotic individual can often be fixed in their thinking, however, or for some, their illness appeared to have ended. Others described an aversion to feeling dependent on drugs, or perceived themselves subject to t heir prescriber’s ‘experimentation’. Some researchers describe resistance to medication as an initial stage (Gray, et al. 2002), but these participants described an on-going and periodic resistance to taking medication. Some described withholding accurate accounts of their symptoms, fearing an increase in dosage or a change in medication. One woman, at first appeared concordant, but described the emotion as one of â€Å"surrender†, a process of â€Å"going with the flow†, rather than fighting the illness and feeling resigned to whatever medication was prescribed. In the conclusion (Carder, et al. 2003), it was acknowledged medication remains the paramount way to manage chronic illness. For those who are asymptomatic while on medication, the medication is the only indicator of illness, and non- concordant individuals are sometimes led to question the need for medication, the diagnosis, or the reliability of the health-care team. The emphasis of this study was how healthcare practitioners must guide people through negotiations, identifying different choices, how best to self-regulate, and the effect that symptoms, side effects, and medication have on the body and on self-identity. A useful exploratory study confirming the findings of Carder, et al. was carried out by Hostick and Newell, (2004). They wished to determine the reasons service users discontinue community mental health-care. Although the presenting problems of respondents could not generally be classified as serious mental illness, the findings were significant. The study began on the premise that users would stop attending for two main reasons, either they had improved, or they were dissatisfied with the service. Few users cited improvement as the reason for non-completion. Many users expressed dissatisfaction about the lack of service flexibility, but could also be linked to practical difficulties or accessibility. The theme therefore continues for the need for a flexible, patient centered approach. Antipsychotics- Hobson’s choice? Hughes, et al. 1997) begins by describing what has become the standard medication regime for schizophrenia sufferers in the community, that is, the depot injection, administered intramuscularly on a regular basis at home, or at a community mental health centre. Depot injections are a dosage form of the anti-psychotic, allowing the drug to be released slowly into the bloodstream over a period of 1-5 weeks. For patients treated in the community, where good compliance with oral treatment cannot be guaranteed, depot anti-psychotics potentially provide a practical solution. However while having a monthly or fortnightly injection may be for some, less problematic than following an oral medication regime, good compliance is not guaranteed. Healy (2002) noted that far from blaming the medication, there was a tendency among mental health personnel to see the compliance issue in terms of patient unreliabili ty or lack of insight. In effect however, the depot removes control from the user, and even the administering nurses, since it is immediately obvious to service managers when someone stops receiving their depot injection. In addition to the unwanted side effects of anti-psychotic medication, there are the potential problems of intra-muscular injections to consider, and whilst good practice should minimize these, subcutaneous fat in adults in the dorso-gluteal area (site of choice for many UK nurses) varies from 1cm to 9cm. If injected into this layer, absorption of the drug will be adversely affected, and the tissue may become irritated. This occurs in up to 15% of patients (Greenway, 2004), and the threat of injury also remains significant to the sciatic nerve, and superior gluteal artery, which lie only a few centimeters from the optimum site. The suggestion was made by Hughes, et al. (1997) that it may not be the presence of unwanted side effects themselves, but rather how these side effects are regarded by the patient, that is in determining compliance. The physical discomfort of side effects may be less important in influencing compliance than the meaning patients attach to these side effects, for example, a movement side effect (tremor) is taken as the beginning of multiple sclerosis, or Parkinson’s disease. In this way, compliance may be improved simply by allowing patients to voice fears and concerns about side ffects. Hughes, et al. (1997) draws attention to another explanation for poor compliance in the hypo-manic or psychotic individual. Some sufferers enjoy the sense of euphoria that can characterize hypo-manic episodes. Similar problems have been experienced with patients with a history of recreational drug use. One likened his psychotic experiences to â€Å"tripping†. Education the patient’s view Carder, et al. (2003) found that even without structured efforts on the part of clinicians to inform patients about medicati on, education played an important role in their decision making. Of note in the context of this review, was the response of persons diagnosed with depression, who, in common with those suffering psychoses, are poorly motivated. They found these persons go through an extensive interpretive process that includes understanding the condition and its causes, the reality of medication side effects, and negotiating with healthcare practitioners. The view of one perplexed woman with bipolar disorder reflected the experience of many. â€Å"Some of the psychiatrists would hand you five or six different medications at once. I mean, how do you know which one’s working, or what’s not working. It took a while before I found a psychiatrist who sat and listened â€Å". The suggestion is made of using motivational interviewing techniques to weigh up identified positive and negative aspects of psychotic symptoms. For this reason, some clinicians have concentrated on schizophreni cs with relatively higher levels of negative symptoms. Hughes, (2004) describes how recent self-management approaches have produced better outcomes in these patient groups. Self-management programmes aim to encourage, or coach, patients, by supporting and influencing health behaviour and increasing knowledge of specific aspects of care, for example, pain and symptom control, or medication side effects. Nurses are well placed to offer holistic support to patients becoming more independent, but issues surrounding power and control in the nurse-patient relationship must be acknowledged in this process. The health belief model has been used to help patients perceive the benefits of following the recommended treatment regimen. Four factors identified as influencing patients were; the benefits of the treatment, susceptibility to relapse, the severity of the symptoms, and the cost in effort and pain from side effects. It was recommended health care practitioners not neglect the †˜secondary’ benefits of the medication, i. e. feeling calmer, sleeping better, easier socializing, and improved concentration, when seeking the views of patients , it was correctly predicted the secondary benefits of the medication would be valued as often as the main benefit of improving positive and negative symptoms. 5% of patient identified the main benefit, but 70% noted the secondary benefits (for example; â€Å"it allows me to make friends†) and these were found to be more strongly associated with medication compliance than the primary benefits. Zygmunt, et al. (2002) was not so favorable to the health belief model. They felt the rational assumptions and broad generalizations implicit in it were not helpful in predicting concordance. This may reflect a more recent shift towards motivational interviewing and its development into compliance therapy. Psychosocial treatment interventions Zygmunt, et al. (2002) carried out a study of psychosocial interventions ta ilored for psychoses. Adherence to medication and outpatient appointments has become crucial for positive outcome during maintenance treatment. No one specific intervention demonstrated significant advantages in improving adherence; however, the small sample size may have been a factor. It was felt that both patients and their families need a more active role and greater self-responsibility. They found the greatest benefit of the six interventions studied, most evident during the first six months of treatment. The most prominent conclusion reached however, was that psycho-education alone had no effect on patient compliance, but felt this finding did not negate the need for further education and implementation of structured treatment programmes Psycho-educational interventions focused primarily on dissemination of information about the illness, medication and treatment, group therapy was based on the evidence of peer support and shared problems. Family interventions derived from a belief in the family as a critical influence on the course of a member’s illness. Community programs typically . involved a complex variety of supportive and rehabilitation services delivered without a choice. Cognitive treatment targets patient’s attitudes and belief toward medication. An assumption is made that adherence is a coping behaviour, heavily determined by each person’s own interpretation of his illness and medication regime. Behavioural modification techniques assumed that behaviours are acquired through learning and conditioning, and can be modified through rewards and punishment, reinforcement, and the promotion of self-management. Behavioural strategies worthy of note include providing selected patients with detailed medication instructions, reminders, self-monitoring tools, cues and reinforcements. In another instance, the therapist used assertiveness training techniques to teach patients to negotiate with their prescribers more effectivel y. An important conclusion about this study was that of the many interventions in practice, most were viewed as too complex, and multifaceted, and hence difficult to identify exactly what contributed to individual successes or failures. Interventions addressing medication non-adherence specifically, were found to work better than those covering a wider range of problem areas. One recommendation noted from this study, was the monitoring of patients with a history of non-adherence involving any medication prescribed for physical, not simply psychotic illness, and the authors opted for a definition of non-adherence as a complete cessation of medication for at least one week, as opposed to dosage deviations. Compliance therapy Kemp, et al. 1996), sought to determine if compliance therapy could improve compliance with treatment and hence social adjustment, and if the effects persisted six months later. 25 patients received compliance therapy and showed significant improvement in their attitude to drug treatment in comparison to a similar control group. Individuals were assigned to the two groups on a random basis. The 4 -6 counseling sessions lasted between 10 and 60 minutes. The following issues were addressed, eliciting the patient’s stance towards treatment, exploring ambivalence to treatment, and a treatment maintenance plan. The patient is first encouraged to review their recent past, identify likely barriers to treatment adherence, and describe any negative outcomes experienced. Secondly, the patient is encouraged to systematically choose possible alternative strategies to their antipsychotic medication. There is an emphasis on â€Å"normalizing† the experiences, for example, â€Å"in extreme situations hallucinations can occur to anyone†, and if requested, provide more information about treatment options. Thirdly, the patient’s freedom to choose whether to maintain treatment is emphasized, and parallels drawn with conditi ons such as diabetes, where regular insulin injections may be required. The object is to lessen any perceived stigma. The patient is encouraged to look ahead, set goals, examine what they find personally important, and the emphasis is on how not taking medication could affect the outcome of their goals. Finally, the therapist acknowledges, and empathizes, with the costs associated with any course of action, including the desired outcome of concordance with treatment. The control group received a similar number of timed sessions, but the sessions had no discussion of treatment, and were less structured. By rating compliance using a scale of 1 to 7, with 1 being fully compliant, and with an added interest in the medication, the authors were able to demonstrate a 23% improvement over six months. There are problems associated with measuring patient compliance, common techniques such as urine tests may overestimate compliance when drugs have a long half-life. Blood serum tests, when a vailable, are invasive, and of limited value in assessing partial compliance. Pill counts are widely considered a useful indicator, but potential exists for inaccuracy or deception, with no guarantee the patient ingested the tablets. A similar problem exists for electronically tagged dosset boxes. The study noted the high human and social costs of relapse, or persisting symptoms, and felt any proved means of counteracting non-compliance had important managerial implications. Kemp, et al. (1998) carried out a further investigation of the original trial, extending the number of participants, and including an 18 month follow-up. An effort was made to measure not only compliance, but also insight, attitudes, and a functional assessment. There were comparatively few participants dropping out, 11 over 18 months, or less than 10%. Results indicated a definite advantage for those who received compliance therapy. Relatively poor results with first admission patients could have been rel ated to acuteness of illness onset, lack of previous experience with antipsychotic effectiveness, or perhaps denial. Overall, the work supported the premise that poor compliance was associated with more severe drug side-effects. A recent study in Dublin (O Donnell, et al. 003), using the same basic techniques, failed to replicate the previous findings, and found no advantage over non-specific therapy in terms of patient adherence. Then again, in common with the earlier studies, there were fewer than 100 participants; therefore the possibility of false negatives remained. They did confirm that patient attitudes change over time, and were a useful predictor of future compliance. Despite the name, compliance therapy fits with a concordance model, involving patients in each decision making phase, with no coercion, implied or explicit, to obey professional opinion. Conclusion and Recommendations All of the papers reviewed agreed that ignorance about medication was common. Frequently, antipsychotic treatment had not been fully explained to patients or their families, where appropriate. The individual needs to be fully informed about the effects of the prescribed medication, there is no justification for withholding knowledge about adverse effects or poor prognosis, this would be paternalistic and unethical. The aim of the treatment should be made as clear as humanly possible, and alternatives clearly presented. Such patient empowerment enables genuine participation, reduces fear, facilitates informed consent, and gives the closest opportunity for concordance. Although by definition, the primary responsibility lies with the consultant, as part of a multi-disciplinary team, nurses on ward level, in primary care, or in the community, are well placed to facilitate evidence-based treatment regimens. The most promising recent development has been â€Å"compliance therapy†. Three of the papers discussed sought to quantify its potential. O’ Donnell et al (2003) gave a conflicting view, but most authors mention it as promising. It is recommended here that further application of its principles, in a local setting, be attempted. As an aid to an admitting nurse, or during a care plan review, a simple evaluation tool be devised, a questionnaire, to address past concordance issues, an area we noted was often overlooked, with the principle of future self-management the goal. If possible, such a tool could be applied on a rehabilitation ward or acute setting. Other considerations that should be studied are: ethical issues, staff education, and through multidisciplinary evaluation. Finally, although in this review evidence has been highlighted from a patient perspective, of the considerable debilitating side effects of antipsychotic medication, it is not the aim to argue here that it has no role in helping to relieve the suffering of patients with psychotic symptoms. There does remain considerable scope for discussion of implementing informed choice for the mentally ill individual, and multidisciplinary cooperation in how to best inform them. References Baker, M. (2003) The coincidental treatment of a major mood disorder Progress in Neurology and Psychiatry, accessed from www. rogressnp. com Carder, P. C. Vuckovic, N. and Green, C. A. (2003) Negotiating Medications: Patient perceptions of long term medication use Journal of Clinical Pharmacy and Therapeutics 28, 409- 417 Faulkner, M. (2002) Instrumental passivity: A behavioural theory of dependence Nursing Older People 14(2) 20- 22 Gray, R. Wykes, T. and Gournay, K. (2002) From compliance to concordance: a review of the literature on interventions to enhance compliance with anti-psychotic medication Journal of Psychiatric and Mental Health 9, 277- 284 Greenway, K. 2004) Using the ventrogluteal site for intramuscular injections Nursing Standard 18 (25) 39- 42 Griffith, R. Griffiths, H. and Jordan, S. (2003) Administration of medicines part one: the law and nursin g Nursing Standard 18 (2) 47- 53 Healy, D. (2002) Psychiatric Drugs Explained (3rd Edition) London, Churchill Livingstone Hostick, T. and Newell, R. (2004) Concordance with community health appointments: service users’ reasons for discontinuation Journal of Clinical Nursing 13 (7) 895- 910 Hughes, I. Hill, B. and Budd, R. 1997) Compliance with anti-psychotic medication: from theory to practice Journal of Mental Health 6 (5) 473- 489 Hughes, S. A. (2004) Promoting self-management and patient independence Nursing Standard 19 (10) 47- 52 Kemp, R. Hayward, P. Applewhaite, G. Everitt, B. and David, A. (1996) Compliance therapy in psychotic patients: randomized controlled trial British Medical Journal 312, 345-349 Kemp, R. Kirov, G. Everitt, B. Hayward, P. and David, A. (1998) Randomised controlled trial of compliance therapy: 18 month follow-up British Journal of Psychiatry 172, 413- 419 Levenson, R. 2003) Compliance in medicine taking- seeking the views of patients London, Depart ment of Health, Medicines Partnership Marland, G. R. Cash, K. (2005) Medicine taking decisions: schizophrenia in comparison to asthma and epilepsy Journal of Psychiatric and Mental Health Nursing 12, 163- 172 Nys, H. Welie, S. Garanis-Papadatos, T. and Ploumpidis, D. (2004) Patient capacity in mental healthcare: legal overview Health Care Analysis 12 (4) 329- 337 O’Donnell, C. Donohoe, G. Sharkey, L. Owens, N. Migone, M. Harries, R. Kinsella, A. Larkin, C. and O’Callaghan, E. 2003) Compliance therapy: a randomized controlled trial in schizophrenia British Medical Journal 327, 834- 842 Repper, J. and Perkins, R. (1998) Different but normal: language, labels, and professional mental health practice Mental Health Care 2 90- 93 Rogers, R. (1975) A protection motivation theory of fear appeals and change Journal of Psychology 91, 93 Wright, D. (2002) Medication administration in nursing homes Nursing Standard 16 (42) 33- 38 Zygmunt, A. Olfson, M. Boye, R. C. and Mechanic, D . (2002) Interventions to improve medication adherence in schizophrenia American Journal of Psychiatry 159 (10) 1653- 1664 Don’t waste time! Our writers will create an original "Improving Medication Concordance in Mental Health" essay for you Create order

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The events that occurred on this day, September 11th 2001 (9/11) have caused significant damage to the minority

Movie Impact Outline Speech Free Essays

To inform my audience about how the movie â€Å"Eternal Sunshine of the Spotless Mind† had an impact on me. Thesis Statement: â€Å"Eternal Sunshine of the Spotless Mind† had an impact on me because its unique take on a love story showed me the bittersweets of romantic relationships in general. Preview: I will discuss the impact that the movie had on me. We will write a custom essay sample on Movie Impact Outline Speech or any similar topic only for you Order Now I will also tell how the movie’s storyline made me appreciate and fall in love with the movie. Body: 1. This movie is one of the only genuine love stories I have ever seen. A. Both of the main characters, Joel and Clementine, were Just so dysfunctional real. B. You experience all the emotions that the characters in the movie experience. Feelings such as loss, regret, anger, instability, sureness, self-discovery, and so much more. 2. This movie also taught me lessons about relationships and breakups. A. It shows why painful memories are Just as important as the good ones. B. It really put into respective how relationships are difficult at times and getting through those hardships will ultimately make you stronger whether It be alone or as a couple. Conclusion: In conclusion, â€Å"Eternal Sunshine of the Spotless Mind† Is one of those movies I’ll probably be going back to throughout all parts of my life. I don’t think our culture teaches us how to deal with sadness and loneliness properly, a feeling that Is as vital for the full human experience Just as happiness and comfort Is. How to cite Movie Impact Outline Speech, Papers

Cult of Domesticity Frq free essay sample

In the early and mid-nineteenth century the roles of women were slowly beginning to change. Up until this point in history, they were mainly housewives, and did not have much of a say in society and the issues that were occurring in the young nation of America. The revival in the second great awakening and the revolutionary changes in economy during antebellum America, allowed women an opportunity to enter the work force, as industry made its way to the northern states.Also women led movements began to be heard by the masses including the temperance movement, the solve to try and improve their rights, and how their families were affected by this sudden change in life style. The industrial revolution began to make its way to major American Cities shortly after the war of 1812. This sudden increase in factories led to the need for a large workforce, and workers with experience in certain areas. Factories began to hire women mainly for jobs such as sewing and in the TEX tile industry.Their knowledge as housewives gave them the training they needed to fulfill these jobs, and caused them to be specifically sought out by business owners. Another factor that made them desirable workers was that they worked for much less money than men did. By the sass the United Stated had expanded westward, making the demand for the market goods of the northeast rise, bringing in the market revolution. The majority of the working women came from poor farming families, and were looking to make some extra money.The Lowell Plant hired young farm girls to work in the factories, and they were also given quarters to stay in during their free hours. The money to pay for these quarters was deducted from their pay-check, causing hem to virtually be paid almost nothing. These women would work long hard hours, with little pay, in dangerous conditions that caused many to become injured and is some case, lose their lives. As the 1 8405 came, so did waves of Irish immigrants trying to escape the famish sweeping their home land. These immigrant women threatened the delicate order of the womens work force.Native white American woman began to lose their jobs and be replaced by cheaper and more effective Irish labor. This caused for the new tenders to be hated by Americans, leading to many anti-Loris exploits to be entered. The second revival of Christianity that began around this time period supported the anti-immigrant movements such as the Know-Nothing Party, because they sought to revive the Protestant faith, and resented that of the Roman Catholic Irish. Women were given an outlet of benefit from the men trying to keep faith strong in the growing country in a time of great foreign impact. Public teaching was promoted, leading women to take a hold on the teaching business, and strive to become educated themselves. The roles Of women were beginning to be questioned and helped inspire women to fight or their rights and equality in the workforce. There were many women that did not approve of the sudden willingness of other women to work in the factories. They believe that a womans job was in the house, and that leaving their children and husbands to work was a poor decision.This celebrated theory was the Cult of Domesticity. Due to the Great Awakening women were no longer seen as sinful, and full of evil, but were instead seen as the care takers of the home and the family. Many women embraced this idea, and it reflected through their house hold. Men used to kook for a wife that could deal with the household well, clean it, and cook for the family also. Their status in society began to depend on how their wife treated their home, and how well she catered to the needs of her family and guests.The growth in the economic market spread their ideas south and west, and they were able to gain much support, and even attempted at Oceans Falls to reform the Declaration of Independence in order to include women in the writing, and gain many deserved rights. Women that were not in the Cult of Domesticity also were very active in these movements. Elizabeth Stanton was one of the main activists involved in the temperance movement, that later worked to help in the struggle for womens rights and suffrage.As the Civil war grew closer, women also began to speak out against slavery, and work towards its abolition, getting them large amounts of notice on both sides. Womens role in the family had always been in the house, as America progressed, and industrialized, they were given an opportunity to work alongside men. Unmarried women began to leave their homes at young ages to find work in the various mills and factories. This work began to prevent hem from latter getting married, and starting a family. Women also tried to make several social reforms that would benefit the family. One such movement was the Temperance movement; women banded together in the hope that they could stop domestic violence and create a safer environment for their children, by stopping the sale of alcoholic beverages to their husbands. The Increase in drinking was one of the many things the immigrants from Europe had brought with them. They used the words of the Bible as their support, and were widely listened to due to the revival in Christianity. The Cult of Domesticity tried to promote women to stay in the household, and do their duty as wives and mothers. This was in retaliation to the market Revolution, opening its door to working women. Their roles in the family were starting to be affected by their work, and many women were not fond of this. Women began to try and find a middle ground between the t;woo, which led to the teaching industry being dominated by women. The roles of women in the family were greatly affected and were beginning to change, although some women tried to hold on to their old ways, and stay true to their beliefs. The first half of the nineteenth century brought many changes to the role and life of American women.Their ability to work and promote their rights was brought about and spread by the market and industrial revolution, while at the same time society began to view them in a new light due to the second great awakening. Many women joined the workforce, and many chose to celebrate being housewives through the Cult of Domesticity. Through their many changes and difficulties, the American women were able to still work together to work for the good of the nation, and to indorse their liberty and rights as American citizens.

Theatre Programme The Merchant of Venice Essay Example For Students

Theatre Programme The Merchant of Venice Essay The Merchant of Venice is a play which is made up of many different characters who each have an important role in the storyline. Some are more involved in the main plots than others, but they all provide the play with different effects. Shylock, Antonio, Portia and Bassanio are the main characters of the story and are the ones who make all the plots possible. Shylocks character is difficult to interpret as earlier in the play he was described as a comic character, but later on could be described as a evil villain. The reason for his change in interpretation is because the whole power of the play would be lost if Shylock is seen throughout the play as a comic character. Shylock is a successful tradesman who lends out money or known as a usurer. In medieval times, this type of job was seen as a sin and therefore making Shylock a sinner. The Christian community in Venice treated him very differently, but despite of their treatment towards him, he makes it clear that his relationship with Christians was strictly business. We will write a custom essay on Theatre Programme The Merchant of Venice specifically for you for only $16.38 $13.9/page Order now I will buy with you, sell with you, talk with you, walk with you, and so following, but I will not eat with you, drink with you, nor pray with you. This passage tells us that Shylock was willing to offer his profit-making services to Christians but was not prepared to socialise with them. The bond plot begins with Antonio becoming one of Shylocks customers of a loan. Shylock agreed to the three thousand ducats Antonio requested, but instead of charging interest he said if he could not pay him back he would have his bond, which was one pound of flesh from any part of Antonios body. Antonio agreed to such bond because he was confident of his ships returning with goods which will sell for lots of money, but Shylock had high doubts concerning the security of Antonios ships. Shylock thought his chances were high on fulfilling his vengeance against Antonio and make his suffer. Shylock said the following about Antonios ships. But ships are but boards, sailors but men; there be land rats, and water rats, water thieves and land thieves (I mean pirates), and then there is the peril of waters, the rocks; the man is notwithstanding, sufficient. Shylock wants this revenge on Antonio so much because Antonio had physically and verbally abused Shylock in the past. Shylock said this about Antonios treatment towards him: You call me misbeliever, cut-throat dog, and spit upon my Jewish gabardine. But after Shylock explains to Antonio how he treats him, Antonio does not regret abusing Shylock and takes matters further by saying: I am as like to call thee so again, to spit on thee again, to spurn thee too. This means Antonio feels no sorrow towards Shylock and will treat him as he wants. Even though Antonio is dependant on Shylock at his point, he still shows his disrespect to Shylocks religion which could result in Shylock not lending the money to him. Antonio is a wealthy merchant in Venice. Although he is the centre of the play, he is portrayed by Shakespeare as a very depressed and is not involved in the social atmosphere around Venice. In sooth, I know not why I am so sad; It wearies me; you say it wearies you; but how I caught it, found it, or came by it, what stuff it made of, whereof it is born, I am to learn The mystery of Antonios sadness remains unsolved, as he denies the sadness is related to his ships or a lost love. Early in the play the other side of Antonio is revealed. A cruel man is displayed with hatred towards the Jewish race, especially Shylock. During Antonios sad and unhappy times, his dear friend Bassanio is there to comfort and try solving his problems. Bassanio has helped him through many troubled times and as soon as Bassanio needs a favour returned, Antonio agrees without a doubt and this is how the bond plot begins. .u1a26fc9ac3818748304d2d7983470996 , .u1a26fc9ac3818748304d2d7983470996 .postImageUrl , .u1a26fc9ac3818748304d2d7983470996 .centered-text-area { min-height: 80px; position: relative; } .u1a26fc9ac3818748304d2d7983470996 , .u1a26fc9ac3818748304d2d7983470996:hover , .u1a26fc9ac3818748304d2d7983470996:visited , .u1a26fc9ac3818748304d2d7983470996:active { border:0!important; } .u1a26fc9ac3818748304d2d7983470996 .clearfix:after { content: ""; display: table; clear: both; } .u1a26fc9ac3818748304d2d7983470996 { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .u1a26fc9ac3818748304d2d7983470996:active , .u1a26fc9ac3818748304d2d7983470996:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .u1a26fc9ac3818748304d2d7983470996 .centered-text-area { width: 100%; position: relative ; } .u1a26fc9ac3818748304d2d7983470996 .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .u1a26fc9ac3818748304d2d7983470996 .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .u1a26fc9ac3818748304d2d7983470996 .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .u1a26fc9ac3818748304d2d7983470996:hover .ctaButton { background-color: #34495E!important; } .u1a26fc9ac3818748304d2d7983470996 .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .u1a26fc9ac3818748304d2d7983470996 .u1a26fc9ac3818748304d2d7983470996-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .u1a26fc9ac3818748304d2d7983470996:after { content: ""; display: block; clear: both; } READ: Twelfth Night EssayPortia is known as the Golden Fleece that suitors from all over the world come to woo. Her beauty and intelligence attracts suitors into the casket story, but during this story she displays racism and prejudice towards the Prince of Morocco, even when he said: Mislike me not for my complexion. The way Portia reacts to the suitors influences the audiences opinion of them. When she picks on a fault of a suitor it is disliked by the audience and when she finds a pleasing point in a suitor the audience also shows interest in him. An example of Portias ability to manipulate the audience is during a conversation with Nerissa about one of the suitors, the County Palatine: He doth nothing but frown, as who should say, an you will not have me, choose. He hears merry tales and smiles not; I fear he will prove the weeping philosopher when he grows old, being so full of unmannerly sadness in his youth. I have rather be married to a deaths-head with a bone in his mouth, than to either of these. Bassanio is the closest friend to Antonio and their relationship is the finest throughout Venice. Antonios other friends know that if anyone could cheer Antonio up, that someone would be Bassanio. But because they did not want to make their jealousy obvious and trouble Antonio even more, they try to change their way of conversation and make it sound like a joke or sarcasm. Here comes Bassanio, your most noble kinsman, Gratiano, and Lorenzo. Fare ye well, we leave you now with better company. Salerio: I would have stayed will I had mad you merry, if wothier friends had not prevented me. Bassanio is determined to woo Portia and needs three thousand ducats to furnish his suit. When he eventually arrives to choose the casket of his dreams, he picks the correct casket and pleases Portia with his charms. Relationships are the most important aspects in Bassanios life, whether it is between his friends or with Portia. The Merchant Of Venice is concerned with two issues that were of importance in the Elizabethan time: Jewry and Usury. The Christian reaction and attitude towards Jews was hostile and that the execution of Rodrigo Lopez in 1594 was characteristic of the Christian rejection of al Jews. Jews were forced to convert to Christianity to live in England, once they did they were generally left alone. Usury was an important issue during Shakespeares time. Shylock is the typical picture of the usurer that most of the Elizabethans had and who is never accepted. He is proud of his race and his religion but he is against the Venetian society that shows no mercy to the outsider. I think William Shakespeare was not against Jews because he included a passage that made Christians and Jews feel alike, Shylock said: I am a Jew. Hath not a Jew eyes? Hath not a Jew hands, organs, dimensions, senses, affections, passions? Fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer as a Christians is? If you prick us, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die? In the 20th century we are more sensitive and conscious about political correctness. The issue of racism has further complicated Shylocks character and his role attracts greater sympathy. One of the most important passages in the play fights for equal rights and gives out a powerful effect to the readers. Shylock said: He hath disgraced me, and hindered me half a million laughed at my losses, mocked at my gains, scorned my nation, thwarted my bargains, cooled my friends, heated my enemies and whats his reason? I am a Jew. Hath not a Jew eyes? Hath not a Jew hands, organs, dimensions, senses, affections, passions? Fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer as a Christians is? If you prick us, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die? And if you wrong us, shall we not revenge? .uc50c29cc3772b170a62bf973305f2df2 , .uc50c29cc3772b170a62bf973305f2df2 .postImageUrl , .uc50c29cc3772b170a62bf973305f2df2 .centered-text-area { min-height: 80px; position: relative; } .uc50c29cc3772b170a62bf973305f2df2 , .uc50c29cc3772b170a62bf973305f2df2:hover , .uc50c29cc3772b170a62bf973305f2df2:visited , .uc50c29cc3772b170a62bf973305f2df2:active { border:0!important; } .uc50c29cc3772b170a62bf973305f2df2 .clearfix:after { content: ""; display: table; clear: both; } .uc50c29cc3772b170a62bf973305f2df2 { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .uc50c29cc3772b170a62bf973305f2df2:active , .uc50c29cc3772b170a62bf973305f2df2:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .uc50c29cc3772b170a62bf973305f2df2 .centered-text-area { width: 100%; position: relative ; } .uc50c29cc3772b170a62bf973305f2df2 .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .uc50c29cc3772b170a62bf973305f2df2 .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .uc50c29cc3772b170a62bf973305f2df2 .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .uc50c29cc3772b170a62bf973305f2df2:hover .ctaButton { background-color: #34495E!important; } .uc50c29cc3772b170a62bf973305f2df2 .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .uc50c29cc3772b170a62bf973305f2df2 .uc50c29cc3772b170a62bf973305f2df2-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .uc50c29cc3772b170a62bf973305f2df2:after { content: ""; display: block; clear: both; } READ: How does Shakespeare create tension in Act 3 scene 1? EssayShakespeare added this passage to show us that he is not against any religion and that al the hatred in The Merchant Of Venice is just a storyline. But this passage is also telling us that shylock is not as sinful as we thought from the beginning of the play. Shylock reveals that he knows the suffering of racism and hatred between religion but yet he still dislikes Christians. He believes that Antonio has sinned upon him more him sinning upon Antonio, and when Shylock makes this speech he thinks that he will get his bond and finish their rivalry. The passage sends out such a powerful effect because of the structure, the words used and how the sentences are arranged. The first thing noticed about the passage is that the sentences are very short or are very slow due to the amount of commas. These short sentences or statements create a slower flow of reading and allow readers to think about the statements before proceeding to the next one. The words have been carefully selected by Shakespeare which summarises the events in life. Most of the words he uses, it creates a rhetorical question and allows readers even more time to think about the statements and reflect on how powerful this passage can be. At the time of the play, the Elizabethan times were still in the age of discovering the world. The Americas and West Indies were among the few best discoveries of the world as it provided spices, silk, and other precious things. These expensive imports were sold around Europe and created jobs as tradesman. Antonio was one of these tradesmen. He owned ships which would collect the items and allow him to sell. This job is not very secure as there is always some uncertainty of the condition of the ships as Antonio finds out later in the play. The Merchant of Venice on stage needed to show a balance between its two worlds of Venice and Belmont. Shakespeare stagecraft in the play already portrays detailed visions whilst reading, but watching the play on stage took the audiences imagination to a next level. His clever use of language changes between characters to suit their separate personalities and this would bring out the best or worst in a character. The style of language he mostly uses in the play is blank verses, which is poetry that does not rhyme, but also the rhythm of human speech used in the play is known as a iambic pentameter. As a member of the audience, the play was received and acted as a comedy but the triadic was not lost through Shylocks character. The scenes of drama were expressed by each character with lots of enthusiasm and they all felt as though they were the main character. The stage was like the entire world in a few paces for the actors and actresses, and in those few paces the whole importance of the play was captured and delivered to the audience. As a reader I think this play is another one of Shakespeare best along with Macbeth and Romeo And Juliet. This dramatic comedy is enjoyable because this is one of his plays which will make you think of how much has changed in the world. Racism and hatred between religion echoes around the Elizabethan society and is not much different from other everyday activity such as having an evening meal. This play has many comedy acts and will take the focus off the main plot for a bit to give readers a break from one large continuous storyline. There are also many dramatic scenes which make a exciting climax in the main plot. The Merchant Of Venice combines the important ingredients of a good comedy and a drama to create this play.

Pros and Cons to Capital Punishment essays

Pros and Cons to Capital Punishment essays For many years the death penalty has been the sentence for murders, rapists, and other serial criminals. But, in recent months it has been an issue in whether the death penalty should or should not be legal. (Lancashire, Ian. Page. 20) There are many people that think that capital punishment should be used and there are others that feel that it should not be used. Also there are some in the middle that think that it doesn't really matter because they feel that whatever happens will be right because it was brought up and decided in a court of law. Capital punishment is the only way to be sure the killing will end with that criminal. If we execute murders and there is in fact no deterrent effect, we have killed but failed to Capital punishment is the only way to stop capital crimes. For example, citizens feel that capital punishment is fair for those that have committed the crime such as murder. This shows that you have to find and prove that the criminal is truly guilty. This could take days, months, even years. Prisons are not hard enough on there inmates. For example the inmates are allowed to attend school and watch TV in case that they are released. But then, didnt they committee a capital crime? That should mean guaranteed life in prison, if not the death penalty. These criminals killed people, and if there not going to be killed they sure better not be released to do it again. It seems like they dont remember that the inmate had no mercy when they were raping, or killing that innocent person, yet we feel sorry for them. There are lots of issues that arise with the death penalty, such as moral issues and innocent lives being taken when may be they shouldnt. For example there is a lot that needs to be done before the initial action is taken place. This shows that their needs to be clear and correct ev ...

Leading by Feel Article Example | Topics and Well Written Essays - 750 words

Leading by Feel - Article Example The article focuses on self-regulation and its impact on an emotionally intelligent leadership. This way the article investigates whether emotionally intelligent and effective leaders are those that can; restrain themselves from unleashing verbal attacks on their subordinates and make well-informed decisions and concede to the values of others through learning while remaining in control. The article also investigates whether the motivation is a common attribute of emotional intelligence. This is especially true because self-motivated leaders were commonly depicted as working in a consistent manner to meet their objectives, which are often set higher, but at an achievable level. The article also investigates whether empathy among corporate and social leadership is critical to administering an effective organizational team. In supporting empathy in leadership, the article presents emotionally intelligent executives as those with the capacity to understand the issues affecting other mem bers of the organization. Lastly, the article purposefully emphasizes social skills as a vital element of effective an emotionally intelligent leadership. In specific, the article explores whether the need to acquire conflict resolution capacities, improving one’s interpersonal skills and learning how to appreciate others as some of the ways to lead the organization by feel usually count. The researcher applied both primary and secondary research methodologies in the article: the article is a review of different scholarly works from different fields relating to business leadership; and an exploratory interview of the previous findings on the importance of emotional intelligence in managing the mood of organizational staffs.

Not waving but drowning Essay Example | Topics and Well Written Essays - 1000 words

Not waving but drowning - Essay Example In each of these states, whether European or American, people were experiencing a great deal of alienation and isolation as a result of these tremendous changes. Perhaps it is not surprising, then, to find the desolation and isolation of this period reflected as a major theme in the poetry created during this period such as â€Å"Not Waving but Drowning† by Stevie Smith. The isolation is almost overwhelming in Smith’s poem as she begins with the desolate lonely cry of a man that nobody hears. Although he is introduced as being dead, â€Å"Nobody heard him, the dead man, / But still he lay moaning† (1-2), making himself known to someone. This introduction presents several possibilities as to his true condition. The first is that the man is only symbolically dead, dead on the inside, and so is physically alive and able to moan in his continued pain and loneliness. He could also be so close to death that there is no possibility of saving him before he’s gone, and he’s moaning in anticipation of the inevitable. Another possibility is that he is actually dead, but there remain a few possibilities as to his continued moaning. The pain and anguish of his death might have been too much for him to bear and thus he is still moaning even after death. Finally, the suggestion that nobody heard him invokes the sense of the ghostly, so that perhaps the man is moaning in the form of a ghost, attempting to warn those who can hear of the dangers of allowing individuals to become too isolated from society. The words that Smith provides him in the second portion of this stanza further emphasize the sense of isolation and failed attempts at connection. The dead man says, â€Å"I was much further out than you thought / And not waving but drowning† (3-4). This indicates that whether he was alive or dead, this man never felt as close to his fellow humans as they perceived him to be and, as a result, they were unable to recognize the signs of distress he was sending

Haemathology-oncology practice Assignment Example | Topics and Well Written Essays - 2000 words

Haemathology-oncology practice - Assignment Example Based on the reports of that test, Ruth was informed that she has acute lymphatic leukemia (ALL) and will need to commence chemotherapy with Cyclophosphomide, Cytarabine and Mercaptoprine for which Hickman line was inserted and kept in situ. She received 4 cycles of chemotherapy until this admission when she got admitted for a complication, febrile neutropenia On this admission, the sixth one since her diagnosis, Ruth presented with fever. On examination, she was febrile, feeling unwell, tearful and anxious, and feeling hot and cold. Her temperature was 38.4C and heart rate 115 beats per minute. Neutrophil count was 0.3 percent, which is suggestive of severe neutropenia. Septic screen was done which included urine culture and sensitivity, stools culture and sensitivity, sputum examination and a full blood count. Chest x-ray and throat swab also was done. Intravenous fluids were commenced as per her weight and first line broad spectrum antibiotics as per hospital protocols were prescr ibed. Problem-1: Chemotherapy-related neutropenia Overview of the problem Ruth is diagnosed with febrile neutropenia.... Neutrophils are very important for innate immunity and comprise the first cellular component of any inflammatory response (Friese, 2006). Neutropenia is common adverse effect of cytotoxic chemotherapy (Brien et al, 2006). This condition typically occurs in the presence of other side effects and these concurrent events affect the quality of life of the patient. Other side effects include asthenia, anorexia, vomiting and dehydration. In addition to these events various precautions that are taken to minimise neutropenia also affect the quality of life. The degree of febrile neutropenia also influences the intensity of adverse events (Padilla and Ropka, 2005). The duration of chemotherapy induced neutropenia is typically 7-10 days (Friese, 2006). The blood culture of Ruth grew staphylococcus aureus. Urine and other cultures were negative. The staphyloccus aureus was resistant to vancomycin. Hence her antibiotics were changed to meropenem and gentamycin. Ruth was constantly monitored for improvement both through physical examination and laboratory tests. This is because, neutropenia is associated with significant morbidity and mortality because of the increased risk of developing infections that could be life threatening. The risk of infections correlates with drop 0f absolute neutrophil count and those with severe neutropenia (ANC < 0.5 ? 109/L) are at greatest risk of developing infections which are life threatening. In Ruth, the neutropenic count was 0.3 and she presented with only fever. More often than not, infection due to neutropenia manifests as just fever and hence presence of fever in neutropenic patients warrants close monitoring (Padilla and Ropka, 2005).

Marketing Mix and Market Segmentation

Marketing Mix and Market Segmentation Marketing mix What is the marketing mix? The marketing mix is probably the most famous marketing term. Its elements are the basic, tactical components of a marketing plan. The flowing marketing four p elements product price place and promotion of marketing mix The term marketing mix was first used in 1953 when Neil Borden, in his American Marketing Association presidential address, took the recipe idea one step further and coined tterm marketing-mix. Marketing Mix is a major concept in modern marketing and involves practically everything that a marketing company can use to influence consumer perception favorably towards its product or services so that consumer and organizational objectives are attained, i.e. Marketing mix is a model of crafting and implementing marketing strategy. It is the same with the marketing mix. The offer you make to you customer can be altered by varying the mix elements. So for a high profile brand, increase the focus on promotion and desensitize the weight given to price. Another way to think about the marketing mix is to use the image of an artists palette. Some commentators will increase the marketing mix to the Five Ps, to include Others will increase the mix to Seven Ps, Price There are many ways to price a product. Lets have a look at some of them and try to understand the best policy/strategy in various situations. Customers directly relate price to quality, particularly in case of products that are ego intensive of technology based. Sony being a company which emphasize product quality, it tends to sell its products with price range from moderately-high to high-prices, depending on the use and the targeted customers. For example, Lets consider Sony series of VAIO laptops. Sony has tried to categorize the laptops according to style, user, purpose, mobility and performance, and each a corresponding price. Another element of Neil Bordens Marketing Mix is Place. Place is also known as channel, distribution, or intermediary. It is the mechanism through which goods and/or services are moved from the manufacturer/ service provider to the user or consumer. Product For many a product is simply the tangible, physical entity that they may be buying or selling. You buy a new car and thats the product simple! Or maybe not. When you buy a car, is the product more complex than you first thought? The Three Levels of a Product The Product Life Cycle (PLC) is based upon the biological life cycle. For example, a seed is planted (introduction); it begins to sprout (growth); The Customer Life Cycle (CLC) has obvious similarities with the Product Life Cycle (PLC). However, CLC focuses upon the creation of and delivery of lifetime value to the customer i.e. looks at the products or services that customers NEED throughout their live. Promotion Sales promotions for example includes free samples, discount, rebates, coupons, contents and sweepstakes, premiums, scratch cards, exchange offers, early bird prizes, etc. Another one of the 4Ps is promotion. This includes all of the tools available to the marketer for marketing communication. Sales promotion is a marketing discipline that utilizes a variety of incentives techniques to structure sales related programs targeted to customers, trade, and/or sales levels that generate a specific, measurable action or response for a product or service. People People are the most important element of any service or experience. Services tend to be produced and consumed at the same moment, and aspects of the customer experience are altered Public Relations and Publicity Public relations is a broad set of communication activities employed to create and maintain favourable relationship with employees, shareholders,to meet the individual needs of the person consuming Process Process is another element of the extended marketing mix, or 7Ps.There are a number of perceptions of the concept of process within the business and marketing. For example to achieve a 30% market share a company implements a marketing planning process. Limitation of Marketing Mix Analysis (4Ps of Marketing) Despite the fact that marketing mix analysis is used as a synonym for the 4Ps of Marketing, it is criticised (Kotler Armstrong, 2004) on the point that it caters sellers view of market analysis not customers view. To tackle this criticism, Lauterborn (1990) attempted to match 4 Ps of marketing with 4 Cs of marketing to address consumer views: Product Customer Solution Price Customer Cost Placement Convenience Promotion Communication How to Write a Good Marketing Mix Analysis To follow a simple and best approach for marketing mix analysis, it is imperative to understand the purpose of this analysis. So the basic key is to analyse the companys overall marketing strategy primarily through the strategies it follows under the 4Ps of marketing Information for Marketing Mix Analysis Students may seek information regarding market mix analysis (4 Ps) from two basic sources: market and academic. For market sources, information is easily available from a companys website, business reports, newspapers/published data on marketing, independent market survey reports and, in some cases, students may visit a retail outlet to analyse a product, its pricing and promotional strategies. However, to get more specific details, marketing and advertising academic journals and secondary data in the form of case studies can be the ideal source. Developing the marketing mix Many non-profit organizations are skilled at event marketing . Events are organized to raise the funds, including dinners, dances, coffee mornings, book ales, sponsored walks and others.The pricing god the services provided by non-profit organizations may not follow the guidelines applicable to profit oriented pricing. For example the price of CE curse organized by non-profit CE center for Gypsies may be held low to encourage poor families to take advantage of this opportunity. Some non-profit organization even provide free access to services. Marketing in non-profit organizations Non-profit organization attempt to achieve some other objectives than profit. This does not mean that they are uninterested in income as they have to generate cash to survive. However their primary goal is non economic, e.g. to provide education. Marketing is of growing importance to many non-profit organizations because of the need to generate funds in an increasingly competitive arena. Even organization who rely on government sponsored grants need to show how their work is of benefit to society: they must meet the needs of their customers. Many non-profit organizations rely on membership fees or donations, which means that communication to individuals and organization .Marketing strategy A strategy gives business a defined route to follow and a clear destination. Build a marketing strategy and you will ensure that marketing is a long-term way of working, not a one-off activity. A marketing strategy provides organisation with shared vision of the future. All too often, an organisation will perform a marketing task, such a direct mail shot, then sit back and see what happens. A strategic approach will ensure that you maximise returns on your marketing spending and boost the profits of your organisation. Strategic marketing manager has a clear picture of the future anticipates changes in the market works towards clear long/term goals Non-strategic marketing manager lives day to day without planning reacts to canges in the market has only short-term objectives During the creating of the marketing strategy the marketing manager should proceed as follows: create the team review current situation set objectives plan action Market segmentation Market segmentation is a concept in economics and marketing. A market segment is a sub-set of a market made up of people or organizations with one or more characteristics that cause them to demand similar product and/or services based on qualities of those products such as price or function. A true market segment meets all of the following criteria: it is distinct from other segments (different segments have different needs), it is homogeneous within the segment (exhibits common needs); it responds similarly to a market stimulus, and it can be reached by a market intervention. The term is also used when consumers with identical product and/or service needs are Positive market segmentation.Market segmenting is dividing the market into groups of individual markets with similar wants or needs that a company divides the market into distinct groups who have distinct needs, wants, behaviour or who might want different products services. Broadly, markets can be divided according to a numbe r of general criteria, such as by industry or public versus private although industrial market segmentation is quite different from consumer market segmentation, both have similar objectives. All of these methods of segmentation are merely proxies for true segments, which dont always fit into convenient demographic boundaries divided up into groups so they can be charged different amounts. These can broadly be viewed as positive and negative applications of the same idea, splitting up the market into smaller groups. Market segmenting is dividing the market into groups of individual markets with similar wants or needs that a company divides the market into distinct groups who have distinct needs, wants, behavior or who might want different products services. Fig positive market segmentation in group. Price Discrimination Where a monopoly exists, the price of a product is likely to be higher than in a competitive market and the quantity sold less, generating monopoly profits for the seller. Market Segmentation is Critical Segmentation can make a huge difference in understanding your market. For example, when a local computer store defines its customer segments as high-end home office and high-technology small business, its segmentation says a lot about its customers. The segmentation helps the company plan its focus on the different types of potential customers MANUFACTURER CUSTOMER RETAILER Decisions with respect to distribution channel focus on making the product available in adequate quantities at places where customers are normally expected to shop for them to satisfy their needs. Depending on the nature of the product, marketing management decides to put into place an exclusive, Summary We Partner With Our Clients to Maximize Profit and Market Share Analytic Partners delivers results-oriented consulting services including marketing mix modelling, forecasting, custom analytics, and software tools designed to: .minimum price Maximize promotion effectiveness ability Support business planning Global Network, Local Experience With offices in North America, Europe, and Asia-Pacific, our global network coupled with our extensive in-country experience allows us to deliver actionable insights at local, regional, and global levels. Client-Centric, Partnership Approach Our organizational model and operating culture is one of collaboration. We work with our clients to help drive action and fully benefit from the insights identified through Please Contact Us to learn more our work. Executive Summary3 In brief, this assignment is concerned about marketing management. It  covers in details about the concept of marketing mix with the aid of Sony  organization which I have taken as a case study in exploring the way this  organization has applied the marketing mix. In this assignment the following points are going to be discussed: Sample List of Marketing Mix being used By the organization. Find out if the marketing mix used by organization is satisfactory. My suggestion to the organization concerning the marketing mix Conclusion The customer needs, usage and  budgets, ajay has provided  several home products ranging from small packages  to big audio systems. They  boast on their Hi-Fi which deliver rich music, made  richer with preset equalizer  Ã‚  settings. Among other features which Sony boast to  offer are like, multiple disc  changers which for putting many discs at a go. Also, some even house additional  features such as the ability to handle multiple  formats, track programming and  repeat and random play.

Empowerment of Women in Sylvia Plaths Lady Lazarus and Eavan Bolands

Empowerment of Women in Sylvia Plath's Lady Lazarus and Eavan Boland's Anorexic Although the title foreshadows an extrinsic approach, this essay mostly features intrinsic analysis. Eavan Boland's "Anorexic" seems descendent from Sylvia Plath's "Lady Lazarus": the two share common elements, yet have significant differences. An examination of the poems' themes reveals that self-destructiveness can serve as empowerment for women. Plath explores Lady Lazarus' nontraditional view of suicide in her poem; (since Plath does not give the speaker of the poem a name, I will refer to her as Lady Lazarus). Lady Lazarus reveals her first suicide was accidental, but she reveals that her two subsequent deaths have been deliberate. This is significant as she is not speaking of attempts, but actual suicides; also, she establishes her intention. In describing the woman's attitude, Plath varies between using metaphors, such as "It's the theatrical/Comeback in broad day" (51-52), and similes: "my skin/Bright as Nazi lampshade" (4-5); "I rocked shut/As a seashell" (38-39). Plath's indifferent and almost positive connotations suggest Lady Lazarus embraces death as indicative of her ability to survive. Also, the poem's structure of three-line stanzas is symbolic of this being Lady Lazarus' third suicide. After her suicide, Lady Lazarus declares she is only "Ash," "Flesh, bone,"(75) "A cake of soap/A wedding ring,/A gold filling" (76-78): she does not reminisce about who she was, but rather, literally what she now is. Plath's repetition of "ash" indicates Lady Lazarus' preoccupation: "I turn and burn" (71); Lady Lazarus does not express resentment towards this death, likely symbolic, as she does not articulate the exact method. Furthermore, Lady... ...logy with negative self-image to create an extreme view that women fell from grace when they needed to eat, making this poem, like anorexia, evocative of sympathy: women should not feel as though they need to deprive their human needs to improve their humanity. These poems should not be considered negative examples of female rationale, but rather, allegories of empowerment: by their own choices, Lady Lazarus rises like the phoenix, and the anorexic woman matures spiritually, each through her own death. Furthermore, each woman acts as the source of morality, as Lady Lazarus transcends heaven and hell, and the anorexic woman judges herself. Though the cause of the anorexic woman's desire is not clear, her reaction, like Lady Lazarus', is a choice free from God, as Nietzsche explains. Thus by destroying themselves, these women are actually asserting their autonomy. Empowerment of Women in Sylvia Plath's Lady Lazarus and Eavan Boland's Empowerment of Women in Sylvia Plath's Lady Lazarus and Eavan Boland's Anorexic Although the title foreshadows an extrinsic approach, this essay mostly features intrinsic analysis. Eavan Boland's "Anorexic" seems descendent from Sylvia Plath's "Lady Lazarus": the two share common elements, yet have significant differences. An examination of the poems' themes reveals that self-destructiveness can serve as empowerment for women. Plath explores Lady Lazarus' nontraditional view of suicide in her poem; (since Plath does not give the speaker of the poem a name, I will refer to her as Lady Lazarus). Lady Lazarus reveals her first suicide was accidental, but she reveals that her two subsequent deaths have been deliberate. This is significant as she is not speaking of attempts, but actual suicides; also, she establishes her intention. In describing the woman's attitude, Plath varies between using metaphors, such as "It's the theatrical/Comeback in broad day" (51-52), and similes: "my skin/Bright as Nazi lampshade" (4-5); "I rocked shut/As a seashell" (38-39). Plath's indifferent and almost positive connotations suggest Lady Lazarus embraces death as indicative of her ability to survive. Also, the poem's structure of three-line stanzas is symbolic of this being Lady Lazarus' third suicide. After her suicide, Lady Lazarus declares she is only "Ash," "Flesh, bone,"(75) "A cake of soap/A wedding ring,/A gold filling" (76-78): she does not reminisce about who she was, but rather, literally what she now is. Plath's repetition of "ash" indicates Lady Lazarus' preoccupation: "I turn and burn" (71); Lady Lazarus does not express resentment towards this death, likely symbolic, as she does not articulate the exact method. Furthermore, Lady... ...logy with negative self-image to create an extreme view that women fell from grace when they needed to eat, making this poem, like anorexia, evocative of sympathy: women should not feel as though they need to deprive their human needs to improve their humanity. These poems should not be considered negative examples of female rationale, but rather, allegories of empowerment: by their own choices, Lady Lazarus rises like the phoenix, and the anorexic woman matures spiritually, each through her own death. Furthermore, each woman acts as the source of morality, as Lady Lazarus transcends heaven and hell, and the anorexic woman judges herself. Though the cause of the anorexic woman's desire is not clear, her reaction, like Lady Lazarus', is a choice free from God, as Nietzsche explains. Thus by destroying themselves, these women are actually asserting their autonomy.

God’s Divine Justice in Dante’s ‘Inferno” Essay

â€Å"Midway through the journey of our life, I found/myself in a dark wood, for I had strayed/from the straight pathway to this tangled ground.† These famous lines from Dante’s Inferno signify the themes of religion and personal salvation in the poem. Often when one embarks on a journey of self-discovery, they travel to places which astound one by their strangeness. Expecting to see what is straightforward and acceptable, one is suddenly presented with exceptions. Just as such self-examiners might encounter their inner demons, so does Dante, both as a character and a writer, as he sets out to walk through his Inferno. The image of being lost in â€Å"dark woods† sets up a clear dichotomy between the supposed unenlightened ignorance that one endures due to a lack of faith in God and the clear radiance provided by God’s love. Dante uses contrasting symbols to indicate the character’s challenge. The â€Å"dark woods† embodies Dante’s fear, yet the â€Å"right road† symbolizes his confidence in God, ultimately revealing that Dante’s journey is to find the presence of God in a sinful world. However, the journey upon which Dante is embarking is not solely his, but rather that of every human being. Consistent with the views of his time, Dante believes that this journey is one that every individual must undertake, so as to understand their sins and find peace with God. This is an element with which modern readers can identify, as present society is conscious of an individual’s right to find peace within themselves and the universe. While there are many different religions and divine beings which are worshipped today, the medieval view of personal salvation and spiritual peace is still applicable to any of these variations. Dante’s journey throughout the Inferno also gives readers a glimpse into his own perception of what constitutes sin. It may be harder, however, for modern readers to agree with the punishment for certain sins, in light of liberal advances in society’s views and the constantly changing nature of moral and societal norms. The torments that sinners are subjected to in Dante’s Inferno may seem extreme to modern readers, however, throughout the poem it becomes clear that there is balance in God’s justice and each sinner suffers to a degree befitting the gravity of their sins. Dante’s journey to save his soul reveals a correspondence between a soul’s sin on Earth and the punishment received in Hell. A few examples are the Sullen, who choke on mud; the  Wrathful, who attack one another; and the Gluttonous, who are forced to eat excrement. This brings into light one of Dante’s main themes, the perfection of God’s justice, which is relevant throughout time. â€Å"THROUGH ME THE WAY TO SOULS IN ABOMINATION./JUSTICE MOVED MY GREAT MAKER IN MY DESIGN.† The inscription over the gates of Hell in Canto III explicitly states that God created Hell and its punishments through the motivation of justice. Hell exists to punish sin and the specific punishments awarded ar e suitable, as they testify to the divine perfection, which all sin violates. To modern readers, however, the torments that Dante and Virgil behold, on their journey through the circles of Hell, may seem harsh. For example, homosexuals must endure an eternity of walking on hot sand and those who charge interest on loans must sit beneath a rainy storm of fire. These, like many of the sins that Dante punishes in the Inferno, are socially acceptable and common in the present world. While many cultures do not accept homosexual relations, intolerance for this style of life has decreased dramatically in the past generation and by many, is no longer viewed as a sin against nature. Likewise, charging interest on loans is common in the commercialized business economies of the modern world. A modern reader would not deem the punishments received by these sinners as appropriate. However, it is important to realize that Dante is writing during a period of great religious influence and obedience to theological ideals. In addition, when the poem is viewed in its entirety, it becomes clear that the guiding principle behind these punishments is one of justice and balance. The poem progresses from minor sins to major ones, as the duo proceeds deeper into the fires of Hell and closer to Lucifer himself. While some readers may object to the placements of some sins, the damned souls that reside in the deepest part of Hell, the 9th Circle, are neither a medieval nor modern view, but in fact, timeless. Dante reserves the harshest punishments for those who have committed sins against those whom the sinner has special ties to, like family or friends. Despite the act, modern readers can agree that a traitor of this nature must be deservedly punished. Early on in Inferno, Dante presents tension between the objective impersonality of God’s justice and the human sympathy that the character of Dante feels for the souls that he sees around him. However, Dante is demonstrating that sinners receive punishment in divine proportion to their sin and to pity their suffering is  to demonstrate a lack of understanding. The reader must be wary of succumbing to the sympathy that Dante first shows towards some of the damned souls, as messengers from heaven show their lack of concern for the damned and eventually, Dante also becomes less inclined to pity the sinners, trusting the infinite wisdom of divine justice. It is assumed in Christian theology that God is divine and just and therefore, it is futile to question His judgments. Subsequently, it should be realized that Dante’s sympathy towards some of the characters in Hell is incorrect. Everything about God is just; it is only in the mortal world of sin and death that one finds injustice, which is the mark of Cain on humanity. Yet Dante’s treatment of some characters asks the reader to put aside their sins and admire their human traits. However, if the reader begins to feel sympathy for Francesca, it must be noted that she is a woman with the habit of blaming others for her own difficulties; Pier delle Vigne has totally abandoned his loyalty for God in favour of his powerful emperor; Ulysses is a character of great ego; and even Ugolino’s paternal feelings have a central concern for his own well-being. These characteristics may, however, elude the reader and thus, two figures from heaven descend into hell to remind Dante of his mission, indicating how the reader should perceive these sinners. Virgil tells Dante of Beatrice’s visit to Limbo, where she admits no compassion for the tribulations of the damned, she only wishes to return to Paradise as soon as possible. When an angel arrives to open the gates of Dis, which had been slammed in the face of Virgil, he makes it clear that he has no interest in the damned nor in Dante’s situation, he only wants to complete his task quickly and leave Hell. Despite these reminders, both the character of Dante and the reader fall victim to their human sympathy for many of the sinners in the earlier cantos. Throughout Canto III, Dante displays a great deal of sympathy for the souls he encounters; his depiction of Hell as a walled city conforms to medieval Catholic theology and exemplifies the religious awareness of the period. Upon passing through the gates of Hell, Dante hears innumerable cries of torment and suffering. Virgil explains that these cries emanate from the souls of those who lived their lives without making conscious moral choices  and thus, did not commit their lives to good or evil. Subsequently, the indifference of these souls have caused both Heaven and Hell to deny them entry. These souls now reside in the Ante-Inferno, within Hell yet not truly part of it, where they must chase constantly after a blank banner. The empty banner symbolizes their meaningless existence on earth. Flies and wasps continually bite them, and writhing worms consume the blood and tears that flow from them. The souls of the uncommitted are joined in this torment by the neutral angels — those who sided with neither God nor Satan in the war in Heaven. â€Å"That death had undone so many, I had not dreamed.† Like Dante, modern readers will also find it hard to accept the fate of these indecisive souls. It seems unfair that by not succumbing to either good or evil, they must still endure punishment in the afterlife. In this canto, Dante also describes Hell as being formed out of justice and also as a city: â€Å"THROUGH ME THE WAY TO THE CITY OF DESOLATION.† Historically, large cities had begun to play an increasingly important role in the social and economic life of Europe during Dante’s time. Particularly in Italy, where city-states such as Dante’s native Florence had become important bases of social organization. Dante portrays Hell as a city in large part because, to a thinker in the early fourteenth century, any substantial human population would have suggested a city. In religious terms, there are only two great â€Å"cities†: Heaven or Hell. While Heaven is a city of God, Hell is a city of Man; as the damned souls have succumbed to temptation and sin, preoccupied only with self-preservation and gain. This may be a more medieval idea, as cities were viewed as a source of evil and were enjoying a relatively new period of prosperity. However, crime in modern times is more prevalent in cities and thus, more citizens prefer to live in the suburbs. Even the structure of Hell represents a city. The outer limits are like the countryside, containing the indecisive souls. As Dante and Virgil progress through the outer circles, which can be seen as the suburbs, they encounter lesser sins. However, as they continue further into the depths of Hell and towards the city’s heart, the sins increase in gravity. Dante’s opinion of the sinners also begins to progress and become less sympathetic at this point. In Cantos XII and XIII, Dante continues to exhibit sympathy for some sinners, however appears to be becoming more cynical as he encounters many damned souls from Florence; the punishments in these cantos also reflect a rationale for appropriate degrees of anguish. In these cantos, Dante encounters souls who were violent towards others and themselves. The first group must stand in a pool of boiling blood. Going along with the theme of appropriate punishment as part of God’s justice, each of these souls is subjected to a different level of agony. The souls who only killed one person stand only with their legs in the boiling blood. However, the souls of tyrants, like Alexander, have even their heads submerged. Why must these souls stand in boiling blood and not water? It is because it was blood which they lusted after during life, causing them to be violent. In this portion of his journey, Dante does not display sympathy for the torment of these souls. â€Å"O senseless rage and blind cupidity/that in the short life stimulate us so/and in eternal one drench us wretchedly.† As opposed to the earlier cantos, Dante recognizes that the greed and anger of these souls during life are responsible for their punishment in Hell. In the next canto, Dante encounters those souls who were violent towards themselves by committing suicide. Their fate in afterlife is to suffer as trees; having discarded their bodies while on earth, these souls have been rendered unable to assume human form for the rest of eternity. To some modern readers, the punishment of souls who commit suicide may seem unnecessary, as these people must have already endured great suffering during life to commit such a sin. The punishment of violence, however, seems appropriate. Towards the end of Canto XIII, Dante learns from one tree-soul that his home city, Florence, constantly succumbs to conflict due to its abandonment of Mars as it patron saint, in favour of John the Baptist. â€Å"†¦The city that chose the Baptist to replace/ its ancient patron, who for all time to come/will therefore use his art to afflict our race.† Mars was the god of war and thus, Florence is persistently filled with feuding factions. Dante, however, tends to blame the state of Florence’s politics on certain influential leaders of his time. In Canto XXVII, Dante shows his intolerance for the political corruption in Florence, along with a more cynical and modern view, believing that moral dilemmas should be addressed using logic and not by blindly following a  religious figure, as Pope Boniface VII led da Montefeltro to Hell. The political and spiritual leaders in Florence are subjected to harsh punishments and viewed with great contempt by the character of Dante, due to the personal history of the author. Dante Alighieri was born in 1265 in Florence, Italy, to a family of moderate wealth that had a history of involvement in the complex Florentine political scene. Dante’s personal life and subsequent writing of The Divine Comedy were greatly influenced by the politics of the late 13th Century. The struggle for power in Florence between the church and state for authority was a conflict that existed throughout Europe. In Florence, these two loyalties were represented by the Guelph party, which supported the papacy , and the Ghibelline party, which supported imperial power. The last truly powerful Holy Roman Emperor, Frederick II, died in 1250, and by Dante’s time, the Guelphs were in power in Florence. However, the party had divided into two factions: the Whites (Dante’s party), who supported the independence of Florence from strict papal control, and the Blacks, who were willing to work with the pope in order to restore their power. Under the direction of Pope Boniface VIII, the Blacks gained control of Florence in 1301 and Dante, as a visible and influential leader of the Whites, was exiled within a year. In Canto XXVII, Dante encounters the damned soul of Guido da Montefeltro, who had been a member of the Ghibelline party but had undergone a spiritual conversion and entered a Franciscan monastery. However, he was subsequently persuaded to re-enter politics on the opposite side by Pope Boniface VIII. Boniface eventually asked da Montefeltro’s advice on how to capture a Ghibelline fortress and promised him absolution in advance, d espite the accuracy of any advice. However, upon his death, da Montefeltro was pulled into Hell by a devil who exclaimed: â€Å"†¦Because of the fraudulent counsel he presented./I’ve been at his hair since the instant of the wrong,/for no one can be absolved who has not repented†¦Ã¢â‚¬  It is impossible for a man to receive absolution before sinning, as absolution cannot precede repentance and repentance cannot precede the sin. At this point, Dante does not question the spiritual authority of the Christian Church. He does, however, show his contempt for Pope Boniface. Dante’s message from this encounter is that when Christians find themselves faced with moral dilemmas, they must use their reason rather than blindly follow the directions of a church  figure. Dante does not believe that the Church’s authority should overrule logic, especially given the Church’s frequent descents to corruption. This is an element of the Inferno which modern readers can greatly relate to. Presentl y, science and other logical studies dictate man’s knowledge of his world. It is also used more frequently in making decisions tha basic reliance on one’s religion, as was the case in medieval times. While the modern reader can relate to Dante’s insistence that logic dominate religion in certain matters, there are still many elements of Dante’s Hell which may trouble a modern audience. As aforementioned, many of the punishments may seem harsh and even unwarranted, given present social and moral norms. Another element of disagreement may be found with Dante’s depiction of Limbo. In Canto IV, Virgil and Dante descend into the First Circle of Hell, known as Limbo, which is inhabited by those souls who led virtuous lives but were not baptized or lived before the advent of Christianity. In a world where there are many different religions and belief systems that, for the most part, co-exist relatively harmoniously, the idea of punishing pagans seems unjust. If these souls were unaware of Christianity or chose not to follow this faith during life, then why should they be subjected to the same judgment as Christians? This is an example of the dominant Christian theme in the Inferno and one of the many reasons why modern readers may find it difficult to identify with Dante’s Hell. Consequently, the greatest challenge that Dante’s Inferno presents to modern readers is its lack of tolerance. This is due to the great influence that the Christian religion enjoyed during this period and the rigid outline of sins that existed in the Bible. The character of Dante is prepared to offer sympathy towards some souls, but is encouraged by heavenly messengers to show no compassion or tolerance for the sins of the damned. French philosopher, Voltaire, later would identify this flaw in the Christian faith: â€Å"Of all religions, Christianity is without a doubt the one that should inspire tolerance most, although, up to now, the Christians have been the most intolerant of all men.†