The Effect Of Gestational Age And Gender On Fetal And...

A study conducted on Wistar rats at two time points in late gestation investigating the impact of gestational age and gender on fetal and placental weight. This study demonstrated that fetal and placental weight increased significantly between days 16 and 21 of gestation whereas gender showed minimal effect on growth. Introduction Fetal development during pregnancy is predominantly related to the placenta and its function in fetal-maternal exchange (Ishikawa et al. 2006). Alterations in the interactions between the fetus and maternal uterine environment thus permit for the modification in fetal growth. In addition, the placenta also acts as an endocrine organ that produces hormones necessary for the establishment and maintenance of pregnancy as well as fetal growth and wellbeing (Malassine, Frendo Evain-Brion 2003). Literature suggests fetal growth relies on the mobilisation of maternal nutrients, which involves placental growth hormone and that dysregulation of the hormone may have an adverse impact on fetal growth (Newbern Freemark 2011). The placenta consists of two distinct regions, which are the junctional (JZ) and labyrinth (LZ) zones that differ in morphological and functional terms (Ishikawa et al. 2006). This complexity therefore reflects the placenta as a highly specialised unit required for the ex change of gases, nutrients and waste products between mother and fetus as alluded to earlier. The interrelationship between the fetus and placenta has been madeShow MoreRelatedBirth Weight Is An Essential Organ Known For Synthesising Growth And Fetal Development1513 Words   |  7 Pagesgrowth and fetal development throughout gestation. The placenta is made up of two morphologically and functionally distinct zonal layers, the junctional (JZ) and labyrinth zone (LZ). The JZ is made up of trophohoblasts and maternal blood vessels but no fetal vessel, and is the major site for the production of hormones (Choi et al. 2005). The LZ on the other hand is too made up of trophoblast cells but also both maternal and fetal vessels and is thus, the major site for maternal-fetal exchange (WaddellRead MoreL D Clinical Rotation Worksheet1408 Words   |  6 PagesStudent: Monica Cooks Date: 10/24/12 Faculty: Kellea Rounds Vaginal Delivery C-section Delivery (circle one) Client’s Initials: JJ Age: 38 G4 T3 P0 A0 L3 (on admission) EDD: 5/12/13 Date of Delivery: 3/19/13 Gestational Age at delivery: 32 Weeks Date of Admission: 3/19/13 Allergies: No known Allergies (NKA) Significant Past OB/Medical/Surgical History: G4 P3003 (4 Gestations, 3 Full Term, 0 Preterm,Read More Fetal Alcohol Syndrome Essay1951 Words   |  8 PagesFetal Alcohol Syndrome Many studies have established that a developing organism is susceptible to exogenous and endogenous factors during certain stage of the organism’s development. The effects of ethyl alcohol or ethanol on the developing fetus, which manifest a variety of characteristic abnormalities, are collectively called Fetal alcohol Syndrome. Ethanol exposure to the fetus causes various malformation ranging from the cellular to the organismic levels with the eventual results frequentlyRead MoreSexual Violence And The Pregnancy2584 Words   |  11 Pagesviolence committed by an intimate male partner such as a husband, boyfriend, or common law partner that are inflicted on a pregnant woman. Intimate partner violence can affect women during pregnancy and during the postnatal period with devastating effects on both the women and the unborn child. Domestic violence against women is more common during pregnancy than with other life complications such as preeclampsia and diabetes mellitus (Mezey, 1997). Research estimates that intimate partner violenceRead MoreThe Nutritional And Health Status Of Women2263 Words   |  10 Pagesnutritional and health status of women, both in adolescence and the pregnancy stage, as well as during pregnancy are important indicators of complications during pregnancy, childbirth and thereafter, as well as of peri-and neo-natal mortality and low weight. Although poor distribution of resources-whether due to harsh geographical or climate condition in a region, or due to poverty resulting from a lack of purchasing power-contributes greatly to the severe imbalance of diets, tabools placed on food forRead MoreSmoking Cessation Of Pregnancy : Review Of Current Strategies9414 Words   |  38 Pages20 years old and those greater than 35 years old [4] Studies have shown various characteristics that are predictive of smoking during pregnancy. Maternal demographics that have been linked to increased success of smoking cessation include maternal age, primi-parity, being married or living with a partner, higher level of education and employment status [5,6,7]. The prevalence of smoking during pregnancy has been established to be inversely proportional to the level of income [3,4,5,8] Higgins et

How Is Unemployment Measured - 824 Words

How is Unemployment Measured? The method used by the Australian Bureau of Statistics (ABS) for determination of unemployment is closely based from the guidelines of the International Labour Organization. Monthly, the ABS conducts the Labour Force Survey from a sample of appropriately 0.33 per cent of the population aged 15 years and over. A person is considered unemployed if he is looking for a job, on a temporary layoff, or is waiting to start a new job. This excludes institutionalised people, overseas residents, members of permanent defence forces and certain diplomatic personnel. (ABS, Labour Statistics: Concepts, Sources and Methods, 2013) Generally, the unemployment rate is a good indicator of labour market conditions. When unemployment is dropping, often this is the result of more spending and faster economic growth. (Morris, 2012) Causes of Unemployment There are two main types of factors affecting the level of unemployment in Australia. When the national expenditure (aggregate demand) and production (gross domestic product) levels are frail as occurs during recessions or depressions, weak aggregate demand-side conditions happens causing cyclical unemployment. It vanishes when the economy is strong. Due to cyclical plummet in total spending on Australian production, sales of goods and services are depressed causing the level of unsold business stocks to rise. Eventually, firms decides to cut output levels to prevent surplus/overproduction. As a result, demandShow MoreRelatedEconomics Is All About The Allocation, Unemployment, Economic Growth And The Value Of The Dollar1487 Words   |  6 Pagesallocation resources and choices individuals, businesses and governments make. Economics decides how much goods and services are bought and sold for, how many people have jobs, how much a currency is worth and much much more. At the moment Au stralia s economy is healthy and isn t too far below or above other countries.This essay will discuss Australia s economic mechanisms such as inflation, unemployment, economic growth and the value of the dollar. It will then compare them historically to the USRead MoreIs The United States Economy Doing Well Since The Great Recession? Essay962 Words   |  4 PagesStates in a given time period. Good economic growth can be measured by the rate of growth of the GDP. The third goal seeks price stability. Is the value of the dollar inflating, deflating, or staying constant? If the answers to these questions are positive, then it can be stated that our economy is in good shape. We can gauge approximately how well the people in our economy are doing by measuring the unemployment rate. The unemployment rate is the percentage of people who are unemployed dividedRead MoreThe Correlation Between Unemployment And Inflation1506 Words   |  7 PagesBoth unemployment and inflation are two important components when it comes to studying an entire economy and it is also very easy to get those statistics from the Bureau of Labor Statistics (BLS) which is a governmental statistical organization that gathers, processes, analyzes, and broadcasts important statistical figures to the American public, the U.S. Congress, other Federal agencies, State and local governments, business, and labor. The Bureau Labor of Statistics also assists as a statisticalRead MoreMacroeconomics And Macroeconomics Of Macroeconomics1445 Words   |  6 Pagesthe two most general fields ineconomics. Macroeconomists study aggregated indicators such as GDP, unemployment rates, National income, price indices, and the interrelations among the different sectors of the economy, to better understand how the whole economy functions. Macroeconomists develop models that explain the relationship between such factors as national income, output, consumption, unemployment, inflation,savings, investment, international trade and international finance. In contrast, microeconomicsRead MoreReal Gross Domestic Product Of The United States And United Kingdom1671 Words   |  7 PagesGross Domestic Product is the measure of the economy’s output of goods and services over a specific period of time. It is usually measured in comparison to the GDP’s of previous years. For instance, if a year-to-year Gross Domestic Product goes up by 2 percent, it is said that the economy has grown by 2 percent. On a more basic level, Gross Domestic Product can be measured by adding everyone’s earni ngs in a year or what everyone spent. This is known as the income approach and the expenditure approachRead MoreEconomic Growth Of The Uk Economy1707 Words   |  7 Pagesa sustained increase in the general price level, leading to a fall in the purchasing power of money. It is measured in two different ways, through the Retail Price Index (RPI) and the Consumer Price Index (CPI). The difference between the two is that the RPI takes into account different things compared to the CPI, such as housing costs. Currently, inflation was at 0.3% in January, measured by the CPI, with the target level being 2%. This fell from 0.5% in December due to ‘Cheaper fuel and lowerRead MoreUnemployment : Unemployment And Unemployment1573 Words   |  7 PagesINTRODUCTION What is unemployment? Unemployment happens when a man who is effectively looking for employment is not able to find some kind of employment. Unemployment is regularly utilised as a measure of the economy’s wellbeing. The most regularly referred to gauge of unemployment is the unemployment rate. This is the quantity of unemployed persons divided by the quantity of individuals in the work force. The unemployed are those individuals capable, accessible and willing to work at the goingRead MoreBusiness Btec Level 3 Unit 381469 Words   |  6 PagesEconomic Environment The economy of each country has features that could be measured in different ways to see how they are changing. The economic environment of countries has an effect on countries due to the trading between countries affecting the money coming in and out of the country which then affects the cost of goods and prices. The economic environment would affect jaguar land rover as the goods and prices will have been affected. By this happening it would result in the prices of the carsRead MoreThe Impact Of Economics On The Ontario Government1046 Words   |  5 PagesThe performance of economies can be measured in many different ways and is measured by many people and institutions. Economies can be rated as performing well or poorly based on the macroeconomic and monetary policies, who is in charge, what the rest of the world is doing and so on. â€Å"Macroeconomics is about many different markets interacting with each other as a whole† (DPE 4). Ontario is an example of an economy that has many macroeconomic markets that are always interacting with each other. ManyRead MoreEconomic Growth Between Emerging And Developed Economics Essay1181 Words   |  5 Pagesand Japan. Emerging countries can be identifying with rapid growth rate and development but lower per capita than developed countries, na mely Brazil, Russia, India, and China, Ireland, Italy, Greece, Spain. The economic growth of countries can be measured by gross domestic product (GDP) per capita. This essay is going to find out â€Å"What are the main reasons behind different rate of economic growth in emerging and developed economics in last 15 years?† In hear I selected five emerging and five developed

Third World and People Free Essays

Academic Skills Research Essay Sl. No. | Essay Topics| Members| 1| Human beings do not need to eat meat in order to maintain good health because they can get all their food needs from meatless products and meatless substances. We will write a custom essay sample on Third World and People or any similar topic only for you Order Now A vegetarian diet is as healthy as a diet containing meat. Argue for or against the opinion above. | | 2| Forests are the lungs of the earth. Destruction of the world’s forests amounts to death of the world we currently know. To what extent do you agree or disagree? | 3| To what extent will migration from the developing world to the developed world become a social and political issue in the 21st century? | | 4| In Britain, when someone gets old, they often go to live in a home with other old people where there are nurses to look after them. Sometimes the government has to pay for this care. Who should be responsible for our old people? Give reasons. | | | | | 5| Telecommuting’ refers to workers doing their jobs from home for part of each week and communicating with their office using computer technology. Telecommuting is growing in many countries and is expected to be common for most office workers in the coming decades. How do you think society will be affected by the growth of telecommuting? | | 6| In some countries the average worker is obliged to retire at the age of 50, while in others people can work until they are 65 or 70. Until what age do you think people should be encouraged to remain in paid employment? Give reasons for your answer. | | 7| To what extent should economic planning be influenced by the need of environmental conservation? | 8| Damage of the environment is an inevitable consequence of worldwide improvements in the standard of living. Discuss. | | 9| The rising levels of congestion and air pollution found in most of the world cities can be attributed directly to the rapidly increasing number of private cars in use. In order to reverse this decline in the quality of life in cities, attempts must be made to encourage people to use their cars less and public trans port more. Discuss possible ways to encourage the use of public transport. | | 10| The idea of going overseas for university study is an exciting prospect for many people. But while it may offer some advantages, it is probably better to stay home because of the difficulties a student inevitably encounters living and studying in a different culture. To what extent do you agree or disagree this statement? Give reasons for your answer. | | 11| Many people believe that women make better parents than men and that this is why they have the greater role in raising children in most societies. Others claim that men are just as good as women at parenting Write an essay expressing your point of view. Give reasons for your answer. | 12| The mass media, including TV, radio and newspapers, have great influence in shaping people’s ideas. To what extent do you agree or disagree with this statement? Give reasons for your answer. | | 13| Tourism is becoming increasingly important as a source of revenue to many countries but its disadvantages should not be overlooked. What are some of the problems of tourism? | | 14| Should developing countries concentrate on impr oving industrial skills or should they promote education first? | | 15| Safety standards are important when building people’s homes. Who should be responsible for enforcing strict building codes – the government or the people who build the homes? | | 16| Discuss the advantage and disadvantage of giving international aid to poor countries. | | 17| Should criminals be punished with lengthy jail terms or re-educated and rehabilitated using community service programs for instance, before being reintroduced to society? | | 18| In most countries disabled people are not catered for adequately, e. g. buildings are often inappropriately designed. Governments rely too heavily on charities and voluntary organizations to provide assistance and funding. What further measures could be taken to assist disabled people? | | 19| In your opinion should government intervene in the rights of the individual with regard to family planning? | | 20| To what extent should university courses be geared to the economic needs of society? | | 21| Many people think that nowadays people are being subjected to more and more pressure in their work, and thus are having less and less time to relax. What is your opinion? | | 22| With the increasing popularity of computers and calculators, student literacy is decreasing dramatically. What are the positive and negative effects the progress of science and technology has brought about? | | 23| In the past, buildings often reflected the culture of a society but today all modern buildings look alike and cities throughout the world are becoming more and more similar. What do you think is the reason for this, and is it a good think or a bad think? You should use your own ideas, knowledge and experience and support your arguments with examples. | | 24| The earth is being filled with waste material such as plastic bags and other rubbish. Is this really happening? What are some solutions to this problem? Gives reasons for your answer and include any relevant examples from your own knowledge or experience. | | 25| The wealth gap between 1st world countries and 3rd world countries seems to be increasing. How can we reduce this gap? Do you think that developed countries have a duty to assist developing countries in every way? | | 26| Some people say that advertising encourages us to buy things we really do not need. Others say that advertisements tell us about new products that may improve our lives. Which viewpoint do you agree with? Use specific reasons and examples to support your answer. | | 27| Some people believe that the best way of learning about life is by listening to the advice of family and friends. Other people believe that the best way of learning about life is through personal experience. Compare the advantages of these two different ways of learning about life. Which do you think is preferable? Use specific examples to support your preference. | | 28| Some people think that human needs for farmland, housing, and industry are more important than saving land for endangered animals. Do you agree or disagree with this point of view? Why or why not? Use specific reasons and examples to support your answer. | | 29| Many parts of the world are losing important natural resources, such as forests, animals, or clean water. Choose one resource that is disappearing and explain why it needs to be saved. Use specific reasons and examples to support your opinion. | | 30| A company has announced that it wishes to build a large factory near your community. Discuss the advantages and disadvantages of this new influence on your community. Do you support or oppose the factory? Explain your position. | 31| The government has announced that it plans to build a new university. Some people think that your community would be a good place to locate the university. Compare the advantages and disadvantages of establishing a new university in your community. Use specific details in your discussion. | | 32| Some people think that children should begin their formal education at a very earl y age and should spend most of their time on school studies. Others believe that young children should spend most of their time playing. Compare these two views. Which view do you agree with? Why? | | How to cite Third World and People, Essay examples

Global Business Strategy-Free-Samples for Students- Myassignment

Question: Discuss about the Global Business Strategy. Answer: Predominantly, geographical structures have operational and strategic merits .From the geographical organizational structure, close consumer communication and better satisfaction of local consumer needs (Business Organisational structure, n. d.).Also, there is the ability to operate different divisions in different physical locations thus meeting the local needs of the market and at the same time running a functional enterprise. In the Bayer scenario, there are various divisions of the company in different physical locations but they are functionally operated by the same Bayer Policy. However, this organizational structure leads to extra expenses going to duplicated resources, employment opportunities, functionality among other factors. Same can be said for Bayer Company had contemplated shutting down one of its divisions owing to cost cutting due to the duplicity of functionality and the additional cost of running it. Advantages and Disadvantages of a matrix structure Through this structure of the organization, integration of objectives, project, and functional as possible as was the case in Bayer BMA NA. The CEO-led team found another way instead of shutting down the company in a bid to minimize the costs. However, matrix organizational structure has potential adverse effects .Specifically, in this case, Babe, the C.E.O of the BMS NA had to reconstitute his team that came up with the proposal to save the division. Under Matric Organizational structure, there might be as structural collapse which is similar to what happened in the Bayer case.Gleeson,2018).In addition, there was an increment in the management cost.In this case, Babe needed a 70m(USD) injection to aid his plan to save the BMS NA division. Also, Babe and his team faced difficulties from the Bayer group top leadership who considered their proposal as deviating from the company norms which is a typical disadvantage of matrix organizational structure. Emerging Markets In the event that is a private equity investor, my targets would be companies with goods or services that are highly competitive.In addition, I would look out for companies with a huge capability of growing or expanding due to the fact that they are likely to get better returns following a substantial investment. Also, I would aspire to work with a company with highly qualified and stable team as part of its management. A stable and qualified management team is likely to produce better outcomes as compared to the reverse combination. In addition, I would target firms with advanced technology in their operations due to the likelihood of producing better products and offer services at considerably affordable prices as compared to a firm with traditional production methods In the event that is approached by a private equity company, as C.E.O, I would first explore options available to my company such as buy to sell option. In addition, I would consider whether a flexibility in ownership might have better outcomes (Barber Goold, 2007).Secondly, I would consider the possibility of a merger and acquisitions. Also, I would consider the private equity firm with a highly substantive equity. In addition, I would conduct a thorough research on the potential private equity company on its financial status, a record of performance with previous companies and its position in the market before I decide on a private equity investment. It is imperative as a C.E.O of a company to exercise due diligence in the vetting of potential investors to ensure you acting in the best interest of the company. References Barber, F, and Goold, M. (2007).The Strategic Secret of Private Equity. Harvard Business Review. Retrieved from https://hbr.org/2007/09/the-strategic-secret-of-private-equity Business Organizational structure. (N. d). No business Info.CO.Uk .Retrieved from https://www.nibusinessinfo.co.uk/content/organisational-structure-geographical-area Gleeson, P. (2018).Advantages Disadvantages of Matrix Organizational Structure in Business Organizations. Chron. Retrieved from https://smallbusiness.chron.com/advantages-disadvantages-matrix-organizational-structures-business-organizations-26350.html Private Equity Investment Criteria. (N. d).Street of walls. Retrieved from https://www.streetofwalls.com/finance-training-courses/private-equit

Matthew Nestasia Essays (309 words) - Law Enforcement, Prevention

Matthew Nestasia Police Operations What does it take to be a good police officer? In my opinion a good officer should show his or her community that they're there to protect them and aid them. In order for an officer to properly demonstrate this to their community they'll need certain characteristics to back them up. To start, they'll need to be compassionate, most officers have on some level compassion or else they wouldn't have become a cop. When it comes down to it a police officer is a person with the ability and desire to help people when they need it, compassion is a necessity. Having compassion also shows the community that cops aren't just here to write out speeding tickets, they're here to help you. A skill that a good cop needs is attention to detail; officers need to have the ability to think on the fly at a moment's notice. For example a detective needs to have developed this skill greatly, or else they could miss a key piece of evidence and likely end up with unsolved cases or guilty men walkin g out of the court room as innocent. Now paired with attention to detail officers should have critical thinking skills. If you as a cop is out on patrol and drive by a playground when you notice there are a lot of older kids doing something suspicious, cops need to be able to assess the situation and act accordingly. In conclusion police officers require many skills and traits in order for them to be a good cop. It is also important to have good relations with the citizens in the area you, as an officer, will be patrolling frequently. Although situations may come by that require force, cops should not be looked at with hate or anger for trying to resolve to conflict.

Sun Tzu And Carl Von Clausewitz Essays - Carl Von Clausewitz

Sun Tzu And Carl Von Clausewitz Essays - Carl Von Clausewitz Sun Tzu And Carl Von Clausewitz Sun Tzu and Carl von Clausewitz both theorized on the strategies, influences, and effects of war. Sun Tzu sees it with an idealistic outlook, believing that war has requirements and predictable outcomes. Clausewitz, on the other hand, thinks that war is more enigmatic and susceptible to chance and happenstance. Both realize that war is a political action of the state with a political purpose. Clausewitz states that war is an extension of politics by other means. As in politics, the outcome is not always certain; there is a sort of enshrouding fog that always conceals the exact characteristics of a situation. This element of uncertainty is key in Clausewitzs philosophy; he believes strongly that war is in large part determined by chance and possibility, that the individual nature of war makes it inherently unpredictable. Clausewitz feels that war is at its most basic level, an individual activity. The commander is obviously the lead individual in an army, and it is often a question of his moral, physical, and psychological capacities as to whether an army can be victorious. These qualities must also trickle down through the ranks to the corpsman, for they are the ones who fight. These military virtues of an army are all-important, whether a nation wins or loses if often determined by the spirit of the army. If morale is low, a force cannot win. A defeat causes a loss of self-confidence, and this in turn leads to fear, a horribly destructive element for an army to have. Thus it is the morale of the troops that greatly affects their performance. The commanders skill is also of paramount significance. A general cannot be weak, he must be strong for to lead the troops into battle; he must present an air of confidence that inspires the army. The general, as well as the troops, must be experienced. The commander must be intelligent and knowledgeable of the terrain, weather, the enemy, every aspect of the engagement. A commanders most dangerous weakness is cowardice, for this gives way to rashness, foolishness, and vanity. Thus Clausewtitz believes that war is greatly dependent on the individual. While Clausewitz stresses the individual, the most important element of war is chance. There are always uncertainties in war which cannot be accounted for and must be handled. If a commander or army lacks some of the military virtues, it must make up for them in other ways: simplicity or size. When an army cannot fulfill all of these virtues, it must rely somewhat on chance to swing in its favor. Clausewitz says that there is a fog in war which covers the predictable situation and conceals some influencing elements. If a commander is to win a war, this fog must lift, so that he can view the situation with perfect clarity, or he must be able to adapt to an unexpected situation that may arise. The interaction between all of the individuals in a force is a breeding ground for chance. Disease may suddenly spread throughout the army, or a fight may break out between two people or two factions within the army. Or something may occur which serves to lifts the troops spirits and helps them win an important battle, thereby turning the war. Chance is also revealed in the structure of alliances. As Clausewitz believes that war is a means to a political end, he knows that an alliance is really an agreement between nations for the protection of self-interests. A country will pledge no more than the bare minimum of troops or supplies when its own interests are not at stake. Only when two nations share a common interest, will an alliance succeed to its fullest potential. Chance is an extremely important element of war. Clausewitz believes that not all events can be anticipated and that there is a general disorder in war which must be expected. When the fighting becomes most severe, communication lines will be severed, between an army and a nation, or between a general and his troops. In such situations, only the intellect and experience of the individual will aid victory. Clausewitz states that there are certain elements that a commander must understand if

A.Photosynthesis consumes carbon dioxide(CO2)and produces Lab Report

A.Photosynthesis consumes carbon dioxide(CO2)and produces oxygen(O2).Brespiration consumes oxygen(O2) and produces carbon dioxide(CO2)as a byproduct - Lab Report Example It takes place in the mitochondria and the by-products are CO2, H2O and energy. Both cellular respiration and photosynthesis relates in that the by-products of each process is a raw material for the other process. The major purpose of the experiment is to determine that photosynthesis consumes CO2 and produces O2 as a by-product while cellular respiration consumes O2 and produces Co2 as a by-product. In photosynthesis experiment, five 50ml test tube were labelled 1, 2, 3, 4 and 5 using wax pencil. A piece of Elodea plant was placed in tube 1-4 while except 5. Tubes were filled to the brim with 7.0 pH phenol red solution and then each tube was plugged with a rubber stopper. The surfaces of the tubes were wiped with paper towel. Tube 2 then wrapped using two sheets of cellophane, tube 3 wrapped using 2 sheets of green cellophane while tube 4 wrapped with one sheet of aluminium foil and tube 1 and 5 were not wrapped. The tubes were placed under bright white light for 11/2 hours and colour changes noted in each tube. In respiration experiment, goldfish was placed in a 50ml tube containing water with normal conditions for fish. The temperature of water was measured and the number of breaths of the fish per 60sec recorded. Tap water was poured into 600ml beaker and tube with the fish was transferred into the beaker. Small pieces of ice were added one by one to the beaker until the tem perature drops to 100C then process stopped and number of breaths recorded. More ice was added until the temperature drops to 50C then cold water was changed and the procedure above repeated for the temperature of 210C and 250C. The colour of the phenol red turned to orange in all the tubes since the CO2 was absorbed from the environment within the enclosed tubes to react with water thus forming weak acid of pH around neutral hence the orange colour. But since tube 1 had all the factors responsible for

Body Mass Index Research Paper Example | Topics and Well Written Essays - 250 words

Body Mass Index - Research Paper Example A BMI value that is above 30 suggests that a person is obese (Brownell & Puhl, 2005). Obesity has been identified as a major cause for concern with respect to discrimination, which has been observed in various aspects of people’s everyday life. This paper seeks to highlight and discuss instances in people’s lives, which are affected by discrimination based on obesity. Various research studies that have been conducted to investigate whether bias against obese individuals led to discrimination in various aspects of people’s everyday life. Findings from research studies have established that there exists a stereotype against obese people, in society. This stereotype is based on the negative attributes that have been pegged on their characters and appearance. One such research study was able to establish that there existed discrimination in the work place, especially when it came to hiring, promotion and remuneration (Brownell & Puhl, 2005). The findings from this research illustrated that there was bias, which evolved to discrimination of obese individuals in all aspects of employment and workplace practice. Obese people have been found to experience discrimination in the health care sector where doctors have prejudice over obese patients. This discrimination and negative stereotyping has led to a decline in the quality of health care that obese individuals receive (Brownell & Puhl, 2005). Obese people have also been found to experience discrimination in the education system from its early establishment through to college. This has been blamed for the rising cases of suicides perpetrated by school going children. Discrimination based on obesity has been increasing over the years that it has been leveled with racial discrimination (Brownell & Puhl, 2005). Discrimination based on obesity has been identified as an increasing threat to the wellbeing of the society, but at the same time, it

Riodan Essay Example | Topics and Well Written Essays - 250 words - 1

Riodan - Essay Example The purpose of outsourcing this project is to reduce the costs, which may be associated with hiring IT managers within the organization. This project can be termed of immense importance to the company since having a team dealing with IT management can be expensive. Moreover, hiring outsiders is beneficial since they will bring in their outstanding expertise to the organization. As such, the company will tap the knowledge of experts and develop sound IT management systems. The other technology project that the company can outsource includes data storage. This project will relieve the company of the burden of purchasing data storage devices, which should be used to store data in the organization. This project is of significant importance since it gives the organization an opportunity to have its data maintained properly. As a result, the company’s data cannot be damaged or lost since experts know how to store data better than the insiders of the company (Poulin, 2006). c. It leads to the synchronizing of variables and problems like stretched delivery times, inappropriate categorization of responsibilities and sub-standard quality delivery may occur (Obaidat & ICETE,

What Is It Governance Information Technology Essay

What Is It Governance Information Technology Essay IT governance is the process for controlling an organisation information technology resource, where these resources are defined to include information and communication systems as well as technology. An organisation management and owners (represented by the board of directors ) share responsibility for governing both enterprise and IT. Enterprise governance is the process of setting and implementing corporate strategy, making sure the organisation achieve its objectives efficiently, and manage risk. It governance is an increasingly important part of enterprise governance because of organisational dependent on information and communication, the scale of IT investment, potential for IT to create strategic opportunities, and the level of IT risk. IT governance also required controlling the process to ensure that it complies with regulatory, legal and contractual requirements. Organisation structure Boards and executive management have long known the need for enterprise and corporate governance. However, most are beginning to realize that there is a need to extend governance to information technology as well, and provide the leadership, organisational structures and processes that ensure that the enterprises IT sustains and extends the enterprises strategies andobjectives. Strategic alignment focuses on ensuring the linkage of business and IT plans; defining, maintaining and validating the IT value proposition; and aligning IT operations with enterprise operations. Value delivery is about executing the value proposition throughout the delivery cycle, ensuring that IT delivers the promised benefits against the strategy, concentrating on optimising costs and proving the intrinsic value of IT. Resource management is about the optimal investment in, and the proper management of, critical IT resources: applications, information, infrastructure and people. Key issues relate to the optimisation of knowledge and infrastructure. Risk management requires risk awareness by senior corporate officers, a clear understanding of the enterprises appetite for risk, understanding of compliance requirements, transparency about the significant risks to the enterprise and embedding of risk management responsibilities into the organisation. Performance measurement tracks and monitors strategy implementation, project completion, resource usage, process performance and service delivery, using, for example, balanced scorecards that translate strategy into action to achieve goals measurable beyond conventional accounting. ITGI: ISACA recognized this shift in emphasis towards IT Governance in 1998, and formed the IT Governance Institute (ITGI) to focus on original research, publications, resources and symposia on IT governance and related topics. In addition to the work carried out by the ITGI, ISACA addresses the topic through a regular column in and occasional dedicated issues of the Information Systems Control Journal, conference sessions and tracks, and education courses. TheIT Governance Institute (ITGI)exists to assist enterprise leaders in their responsibility to ensure that IT goals align with those of the business, it delivers value, its performance is measured, its resources properly allocated and its risks mitigated. Through original research, symposia and electronic resources, the ITGI helps ensure that boards and executive management have the tools and information they need for IT to deliver against expectations. ITGI: ISACA recognized this shift in emphasis towards IT Governance in 1998, and formed the IT Governance Institute (ITGI) to focus on original research, publications, resources and symposia on IT governance and related topics. In addition to the work carried out by the ITGI, ISACA addresses the topic through a regular column in and occasional dedicated issues of the Information Systems Control Journal, conference sessions and tracks, and education courses. TheIT Governance Institute (ITGI)exists to assist enterprise leaders in their responsibility to ensure that IT goals align with those of the business, it delivers value, its performance is measured, its resources properly allocated and its risks mitigated. Through original research, symposia and electronic resources, the ITGI helps ensure that boards and executive management have the tools and information they need for IT to deliver against expectations. Publications: There are two major publications from ISACA in the field of IT Governance. COBIT VALIT COBIT: The Control Objectives for Information and related Technology (COBIT) is a set of best practices (framework) for information technology (IT) management created by the ISACA, and ITGI in 1996. COBIT provides managers, auditors, and IT users with a set of generally accepted measures, indicators, processes and best practices to assist them in maximizing the benefits derived through the use of information technology and developing appropriate IT governance and control in a company. COBIT supports IT governance by providing a framework to ensure that: IT is aligned with the business IT enables the business and maximises benefits IT resources are used responsibly IT risks are managed appropriately COBIT Framework and IT Governance Areas: COBIT Product: Briefly, the COBIT products include: Board Briefing on IT Governance, 2nd Edition—Helps executives understand why IT governance is important, what its issues are and what their responsibility is for managing it. Management guidelines/maturity models— Help assign responsibility, measure performance, and benchmark and address gaps in capability Frameworks—Organise IT governance objectives and good practices by IT domains and processes, and link them to business requirements Control objectives—provide a complete set of high-level requirements to be considered by management for effective control of each IT process IT Governance Implementation Guide: Using COBIT  ® and Val IT TM, 2nd Edition—provides a generic road map for implementing IT governance using the COBIT and Val ITTM resources COBIT ® Control Practices: Guidance to Achieve Control Objectives for Successful IT Governance, 2nd edition—Provides guidance on why controls are worth implementing and how to implement them IT Assurance Guide: Using COBIT  ®Ã¢â‚¬â€Provides guidance on how COBIT can be used to support a variety of assurance activities together with suggested testing steps for all the IT processes and control VALIT: Val IT is a governance framework that consists of a set of guiding principles, and a number of processes conforming to those principles that are further defined as a set of key management practices. The Val IT framework will be supported by publications and operational tools and provides guidance to: Define the relationship between IT and the business and those functions in the organization with governance responsibilities Manage an organizations portfolio of IT-enabled business investments; and Maximize the quality of business cases for IT-enabled business investments with particular emphasis on the definition of key financial indicators, the quantification of soft benefits and the comprehensive appraisal of the downside risk Val IT addresses assumptions, costs, risks and outcomes related to a balanced portfolio of IT-enabled business investments. It also provides benchmarking capability and allows enterprises to exchange experiences on best practices for value management. Certification: Certified in the Governance of Enterprise Information Technology (CGEIT) is an advanced certification created in 2007 by the ISACA. It is designed for experienced professionals, who can demonstrate 5 or more years of experience, serving in a managing or advisory role focused on the governance and control of IT at an enterprise level. The certification is intended to: support the growing business demands related to IT governance increase the awareness and importance of IT governance good practices and issues define the roles and responsibilities of the professionals performing IT governance work Requirements: To earn the CGEIT credential, an individual must: Pass the CGEIT exam (first exam December 2008) Adhere to the ISACA Code of Professional Ethics Agree to comply with the CGEIT Continuing Education Policy Provide evidence of appropriate IT governance work experience as defined by the CGEIT Job Practice IT Governance experience Five (5) years required: Five (5) or more years of experience managing, serving in an advisory or oversight role, and/or otherwise supporting the governance of the IT-related contribution to an enterprise is required to apply for certification. This experience is defined specifically by the domains and task statements described in the CGEIT Job Practice. Specifically: A minimum of one (1) year of experience relating to the development and/or maintenance of an IT governance framework is required. The type and extent of experience accepted is described in CGEIT domain one (1) (see IT Governance Framework). Additional broad experience directly related to any two or more of the remaining CGEIT domains are required. The type and extent of experience accepted is described in CGEIT domains two (2) through six (6). These domains are:  § Strategic Alignment  § Value Delivery  § Risk Management  § Resource Management  § Performance Measurement Individuals can take the CGEIT exam prior to earning the above work experience. Substitutions for IT governance experience (2 years maximum) To recognize other management experience and/or the achievement of specific IT governance related credentials, advanced (post-graduate) degrees and certificates, up to two (2) years of the five years of required IT governance experience can be substituted. Specifically, each of the following will qualify (substitute) for one (1) year of IT governance experience, with a maximum of two years of substitutions being accepted. Other Management Experience—other management experience that is not specific to IT governance, such as performing consulting, auditing, assurance or security management related duties will qualify for up to one year of substitution. Specific Credentials, Advanced (Post-graduate) Degrees and Certificates—Credentials (in good standing), advanced (post-graduate) degrees and certificate programs which include an IT governance and/or management component or are specific to one or more of the CGEIT domains will qualify for up to one year of substitution. These include: Certified Information Systems Auditor (CISA) issued by ISACA Certified Information Security Manager (CISM) issued by ISACA Implementing IT Governance using COBIT and Val IT certificate issued by ISACA (available in 2008) ITIL Service Manager certification program Chartered Information Technology Professional (CITP) issued by the British Computer Society Certified Information Technology Professional (CITP) issued by the American Institute of CPAs Project Management Professional (PMP) issued by the Project Management Institute Information Systems Professional (I.S.P.) issued by the Canadian Information Processing Society Certified Internal Auditor (CIA) issued by the Institute of Internal Auditors Certified Business Manager (CBM) issued by The Association of Professionals in Business Management Prince2 Registered Practitioner certificate from the Office of Government Commerce Advanced (post-graduate) degree from an accredited university in governance, information technology, information management or business administration (For example: Masters in Corporate Governance, Masters of Business Administration, Masters in Information and Operations Management, Masters of Information Systems Management, Masters in Information Technology) Exception: Two years as a full-time university instructor teaching IT governance related subjects at an accredited university can be substituted for every one year of IT governance experience. Applicants who have earned/acquired other credentials, advanced (post-graduate) degrees and/or certificates that include a significant IT governance and/or information management component and are not listed above are welcome to submit them to the CGEIT Certification Board for consideration. IT Governance Characteristics Sets direction and oversees compliance and performance Specifies the decision-making authority and accountability to encourage desirable behaviors in the use of IT Is a process for managing and controlling the use of technology to create value Are the rules and regulations under which an IT organization functions Ensures that everyone is playing by the same rules so that the computing environment works for everyone. Road Map for Implementing IT Governance The initial focus for developing an IT Governance Program is identifying needs and governance input rights and decision making based on:    Current state of IT within and supporting business organization and objectives      Internal and external requirements/regulations and applicable best business practices Business Alignment IT Business Executives set the IT Strategy, resolve issues, and shadow IT organizations eliminated Investment Board sets project priorities, costs,   oversees progress, reduced millions $ in costs Change Management and failures impacting users Changes managed actually blocked where not properly vetted or tested Number of user impact failures reduced from 200+ to Number of unauthorized application and infrastructure changes reduced to 1 or less per month Emergency changes reduced to less than 3% of total changes Improved results across the board, accountability built into personal performance evaluations Projects Projects on time, on budget increased by 60+% Improved from 40% SDLC compliance to 100% Technology Standards and architecture established and enforced via tech reviews reduced number of system software tools by over 50% 100% of the equipment on the network identified and none added unless authorized 24 hour server back-ups improved from 95% to 99.9% Security patches being performed within 24 hours of approval â€Å"System Admin Accounts† reduced by over 50% Governing Document Framework SAMPLE Conclusion: As we have discussed that in todays business environment information is the most valuable asset, therefore in order to protect the information we require a profound infrastructure that enables us to not only secure the information we have but to validate that information as well, plus enable the organization towards IT.

Hawthornes Puritanical Beliefs Revealed in The Scarlett Letter and You

Hawthorne's Puritanical Beliefs Revealed in The Scarlett Letter and Young Goodman Brown When an author depicts a person or group of people in his or her work, the opinion of the writer most often sifts into the descriptions, whether intentionally or unintentionally. Some writers are very guarded regarding their feelings toward any particular subject, while others are very open and happy to share. Nathaniel Hawthorne belongs to the latter group. The purpose of the majority of his literary work was to share his view of the group of strict Christians known as the Puritans. Hawthorne himself was a direct descendent of Puritans, and he obviously held very particular views of his ancestors. These views are clearly demonstrated in his works The Scarlett Letter and "Young Goodman Brown," in which Hawthorne shows his disdain for the judgement and hypocrisy that was a daily practice of the Puritan church. In the New Testament of the Holy Bible, Matthew wrote in the Gospel of Matthew, Chapter Seven, Verse 1, "Judge not, that you be not judged." This is an often quoted verse of scripture that has been the subject of countless sermons and has been the chastisement to even more Christians. The Puritans, without a doubt, had this verse branded on their hearts, and yet, according to the works of Hawthorne, never practiced the Bible that they quoted so frequently. His disdain toward them and the judgement that they inflict on others, as well as the hypocrisy that they are immersed in from the time of birth. In the second chapter of The Scarlett Letter, Hawthorne shows the reader both the judgement and hypocrisy of a small part of the society - the women. As they wait for the arrival of Hester Prynne, this town's resident adulteress, they... ...n authors Anne Bradstreet and Edward Taylor. Perhaps, had Hawthorne studied these two writers, he may have discovered the bit of beauty that is hiding in stoic Puritanism. Works Cited Baym, Nina. The Norton Anthology of American Literature vol. I. New York: Norton and Co., 1998. McKeithan, D. M. "Hawthorne's 'Young Goodman Brown': An Interpretation." Modern Language Notes (1952): 93-96. Reprinted in Short Story Criticism vol. 29. "A Review of The Scarlet Letter." Littell's Living Age (1850): 203-207. Reprinted in Nineteenth Century Literary Criticism vol.10. Duyckinck, E.A. "Nathaniel Hawthorne." The Literary World (1850): 323-325. Reprinted in Nineteenth Century Literary Criticism vol.10. Macy, John. "Hawthorne." The Spirit of American Literature (1913): 77-96. Reprinted in Nineteenth Century Literary Criticism vol.10.

A Meaningful Place to You

A dream made into reality. That is how I perfectly describe Disneyland in Florida. As far as I know, this is the only Disneyland which is called the Walt Disney World. Maybe because it is the biggest Disneyland among the rest of those situated in other places like Japan, Hong Kong and Los Angeles.This place is indeed a meaningful place for me because it is the fruit of my labor. I earned hard to be in this place. My visit to this place also proves my confidence being there without any of my family members. This is a dream come true for me because I made a meaningful experience out of my meaningful sacrifices just to get there.Set in Orlando, Florida the Walt Disney World is different from other Disneyland theme parks that I've been in. All of my trips to Disneyland in Japan, Los Angeles and Hong Kong were all planned by my parents.I've been there without any friend or girlfriend because it calls out for family affairs only. I can say that I also enjoyed being in those places because I am with my dear family but my experience at Walt Disney World Florida is a gargantuan event because I went there without asking any help from my family.What is really exciting about my trip there is that I was with friends of my age. It is also a romantic experience because I was with my beloved girlfriend which is also a dream come true for me to be with her on that very special place.It was very easy for me to ask permission from my mom and dad to visit Disneyland, Florida. I just give them an assurance that I will take care of myself and not to get into any troubles while staying there with mu friends and girlfriends. It was indeed a happy journey heading towards the place.Visiting Disneyland made our friendship even tighter and my relationship with my girlfriend even lovelier. We arrive there early because it was really a huge place to visit. There are four renowned theme parks and two water parks to visit. Aside from that there are golf courses, hotels and other establishment s that made way for our enjoyments.The first theme park that we went to is the Magic Kingdom. Here, we were able to see Disney characters and the Cinderella Castle which became my girlfriend's favorite. I am really happy to see her smiling all the time that we were in the Magic Kingdom. There are also rides which we all enjoyed riding from one ride to another.Then we proceed to the Epcot. It is the second theme park in Disneyland, Florida which s divided into 2 beautiful sections the World Showcase and the Futuristic World. We enjoyed viewing the futuristic world because it shows how the future will look like. It displays advancement that will happen in the future.How life will look like years from now that will improve people's way of living. World Showcase on the other hand shows other nations and their culture, entertainment, food, attractions and many more. It is like traveling out of the country and going to countries like China, Mexico, Italy, Germany and many more.Before goin g to the next theme park, we decided to eat first. I am proud to say that being in that place made me feel more proud of myself. This is because I went there with my own savings and without any cent from my parents.It was a meaningful place because I am the one who organized our trip to that place and it was really a success. I even missed out one dear friends birthday because of going there but I'm sure he does understand why I wasn't able to join that special occasion.The next destination that we went to is the Hollywood Studios. It is a theme park that made us feel were in the movies too. We get to see amazing special effects from block buster movies and enjoyed rides which are really thrilling.We also went to the Disney's Animal Kingdom the fourth theme park in Disneyland, Florida. It is composed of real like animal figures and interactive rides. My girlfriend even got scared on dinosaur figures because of the safari ride which made dinosaurs come to life.There are also other at tractions in the Walt Disney World. There are water parks and golf courses within the vicinity of Disneyland Florida. There are also people who does surfing and skiing there.Night time comes and we got to see beautiful fireworks displays there. The fact that I was with my girlfriend that time made the moment really romantic. It was my very first time to see fireworks in the United States and I felt really happy. My hard work pays off because it is such a priceless moment being in that magical place.It was a dream come true to visit the place because it shows how confident I became going there without any family member with me. It also symbolizes our friendship and of course my great love for my girlfriend because I was able to spend moments with her in Disneyland. Until this time, whenever I get sad I just recall those times that I am at Disneyland, Florida and the memory makes me smile and smile all day. It represents a part of me because I was able to go there from my hard work an d my confidence.

Consumer Buying Process

Consumer Buying Process A vast number of existing formulations of consumer decision making assume that consumers go through a specified succession of mental and behavioral stages in their decision processes as they engage in a convoluted search of the set of available alternatives to make a purchase.Advertising We will write a custom essay sample on Consumer Buying Process specifically for you for only $16.05 $11/page Learn More A widespread characteristic of many of the formulations is that they are grounded on hierarchy-of-effects models postulating that on their way from identifying the need for a particular product/service to making the actual purchase, consumers move in one direction through a given sequence which involves or incorporates a set of stages (Dellaert Haubl, 2012). The present report employs the five-stage consumer decision process to critically analyze the online buying process of an Olympus digital camera from the marketer’s point of view. First introduc ed by John Dewey in the formative years of the last century, the five-stage consumer decision process continues to take the center stage in the marketing domain as scholars and practitioners attempt to understand consumer decision making and buying processes (Tanner Raymond, 2010). The first stage – problem recognition – is undoubtedly the critical stage of consumer buying process by virtue of the fact that consumers must first recognize a need for the purchase to happen. Extant literature demonstrates that this stage of the buying process is hinged on the extent of departure from homeostasis, the balance between the consumer’s actual state of affairs and the desired end state (Tanner Raymond, 2010). In this regard, the need/problem to buy the digital camera from online sites was recognized when the departure from homeostasis was acute enough due to an oncoming holiday, and this unfulfilled need/problem required a resolution in the form of a purchase to satisf y the situation. The second stage of the five-stage consumer buying process is the information search, where consumers begin collecting information from numerous sources about the products they need using internal or external search techniques (Dellaert Haubl, 2012).Advertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More The search for the digital camera was done internally, where information about the desired digital camera models was recalled from memory and was intrinsically determined by existing knowledge about the models, along with the capacity to retrieve relevant product information from online product reviews and Websites. Based on need recognition and internal information search, it was then decided that the desired alternative models included Nikon, Sony, Philips and Olympus. It is important to illuminate the fact that it is at this stage of the process where advertisers and marketers have the opportunity to influence a customer’s purchasing decision, particularly if the customer applies the external search as it involves largely personal interaction by word-of-mouth or mass-market communication (Tanner Raymond, 2010). Evaluation of alternatives is the third stage of the five-stage consumer buying process and entails evaluating the alternatives and selecting the one that meets the consumer needs and expectations (Dellaert Haubl, 2012). In this phase of the sequence, consumers evaluate product/service benefits and drawbacks and may allocate priorities to various features and specifications to assist them select the best choice (Tanner Raymond, 2010). In this view, the criteria employed to conduct an alternative evaluation for the digital camera included price considerations, brand name and reputation, gadget specifications, quality, country of origin as well as the location convenience of the online sellers’ eBay, Buy.com, CeX and SiteS ell. It is important to note that some dimensions, such as price, quality and brand name, had a greater impact than other presumably contingent dimensions during the evaluation of the mentioned alternatives. Overall, the Olympus digital camera topped the list of alternatives based on the mentioned criteria The fourth stage of the consumer decision/buying process is the purchase decision, which is initiated after the consumer has carefully reflected on all of the factors relating to the product, and has shopped around for the best option based on need/expectations and if the product will solve their problem (Dellaert Haubl, 2012).Advertising We will write a custom essay sample on Consumer Buying Process specifically for you for only $16.05 $11/page Learn More Extant literature identifies three purchase decision categories that consumers usually follow – fully planned purchase (both product/service and brand are selected prior to visiting the store), partially planned purchase (consumer makes an intention to purchase the product/service but brand selection is delayed pending shopping) and impulse purchase (consumer selects both the product/service and brand upon visiting the store) (Tanner Raymond, 2010). A fully planned purchase of Olympus digital camera was made at eBay since the product and brand had already been decided prior to visiting the eBay site to make the purchase. The choice of eBay was due to contingent and situational considerations, including convenient delivery, onsite product promotion and huge discounts. The concluding stage of the buying process is the post-purchase evaluation of the purchasing decision, during which consumers not only deliberate their experience after the purchase but also attempt to establish if their purchasing decision was the right one (Tanner Raymond, 2010). The Olympus digital camera was deeply satisfying due to its elaborate features and quality, but also due to the fact that collea gues and friends fell in love with the gadget during the holidays. Advertisers and marketers may use such elicitation of positive results with a particular product/service to influence consumers decision/buying process for future similar purchases, particularly at the phases of problem recognition and information search (Tanner Raymond, 2010). References Dellaert, B.G.C., Haubl, G. (2012). Searching in choice mode: Consumer decision processes in product search with recommendations. Journal of Marketing Research, 49(2), 277-288. Tanner, J., Raymond, M.A. (2010). Principles of Marketing. New York, NY: Flat World Knowledge, Inc.Advertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More

Direct Object Pronouns in Italian

Direct Object Pronouns in Italian â€Å"I’m reading a book. I’m reading the book for my Italian course. My husband bought the book as well because he is taking the same course.† When you read the three sentences above, they sound pretty choppy and that’s because instead of using a pronoun, like â€Å"it,† the person speaking is just saying â€Å"book† over and over again. This is why pronouns, and in this particular case, direct object pronouns are such an  important topic to understand in Italian. What is a direct object? A direct object is the direct recipient of the action of a verb. Let us explain that with some more examples. I invite the boys. Whom do I invite? → The boys.He reads the book. What does he read? →   The book. The nouns boys and books are both direct objects because they answer the question what? or whom? When you study verbs in Italian, you may often see a note about whether a verb is transitive or intransitive. While there is a lot to know about those verbs, I want you to simply note that verbs that take a direct object are called transitive verbs. Verbs that do not take a direct object (she walks, I sleep) are intransitive. As we saw in our first example, direct object pronouns exist because they replace direct object nouns. I invite the boys. I invite them.He reads the book. He reads it. Here’s what direct object pronouns (i pronomi diretti) look like: SINGULAR PLURAL mi me ci us ti you (informal) vi you (informal) La you (formal m. and f.) Li you (form., m.) Le you (form., f.) lo him, it li them (m. and f.) la her, it le them (f.) Where do direct object pronouns go? A direct object pronoun is placed immediately before a conjugated verb. Se vedo i ragazzi, li invito. - If I see the boys, I’ll invite them.Compra la frutta e la mangia. - He buys the fruit and eats it. In a negative sentence, the word  non  must come before the object pronoun. Non la mangia. - He doesn’t eat it.Perchà ¨ non li inviti? - Why don’t you invite them? The object pronoun can also be attached to the end of an  infinitive, but note that the final –e of the infinitive is dropped. È importante mangiarla ogni giorno. - It is important to eat it every day.È una buona idea invitarli. It’s a good idea to invite them. FUN FACT: You’ll notice that when you use a direct object pronoun in the  past tense that it will often connect with a  conjugation of the verb â€Å"avere†. For example, â€Å"Non l’ho letto - I didn’t read it†. The â€Å"lo† connects with â€Å"ho† and creates one word â€Å"l’ho†. However, keep in mind that the  plural forms li and le never connect with any conjugations of the verb â€Å"avere†, like â€Å"Non li ho comprati - I didn’t buy them†. You may also see: M’ama, non m’ama. (Mi ama, non mi ama.). - He loves me, he loves me not.Il passaporto? Loro non (ce) l’hanno (lo hanno). - The passport? They don’t have it. Which verbs take a direct object? A few Italian verbs that take a direct object, such as ascoltare, aspettare, cercare, and guardare, correspond to English verbs that are used with prepositions (to listen to, to wait for, to look for, to look at). That means that you don’t have to use â€Å"per - for† when saying â€Å"Who are looking for?† in Italian. A: Chi cerchi? - Who are you looking for? B: Cerco il mio ragazzo. Lo cerco gi da mezz’ora! - I’m looking for my boyfriend. I’ve been looking for him for half an hour! What about â€Å"ecco†? â€Å"Ecco† is often used with direct object pronouns, and they attach to the end of the word to mean â€Å"here I am, here you are, here he is†, and so on. Dov’à ¨ la signorina? – Eccola! - Where is the young woman? – Here she is!Hai trovato le chiavi? – Sà ¬, eccole! - Have you found the keys? – Yes, here they are!Eccoli! Sono arrivati! - Here they are! They arrived!Non riesco a trovare le mie penne preferite - Eccole qua amore! - I can’t find my favourite pens.- Here they are honey!

Megacities in Asia - City report Essay Example | Topics and Well Written Essays - 1500 words

Megacities in Asia - City report - Essay Example Tokyo’s population growth has been influenced by the availability of jobs that lure Japanese citizens to move in to work in the industries. Despite the city’s area being 0.6% of total Japan landmass, the city holds approximately 10% of total japan population. The large population in the city makes Tokyo the most densely populated prefecture in Japan. However, like the whole of Japan, the city is characterized by an ageing population. The birth rate is low thus growth in population is almost zero. For example, in 2010, there were 109000 births and 104000 deaths. This implied that the population grew by only 4000 for the whole year (Tokyo Metropolitan Government). In the same year, the child population (ages 0 – 14) was 1.477 million labor force (ages 15 – 64) at 8.85 million and finally the aged populace (ages 65 and over) at 2.642 million. The figures can be simplified into percentages to 11.4%, 68.2% and 20.4% respectively. Tokyo is characterized by light industries that are comprised of electronics, and manufacturing of agricultural chemicals and products. Moreover, the city is more of managerial city that houses the offices of many companies in other areas in japan. Most heavy industries are located outside in the prefectures surrounding Tokyo and also other cities such as Fukushima and Osaka. Japan is a heavily industrialized country. Thus, Tokyo offers a center where stock trade is done. The Tokyo stock exchange takes the second position in the world after New York. In 2013, the stock exchange market was US$4.5 trillion. This depicts Tokyo as a major economic center in Japan and the world (Clark 164). The per capita income of japan is one of the highest in the word. Tokyo, being the biggest city in terms of GDP in the world, enjoys a high per capita income of $55766. This is relatively higher than that of the whole country because of the high GDP of Tokyo is in excess of $837 billion. Education in Tokyo

Public University Analysis Essay Example | Topics and Well Written Essays - 1000 words

Public University Analysis - Essay Example The Commonwealth, and not the University, has the full duty of contributing to the plan. Significantly, the entire full-time faculty, particular managing staff, and the health care personnel involve themselves in the Faculty Discretional Retirement Plans. These are set-contribution strategies in which the retirement gains got are linked to the employer and employee aids (of which most of them are paid by the University), and the dividends and interest. Personal contracts provided the strategies for full-time faculty and given managing personnel provide for complete and instant entrusting of both the participant’s and University’s contributions (Sigo, 2014). The health care personnel’s employer aids completely entrust after a single year of employment. Full pension costs under the plans were about $36.3 million. Contributions to the Discretional Retirement Plans were aggregated by use of the base salaries of about $337.6. The input value amounted to 9.9%. Considering the Retirement Plans, it is definite that each and every stable full-time employee, as a rule of work, is an affiliate of both the State and Teachers’ Employees ‘Retirement Structure or the Discretionary Retirement Program. Fit workers can choose to participate in the Discretionary Retirement Program at the time of work, or else they get enrolled in the State and Teachers’ Employees’ Retirement Structure. The State and Teachers’ Employees’ Retirement Structure (TSERS) at the Virginia University comprise of a cost-sharing multiple-worker described benefit pension plan that is recognized by the State to give pension gains for workers of State, local boards of education and its component sections (Sigo, 2014). The TSERS is managed by around 14 members of Board of Trustees, with the Chairman of the Board being the State Treasurer. GASB proposed changes that were to affect the financial statements of institutions and

Economics Essay Example | Topics and Well Written Essays - 750 words - 2

Economics - Essay Example This way corn serves a two-way purpose and that will definitely increase its demand. Corn and soybean are considered as substitutes and according to economic theory if demand for a product raises then the demand for its substitute will obviously decline. Following this principle the price of the soybean will decline. Again corn and soybean shares the same habitat for production, especially the prime raw material for any agricultural production the land. Now an increased demand for corn will also lead to a higher price for the same, since price and demand are directly correlated. A product that is offering higher price will definitely translate into higher profit for the producer and an immediate shift from production of soybean to that of corn. Higher percentage of land and effort will now be directed towards corn production than that of soybean (Pearce, 2006). The above discussion seems economically sound, however a careful investigation might reveal that this holds for short run. O nce the producer starts to devote more land and other raw materials to the production of corn, corn production will rise and production of soybean will fall. Hence in long run owing to higher supply of corn its price will come down and that of soybean will go up as it is scarce now. These points to the fact that in long run an eventual equilibrium will be reached where both will be produced at an optimum level for the economy. Last but not the least since, energy has an ever increasing demand, hence if corn can project itself as a viable source of alternative energy in long run that have enough potential to replace fossil fuels then the trend for substituting soybean production land and raw material in favor of the corn might show a sustained trend, with soybean production looking for an alternative way as itself is a nutritious and valuable food source along with a rich source for food oil. It is obvious that since there is high need of alternative form of energy and that especiall y of bio fuel; corn oil as an important source of bio fuel will enjoy this boom in demand and price for this product will go up. The magnitude of this rise in price is subject to much debate. First of all if demand for a product is matched by its supply then the rise in price is minimal or zero. However if this is not the scenario that is there is excess demand then the price will go up. Interestingly it is worth noting that in case of excess supply the price might also go down even courting a rise in demand for the concerned product. The excess supply often follows a rise in demand owing to the behavioural pattern of the producer who might over estimate the rise in demand and increase his supply of corn in tune of his expectations. Apart from this demand-supply interaction, many other factors do operate while determining the fate of the corn oil. If people are well aware of the potential that corn oil holds as a fuel and alternative source of energy that will definitely translate i nto higher demand. Again this has to be also undertaken into the realm of analysis that whether any other form of substitutes to corn oil does exist, that might be cheaper, easily available in plenty and better source of energy. As a viable source of alternative energy in the long run corn oil will face quite a competition with Jatropha and Pongamia pinnata (Bridgewater, Halford and Karp, 2010, p. 236) and that outcome will

Importance of Examinations Essay Example for Free

Importance of Examinations Essay The world Examination is noun of the word examine. It means to test in order to verify, to judge and to certify, certain facts. Examination is a very wide word, which is used in all spheres of life. The learned examiner does not want that sense of examination to be discussed. He has in his mind the University Examination and he wants to know whether the institution of Examination should continue or should be abolished. Some persons are of opinion that examination is not the sure test of the ability of a candidate. The present examina ­tion system is based on cramming and to pass the examina ­tion has become more a matter of chance than that of abil ­ity. Again, the present system of examination promotes other evils such as copying and even corruption. The violent acci ­dents in the examination halls strengthen this claim. Even today we are told that a third-year student in one of the centers in Delhi gave a sound beating to an invigilator who objected that the candidate should not copy. The pity of the incident is that a police constable was in league with that candidate and he brought the material for him to be copied. Again, how can, the ability of a student be checked by a few questions? The answer to it is certainly in the negative. Thus, there is a strong case that it should be abolished. There are others who think that examination is a must. How can we do without an examination? Life in itself is a big examination. At every footstep we have to face certain tests. The success is always marked with dignity and honor in all the examinations of life. Examinations add to our abil ­ity, power of toleration, perseverance and other good quali ­ties. They think that examination is not only necessary but it is also a blessing. Everybody has been afraid of examinations. Even Lord Christ once uttered, May God not put anybody to test. Teachers, students, examiners and examinees, all think that examination is a curse, a horror and a terror. Most of the mental diseases among the students are the outcome of the examination and cramming. Inspite of all this, there must be something to mark the standards and to judge the ability of the candidates. The students are being led astray. They only study because they fear examinations. If this institution is abolished, it is certain they will not study even a word. Thus, we must assume that the system of examination should not be abolished, but it should be reformed so that it should be of a great advantage both to the student community and the society. The examination is an evil but it is necessary, therefore, it cannot be abolished. We cannot do without examinations, but the system needs a total reform. We should not follow the old orthodox methods, but the scientific change should be brought in the system of examinations.

Antidepressants for Postnatal Depression

Antidepressants for Postnatal Depression Antidepressants are they a safe and effective choice for the treatment of postnatal depression? This review assessed the evidence concerning the effectiveness and safety of antidepressants in the management of postnatal depression. This would facilitate evidence-based clinical decisions in the treatment of patients. Data was sourced from several electronic Athens-based and free databases covering the psycho-biomedical and nursing literature. Studies found included randomised clinical trials, case- and cohort-controlled studies, questionnaire surveys, and qualitative/exploratory research. Previous reviews were also appraised. Outcomes from over 1200 mothers, mother-infant pairings, or infants, exposed to antidepressants were considered. Antidepressants appear to significantly alleviate depressive symptoms. Furthermore, the reported side effects are generally benign and clinically insignificant. However, methodological and analytic flaws negate conclusive inferences. Many studies fail to account for important covariates that may explain effects attributed to antidepressants. Furthermore, most studies fail to account for interactions between antidepressants and patient characteristics, which may reveal more severe adverse effects. Additionally, there is a paucity of literature on long-term effects. Finally, a lack of randomised clinical trials precludes inferences of causality. Given these constraints it is recommended that antidepressants are used as a last resort, and patients are closely monitored to identify unexpected side effects, or recovery induced by covariates rather than antidepressants. Chapter One Introduction, Rationale, AIMS Introduction According to Beckford-ball (2000) postnatal depression (PND) fails to attract public attention because it is associated with a positive event – childbirth – notwithstanding the evidence that a sizeable majority of women experience this phenomenon after delivering their baby (RCP , 2004). Nevertheless postnatal depression, if left untreated, can have adverse effects for mother-child relationship and infant development (Green, 1995). This brief reviews evidence concerning the safety and effectiveness of antidepressants for treating postnatal depression. It is argued that while antidepressants may alleviate depressive symptoms, with benign side effects, various methodological and analytic constraints in the literature negate conclusive inferences on the subject. Antidepressants According to the RCP antidepressants are drugs developed in the 1950s for treating symptoms of depression (RCP, 2006).They work by stimulating neurotransmitters in the brain. Three main types of antidepressants are specified: 1. Tricyclic’s (TCAs): amitriptyline, imipramine, nortriptyline. 2. Selective Serotonin Reuptake Inhibitors (SSRIs): sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, moclobemide. 3. Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs): venlafaxine, reboxetine. 4. Monoamine Oxidase Inhibitors (MAOIs): tranylcypromine, moclobemide, phenelzine. The RCP posits that following three months of treatment 50% to 65%of people given an antidepressant show improvements in mood, compared with 25% to 30% of people administered a placebo. Thus, even after accounting for placebo effects, antidepressants still facilitate further recovery from depressive symptoms. TCAs are generally older than SSRIs and are considered to produce more side effects, especially if there is an overdose. However, all four classes of antidepressants are considered to have by-products, such as high blood pressure, anxiety, indigestion, dry mouth, heart tremor, and sleepiness. Most of the adverse effects are considered mild and expected to dissipate after few weeks. The RCP cites evidence of withdrawal symptoms in infants shortly after birth, especially with paroxetine (RCP, 2006). Babies can also receive a minute concentration of antidepressants via breastfeeding (Kohen,2005), albeit the risk of pathology is considered small due to the rapid development of kidneys and livers in infants. Overall, use of antidepressants during breastfeeding is not discouraged. Some pregnant women suffer a recurrence of depressive symptoms, and therefore may need to take antidepressants continually. The National Institute for Clinical Excellence (NICE, 2004) has published guidelines for the treatment of depression. However, there is no special emphasis on pregnancy-related depression. Antenatal and postnatal guidelines are due to be published by 2007 (Green, 2005). Postnatal Depression According to the RCP (2004) postnatal depression (PND) â€Å"is what happens when you become depressed after having a baby† (p.1). It is quite common, affecting circa 10% of newly delivered mothers, and can last for several months or longer if untreated. Symptoms include feeling depressed (unhappy, low, wretched, with symptoms becoming worse at particular times of the day), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in sexual intercourse. Many women may feel they are unable to cope with the new situation, or even experience anxiety and detachment towards the infant. Various causes of PND have been identified including a previous history of depression, not having a supportive partner, having a sick infant or premature delivery, losing one’s own mother as a child, and stressful life events (e.g. bereavement, divorce, financial problems) within a short time scale. PND has also been associated with hormonal changes. PND appears to progress through several stages (Beckford-Ball, 2000; Green, 2005): 1. Postpartum ‘blues’; 2. Postnatal depression; 3. Puerperal psychosis. Postpartum ‘blues’ â€Å"is usually a transient phase occurring 3-5 days after the birth of the child, with few or no psychiatric symptoms. This stage is characterised by mood swings, tearfulness, fatigue, lack of concentration, confusion, anxiety and hostility† (p.126). This condition is easily treated using hormone replacement therapy. Postnatal depression is less frequent, and emerges as a deep and protracted ‘sadness’ which â€Å"is much more intense and persistent than postpartum blues and its symptoms rarely subside without help† (p.126).Many mothers may feel insecure, incompetent, irritable, guilty (about feeling sad following a happy event), weight changes, insomnia/hypersomnia, psychomotor retardation/agitation, tiredness, and loss of interest in activities. This condition often results in hospitalisation and treatment with antidepressants and cognitive-behavioural counselling. Puerperal psychosis is a severe mood disorder typified by delusions and hallucinations. This condition is considered a psychiatric emergency, necessitating admission to a psychiatric institution and treatment with antidepressants and other drugs. Rationale Despite clear guidelines regarding the use of antidepressants during pregnancy it is necessary to appraise existing literature on the topic, for several reasons: 1. Limited scope of existing reviews. 2. Identification of gaps and inconsistencies in the literature 3. Verification of current claims and guidelines, for example by the RCP, regarding the management of postnatal depression. Limited scope Previous literature reviews are considered in this brief (see Chapter 3). Most reviews are limited in scope mainly because they focus on studies using a particular research methodology(e.g. Booth et al, 2005), mother-child transmission through breastfeeding (e.g. Cohen, 2005), and effects on depressive symptoms(e.g. Hendricks, 2003; Bennett et al, 2004). Thus, there is a need for an all-inclusive review that offers a broader insight into current literature. Identification of gaps and inconsistencies Previous reviews on the topic have highlighted problems that need to be addressed in future research. However each review is different and new research findings continually emerge that may have implications for previous reviews. For example, past reviews have found little evidence of malformations resulting from SSRI use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding various analytic and methodological constraints that negate conclusive inferences about the safety of SSRIs. Verification of current claims The RCP publishes an information guide for the use of antidepressants. Various claims are made regarding safety and efficacy of use during/after pregnancy, consistent with NICE(2004) standards. While most assertions are based on research evidence there is a need for on-going reviews that highlight recent findings and consider their implications for existing guidelines. Some of the key pronouncements and guidelines are as follows: 1. People who take antidepressants show a significant improvement over persons administered a placebo. 2. TCAs and SSRIs are equally effective but the latter (newer drug) is safer because it seems to have fewer side effects. 3. MAOIs can induce high blood pressure given certain (dietary) conditions 4. Babies whose mothers take antidepressants (especially paroxetine) may experience adverse effects. 5. It is best to carry on taking antidepressants while breastfeeding, since only minute amounts will be transferred to the baby. Livers and kidneys develop rapidly in babies only a few weeks old, helping to breakdown and filter antidepressants in the bloodstream. Aim The aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND. Chapter Two Literature Review The evidence/data to be reviewed here is based on a comprehensive search of multiple databases including HIGHWIRE Press, ACADEMIC SEARCH PREMIER (access through EBSCO databases), Psych INFO, INTERNURSE, and the BRITISH MEDICAL JOURNAL database. The Internet was also searched with emphasis on peer-reviewed published journal articles. Key words included: ‘antidepressants’, ‘depression’, and ‘postnatal depression’. There were no problems of access: all the databases reviewed are available to the general public through university library resources and/or Athens protected resources. These particular databases were chosen because of their emphasis on psychological, biomedical, and practice-based literature, and easier access to full-text files. For example, Psych INFO contains more than1,500,000 references to journal articles, books, technical reports, and dissertations, published in numerous countries. As a form of psychopathology, PND is comprehensively addressed. INTERNURSE provides access specifically to the nursing literature and incorporates may key journals (e.g. British Journal of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of Palliative Nursing). HIGHWIRE Press is one of the two largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorporates over4000 scholarly journals and 3100 peer review articles. These databases were preferred to others such as SCIENCE DIRECT, have a more general emphasis on scientific (rather than clinical, medical) literature, or not provide sufficient access to full-text articles. Only studies that satisfied the following criteria were eligible to be reviewed: 1. Empirical studies using either qualitative or quantitative methods. Thus, this included case studies, questionnaire surveys, retrospective/prospective designs, and randomised controlled trials(RCT). 2. Review articles and meta-analysis, including Cochrane reviews. 3. Focus on the effects of antidepressants on mother and/or child, and with or without breast-feeding. 4. Focus on postnatal depression, at any stage (i.e. postpartum ‘blues’, depression, and puerperal psychosis [Beckford-Ball, 2000]). 5. Focus on mothers perceptions of antidepressants as treatment for postnatal depression. The review also considered bits of literature published by the Department of Health (DOH), National Institute of Clinical Excellence(NICE), and the Royal College of Psychiatrists (RCP). The emphasis was on the role of SSRIs and TCAs albeit some literature on MAOIs and SNRIs was also considered. Individual studies are reviewed first, followed by review articles. Value of conducting a literature review The safety and effectiveness of antidepressants can easily be established by conducting an original empirical study. However, individual studies are severely constrained in scope and will ultimately provide a ‘snap-shot ‘or ‘localised’ insight on the subject. Moreover, scientific knowledge advances from the accumulation of evidence rather than the results of isolated studies, except in cases where there is a virtually no research on a topic, so that the findings of individual studies assume greater importance. Depression as a topic has been heavily researched. Numerous studies have been published on antidepressants and PND. The multiplicity of published literature reviews on antidepressants/PND attests to the abundance of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single study would still require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of merely reinventing the wheel. Thus, proper scientific protocol dictates that the researcher first begins by reviewing the literature, in order to get a bird’s eye view of the available evidence, identify gaps in the literature, and highlight avenues for further research (Cool can, 1994). Effects of anti-depressants Appleby et al (1997) conducted a randomised control trial to assess the effects of fluoxetine and cognitive-behavioural counselling on postnatal depression. Another aim was to compare fluoxetine and placebo groups, and also drug combinations and counselling. Hitherto there had been a paucity of randomised clinical trials in this area. Appleby et al (1997) question the clinical benefits of using antidepressants, given that prognosis for PND is often good, despite concerns about over-sedation, and other considerations. The study aimed to establish the optimal treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban health district(Manchester) as being depressed 6-8 weeks post childbirth. They completed the EPDS , and those with sufficiently high scores were interviewed using a revised clinical schedule, to identify cases of significant psychiatric depression. Women with a prior history of depression, substance abuse, severe illness that required hospitalisation, or breastfeeding, were excluded. Participants were randomly assigned to one of four experimental conditions: fluoxetine, placebo, one counselling session, and six counselling sessions. Mood assessments took place at 1, 4, and 12 weeks post-intervention, using the revised interview schedule, EPDS, and Hamilton depression scale. Data was analysed using analysis of variance for repeated measures (to account for the multiple outcome variables).Overall, 188 verified cases of PND were identified, from a sample of2978 women eligible to participate. Of these, 87 took part in the clinical trial. Results revealed significant improvements in all four treatment groups. Fluoxetine produced better improvement compared with the placebo: the percentage (geometric) differences in means scores based on the revised clinical interview schedule was 37.1% (at 4 weeks)and 40.7% (12 weeks). The effect of fluoxetine was not moderated by(i.e. did not interact with) counselling. Improvements in mood occurred within one week of participating in the clinical trial. The authors concluded â€Å"this study shows the effectiveness of both fluoxetine and cognitive-behavioural counselling in the treatment of women found by community based screening to be depressed 6-8 weeks after childbirth† (p.932). The use of a classic experimental design(RCT) permits causal inferences about the impact of an antidepressant. However, the analysis failed to control for potential confounding variables. While Appleby et al (1997) took steps to eliminate extraneous variance, through strict eligibility criteria, it would have been useful to incorporate detailed background information in the analysis (e.g. availability of social support, marital relationship, stressful life events, side-effect profile, history of drug compliance, patient preference [Green, 2005]) to demonstrate the statistical significance of these variables, and the unique contribution of SSRI treatment after controlling for covariates. Thus, analysis of covariance would have been a more appropriate test. Nolan et al (1997) assessed the effect of TCA and SSRI drugs on feta neurodevelopment. The study compared children of mothers who had been prescribed a tricyclic antidepressant during pregnancy, mothers who had taken fluoxetine during pregnancy, and mothers who had not taken antidepressants. Outcomes measures comprised global IQ and language development, assessed from 16 to 18 months postnatal, using age-specific Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities (measures IQ), and the Rendell Developmental Language Scales. Results revealed no significant group differences in any of the outcome variables, suggesting that in utero ingestion of either TCAs or fluoxetine does not impair cognitive, linguistic, or behavioural development in infants. Null man et al (2002) conducted follow-up prospective controlled study assessing the effects of TCA and fluoxetine use throughout pregnancy on child development. Three groups of mother-child pairs were recruited. The first two groups were drawn from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, which had been maintained throughout the duration of the pregnancy. A comparison group was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for Epidemiological Studies Depression Scale [CES-D]), exposure to chemical or radiation pollution, or severe health problems likely to affect fatal development. This group was randomly selected from among visitors to the author’s clinic. Women who had discontinued the use of antidepressants after conception or during the pregnancy were not eligible to participate. Women were also excluded from the comparison group based on the same criteria applied to the Mothers groups. Outcome data was collected using the CES-D, antenatal and postnatal assessments, neurobehavioral tests (Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up testing of them other (Wechsler Adult Intelligence Scale, and other measures). A one-way analysis of variance was used to compare outcome measures across the three groups. Correlational and regression tests were used to assess the contribution of confounding variables. Results revealed no group differences in child’s global IQ, language development, or behaviour (see Figure 1). The authors concluded, â€Å"Exposure to tricyclic antidepressants or fluoxetine throughout the gestation period does not appear to adversely affect cognition, language development, or the temperament of preschool and early-school children. Although regression was used to account for the contribution of confounding factors, such as verbal comprehension and expressive language, the variance explained by these variables was not in fact partial led out before testing for group differences. This would have required a multivariate analysis of covariance in which adjustments for covariates are built into the analysis. More importantly, the observed similarity in outcomes across the three groups may reflect simple or complex interactions with other variables. This issue is discussed in greater detail in Chapter 3. Figure 1 Cognitive outcomes (mental and psychomotor development, and cognitive abilities) across antidepressant and control groups(Nolan et al, 2002). Differences are not significant. Wisner et al (2001) performed a double-blind randomised control trial to assess the effect of nortriptyline on the rate of reoccurrence of postpartum depression in non-depressed women who had previously had at least one depressive episode. Women were randomly exposed tonortriptyline or a placebo immediately after childbirth. Outcome data was collected over a 5-month period using the Hamilton Rating Scale for Depression, and Research Diagnostic Criteria for depression. No group differences emerged, suggesting that nortriptyline was no more effective than a placebo in treating PND. This study was followed up with another RCT (Wisner et al, 2004), this time evaluating the effect of sertraline on the rate of and time to reoccurrence of postpartum depression. They highlighted a paucity of clinical trials on the impact of antidepressants in women who have previously had a depressive episode, and hence may be prone to experience a reoccurrence. Participants were pregnant women with gestation periods of 9 months or less, and at least one episode of postpartum depression that fits that the DSM-IV definition of major depression. Women with other forms of psychopathology (e.g. psychosis, or bipolar disorder) were excluded. Participants were randomly assigned to a treatment (sertraline) or placebo group. The drug was administered immediately after birth, beginning with a 50mg/day dose, which was later dropped to 25mg/day to minimise side effects (e.g. headache). Data analysis using Fisher’s exact test showed a significant group difference in rate of reoccurrences, during a 17-week preventive treatment period. Reoccurrences occurred in 4/8 women assigned to the placebo group, and1/14 women in the treatment condition, translating into a 0.43difference in reoccurrence rates. All women had adhered to the treatment regime, thus minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence beginning much earlier for the placebo group (at 5 weeks, followed by more reoccurrences) compared with the treatment group (at 17 weeks, followed by more reoccurrences). However, the treatment group reported more side effects (e.g. Dizziness, drowsiness). This RCT clearly demonstrates the effectiveness of an SSRI in preventing the reoccurrence of postpartum depression, albeit the conclusiveness of these findings is constrained by the failure to control for key background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, lingering symptoms of a distant depressive episode may help precipitate a quicker reoccurrence. Figure 2 Rate of recurrence of postpartum depression in placebo and SSRI women (Wisner et al, 2004) Oberlander et al (2005) tested the effect of SSRI exposure on bio behavioural responses to acute procedural pain in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine painful event in infants, after prenatal exposure to SSRI antidepressants. There is paucity of literature on the long-term effects of SSRIs on neuro behavioural variables, such as cognitive, language and motor development. Given that SSRIs work by inhibiting the reuptake of serotonin(5-hydroxytrypamine [5HT], a neurotransmitter that regulates cardiovascular function and pain signals in the developing brain), and given that SSRIs easily pass through the placenta, it is possible that regions of the brain associated with pain reactivity may be affected. Participants were recruited from a cohort of mothers and their infants during pregnancy, as part of a longitudinal study of prenatal medication use. Only Mothers/infants with no psychotropic or antidepressant use during pregnancy, whose pregnancy was 9 to 10 weeks, and no history of maternal mental illness, were eligible to be assigned to the control group. Three groups of infants were compared: (a) infants exposed to prenatal SSRI (fluoxetine); (b) infants exposed postnatal via breastfeeding(paroxetine, fluoxetine, sertraline); and (c) control infants. Behavioural (facial activity), physiological (variations in heart rate[HR], often used as a measure of pain reactivity in infants), and pharmacological (analysis of blood and breast milk samples) data was collected. Results showed impaired facial reactions in infants exposed to prenatal SSRI. Altered pain reactivity was observed in both prenatal and postnatal exposed infants, suggesting enduring neuro behavioural SSRI effects that extend beyond the new-born phase. Oberlander et all’s(2005) study was constrained by low power and generalizability (limited sample size), and lack of a non-medicated control group with depressive symptomatology. They were uncertain about the clinical implications of these findings, suggesting that use of SSRIs for treating maternal depression was appropriate pending further research on the sustained effects of SSRIs. Marcus et al (2005) screened prenatal depression in pregnant women attending an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, measured byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within two years of conception were screened. Average age was 28.6 years, and most women were married and Caucasian (73%). Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinued use following pregnancy, in addition to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology. A t-Test was used to compare two groups: women who reported they stopped using anti-depressants and hence were not currently on medication (n=248); and women who continued to use antidepressants during pregnancy (n=68). The dependent/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of antidepressant medication and CES-D groupings (i.e. Figure 3 CES-D data for women who did and those who did not use antidepressants during pregnancy (Marcus et al, 2005). Observed differences are not significant. The authors attributed the null results to poor treatment adherence, and inadequate prescribing/monitoring. Furthermore, they suggested that group differences might have been more pronounced if the study focused on unmediated women (i.e. those who had not used antidepressants at all, rather discontinued use). This study was unique because it assessed antidepressant use around the time of conception. However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the null results. A more serious problem is the possibility that certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The huge disparity in group sizes (268 versus 68) hugely increases the possibility of significant differences in group variances, which in turn would obscure reliable differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogeneity issue. Perhaps a non-parametric test (e.g. Mann-Whitney) may have been more appropriate. Furthermore, it is not clear why the authors conducted a chi-square test! Collapsing the CES-Scores into a dichotomy reduces the quality of the data because it obscures subtle differences between scores. Overall, the chi-square analyses amounted to a less precise duplication of the t-Test results! Finally, this study was entirely based on women’s self-reports of medication use, with no familial, clinical, or other verification. Its therefore unclear to what extent the null results are attributable to self-report bias. Several review articles on antidepressants and postnatal depression have been published. These range from limited commentaries (e.g. Goldstein Sun dell, 1999; Yoshida et al, 1999; Misery Kostas’s, 2002; Hendricks, 2003; Bennett et al, 2004; Cohen, 2005;Marcus et al, 2005) to comprehensive and systematic appraisals. Goldstein and Sun dell (1999) reviewed literature on the safety of SSRIs during pregnancy. Their work was based on the premise that although antidepressants may be necessary during pregnancy it is essential identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. Due to the paucity of randomised controlled trials on the topic, the review focused on evidence obtained from cohort/case-controlled studies, patient surveys, retrospective studies, and anecdotal reports. Electronic databases searched included Medline, EMBASE, Daren’t Drug File, and Psych INFO. Four cohort-controlled and 5 prospective studies were found which evaluated the impact of SSRI exposure. One study compared fluoxetine, TCA, and non-teratogen (e.g. antibiotics) exposed groups of non-depressed females. SSRI and TCA exposure produced no significant malformations, or differences in birth weight and infant prematurity. However, there was a greater tendency for fluoxetine- and tricyclic-exposed women to miscarry compared with controls. However, this effect was not significant and hence may simply have occurred by chance. Goldstein and Sun dell (1999) report another study which compared early exposed (prior to 25 weeks), late exposed (continuing after 24 weeks),and a non-teratogen control group. Again findings revealed no adverse effects in the treatment groups, albeit infants exposed to fluoxetine early showed a higher prevalence of minor anomalies that have little or no clinical importance. Furthermore late exposure to fluoxetine seemed to increase the rates of admission to special care nurseries and impaired fatal development. However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. Still other research suggests no effect of SSRIs (sertraline) on the prevalence of stillbirth, prematurity, mean birth weight and gestational age. Evidence suggests no statistically significant differences between SSRI exposed and control groups on IQ, language development, height, and head circumference. Of the prospective studies reviewed three assessed paroxetine, and fluoxetine, and two tested sertraline. All studies reported no significant increase in the rate of malformations and spontaneous abortion, although there was some evidence of lower birth weight given protracted use of antidepressants. Goldstein and Sun dell (1999) found one study, which showed that fluoxetine exposure during the first trimester did not increase the risk of malformations Antidepressants for Postnatal Depression Antidepressants for Postnatal Depression Antidepressants are they a safe and effective choice for the treatment of postnatal depression? This review assessed the evidence concerning the effectiveness and safety of antidepressants in the management of postnatal depression. This would facilitate evidence-based clinical decisions in the treatment of patients. Data was sourced from several electronic Athens-based and free databases covering the psycho-biomedical and nursing literature. Studies found included randomised clinical trials, case- and cohort-controlled studies, questionnaire surveys, and qualitative/exploratory research. Previous reviews were also appraised. Outcomes from over 1200 mothers, mother-infant pairings, or infants, exposed to antidepressants were considered. Antidepressants appear to significantly alleviate depressive symptoms. Furthermore, the reported side effects are generally benign and clinically insignificant. However, methodological and analytic flaws negate conclusive inferences. Many studies fail to account for important covariates that may explain effects attributed to antidepressants. Furthermore, most studies fail to account for interactions between antidepressants and patient characteristics, which may reveal more severe adverse effects. Additionally, there is a paucity of literature on long-term effects. Finally, a lack of randomised clinical trials precludes inferences of causality. Given these constraints it is recommended that antidepressants are used as a last resort, and patients are closely monitored to identify unexpected side effects, or recovery induced by covariates rather than antidepressants. Chapter One Introduction, Rationale, AIMS Introduction According to Beckford-ball (2000) postnatal depression (PND) fails to attract public attention because it is associated with a positive event – childbirth – notwithstanding the evidence that a sizeable majority of women experience this phenomenon after delivering their baby (RCP , 2004). Nevertheless postnatal depression, if left untreated, can have adverse effects for mother-child relationship and infant development (Green, 1995). This brief reviews evidence concerning the safety and effectiveness of antidepressants for treating postnatal depression. It is argued that while antidepressants may alleviate depressive symptoms, with benign side effects, various methodological and analytic constraints in the literature negate conclusive inferences on the subject. Antidepressants According to the RCP antidepressants are drugs developed in the 1950s for treating symptoms of depression (RCP, 2006).They work by stimulating neurotransmitters in the brain. Three main types of antidepressants are specified: 1. Tricyclic’s (TCAs): amitriptyline, imipramine, nortriptyline. 2. Selective Serotonin Reuptake Inhibitors (SSRIs): sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, moclobemide. 3. Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs): venlafaxine, reboxetine. 4. Monoamine Oxidase Inhibitors (MAOIs): tranylcypromine, moclobemide, phenelzine. The RCP posits that following three months of treatment 50% to 65%of people given an antidepressant show improvements in mood, compared with 25% to 30% of people administered a placebo. Thus, even after accounting for placebo effects, antidepressants still facilitate further recovery from depressive symptoms. TCAs are generally older than SSRIs and are considered to produce more side effects, especially if there is an overdose. However, all four classes of antidepressants are considered to have by-products, such as high blood pressure, anxiety, indigestion, dry mouth, heart tremor, and sleepiness. Most of the adverse effects are considered mild and expected to dissipate after few weeks. The RCP cites evidence of withdrawal symptoms in infants shortly after birth, especially with paroxetine (RCP, 2006). Babies can also receive a minute concentration of antidepressants via breastfeeding (Kohen,2005), albeit the risk of pathology is considered small due to the rapid development of kidneys and livers in infants. Overall, use of antidepressants during breastfeeding is not discouraged. Some pregnant women suffer a recurrence of depressive symptoms, and therefore may need to take antidepressants continually. The National Institute for Clinical Excellence (NICE, 2004) has published guidelines for the treatment of depression. However, there is no special emphasis on pregnancy-related depression. Antenatal and postnatal guidelines are due to be published by 2007 (Green, 2005). Postnatal Depression According to the RCP (2004) postnatal depression (PND) â€Å"is what happens when you become depressed after having a baby† (p.1). It is quite common, affecting circa 10% of newly delivered mothers, and can last for several months or longer if untreated. Symptoms include feeling depressed (unhappy, low, wretched, with symptoms becoming worse at particular times of the day), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in sexual intercourse. Many women may feel they are unable to cope with the new situation, or even experience anxiety and detachment towards the infant. Various causes of PND have been identified including a previous history of depression, not having a supportive partner, having a sick infant or premature delivery, losing one’s own mother as a child, and stressful life events (e.g. bereavement, divorce, financial problems) within a short time scale. PND has also been associated with hormonal changes. PND appears to progress through several stages (Beckford-Ball, 2000; Green, 2005): 1. Postpartum ‘blues’; 2. Postnatal depression; 3. Puerperal psychosis. Postpartum ‘blues’ â€Å"is usually a transient phase occurring 3-5 days after the birth of the child, with few or no psychiatric symptoms. This stage is characterised by mood swings, tearfulness, fatigue, lack of concentration, confusion, anxiety and hostility† (p.126). This condition is easily treated using hormone replacement therapy. Postnatal depression is less frequent, and emerges as a deep and protracted ‘sadness’ which â€Å"is much more intense and persistent than postpartum blues and its symptoms rarely subside without help† (p.126).Many mothers may feel insecure, incompetent, irritable, guilty (about feeling sad following a happy event), weight changes, insomnia/hypersomnia, psychomotor retardation/agitation, tiredness, and loss of interest in activities. This condition often results in hospitalisation and treatment with antidepressants and cognitive-behavioural counselling. Puerperal psychosis is a severe mood disorder typified by delusions and hallucinations. This condition is considered a psychiatric emergency, necessitating admission to a psychiatric institution and treatment with antidepressants and other drugs. Rationale Despite clear guidelines regarding the use of antidepressants during pregnancy it is necessary to appraise existing literature on the topic, for several reasons: 1. Limited scope of existing reviews. 2. Identification of gaps and inconsistencies in the literature 3. Verification of current claims and guidelines, for example by the RCP, regarding the management of postnatal depression. Limited scope Previous literature reviews are considered in this brief (see Chapter 3). Most reviews are limited in scope mainly because they focus on studies using a particular research methodology(e.g. Booth et al, 2005), mother-child transmission through breastfeeding (e.g. Cohen, 2005), and effects on depressive symptoms(e.g. Hendricks, 2003; Bennett et al, 2004). Thus, there is a need for an all-inclusive review that offers a broader insight into current literature. Identification of gaps and inconsistencies Previous reviews on the topic have highlighted problems that need to be addressed in future research. However each review is different and new research findings continually emerge that may have implications for previous reviews. For example, past reviews have found little evidence of malformations resulting from SSRI use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding various analytic and methodological constraints that negate conclusive inferences about the safety of SSRIs. Verification of current claims The RCP publishes an information guide for the use of antidepressants. Various claims are made regarding safety and efficacy of use during/after pregnancy, consistent with NICE(2004) standards. While most assertions are based on research evidence there is a need for on-going reviews that highlight recent findings and consider their implications for existing guidelines. Some of the key pronouncements and guidelines are as follows: 1. People who take antidepressants show a significant improvement over persons administered a placebo. 2. TCAs and SSRIs are equally effective but the latter (newer drug) is safer because it seems to have fewer side effects. 3. MAOIs can induce high blood pressure given certain (dietary) conditions 4. Babies whose mothers take antidepressants (especially paroxetine) may experience adverse effects. 5. It is best to carry on taking antidepressants while breastfeeding, since only minute amounts will be transferred to the baby. Livers and kidneys develop rapidly in babies only a few weeks old, helping to breakdown and filter antidepressants in the bloodstream. Aim The aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND. Chapter Two Literature Review The evidence/data to be reviewed here is based on a comprehensive search of multiple databases including HIGHWIRE Press, ACADEMIC SEARCH PREMIER (access through EBSCO databases), Psych INFO, INTERNURSE, and the BRITISH MEDICAL JOURNAL database. The Internet was also searched with emphasis on peer-reviewed published journal articles. Key words included: ‘antidepressants’, ‘depression’, and ‘postnatal depression’. There were no problems of access: all the databases reviewed are available to the general public through university library resources and/or Athens protected resources. These particular databases were chosen because of their emphasis on psychological, biomedical, and practice-based literature, and easier access to full-text files. For example, Psych INFO contains more than1,500,000 references to journal articles, books, technical reports, and dissertations, published in numerous countries. As a form of psychopathology, PND is comprehensively addressed. INTERNURSE provides access specifically to the nursing literature and incorporates may key journals (e.g. British Journal of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of Palliative Nursing). HIGHWIRE Press is one of the two largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorporates over4000 scholarly journals and 3100 peer review articles. These databases were preferred to others such as SCIENCE DIRECT, have a more general emphasis on scientific (rather than clinical, medical) literature, or not provide sufficient access to full-text articles. Only studies that satisfied the following criteria were eligible to be reviewed: 1. Empirical studies using either qualitative or quantitative methods. Thus, this included case studies, questionnaire surveys, retrospective/prospective designs, and randomised controlled trials(RCT). 2. Review articles and meta-analysis, including Cochrane reviews. 3. Focus on the effects of antidepressants on mother and/or child, and with or without breast-feeding. 4. Focus on postnatal depression, at any stage (i.e. postpartum ‘blues’, depression, and puerperal psychosis [Beckford-Ball, 2000]). 5. Focus on mothers perceptions of antidepressants as treatment for postnatal depression. The review also considered bits of literature published by the Department of Health (DOH), National Institute of Clinical Excellence(NICE), and the Royal College of Psychiatrists (RCP). The emphasis was on the role of SSRIs and TCAs albeit some literature on MAOIs and SNRIs was also considered. Individual studies are reviewed first, followed by review articles. Value of conducting a literature review The safety and effectiveness of antidepressants can easily be established by conducting an original empirical study. However, individual studies are severely constrained in scope and will ultimately provide a ‘snap-shot ‘or ‘localised’ insight on the subject. Moreover, scientific knowledge advances from the accumulation of evidence rather than the results of isolated studies, except in cases where there is a virtually no research on a topic, so that the findings of individual studies assume greater importance. Depression as a topic has been heavily researched. Numerous studies have been published on antidepressants and PND. The multiplicity of published literature reviews on antidepressants/PND attests to the abundance of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single study would still require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of merely reinventing the wheel. Thus, proper scientific protocol dictates that the researcher first begins by reviewing the literature, in order to get a bird’s eye view of the available evidence, identify gaps in the literature, and highlight avenues for further research (Cool can, 1994). Effects of anti-depressants Appleby et al (1997) conducted a randomised control trial to assess the effects of fluoxetine and cognitive-behavioural counselling on postnatal depression. Another aim was to compare fluoxetine and placebo groups, and also drug combinations and counselling. Hitherto there had been a paucity of randomised clinical trials in this area. Appleby et al (1997) question the clinical benefits of using antidepressants, given that prognosis for PND is often good, despite concerns about over-sedation, and other considerations. The study aimed to establish the optimal treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban health district(Manchester) as being depressed 6-8 weeks post childbirth. They completed the EPDS , and those with sufficiently high scores were interviewed using a revised clinical schedule, to identify cases of significant psychiatric depression. Women with a prior history of depression, substance abuse, severe illness that required hospitalisation, or breastfeeding, were excluded. Participants were randomly assigned to one of four experimental conditions: fluoxetine, placebo, one counselling session, and six counselling sessions. Mood assessments took place at 1, 4, and 12 weeks post-intervention, using the revised interview schedule, EPDS, and Hamilton depression scale. Data was analysed using analysis of variance for repeated measures (to account for the multiple outcome variables).Overall, 188 verified cases of PND were identified, from a sample of2978 women eligible to participate. Of these, 87 took part in the clinical trial. Results revealed significant improvements in all four treatment groups. Fluoxetine produced better improvement compared with the placebo: the percentage (geometric) differences in means scores based on the revised clinical interview schedule was 37.1% (at 4 weeks)and 40.7% (12 weeks). The effect of fluoxetine was not moderated by(i.e. did not interact with) counselling. Improvements in mood occurred within one week of participating in the clinical trial. The authors concluded â€Å"this study shows the effectiveness of both fluoxetine and cognitive-behavioural counselling in the treatment of women found by community based screening to be depressed 6-8 weeks after childbirth† (p.932). The use of a classic experimental design(RCT) permits causal inferences about the impact of an antidepressant. However, the analysis failed to control for potential confounding variables. While Appleby et al (1997) took steps to eliminate extraneous variance, through strict eligibility criteria, it would have been useful to incorporate detailed background information in the analysis (e.g. availability of social support, marital relationship, stressful life events, side-effect profile, history of drug compliance, patient preference [Green, 2005]) to demonstrate the statistical significance of these variables, and the unique contribution of SSRI treatment after controlling for covariates. Thus, analysis of covariance would have been a more appropriate test. Nolan et al (1997) assessed the effect of TCA and SSRI drugs on feta neurodevelopment. The study compared children of mothers who had been prescribed a tricyclic antidepressant during pregnancy, mothers who had taken fluoxetine during pregnancy, and mothers who had not taken antidepressants. Outcomes measures comprised global IQ and language development, assessed from 16 to 18 months postnatal, using age-specific Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities (measures IQ), and the Rendell Developmental Language Scales. Results revealed no significant group differences in any of the outcome variables, suggesting that in utero ingestion of either TCAs or fluoxetine does not impair cognitive, linguistic, or behavioural development in infants. Null man et al (2002) conducted follow-up prospective controlled study assessing the effects of TCA and fluoxetine use throughout pregnancy on child development. Three groups of mother-child pairs were recruited. The first two groups were drawn from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, which had been maintained throughout the duration of the pregnancy. A comparison group was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for Epidemiological Studies Depression Scale [CES-D]), exposure to chemical or radiation pollution, or severe health problems likely to affect fatal development. This group was randomly selected from among visitors to the author’s clinic. Women who had discontinued the use of antidepressants after conception or during the pregnancy were not eligible to participate. Women were also excluded from the comparison group based on the same criteria applied to the Mothers groups. Outcome data was collected using the CES-D, antenatal and postnatal assessments, neurobehavioral tests (Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up testing of them other (Wechsler Adult Intelligence Scale, and other measures). A one-way analysis of variance was used to compare outcome measures across the three groups. Correlational and regression tests were used to assess the contribution of confounding variables. Results revealed no group differences in child’s global IQ, language development, or behaviour (see Figure 1). The authors concluded, â€Å"Exposure to tricyclic antidepressants or fluoxetine throughout the gestation period does not appear to adversely affect cognition, language development, or the temperament of preschool and early-school children. Although regression was used to account for the contribution of confounding factors, such as verbal comprehension and expressive language, the variance explained by these variables was not in fact partial led out before testing for group differences. This would have required a multivariate analysis of covariance in which adjustments for covariates are built into the analysis. More importantly, the observed similarity in outcomes across the three groups may reflect simple or complex interactions with other variables. This issue is discussed in greater detail in Chapter 3. Figure 1 Cognitive outcomes (mental and psychomotor development, and cognitive abilities) across antidepressant and control groups(Nolan et al, 2002). Differences are not significant. Wisner et al (2001) performed a double-blind randomised control trial to assess the effect of nortriptyline on the rate of reoccurrence of postpartum depression in non-depressed women who had previously had at least one depressive episode. Women were randomly exposed tonortriptyline or a placebo immediately after childbirth. Outcome data was collected over a 5-month period using the Hamilton Rating Scale for Depression, and Research Diagnostic Criteria for depression. No group differences emerged, suggesting that nortriptyline was no more effective than a placebo in treating PND. This study was followed up with another RCT (Wisner et al, 2004), this time evaluating the effect of sertraline on the rate of and time to reoccurrence of postpartum depression. They highlighted a paucity of clinical trials on the impact of antidepressants in women who have previously had a depressive episode, and hence may be prone to experience a reoccurrence. Participants were pregnant women with gestation periods of 9 months or less, and at least one episode of postpartum depression that fits that the DSM-IV definition of major depression. Women with other forms of psychopathology (e.g. psychosis, or bipolar disorder) were excluded. Participants were randomly assigned to a treatment (sertraline) or placebo group. The drug was administered immediately after birth, beginning with a 50mg/day dose, which was later dropped to 25mg/day to minimise side effects (e.g. headache). Data analysis using Fisher’s exact test showed a significant group difference in rate of reoccurrences, during a 17-week preventive treatment period. Reoccurrences occurred in 4/8 women assigned to the placebo group, and1/14 women in the treatment condition, translating into a 0.43difference in reoccurrence rates. All women had adhered to the treatment regime, thus minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence beginning much earlier for the placebo group (at 5 weeks, followed by more reoccurrences) compared with the treatment group (at 17 weeks, followed by more reoccurrences). However, the treatment group reported more side effects (e.g. Dizziness, drowsiness). This RCT clearly demonstrates the effectiveness of an SSRI in preventing the reoccurrence of postpartum depression, albeit the conclusiveness of these findings is constrained by the failure to control for key background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, lingering symptoms of a distant depressive episode may help precipitate a quicker reoccurrence. Figure 2 Rate of recurrence of postpartum depression in placebo and SSRI women (Wisner et al, 2004) Oberlander et al (2005) tested the effect of SSRI exposure on bio behavioural responses to acute procedural pain in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine painful event in infants, after prenatal exposure to SSRI antidepressants. There is paucity of literature on the long-term effects of SSRIs on neuro behavioural variables, such as cognitive, language and motor development. Given that SSRIs work by inhibiting the reuptake of serotonin(5-hydroxytrypamine [5HT], a neurotransmitter that regulates cardiovascular function and pain signals in the developing brain), and given that SSRIs easily pass through the placenta, it is possible that regions of the brain associated with pain reactivity may be affected. Participants were recruited from a cohort of mothers and their infants during pregnancy, as part of a longitudinal study of prenatal medication use. Only Mothers/infants with no psychotropic or antidepressant use during pregnancy, whose pregnancy was 9 to 10 weeks, and no history of maternal mental illness, were eligible to be assigned to the control group. Three groups of infants were compared: (a) infants exposed to prenatal SSRI (fluoxetine); (b) infants exposed postnatal via breastfeeding(paroxetine, fluoxetine, sertraline); and (c) control infants. Behavioural (facial activity), physiological (variations in heart rate[HR], often used as a measure of pain reactivity in infants), and pharmacological (analysis of blood and breast milk samples) data was collected. Results showed impaired facial reactions in infants exposed to prenatal SSRI. Altered pain reactivity was observed in both prenatal and postnatal exposed infants, suggesting enduring neuro behavioural SSRI effects that extend beyond the new-born phase. Oberlander et all’s(2005) study was constrained by low power and generalizability (limited sample size), and lack of a non-medicated control group with depressive symptomatology. They were uncertain about the clinical implications of these findings, suggesting that use of SSRIs for treating maternal depression was appropriate pending further research on the sustained effects of SSRIs. Marcus et al (2005) screened prenatal depression in pregnant women attending an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, measured byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within two years of conception were screened. Average age was 28.6 years, and most women were married and Caucasian (73%). Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinued use following pregnancy, in addition to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology. A t-Test was used to compare two groups: women who reported they stopped using anti-depressants and hence were not currently on medication (n=248); and women who continued to use antidepressants during pregnancy (n=68). The dependent/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of antidepressant medication and CES-D groupings (i.e. Figure 3 CES-D data for women who did and those who did not use antidepressants during pregnancy (Marcus et al, 2005). Observed differences are not significant. The authors attributed the null results to poor treatment adherence, and inadequate prescribing/monitoring. Furthermore, they suggested that group differences might have been more pronounced if the study focused on unmediated women (i.e. those who had not used antidepressants at all, rather discontinued use). This study was unique because it assessed antidepressant use around the time of conception. However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the null results. A more serious problem is the possibility that certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The huge disparity in group sizes (268 versus 68) hugely increases the possibility of significant differences in group variances, which in turn would obscure reliable differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogeneity issue. Perhaps a non-parametric test (e.g. Mann-Whitney) may have been more appropriate. Furthermore, it is not clear why the authors conducted a chi-square test! Collapsing the CES-Scores into a dichotomy reduces the quality of the data because it obscures subtle differences between scores. Overall, the chi-square analyses amounted to a less precise duplication of the t-Test results! Finally, this study was entirely based on women’s self-reports of medication use, with no familial, clinical, or other verification. Its therefore unclear to what extent the null results are attributable to self-report bias. Several review articles on antidepressants and postnatal depression have been published. These range from limited commentaries (e.g. Goldstein Sun dell, 1999; Yoshida et al, 1999; Misery Kostas’s, 2002; Hendricks, 2003; Bennett et al, 2004; Cohen, 2005;Marcus et al, 2005) to comprehensive and systematic appraisals. Goldstein and Sun dell (1999) reviewed literature on the safety of SSRIs during pregnancy. Their work was based on the premise that although antidepressants may be necessary during pregnancy it is essential identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. Due to the paucity of randomised controlled trials on the topic, the review focused on evidence obtained from cohort/case-controlled studies, patient surveys, retrospective studies, and anecdotal reports. Electronic databases searched included Medline, EMBASE, Daren’t Drug File, and Psych INFO. Four cohort-controlled and 5 prospective studies were found which evaluated the impact of SSRI exposure. One study compared fluoxetine, TCA, and non-teratogen (e.g. antibiotics) exposed groups of non-depressed females. SSRI and TCA exposure produced no significant malformations, or differences in birth weight and infant prematurity. However, there was a greater tendency for fluoxetine- and tricyclic-exposed women to miscarry compared with controls. However, this effect was not significant and hence may simply have occurred by chance. Goldstein and Sun dell (1999) report another study which compared early exposed (prior to 25 weeks), late exposed (continuing after 24 weeks),and a non-teratogen control group. Again findings revealed no adverse effects in the treatment groups, albeit infants exposed to fluoxetine early showed a higher prevalence of minor anomalies that have little or no clinical importance. Furthermore late exposure to fluoxetine seemed to increase the rates of admission to special care nurseries and impaired fatal development. However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. Still other research suggests no effect of SSRIs (sertraline) on the prevalence of stillbirth, prematurity, mean birth weight and gestational age. Evidence suggests no statistically significant differences between SSRI exposed and control groups on IQ, language development, height, and head circumference. Of the prospective studies reviewed three assessed paroxetine, and fluoxetine, and two tested sertraline. All studies reported no significant increase in the rate of malformations and spontaneous abortion, although there was some evidence of lower birth weight given protracted use of antidepressants. Goldstein and Sun dell (1999) found one study, which showed that fluoxetine exposure during the first trimester did not increase the risk of malformations