Analysis of as new park case study Essay Example for Free

Analysis of as new park case study Essay Analysis of as new park case study Introduction                   The planning process involves developers, communities, engineers, planners, and government. The involvement of all the stakeholders in planning process ensures that a project is positively implemented in the public interests (Carmona, 2010). The new project would commence as an improvement the old city. The old city was widely used by women and children. Although it was developed 30 years ago, it still remained as the best choice for the people living at its vicinity. It formed the best recreation centre for people during warm winter season. The new park would replace the old trees, grass, and build new shades and buildings that would be used to shade people during hot weather. The case involved closed down of the old city for 2 years and relocation of people living around the city to place where there were no social amenities such as schools and recreation centre. The case represents of unethical issues that pertains to urban planning evident through the developers.                   The ethical issues include closure of the city and denying people their recreational facility. The new park development would deny people a chance to enjoy their recreational facilities, which is professionally unethical to a developer. In addition, the developer would be destroying people’s heritage on old trees and grass. The modern buildings would destroy the old trees and grass heritage in the new park. Moreover, it is not ethical to transfer people from their own comfort zone where they enjoyed social amenities such as schools, parks and other infrastructures such other shopping malls to a place where they no longer enjoy the amenities. The act is believed to on self- interests that do not care about other community. In planning process, it is important for planners and developers to consider professional ethics while executing their city planning so that respect between communities and the affected people is maintained (Allen, 2009).                   In this case, the most probable solution would be first to develop the area where the two communities would be relocated before relocating them. It would be most appropriate if the government could start by developing infrastructures such as roads, schools, hospitals, and recreational centres before displacing people in towns if the new park would not be avoidable. On the other hand, a new park could be developed elsewhere and the old one be renovated to maintain national heritage. Moreover, the old park renovation should not be closed for a long period and should developers should allow people to access the park even under constructions. The renovation of the park would ensure that the national heritage on traditional trees and grass would not be destroyed thus maintain it as way of protecting the countries indigenous species. This would ensure that people are not relocated from their original comfort zone. Consequently, development of area that the two communities were transferred would ensure that the communities’ living standards would not be affected except their geographical shift. The move would maintain the respect between the communities, planners, developers and engineers as their lives will not be affected.                   The solution approach where the planners would ensure that all the social amenities are developed before relocation would ensure that the professional code of ethics on the conscious on the right of a third party would be upheld (American Planning Association, 2009). In addition, the code of ethics on fairly dealing with all the people involved in the process will be highly upheld. However, the value of professional code of ethics on heritage will be violated through electing a new park and indigenous trees will be destroyed. The planners will have made sure that the decision making process involves all the party and thus no one would be negatively affected by the new project. Similarly, the second approach of electing the new park elsewhere would ensure professional code of ethics for planners to ensure social justice and responsibility not to disadvantage people would be upheld. This solution would ensure that people are not relocated and at the same t ime the national heritage is maintained. The value of heritage that is attributed to indigenous trees will be upheld while that of excellence design and updated design will be violated (American Planning Association, 2009).                   Both solutions would minimize the negative impacts of the planning in the city. However, the best solution will be to design and construct the new park elsewhere near the old park. The solutions to planning dispute safeguard the rights of the people and the professional ethics of the planners (Staatskoerant, 2011).The old park can only be renovated so that the heritage of the city will be upheld. Similarly, there would be relocation of people to new areas and thus they will be fairly treated and their lives will not be affected. In addition, the solution will ensure that people are not denied their rights to enjoy themselves during winter. Renovation for the old park could be done during summer when people are not using the park so that they would not be limited access during winter. The move will impact positively to people living there and would retain the respect of communities to developers.                   The solution would limit the planners, developers and engineers from implementing their own design and planning of the city. In addition, the people would not have a chance to enjoy a modern facility. However, there would still be a chance for them to construct a new park elsewhere in the city and increase the number of parks. One that would be rich in heritage and there other one would be modern. Although space and area allocation may be a problem, a new park elsewhere would stand out for this case. Conclusion                   In conclusion, it can be noted that planners, developers and engineers should highly consider professional ethics when carrying out new projects that would impact negatively to the public. All planning processes should involve all stakeholders and fair implementation of the project should be considered to avoid unethical issues that are evidenced in the case of new park development. References Allen, J. (2009).  Event planning: Ethics and etiquette : a principled approach to the business of special event management. Mississauga, Ont: Wiley. American Planning Association,. (2009). AICP Code of Ethics and Professional Conduct. Planning.org. Retrieved 13 May 2014, from http://www.planning.org/ethics/ethicscode.htm Carmona, M. (2010). Public places, urban spaces: the dimension of urban design. Oxon: Routledge. Staatskoerant,. (2011). Code of ethics and professional conduct for the urban and regional planning profession. Gov.za. Retrieved 13 May 2014, from http://www.gov.za/documents/download.php?f=147400 Source document

Diagnosis of Middle Ear Disorders Using Wideband Energy

Diagnosis of Middle Ear Disorders Using Wideband Energy CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERSÂ  USING WIDEBAND ENERGY REFLECTANCE A Doctoral Thesis Presented to The Graduate College of Missouri State University In Partial Fulfillment Of the Requirements for the Degree Copyright 2008 by [Alaaeldin Elsayed] CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCE Communication Sciences and Disorders ABSTRACT Accurate diagnosis of middle ear disorders in adults and children is a challenging task because of the complexity of disorders. Wideband energy reflectance (WBER) technique provides simplicity and accuracy in diagnosing middle ear disorders across wide frequency range. This research is expanding the studies of WBER to investigate the middle ear function in normal and pathological conditions of the middle ear in adults and children. Findings showed that WBER not only can distinguish abnormal from normal middle ear function but also can characterize different middle ear disorders in adults and children. Several specific WBER patterns were established in a variety of middle ear disorders among adults and children that will help in early diagnosis of such pathologies. The ER pattern was including significant higher ER in the children control group than the adult control group at 0.5 kHz and 1 kHz, abnormally high or shallower in otosclerotic ears, abnormally low in ears with TM perforati on and abnormally low ER with deep notch in ears with hypermobile TM. In presence of negative middle-ear pressure, elevated ER at ambient pressure is also expected. Results also showed that standard tympanometry was less sensitive in diagnosing middle ear disorders when compared to WBER especially in otosclerotic cases. Further studies are still required to validate the clinical use of ER in larger number of individuals with confirmed middle ear disorders. KEYWORDS: wideband energy reflectance, otosclerosis, otitis media with effusion, eustachian tube dysfunction, tympanometry. This abstract is approved as to form and content Wafaa Kaf, MD, MS, PhD Chairperson, Advisory Committee Missouri State Universit CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCETITLE OF THESIS By Alaaeldin Elsayed A Doctoral Thesis Submitted to the Graduate College Of Missouri State University In Partial Fulfillment of the Requirements For the Degree of Doctorate, Audiology ACKNOWLEDGEMENTS I would like to thank so many who encouraged me along this dissertation. First and foremost, I am thankful to God for all his blessings. I am very grateful to Dr. Neil DiSarno for all his support and kind caring throughout my graduate school education. Further, I am indeed grateful to Dr. Wafaa Kaf, my doctoral advisor, for her guidance, encouragement, and support throughout this work. In addition, I would like to show appreciation to my committee members for their helpful comments and direction for this dissertation. Special thanks also to the faculty and secretarial staff of the Department of Communication Science and Disorders. Thanks to Dr. Walid Albohy, and Dr. Ahmad Alhag for their help in collecting data for this study. Special thanks and appreciation for my wife Enass and my children Mohamed and Nada, your love and delightful spirits has kept me going forward. DEDICATION This work is dedicated To My dear parents, My beloved Enass, Mohamed, and Nada, Who made all of this possible, for their endless encouragement and patience. REVIEW OF THE LITERATURE Hearing mechanism and the middle ear Sound transmission. The hearing process includes the transmission of sound energy through the auditory canal to the tympanic membrane (TM). This sound energy results in vibration of the TM with an equal atmospheric pressure on both sides of the TM. The mechanical vibrations are, then, transmitted from the TM to the air-filled middle ear space and ossicles (malleus, incus and stapes), which further amplify the sound energy and transmit it, via oval window, to the fluid-filled inner ear. At the inner ear, the mechanical vibration is converted into electric waves and transmitted as nerve signals that are interpreted by the brain as sounds. Mechanical properties of middle ear. The middle ear is an air-filled cavity that connects the outer ear canal to the labyrinth of the inner ear. This connection is established through the middle ear ossicels-malleus, incus and stapes. The malleus is attached to the TM by its handle; the incus bone lies in the middle between the malleus and the stapes while the footplate of the stapes is attached to the oval window of the inner ear. The middle ear cavity is also connected to the nasopharyngeal cavity through the Eustachian tube (Musiek and Baran, 2007). The Eustachian tube is important in maintaining an equal pressure on both sides of the TM and ventilation of the middle ear cavity. The tube also drain the middle ear into the nasopharynx (Channell, 2008). Figure 1 demonstrates schematic representation of the anatomy of the ear. When the sound pressure moves the TM the mallus and incus consequently move together as one unit around a pivotal point. In doing so, both bones act as a lever; the lever arm formed by the manubrium of the malleus is slightly longer than that of the incus (about 1:1.3 ratio). In turn, the rotation of the long process of the incus around its pivotal point leads to the back and forth (piston-like) movement of the stapes footplate in the oval window of the inner ear. The movement of the stapes footplate is directly proportional to the frequency and amplitude of the sound waves. This route of sound transmission is called the ossicular route. Acoustic route is another way of transmitting sound waves directly from the TM and the oval window to the cochlea. The direct acoustic stimulation of the oval and round windows, by passing the ossicles (acoustic route), plays a part in sound transmission In normal ears both routs are functioning but the upper hand is for the ossicular route (Voss, Ro sowski, Merchant, and Peake, 2007). From the above information, it appears that the middle ear plays important role in the hearing process. The middle ear mainly helps to correct the impedance mismatching between the air-filled middle ear and the fluid-filled cochlea and to transform the acoustic energy at the TM into mechanical energy that will eventually be transferred to the inner ear. The Impedance matching function of the middle ear is carried out by three mechanisms: the lever action of the ossicles of the middle ear, the area difference between the TM and the area of the stapes footplate, and the buckling of the curved TM. An outcome of these mechanisms is that the vibration obtained from the large area of the TM is focused to the much smaller oval window of the inner ear (21:1 area ratio), resulting in a differential pressure between the oval window connected to scala vestibuli and the round window connected to the scala tympani. This pressure differential is critical in maximizing the flow of sound energy and activation of the cochlear structures (Cummings, 2004). Accordingly, middle ear disorders are expected to affect the normal transmission of sound, resulting in conductive hearing loss (discussed below). An illustration of the anatomical structure of External, Middle and Inner ear. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. In addition to correcting the impedance mismatch between the air-filled middle ear and the fluid-filled cochlea, the middle ear also protects the inner ear from loud sound via the acoustic reflex. This mainly occurs as a result of reflex contraction of the two middle ear muscles, the tensor tympani and the stapedius, in response to loud sound leading to increased stiffness of the oscicular chain, and hence diminished sound transmission (Allen, Jeng, and Levitt, 2005). Given that the acoustic reflex mainly decreases the transmission of low frequency sounds thus, it improves speech discrimination in loud, low-frequency noisy environments. Unfortunately, the reflex does not protect the ear against impulsive sounds as gun shots due to prolonged latency in muscle contraction (Lynch, Peake, and Rosowski, 1994). Pathophysiology of middle ear disorders To further understand the pathology of middle ear disorders, it is important to consider the middle ear system as a vibrating mechanical system. Such a system is composed of three elements: mass, stiffness, and friction. When the mass and stiffness components are equal, so-called resonant frequency of the middle ear, it is expected that the amplitude of vibration of the middle ear is at maximum. On the other hand, when there is an increase in the mass without change in stiffness or friction the resonant frequency is lowered and the amplitude of vibration is lowered at frequencies above the resonant frequency. In contrast, when there is an increase in the stiffness component of the middle ear the resonant frequency increases and the magnitude of vibration reduces for frequencies below the resonant frequency (Roeser, Valente, and Hosford-Dunn, 2000). Middle Ear Disorders are a variable group of pathological conditions that includes, for example, middle ear infection (Otitis Media with Effusion: OME), chronic otitis media with perforation of the TM, Eustachian Tube Dysfunction (ETD), ossicular disruption or dislocation and or/ otosclerosis. Such middle ear disorders may lead to conductive hearing loss due to their effects on mass, stiffness, and/or friction elements of the normal middle ear. Perforated TM is induced by chronic otitis media or trauma to the ear. As a result, the normal structure and the function of the TM are altered. The degree of hearing loss is directly related to the size of the perforation (Voss et al., 2000) The perforation leads to equalization of pressure on both sides of the membrane which consequently leads to disturbance of the ossicular route and hearing loss (Voss et al., 2000). Normally the inward movement of the stapes is followed by an outward movement at the round window (push and pull mechanism). In the presence of TM perforation, this push and pull mechanism of the ossicles is disturbed and the sound waves energy reaching the oval window is reduced. Ossicular dislocation usually follows a violent trauma to head or as a consequence of chronic otitis media and/or cholesteatoma. Disarticulation of the incudostapedial joint due to traffic accident was the most common pathlogy of ossicular disruption(Yetiser s, 2008). With the exception disruption due to chronic otitis media, the dislocation of the ossicles may or may not be accompanied by TM rupture. The injury results in loss of the impedance matching mechanism of the middle ear and a conductive hearing loss of about 40-60 dB (Merchant, Ravicz, and Rosowski, 1997). Otosclerosis is a progressive disease of bone resorption and reformation that affects bones derived from the otic capsule. The etiology of the disease is not fully understood. The disease leads to osteodystrophy and fixation of the stapes in the oval window. Among the most accepted eatiological factors is genetic factors and viral infection. Otosclerosis is characterized clinically by progressive hearing loss, tinnitus and vertigo (Menger and Tange, 2003). Both conductive and sensory neural hearing loss has been reported in otosclerotic patients (Ramsay and Linthicum, 1994). Otosclerosis may affect the cochlea and other parts of the labyrinth as well (Menger and Tange, 2003). The resulting fixation of the footplate of the stapes leads to increased stiffness of the ossicular chain early in the disease. Increased stiffness of the middle ear affects the transmission of low frequency sounds. At later stages of the disease, the bone starts to grow adding a mass effect. This increase in ma ss of the middle ear affects the transmission of high frequency sounds as well (Shahnaz and Polka, 1997). More disorders include inflammatory conditions of the middle ear such as otitis media (OM) and media with effusion (OME), chronic otitis media, and cholesteatoma. OM usually results from upper respiratory infections or allergies that lead to obstruction of the Eustachian tube (Channell, 2008). As a consequence, negative pressure develops in the middle ear resulting in otalgia due to stretching of the TM and mild hearing loss due to the increased stiffness of middle ear transmitting mechanism. If the negative pressure inside the middle ear is not relieved, a transudate accumulates inside the middle ear. The condition is then called OME. The hearing is further affected by the mass- friction effect. The degree of hearing loss depends on the type and the amount of the transudate. The combination of fluid and pressure in the middle ear was found to reduce TM movement at the umbo by 17 dB over the auditory frequency range (Dai, Wood, and Gan, 2008). Middle ear function measures Tuning fork testing. The tuning fork testing is one of the traditionally used qualitative hearing tests. They are used to examine the conductive component of hearing loss (external or middle ear pathology). Several tests have been descried including: Rinne, Schwabach, Bing, and Weber tests. For Rinne test, the vibrating tuning fork is held against the skull, usually on the mastoid process bone behind the ear to cause vibrations through the bones of the skull and inner ear. To cause vibrations in the air next to the ear, the vibrating fork is then held next to, but not touching, the ear. In the test the patient is asked to determine if the sound heard through the bone is louder or that heard through the air. The results of the test are categorized as positive, negative, or equivocal. A negative Rinne test is indicated when the sound is heard louder by bone conduction than by air conduction which suggests a conductive component of the hearing loss. Although Rinne test was found to be highly specific in one study; the same author has suggested that it should be carried out only as a pack up test for pure tone audiometry in audiological evaluation of hearing loss (Browning and Swan, 1988; Thijs and Leffers, 1989). The Schwabach tuning fork test compares patients bone conduc tion to the normal examiner. Bing tuning fork tests determines the presence or absence of the occlusion effect. Weber tunning fork test determines the type of a unilateral hearing loss. While Rinne test compares air conduction to bone conduction in the same patient. Although the tuning fork testing is easy and reliable; it is still a subjective test that depends on the response of the patient and the degree of hearing loss. Additional drawbacks are that tuning fork testing is a qualitative and not a quantitative test, and does not diagnose the etiology of the conductive hearing loss. Pure-tone Audiometry. Pure-tone Audiometry is a behavioral test that measures hearing threshold. The test has been used to diagnose type and degree of hearing loss for more than one hundred years. During test setting, the patient is subjected to different tones to test the hearing mechanisms via air-conduction and bone conduction. Typically, the normal level of pure tone audiogram air and bone conduction will lie between 0-15 dB HL for children and 0-25 dB HL for adults. According to Northern and Downs (1991), the degree of hearing loss can be classified in adults as (0-25 dB HL) within normal limits, Mild (26-40 dB HL), Moderate (41- 55 dB HL), Moderate-Severe (56-70), Severe (71-90 dB HL) or Profound (91 + dB HL) hearing loss. In children it is classified as normal (0-15 dB HL), Slight (15-25 dB HL), Mild (25-30 dB HL), Moderate (30-50 dB HL), Severe (50-70 dB HL), Profound (70 + dB HL) hearing loss. This classification is applied to PTA of 500, 1000, and 2000 Hz (Roeser et al, 2000). Different types of hearing loss are interpreted by comparing air conduction thresholds to bone conduction thresholds. When the air conduction threshold elevated to a maximum around 60-70 dB HL in the presence of normal bone conduction threshold, this type of hearing loss is called conductive hearing loss. In sensorineural hearing loss the pure tone audiogram shows both air and bone conduction thresholds are elevated and with a 10 dB HL or less in between. Mixed hearing loss displays elevation in both air and bone conduction thresholds, but with the bone conduction threshold at better intensities than the air conduction by 10 dB HL or more. In both conductive and mixed hearing loss, the difference in air and bone conduction thresholds is called air-bone gap; and it represents the amount of conductive hearing loss present (Roeser et al, 2000). The use of pure-tone audiometry provides quantitative information regarding the degree and type of hearing loss. However, it does not diagnose the cause of hearing loss and cannot be used in infants, young children, and difficult-to-test subject. Mannina (1997) reported that the diagnosis of middle ear disorders in school-aged children is less efficient when using pure-tone audiometry alone. To improve the diagnosis of middle ear disorder, Yockel (2001) demonstrated that the addition of tympanometry to audiometry does improve the diagnosis of OME than using audiometry alone. Assessing Middle ear function is a very important step in early diagnosis and treatment of conductive hearing loss. Since the usually used subjective tests, the tuning-fork and pure tone audiometry, cannot identify the etiology of underlying middle ear disease, other objective measures such as acoustic immittance are needed for differential diagnosis and accurate diagnosis of specific middle ear disorders. Acoustic Immittance. Several objective measurements of middle ear function have been developed over the last four decades. Various anatomical structures of the middle ear represent complex network system that affects the sound presented to the ear. Not all the sound represented to the middle ear is delivered to the cochlea, but some of the power is absorbed by the bony structure of the middle ear (Zwislocki, 1982). Acoustic Immittance using tympanometry assess the middle ear status by measuring the transmitted sound energy to the middle ear. Acoustic Immittance provides objective information about the mechanical transfer function in the outer and middle ear. Acoustic Immittance is defined, as the velocity with which an objects moves in proportional to an applied force, while Acoustic Impedance (Za) is the opposition offered by middle ear and the TM to the flow of energy. Mathematically acoustic admittance (Ya) of a system is the reciprocal of impedance. Acoustic Immittance refers collectively to acoustic admittance, acoustic impedance or both (Tympanometry. ASHA Working Group on Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation, 1988). Investigators have found that abnormalities in the middle ear transmission might be reflected in the acoustic condition of the TM (Allen et al, 2005). Acoustic Immittance can be measured to single probe-tone frequency (single frequency tympanometry) or to series of multiple probe frequencies (multifrequency tympanometry). Single frequency tympanometry. Tympanometry is one of the earliest objective methods used to evaluate middle ear function. Tympanometry measures the acoustic immittance of the middle ear as a function of changing the air pressure in the ear canal. A single probe tone tympanometry is the conventional measure of middle ear function in response to low frequency probe tone, 226 Hz, under varying static air pressure. Evaluation of the acoustic immittance of normal and different middle ear disorders was done by Otto Metz, 1946, and confirmed later by Feldman, 1963 (Katz, 2009) In 1970, James Jerger began to incorporate immittance measurement into the routine audiological evaluation. Jerger classified tympanograms as type A, B, or C depending on the shape of the tympanogram (with or without peak) and location of the peak when present. Type A is the normal tympanogram with the peak at or near the atmospheric pressure (+25 to -100 daPa). Type A is further divided into subtypes Ad and As for high and low peaked type A tympanograms respectively (Feldman, 1976). Type B tympanogram has no peak and relates to middle ear effusion, infection with normal ear canal volume, or due to large TM perforation with large ear canal volume. Type C is a negatively shifted tympanogram that reflects Eustachian tube dysfunction, a precursor of serous OM, mostly evolved from type B (Katz, 2009). Since 1970, single frequency Tympanometry is the conventional clinical middle ear measure because it is a non-invasive, objective, and cheap indicator of many middle ear pathologies in children and adults. Unfortunately, low frequency probe tone tympanometry has high false negatives in infants younger than seven months (Holte, Margolis, and Cavanaugh, 1991). This is explained by the movement of the infants ear canal wall with pressure changes in the external ear canal due to immaturity of the bony part of the external auditory canal. In addition, tympanometry was found to be relatively insensitive to many lesions that affect the ossicular chain of the middle ear (Lilly, 1984). Furthermore, Keefe and Levi (1996) reported false positive tympanometry results compared to energy reflectance, a recent middle ear function measure. They found normal middle ear energy reflectance at higher frequencies in infants with flat low probe tone tympanometry. Multifrequency tympanometry. Multifrequency Tympanometry (MFT), which was first introduced by Colletti in 1976, measures middle ear impedance using multiple frequency probe tones ranging from 226-Hz to 500 Hz and up to 2000 Hz (Colletti,1976) . Similar to previous discussion about the three elements of the mechanical system of the middle ear, admittance of the middle ear has three components: stiffness (compliant susceptance), mass susceptance and conductance (resistance). A tympanometric pattern was developed by Vanhuyse and colleagues in 1975 that helped in interpreting the underlying middle ear pathology using MFT. The Vanhuyse tympanometric pattern is based on the assumption of the shapes and locations of reactance (X) and resistance (R) tympanograms. Using a conversion equation the model can predict the shapes of susceptance (B) and conductance (G) tympanograms. Vanhuyse et al proposed four normal patterns: 1B1G, 3B1G, 3B3G, and 5B3G as shown in Figure 2. 1B1G pattern is the normal tympanogram with a one susceptance (B) and one conductance (G) peak. It occurs when reactance (X) is negative and its absolute value is greater than resistance (R) at all pressure used (the ear stiffness is controlled). As the probe frequency increases the curve becomes more complex and notched. 3BIG model has three peaks of susceptance (B) and one conductance (G) peak. It represent negative reactance (X) with an absolute value greater than resistance (R) at low pressur e and smaller than resistance (R) at high pressure. The third model (3B3G) appears when the ear is mass-controlled. In 3B3G model the reactance is positive and less than resistance (X R) at low pressure and becoming negative at high pressure (Margolis, Saly, and Keefe, 1999). Figure 2. A graphic presentation of the model presented by Vanhuyse, Creten and Van Camp (1975). The resistance (R) , negative resistance (-R) and the reactance (X) tympanograms is shown in the upper left corner of each panel. Negative R is shown to compare the magnitude of the reactance X. The corresponding admittance (Y), (lower left corner), susceptance (B), (upper right corner) and conductance (G), (lower right corner) are also shown in each panel. Four patterns are presented and classified according to the number of extrema in the susceptance B and conductance G tympanograms. The pattern (1B1G) in panel one shows both susceptance and conductance have single extrema and reactance is negative. The pattern (3B1G) in panel two shows conductance G is single peaked with three extrema in susceptance B, reactance X is still negative but its absolute value is greater than resistance at high pressure. The pattern (3B3G) in panel three shows three extrema in susceptance B, conductance G, and admitta nce Y tympanograms, reactance Y is positive but less than resistance R . The pattern (5B3G) in panel four shows five extrema in susceptance B tympanogram and three extrema in conductance G, and admittance Y tympanograms, reactance Y is positive and greater than resistance R at low pressure. Because of the use of measuring middle ear function to several probe tone frequency, MFT is considered superior to single frequency tympanometry in detecting high impedance pathological conditions of the middle ear such as middle ear effusion, otosclerosis, and cholesteatoma. Such pathological conditions were not detected by conventional tympanometry (Colletti, 1976, Keefe and Levi, 1996, Shahnaz et al 2009). Several studies have shown that MFT has higher sensitivity and specificity in detecting middle ear pathologies such as TM mass or adhesions (Margolis, Schachern, and Fulton, 1998). Also, MFT is more sensitive than single frequency tympanometry in identifying normal and abnormal middle ear condition in neonates (Shahnaz, Miranda, and Polka, 2008). However, MFT is of limited clinical use for several reasons: long testing time, limited frequency range, and unreliable data above 1000 Hz (Allen et al, 2005). The use of wideband energy reflectance is shown to address the above limitat ions of MFT. Wideband energy reflectance. The wideband energy reflectance (WBER) is a new technique that has been introduced recently to evaluate middle ear dysfunction (Keefe, Ling, and Bulen, 1992). Simply the idea of WBER is that incident sound to the ear is transmitted through the ear canal and TM, some of this sound energy is absorbed through the middle ear and cochlea and part of it is reflected back (Figure 3). The energy reflectance (ER) is defined as the square magnitude of pressure reflectance ÂÂ ¦R(f) ÂÂ ¦2, which represents the ratio of the sound energy reflected from the TM to the incident sound energy at frequency (f). ER ratio ranges from one to zero (1.0 = all incident sound energy is reflected, and 0.0 = all sound energy is absorbed) (Allen et al, 2005). ER is an indicator of the middle ear power to transfer sound (Feeney, Grant, and Marryott, 2003). Energy reflectance (ER) measurers middle ear function over a wide band of frequencies (0.2- 8 kHz). ER is the ratio of the reflected energy (red arrow) to the incident energy (yellow arrow). When all incident sound energy is reflected back ER ratio equals one. When all incident sound energy is absorbed ER equals zero. Red arrow represents reflected sound energy; yellow arrow represents incident sound energy; green arrow represent absorbed sound energy. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. WBER measures middle ear function using a chirp stimulus at 65 dB SPL over a wide frequency range, typically 0.2 to 8 kHz and at fixed ambient pressure (Feeney et al, 2003) . Normative data has shown that most incident acoustic power is reflected back to the ear canal (ER ratio closes to 1) at frequency range below 1 kHz or above 10 kHz that also show poor hearing threshold or at frequencies below 1 kHz and above 4 kHz (less efficient middle ear function) (Keefe, Bulen, Arehart, and Burns, 1993). More specifically, 50% of the acoustic power is transmitted to the middle ear between 1-5 kHz frequency range, indicating that the most effective middle ear transfer function (ER is at its lowest values, closer to one) occurs around 1-5 kHz (Allen et al, 2005; Keefe et al, 1993; Schairer, Ellison, Fitzpatrick, and Keefe, 2007). WBER has been used in measuring normal middle ear function and middle ear disorders using ambient pressure (Allen et al, 2005; Feeney et al, 2003; Shahnaz et al., 2009). In other studies the researchers used pressure to measure the acoustic stapedial reflex (Feeney and Sanford, 2005; Schairer et al, 2007). Development of the middle ear in infants was also investigated using WBER (Keefe and Abdala, 2007; Keefe e al, 1993; Keefe and Levi, 1996). Wideband energy reflectance in neonatal screening Keefe et al. (1993) and Keefe and Levi (1996) reported that the acoustic response properties of the external and middle ear varies significantly over the first 2 years of life. These changes, mostly physical changes, are responsible for the mass-dominant infants middle ear system with lower resonant frequency. The main components of this mass-dominant effect is the pars flaccida of the TM, ossicles, and perilymph in the cochlea (Van Camp, Margolis, Wilson, Creten, and Shanks, 1986). The mesenchyme in infants middle ear may add to the mass effect (Meyer, Jardine, and Deverson, 1997). This is completely in contrast to adults middle ear, which is a stiffness-dominant system at low frequency (Holte et al, 1991; Keefe and Levi, 1996). The TM, tendons and ligaments, the space between the mastoid and the middle ear cavity, and the viscosity of the perilymph and the mucous lining of the middle ear cavity constitute the stiffness component of the middle ear (Van Camp, Margolis, Wilson, Creten , and Shanks, 1986). Recently, Shahnaz (2008) have compared MFT and WBER findings between normal adults and normal-hearing neonates in the neonatal intensive care units (NICU), who passed the neonatal hearing screening test. The researcher found maximum absorption of the incident energy at narrower range of frequencies (1.2 2.7 kHz) in normal babies compared to adults (2.8 4.8 kHz) (Shahnaz, 2008; Shahnaz et al, 2008). This preliminary normative data from 49 neonatal ears reflects the potential diagnostic benefits of the WBER test in detecting middle ear effusion in neonates. Wideband energy reflectance in otosclerosis Although the main definitive diagnosis of Otosclerosis is during surgery, an accurate preoperative audiological diagnosis is very important indication for surgery. Still, pure-tone audiometry has its own limitations that prevent accurate diagnosis of otosclerosis. Also, standard 226 Hz tympanometry is usually within normal type A tympanogram in most otosclerotic patients (Jerger, Anthony, Jerger, and Mauldin, 1974). While multiple frequency tempanometry may be helpful in diagnosing otosclerosis, it adds little information to the diagnosis (Probst, 2007). On the other hand, the WBER responses in three ears of otosclerosis fell outside the 5th to 95th percentile of the normative data and presented a distinctive pattern for the disease (Feeney et al, 2003); which suggests that WEBR is a sensitive middle ear measure. In a recent study WBER was found to be helpful in distinguishing 28 otosclerotic ears from normal and/or other causes of conductive hearing loss. A significantly higher ER w as found in otosclerotic ears at frequency range of 0.4- 1 kHz as compared to normal ears. In the same study WBER was found to be more sensitive in diagnosing otosclerosis than the conventional 226 Hz tympanometry and the MFT (Shahnaz et al., 2009). Wideband energy reflectance in other middle ear pathology Hunter and colleagues (2008) found higher sensitivity of WBER in detecting otitis media in infants and children with cleft palate (Hunter, Bagger-Sjoback, and Lundberg, 2008). Feeney and colleagues in 2003 studied WBER at ambient pressure in 13 ears with different middle ear disorders and comparative normal. Different middle ear disorders were involved in this study included: four ears with OME, one ear with ossicular discontinuity, two ears with otosclerosis, two ears with hypermobile TM, two ears with perforated TM, and one participant with bilateral sensorineural hearing loss. The results suggested a distinctive WBE

Gilbert Ryles The Concept of Mind Essay -- Concept Mind Gilbert Ryle

Gilbert Ryle's The Concept of Mind In The Concept of Mind Gilbert Ryle attempts, in his own words, to 'explode the myth' of Cartesian dualism. His primary method in this endeavour is to explain why it is a logical error to describe minds and bodies with semantically similar language; while secondarily, he proposes that even to speak of 'minds' as a second-order ontology is to take the first step in the wrong direction towards intellectual clarity. Thus, with the desire to arrive at this hypothetical locale, the following peripatetic discussion will set out with Ryle at his point of departure, viz. Descartes' Myth; it will then survey the "lay-of-the-land" at Ryle's mapped out midway point, viz. Self-Knowledge; and from there, judge whether Ryle himself is headed in the right direction, or, whether despite the ribbons and fan-fare, Ryle's excursion takes place on a circular track. Ryle begins by seeking to expose the theory of Cartesian Dualism as an absurd logical error. To do this, he accuses it of having an inherently faulty structure; that it exemplifies "one big category-mistake."1 To understand this claim we must first look at what Ryle deems a 'category-mistake.' A category-mistake is committed when one accounts for a concept by placing it in a certain logical type, or category, when in fact it belongs to a different division altogether. So to describe or qualify two items or ideas of dissimilar constitution within the same linguistic framework is to commit this mistake. Ryle provides numerous examples for the elucidation of this error, only one of which follows: "she came home in a flood of tears and a sedan chair."2 The absurdity of this statement shows the category-mistake for what it is: a failure to use langu... ...ons it is my considered opinion that despite Ryle's attempt at intellectual clarity, this clarity is an illusion. NOTES 1 Gilbert Ryle, The Concept of Mind, p. 17.Back to note location in text 2 Ibid., p. 23.Back to note location in text 3 Ibid., p. 15.Back to note location in text 4 Ibid. Back to note location in text 5 Ibid., p.21.Back to note location in text 6 Ibid., p. 23.Back to note location in text 7 I refer to John R. Searle, The Rediscovery of The Mind, in which the author states: "Mental phenomena are caused by neurophysiological processes in the brain and are themselves features of the brain." p. 1.Back to note location in text 8 Gilbert Ryle, The Concept of Mind, p. 149.Back to note location in text 9 Ibid., p. 149.Back to note location in text 10 Ibid., p. 162.Back to note location in text

Quentins Struggle in The Sound and the Fury Essay -- Sound and the Fu

Quentin's Struggle in The Sound and the Fury      Ã‚  Ã‚   Too much happens...Man performs, engenders so much more than he can or should have to bear.   That's how he finds that he can bear anything.  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   William Faulkner (Fitzhenry   12) In Faulkner's The Sound and the Fury, we are given a character known as Quentin, one who helps us more fully understand the words of the author when delivering his Nobel Prize acceptance speech "The young man or woman writing today has forgotten the problems of the human heart in conflict with itself" (The Faulkner Reader   3).   Quentin engenders so much more than he can or should have to bear, as the opening quote by Faulkner suggests is the fate of all humans, but he does not discover he can bear anything.   Instead, Quentin's heart is so in conflict with itself, a condition Faulkner argues many overlook in his speech excerpt above, that he commits suicide.    There are three kinds of struggles in life.   There is man versus the universe, man versus man, and man versus himself.   Quentin's conflict is with himself.   In fact, despite his imagining otherwise, Quentin is completely locked within himself, unable to cope with external reality.   Internal reality is the only reality which he entertains.   Like Hamlet, he tries to live up to the internalized idealized image of nature and himself that he imagines should be external reality.   As noted in Thompson and Vickery (224) "Psychologically unbalanced by his own inner and outer conflicts, Quentin is represented as being partly responsible not only for what has happened to himself but also for what has happened to some other members of his family.   He has permitted his warped and warping ego to invert exactly those basic and primit... ...   87)    Thus, we can see that Quentin's internal fictions of what he would like reality to be are too much for him to endure in the face of existential realities that are all too often not aesthetic.   He cannot endure because he cannot bear the distance between his internal fictions of reality and reality as it truly exists outside those fictions.    WORKS   CITED The Faulkner Reader:   Selections from the Works of William Faulkner.   New York, Random House, 1954. Faulkner, W.   The Sound and the Fury.   New York, Random House, 1956. Fitzhenry, R. I. (ed.).   The Barnes & Noble Book of Quotations.   New York, Barnes & Noble Books, 1987. Hoffman, F. J. and Vickery, O. W.   William Faulkner:   Three Decades of Criticism.   New York, Harbinger, 1960. Polk, N.   New Essays On:   The Sound and the Fury.   Cambridge, Cambridge University Press, 1993.  

Epic of Beowulf Essay - Beowulf and the Hero Myth :: Epic of Beowulf Essay

Beowulf and the Hero Myth Beowulf contains a myriad of different heroic ethical and social values. Most of these values are ingeniously rooted within, or made evident by the opposing forces of the poem. The initial opposing force arrives in the form of Grendel, a vile creature who's rampages mirror that of a modern serial killer. As the poem draws toward the conclusion, it focuses on the dragon, a creature developed by the poet to solidify the rise and fall of the archetypal hero. After Adolf Hitler failed in his artistic studies at Vienna, he began to develop what would become a reign of terror on those who were not like him. His backlash towards a society that rejected him as an artist spawned his anti-Semitic and political beliefs. The same anti-societal anger has found its way into the minds of countless other killers, both past and present. Take for example Theodore (Ted) Bundy, who in 1978, after watching students drink and dance in a college bar, witnessed "a healthy ritual of joy from which we know he forever felt exiled". Shortly thereafter, Bundy left the bar and traveled to the Chi Omega sorority house where he watched from outside, entered, and then killed two girls and wounded two others. Just as Bundy had done, Grendel watched and surveyed from the distance. He waited outside the great hall, listening to the mirth and celebration from within. He hated them. The revelers inside felt no "misery of men." They were not uninvited, outcast, and below the social class of Hrothgar's company. These feelings of inadequacy propel Grendel to slaughter those who oppress him. For "twelve winters" he smashes bodies and eats his victims, creating a bloody rampage and a dire need for a savior. The question of Grendel's origin is difficult to trace. The author remains ambiguous throughout the poem, referring to Grendel as biblical, but also suggesting that he is human. The original manuscript often refers to Grendel as "man", but man" with a long vowel meant evil, whereas "man" with a short vowel literally meant a man. It cannot be certain which pronunciation the author intended, what has been butchered in the translation, or whether this was meant to be a crafty play on words.

Michael Cunningham Essay

Michael was the most ambitious of blokes. He stole the Wright Brothers’ ‘plane. He then flew all the way to Pluto, on one tank of fuel, to find one of his best mates eating the small planet. So he carried on to the end of the Milky Way and on to the next, Chocolate Log. The returned twenty years later saying that he had discovered another species of complex organisms and â€Å"humans† in the next galaxy. Michael Cunningham was born on the 14th of October in 1987 in the city of Birmingham. At the age of three he acquired a younger brother named Dean. In 1991 Michael started attending Harborne Primary School, then at the age of eleven he left Harborne Primary to start in Shenley Court Specialist Arts College and Sixth Form Centre. At the end of year eleven, aged sixteen, he left his secondary school with 10A* GCSE grades, and started training in the ATC in 2005. After two years he completed his training and startye4d full time work as an electrician for the Royal Air Force. Towards the end of October 2007, he was transferred to Duxford airbase to work as the Chief Electrician. At this time he was nineteen and Britain’s youngest Chief Electrician. Then towards the end of 2009 he received a letter telling him that Kelly, once the love of his life, had been killed in a car crash. After attending her funeral Michael stole the world famous Wright brothers’ ‘plane and that was the last the world saw of him for twenty years. Michael reappeared in 2029, aged 41, with claims that he had seen one of his best mates, David Smith, eating Pluto during 2019. Then during a press conference he also claimed that he had found another three planets on his â€Å"adventure† that were inhabited with beings more intelligent than us. â€Å"There is more life in this universe, more than you could ever imagine. † He later went on to say, â€Å"It is unbelievable how intelligent they are, and I mean when compared to them we know nothing. † Scientists later confirmed that Pluto had disappeared and we received a few visits from the intelligent beings Michael had found. Michael, at the age of forty-six, started studying some of the species he had discovered, he discovered that they were approximately five million years more advanced than us. Also that they were born with intelligence and ability to communicate, walk and work. At the age of seventy-three he retired to a semi-detached bungalow in Skegness after his wife, Jenny, had passed away. About six months after moving a killer ninja penguin attacked him. Another of his mates, Tom Bates, saved him moments before he was eaten. Approximately five minutes later Michael suffered a heart attack; after an examination it was determined that the heart attack was caused by the shock of the attack by the penguin. Looking at his personal life he had had a few girlfriends throughout his secondary school life, although only a couple had been serious, and from when he had joined the ATC until he had returned from his â€Å"adventure† he hadn’t had much of a social life. Then at the age of forty-three he started dating an old school friend, Kate, but this didn’t last for more six months. Then he became engaged to Jenny Wattrus in July of 2035 and married in November that year. They had seven children, five girls and two boys, and moved to London where they bought a large house and lived there until their children had moved out, at which point the two of them moved down to Devon and into a smaller house so that they didn’t feel so lonely. Show preview only

Health Promotion in Nursing Care Essay

Many years ago, people focused on disease and illness and not staying healthy or preventing illness from occurring. People did not go to the doctor for wellness checks but rather only if they had an ailment. Immunizations have removed some of the diseases that were causing death among the individuals that had contracted the illness. Health promotion has come to the forefront in medical practice since the movement of Healthy People that focuses on health and not illness. Health promotion can be perceived differently by individuals. â€Å"Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions† World Health Organization website (as cited in Casey 2007). Nurses have a vital role in health promotion in all health care settings, be it at home, in a clinic, hospital, or out in the community. It is important for the nurse to understand that health promotion is not only for the healthy but also for individuals that are disabled, have a chronic disease or are dying. By administering education and referrals to other health care professionals, the nurse is providing individuals the tools they need to experience the highest level of health possible for their given situation. Often nurses are engaging in health promotion activities while interacting with patients and are not aware of this as it becomes automatic in daily practice. Health promotion in a hospital setting can be as simple as encouraging deep breathing exercises and early mobilization to prevent pneumonia. Nurses can serve as a role model and educator in different settings such as at home with their own family members, clinics, hospitals or in the community (Lazarou, C., & Kouta, C. 2010 ). One role of the nurse in health promotion is to collaborate with all providers involved. Collaboration is especially important when working in a homecare setting to make sure a diagnosis hasn’t changed or the primary provider hasn’t changed the treatment plan. Supporting health promotion will help the economy by reducing illness and disease, allow faster recovery of illness and improve one’s quality of life. Effective health promotion teaching ultimately depends on how open the individual(s) is to change (Casey 2007). Prior to providing health promotion material, it is important to assess the learner to obtain their preferred learning method and any cultural issues that would affect the teaching. The teaching material has to be age appropriate for the learner. If they do not understand what is being taught, the teaching will be a waste of time for the nurse as well as the individual(s) involved. A nurse can passively mention a health promotion idea while caring for their patient to see their response to the concept. This passive approach could spur a conversation regarding the idea and make the patient more receptive to learning. After assessing the patient for learning readiness, providing written material and encouraging individuals to make a change is a good place to start a promotion activity. Another implementation approach would be to involve the patient’s family if the teaching involves cooking or other lifestyle changes. This approach will add a support system for the patient but also make others in the household aware of changes that need to be made. Depending on what the lifestyle changes are, they could benefit the entire household, not just the patient. The patient should be involved when setting health promotion goals (Casey 2007). If the goals are set by the nurse, the patient will probably not be as receptive to making a lifestyle change. Another method effective for health promotion is motivational interviewing. The patient is involved during all stages of planning. They not only decide on the goal, but also figure out what barriers they may face that would hinder their success. This approach would work well for implementing health promotion for increased activity and incorporating more fruits and vegetables into one’s diet. (Whittemore et al., 2010) There are three types of health promotion. The first type of health promotion is primary prevention. This type of prevention is often carried out in a community setting. Fluoridation of water to help lessen cavities, smoking bans in public areas and immunizations are examples of primary prevention as they remove the risk factors or causes of disease. The second type of health promotion is secondary prevention. Annual physicals, mammograms and colonoscopies are examples of secondary prevention because they are able to detect disease early, often before the patient is symptomatic. At this level of prevention, it is hoped that the disease is caught early enough so the effects can be reversed. The third type of health promotion is tertiary prevention. During this stage of health promotion, the patient already has the disease so the aim is to slow the progression to allow the patient to have the highest quality of life possible. Blood glucose control for the diabetic to try to prevent blindness and limb amputations is one example of tertiary prevention. Rehabilitation after a stroke would also fall under tertiary prevention (Oberg 2010). Over the years, health promotion is an important responsibility that has shifted from the physician to the nurse. They can participate in health fairs or partner with organizations and schools within the community to provide seminars. If funding for a program is an issue, grants might be available for funding. Physicians, dentists or dieticians may volunteer their time or help with the funding for school programs. Nurses could also participate with corporations to promote healthy lifestyle changes to lower health insurance premiums for their employees. As more people focus on wellness instead of illness, opportunities for the nurse to encourage health promotion are endless. References Casey, D. (2007). Nurses’ perceptions, understanding and experiences of health promotion. Journal Of Clinical Nursing, 16(6), 1039-1049. doi:10.1111/j.1365-2702.2007.01640.x Lazarou, C., & Kouta, C. (2010). The role of nurses in the prevention and management of obesity. British Journal Of Nursing (BJN), 19(10), 641-647. Oberg, E. (2010). Preventive services update. Integrative Medicine: A Clinician’s Journal, 9(4), 22-26. Whittemore, R., Melkus, G., Alexander, N., Zibel, S., Visone, E., Muench, U., & †¦ Wilborne, S. (2010). Implementation of a lifestyle program in primary care by nurse practitioners. Journal Of The American Academy Of Nurse Practitioners, 22(12), 684-693. doi:10.1111/j.1745-7599.2010.00562.x View as multi-pages