Saturday, August 24, 2019
Apple - Research Paper Example It states that the company has done a very good job of marketing its sustainability efforts in order to increase the brand value of the company. Another good aspect about the firmÃ¢â¬â¢s sustainability efforts is that Apple has been an early adopter of new sustainability technology. Article 3: Sustainability Faceoff: Microsoft vs. Apple URL: http://www.fastcompany.com/1650270/sustainability-faceoff-microsoft-vs-apple The article provides a comparison of the sustainability efforts of Apple and Microsoft. Overall the author believes that the sustainability efforts of Microsoft are better, but he does mention a lot of good things that Apple is doing in terms of sustainability actions. Ã¢â¬Å"The company claims that the new iMac and MacBook computers are already free of the toxic substances.Ã¢â¬ (Schwartz, 2010). Article 4: Responsible Supply Chain Leadership: Should Apple Just Do It? URL: http://www.sustainablebrands.com/news_and_views/mar2012/responsible-supply-chain-leadership-sh ould-apple-just-do-it The author of this article discusses the steps that Apple has taken since 2005 to improve its sustainability program. In 2005 the company established a code of conduct outlining expectations for suppliers. During the next five years the company took steps to enforce compliance of its supply chain responsibilities, it incorporated an internal control system, and established worker empowerment training. Article 5: Apple Inc. Making Progress on Sustainability In China, Though Workers and the Environment Still Deserve Better URL: http://www.joshuawickerham.com/2011/10/11/apple-update/ The article focuses on AppleÃ¢â¬â¢s sustainability efforts from the perspective of the importance of establishing good stakeholder relationships, social causes, and environmental efforts. One of the good things about the sustainability efforts of the company is that Apple integrates them into its production processes. The company has improved a lot its sustainability program in the PeopleÃ¢â¬â¢s Republic of China. Article 6: Apple: Sustainability, Child Labor, Bribes and Suicide URL: http://www.caelusgreenroom.com/2011/02/15/apple-sustainability-child-labor-bribes-and-suicide/ The purpose of this article is to discuss the results of AppleÃ¢â¬â¢s 2011 progress report for Apple supplier sustainability. Ã¢â¬Å"The report offers several examples of Apple improving worker conditions, employer practices, material sourcing, and other changes in its supply chain, including a 24.5% increase in the number of independent audits on work sites in that chain.Ã¢â¬ (Caelusgreenroom, 2011). The firm has increased the number of sustainability audits to 102 per year. Part II: CompanyÃ¢â¬â¢ efforts to improve/promote environmental sustainability Apple is truly committed towards the use of sustainability practices into its operations. The company has done a lot of good things to improve its sustainability program. The firm incorporates sustainability throughout its entire supply chain. Ã¢â¬Å"We've learned that about 98 percent of AppleÃ¢â¬â¢s carbon footprint is directly related to ourÃ products. The remaining 2 percent is related to our facilitiesÃ¢â¬ (Apple, 2012). The company applies sustainability in its transportation efforts. The company designs products with less material, ships with smaller packages, and they are free of toxic
Friday, August 23, 2019
Meteorites Evidence in Support of Solar Nebular Hypothesis - Research Paper Example This theory has been widely accepted because it is thought to provide a worthwhile explanation of the orbital properties of the solar system and the way planets orbit less or more in the same plane (Abruzzo 44). According to this theory, originally, there existed a big cloud of gas and dust, which became unstable, probably because of the shock waves originating from the nearby density waves or supernova. The part of the cloud, which was the densest begun collapsing under the force of gravity. This force of gravity, then pulled the gas and dust towards the center point of the cloud. The cloud was forced to take a spherical shape, thereby becoming a protostar. Increased centrifugal force or rotation of gas and dust caused this cloud to form a flattened shape or accretion disk around it (Abruzzo 46). According to this hypothesis, this explains why the rotating disk if gas and dust is solar Nebula. A number of studies have sought to confirm this hypothesis, however, the practically of th is hypothesis has never been illustrated as it has been illustrated in the American Museum of national History (AMHH). American Museum of Natural History (AMNH) has been one of the world prominent scientific institutions, known for its exhibitions and collections, which illuminate of the Earths evolutions, right from the origin of the present planet to its present form. AMNH is New York Icon. I have always wondered how everything came into being. The mystery of life and therein has been a closely contested subject. Besides, it has always been my dream to visit AMNH and learn of the scientific evidence located in meteorites supports Solar Nebula Hypothesis. Recently, I made my way into the AMNH. The Museum is located at Central park West on the 79th Street and is easily accessed by public transport. Driving to the museum, I got inclined to give a benefit of doubt, though I had no basic grasp of the real evidence for the Solar Nebular Hypothesis. The main entrance to the Rose Center for Earth and Space is situated at 81st Street between the Columbus Avenue and Central Park West. Although I have a perso nal car, I chose public transport perhaps to evade the huge parking fees. When I arrived at 10 am, I was surprised to find many uniformed police at the entrance, directing traffic. The heavy police presence depicted the 9-11post security situations. Perhaps, this shows the importance of the structure under close security. I marveled at the structureÃ it was huge yet with a modern style. While, at the museum, I sought direction to the Arthur Ross Hall of Meteorites. The hall is situated on the far end of the AMNH bordering Sacker Educational library to the south and The Hall of Minerals to the East. First, we watched a movie in the Meteorite Theater, located in the Hall along the Planet Wall display. The movie was breathtaking. It brought into perspective the events that took place million years ago. In essence, the film presented the role of meteorites and their connectedness to the history of the solar system. This offered a solid foundation for the understanding of the concepts later presented in the exhibition. I came across one of this displays which stated that meteorite were rocks from space, which had survived their passage in the universe to land to the surface of the Earth. Some meteorites, are often heard or seen, when they fall and are collected afterwards while other are discovered later. The size of meteorites varies, in that some are large to cause craters upon falling while others are small and one need a help magnifying equipments to vie them. They take different forms, where some resemble igneous rocks, and others are metals. Despite their variation in terms of appearance, size, and manner of discovery, they are all pieces of different bodies in space,
Thursday, August 22, 2019
Women In Power Roles - Essay Example As the report declares traditional gender roles were challenged by the Feminist Movement initiated by Betty Friedan, who encouraged women to shake off their domestic role and emerge into the workplace. As a result many women are financially independent and have even emerged into positions of political power, such as for example women like Margaret Thatcher, Golda Meir and Hilary Clinton. The Macquarie Dictionary defines feminism as Ã¢â¬Å"advocacy of equal rights and opportunities for women, especially the extension of their activities into the social and political lifeÃ¢â¬ . This definition suggests that womenÃ¢â¬â¢s access to power within the public sphere has always been one of the main objectives of the feminist movement. This paper stresses that in Western societies, women have moved far ahead of their contemporaries in developing countries in terms of increased power and competition with men in all arenas. Workplace empowerment and womenÃ¢â¬â¢s rights have pushed forward the cause of women and increased their power and influence in the world. Many of the traditional notions of feminity and restrictions within gender defined roles are being challenged as the world view is being changed by radicals such as Toni Morrison, Virginia Woolf, Betty Friedan, Oprah Winfrey and many Asian writers and reformers. Perhaps one of the best examples of gender power play that has occurred in recent times is the example of Bill and Hilary Clinton.
Towards Equality Of Women Essay Nowadays, gender became a very sensitive issue. The word gender is not only limited to feminist and masculinity. Other than that, feminist movements are very active. They claim that man and women should be equally treated. Certain jobs and career should not be limited to a specific gender. There is also a kind of feminist movement that claims that women can do masculine work and engage in masculine sports. Examples are women who are working as cab drivers, police, and soldiers and joining sports such as weight lifting, wrestling, and boxing. Sapphireblue.com defines amazon feminism as follows: Ã¢â¬Å"Amazon feminism is dedicated to the image of the female hero in fiction and in fact, as it is expressed in art and literature, in the physiques and feats of female athletes, and in sexual values and practices. Amazon feminism is concerned about physical equality and is opposed to gender role stereotypes and discrimination against women based on assumptions that women are supposed to be, look or behave as if they are passive, weak and physically helpless. Amazon feminism rejects the idea that certain characteristics or interests are inherently masculine (or feminine), and upholds and explores a vision of heroic womanhood. Thus Amazon feminism advocates e.g., female strength athletes, martial artists, soldiers, etc. [TG]Ã¢â¬ Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã In my own opinion, feminism and masculinity are only defined by the society. Masculinity just varies and it depends on how it is viewed in a culture. For example, there was a time in Japan when crying and being soft was their idea of masculinity. This view of masculinity might shock us because of our modern view but there was a time when it really existed in Japan. It is very interesting to know that there was also a time in Japan when masculinity means being a warrior or a samurai. It only means that an era or culture sets the standard of masculinity and there is no such thing as absolute masculinity. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã On the other hand, there are people who think that there is such word as Ã¢â¬Å"too masculineÃ¢â¬ . It only means that an image or nature of work display too much quality that only man can satisfy. This word disqualifies any woman from doing or fulfilling that Ã¢â¬Å"too masculine responsibility. Now that we are living in a modern society, I think that the word Ã¢â¬Å"too masculineÃ¢â¬ is no longer applicable. Thanks to some feminist movements, career or any other responsibility are no longer limited to a specific gender. Any person, man or woman, is entitled to a career or responsibility as long as he or she is qualified. Actually, there are a lot of woman who are excelling in those fields which are traditionally for men. Examples are successful political leaders such as Gloria Macapagal Arroyo of the Philippines, Benazir Bhuto of Pakistan, and Margaret Thatcher of Great Britain. They have proven that women can lead a nation as long as effective as men. Here, we can see that leadership position in the field of politics is no longer too masculine for a woman. Personally, I donÃ¢â¬â¢t believe in the word Ã¢â¬Å"too masculineÃ¢â¬ anymore. When I was a young student, I used to believe that each gender has a specific responsibility assignment. For example, taking care of children is for women only because of their gentle nature. But now, my mind was opened by feminist movements. Women can do tough work because they can also display strong character. On the other hand, men can also take the responsibility of women because they also have a gentle side. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Although feminist movements promote gender equality, it also has a negative impact in our society. Based on what I observe in our society, manhood is no longer respectable. Sometimes, I feel that women are abusing gender equality. As a matter of fact, there is a kind of feminist movement which claims that men are no longer needed in the society. It is called radical feminism. About.com defines radical feminism as follows: Ã¢â¬Å"Radical feminism is a philosophy emphasizing the patriarchal roots of inequality between men and women, or, more specifically, social dominance of women by men. Radical feminism views patriarchy as dividing rights, privileges and power primarily by gender, and as a result oppressing women and privileging men. Radical feminists tend to be more militant in their approach (radical as getting to the root). Radical feminism opposes existing political and social organization in general because it is inherently tied to patriarchy. Thus, radical feminists tend to be skeptical of political action within the current system, and instead support cultural change that undermines patriarchy and associated hierarchical structures. Ã¢â¬Å" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Even media promotes an image of a man that is submissive to women. Example is the Ax deo spray commercial where men act like sex slaves of women. Also, media nowadays suggest that women can use sex and their physical beauty to manipulate men. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã During our pre-agricultural past, when men and women are still hunters and gatherers, gender equality already exists. We can say that gender equality already exists because men and women are living in a egalitarian society. They had what we call values of belonging which is characterized by self restraint, generosity and mutuality. As explained by Carol Finders in tworock.com: Ã¢â¬Å"Throughout the eons that preceded the agricultural revolution, Flinders notes, our ancestors were hunter-gatherers. Certain values are intrinsic to that way of life wherever it is lived.Ã Self-restraint, generosity, mutuality, balance, and a warmly reverent connection to the earth and other creatures are all adaptive to a nomadic, foraging existence. Ã They are the values of Belonging, and they defined the human condition for so long they exist still Ã¢â¬â in longing, in faint memory as an indestructible stratum in consciousness itself.Ã¢â¬ Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã On the other hand, the culture of enterprise started to emerge during agricultural development. Men and women started to acquire their own property. In the culture of enterprise, aggression and competition are prevalent. As stated by Finders: Ã¢â¬Å"With the rise of agriculture and city-states, beginning just ten thousand years ago, a new set of values became adaptive: irreverence, willingness to exploit the natural world for profit; acquisitiveness, aggression, and competitiveness. The values of Enterprise.Ã¢â¬ I think that it is not necessary to take more of values of belonging because it is no longer applicable to our society. Culture of enterprise is well stabilized in our society and changing it may cause instability. Although aggression and inequality is inevitable in the culture of enterprise, I believe that we can regulate it by promoting positive values such as justice and respect. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã I chose education as a subject area to discuss the contrast between values of belonging and culture of enterprise. It is obvious that the culture of enterprise is very dominant in field of education. Nowadays, education is used to promote a person from his or her current social status. We can notice that mostly, education is only exclusives to the rich and middle class people. It is because educating the poor will surely uplift the status of poor people. If everyone can have an equal opportunity for education, poverty will be lessen. Here, the characteristic of the culture of enterprise is very evident and these are competition and acquisitiveness. We canÃ¢â¬â¢t deny the fact that educated people acquire the most number of properties and wealth. Meanwhile, if our society is still living in the values of belonging, definitely education will be free for all. Because in the values of belonging, everyone is equal and there is no competition. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã We can apply the culture of enterprise to those societies where there is gender inequality. In those cultures where women are treated as second class citizen, women are deprived of the rights to education. It is because education can uplift the status of women in the society. Educated women will threaten the status of men in the society. Educated women can acquire more property than educated women. Here we can see that there is aggression and competition which are qualities of culture of enterprise. I believe that moving the values of belonging can be a solution to this gender inequality in education because the said values promote equality. When we move to the values of belonging, there will be an absence of competition between men and women in the society. Men will not be threatened by educated women. Equal opportunity for education will be easy to achieve. http://www.tworock.org/Values%20of%20Belonging.htm http://www.sapphireblue.com/dissident_feminist/factions.shtml#amazon
Wednesday, August 21, 2019
The Origins Of Opera ITALIAN OPERA is both the art of opera in Italy and opera in the Italian language. Opera was born in Italy around the year 1600 and Italian opera has continued to play a dominant role in the history of the form until the present day. Many famous operas in Italian were written by foreign composers, including Handel, Gluck and Mozart. Works by native Italian composers of the 19th and early 20th centuries, such as Rossini, Bellini, Donizetti, Verdi and Puccini, are amongst the most famous operas ever written and today are performed in opera houses across the world. Dafne by Jacopo Peri was the earliest composition considered opera, as understood today. Peris works, however, did not arise out of a creative vacuum in the area of sung drama. An underlying prerequisite for the creation of opera proper was the practice of monody. Monody is the solo singing/setting of a dramatically conceived melody, designed to express the emotional content of the text it carries, which is accompanied by a relatively simple sequence of chords rather than other polyphonic parts. Italian composers began composing in this style late in the 16th century, and it grew in part from the long-standing practise of performing polyphonic madrigals with one singer accompanied by an instrumental rendition of the other parts, as well as the rising popularity of more popular, more homophonic vocal genres such as the frottola and the villanella. In these latter two genres, the increasing tendency was toward a more homophonic texture, with the top part featuring an elaborate, acti ve melody, and the lower ones (usually these were three-part compositions, as opposed to the four-or-more-part madrigal) a less active supporting structure. From this, it was only a small step to fully-fledged monody. All such works tended to set humanist poetry of a type that attempted to imitate Petrarch and his Trecento followers, another element of the periods tendency toward a desire for restoration of principles it associated with a mixed-up notion of antiquity. By the end of the 17th century some critics believed that a new, more elevated form of opera was necessary. Their ideas would give birth to a genre, opera seria (literally serious opera), which would become dominant in Italy and much of the rest of Europe until the late 1700s. The influence of this new attitude can be seen in the works of the composers Carlo Francesco Pollarolo and the enormously prolific Alessandro Scarlatti. During the eighteenth century artistic and cultural life in Italy was heavily influenced by the aesthetic and poetic ideals of the members of the Accademia dellArcadia. The Arcadian poets introduced many changes to serious music drama in Italian, including: the simplification of the plot the removal of comic elements the reduction of the number of arias a predilection for plots drawn from ancient Classical or modern French tragedy, in which the values of loyalty, friendship and virtue were extolled and the absolute power of the sovereign was celebrated By far the most successful librettist of the era was Pietro Metastasio and he maintained his prestige well into the 19th century. He belonged to the Arcadian Academy and was firmly in line with its theories. A libretto by Metastasio was often set by twenty or thirty different composers and audiences came to know the words of his dramas by heart. In the 1600s comic operas were produced only occasionally and no stable tradition was established. Only in the early years of the 18th century was the comic genre of opera buffa born in Naples and it began to spread throughout Italy after 1730. Opera buffa was distinguished from opera seria by numerous characteristics: the importance given to stage action and the consequent need for the music to follow the changes of the drama, emphasising the expressiveness of the words the choice of singers who were also excellent actors able to perform the drama convincingly a reduction in the use of scenery and stage machinery and in the number of orchestral players the use of a small cast of characters (at least in the short form of comic opera known as the intermezzo) and simple plots, a good example being Pergolesis La serva padrona libretti inspired by commedia dellarte, with realistic subjects, colloquial language and slang expressions as far as singing was concerned: the complete rejection of vocal virtuosity; a tendency to an incorrect pronunciation of the words; the frequent presence of rhythmic and melodic tics; the use of onomatopoiea and interjections. In the second half of the 18th century comic opera owed its success to the collaboration between the playwright Carlo Goldoni and the composer Baldassare Galuppi. Thanks to Galuppi, comic opera acquired much more dignity than it had during the days of the intermezzo. Operas were now divided into two or three acts, creating libretti for works of a substantially greater length, which differed significantly from those of the early 18th century in the complexity of their plots and the psychology of their characters. These now included some serious figures instead of exaggerated caricatures and the operas had plots which focussed on the conflict between the social classes as well as including self-referential ideas. Goldoni and Galuppis most famous work together is probably Il filosofo di campagna (1754). The collaboration between Goldoni and another famous composer NiccolÃ ² Piccinni produced another new genre: opera semiseria. This had two buffo characters, two nobles and two in between characters. The one-act farsa had a significant influence on the development of comic opera. This was a type of musical drama initially considered as a condensed version of a longer comic opera, but over time it became a genre in its own right. It was characterised by: vocal virtuosity; a more refined use of the orchestra; the great importance given to the production; the presence of misunderstandings and surprises in the course of the drama. Glucks reforms Opera seria had its weaknesses and critics; a taste for embellishment on behalf of the superbly trained singers, and the use of spectacle as a replacement for dramatic purity and unity drew attacks. Francesco Algarottis Essay on the Opera (1755) proved to be an inspiration for Christoph Willibald Glucks reforms. He advocated that opera seria had to return to basics and that all the various elements-music (both instrumental and vocal), ballet, and staging-must be subservient to the overriding drama. Several composers of the period, including NiccolÃ ² Jommelli and Tommaso Traetta, attempted to put these ideals into practice. The first to really succeed and to leave a permanent imprint upon the history of opera, however, was Gluck. Gluck tried to achieve a beautiful simplicity. This is illustrated in the first of his reform operas, Orfeo ed Euridice, where vocal lines lacking in the virtuosity of (say) Handels works are supported by simple harmonies and a notably richer-than-usual orc hestral presence throughout. Glucks reforms have had resonance throughout operatic history. Weber, Mozart and Wagner, in particular, were influenced by his ideals. Mozart, in many ways Glucks successor, combined a superb sense of drama, harmony, melody, and counterpoint to write a series of comedies, notably CosÃ ¬ fan tutte, The Marriage of Figaro, and Don Giovanni (in collaboration with Lorenzo Da Ponte) which remain among the most-loved, popular and well-known operas today. But Mozarts contribution to opera seria was more mixed; by his time it was dying away, and in spite of such fine works as Idomeneo and La Clemenza di Tito, he would not succeed in bringing the art form back to life again.  Instrumental music The dominance of opera in Italian music tends to overshadow the important area of instrumental music. Historically, such music includes the vast array of sacred instrumental music, instrumental concertos, and orchestral music in the works of Andrea Gabrieli, Giovanni Gabrieli, Tomaso Albinoni, Arcangelo Corelli, Antonio Vivaldi, Luigi Boccherini, Luigi Cherubini and Domenico Scarlatti. (Even opera composers occasionally worked in other forms-Giuseppe Verdis String Quartet in E minor, for example. Even Donizetti, whose name is identified with the beginnings of Italian lyric opera, wrote 18 string quartets.) In the early 20th century, instrumental music began growing in importance, a process that started around 1904 with Giuseppe Martuccis Second Symphony, a work that Malipiero called the starting point of the renascence of non-operatic Italian music. Several early composers from this era, such as Leone Sinigaglia, used native folk traditions. The early 20th century is also marked by the presence of a group of composers called the generazione dellottanta (generation of 1880), including Franco Alfano, Alfredo Casella, Gian Francesco Malipiero, Ildebrando Pizzetti, and Ottorino Respighi. These composers usually concentrated on writing instrumental works, rather than opera. Members of this generation were the dominant figures in Italian music after Puccinis death in 1924. New organizations arose to promote Italian music, such as the Venice Festival of Contemporary Music and the Maggio Musicale Fiorentino. Guido Gattis founding of the periodical il Piano and then La rassegna musicale also helped to promote a broader view of music than the political and social climate allowed. Most Italians, however, preferred more traditional pieces and established standards, and only a small audience sought new styles of experimental classical music.[
Tuesday, August 20, 2019
Health and Social Care Essays red dot system Introduction In the frequently frantic and universally pressured world of the AE departments of this countrys hospitals, mistakes get made. This is a fact of life. In any human endeavour this is sadly true. Until recently, the blame culture that was prevalent within the NHS, made certain defensive behaviour patterns amongst staff almost endemic (Vincent, 1994). It is one of the characteristics of a professional life that you have to take responsibility for your actions. If you take the wrong action, you will be criticised. This defensive attitude was, to a large extent, fostered by the professional health insurers who, worried about paying out large quantities of their funds, demanded secrecy, no apology and a defensive stance from those that they insured.(Clinical Services Committee) It became apparent to those who were in a position to have an overview of the situation that such a situation was actually in nobodys interest (Barley, 2000). Healthcare professionals were practising defensive medicine, patients were being kept in the dark when mistakes were made, and most important of all, because problems were not examined in an open and constructive way, productive lessons were not learnt. All that was happening was that defensive stances were becoming entrenched. The advent of the no-blame culture is helping to erode these stances and attitudes (Aldridge 2000). It is allowing the development of practices which may help the efficiency of our hospitals and provide the patient with a better service. The red dot system arose as a product of both of these factors. The pressure on the AE department staff is often relentless and great. The structure of the system is that many decisions are taken by comparatively inexperienced staff members and often not the most appropriate for the decision that needs to be taken. Huge numbers of X-Rays are seen by junior doctors and decisions regarding treatment are initially made before a senior specialist has a chance to oversee them. It would follow, by any common sense analysis of the situation, that any measure that could help in the decision making process should be welcomed. This argument is taken further by the article by Vincent et al. (1988) . In the days before the red dot system was seriously considered, Vincent and his colleagues carried out a study of the radiological errors made by junior hospital doctors. They found an error rate of 35% when the X-Ray was assessed by the SHO alone. For errors with a clinically significant impact the rate was 39% (of abnormal films). The red dot system represents a mechanism to try to address this gap. It involves the radiographer usually, but not always, the one who has taken the film giving the clinician some feed back. Radiographers see many thousands of films and are generally very familiar with the structures that they show. Quite apart from their formal training, simply by everyday familiarity and experience, they get to know what is normal and what is not. The radiographer is therefore well placed to recognise an abnormality even though they may not fully appreciate the full clinical significance of what is on the film. The same argument can be applied to the clinician, who can generally recognise pathology in a patient but may not be so familiar with the X-Ray changes. The red dot system requires the radiographers to examine the film after it has been ordered by the clinician. If they feel that there is an abnormality on it they will place a self-adhesive red dot on it to denote that they believe that it contains an abnormality. Clearly this does not relieve the clinician of the responsibility of examining the film as, the legal responsibility for interpreting the film must rest with him. This is only reasonable since even the most experienced radiologist would only give a report on what he could see on the film, the full significance of the changes seen can only be fully assessed by a healthcare professional who has also seen and assessed the patient. As we will discuss later, the converse argument that the absence of a red dot does not imply that there isnt an abnormality it only denotes that the radiographer hasnt seen one. The red dot system In a letter to the BMJ Keith Piper (2003) outlined the case for the red dot system and the radiographer reporting system (See on). It was initially suggested by the Audit Commission in 1993 that radiographers could be trained to interpret certain images and this was found to be of particular interest in view of the difficulties that some departments currently experience with the reporting service The first accredited course was run in 1994 many radiographers have since been reporting on primary skeletal X-Rays in AE departments Piper points out that the system is designed to reduce errors in reporting X-Rays. It is ultimately totally reliant on the radiographs being finally reported by a senior radiologist in a timely fashion. Unfortunately, this is not always the case as Beggs pointed out in 1990 when it was found that over 20% of UK teaching hospitals did not report on all accident and emergency films With specific reference to the red dot system, the letter by Aldridge and Freeland (2000) passes comment on the system which is in use in their hospital and, having audited it, they present their results. The system in use conforms to that currently outlined by British Association of Accident and Emergencys guidelines (1983). The important facets of their system include The rapid return of X-Rays to the requesting clinician Reporting of X-Rays by a consultant radiologist within 24 hrs. Telephone recall of patients who have mistakes picked up The use of the red dot system by the radiographers The use of such X-Rays for teaching purposes for staff As far as the audit of the red dot system was concerned, they report the last audit showed an 1.5% false positive result, 2.0% false negative result with the rest categorised as true positive or negative results. The authors felt that this represented an excellent approach to what they described as an error prone activity, reducing mistakes by accident and emergency staff (often junior), increasing patient satisfaction, and reducing long term patient morbidity and litigation. This letter is a significant piece of evidence as it is written by two clinicians who are clearly anxious to assess the system and to make it work. They appreciate the problems, quantify them and address them by placing safeguards to minimise problems. Significantly, they suggest the use of the red dot system where it has picked up omissions by the clinical staff to be the basis of teaching junior staff in an attempt to further reduce potential problems. These results should be seen in the context of a study by de Lacey et al.(client to supply date) who considered the accuracy of casualty officers interpretation or X-Rays in their departments. They found that by comparing the casualty officers interpretation with that of a radiologist, it only compared favourably in 83% of cases. The 17% discrepancy clearly represents a major burden in terms of clinical implications for the patient, financial implications for the hospital and possibly litigation implications for the casualty officer. The study also examines the implications of a delayed reporting system (by the radiologist). It was found to reduce their workload by 25% by restricting their reporting to those films which the casualty officer was unsure or thought may have an abnormality. It clearly follows from this that any measure that is likely to increase efficiency inaccuracy of reporting is likely to have benefits of both economy and patient suffering. We therefore need to exami ne the premise that the red dot system does exactly that. These figures are clearly worrying insofar as the 17% discrepancy is a wide margin. The figures still have to be viewed in context however as, although they represent the interpretation of as specialist (the radiologist) as compared with that of the non-specialist (the clinician), the paper does not draw any distinction between the experience levels of the two groups. The clinicians may be comparatively inexperienced casualty officers and the radiologists probably are consultant grade. If that is the case, then the figures are much less alarming. This point is discussed in detail further on in the piece (Williams et al 2000) where radiologists in training are compared to radiologists of consultant grade. The point is brought into sharper focus by consideration of the next two papers. Before we consider this aspect however, we need to evaluate the accuracy of reporting in the AE Department environment. Benger and Lyburn (2003) attempted to investigate exactly that. They scrutinised the X-Ray output of an AE Department over a six month period (nearly 12,000 films). They identified the films which had discrepancies in reporting between the X-Ray staff and the AE Department staff. From the 12,000 films they found (only) 175 discrepancies. In clinical terms, this equated to a rate of 0.3% of patients who needed a change of management as a result. In all our deliberations on the subject, perhaps it is this that actually is the subjective criteria for whether a system works within tolerable limits or not. Different studies may find different discrepancy rates in interpretation of X-Ray films, but what is of practical value is the actual number of patients who require a change of management as a result. If a minor degree of subluxation of a proximal interphalangeal joint is missed by a casualty officer and subsequently picked up by a radiologist, it will appear on inventories of discrepancies such as the ones discussed above. In terms of patient care or treatment, it will not make a scrap of difference. This point is made, rather more eloquently and in a different context, by Fineberg (1977) and the Institute of Medicine (1977). This point should not be taken lightly and indeed, it goes to the core of this piece. Academic studies may show different abnormality detection rates between the different professional groups. While recognising that these are clearly important, they are not the yardstick by which we must judge the red dot system. We have already examined two papers on the subject that have reported differences in abnormality detection at each end of the spectrum one of 17% and one of 1.5%. We should not be blinded by these figures themselves. What actually matters is the number of patients who have a change of management decision as a result of this discrepancy. The paper quoted above (Benger and Lyburn 2003) is one of the few which actually gives us this information. They quote an observed change of management in only 0.3% of patients which, for any system, is a very tolerable level of error. This is clearly a very fundamental point and one that we need to examine further. The next paper that we sh ould consider looks at exactly this point and examines it in great detail. Taking a more academic approach Brealey and Scally (2001) tackle the difficult issue of just how to interpret the findings of a study that purports to evaluate the reading of X-Rays by two or more different professional groups. This is a very technical paper and is included here for the sake of completeness. It examines all of the possible margins for error and bias when reporting a trial. It throws little direct light onto our deliberations here because of its very technical nature, but it would be of considerable importance to one who wished to interpret the findings of a major trial independently. The point needs making that the trial design can influence the outcome of the trial (and therefore its usefulness) to a great extent. As we have made the point above, the actual figures produced at the end of the trial must be interpreted in the light of the trial design. Actual detected differences in readings between two groups of professionals may be of academic interest, but in the c ontext of our examination of the red dot system, they are not nearly as important as a critical examination of the discrepancies which resulted in a change of patient menagement. On the direct issue of the red dot system, an almost immediate precursor to the system was reported in the BMJ in 1991 by Renwick et al. . He discussed a system that was tried out of getting radiologists to indicate their diagnoses on the pre-reported X-Rays, in order to guide the casualty officers in their decisions. The conclusions of the study were that, because of the high rate of false positive reporting (7%) and higher rate of false negatives (14%) it was appropriate for radiologists to offer useful advice but to take no more responsibility than that. We shall discuss the issues of false positives and false negatives further on in this piece and clearly they are an inherent problem with the system. It follows that we should, perhaps, address the reasons why there are these discrepancies and use them as a learning exercise to try to reduce the gap. In the excellent and concise article written by Touquet et al. (1995) the authors address the Ten Commandments of AE Department radiology. They discuss the red dot system in the following terms. Inexperienced doctors will inevitably come across injuries that they have never seen before. In these cases it may not be possible to make a diagnosis but you will notice that the films do not look quite right. Good examples of this are lunate and perilunate dislocations of the hand. It is important to seek senior advice and also to listen to the radiographer. Many departments operate a red dot system, in which the radiographer flags up an abnormality. An experienced radiographer may be as good as or even better than a junior doctor at interpreting films. The problem with this system is that the absence of a red dot does not necessary mean that there is no abnormality. This is important to remember because the final responsibility lies with the doctor, and not the radiographer. Therefore never accept poor quality or inadequate films. The most salient point of this article is in the last paragraph. The absence of a red dot does not mean the absence of an abnormality and the liability lies with the doctor not the radiographer. This is clearly proper, as any experienced healthcare professional will state, any investigation (particularly an X-Ray) is only an adjunct to diagnosis, it is the person who is clinically in charge of the patient who has to assimilate all the available evidence to make a diagnosis. The radiographer has not seen the patient to examine, and certainly will not have to hand all of the other potential diagnostic aids that are available in a modern AE Department. It is entirely reasonable to ask for his opinion on an X-Ray film, but it is not reasonable to hold him responsible for its definitive interpretation when he has not seen it in the context of the patient. This statement is behind the reasoning for the legal responsibility of X-Ray interpretation. It would be clearly inappropriate to ask a radiographer for his opinion on a film and then make him responsible for any subsequent management decisions that were based on that opinion. Some commentators have criticised the red dot system for its clear lack of apportionment of responsibility to the radiographer. We would suggest that this shows a fundamental lack of appreciation of the problems involved. The radiographers are trained to be experts in taking X-Ray films. They are not, and do not pretend to be, trained in the biological sciences and their applications to pathology and the human disease processes. It is quite appropriate to ask their opinion in an area of their expertise (the interpretation of the X-Ray film), but it is quite inappropriate to ask them to make clinical management decisions. For this reason, all questions of liability always rest on the clinician in charge of the p atient, and it is only right that this should be the case. It is fair to say that some of the views reviewed so far have been old school necessarily so, as the intention was to document the evolution of the red dot system. It is equally fair to state that we have only considered the use of the system in the AE Department. The truth of the matter is that in the recent past, the status of the radiographer has increased in professionalism both within their own speciality and within the NHS as a whole. Many of the comments made in some of the earlier papers quoted will therefore, now seem rather outmoded and not consistent with the modern experience of working in the NHS. To redress the balance we shall look at an article from Papworth hospital by Sonnex et al; (2001) . The authors describe a system currently in use at an acute cardiothoracic unit. Radiographers were asked to assess all the X-Rays taken over a six month trial period. Those that were assessed as showing acute changes had a red dot placed on them to denote an abnormality and these were then assessed by a radiologist. The success or failure rate was then measured against this standard. The figures are rather different from the figures quoted in the studies that looked at skeletal X-Ray in AE Departments. The reason for this is almost certainly that a chest X-Ray is notoriously hard to interpret, even more so when it is a post operative X-Ray. The results were reported as a total sample of 8614, of which 464 (5%) had red dots applied. Over 100 of these were considered inappropriate. 38 X-Rays which were abnormal were not picked up. It would appear that radiographers tend to err on the side of caution when reviewing an abnormal chest X-Ray, even more so when previous comparative films were not available for comparison. This particular study had a high false positive rate. One should not lose sight of the fact that the radiographers concerned were dealing with a different population to those that we were considering earlier. The patients were generally very ill and often in a post operative state making assessment far more critical than perhaps the colder X-Ray of the AE Department where decisions could reasonably be delayed safely for 24-48 hrs. there was therefore perhaps far more pressure on them to report any possible abnormality. It is also appropriate to comment that this was the first stage of a study which then went on to review the radiographers performance after a further period of training. One would reasonably anticipate a higher agreement rate after appropriate training. As we have already seen the red dot system has evolved in several different variants. The basic premise is the same in each case how is it possible to minimise the potential sources of error caused by inexperience? A further variant is outlined by Williams et al (2000). His paper title specifically involves the cost effectiveness of the scheme as well as the overall impact on patient management. In this scheme ( which was running at the Radcliffe Hospital in Oxford) the original AE Department films were reviewed by radiologists-in-training. They identified 684 incorrect diagnoses over a one year period. These were then called red reports and reviewed by a consultant radiologist. During this process 351 missed fractures were detected with ankle, finger and elbow fractures being the main areas where pathology was missed. Williams also reported 11 incidences of pathology on a chest X-Ray as being missed. This amplifies the point made earlier that the radiologists-in-training tended to produce false positives at a rate of about 18% when compared to the subsequent, more expert opinion. In this particular study, further action was taken by the AE Department staff in 42% of those cases although no operative intervention was required in any patient as a result of the missed diagnosis. Despite these figures, it must be noted that these cases form a very small percentage of the X-Rays taken in a busy AE Department False positives and false negatives We have looked at a number of studies that have compared radiographers interpretations of X-Ray films against that of a Consultant Radiologist who has generally been used as the Gold Standard. The difference between the two sets of interpretations is then subdivided into false positives and false negatives. This group is actually the most important as it is firstly an indication of the usefulness of the whole system of red dot reporting and secondly it is also an indication of how much more training any particular reader (radiographer or casualty officer ), of the films has to undergo, in order to make fully competent assessments. The false positive is the situation where the radiographer has identified a problem that is not there. Conversely, the false negative is when they have missed pathology that is there. In most of the assessments that we have seen, there are more false positives than negatives. This implies that the radiographers are being over cautious when confronted with an equivocal film. Several of the papers that we have seen so far have stated (either explicitly or otherwise) that the absence of a red dot does not imply the absence of any pathology. Any common-sense analysis of the situation would suggest that this is clearly self-evident. It must be the case where two highly trained but clearly not expert healthcare professionals are looking at a film for pathology, they are probably more likely to arrive at the right answer than one alone. Brealey (2005) produced a Meta-analysis of studies involving radiographers input in interpreting films and found that radiographers involved either in the red dot system of X-Ray reading improved with experience and with training, acquired an accuracy approaching that of radiologists when dealing with skeletal X-Rays. The red dot system is designed to utilise the expertise of specially trained radiographers to interpret plain X-Rays. From the evidence presented above we can say that there is evidence that radiographers are clearly more expert in interpreting plain skeletal X-Rays than chest X-Rays or visceral radiographs. The red dot system appears to be a growing movement within the profession. A paper by Brealey (2003) pointed out the fact that between 1968 and 1991 the radiologists workload increased by 322% but the number of posts increased by only 213%. As a result of this the number of films successfully reported within 48hrs fell to 60%. As a result of this trend the Royal College of Radiologists decided to endorse the trend of radiographers giving indications of pathology on X-Rays . Brealeys paper examines the initial cohort of radiographers who were trained under this scheme and found that, statistically, there was no significant difference between the reading of an X-Ray by a radiograph er or a radiologist (in the case of plain skeletal X-Rays) which supports the view that the red dot system is viable. Any examination of this issue would be incomplete without a consideration of the detailed and analytical paper by Friedenberg (2000) which he provocatively entitled The advent of the supertechnologist. It is particularly relevant to our consideration of the red dot system and the role of the radiographer as it looks at the background to the whole issue. Friedenberg uses the term Skill mix as a specific term to define the current trend in medicine away from specialisation and departmentalisation and towards the communal utilisation of expertise from different individuals in related fields to complement or increase the expertise available to patients. He points out that this is not actually a new concept and cites the optician who relieves the workload of the ophthalmologist and the nurse specialist anaesthetist who relieves the anaesthesiologist by performing uncomplicated procedures. He quotes a whole host of paramedical providers who now assist the physician, in most cases without p roblems Loughran et al (1996a, 1996b, 1992) have specifically looked at the practicality of utilising the skills of the radiographer to better advantage than just taking the films. He contrasts the difference in practice between the UK and the USA, citing the cause of the complete separation of the roles of radiographer and radiologist in the USA as being due to the fact that in the USA, the radiologists still operate largely on a fee-per-service basis whereas in the UK the pressure is primarily on clinicians to become more efficient and to keep costs down. Friedenberg, interestingly also examines the evolution of the legality of the roles of radiographer and radiologist. Between 1900 and 1920, there was competition between radiographers and radiologists with regard to the performance of radiography and the interpretation of radiographs. In the middle 1920s in England, radiographers were prohibited from accepting patients for radiography except under the direction of a qualified medical practitioner (Quotes Larkin 1983) After this the professions came closer and by 1971 Swinburne (1971) was suggesting that radiographers could perfectly well separate normal from abnormal films, which after all is the basis behind the red dot system . As we have discussed earlier, this move then progressed into the first formal appearance of the red dot system in North Park Hospital in 1985. The first trials of the system found that approximately half of the abnormalities that were not picked up by the junior casualty officers were detected by the radiographers. The early safe guards were outlined by Loughran (1996) as follows: 1. It is made clear to the referring physician that the report is a technologists report. The physician is encouraged to consult the radiologist if there is a lack of clinical correlation. 2. The technologist must consult the radiologist if he or she is in doubt. 3. The physicians, radiologists, and technologists have devised a set of guidelines to create a safe environment for this practice. 4. Initially, the technologists practice is monitored on a regular basis. After the technologist is experienced, however, monitoring is no longer performed. Such monitoring should be performed if a new technologist enters this practice. Interestingly, Loughran also subsequently produced a set of guidelines for the radiographer : 1. The technologist should be confident in his or her report. 2. In cases of doubt, a radiologists opinion should be obtained. 3. In such cases, although the report may be issued by the reporting technologist, the consultants name should be appended to the report. 4. All reports by a technologist should be clearly designated as a technologists report. 5. If the patient re-presents for radiography of the same body part within 2 months, this should be reported by a radiologist. 6. Non-trauma examination findings should be reported by the radiologist. 7. All accident department images in patients who are subsequently admitted as inpatients should be reported by the radiologist. 8. Clinicians are to be advised to consult the radiologist if clinical findings do not match those in the technologists report. 9. Regular combined reporting sessions are to be held with the consultant radiologist. Robinson (1999) Defines the ideal areas for radiographers and radiologists with the following definition between cognitive and procedural tasks thus: Procedural tasks can be described, defined, taught, and subjected to performance standards that make them transferable to other staff with appropriate training. Cognitive tasks that are related not only to the interpretation of images but also to decisions about differential diagnosis and appropriate choice of further investigations are more difficult. We have examined the evolution of the red dot system and there have been moves towards the logical progression beyond the radiographer simply indicating that there may be a problem to the situation where radiographer who have undertaken further training have developed their skills in other ways as well, but this is beyond the scope of this piece. Perhaps we should leave the last thought to Friedenberg who envisages the future as being the era of the Supertechnologist and it is the specialist who is left to do a small number of very highly specialised procedures. References 1. Jonathan Aldridge, Peter Freeland, (2000) Safety of systems can often be improved BMJ 2000;321:505 ( 19 August ) 2. The Audit Commission (1995). Improving Your Image How to manage Radiology Services More Effectively. London: HMSO.1995 3. Victor Barley, Graham Neale, Christopher Burns-Cox, Paul Savage, Sam Machin, Adel El-Sobky, Anne Savage (2000) Reducing error, improving safety BMJ 2000;321:505 ( 19 August ) 4. Beggs I, Davidson JK 1990. AE reporting in UK teaching departments. Clinical Radiology, 41, 264-267. 5. J R Benger, I D Lyburn (2003) What is the effect of reporting all emergency department radiographs? Emerg Med J 2003; 20:40-43n. 6. Benger JR. (2002) Can nurses working in remote units accurately request and interpret radiographs? Emerg Med J. 2002 jan;19(1):68-70 7. S Brealey, A J Scally (2001) Bias in plain film reading performance studies British Journal of Radiology 74 (2001),307-316 8. S Brealey, D G King, M T I Crowe, I Crawshaw, L Ford, N G Warnock, R A J Mannion, S Ethell,(2003) Accident and Emergency and General Practitioner plain radiograph reporting by radiographers and radiologists: a quasi-randomised controlled trial British Journal of Radiology (2003) 76, 57-61 9. Brealey S, Scally A, Hahn S, Thomas N, Godfrey C, Coomarasamy A. (2005) Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. Clin Radiol. 2005 Feb;60(2):232-41 10. Brennan TA, Leape LL, Laird NM, Herbert L, Localio AR, Lawthers AG, (1991) Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice study. N Engl J Med 1991; 324: 370-376 11. Clinical Services Committee, British Association for Accident and Emergency Medicine. X-ray reporting for accident and emergency departments. London: BAEM, 1983. (Currently under revision.) 12. C K Connolly (2000) Relation between reported mishaps and safety is unclearBMJ 2000;321:505 ( 19 August ) 13. Fineberg HV, Bauman R, Sosman M. (1997) Computerised cranial tomography: effect on diagnostic and therapeutic plans. Institute of Medicine. Policy statement: Computed tomographic scanning. Washington DC: National Academy of Sciences, JAMA 1977;238:224-7. 14. Richard M. Friedenberg, (2000) The Role of the Supertechnologist Radiology. 2000;215:630-633.) 15. Johansson H, RÃÆ'Ã ¤f L. (1997) A compilation of diagnostic errors in Swedish health care. Missed diagnosis is most often a fracture.Lakartidningen 1997; 94: 3848-3850 16. Pia Maria Jonsson, GÃÆ'Ã ¶ran Tomson, Lars RÃÆ'Ã ¤f, (2000) No fault compensation protects patients in Nordic countries BMJ 2000;321:505 ( 19 August ) 17. G de Lacey, A Barker, J Harper and B Wignall An assessment of the clinical effects of reporting accident and emergency radiographs 18. Larkin G. (1983) Occupational monopoly and modern medicine London, England: Tavistock, 1983. 19. DD Loughran CF, Alltree J, Raynor RB, (1996) Skill mix changes in departments of radiology: impact on radiologists workloadreports of a scientific session.
Monday, August 19, 2019
1764 saw the birth of Gothic literature with the novel 'The Castle of Otranto', written by Horace Walpole. Although, this novel was based on some much earlier literature it set the standard for all the gothic novels that followed. The 18th century was a time when political power was in the hands of a few rich men. Women did not have the vote, let alone any legal rights. The majority of the population lived in poverty. However things were changing ? the Church was no longer as powerful and the social structure was being questioned. For example, in 1789 the French monarchy was overthrown by the masses starting the French revolution. People were no longer so willing to accept their ?lot in life?. It was in this background that the genre of Gothic literature was first written. It was called gothic because it placed emphasis on emotions such as awe, terror, insignificance and vulnerability. Gothic novels were fascinated with the grotesque, horrible and supernatural. They were a reaction against realistic literature of the 18th century. Some saw it as a sub-genre of romantics but others argued it was a genre in its own right. Whatever its genre, gothic novels were typically characterized by their romanticism, melodrama and dark foreboding settings. They were critical of the society of the day and fiercely anti- catholic, disliking the church?s power and brutality. Some of the main gothic writers of the time included Edgar Alan Poe, Charles Dickens, H.G.Wells, Charlotte and Emily Bronte. By the end of the19th century Mary Shelley?s famous novel of Frankenstein had been published and later on Bram Stoker?s Dracula. Of all the stories written in the gothic era, they all contain many of the typical gothic ... ...ation and descriptive language. Also, with The Tell Tale Heart the tension and suspense has great effect, making the reader wanting to read on. The building of suspense through specific language and literary devices is so firm and efficient that ?The Tell-Tale Heart? has become one of the most famous Gothic short stories in English literature. Poe?s choice of words is known to be precise and concise, and so is his writing style: no devices are used without having certain effects. The Cask of Amontillado is the least representative of the genre because it does not contain so many gothic features and the narrator has a reason for killing: revenge. I believe gothic literature has remained so popular because people like to be thrilled by horror and ghost stories and the central themes never age. The reader can empathise with the story without having to believe it.