Specification and Design Dissertation Example | Topics and Well Written Essays - 1500 words

Specification and Design - Dissertation Example For instance crime scenes where a person had been shot, when the medics arrive, they had to wait for the police before they could save the individual, therefore the sponsors found the need for a communication system where the information from an emergency scene would reach all the people involved in the emergency simultaneously. The aim of the project, therefore, is to create a communication system where information that originated from a scene of emergency would reach all the people involved at the same time, therefore, hasten the pace of response. In this project, the solution that would enable the integration of all the people involved in response in one call would be the use of Voice over Internet Protocol (VoIP). In designing the VoIP, a software will be designed that will enable a victim of an emergency to communicate with several departments that are responsible for responding to a certain emergency. The software will be designed in such a way that for instance when it is a fi re emergency, the relevant personnel will be notified which will be different from the case of a crime scene. This will be enabled by the programming which when a person chooses the type of an emergency, the software will direct the calls to the specific departments that are responsible to respond to the emergency. There will be no major modifications, however, due to the sophistication of crime and to avoid tampering of the software by criminals, the security protocol of the software will be improved to match the best practices in the communication sector. Literature survey With the current paces in technology where there is the increasing number of service that is available over a wire and wireless connections, the technology is changing from narrowband such as telephones over wires to the wideband where the services that previously used the narrowband would migrate and use the wideband. According to Bonometti article, â€Å"competitive business advantages in the era of unified s uper convergence† digital convergence will expand by entailing the following. Improved evenness in information flow between the cable and cable-less communication technologies, which will be the outcome of changes in cable-less technology, standards and protocol. Real dependence between gadgets, platforms and the multimedia types that they support. The third thing that digital convergence will entail is the intelligence functions such as the semantic web and other machine-based interactions and embedded applications that enable content searches in rich media (Bonometti, 2009, p 248-257). A study by William and Russell on Huawei, which is a technology firm, based in China where it has always been believed that the country is the greatest copier of technologies that have been developed by other countries. In this study, they found out that despite Huawei being a global leader in the provision of Softswitch platform that is used in VoIP, it has been involved in developing of tech nologies in the next generation networks (NGN) that provide for the multimedia solution across different platforms such as mobile phones, landlines, and television sets. The article â€Å"Customized Executive Learning: a Business Model for the Twenty-First Century† by Jamie Anderson and Gert-Jan.

Hebrew Wisdom Essay Example for Free

Hebrew Wisdom Essay The book of Proverbs can be very useful to its readers when in need of wisdom or helpful insight. Everyday people are forced to make life choices—good or bad. The book of Proverbs covers various issues and topics that can be found useful when making any decision. Whether it is an issue of marriage, sexuality, wealth, poverty, guarding the tongue, dealing with emotions, or many more, Proverbs paints a vivid picture of what both the right path and the wrong path have in store. The book of Proverbs â€Å"presents a vivid contrast between the life of wisdom and the life of folly† (Hindson and Yates 263). Proverbs is God’s manual to His people on how to live a life that is pleasing to Him. Throughout the book of Proverbs, readers will see the words diligence and laziness multiple times. These words correspond with the contrast between wisdom and folly because diligence is the result of wisdom and laziness is the result of folly. Towards the beginning of the book of Proverbs one verse in particular tells its readers clearly where the root of gaining wisdom and diligence is at: â€Å"The fear of the Lord is the beginning of knowledge, but fools despise wisdom and discipline† (New International Version, Prov. 1.7). All wisdom comes from fearing the Lord. This type of fear is not a fear of terror but rather a fear of awe and reverence. By having a respect for God, His children should want to please Him, which would result in considering the outcome in every decision being made. When people make wise choices it results in diligence, peace of mind, wealth (literally or spiritually), and gaining more knowledge. In contrast, foolish decisions bring about destruction, fear, laziness, and much more. Throughout Proverbs readers will repeatedly see warnings against laziness and rewards for diligence: â€Å"Diligent hands will rule, but laziness ends in slave labor† (Prov. 12.24). There is a theme throughout Proverbs repeatedly stating the benefits of diligence and the consequences of laziness. These  principles tie into wisdom and folly because when being wise, people will be wise with their time and are on the path to be continually growing in themselves and in the Lord. The reward in being diligent is an overflow of blessings â€Å"The blessings of the Lord brings wealth, and he adds no trouble to it† (Prov. 10.22). When being foolish people do not recognize the preciousness of time. In being selfish, they do not understand that their lack of action affects others†¦or they do not seem to care. When not walking with God and depending on our own abilities and understanding, people will miss out on the rewards of diligence. â€Å"He who trusts in himself is a fool, but he who walks in wisdom is kept safe† (Prov. 28.26). When reading the book of Proverbs, readers will find the book to be overflowing with wise instructions on how to live a life that glorifies God. Big or small, Proverbs offers many wise words and teachings for every situation people walk through in life. Whatever circumstance someone is going through the book of Proverbs gives helpful insight on how to wisely navigate life. Throughout the book of Proverbs readers will see a pattern of the rewards that diligence reaps and the natural consequences one must face when being lazy. This compares to the contrast between wisdom and folly in that when being wise in all one does, there will be a multitude of blessings and rewards. â€Å"†¦Get wisdom, discipline and understanding† (Prov. 23.23b). Just like when being lazy, when one is foolish there will be some unpleasant consequences in hopes that a lesson will be learned the next time around. â€Å"A wise man fears the Lord and shuns evil, but a fool is hotheaded and reckless† (Prov. 14.16). Works Cited Hindson, Ed, and Gary, Yates. The Essence of the Old Testament: A Survey. Nashville: BH Publishing Group, n.d. Print. New International Version. Grand Rapids: Zondervan, n.d. Print.

Marketing creating hedonistic consumers

Marketing creating hedonistic consumers Within the academic and the marketing world it is recognised that there is debate on what role the discipline of marketing plays in the creation of hedonistic consumers. The most extreme debates come from those who hold opposing views. This paper will look at some of these polarised views and perspectives in regard to consumer behaviour and will argue that marketing has not created hedonistic consumers that such a stance does not allow for the complexities of human behaviour and motivations and does not take account of the dynamic nature of consumer society. We agree there are associations and parallels in the development of both consumerism and marketing but there is no evidence to prove cause and effect. According to Armstrong et al (2009, p8), wants are the form human needs take as they are shaped by culture and individual personality. Wants are shaped by ones society. Therefore, consumer wants are not shaped solely by marketers. Conversely, Solomon et al (2006, p21) highlight that marketing is often criticised for employing techniques that convince consumers that they need many material goods and that they will be unhappy and inferior if they do not have these necessities. Do marketers give people what they want, or do they tell us what we ought to want? Marketing is often assumed to be responsible for our consumer society and its hedonistic approach to consumption, and as a consequence undermines other cultural values by promoting a materialistic stance. For many commentators it is the dark side of marketing and worthy of review as it diminishes the marketing professions reputation. 1.1 Definitions Before defining hedonistic consumption, it is useful to define the philosophy of hedonism. This is a school of thought that says the pursuit of pleasure is the most important thing in life, that views man as being motivated by the desire for sensual pleasures therefore this quest for the good life becomes mans driving force. The hedonistic consumer can be viewed as pleasure loving or self indulgent person with a high level of consumption, more preoccupied with their own material goals than thinking of the wider view of society. Hedonistic consumption is the multi-sensory, fantasy and emotional aspects of consumers interactions with products. (Soloman, 2006, p39). This element of fantasy is crucial to this theory as it is the imagined pleasure that attracts the consumer. OShaughnessy and OShaughnessy describe this as the general agreement that consumer pleasure lies not so much in the physical sense as in the total emotional experience. So the pleasure and happiness is real even though the experience can be imagined in the consumers brain. From a negative point of view Migone, 2006 views it as a highly wasteful and discrimatory pattern of consumption that predominates in current capitalist models. Hedonism and Fantasy The role of fantasy in hedonic consumption is key and whilst academics view it from different perspectives they do agree that it plays a pivotal role in pleasure seeking. Gabriel and Lang (2006) are of the view that Western consumption many agree is a realm of seduction alluring and glamour. As goods leave the world of production to enter the sphere of display, circulation and consumption, they become objects of fantasy and instruments of pleasure. Whilst Abercrombie states that lives are organised around fantasies and daydreams about consuming; they are hedonists, primarily interested in pleasure, and sensual pleasure at that they are individualists, largely pursuing their own ends and uncaring about others.(Abercrombie, 1994, 44). Campbell (1987) in The Romantic Ethic and the Spirit of Modern Consumerism described the key aspect in the creation of the hedonistic consumer as being one concerned with the power of the imagination, he highlights the differences between what was regarded as the traditional view of hedonism and the modern view. He suggested that traditional version was a hedonism of a multitude of pleasures, of the senses whilst modern hedonism seeks pleasure not in sensation but in emotion accompanying all kinds of experiences. The pleasure lies in the meaning of the experience to the individual. This is the form we are dealing with in postmodern culture. Campbell suggested that the consumer as hedonist must be able to derive pleasure from every item they come into contact with and everything must be orientated to that end. That consumers are in a constant state of unsatisfaction, an ongoing state where we are dreaming about something new however this is linked to the other defining factor of modern hedonism that disillusionment comes from the disappointment when the imagined pleasure are always greater than the actual. When anticipate the enjoyment and pleasure that we will gain when we finally purchase and wear the new phone/watch/car we have been day dreaming about buying, our pleasure is often not as we imagined and is fleeting. We have moved on to dreaming about the next better version and start to feel bad about not having it. Consumerism good or bad? Underpinning the debate on whether marketing has created hedonistic consumers is the view on whether consumerism is a positive or negative force. Some celebrate the rise of the consumer, taking the view that consumerism is the essence of the good life, that a consumer society allows us personal freedom, power and happiness through our ability to choose, acquire, use and enjoy our material objects and experiences. Seen as a sophisticated, mature individual who seeks enjoyment in life: by making choices and exercising freedom. (Gabriel and Lang, 2006, p8). Others are concerned that consumerism is associated with reduced consumer well being, partly in terms of quality of human relationships and levels of happiness. That those focused on materialistic values have lower personal well being and psychological health. (Kasser,2002). Abela (2006) furthers this argument indicating that hedonistic consumerism shows an association between marketing practice and the harms of consumerism may be greater than it is generally believed to be by marketing academics. 3. Claims against Marketing Too much interest in material possessions is the responsibility of marketing? Critics have argued that the marketing system encourages too much interest in material possessions. people are judged by what they own not who they are. (Armstrong et al, 2009 p.552). Critics dont view this as a natural state of mind but one created by marketing. In answer to this claim many marketers would argue that this alleged ability of marketing to create needs is wishful thinking and is overstating marketings scope. In support of this it follows that marketers are most successful when they appeal to existing wants rather than when they attempt to create new ones. Also that people seek information when making important purchases and mostly do not rely on a single source (Gabriel and Lang, 2006). However, todays mania for goods is learnt not instinctive according to Naish, 2002. On a deeper level our wants and values are influenced by many factors including family, peer group, religion, ethnic background and education. If modern society is highly materialistic, these values arise out of socialisation processes that go much deeper than business and mass media could produce alone (Gabriel and Lang, 2006). OShaughnessy and OShaughnessy (2002) argue that accumulation of material possessions is a consequence of wealth. Marketers create artificial needs? According to Solomon et al (2006), some conservative traditionalists are of the view that advertising in particular, contributes to the moral breakdown of society by presenting images of hedonistic pleasure. Conversely, leftists argue that they same misleading promises of material pleasure function to buy off people who would otherwise be revolutionaries working to change the system. OShaughnessy and OShaughnessy (2002) note that wants must be created and that there must be an underlying appetite for the product in the first place. Solomon at al conclude that while marketers do not create artificial needs, they do contribute heavily to the socialization of people in contemporary society and thus to the establishment of the social system of needs. Consequently marketers must take a share of responsibility for the development of society. Marketers promise miracles? Consumers are led to believe that via advertising that products have special properties; they will so special things for them that will transform their lives. Soloman et al argues that the manipulative effect of advertising is often overstated, however does concede that there is little doubt that advertising creates and changes patterns of consumption. They offer the view that the main affect may be that the idea that we are defined by our consumer choices is perpetuated by the advertising medium. The impact of fantasy and imagery in influencing buying OShaughnessy and OShaughnessy (2002) cite Baudrillard (1981) who suggested that due to the new technology of electronic media we now have a world where the distinction between real and images has become blurred and consumers are viewed as non-rational who gravitate to instant gratification. The claim is that the consumer thinks that this is the reality, however according to OShaughnessy and OShaughnessy there is no proof to substantiate the claim. Image saturated environment pressing consumers to buy The sheer insistence and multiplication of marketing messages is evidence to critics of marketing. The sum of the mass effect on consumers pushes them in a hedonistic direction. However consumers are sophisticated and selective, they take notice of the products that attend to them. (OShaughnessy and OShaughnessy,2002). Consumerism and Identity Many cultural forces have been accused of having a role in the creation of hedonistic consumers the marketing of Hollywood and Celebrity culture are named often in the debate. Its is recognised by psychology that our ability to weigh desirability and value is knocked awry if the item is endorsed by a well known face. The part of the brain involved in trust and learning is activated and as a result we feel like we are their acquaintances and we want to be like them. (Naish, 2008). We chose carefully who we copy and why and have evolved to emulate the most successful, maybe why many of us feel compelled to keep up materially with celebrities. Consumption, is it addictive? Lasch (1991) takes a pessimistic view believing that western consumerism, sustained by mass production and celebrated in the mass media, amounts to a mechanism of addiction. Though Migone (2007) concedes that rather than marketing being at the root of this addiction: it is due to technological advances which facilitated large scale production which in turn leads to large scale consumption. Consumerism and loss of Community Naish notes that only modern capitalist countries concentrate on material greed. In pre capitalist societies the highest worths was ascribed to things like family, clan, religion, honour not shiny new objects. This he says relates to our most base instincts which are the need to relate to others and feel part of a community. According to Naish, man has lost his moral framework, sense of community and lifes higher meaning, so that now all that remains is our thirst for possessions and pleasure. That being a hedonistic consumer does not make us happy and has a detrimental effect on our human relationships. Critics have linked this loss to marketings lack of focus on these types of human values. In defence of Marketing Consumerism and Wealth The 80s recognised a triumph for consumerism old moral restraints on consumption (frugality, thrift and guilt) swept aside by an extraordinary, credit lead consumerist boost (Lee, 1997). Gabriel and Lang recall that greed lost some of its pejorative and puritanical connotations, in reference to the 1980s. Consumption and Identity It has been said that consumers take identity from their possessions. Consumption has expanded to fill the vacuum left by the decline of the work ethic. Bauman (1988) also argues that consumption is the new pioneer frontier in which individuals may successfully assert themselves, with no insecurity and not harming others. Shopping is not merely the acquisition of things: it is the buying of identity. (Clammer,1992). This is another view that consumer consumption comes from within. Also the general rise in disrupted families has been linked to new ways of forming identities through goods how negative the effects are depends on the underlying motives. Human Nature Naish believes we are genetically programmed to always want more. In prehistoric times its been discovered that cave dwellers had collections of axe handles, that these were the Jimmy Choos and Ferraris of their time. Important to note that OShaughnessy and OShaughnessy argue that marketing materialism are interdependent and that marketing helps precipitate materialism and materialism in society advances the development of marketing. According to Bauman, (1999) the major contributing factors to hedonistic lifestyle are pervasive insecurity and uncertainty fear of the future and the ecology of the planet; danger- threat of terrorism and wars; decline of family breakdown of traditional institutes such as family as one of the main cultural reference points. It has been argued that marketing creates hedonism by creating wants. This begs the question can wants be created? According to Moore (1994) materialism and hedonism were not invented by consumer marketing; they were there before its advent. Although, it has been widely acknowledged that consumers have latent wants that can be activated, but recognise that they have a great ability to filter information. Marketers often chose hedonistic appeals, but marketing in itself is simply an orientation and a set of tools that are value neutral and can be used to proselytise any perspective. (Cook, 1992). Social commentators have noted that that pursuit of pleasure is mans natural position and it goes against human nature to deprive oneself and that accumulation of material possessions is due to the fact we have the means to indulge our wants. However they agree there is an acknowledged link but no proven cause and effect but this is viewed as marketing being in the role of facilitator not creator. Marketing and Economy Marketers have accused critics of taking the hyper real world of marketing, advertising and dreams too literally. Arguing that freedom of choice is better for consumers and is a fundamental underpinning of our economic system. Stimulus-response model of buyer behaviour This widely accepted model of consumer behaviour illustrates that whilst marketing stimuli are important so are as are culture, politics, economics and technology. These come merge with consumer psychology and the individual consumer characteristics. These are interlinked and conclude with a final selection of a product. This model is illustrative of the fact that marketing stimulus is only part of the consumer behaviour process. (Please refer to appendix 1). The Future Western style consumerism is facing and creating serious threats ecological crisis, climate change, resources shortages and financial uncertainties. There is an increased awareness among academics and consumers of the ecological limits of consumerism and current debate is focused on its sustainability. Consumers are said to dictate production, they fuel innovation, create new social systems, drive modern politics to have the power to save the environment and protect the future of the planet and yet at the same time are seen as weak and malleable creatures, easily manipulated, dependant, passive and foolish. (Gabriel Lang, 2006). It is recognised that there is a need to engage in debate on the containment of the negative aspects of consumerism. At the centre of the debate is the question of social consequences and the role of marketing in creating the consumption culture.. If we suspect that marketing is contributing to the harmful effects of consumerism what are the courses of action marketers should review? Abela (2006) cites Csikszentmihalyis (2000) suggestion that greater transparency about the effects of materialism would help. Recommends marketers undertake studies for emerging groups the non consumerist consumer, anti consumerism groups and should monitor general consumer awareness. So if the consumer is more aware of the consequences they might not choose the path of consumption especially if it leads to unhappiness and dissatisfaction. Increased efforts at consumer education maybe able to correct this and lead to changes in consumer behaviour. One possible area of study is to look at regions not affected yet possibly in eastern cultures. Some believe we are at the point of a fundamental structural change in the nature of consumerism. Others keeping the faith in the market to right itself. Optimists believe technology will provide an answer (cleaner cars, recycling, energy conservation). The outcome will be a complex dynamic between politics, production, international trade, economics cultural and moral values. (Abela, 2006, Gabriel Lang, 2006, Kasser 2002). In summary, the main culprit behind hedonism would be the development of strong value orientation that puts unrestrained freedom to the forefront. Marketing does not invent or creates wants; it merely surfaces them. Man has always been, in all societies materialistic. In older days poverty didnt allow him/her to indulge into hedonistic lifestyle. The role of marketing in creation of hedonism, is more of a facilitator than of an inventor. (OShaughnessy and OShaughnessy, 2002). Conclusion This paper has recognised that there is debate on what role the discipline of marketing plays in the creation of hedonistic consumers and outlined the argument that marketing has not created hedonistic consumers, that such a stance does not allow for the complexities of human behaviour and motivations and does not take account of the dynamic nature of consumer society. We agree there are associations and parallels in the development of both consumerism and marketing, but there is no evidence to prove cause and effect. However neither is there evidence to disprove. When deciding what marketing strategy an organisation should follow the primary aim is building profitable relationships with the target consumer however, the organisation has many choices in guiding their marketing strategy in terms of which philosophy should underpin the strategy. Many of todays large corporations employ the marketing concept by knowing the needs/wants of the target market and delivering satisfaction better than the competition. (Armstrong et al,2009). Based on the theory that there is a parallel in the patterns between the rise of the hedonistic consumer and the sophistication and intensity of marketing efforts (Abela, 2006) ethical marketers would be advised to consider a move toward the Societal marketing concept a concept that holds that marketing strategy should deliver value in a way that maintains or improves both the consumer and the societys well-being (Armstrong et al, 2009, p14-15). Executed correctly this strategy would provide long term profits and protect both society and the consumer within this framework. sReferences Abela, A.V. (2006) Marketing and consumerism European Journal of Marketing Vol. 40 Number 1/ 2 pp 5-16 Abercrombie, N. (1994)The Authority of the Consumer, Routledge, London,UK Armstrong, G et al (2009) Marketing an Introduction, Prentice Hall, UK Baudrillard, J. (1981), The Critique of the Political Economy of the Sign, tr. Levin, C., Telos Press, St Louis, MO in OShaughnessy,J. OShaughnessy, N.J. (2002) marketing, the consumer society and hedonism European Journal of Marketing, Vol.36 Number 5/6 pp 524-547 Bauman, Z. (1988) Freedom, Open University Press, UK Campbell, C (1987) The Romantic Ethic and the Spirit of Modern Consumerism, Basil Blackwell, UK Csikzentmihalyi, M. (2000) The cost and benefits of consuming, Journal of Consumer Research, Vol.27,September, pp 267-272 in Abela, A.V. (2006) Marketing and consumerism European Journal of Marketing Vol. 40 Number 1/ 2 pp 5-16 Douglas, M and Isherwood, B. (1979) The World of Goods, Basic Books, US Firat, A.F and Schultz, C.J. (1997) From Segmentation to Fragmentation: Markets and Marketing Strategy in the postmodern era, European Journal of Marketing, Vol. 31, No 3 /4 Hirsch, F. (1977), Social Limits to Growth, Routledge Kegan Paul, London, UK Jantzen, C., Ostergaard, P. and Fitchett, J.A. (2004) A History of Mentality based Analysis of Hedonic and Experiential Comsumption, Advances in Consumer Research, Vol.31 pp 328 340 Gabriel, Y. and Lang, T (2006), The Unmanageable Consumer, 2nd Edition, Sage, UK Kagan, J. (1999) Three Seductive Ideas, Harvard University Press, US Kasser, T. (2002),The High Price of Materialism, MIT Press, Cambridge, US Kotler, P and Keller K.L. (2006) Marketing Management 12th Edition, Prentice Hall, UK Lasch, C. (1991) The True and Only Heaven; Progress and Its Critics, Norton New York Lee, M.J. (1997) Consumer Culture Reborn, Routledge, London Mick, D.G (2008) Degrees of Freedom of will: An essential endless question in consumer behaviour, Journal of Consumer Psychology, Vol.18, pp17-21 Migone, A. (2006) Hedonistic Consumerism: Patterns of Consumption in Contemporary Capitalism, Review of Radical Political Economics, Vol. 39, No 2, pp 173-200 Moore, R.L. (1994), Selling God, Oxford University Press, New York, NY Naish, J. (2008) Enough Breaking free from the world of more, Hodder and Stoughton, UK OShaughnessy,J. OShaughnessy, N.J. (2002) marketing, the consumer society and hedonism European Journal of Marketing, Vol.36 Number 5/6 pp 524-547 OShaughnessy,J. OShaughnessy, N.J. (2007) Reply to criticisms of marketing, the consumer society and hedonism, European Journal of Marketing Vol. 41, Number 1 /2 pp7-16 Richins, M.L. and Dawson, S. (1992) A Consumer Values Orientation for Materialism, Journal of Consumer Research, December 1992 Salzer-Morling, M. and Strannegard, L. (2007) Aint misbehavin consumption in a moralized brandscape, Marketing Theory, Vol.7(4) pp 408-425 Simmons (2008) Marketing to post modern consumers: introducing the Internet Chameleon, European Journal of Marketing, Vol. 42, No  ¾, pp 299-310 Solomon, M., Bamossy, G. Askegaard, S. and Hogg, M.K. (2006) Consumer Behaviour A European Perspective, Third Edition, Prentice Hall, UK. Further Reading: Arnould, M.J. and Reynolds, K.E (2003), Hedonic Shopping Motivations, Journal of Retailing, Vol. 79 Dittmar, H. (2004) Are you what you have? The Psychologist, Vol.17, No 4 pp 206-210 Dholakia (1999) Going Shopping: Key determinants of shopping behaviour and motivations, International Journal of Retail and Distribution Management, Vol. 27,No 4 pp 154-165 Mick, D.G. (1996) Are studies of Dark Side Variables Confounded by Socially Desirable Responding? The Case of Materialism, Journal of Consumer Research, Vol.23 pp106-119 Naish, J (2008) Enough is Enough: Learn to want less, http://women.timesonline.co.uk/to/life, Date accessed 04/10/09

Management of Melanoma Brain Metastases (MBM)

Management of Melanoma Brain Metastases (MBM) 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 incre asingly 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 sam ples 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 e stimate 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 over all 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 patie nts 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 pretreat ed 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 tr eated 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 ther apy (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). Molec ular 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 inhib itor; 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 t eam including radiation oncologists, neurosurgeons, and medical oncologists.

Ironic Cycles :: essays research papers

Ironic Cycles In The Sun Also Rises, Ernest Hemingway uses irony and symbolism to illustrate how a group of Americans and English expatriates lived life. They try to forget the war and restore a sense of meaning to their lives, which he would have liked to do. Hemingway’s attitudes are expressed in the book, including his idea of, â€Å"emphasize the optimistic idea of progress of life’s cycle.†   Ã‚  Ã‚  Ã‚  Ã‚  When Hemingway was growing up, he would perfect his fishing during his family’s summer vacations to Horton’s Bay. Right up until he decided to enlist in the army, his passion was fishing. The fishing trip in the book demonstrates that Jake can find happiness in the sun, without Brett. Spending time with two men that know the woman he loves makes him realize he is better off without Brett.   Ã‚  Ã‚  Ã‚  Ã‚  Jake seems to be the â€Å"mature, stabilizing friend to all,† but his own life is in a mess. Hemingway shared the same characteristics. When he was rejected from the army because of his bad eyesight, he still wanted some adventure in his life. So he decided to be an ambulance driver for the Red Cross. After he was wounded, he helped another injured man find his way to a trench and out of harm. He put other people’s problems ahead of his own, just as his character, Jake, does. Jake symbolizes the steers being put into the ring to calm the bulls. He is put into the rowdy group to help them maintain some order. His true emotions do not show through much. This is one of Jake’s flaws, along with his impotence. As Hemingway was wounded in war, he portrays this in Jake’s character.   Ã‚  Ã‚  Ã‚  Ã‚  Hemingway joined the â€Å"Lost Generation† crowd during his hardships. During these years people spent time aimlessly walking around. They didn’t think there was a purpose to their lives. In the book, the characters wandered together through an â€Å"endless, drunken procession of parties, cafes, and sexual affairs,† in a desperate search for meaning to their lives. Some of the story Jake tells the reader lies between the lines in the book, possibly symbolizing the absence of meaning in the characters’ lives.   Ã‚  Ã‚  Ã‚  Ã‚  The war constantly haunts the characters throughout the book. The effects of war are evident in their alcoholism and their unconscious cruelty to each other. It is the war and its effects they are running away from with their continuous drinking.

Incest Essay -- essays research papers

Incest Incest is one of the most interesting taboos of our time. The definition of incest is a highly controversial topic. Yet, the definition of incest is one of the most important definitions for the people involved, though the law's and psychologists' meanings are not much the same. Incest needs to be similarly defined for the incestuous parties, both by the law and by psychologists. The definition of incest should be determined by the cases of incest. The people who commit incest, and the types of incest should be considered when making this definition for the law. Why incest occurs has a great deal to do with the people and the types of incest. With the definition dissimilar between the law and psychologists, it is very difficult for the involved to do anything about it. The definition is both stated as wrong by law and by most religious morals. According to psychologists, incest is defined as A- any intimate physical contact that is sexually arousing between non-married members of a family." (Justice, pg 25) What this is interpreted as is that sexual intercourse does not need to occur for a situation to be considered incestuous. Stroking, fondling, or even intimately kissing can be considered incest. This is not all true for the law's definition. In Georgia, incest is defined as any sexual intercourse between known relatives, by blood or by marriage, (meaning a step-parent and step-child.) Incest laws basically exist to prohibit marriage or inbreeding between family members, and the sentences are almost never carried out. (Kosof, pg 53) So incest is stated as wrong, but not enforced. The Bible states that incest is wrong, just as the law does. ACursed be he who has relations with his father's wife... Cursed be he who has relations with his sister or half-sister!" (Deu 27:20,22.) Therefore, the definition can be altered to fit the needs of the definer. The different forms of incest are as follows: father-daughter, mother- son, brother-sister, and father-son. Conditions of incest don't always involve intercourse, but still hurt the included. So, the conditions should help to define the firm meaning. "But surely at fourteen, I should have been capable of escaping..." (Armstrong, pg 7) Father-daughter is the most common form of incest. Three-fourths of all reported cases usually involve dad and his oldest daughter. It is usually non-... ...ween mother and father. Mom either denies dad sex, there is a major life crisis, or opportunity knocks. The opportunity for incest occurs when mother is gone all the time and so the daughter assumes the role of the mother. When this happens, there is a need for treatment. This is when the definition of incest is most important. The children are very scared and need confidence. If he/she tells a psychologist or teacher, that person is required by law to tell the authorities. (Kosof, pg 53) When the authorities are contacted, the definition comes into play. The child wants to feel safe, and if their definition of incest doesn't live up to the law's, then the charges could be dropped and the child gets into more problems with incest. Therefore, the background of the incest is very important to the law's definition. By the people involved, the form, and why it occurs are critical to helping the child out when defining the term. The definition of incest by the law should be closer to the definition of psychologists in order to help out the family. AIt is evident that we still know very little about how to treat the sexual offender and the abused child effectively." (Kempe, pg 109)

Classroom Field Study Report Essay

General Description Disston Elementary School, located at Knorr and Cottage Streets, in the Tacony/Wissinoming neighborhood of Philadelphia, is a four-story brick building. The school, K through 8, has a gym, auditorium, and library. There is also a computer lab, consumer education classroom, and a music room. The floors are organized by grade levels, starting with the lower grades on the first floor and working their way up the building. The ground floor, or basement, is reserved for specialty classes, such as music, etc. The school, built in the early 1900’s, has very few modern improvements, mainly because it is a historical landmark. There are no elevators or ramps making it inaccessible to those with walking disabilities or are wheelchair bound. The school, which has approximately 800 students and 40 teachers on staff, is maintained well and kept clean. The staff members I encountered at the school were well informed and professional. The neighborhood is predominately middle class, but does include some low-income families. In addition, about 15% of the students are bussed to Disston from neighborhoods that are at or below the poverty level. The cooperating teacher, Ms. Bledy, was happy to share her classroom as well as her experiences. She provided a pleasant atmosphere and gave me the opportunity to observe her seventh grade science, mathematics, and social studies classes, and fifth grade reading and English classes, which she also instructed. Her seventh grade classes consist of 29 students and her fifth grade RELA (Reading/Language Arts) class consists of 25 students. Learner Differences In the 7th grade class, there are 26 students with average or near-average ability and three students who have been identified with reading and math disabilities. These 3 students attend special classes for those subjects and return to Ms. Bledy for science and social studies. Ms. Bledy adapts the content in science and social studies according to each of the special education students’ I. E. P. (Individual Education Plan). Since all three students are at, or below a second grade reading level, Ms. Bledy uses the school library to find appropriate stories, books, or articles at each students grade level. She looks for material that is parallel, or as close as possible, to the content that is being covered in science and social studies. While lower grade level books have less detail, the teacher tries to provide the special education children with some reading material on the same or a related topic. For example, in a science class on metamorphosis, Ms. Bledy found a story called â€Å"The Very Hungry Caterpillar† by Eric Carle. This grade 1 story, through pictures and words, shows the four life stages from an egg to a butterfly (Surprisingly, the students of average ability also enjoyed this 1st grade book). Ms. Bledy also provides daily hands-on and visual learning experiences for all her students; therefore she finds it easy to adapt lessons for the special education students mainstreamed into her classroom. With the exception of the 3 special educations students, the remaining 26 students in Ms. Bledy’s math class are instructed on a 7th grade level. The teacher uses various visual, auditory, and hands-on learning techniques to adjust to each students learning style. Disston School provides a â€Å"reading cycle† for 90 minutes each day from 10:15 to 11:45 a. m. During this time, students throughout the school change classes to attend reading and language arts at their ability levels. Ms. Bledy teaches level 5 reading, writing, and English. In this class, there is a mixture of 28 students from grades four through eight. Within the groups of students I observed, there were no students with physical handicaps, nor did I observe anyone with severe emotional behavior differences. Ms. Bledy did inform me that 2 students receive the prescription drug Ritalin daily, administered either by the school nurse or a parent. There were very few behavior difficulties in Ms. Bledy’s classroom. She has created a structured, firm and fair atmosphere that the students find comfortable. Motivation Techniques Ms. Bledy facilitates safety, belonging, and positive self-worth to each of her students on a daily basis. The atmosphere in the class is one of calm, encouragement, respect, and unity. During the entire time I attended her classes, I saw students actively engaged in learning, any disruptions were addressed quickly, quietly and effectively. The children seemed to have little difficulty in dividing work in cooperative learning groups and they readily helped each other during class activities. I observed Ms. Bledy’s classes in the last few weeks of school, but it was apparent that the students had become accustomed to routines and had a sense of trust among them. The special education students mainstreamed into the regular education classes were not afraid or embarrassed to show their group members any lower level materials they were using. Although the students were grouped heterogeneously, Ms. Bledy is careful to place the special education students in groups with students that are more patient and have a kinder disposition. These easy-going students are more compassionate toward a special education group member who might take longer to complete an assignment. Some examples of motivation techniques I observed are: Safety: While Ms. Bledy was giving directions for a map activity in social studies class, one of her students, Brandon, rolled up a few small pieces of paper and was proceeding to put them into an empty pen tube. Just as he was about to put the pen to his lips, Ms. Bledy made eye contact with him as she continued giving directions for the activity. She walked over to Brandon and put out her hand so that he could hand over the â€Å"spitball† tube. She never stopped giving directions, but did stop this young man from throwing spitballs around the class causing a disruption. She then pointed to the behavior book and motioned for Brandon to sign it. He shrugged, but quietly walked over, found the page in the book with his name on it and wrote the date and what he did. Brandon wrote, â€Å"trying to make spit ball tube, but Ms. Bledy took it from me. This is a warning, if I do something disruptive again today I will receive a penalty. † At the beginning of the school year Ms. Bledy taught and practiced with her students the class rules and what was expected of them. She feels that if the students write down what they did and make some notation of either a consequence or some other thing that helps them improve their behavior, that there are fewer disruptions in class. Effort and Improvement: Eric is having difficulty creating a circle graph from information on a complicated bar graph. Ms. Bledy gives Eric some individual attention. She goes over to his desk and helps him create some simple circle graphs from simple bar graphs. She then has him practice a few more circle/bar graphs escalating the difficulty each time. She gives encouragement and approval when he is correct and guidance as needed. In a short time, Eric is on his own, confident that he can probably handle the more difficult work. Ms. Bledy moves on, but keeps a watchful eye out for Eric. By the end of class, Eric is successful in completing his graphs. Rewards: Ms. Bledy makes positive comments to her students regularly. She also gives students simple, but effective, rewards. One student, Melissa, not only was helpful to the teacher, but she went out of her way to help Antoine (a special education student) locate the Allied countries of WWI on a map. At the end of class, Ms. Bledy used her cell phone to call Melissa’s mother and told her what a wonderful person Melissa is. Multiple Intelligence: Like most classrooms Ms. Bledy’s class has a variety of intelligences. One of the techniques she uses to address this is by having students divide up work in cooperative learning groups according to their interests. In science class where the students were working on a project on acid rain, the students in each co-op group were required to provide research, complete an experiment, keep a daily journal of results and conclusions, make drawings and graphs of the results, and complete a cover page. Each group is permitted to divide the work according to their talents, although all group members must share in the experiment. Behavioral Learning Principles Ms. Bledy’s classroom atmosphere stresses learning, from the various information provided on classroom bulletin boards, posters, and at workstations to the organization and structure of daily activities she creates for her students. Here are some examples I observed: Fact Learning: Ms. Bledy begins each math class with a math warm-up. The students complete a few simple questions (no more than 5) in two or three minutes. These warm-ups are designed to practice various skills. Students practice basic multiplication, addition, subtraction, and division skills by playing the math game â€Å"24†. Students prepare study cards, usually for homework. They are similar to a flash card, where they put a definition on one side and the term on the other side. This is done on 3Ãâ€"5 index cards. In class, the students play a memory game either in pairs or small groups, using these cards. Reinforcement: Ms. Bledy uses positive reinforcement in her classroom. When she praises a student she uses concrete words that describe the achievement made. One student, Regina, who struggles with math but excels in social studies, was trying to figure out the average winter temperature in Celsius in the country of Germany. She knew the temperature in Fahrenheit. Regina recalled that during a math and science class, Ms. Bledy had shown them how to convert Fahrenheit into Celsius. During this social studies class, Regina applied those skills and was successful in finding the answer. When she told Ms. Bledy the answer, the teacher complimented her on her math skills. Regina beamed the rest of the afternoon and took pride in showing her classmates how to convert the temperatures. Punishment: I observed Ms. Bledy use both presentation and removal punishment techniques. She regularly removes items from the students that can cause them to be disruptive, such as when she removed Brandon’s spitball tube. But, I only saw her need to remove one student to a time-out area. Patrick refused to cooperate with his group and Ms. Bledy had him complete a writing activity (presentation punishment) on cooperation in a time-out area (removal punishment). When he completed this activity he was eager to get back to his group. Ms. Bledy allowed him to rejoin the group where he participated mannerly. Schedules of Reinforcement: Ms. Bledy uses a variable ratio as the schedule of reinforcement in her classroom. She calls on students randomly who offer answers. Although Ms. Bledy schedules particular educational trips with specific dates, she randomly assigns points that students need to earn toward that trip. At the beginning of an activity on statistics in math class, Ms. Bledy told the class that each student could earn 10 points toward Spirit Day, by completing the activity in a timely and thorough manner. One of the requirements she listed was that each group member helps each other complete the assignment. Behavior Modification: Ms. Bledy uses a daily report for students to help them improve behavior. On this report the students identify the behavior they are trying to improve, whether it is disciplinary or academic. The student presents the daily report to all teachers throughout the day. Each teacher writes whether or not the child improved that targeted behavior for that class and lists any suggestions the student can follow for further improvement. At the end of the day, the child takes the daily report home for a parental signature (This is not always a requirement. It is done on a case-by-case situation). Ms. Bledy and the student review the daily report each morning and discuss other ways the child can help him/herself. Modeling: Ms. Bledy uses modeling as part of her direct instruction at the beginning of most classes. In one instance, the students were to create a time line of their future. Ms. Bledy created a time line for herself and shared it with the class. She showed them how she started out by making a list of 10 goals for herself on paper. Then she explained how long she thought (realistically) it would take her to achieve each goal. Finally, she picked 2001 as a starting point and systematically set up her time line. The students grasped the idea and went quickly to work. Cognitive Learning Principles Ms. Bledy increases her students learning by using a number of cognitive learning principles. Concepts are learned through practice and examples, information is processed by using chunking, categorizing, etc. and her students regularly participate in meaningful activities linking new information to existing knowledge. Concept Learning: Ms. Bledy writes a list (or row) of terms that are related and adds one that is unrelated. In a science lesson on solutions she listed the terms â€Å"dissolving, hard water, soft water, bacteria, solute, solvent. † The students identified the term â€Å"bacteria† as the one that did not fit into this list. She continued by listing 3 or more groups. Information Processing: Ms. Bledy makes constant use of charts and graphs. The students created bar graphs for a math class I observed based on statistical information they collected. Students surveyed Ms. Bledy’s class as well as seven other classrooms on how they would like, or wish, to spend their summer vacations. They combined their information and converted it into percentages. Then they created bar graphs and later in the week made circle graphs. Constructivism: Ms. Bledy’s students went on to accumulate information on how they actually spent their summer vacations (meaningful activity) and created graphs using this information. As a conclusion to this assignment, Ms. Bledy had the students compare the way they actually spend vacation to how they wish their vacations would be like. Classroom Management Ms. Bledy’s classroom is well organized and well managed. She has three osters above the side blackboard that lists rules, penalties, and rewards (see attached copy of Ms. Bledy’s Discipline Plan).