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Impact Of Globalisation On Biodiversity Environmental Sciences Essay

Biodiversity is the diverseness in the different varieties of flora and fauna in a particular habitat. It comprises of the totality of genes, species and ecosystems in a specific place. It serves as a source of aesthetic and economic value, is used as food and related items, provides scientific information and replaces engineering solutions such as flood control and water pollution abatement. Bio richness thus is rated of higher preference to stand as a major factor for the future economic growth and thereby the overall sustainable development. Globalisation is the concept where people, nations, technologies, businesses and networks are interconnected and interdependent politically, economically and socially unhindered by different time zones making the whole world as a unified globe. It helps in the increase of transportation and communication networks and allows cross border trade and resource movements. The international business activities and cross national treaties and agreements are done with much ease. The question put forward was whether globalisation is a cause for the loss of biodiversity. The notion of globalising the world comprises of upgrading and furthering of all the sectors and spheres of economy. People started enjoying the luxurious lifestyles and became attached to opulent materials and drew pleasure out of it. This drastically depleted the natural resources and their fullness. Since bio diversity is the key factor comprising of both the biotic and abiotic factors in an environment, the loss of its magnificence will drastically affect the present pace and thereby indirectly strike hard on the future generations to follow. STANDPOINT PROPOSITION The failure to proper recycling, inefficiency in the process of restoration of the near extinct varieties by newer fertility techniques, over exploitation of fossil fuels and enormous population growth have lead to serious troubles. Measures must be taken to search for the best breeding grounds and home habitats that would rejuvenate the endangered species. Ethical values and morale of people must be exploited for the protection of the extinct flora and fauna. The buffer zones must be encouraged to be set up for creating space between human intervention and original wild dwellings. All the intergovernmental organisations and related institutions must come together to coordinate and participate in meetings and seminars annually or semi-annually to formulate plans and implement strategies to avoid the hidden disasters that could arise from the advancing loss of biodiversity and the rare species. The value of ecosystem balance and a sustainable economy must be essential for a stable economy. Thus a good effort must be taken to uplift biodiversity as it contributes to both utilitarian and non utilitarian grounds. I take a mediocre stand in the preservation of bio diversity along with globalising the world extracting mutual benefits from both and contributing to a better economy. Thus a world would be possible enjoying the aspects of global benefits and equally valuing the bio assets. ESSAY The term ‘Globalisation’ creates a big difference in the entire aspect of revolutionising an economy. It would generate a new world where people would agree upon common grounds and come into harmony to deal with arising conflicts and disputes with ease. It would make the dream of unifying the globe with a single culture, heritage, human rights and standards come true. The economies will unite together for a common goal, purpose and intention to individually contribute to the overall general development of the communities. The people would come into the point of giving their best by becoming mutually accountable for each other and developing complimentary skills. Effective participation and shared leadership will be displayed by each and every one being to make their part become clear and true. There would be right use of power and its implementation by the right set of people at the right occasion. Globalisation would make the technology to advance and grow in right proportions to all the sectors and areas in equalised amounts and contribute for the well being of its source. The cognitive, affective and behavioural patterns of economies will be furnished to contribute more and more to the well being of the nations together as a single unit with defined principles and etiquettes. The basic requirements of self actualisation needs, security concerns, sociability factors, status and dignity counts and general morale of the future generations will be revised and viewed upon in a different and broader perspective. The cross border issues and interstate matters will be held with concerns and peace treaties and negotiations would harmonise different colonies and related territories. Surely globalising the world is one of the most important factors required for inculcating a necessary change to the economy. Biodiversity on the other hand is one of the key factors comprising the earth to its entirety. It is the totality of genes, species and ecosystems together contributing to the biotic and abiotic factors of the planet. The richness of flora and fauna constitutes the green factor and spreads the value of aesthetic beauty. It is the basic building block of the earth and is the keystone element giving space for future growth and flourishing of newer breeds and varieties of species. Since globalisation struck the heads of people, so did occur the excess loss of biodiversity. People began to enjoy the taste of comfort and foolish luxury. The age of Americanisation, Mc donalisation and computerisation paved way to more and more relaxed methods of living and effortless access to materials. It generated a pathway to ready and immediate entrée to the acquiring of the needs and wants of greedy souls. The corporate world and related institutions began to exploit the economy under the name of globalisation. Newer generations demanded latest and advanced gadgets to meet the competency levels and to satisfy the needs of emerging markets and labour forces. Nanotechnology, biotechnology, biomedical engineering, aeronautics, geospatial technology, genetics, fitness and holistic nursing, emergency and disaster management strategies, computer forensics, robotics and fields like artificial intelligence have created a yet different view in the whole living standards. The intensity, vastness and propensity of interconnectedness made possible through globalisation thus produced a huge impact on the present existence of people. Huge areas got cleared by excess amounts of deforestation and replacement of the space with new constructions and buildings. The prevention factors were suggested by planting quick growing trees in the place of the cut trees. But quick growing trees demanded adequate quantities of surplus water which was impossible to be provided in such high proportions. The typical example was of eucalyptus trees that required enormous gallons of water sources for its growth. Since it was a difficult move, it finally lead to a stop to the immediate growing of trees after mass felling. The activities like mining of fossil fuels like coal and petroleum from marine environments and the oil spills extended the hands of humans onto the natural habitats of the species dwelling inside the oceans. In a way the activities disturbed the entire food cycles in ocean environments. The plants that grow in the surface absorbs the contaminated water which harms the small fishes that depend on plant ingredients for their survival. Hence the luminous and bizarre creatures that grow in the twilight zone gets harmed which again spoilt the bigger predators that dwell in the bathypelagic zone and the abyssal zone. An incident occurred in California where a particular breed of pink pelicans got wiped out within few months due to the excess amounts of pesticides that was sprayed onto the rivers that was the main habitat for the pelican population in that region. As a result of the toxin, the plants got infected that automatically created problems to the fishes in that environment. So when the pelicans whose main food was fishes, consumed the fishes as in normal ratios, the toxin entered their body too. Since the energy transfer occurs based on a 10 percent law, the quantity of toxic chemicals that penetrated into the pelican body also. The chemical had a substance inside it that eliminated the cause of formation of coating for the eggs formed inside the pelican bodies. As a result, when the eggs fell onto the ground, broke due to the absence of the hard shell around. Since newborns were not produced, the species got extinct with the current population. The introduction of exotic species is yet another important factor that lead to the extreme loss of biodiversity. The exotic species are introduced for better resilience and adaptability factors with the environment. They display greater survival capacity with their advanced body adjustments and resistance capabilities. A typical example was the bringing in of the population of mongooses in a particular village to reduce the disturbance of snakes. After a period of time, the mongooses wiped off the snakes but as a result of the complete extinction of snakes in that area, there occurred extreme multiplication of rats and rodents since there was an imbalance in the food chain. The end result was snake control but excess population of mice. Hence the theory is that never cause problems to the natural co-existence of species as it would create other uncontrollable troubles in the future. The International Union of Conservation of Nature (IUCN) listed the latest trends of biodiversity loss with the help of figurative graphs and ratios. According to the studies, the results obtained were that 21% of mammals, 28% of reptiles, 37% of freshwater fish, 70% of plants are under serious threat. Among the 33 largest biotic deltas, almost 24 are in a heavy sinking stage. From the conclusions of United Nation Environmental Programme (UNEP) yearbook, a rounded figure of US 50 dollars fish stocks have been depleted. The Amazon activists and reporters have given their analysis on almost 80 percent of the timber forests being sold illegally for personal gains under the disguised name of globalisation. The increasing industrial activities and factory outlets have created havoc in the nearby neighbourhood regions and the rivers and lakes in the vicinity. Excess toxic wastes and chemicals gets drained out onto the lands and the water sources. As a result of this toxic secretions, the fertility of the grounds are lost and it penetrates onto the inner regions of earth through crevices and holes. Thus the water table gets affected and the deeper roots of giant trees and plants sucks the venom into it causing great trouble in the entire nutritional cycles and food chain. When surface run off and soil erosion occurs, the chemicals flows onto the rivers and its tributaries producing chaos and confusion to the fish stocks and marine plants. The evaporation process absorbs these harmful and unhealthy poisonous chemical substances onto the atmosphere. The rain when occurs causes acid showers and expelling of dangerous gases onto the surface of the earth’s layers. Many of these unbalanced cycles have contributed to the climatic changes and melting of polar ice caps thereby flooding the low lying regions. Ozone depletions and noxious gases have still been hot topics in the immediate future. Genetics have been another field that has brought in greater danger in the present scenario. Though it has played an important lead role in globalisation and its effective measures by raising improved varieties of cattle and stock, yielding better quality crops, producing healthy and resistant breed of animals and plants, genetically modified and reengineered products for the nourishment and proper intake of nutrient enriched food materials, it has also displayed itself as a necessary evil. Better varieties of crops and breeds of cattle are produced by artificial techniques and methods of cross breeding and genetically modifying the genital regions of livestock. Disease resistant and pest resistant varieties of crops and related types have lots of preservatives and chemicals added onto it to give the extra juicy and luscious appearance, which are too harmful for the normal metabolic activities to be carried on the human body if consumed above optimum limits. Nowadays Kentucky Fried Chicken (KFC), whoppers and double beef pattie burgers have constantly filled the stores, restaurants and bakeries. People are so addicted to the junk food that there is no way to make them realise the harm it can cause to their delicate skin and body. The heavy dose of calories that gets added onto the body can cause dangerous health hazards like obesity, chronic rise in blood pressure, heart attacks, palpitations and nervous breakdowns. The fat molecules when deposited around the vital organs can cause bad and alerting symptoms of body disorders. The hybrid cattle might produce milk, flesh and wool in much higher proportion than normal and original breeds. But the milk, flesh and related products will be full of injected hormones and dangerous equalisers. It is not the quantity that has to be counted and taken into account, but the quality and health parameters. Pollution has been yet another factor that has created problems for the people. Excess gas emissions, automobile exhaustions, ejection of chlorofluorocarbons and toxic chemicals onto the surface of the air causes respiratory disorders and nasal blockages. The people living along the roadsides and nearby factory buildings develop skin, eye and nose irritations followed by excess breathing problems. The wildlife too gets affected with extreme inhalation of toxic gases like carbon dioxide and carbon monoxides. The pressure thus generated around the valves of respiratory tract for sometime can even lead to a state of unconsciousness and if continued death. Lungs have a minimum capacity to filter out the unwanted toxins from the general pollution. When it exceeds the limit, the victim gets subjected to chronic unrecoverable ailments. The red list has cited an alarming number of hotspots all around the world. Rare and last of some of the keen species have gone extinct due to the high levels of human interventions and penetration onto the natural habitats and dwellings of the collection of species. The main trouble occurs when a particular breed of species completely vanishes from the earth. There is no means to bring it back onto the surface again into full strength. Therefore the best option is to protect and preserve the last survivals and constantly work for its maintainance and upbringing. One wouldn’t know the true values of an asset until otherwise it is fully gone from the visibility of our eyes. Thus make the maximum effective utilisation of resources without causing harm to their balancing cycles and its self capacity to replenish itself. Usage is not a problem, but the way of handling it is the right method to be practised by individuals. Hence globalisation has brought about lots of positive outcomes but at the same time created havoc and disorder on the other end. Clear cut ideas and its implementation is yet an art that has to be handled and practised by the world and its inhabitants for the well being of the future and the effects to follow. If one does create an issue, he is fully responsible and liable to suffer the consequences that are to follow by his/her deeds. It has played a very important role in the destruction and devastation of the biotic reserves and its richness. CONCLUSION Globalisation is a true and positive measure that has made a huge impact on the entire assembling of the world as a unified globe. The effects and measures of its implications and scheduling have brought about lots of benefits to the world as an economy. People have gone forward into thinking seriously about the whole idea of globalising the world due to the increased chances of benefit factors and the thought of a better world has made them go for it. Every aspect has a positive part and a negative part. The positive side is that it has lead to liberalisation of trade, made technological advancements, built, stronger cross border relations, harmonised the economies despite of cultures shocks, communication barriers, age and gender bias, class disparities and rich poor inequalities. Globalisation as in itself is a key criteria expanding and extending its roots onto newer and fresher aspects of better chance and change factors and looks forward for innovative ideas and opportunities. The negative side is that the basic nature of globalisation is that whoever stands on its way is removed and destroyed in the process of advancement. So whether it is an industrial progress or a technological plant construction, no matter what, the surrounding areas and the nearby habitats are deeply destructed and devastated. The advancements are invariably achieved by whatever means. There may be many institutions and greedy eyes whose intentions are fixed to draw profits and money under the disguise of progress and emergence as a sole and supreme power. According to me summing up all the aspects covered till now, I go with my stand point proposition as to draw positive benefits from both the parties as both are interlinked and connected to each other. None can stabilise without the other. So giving space for the growth of both simultaneously can only bring about an actual change in the development of economy. Biodiversity is important for the continuation and survival of life and globalisation is required for the regular and constant growth of the existing life. It is true that damage may occur on any of the grounds, but make it a point that the damages affected are less and that the positives overpower the harms followed. Effective strategies and plans can be brought about to implementing right lengths of standards and formulation of techniques to sustain the growth of biodiversity and globalisation parallely. Scheduling and making proper plans as to conserve and preserve the balance of the existing species and creating the environment for their full fledged revival are very important for the future advancement of generations. All the environmental organisations and institutions must cordially work together in establishing a common ground and reap out the necessary outcomes for the mutual benefit of all the economies together as one.
California University Community Teaching Plan Discussion & Presentation.

This is an individual assignment. In 1,500-2,000 words, describe the teaching experience and discuss your observations. The written portion of this assignment should include: Summary of teaching planEpidemiological rationale for topicEvaluation of teaching experienceCommunity response to teachingAreas of strengths and areas of improvement Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required._______________________________________________________________________________________________Topic: Community PresentationPrepare a presentation based on the Teaching Work Plan and present the information to your community.Options for DeliverySelect one of the following options for delivery and prepare the applicable presentation:PowerPoint presentation – no more than 30 minutesPamphlet presentation – 1 to 2 pagesPoster presentationSelection of Community SettingThese are considered appropriate community settings. Choose one of the following:Public health clinicCommunity health centerLong-term care facilityTransitional care facilityHome health centerUniversity/School health centerChurch communityAdult/Child care centerCommunity Teaching Experience Approval FormBefore presenting information to the community, seek approval from an agency administrator or representative using the “Community Teaching Experience Approval Form.” Submit this form as directed in the Community Teaching Experience Approval assignment drop box.General Requirements While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should.
California University Community Teaching Plan Discussion & Presentation

MGT 498 University of Phoenix Wk 2 Physical Stores and Online Businesses Responses.

Respond to peers in 175 words or more. Response 1:Since the tech boom in the late 90s/early 2000s, brick and mortar stores have found it increasingly difficult to compete with online retailers. If there’s one thing shoppers prioritize above almost all other things, it’s convenience. Online shopping allows customers to shop at any time, regardless of time of day, season, weather, etc. Brick and mortar stores face many challenges, but my advice would be to focus on things that the online retailers can’t compete with, such as price, relationships, ease of trying/returning products, and even the “shopping experience”. Just the same as some avid readers enjoy the feeling of holding a real book and physically turning the pages, routine shoppers still enjoy walking from store to store, getting to physically touch the merchandise before they make their purchase. Also, most brick and mortar retailers are classified as small businesses and there is still a big push in society to help “the little guy” instead of padding the pockets of large online retailers like Amazon. Forging those relationships with local retailers also brings a sense of community and togetherness that you won’t get from making your purchases online.Response 2:Brick and mortar stores are found within a physical location out in our world. When shopping online the customer is looking to do their buying online from their computer and the possibility of leaving their home to shop is slim. Amazon is a prime example of how online shopping has taken off and boutiques are a prime example of whay brick and mortar businesses are. I believe there several advantages to shopping in both places and I can see how with this pandemic online shopping has become more popular and is at a higher demand. When I look at for example Palm Springs in California there are many small boutiques in downtown that are going to have personable items that are unique and most likely cannot be found online easily. I think shops like this need to try and have a bigger online presence to help compete with the onlinr business community. Since the pandemic has started I noticed quite a few of these shops went out of business because people are not going out to shop. I myself find that I use instacart or Amazon a lot more now than I used to. If these little brick and morter businesses tried to habe a larger online presence even if it is just advertising they may have a better chance against the bigger corporations.
MGT 498 University of Phoenix Wk 2 Physical Stores and Online Businesses Responses

Effectively Treating the LGBT Older Person—Presentation.

For this assignment, you will need to review research on the LGBT older person on the following two websites:National Resource Center on LGBT Aging at…International Gay & Lesbian Human Rights Commission at (Links to an external site.)Links to an external site.Create an 8-10 slide presentation (excluding the title slide and reference slide) that uses images and text to describe the unique needs of the aging lesbian, gay, bisexual, and transgender individual (you may focus on a country of your choice).Address the following in your presentation:Create a list of guidelines for human services professionals working with this unique population. Include a list of resources that human service professionals could use to educate themselves about the LGBT older person’s needs.Ensure that your slide presentation has appropriate and engaging images and text on each slide that provides key points of information.Include notes in the slide notes section to additionally support the information included on each slide. You might include, for example, statistics on some aspect of the population or additional information regarding current and best practices in the profession. In addition to the research you use from the two websites, above, cite and incorporate research from at least two additional credible sources—scholarly journals, government information, or professional association publications. The CSU-Global Library is a good place to find these resources. Use in-text citations and a reference section slide at the end of your presentation, following APA style. Remember to cite any research you use from the websites, above.Your entire presentation must follow the CSU-Global Guide to Writing and APA Requirements (Links to an external site.)
Effectively Treating the LGBT Older Person—Presentation

Management of Melanoma Brain Metastases (MBM)

Share this: Facebook Twitter Reddit LinkedIn WhatsApp Abstract: Melanoma is the third most common cause of brain metastases, after lung and breast cancer. Common clinical manifestations include headache, neurologic deficits, cognitive impairment and seizures. The management of melanoma brain metastases (MBM) can be broadly divided into symptom control and therapeutic strategies. Supportive treatment includes corticosteroids to reduce peritumoral edema, antiepileptics for seizure control and medications to preserve cognitive function. Until recently the therapeutic strategies focused on local treatment including surgery, whole brain radiation therapy (WBRT), and stereotactic radiation (SRS). Historically, systemic therapy has had limited utility. Immunotherapeutic drugs like anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and anti-programmed cell death protein 1 (PD1) and agents targeting BRAF- MEK pathway have revolutionized the systemic treatment of MBM. Recent clinical trials with these agents have shown activity against MBM and increasingly being used in clinical practice. In this article, we will discuss epidemiology, biology of MBM and the role of surgery, WBRT, SRS in this patient population. An overview of the currently available systemic therapeutic agents that includes immunotherapy and targeted tyrosine kinase inhibitors (TKIs) and a practical multidisciplinary management algorithm to guide the practicing oncologist will be outlined. Introduction: Recent advances in the management of advanced melanoma have resulted in improved 5-year survival rates, however, MBM remain a significant cause of morbidity and mortality. Approximately 20% of metastatic melanoma patients have brain metastases at diagnosis. Overall about 50% of stage IV melanoma patients will develop symptomatic brain metastases (1-3). Cerebral hemispheres are the site of 80% of brain lesions from melanoma followed by the cerebellum (15%) and brainstem (5%)(4).Common clinical manifestations include headache, neurologic deficits, cognitive impairment and seizures. Until recently, patients with MBM had a dismal prognosis with a median overall survival (OS) of 6 months (5). The management of MBM can be broadly divided into supportive management and therapeutic strategies. Supportive treatment includes steroids to reduce peritumoral edema, antiepileptics for seizure control and medications to preserve cognitive function. Traditionally, therapeutic strategies focused on local treatment including surgery, WBRT, and SRS. Historically, systemic therapy has had limited utility in the management of MBM. However, the treatment paradigm has changed considerably with the advent of targeted therapy and immunotherapy. Approximately 50% of advanced melanoma patients harbor a BRAF mutation and a number of targeted agents for this mutation and downstream pathway have shown promise in the management of metastatic melanoma. Immunotherapeutic agents like anti- CTLA-4 and anti- PD-1 have shown clinical efficacy in MBM and now constitute first line treatment options for metastatic melanoma. Biology of brain metastases: Until recently MBM were believed to have the highest mutational discordance compared to the primary site (6). However, Chen et al. reported molecular profiling that included hot spot mutations, global mRNA expression patterns, quantitative analysis of protein expression and activation by reverse protein array (RPPA) analysis of 16 patients (7). In this study, authors reported complete concordance in mutational profile between intracranial and extracranial sites. Despite these similarities crucial differences in the expression of PI3K/AKT pathway were noted by RPPA. Another study compared the expression of BRAF mutation in different sites of metastases in advanced melanoma and showed greater mutational concordance (16/20 patients) in brain compared to other visceral/subcutaneous metastases (8). These studies provide an initial understanding of the molecular characteristics of MBM. With the advent of immunotherapy, tumor microenvironment and immune infiltration has been a focus of intense research. Brain has been traditionally thought of as an immune privileged organ but recent studies have established the existence of a neuro-immune axis and questioned this belief(9). Our understanding of this unique interplay between the immune system and central nervous system has dramatically evolved over time. Berghoff et al. investigated the expression of PD-1, PD-L1, CD3, CD8, CD45RO, forkhead box protein 3 (FoxP3), CD20, and BRAF V600E by immunohistochemistry in MBM samples (10). Varying degrees of tumor infiltrating lymphocytes (TILs) were reported in this study, 33 out of 43 specimens stained positive for CD3( ) T-lymphocytes, 39 for CD8( ) T-lymphocytes, 32 for CD45RO ( )memory T-lymphocytes, 27 for PD-1( ), 21 for FoxP3( ) T regulatory lymphocytes, and 19 for CD20( ) lymphocytes. Significant tumoral PD-L1 expression (>5%) was observed in 9 specimens while 22 samples stained positive for PD-L1 suggesting role of immunotherapeutic agents in MBM. Prognostic indices Although the median OS of MBM is dismal, approximately 5% patients are long term survivors(2). Hence prognostic factors that predict outcomes and can guide the treatment decisions and enrollment in clinical trials are of value. Several large single center series have examined various primary tumor, brain metastases, and patient characteristics predictive of survival (2, 11, 12). Age, performance status, number of brain metastases, extra-cranial metastases, time from primary tumor diagnosis, presence of neurologic symptoms and elevated LDH are factors that determine survival. (13). Sperduto et al proposed a new disease basedscoring index based on 483 newly diagnosed MBM patients from 8 different centers (14). On multivariate analysis, performance status and number of BMs were prognostic for survival in MBM. The outcomes of ds-GPA MBM varied from GPA class I with survival of 3.4 months to GPA class IV with survival of 13.2 months. These prognostic indices have inherent limitations. All of them were evaluated retrospectively, had only overall survival as the end point, did not include molecular and genetic profile of the primary malignancy, and did not take systemic therapy into consideration (15). A large single institutional experience of 366 patients treated to 1,336 brain metastases has also shed some light on the interplay of important prognostic variables in patients with MBM. In this series, characteristics associated with survival included younger age, lack of extracranial metastases, performance status, and treatment with BRAF inhibitors or immunotherapies. This work specifically highlights the importance of modern out outcomes in patients who are eligible for and receive newer targeted therapies. For example, the 12-month survival estimate for patients treated with BRAF inhibitors was 37% compared to 23% for those patients who did not receive these therapies (p=0.01). Moreover, the 12-month survival estimate for patients treated with immunotherapies was 47% compared to 22% for those patients who did not receive these therapies (p=0.04). Clearly, further work is needed to define the impact of mutation, targeted drugs and immunotherapy in the current era. Diagnosis: The neurologic symptoms associated with brain metastases include headaches, seizures, cranial nerve deficits to motor or sensory deficits. All melanoma patients with neurologic symptoms worrisome for MBM should undergo a gadolinium enhanced magnetic resonance imaging (MRI) of the brain, if no contraindications exist. Guidelines recommend routine MRI of brain with and without gadolinium contrast for patients with stage IV melanoma due to the high prevalence of asymptomatic brain metastases(16). Computed tomography of brain with and without contrast can be used as an alternate imaging. Management: The options available for management of brain metastases include surgery, WBRT, SRS, systemic therapy and symptom management. The management plan to treat these patients should take into account the overall prognosis, performance status and morbidity associated with the treatment. 5.1 Management of symptoms: Supportive care for patients with brain metastases is typically to control the cerebral edema with steroids. Due to minimalmineralocorticoid effect and long half-life, dexamethasone is the steroid of choice, however, other steroids at an equivalent dose can be used and tapered gradually over a two week period(17). A randomized trial in 1990s compared different doses of dexamethasone ranging from 4 mg/day to 16 mg/day and concluded that 4-8 mg/day would provide same degree of clinical improvement in 1 week (18). Routine use of prophylactic anti-epileptics in patients with brain metastases is not recommended(19). When patients have seizures several anti-epileptics are available including phenytoin, carbamazepine, valproic acid and levetiracetam. Non-enzyme inducing agents like levetiracetam are preferred to avoid interactions with systemic agents. 5.2 Neurosurgical Options: Surgery has traditionally been used for management of solitary brain metastases, or large symptomatic brain lesions. Multiple retrospective studies have reported improved survival with surgery compared to best supportive care(13, 20-22). Younger patients with good performance status, fairly well-controlled extracranial disease, solitary brain metastasis, lesions in accessible locations and of small size generally have better outcomes with surgery (21, 23). Surgery is usually followed by radiation boost to the surgical bed by either WBRT or SRS, with an intention of sterilizing the surrounding tissues and preventing local recurrence. Two randomized trials comparing adjuvant WBRT to surgery alone have shown improvement in outcomes(24, 25). Patchell et al. evaluated the role of WBRT post-resection of a single brain metastasis compared to surgery alone(25). Postoperative WBRT resulted in a significant reduction in local and distant intracranial failure. However, no difference in the overall survival or time duration of functional independence was noted. Similar results were seen in the EORTC 22952-26001 study with decreased 2-year intracranial and resection site recurrence without significant survival benefit. Multiple retrospective reports of post-operative SRS have shown improved patient outcomes however prospective data is awaited (26, 27). Bindal et al. showed benefit of resection in select group with multiple metastases in a retrospective review of 56 patients(28). In practice, surgery plays an important role in debulking or removal of life-threatening lesions. Surgery also provides immediate relief from intracranial hypertension by eliminating the mass effect, and symptomatic hydrocephalus by reestablishing the flow of cerebrospinal fluid (CSF). 5.3 Whole brain radiation therapy: Melanoma brain metastases lesions are generally considered radio-resistant compared to other histologies (29). Randomized trials with WBRT have reported survival in the range of 2.4 to 4.8 months.(30) The ideal dose and number of fractions, balancing the intracranial control and cognitive decline, has been subject to intense debate. WBRT fraction sizes of ≤ 3 Gy do not lead to significant neuro-cognitive decline. A retrospective study compared higher dose of radiation, 40 Gy in 20 fractions with 30 Gy in 10 fractions(31). The 40 Gy group had overall survival of 5.6 months compared to 3.1 months. However most of these trials were not melanoma specific and included patients with all tumor types. Patients who are symptomatic with change in mentation, headaches and seizures but are deemed unfit for surgery or SRS due to large number of metastases, poor performance and uncontrolled extracranial metastases are generally treated with WBRT(32). 5.4 Stereotactic radiation therapy: Stereotactic radiation has been increasingly used in the management of MBM in the last two decades. SRS in MBM results in local control rates of 50-75% at 1 year(33-35). SRS is generally limited to lesions smaller than 4 cm in diameter (36). In a retrospective review of 333 patients treated with SRS showed a sustained tumor control rate of 73%(35). The 12-month cumulative incidence of local failure was 14% in another single institution experience of 191 patients treated to 793 MBM. Number of brain metastases that can be treated with SRS has been intensely investigated. SRS for solitary brain metastasis was compared to surgery plus WBRT in a phase III trial that closed prematurely due to poor accrual. The overall survival, freedom from local recurrence and neurological death rates were similar in both groups(37). Several studies have evaluated the role of SRS in patients with 1-3 brain metastases (38, 39). Aoyama et al. compared SRS alone with SRS followed by WBRT in patients with 1-4 brain metastases(38). No difference in neurocognitive function and survival was observed. SRS-alone arm had increased local and distant intracranial failure. A phase III trial compared WBRT followed by SRS to WBRT alone, in 333 patients with 1-3 brain metastases from different histologies that included only 13 MBM patents (40). Performance status at six months improved significantly with addition of SRS to WBRT. SRS for patients with 5-10 brain lesions was evaluated in a multi-institution prospective observational Japanese study of 1194 patients(41). The overall survival, neuro-cognitive function and post SRS complications did not differ for patients with 5-10 brain lesions compared to 2-4 brain lesions(42). 5.5 Systemic therapy: Traditional systemic therapy had a limited role in MBM due to challenges of drug delivery in the brain from blood brain barrier (BBB) with its tight junctions and efflux pumps (P-gp and MRP transport proteins) (43). The concept of localized disruption of BBB at the site of brain metastases has been proposed, as demonstrated on MRI by contrast enhancement (44). Chemotherapy: Chemotherapy agents have not shown good activity in MBM. Dacarbazine which is the approved chemotherapy for metastatic melanoma does not cross the BBB(45). A number of studies evaluated the role of alkylating agents with good BBB penetration such as temozolomide (TMZ), lomustine and fotemustine in MBM patients. In a phase II trial Agarwala et al. enrolled 151 MBM patients with no local radiation therapy for BM to receive TMZ (46). TMZ use showed a modest intracranial response of 6%, median PFS of 4.3-5.2 weeks and median OS of 3.2 months. Two phase II trials of WBRT with TMZ(47, 48); or thalidomide, WBRT with TMZ (49) failed to improve the response rates significantly. Lomustine in combination with TMZ showed modest efficacy in a phase I/II study(50). Intracranial activity of fotemustine was first reported in a phase III trial of fotemustine versus dacarbazine for metastatic melanoma (51). This led to a randomized phase III trial that compared fotemustine plus WBRT to fotemustine alone in MBM (52). The response rates were 7.4% for fotemustine alone and 10% for fotemustine plus WBRT. Fotemustine is not currently approved by FDA for use in MBM due to delayed thrombocytopenia and leukopenia(53). Targeted therapy: BRAF, NRAS and KIT are three common, mutually exclusive driver mutations seen in metastatic melanoma (54, 55). Of these three, BRAF mutation is the most common mutation seen in approximately 40-50% of patients with advanced melanoma. The presence of BRAF, NRAS increases the risk of CNS metastases seen in patients with advanced melanoma. Prior studies have reported 24% CNS metastases rate in BRAF and 23% CNS metastases incidence in NRAS mutant melanoma compared to 12% rate in those who lack these mutations(56). Dabrafenib and vemurafenib target BRAF V600 mutation and FDA approved for metastatic melanoma. A phase I trial of dabrafenib in ten patients with untreated asymptomatic brain metastases, intracranial response was seen in 8 patients (four CR, four PR) (57). This impressive 80% response rate prompted the phase II trial of dabrafenib in BRAF mutant melanoma brain metastases (BREAK-MB) (58). This multicenter open label study accrued 172 patients’ asymptomatic brain metastases with BRAFV600E or BRAFV600K mutation and one measurable lesion (defined as atleast 1 cm in diameter). Cohort A consisted of 89 patients who were radiation naive and cohort B consisted of 83 patients who had failed prior radiation therapy for BM. BRAFV600E patients had an intracranial response rate (IRR) of 39% (29/74) in cohort A and 31% (20/65) in cohort B, PFS of 16.1 weeks in cohort A and 16.6 weeks in cohort B with OS of 33.1 weeks in cohort A and 31.4 weeks in cohort B. BRAFV600K patients had a lower IRR of 7%(1/15) in cohort A and 22% (4/18) in cohort B. This trial supports the efficacy of dabrafenib in BRAF mutant MBM patients, especially those with BRAFV600E mutations with acceptable toxicity. In an open label study of 24 non-resectable, untreated MBM patients harboring BRAFV600 mutation, treatment with vemurafenib resulted in tumor regression of more than 30% (7/19)and partial response was seen in 3 patients. Median PFS and OS was 3.9 and 5.3 months respectively in this study. In a phase II study, 146 BRAF mutant MBM patients were treated with vemurafenib(59). The first cohort included 90 patients with untreated BM, the second cohort comprised of 56 patients with previously treated BM. Complete response was noted in 2 patients, with 14 PRs, and a best objective response rate of 18%. In previously untreated MBM, the median intracranial PFS and OS were 3.7 months and 8.9 months respectively. Previously treated MBM had similar PFS and OS of 4.0 months and 9.6 months respectively. There is no prospective data of safety and efficacy of combination of BRAF inhibitors and radiation therapy. Most reports are retrospective in nature with increased incidence of dermatitis seen in extracranial skin associated with concurrent use of BRAF inhibitors and radiation (60). Rompoti et al. reported five patients with MBM treated with combined radiation and BRAF inhibitor(61). Two patients underwent SRS and three received WBRT. Patients treated with SRS did not experience any skin adverse effects while all three patients treated with WBRT noted grade1/2 dermatitis. A retrospective analysis evaluated effectiveness of vemurafenib and radiation in BRAFV600 MBM (62). All of them received vemurafenib, six patients underwent SRS, two received WBRT, one received SRS and WBRT and three underwent surgery and radiation. Thirty-six of the 48 index lesions responded with 23 (48%) CRs and 13(27%) PRs. Major limitations were the retrospective nature of the study, small number, and pretreated patients with radiation and systemic therapy including ipilimumab. Several small retrospective case series have reported outcomes of MBM treated with targeted agents and SRS/WBRT (Table-1). A recent study of 19 patients with BRAF mutations undergoing SRS and concurrent BRAF directed therapies has shown impressively few local failures (12-month cumulative incidence of 1%). Additional studies of combination therapy are clearly warranted. Immunotherapy: Melanoma is an immunogenic malignancy (63) with a high mutational burden that results in high number of neo-antigen(64). It has been proposed that the relatively high neo-antigen burden makes this malignancy more susceptible to immunotherapy. However, the brain has traditionally been considered an immunologically privileged site due to the presence of the BBB. Recent studies on the intracranial tumor microenvironment as elucidated above have suggested otherwise, showing CD8 T-cells, CD 20 cells, T-regulator cells and PD-L1 expression within intracranial tumor(10). The intracranial activity of interleukin-2 (IL-2, one of the first immune modulatory agents) was reported in two retrospective reviews(65, 66). A response rate of 5.6% was seen in 37 patients with untreated brain metastases within a larger group of 1069 metastatic melanoma and renal cell carcinoma patients treated with high dose IL-2(65). In a second report, two of the 15 brain metastases patients treated with high dose IL-2 showed CR (66). No prospective trials were initiated with high dose IL-2 due to concerns for cerebral edema and neurotoxicity. Two pathways that have revolutionized the management of advanced melanoma are those involving CTLA-4 and PD-1/PD-L1. The CTLA-4 receptor is expressed exclusively on T-cells and downregulates the interaction between antigen presenting cells and T-cells. Ipilimumab is a fully human monoclonal antibody against the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)(67). The pivotal phase III trial that compared ipilimumab with or without gp 100 peptide vaccine to gp 100 vaccine as a single agent allowed enrollment of patients with asymptomatic and/or previously treated MBM (68). A non-significant trend towards better survival in the MBM subgroup was noted among the patients treated with either ipilimumab alone or ipilimumab plus gp 100 compared to gp 100 alone(69). In an expanded access program (EAP) in Italy, 146 MBM patients received ipilimumab and a global response rate of 12% was seen (70). An American EAP reported a 1-year overall survival rate of 20% among 165 MBM patients treated with ipilimumab (71). Margolin et al. conducted an open label phase II clinical trial of ipilimumab for MBM (72). The trial enrolled 72 patients 51 patients in cohort A (those who were not on steroids for cerebral edema) and cohort B of 21 patients (on treatment with steroids). According to the WHO criteria, the response rate was 18% (9/51) in cohort A compared to 5% (1/21) in cohort B, and by immune-related response criteria the response rate was 25% (12/51) in cohort A and 10% (2/21) in cohort B. The median OS was 7.0 months and 3.7 months in cohort A and cohort B respectively. The study concluded that ipilimumab can be used safely in MBM patients. An Italian phase II trial tested a combination of ipilimumab and fotemustine in patients with advanced melanoma including asymptomatic MBM patients (73). A total of 20 patients (out of 83 patients) had asymptomatic MBM, and among these patients the study reported a PFS of 3.0 months and 3-year OS rate of 27.8% (74). A randomized, 3 arm, phase III trial of fotemustine, versus fotemustine plus ipilimumab, versus ipilimumab plus nivolumab (NIBIT-M2) is currently recruiting patients (75). Several retrospective studies have evaluated the safety of combining ipilimumab and radiation therapy (SRS or WBRT), and prospective trial data is forthcoming (76-78). PD-1 receptors are expressed on several cells including T-cells and antigen presenting cells. Their interaction with PD-L1 ligands on tumor cells leads to T-cell exhaustion and downregulation of tumor-specific immune response(79). Nivolumab and pembrolizumab are two anti-PD-1 antibodies that are currently approved for the management of advanced melanoma, and several others are under evaluation. An open label, single-center, phase II clinical trial is currently enrolling patients with untreated brain metastases from melanoma or non-small cell lung cancer (80). In a published early analysis, a response rate of 22% (4 patients) was reported in a total of 18 MBM patients and the responses were durable. Authors noted a high concordance between systemic and brain metastasis responses. Additionally, 11% (2 patients) had stable disease. Intriguingly all responders lacked a BRAF mutation. Relatedly, 4 patients were not evaluable either due to rapid progression necessitating BRAF-targeted therapy (3 patients), or intralesional hemorrhage (1 patient). Toxicities in the MBM cohort included grade 3 transaminitis (1 patient), as well as grade 1-2 seizures (3 patients) and grade 3 cognitive dysfunction (1 patient) from peritumoral edema. Leptomeningeal disease in melanoma Leptomeningeal disease (LMD) is a subset of metastatic with extraordinarily poor prognosis and median survival of 8 weeks(81, 82). About 5% of malignant LMD originates from melanoma (Kesari) and up to 23% of melanoma cases develop LMD(1, 83). Primary leptomeningeal melanoma also exists as a separate clinical entity and should be a consideration in the context of a person with multiple congenital melanocytic nevi(84). Diagnosis of LMD is usually made based on the combination of neurologic symptoms along with corresponding leptomeningeal enhancement on MRI. While cytology from cerebrospinal fluid (CSF) is considered to be the gold standard for LMD diagnosis, sensitivity of this testing ranges from 50% to 80%, depending on number of lumbar punctures performed (85). Like with MBM, treatment of LMD with chemotherapy has low response rates(86). The clinical course of LMD is more treacherous in melanoma in other malignancies given the propensity for melanoma LMD to hemorrhage(87). Molecular characterization of melanoma LMD suggests a higher percentage of BRAF mutations in comparison to the general melanoma population (68% v 45%), based on a single center melanoma LMD cohort of 60 patients(76). Several case reports have been published highlighting complete and partial responses as well as prolonged ongoing survival beyond 15-18 months with BRAF inhibitors (86). Immunotherapy approaches, including intrathecal IL-2, adoptive cell therapies with tumor infiltrating lymphocytes (TILs) and cytotoxic T-lymphocytes (CTLs), and immune checkpoint inhibitors, have also reported prolonged survival in comparison to historic medians (86). A single center study of 38 patients with melanoma LMD who were treated with intrathecal IL-2 reported a median survival of 9.1 months, and the best 15% of patients reached a median survival over 24 months(88). Ongoing survival over 18 months in a melanoma LMD case was reported with WBRT followed by ipilimumab, an immune checkpoint CTLA-4 inhibitor; in this case, treatment with ipililumab resulted in complete radiologic response(89). A phase II trial of combination immunotherapy with ipilimumab and nivolumab, a PD-1 inhibitor, in melanoma LMD has recently opened to accrual(90). In summary, these early data suggest that both targeted therapy and immunotherapy have efficacy in melanoma LMD and can result in durable responses well over a year. Upcoming trials addressing melanoma LMD with newer therapies will likely yield significantly improved survival data over the next decade. Conclusion: Despite significant recent improvement in the outcomes of patients with melanoma, brain metastases remain a major determinant of mortality and morbidity in melanoma patients, and patients with MBM remain in the worst prognostic category. The vast majority of clinical trials with newer agents exclude patients with MBM, thus data on the effectiveness of new drugs in the context of MBM is still lacking. Understanding the biology of MBM and its clinical response to newer agent and particularly combinations of agents and strategies is crucial to increasing the longevity of the poorest-risk melanoma. Appropriate care of MBM begins with diagnosis. In melanoma, the brain is a common site of metastatic spread, both early and late. It is crucial to begin screening patients for MBM at diagnosis, and NCCN guidelines have recently been updated to reflect this changing diagnostic paradigm. The frequency at which to repeat imaging is still not known. Several therapeutic options now exist for the treatment of MBM (A proposed algorithm is provided in Figure-1). Surgical resection, radiation therapy, targeted therapy and immunotherapy all show some degree of efficacy with MBM. Even in cases of LMD, perhaps the worst subset of MBM in terms of survival, treatment with targeted therapy and immunotherapy can induce prolonged survivals from historic means. Initial reports involving combinations of these therapies, such as radiotherapy with either targeted therapy or immunotherapy, appear promising, but will need to be systematically studied in cohorts with larger numbers. Equally important will be the parallel investigation of predictive markers in MBM with these therapies and combinations. Thus, whenever possible, patients with a new diagnosis of brain metastases should be enrolled in appropriate clinical trials. If an appropriate clinical trial is unavailable, treatment decisions should be made with input from a multidisciplinary team including radiation oncologists, neurosurgeons, and medical oncologists. Share this: Facebook Twitter Reddit LinkedIn WhatsApp

Syrian Refugee Debate Essay

professional essay writers Syrian Refugee Debate Essay.

In the Helping Profession Field, you will inevitably come across people whose situations will challenge you and tap into your biases (we all have them). An important part of being able to successfully work with people from different types of backgrounds and situations who access your services will be your ability to process these feelings and biases and reflect on them. This Self Reflection Journal serves as a way to start practicing this skill now.Each week as you read about different vulnerable groups of people (Note: this week’s vulnerable group of people: Syrian Refugee), reflect on some initial feelings and reactions you have as you read about them for various assignments. In your journal, write about your initial reactions (either positive or negative), and then discuss why you think that these feelings came up and how you think that this can impact your work with people who are clients from these vulnerable groups.Resources for Assessment:Self-reflection and academic performance: is there a relationship? (Links to an external site.)Writing a Reflective Journal: Personal Development (Links to an external site.)Journal Writing BenefitsThis activity is matched to the following Learning Outcomes: Discuss the deficits and strengths of different vulnerable client populations, Define the term privilege in a sociological framework, Differentiate how oppression presents itself for specific groups of people, Differentiate the reality of oppression vs the myth and how that impacts policy, and Speak with confidence, clarity, and conciseness.
Syrian Refugee Debate Essay

Geothermal Energy and Its Application in the Middle East Report

Introduction Addressing the modern concerns voiced by economists and environmentalists with regard to the fuel resources on the planet, it is especially remarkable that more and more hopes are reposed in the so-called alternative sources of energy. The requirements to the fuel of the present day mostly concern its sustainability and environmental friendliness in terms of low greenhouse gas emission. Among the most attractive options to consider when choosing an alternative source of energy is geothermal energy. This type of energy is produced by using the natural heat of the Earth interior that is released at certain surface areas at the temperature of more than 100°C (German Advisory Council on Global Change 71–72). In contrast to other types of sustainable energy like solar and wind power, the source of geothermal energy is constant and continuously available, which makes it an especially attractive alternative. Against the general trend in the global community towards producing sustainable energy from ecologically friendly sources, the situation in the Middle East can be described as rather conservative. According to the latest estimates, the main sources of energy and, respectively, electricity in the Middle East states still remain traditional and include gas, oil, hydropower, and coal (see table 1). However, the demand for energy is steadily increasing: only within the two decennia from 1980 to 2000 the annual energy consumption for Iran skyrocketed from 1.6 quadrillion Btu to 4.7 quadrillion Btu per year (Mostafaeipour

Siegel and Strain Archticets Research

Siegel and Strain Archticets Research.

I’m working on a writing Research Paper and need support to help me study.

I would like to know if you could help with a research papercheck the attached pdf please let me know if you could work on it if not I understandif do you understand well I need this to be perfect, pleasealso for the scenerioI wanted to do from either Project A. A 50- unit affordable/ low income level apartment building with ground floor grocery store and cafe orProject D . A new green/ sustainable and carbon neutral community recreation center and library.and the two firms that I like are SIEGEL & STRAIN Architects and Fougeron Architecturecheck them out and let me know
Siegel and Strain Archticets Research