Night World Huntress Chapter 1 Free Essays

It’s simple,† Jez said on the night of the last hunt of her life. â€Å"You run. We chase. We will write a custom essay sample on Night World : Huntress Chapter 1 or any similar topic only for you Order Now If we catch you, you die. Well give you three minutes head start.† The skinhead gang leader in front of her didn’t move. He had a pasty face and shark eyes. He was standing tensely, trying to look tough, but Jez could see the little quiver in his leg muscles. Jez flashed him a smile. â€Å"Pick a weapon,† she said. Her toe nudged the pile at her feet. There was a lot of stuff there- guns, knives, baseball bats, even a few spears. â€Å"Hey, take more than one. Take as many as you want. My treat.† There was a stifled giggle from behind her and Jez made a sharp gesture to stop it. Then there was silence. The two gangs stood facing each other, six skinhead thugs on one side and Jez’s gang on the other. Except that Jez’s people weren’t exactly normal gang members. The skinhead leader’s eyes shifted to the pile. Then he made a sudden lunge and came up with something in his hand. A gun, of course. They always picked guns. This particular gun was the kind it was illegal to buy inCalifornia these days, a large caliber semiautomatic assault weapon. The skinhead whipped it up and held it pointed straight at Jez. Jez threw back her head and laughed. Everyone was staring at her-and that was fine. She looked great and she knew it. Hands on her hips, red hair tumbling over her shoulders and down her back, fine-boned face tipped to the sky-yeah, she looked good. Tall and proud and fierce†¦ and very beautiful. She was Jez Redfern, the huntress. She lowered her chin and fixed the gang leader with eyes that were neither silver nor blue but some color in between. A color he never could have seen before, because no human had eyes like that. He didn’t get the clue. He didn’t seem like the brightest. â€Å"Chase this,† he said, and he fired the gun. Jez moved at the last instant. Not that metal through the chest would have seriously hurt her, but it might have knocked her backward and she didn’t want that She’d just taken over the leadership of the gang from Morgead, and she didn’t want to show any weakness. The bullet passed through her left arm. There was a little explosion of blood and a sharp flash of pain as it fractured the bone before passing on through. Jez narrowed her eyes, but held on to her smile. Then she glanced down at her arm and lost the smile, hissing. She hadn’t considered the damage to her sleeve. Now there was a bloody hole in it. Why didn’t she ever think about these things? â€Å"Do you know how much leather costs? Do you know how much aNorthBeach jacket costs?† She advanced on the skinhead leader. He was blinking and hyperventilating. Trying to figure out how she’d moved so fast and why she wasn’t yelling in agony. He aimed the gun and fired again. And again, each time more wildly. Jez dodged. She didn’t want any more holes. The flesh of her arm was already healing, closing up and smoothing over. Too bad her jacket couldn’t do the same. She reached the skinhead without getting hit again and grabbed him by the front of his green and black Air Force flight jacket. She lifted him, one handed, until the steel toes of his Doc Marten boots just cleared the ground. â€Å"You better run, boy,† she said. Then she threw him. He sailed through the air a remarkable distance and bounced off a tree. He scrambled up, his eyes showing white with terror, his chest heaving. He looked at her, looked at his gang, then turned and started running through the redwoods. The other gang members stared after him for a moment before diving for the weapons pile. Jez watched them, frowning. They’d just seen how effective bullets were against people like her, but they still went for the guns, passing by perfectly good split-bamboo knives, yew arrows, and a gorgeous snakewood walking stick. And then things were noisy for a while as the skinheads came up from the pile and started firing. Jez’s gang dodged easily, but an exasperated voice sounded in Jez’s head. Can we go after them now? Or do you want to show off some more? She flicked a glance behind her. Morgead Blackthorn was seventeen, a year older than she, and her worst enemy. He was conceited, hotheaded, stubborn, and power-hungry-and it didn’t help that he was always saying she was all those things, too. â€Å"I told them three minutes,† she said out loud. â€Å"You want me to break my word?† And for that instant, while she was snarling at him, she forgot to keep track of bullets. The next thing she knew Morgead was knocking her backward. He was lying on top of her. Something whizzed over both of them and hit a tree, spraying bark. Morgead’s gem-green eyes glared down into hers. â€Å"But†¦ they’re .. . not. . . running,† he said with exaggerated patience. â€Å"In case you hadn’t noticed.† He was too close. His hands were on either side of her head. His weight was on her. Jez kicked him off, furious with him and appalled at herself. â€Å"This is my game. I thought of it. We play it my way!† she yelled. The skinheads were scattering anyway. They’d finally realized that shooting was pointless. They were running, crashing through the sword fern. â€Å"Okay, now!† Jez said. â€Å"But the leader’s mine.† There was a chorus of shouts and hunting calls from her gang. Val, the biggest and always the most impatient, dashed off first, yelling something like â€Å"Yeeeeeehaw.† Then Thistle and Raven went, the slight blond and the tall dark girl sticking together as always. Pierce hung back, staring with his cold eyes at a tree, waiting to give his prey the illusion of escaping. Jez didn’t look to see what Morgead was doing. Why should she care? She started off in the direction the skinhead leader had taken. But she didn’t exactly take his path. She went through the trees, jumping from one redwood to another. The giant sequoias were the best; they had the thickest branches, although the wart like bulges called burls on the coastal redwoods were good landing places, too. Jez jumped and grabbed and jumped again, occasionally doing acrobatic flips when she caught a branch just for the fun of it. She loved Muir Woods. Even though all the wood around her was deadly-or maybe because it was. She liked taking risks. And the place was beautiful: the cathedral silence, the mossy greenness, the resinous smell. Last week they’d hunted seven gang members throughGolden GatePark . It had been enjoyable, but not really private, and they couldn’t let the humans fight back much. Gunshots in the park would attract attention. Muir Woods had been Jez’s idea- they could kidnap the gang members and bring them here where nobody would disturb them. They would give them weapons. It would be a real hunt, with real danger. Jez squatted on a branch to catch her breath. There just wasn’t enough real danger in the world, she thought. Not like the old days, when there were still vampire hunters left in the Bay Area. Jez’s parents had been killed by vampire hunters. But now that they’d all been eliminated, there wasn’t anything really scary anymore†¦. She froze. There was an almost inaudible crunching in the pine needles ahead of her. Instantly she was on the move again, leaping fearlessly off the branch into space, landing on the spongy pine-needle carpet with her knees bent. She turned and stood face-to-face with the skinhead. â€Å"Hey there,† she said. How to cite Night World : Huntress Chapter 1, Essay examples

Margaret case Essay Example

Margaret case Essay Psychology paper #4 May, 10, 2013 Margaret Case Since antiquity, human exposes to many environmental stresses that lead to behavioral changes. These changes were studied by experts, which we call psychologists nowadays. Psychologists analysis human behaviors, define the type of stress that influence it and then try to fix that abnormal behaviors by one of the treatments. In the beginning, psychologists were unable to define some of abnormal behavioral changes (disorders) and what might cause these changes. However, later this science evolved through the psychologist, who faced a lot of cases and who were able to understand the behavioral disorders. In this paper I will follow the footprints of these psychologists in order to diagnose one of the patients, and in order to help her to get her normal life back. The patient name is Margaret. She is a clerical worker at manufacturing company. Recently, Margaret stopped going to her work due to many mental problems. When she came to the clinic, she complained about some of the feelings and the things that made her life abnormal. She said that she often awoke feeling deplorable on Mondays. Moreover, Margaret explained that she suffers from Amnesia, which means that she lost the time and the memory. She rarely remembers what she usually does in the weekends. Margaret also complained that she cant understand how sometime she would find a stranger man in her bed or receive a call from men that she never met, who called her Janie. Suddenly, while Margaret was describing her sufferance in the therapy session, she started to talk and to act like a kid who refers to herself as Suzie. Thus, based on these symptoms, its clear that she suffers from dissociative identity disorder (DID). This disorder can be define as a condition in which a person has more than one, each personality acts differently from the other personality. This disorder is a result of a trauma or extremely bad experiences. According to psychoanalytic theory of Freud, Margaret disorder is a result of one of the defense mechanisms. Defense mechanisms are psychological or mental mechanisms brought by the unconscious to protect the ego, to deny the reality and to preserve a socially cceptable image of self. We will write a custom essay sample on Margaret case specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Margaret case specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Margaret case specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Margaret disorder can be explained by one of these mechanisms that called denial mechanism. Denial mechanism is when the patient refuses to accept the reality because it cause anxiety, and its too threatening. In Freud opinion, human deny things or events to protect the ego from things that cannot be cope with. Therefore, Margaret hides her real personality, and shows other personalities because she is trying to deny a bad experience or a bad memory that she faced in her childhood. Margaret condition can be treated by using ifferent kinds of therapy. However, I would like to use cognitive behavioral therapy with her. Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that treats mental disorder or emotional disorder. CBT is based on the idea that our thoughts cause our behaviors or feeling. Margaret negative ideas influence the way she acts and the way she feels. My task with Margaret will be making her aware of the influence that negative ideas have on her life. By making Margaret aware of her negative ideas and the wrong view of life, it will be easier to change the way she hinks. Modifying the way the patient thinks will cause changing in her behaviors, and thats will decrease the number of personality she has. In addition, Margaret might benefit from medication such as antidepressant or anti-anxiety drugs. In conclusion, there are many patients that suffer from dissociative identity disorder. This disorder affects their daily life and also affects their families. Undoubtedly, its difficult to be a round people who suffer from DID, because every period of time they will have different personality. Also, they suffer from amnesia that causes them to forget a lot. Therefore, informative workshops would be needed in the society. The question that remains on the line is, would theses workshops succeed to change the way people react to such a disorder? Books list that associate with DID: Sybil: The Classic True Story of a Woman Possessed by Sixteen Personalities The Sum of My Parts: A Survivors Story of Dissociative Identity Disorder Switching Time: A Doctors Harrowing Story of Treating a Woman with 17 Personalities When Rabbit Howls The Three Faces Of Eve Twenty-Two Faces

Demat account Essay Essays

Demat account Essay Essays Demat account Essay Essay Demat account Essay Essay The trading on stock exchanges in India used to take topographic point through unfastened call without usage of information engineering for immediate matching or recording of trades. This was clip consuming and inefficient. This imposed bounds on trading volumes and efficiency. In order to supply efficiency. liquidness and transparence. NSE introduced a nation-wide online to the full automated screen based trading system where a member can plug into the computing machine measures of securities and the monetary values at which he likes to transact and the dealing is executed every bit shortly as it finds a duplicate sale or purchase order from a counter party. Screen based electronic system electronically matches orders on a rigorous price/time precedence and hence cuts down on clip. cost and hazard of mistake. every bit good as on fraud ensuing in improved operational efficiency. It allows faster incorporation of monetary value sensitive information into predo minating monetary values. therefore increasing the informational efficiency of markets. It enables market participants. irrespective of their geographical locations. to merchandise with one another coincident. bettering the deepness and liquidness of the market. It provides full namelessness by accepting orders. large or little. from members without uncovering their individuality. therefore supplying equal entree to everybody. It besides provides a perfect audit test. which helps to decide differences by logging in the trade executing procedure entireness. The sucked liquidness from other exchanges and in the really first twelvemonth of its operation. NSE became the taking stock exchange in the state. impacting the lucks of other exchanges and coercing them to follow SBTS besides. Today India can tout that about 100 % trading return topographic point through electronic order fiting. In order to advance dematerialization of securities. NSE joined custodies with taking fiscal establishments to set up the national securities depositary Ltd. ( NSDL ) . the first depositary in the state. with the aim of heightening the efficiency in colony systems as besides to cut down the threat of fake/forged and stolen securities. This has ushered in an epoch of dematerialised trading and colony. SEBI has made dematerialised colony mandatary in an of all time -increasing figure of securities in a phased mode. therefore conveying about an addition in the proportion of portions delivered in dematerialised signifier. There is an increasing penchant to settle trades. peculiarly in high value securities. in demat signifier. Such high degree of demat colony reassures success of turn overing colony. What is DEMAT In India. a demat history. the abbreviation for dematerialised history. is a type of banking history which dematerializes paper-based physical stock portions. Conversion of Securities from Physical ( Paper ) Mode into Electronic Mode is Called Dematerialisation. The Client opens Demat Account with any DP. Upon Demat. the Certificates are destroyed and recognition entry of precisely equal figure of Securities is created in Depository in Electronic manner. The B. O. history of holder is credited and the securities loose their individualities. The dematerialised history is used to avoid keeping physical portions: the portions are bought and sold through a stock agent. This history is popular in India. The market regulator. securities and exchange board of India ( SEBI ) mandates a demat history for portion trading above 500 portions. As of April 2006. it became compulsory that any individual keeping a demat history should possess a lasting history figure ( PAN ) . and the deadline for entry of PAN inside informations to the depositary lapsed on January 2007. Dematerialisation is the procedure by which physical certifications of an investor are converted to an tantamount figure of securities in electronic signifier and credited in the investor’s history with its DP. In order to dematerialise certifications ; an investor will hold to first open an history with a DP and so bespeak for the dematerialisation of certifications by make fulling up a dematerialisation petition signifier [ DRF ] . which is available with the DP and subjecting the same along with the physical certifications. The investor has to guarantee that before the certifications are handed over to the DP for dem at. they are defaced by taging â€Å"Surrendered for Dematerialisation† on the face of the certifications. Aim of the Study The chief aim of the survey is to cognize about the potency of the market sing people’s covering in portion market. To cognize the function of Demat Account. To cognize the process of opening DEMAT ACCOUNT. The aim is to cognize that how many people in the metropolis are cognizant of the UNICON SECURITIES PVT. LTD. To cognize where people have already opened their demat a/c and on what footing. Procedure for Opening an History A demat history are opened on the same lines as that of a Bank Account. Prescribed Account gap signifiers are available with the DP. demands to be filled in. Standard Agreements are to be signed by the Client and the DP. which inside informations the rights and duties of both parties The DP functionaries will do available the relevant history opening signifier ( depending on whether the client is a retail investor or corporate client/clearing member ) and stipulate the list of paperss sing mentions that should be submitted along with the signifier. It will besides give a transcript of the relevant understanding to be entered with the client. in extra. The client will subject the duly filled in history opening signifier and client has to see personally for opening the history in DP. The DP functionaries have to make in individual confirmation and stick on the â€Å"IN PERSON VERIFICATION† cast on the history opening signifier. It should besides supply such paperss sing mentio ns. as specified by the DP. along with the history opening signifier. After put to deathing the understanding the client has to send on it to the DP. The DP functionaries will verify that the history opening signifier is punctually filled in. It will besides verify the enclosed paperss. if any. Incomplete signifiers will be forwarded to the client for rectification. For Corporate Clients. the DP functionaries will verify if the board declaration for the authorised signers is enclosed. In instance the paperss are non proper. the DP functionaries will reject the signifier and adumbrate the client of the same. saying the grounds for making so. If the signifier is in order ; the DP functionaries will accept the same and stick on the cast â€Å"verified with original† on each and every cogent evidence after seeing the original cogent evidence. After completion of all certification. the DP functionaries will verify the pan from income revenue enhancement web site. And affix the cast â€Å"PAN VERIFIED† with day of the month and mark on the cast. The DP functionaries will come in the client inside informations as mentioned in the history opening signifier in the DPM ( package provided by NSDL A ; CDSL to the Participant ) screen provided for the intent. In instance of NSDL A/c opening the SR. Assist will capture all the inside informations in the DPM and enter the client’s signature ( on the signifier ) as specimen for mandates in the hereafter. After come ining client inside informations in the system. a client history figure will be generated by the DPM. The DP functionaries will come in this in the history opening signifier. After that the officers will verify the inside informations in the DPM captured by the SR. Assist. and activate the history. The DP functionaries are non allowed to give the demat a/c no to the clients until the a/c is activate. this is applicable for both NSDL A ; CDSL. When the demat a/c is activated the DP functionaries have to direct the client maestro and the transcript of understanding between DP and client at the client’s reference DEMAT Process The registered holder of the securities makes the petition. Securities must be recognised by Depository as eligible. Client submits DRF A ; physical certifications to DP. DP checks securities. Client defaces certifications and DP clouts two holes on name of company. DP enters demat petition in system for Depository. DP despatchs certifications along with DRF to R A ; T. Depository records the inside informations and sends to R A ; T. R A ; T agent verifies the inside informations and confirms to Depository. Depository credits the demat securities to BO a/c of client and intimates DP electronically. DP issues statement to client

Most Liberal U.S.Supreme Court Justices in History

Most Liberal U.S.Supreme Court Justices in History Associate Justice Ruth Bader Ginsburg has long been a thorn in the side of American conservatives. Shes been pilloried in the right-wing press by a range of so-called political experts, including college drop-out and shock jock Lars Larson, who publicly declared that Justice Ginsburg is anti-American. Her stinging dissent in Burwell v. Hobby Lobby, which recently granted corporations certain exceptions to the Affordable Care Act with regard to birth control coverage, has once again loosed the gates of extreme conservative rhetoric. One columnist in The Washington Times even crowned her liberal bully of the week  even though hers was the dissenting, not majority, opinion. These critics act as if a liberal judge on the Supreme Court is a brand new development, but its the work of previous liberal judges that protects their right to come pretty close to slandering Justice Ginsburg in their published work. The Most Liberal U.S. Supreme Court Justices Also unfortunate for her critics is the fact that its unlikely that Justice Ginsburg will go down in history as the most liberal justice. Just take a look at her competition. While they sometimes sided with their conservative colleagues (often in tragic ways, such as in Korematsu v. United States, which upheld the constitutionality of the Japanese-American internment camps during World War II), these justices are generally considered to be among the most liberal of all time: Louis Brandeis (term: 1916-1939) was the first Jewish member of the Supreme Court and brought a sociological view to his interpretation of law. He is justly famous for establishing the precedent that the right to privacy is, in his words, the right to be let alone (something right-wing extremists, libertarians, and anti-government activists seem to think they invented).William J. Brennan (1956-1990) helped expand civil rights and liberties for all Americans. He supported abortion rights, opposed the death penalty, and provided new protections for freedom of the press. For example, in New York Times v. Sullivan (1964), Brennan established the actual malice standard, in which news outlets were protected from charges of libel as long as what they wrote was not deliberately false.William O. Douglas (1939-1975) was the longest-serving justice on the Court, and was described by Time Magazine as the most doctrinaire and committed civil libertarian ever to sit on the court. He fought against any regulation of speech and famously faced impeachment after he issued a stay of execution for convicted spies Julius and Ethel Rosenberg. He is probably most well-known for arguing that citizens are guaranteed a right to privacy due to the penumbras (shadows) cast by the Bill of Rights in Griswold v. Connecticut (1965), which established the right of citizens to have access to birth control information and devices. John Marshall Harlan (1877-1911) was the first to argue that the Fourteenth Amendment incorporated the Bill of Rights. However, hes more famous for earning the nickname The Great Dissenter because he went against his colleagues in significant civil rights cases. In his dissent from Plessy v. Ferguson (1896), the decision that opened the door to legal segregation, he affirmed some basic liberal principles: In view of the constitution, in the eye of the law, there is in this country no superior, dominant, ruling class of citizens...Our constitution is color-blind...In respect of civil rights, all citizens are equal before the law.Thurgood Marshall (1967-1991) was the first African-American justice and is often cited as having the most liberal voting record of all. As an attorney for the NAACP, he famously won Brown v. Board of Education (1954), which outlawed school segregation. It should not be surprising, then, that when he became a Supreme Court justice he continued to argue on beha lf of individual rights, most notably as a strong opponent of the death penalty. Frank Murphy (1940-1949) fought against discrimination in many forms. He was the first justice to include the word racism in an opinion, in his vehement dissent in Korematsu v. United States (1944). In Falbo v. United States (1944), he wrote, The law knows no finer hour than when it cuts through formal concepts and transitory emotions to protect unpopular citizens against discrimination and persecution.Earl Warren (1953-1969) is one of the most influential Chief Justices of all time. He forcefully pushed for the unanimous Brown v. Board of Education (1954) decision and presided over decisions that further expanded civil rights and liberties, including those that mandated publicly-funded representation for indigent defendants in Gideon v. Wainright (1963), and required police to inform criminal suspects of their rights, in Miranda v. Arizona (1966). Certainly other justices, including Hugo Black, Abe Fortas, Arthur J. Goldberg, and Wiley Blount Rutledge, Jr. made decisions that protected individual rights and created greater equality in the United States, but the judges listed above demonstrate that Ruth Bader Ginsburg is just the most recent participant in the strong liberal tradition of the Supreme Court and you cant accuse someone of radicalism if theyre part of a long-standing tradition.

Alternative energy source, technology, or energy storage method Assignment

Alternative energy source, technology, or energy storage method - Assignment Example Apart from the environmental impact, the other major concern with fossil fuels is their limited capacity. Fossil fuels run the risk of becoming extinct with the rate at which it is being utilized. It is for these reasons that the need for a sustainable, alternate energy resource has become a necessity. Renewable energy has been defined by Lund (2009), â€Å"as the energy that is produced by natural resources-such as sunlight, wind, rain, waves, tides, and geothermal heat-that are naturally replenished within a time span of a few years†. This energy domain encompasses all those energy systems that convert natural resources into useful energy for instance; wind, wave, tidal, hydropower, biomass, biofuel and solar energy. For centuries plants have been harnessing solar energy to process their energy needs through photosynthesis. The earth receives 174 petaWatts (PW) of solar radiation in the upper atmosphere (A.I. & N, 2011). The thought of harnessing the sun’s energy to power man-made devices was first commercially incorporated in 1958. Space exploration equipments such as satellites and space stations were powered by solar energy. Since then, the technology of harnessing solar energy has progressed. Currently there are two major methods of acquiring solar energy. The first is direct heating; which involves concentrating the solar rays onto a specific target to heat it. Solar water heaters utilize direct heating. However, there are two significant techniques involved in direct heating which are; solar ponds and flat plate collectors (Pimentel, 2008). Solar ponds are artificially constructed ponds in which solar energy may be stored by allowing temperature rise on the bottom layer of the liquid and preventing convection currents from developing. There are multiple methods in which convection currents can be halted. The most suitable, however, is the addition and maintenance of salt concentration gradient. The

Visitor Impacts on Public Parks Research Paper Example | Topics and Well Written Essays - 750 words

Visitor Impacts on Public Parks - Research Paper Example This paper will look at the effects of uncontrolled continual streams of visitors to my local park and the solutions to the problems they cause while enjoying the privilege. Parking at our local park has become a nightmare due to limited zonal spots for everyone involved. In fact, the numbers of vehicles lined up at the gate of the park have become a nuisance as they are preventing access to the park itself and discouraging more people from gaining access. This is a menace as the image of the park is tainted since they are regarded as negligent in providing for the needs of the visitors. In addition, the cars pollute the environment, with the effects being carried over to the protected resources inside the park1. In my view, people should be made to leave their personal means of transport at home and the park should have the mandate of providing public transport to people at designated times and venues. Such a move will ensure that the number of visitors gaining access to the facilit y is controlled in any one time. While inside the park, it has become apparent that the standard of cleanliness is deteriorating each day as the visitors are trashing everywhere they go. Plastics are the order of the day not mentioning the unsightly array of leftover food at every footpath in the surrounding environment. Some of the caged animals can be seen munching on some of these foods which they may have been offered by the visitors or perhaps collected as they roamed freely in their habitats. Ingestion of these foods can be dangerous since of it may not blend in well with their natural diets. There have been cases of food poisoning reports at alarming rates for the last quarter of the year. The management should provide more employees to investigate into the matter while drawing a keen eye that would help identify the culprits. These visitors should be fined heavily for their acts and given restriction from gaining access to the park until deemed necessary2. Some sections of t he park do not access to public foot paths or bridges across water bodies. This has forced visitors to find their own way around thus they have resulted in a lot erosion of the ground and destruction of vegetation and leading to deterioration of the environment. Some of them have penetrated sensitive parts of the forest which have led to some animals strayed into areas of the park they are not supposed to. These animals can be dangerous to the general public making the park to be hazardous for visitors and could lead to closure of the park. Measures should be taken to ensure that a guard is placed at strategic positions in the park where they can prevent such destructions from taking place in the first place. In another instance, campsites have been devouring parts of the forest since some extreme campers have brought down trees to create room for their tents or just for the mere advantage of the experience. The fires that have been made are frightening the wild animals and eating a way at the vegetation that may have been growing for thousands of generations. The animals have disappeared into the heart of the forests and are not seen during day which has proved to be very disappointing to the visitors of the park. This has also led to loss of enthusiasm for the diehard animal lovers who come to the park with the sole intention of sighting the fascinating creatures. Poaching is another vice that has risen lately amongst the visitors.

Problems with UK Glaucoma (POAG) Treatment

Problems with UK Glaucoma (POAG) Treatment CHAPTER 1: INTRODUCTION Glaucomas are a group of diseases which have the potential of causing damage to the eye and are distinguished from other eye related diseases by the fact that they can cause an increase in intraocular pressure inside which in turn causes damage to the optic nerve and to the retina. Primary Open Angle glaucoma (POAG) is the second commonest cause of registerable blindness and partial sight registrations in the UK (Bougard et al 2000). It is particularly dangerous because of its progressive nature and ability to go unnoticed for years thereby preventing treatment of the disease until, in some cases it can be too late to rescue the vision completely. Therefore the only way to detect the disease before it becomes a serious problem is with a thorough screening program. Optometrists usually are the first in line to examine a patients ocular health and refer patients onto the hospital based on several risk factors. The prevalence of POAG increases with age. This was shown in the Framingham Eye Study which estimated prevalence to be 1.2% between 50 and 64 years, 2.3% from 65 to 74 years and 3.5% in 75 years and over (Leibowitz et al, 1980). Another study has shown that POAG is positively related to the levels of intraocular pressure. The Baltimore Eye Survey concluded that the prevalence of the disease was 1.18% in patients with IOPs less than 22mmHg and 10.32% above this IOP level (Tielsch, 1991). Hereditary links have also been associated with POAG especially African-Americans who are at higher risk of developing the condition than Caucasians and, if there is a family history of glaucoma, the risk is up to six times higher than for the general population. Also, patients who are highly myopic, have diabetes mellitus or cardiovascular problems are at high risk of developing glaucoma and so these are the individuals who need to be monitored and checked regularly. Thus, in the first instance it may seem appropriate to test all individuals who present as being at a (low) threshold risk of developing the disease at regular intervals for disease progression; however the numbers of patients who are referred for suspect chronic open angle glaucoma and then found to have no glaucoma is around 40%. These false positive referrals are thought to cause unnecessary anxiety to the patient, alongside adding to the volume of paperwork that is needed to be completed by the practitioner and also thought to be a waste of local hospital resources (Parkins, 2006). Hence, these matters alongside the increasing requirements for patient centered care and reducing the costs occurred by the NHS have led to the development of certain criteria which enables optometrists to refine their own referrals for glaucoma prior to deciding whether or not a patient should be referred. This can be made easier by carrying out simple procedures or following specific protocols, for e xample, repeating suspicious IOP measurements preferably at a different time of day by using a contact method (Perkins or Goldmann) and repeating visual field tests on a separate occasion. (Parkins, 2006). More importantly, further schemes have been introduced where referrals are directed to specially trained optometrists who then decide on whether to refer the patient to the hospital eye service (HES) or return the patient for management under primary care. This appears to have ultimately increased the role played by optometrists in diagnosing and referring patients thought to be suffering from POAG, increasing their abilities to reach and treat individuals within the community more effectively. This in turn reduces the number of cases of POAG observed within the population as individuals are able to gain access to primary or more conventional methods of health care, i.e. hospitals. By reviewing the literature which has been published regarding the treatment and management of patients with POAG by optometrists, this paper aims to look at the way new schemes and interventions will affect the treatment and management of the disease within the UK. In addition, the ability of optometrists to prescribe certain drugs and the potential benefits will be discussed. CHAPTER 2: GLAUCOMA IN THE UK. (EPIDEMIOLOGY) This chapter will focus on the distribution, occurrence and control of the disease within the UK population. Glaucoma, as described above is one of the most frequent causes of blindness, predominantly in the industrialized world and therefore accounts for a high proportion of blindness observed within the UK. (Coyle and Drummond, 1995) The disease accounts for 14% of blind registrations in the UK and many cases around the country present at an advanced symptomatic stage (Aclimandos Galloway, 1988). With the potential to cause blindness in both eyes glaucoma has a dramatic effect on the individuals who are suffering from it but it also has a severe economic burden upon the nation, including direct and indirect costs. Within the UK alone these were estimated to be  £132 million in 1990. (Zhang et al, 2001) The most frequently prescribed drug for treatment of glaucoma is timolol which is a non-selective beta-adrenergic receptor blocker. The drug is used to treat open-angle glaucoma due to its ability to reduce the aqueous humour production by blocking the beta receptors on the ciliary epithelium. However, beta-adrenergic receptors blockers are thought to have serious side effects on patients who are suffering from cardiovascular or pulmonary disorders. For this reason an additional drug, 2-4 Pilocarpine, which is a cholinergic agonist may be used. This acts on a specific type of muscarinic receptor (M3) found on the iris sphincter muscle which causes contraction of the muscle and therefore miosis. This widens the trabecular meshwork through increased pressure on the scleral spur which aids the aqueous humor to leave the eye and reduce intraocular pressure. However this drug also has its limitations which are primarily associated with the requirement for it to be administrated four times per day and its ability to cause miosis, myopia and occasionally in some patients, retinal detachment and progressive closure of the anterior chamber angle. Thus, new drugs which will be more effective and safer methods of treating open-angle glaucoma are required. There have been many agents suggested for use for the treatment of the disease, however they often fail on several counts, including their failure to control intraocular pressure. (Schwab et al, 2003) This problem is observed within the three non-beta blocker drugs: latanoprost (a prostaglandin F2à ¡ analogue), dorzolamide (a topical carbonic anhydrase inhibitor), and brimonidine (a Selective à ¡2 agonist). However, out of these three drugs, Latanoprost seems to be the most highly promising because of its comparable or, in some cases, better efficacy when compared with timolol. (Zhang et al, 2001) Risk factors, which are associated with the development of the disease, include individuals who are members of a family pedigree, which have suffered from glaucoma in the past. (OMIM, 2006) It is thought that a family history of the disease increases ones likelihood of developing the disease by 6%. This is suggestive of a genetic link or predisposing factor which may be associated with the development of the disease. Diabetes and being of African descent are also factors which are thought to increase the likelihood of developing the disease, and individuals with either of these factors, are three times more likely to develop the disease than the average individual. Asian populations have a dramatically higher risk of developing glaucoma than Caucasians, increasing their chances of disease development by a staggering twenty to forty percent. Men are also three times more likely to develop open-angle glaucoma than women due to the presence of wider anterior chambers in the eye. (Paron and Craig, 1976) Evidence is becoming increasingly available to suggest that the levels of ocular blood flow are involved within the pathogenesis of glaucoma. Fluctuations in blood flow are more harmful in those with glaucomatous optic neuropathy than those who experience a steady reduction in the blood flow to their eye through the optic nerve head. This also correlates with the damage observed to the optic nerve head and to the deterioration in the visual field acuity. (National Institute of Health, web Reference) There are also a number of studies which suggest that there is a correlation between glaucoma and systemic hypertension. This is linked with the fluctuations in blood flow mentioned above, as varying blood pressure can affect blood flow. There is however, no evidence that vitamin deficiencies play any role in the development of glaucoma. A survey carried out (Rhee et al, 2002) revealed that it is highly unlikely that vitamin supplements provide a useful treatment method for any individual suffering from the disease. CHAPTER 3: SCREENING FOR GLAUCOOMA IN THE UK. As we are now aware of the epidemiology of glaucoma within the population in the UK, it is clear that screening of individuals, particularly of those individuals at high risk of disease development is required. Many factors influence whether or not screening is considered a necessary precaution by ophthalmologists. However, it is perhaps first, most useful to provide an overview of what screening is and why it is a procedure invested in for treatment of open angle glaucoma. 3.1 Definition of screening Screening may be defined as the examination of a group of usually asymptomatic individuals to allow the early diagnosis or detection of those individuals with a high probability of having a given disease, (Collegeboard, 2008) and it is often carried out on individuals who are considered to theoretically have a high chance of inheriting or suffering from the disease, due to either genetic or environmental factors or even a combination of these issues. It is thought that screening is useful when it enables the diagnosis of a disease earlier than it would usually have been detected giving the ability to improve the patients outcome. However, there are several ethical issues surrounding screening processes as some individuals are of the opinion that it is only right to screen for some diseases when an individual is at an age to consent to such a procedure. This raises issues surrounding the onset of screening procedures, and whether siblings and offspring of individuals with a family history of open angle glaucoma should be screened for the disease because of certain opinions that suggest the patient themselves should decide whether or not to be screened. This is debatable because of the implications on the individuals life and the worry which is associated with the knowledge of perhaps developing such a disease which could eventually lead to blindness. However, due to the fact that the screening procedure gives the potential for treatment of the disease symptoms, it is likely that many ethical issues which surround some screening processes are not relevant to the screening of individuals at high risk of open angle glaucoma, particularly due to the fact that the genetic risk is minimal in comparison to the environmental risk factors and thus, genetic screening of parents and their offspring is not yet (and is unlikely to become) an issue. 3.2 Tests for glaucoma There are several tests that are used to identify those patients with glaucoma, however, there is no single test that can determine whether a patient has the disease or not. To start with a thorough eye examination is a prerequisite prior to undergoing the specific tests for glaucoma. Following this examination, the management of glaucoma involves serial tests which are carried out at regular intervals over several years allowing the practitioner to determine whether the pressure in the eye has become stable and hence further damage will be avoided. Good record keeping is vital as it is only possible to determine whether the pressure has worsened by using previous values and measurements as a comparison. The ‘Gold Standard tests for glaucoma are determination of eye pressure with an application tonometer, assessment of optic nerve head and visual field screening. In optometric practice these tests are carried out once every year under NHS regulation, however, a patient under hospital management will usually be seen at least 3 or 4 times to monitor their intraocular pressure. The established ‘Gold Standard for intraocular pressure measurement is the Goldman applanation tonometer. To carry out this procedure, the Goldman head is mounted on a slit lamp and a drop of anesthetic a dye (fluorescein) is placed in the eye. Then a gonioprism is placed in contact with the cornea through which practitioner is able to see green rings and make adjustments to arrive at the end point where the half rings overlap. The eye pressure reading (in mmHg) is recorded at this position. There are several other means of recording intraocular pressure using different types of tonometers, which include the air puff tonometer, Perkins tonometer, Pneumotonometer and Schiotz tonometer. In addition, there are tonometers, which allow the estimation of eye pressure at home. One such example is the ‘proview eye pressure monitor (Bausch and Lomb, 2001). The visual field is usually the first to be affected in glaucoma and by the time the central vision is affected, the disease is already far advanced with almost all of the vision in the periphery permanently lost (Parks, 2006). Perimetric threshold-measuring techniques are sensitive to the early progression of such glaucomatous field loss and full threshold screening programs are seen as the ‘Gold Standard. However, threshold tests can be lengthy and can induce fatigue within a patient causing them to lose fixation and overall lead to unreliable results. This lead to the development of SITA testing which reduced the testing time while maintaining the same quality of results as full threshold testing (Bengtsson, et al 1998). The computers, which are used to compute the visual field, are those such as the Humphrey or the Octopus perimeters. These machines use a light point that is presented in a predetermined fashion (location sequence) in a lighted bowl and the patient is asked to press a button when they see the light point. The patients responses are analyzed statistically and compared with a database of ‘normal responses. From this information, any deviations from normal are marked on a printout as black squares which represent visual field-defect areas. à ¢Ã¢â€š ¬Ã‚ ¨ Optic nerve head assessment is mandatory in all eye examinations performed and the ‘Gold Standard method is the use of a Volk lens with the patient dilated. The preliminary signs of the disease occur at the optic nerve head where nerve fibre loss is apparent. However, it only until the loss of fibres exceeds a certain threshold that visual field impairment is noticed. Evidence from histological studies and glaucoma modelling has shown that up to 40% of optic fibres can be damaged before a loss of visual function takes place (Quigley, et al 1982). Diffused thinning and localised notching of the neuroretinal rim (NRR) indicate early signs of the disease. The cup is affected due to the loss of fibres and it widens and deepens as a result. Also, the optic disc of a glaucomatous patient will not follow Jonas ISNT rule where the NRR is thickest at the inferotemporal sector, then at superotemporal, followed by nasal and temporal. Clinical examination using a Volk lens is, however, affected by inter-observer variability amongst optometrists. Another useful technique is stereoscopic optic nerve photography which is a cost-effective method for the detection of glaucoma and its progression. With the benefit of 3-dimensional and permanent data, practitioners can study the optic nerve features (disc cupping, vessel baring) over time (Tielsch et al, 1988). Under hospital management, comparison of these photos which have been taken over the course of the year is a highly effective method of following glaucoma progression. CHAPTER 4:HOW SUCCESSFUL ARE OPTOMETRISTS AT SCREENING FOR GLAUCOMA? A number of studies and clinical trials have been carries out on the effects of treatment on newly discovered primary open-angle glaucoma patients, and it has been noted on several occasions that immediate treatment leads to a slower rate of disease progression. (Bullimore, 2002) As one must first identify that a patient has the disease before the individual can be treated, this ultimately implies that effective screening procedures would be beneficial in the treatment of glaucoma. However, one question which this leads to is: how successful are optometrists at screening for glaucoma and are all patients who should be screened, being checked for disease progression or any clinical symptoms. 4.1 The Baltimore eye Survey The Baltimore eye survey (Tielsch, 1991) was carried out to evaluate the efficacy of population level screening procedures and evaluate the performance of the screening methods used to test for glaucoma. The research team noted that â€Å"†¦screening for glaucoma has a long history and is a well-established activity† (Tielsch, 1991). However, they also were aware that most screening organizations used tonometry as the screening technique even though it is known to have several limitations associated with its use. The efficacy of the other known screening processes were thought, by the research team, to have not received deep enough investigations into their effectiveness, and this was considered to be a reason why these methods were not being utilized in the screening processes. In research studies which had been carried out prior to this study, only small research groups had been used or the studies had proved to being biased towards individuals who have a family history of the disease and therefore highly likely to developing glaucoma themselves. (Leibowitz et al, 1980) Hence the studies were thought to provide false information about the usefulness of the analyzed screening methods. The Baltimore Eye survey looked at a total of 5,308 individuals who were forty years of age or older, including both black and white individuals and analyzed the success of screening each individual for glaucoma using â€Å"†¦tomometry, visual fields, stereoscopic fundus photography and a detailed medical and ophthalmic history.† (Tielsch et al, 1991) The survey was not limited to looking at individuals who were known to be at a high risk of developing glaucoma as this would influence the analysis of the success of certain screening methods. After the examination was complete, a diagnosis of glaucoma was made for any participant found to have indicative symptoms. Out of the 5,308 individuals participating in the study, 196 were diagnosed with glaucoma. (Tielsch et al, 1991) The research team then evaluated tonometry, cup to disc ratio, and narrowest neuroretinal rim width for their ability to correctly classify subjects into diseased or non-diseased states. There was no defined cutoff values at which these variables provided a reasonable balance of sensitivity and specificity, (separately or in combination) as this made the test more robust and thus allowed the screening method to only gain positive results if it was able to identify an individual who did indeed have glaucoma. The statistical analytical methods used to analyze the data obtained from the study included making logistic regression models of the results, which were then fit to the data. These models included demographic and other risk factors, to ensure that the analysis of the data was as accurate as possible. Sensitivities and specificities were then calculated for varying cutoff levels on the distribution of predicted probabilities. The research team came to the conclusion that there was no cut off for reasonable sensitivity and specificity and that the effectiveness of current techniques for glaucoma screening was limited. (Tielsch et al, 1991) The research said that although â€Å"at first glance, glaucoma fits the model of a disease for which screening could make a significant impact on the burden of disability in the population†¦unfortunately, objective assessments of the most commonly used technique for screening†¦demonstrate its ineffectiveness.† (Tielsch et al, 1991) The study identified that tonometry was a poor technique when it came to correctly classifying subjects as diseased or non-diseased. It also mentioned that despite intraocular pressure remaining as one of the strongest known risk factors for open angle glaucoma; measurements of this were not used as a criterion for referral in order to maximize the sensitivity of the screening examination. Tielsch et al (1991) identified only Only 215 subjects out of 1770 who were referred for further tests simply because of their intraocular pressure measurements and only four of these individuals actually had definite or probable glaucoma. This was a detection rate of 1.86 percent which is very low. Thus, the use of the intraocular pressure as a guide added little additional sensitivity beyond what was contributed by the other referral criteria. Other methods of screening for the development of glaucoma were also considered to be ineffective and cumbersome. Despite this study being carried out forty years after the initiation of screening programmes for glaucoma, the program still appeared to require extra work in order to develop a more successful screening programme. 4.2 Frequency-doubling technology study In contrast to the study carried out by Tielsh et al (1991) a study was carried out by Yamada et al (1999) with the aim to assess glaucoma screening using frequency-doubling technology (FDT) and Damato campimetry. The research group carried out a two day public glaucoma screening programme which was implicated at two different institutions. Each participant underwent the following visual field tests: Damato campimetry, FDT perimetry in screeningmode and Humphrey perimetry(24-2 FASTPAC). A full ophthalmologic examination, for each eye was also carried out. The data collected from this study was then divided into four categories, including normal, ocular hypertensive, glaucoma suspect and definite glaucoma. The sensitivity and specificity level of each test was then estimated with â€Å"receiver operating characteristic curves† (Yamada et al, 1999). The results of the eye examinations revealed that out of the 240 individuals who underwent testing, 151 were identified as being no rmal, 28 were classified as ocular hypertensive, 35 were described as having suspect glaucoma and 26 were classified as being definite glaucoma individuals when using the FDT perimetry screening mode. Out of the one hundred and seventy five subjects who underwent Damato campimetry, the numbers for the same groups were 118, 19, 19 and 19 respectively. The specificities for each test were 92-93% for the FDF perimetry and 53-90% for the Damato campimetry tests respectively, hence leading to the conclusion that FDT perimetry was superior to Damato campimetry in the screening for glaucoma within the study. (Yamada et al, 1999) However, these methods for screening are rarer than the usual tonometer and visual field analysis methods described within this paper. Despite the fact that they appear to be useful and effective methods for glaucoma screening in this case, the tests are rarely used in conventional practice and therefore the results of this study should be regarded with caution. 4.3 Burton Hospital screening study The aim of this study was to investigate the â€Å"referral practices to the outpatient clinic of a consultant ophthalmologist† and also to identify the current screening routines of optometrists and general practitioners in regards to glaucoma and diabetic retinopathy diagnosis. (Harrison, et al 1988) A total of 1437 patients were referred to Burton District Hospital, from 1 November 1986 to 31 December 1987, to be viewed by a consultant ophthalmologist. The patients were grouped into urgent, semi-urgent or non-urgent depending on their referral letters. Only 1113 patients were ultimately reviewed as the remaining 324 could not be seen by the end of the study. (Harrison, et al 1988) Selected biographical data was recorded from the case notes such as age, sex and more importantly the source of referral. Any symptoms as well as the reasons for referral were looked for in the referral letters. A classification system was used for the reason for referral; this was based on symptoms and bodily location. Furthermore, there was an analysis on the referral data for the procedures used by the referring source, in this case assessment of visual acuity, visual fields, binocular vision and the optic nerve head. Also, intraocular pressure readings as well as any fluorescein checks for corneal staining. (Harrison, et al 1988) The results showed that optometrists were responsible for 39% of the referrals (439 patients) in comparison to the 49% (546 patients) of general practitioners. The most important reason for referral was visual field loss which account for 31% (345) of cases, followed by suspected glaucoma which accounted for 13% (145). The reasons for referral were also different when comparing the two referrers. GPs referred 107 (84%) patients due to eyelid disorders and 66 (77%) patients with conditions on the outer adnexa. On the other hand optometrists were responsible for referring 118 (81%) of the patients on suspicion of glaucoma. (Harrison, et al 1988) In total there were 70 referrals for possible asymptomatic glaucoma and another 77 for symptomatic disease. In 33 cases glaucoma was confirmed (20 asymptomatic) and borderline glaucoma was found in 73 cases (48 asymptomatic). â€Å"The diagnosis was confirmed in 96 (80%) of the referrals from ophthalmic opticians but in only 10 (37%) cases referred by general practitioners.† (Harrison, et al 1988) This showed that optometrists were far more accurate in referring suspect glaucoma patients, i.e. a greater number of true positives. Using information from the referral letters, the diagnostic procedures undertaken by both referral sources was explored. Optometrists relied on intraocular pressure readings in 52 of the 96 referrals (54%). The rest of the patients were referred because of suspicious cup-disc ratios, visual field loss or other clinical aspects. However, GPs would refer mainly on the grounds of symptoms that are present. Also, the ophthalmologist did not confirm suspect glaucoma in 24 patients from the optometrists referrals and 17 from the referrals by GPs. The main conclusions from the report show that optometrist were far more likely to refer retinal or optic disc disorders. There was insufficient evidence to show that GPs screened for glaucoma â€Å"whereas ophthalmic opticians screened for glaucoma with considerable skill.† (Harrison, et al 1988). Several factors contribute to these differences between the referral abilities of both professional groups. Patients will normally visit an optometrist when they are experiencing visual loss because they are usually under the impression that they require new glasses. However, when patients have external symptoms they normally go to their GP. Due to the equipment available to optometrists they are also more likely to pick up on pathologies within the eye especially those affecting the retina and optic nerve head, hence â€Å"maintaining a high degree of vigilance for asymptomatic conditions such as glaucoma.† (Harrison, et al 1988) The suggested diagnostic accuracy, however, u ndermined the actual accuracy of the opticians examination. Any difference was due to the importance given to the findings of the ophthalmologist. The quality of referrals to the hospital is vital for maintaining an effective service, especially in Britain where many outpatients departments are overstretched. Improvement in the accuracy of referrals eventually leads to less false positive referrals, therefore enhancing the value of true positive referrals. One of the protruding reasons for false positive referrals in this study was suspected glaucoma but with â€Å"greater utilisation or development of community based screening programmes† the false positive referral rate could be reduced. Harrison, et al (1988) states that currently the closest approach to a screening programme is offered by optometrists. Harrison et al (1988) is also of the opinion that by establishing a planned screening service where ophthalmologists and optometrists work in conjunction on the basis of a fixed referral criteria, the progression of the disease in patients will reduce and so will the burden on HES. There is evidence from the data within the study to show that such glaucoma screening programme would have an influence. The 41 false positive glaucoma referrals would have been prevented and so would most of the 73 referrals for borderline glaucoma. A potential 100 outpatient appointments could have been saved with a community based screening strategy and this in turn would free up follow-up appointments. The study does show the benefit of current screening procedures and how optometrists are successful at accurately referring suspect glaucoma patients. Harrison, et al (1998) highlights that this is an invaluable skill which would prove more beneficial if used within a community based screening scheme. 4.4 England and Wales survey The objective of this survey was to investigate â€Å"the efficiency of referral for suspected glaucoma to general practitioners and consultants by optometrists.† (Tuck Crick, 1991) This survey involved 241 optometrists who represented areas clustered in England and Wales. Majority were enrolled through an interview procedure, but some responded to an advert in optometric publications. The scheme ran from November 1988 to February 1989 and each time a referral took place the optometrist would fill out a questionnaire on the individual patient. In total the respondents completed 275600 sight tests, which accounted for â€Å"about five per cent of the national total†. The actual number of referrals was 1505 for those suspected of glaucoma. For people over the age of 40 an estimated 0.9% referral rate was found. The end result of the referral was established for 1228 individuals. There were 125 patients were not examined at all and the remaining 1103 were examined by a consultant ophthalmologist. (Tuck Crick, 1991) An analysis was done on 704 cases to assess the accuracy of the referrals. Glaucoma was confirmed in 40.19% (283) of patients and 31.53% (222) of patients were further monitored. The data showed that in nearly all the confirmed patients the disease was at a chronic stage. Optometrists were further questioned to specify the key reasons for referral in each of the cases. There were 171 patients referred due to intraocular pressure in at least one eye being greater than 30mmHg. From these, 112 (65%) were positively diagnosed with glaucoma and only 20 were discharged as false positives. It was noted, however, that accuracy of referral in patients with lower IOPs (20-25mmHg) was much less. Only 7 individuals out of the 87 with lower IOPs were found to have glaucoma. Amongst them 50 patients who were released with no glaucoma. (Tuck Crick, 1991) When the optometrist recorded optic nerve head changes and visual field plots, the IOP referral accuracy was greater. However, when the referral was based on optic disc appearance and visual fields alone the accuracy was low. This category of referral accounted for 28 (10%) of confirmed cases. Furthermore, only 331 of the 704 patients had undergone a visual field test. This explained those cases in which visual field loss was not described as a reason for referral because the screening test had not been carried out in the first place. Even so, the analysis stressed â€Å"that field screening generally enables a case to be more precisely described and the risk of glaucoma thereby better assessed at the primary level.† (Tuck Crick, 1991) Gathering the evidence from th