CD for Holden Essay Example for Free

CD for Holden Essay How have you been? I have actually missed you a lot. The other day, I took a road trip with my parents and I thought of you. I remembered how you told me you wanted me to burn a CD with music for you. Thus, I listened to my iPod the whole way and selected many cool songs that I think you would like. Please get back to me and tell me which ones you liked and all. Also, I know you told me to only put around 10 songs but I could not contain myself and I chose 16 of them. I hope you will like them, because to tell you the truth all of these songs kill me. The first song I chose to put in the CD is 3 Cigarettes by The Sleeping. Besides the beat and instruments that are cool as hell, the lyrics really remind me of you. First of all, there are the obvious connections to cigarettes, which seem to be one of your passions. Also when he says I have been drinking more and eating less reminds me of you. It is pretty much all that you have done lately, smoked, drank, and thought of Jane. Just remember that just like they say we dont have to blame ourselves you should not blame yourself for everything that has been happening. Finally, the line Do you care? Are you there? Are you listening? kills me and I am sure it will kill you too. It is calling for peoples attentions, it is calling all those phonies and it makes me wonder if anyone really cares about me. I am sure it will make you feel the same way too. The next song I chose was Through the Glass by Stone Sour. I think that this song is talking about an insider who became a stranger and now they are looking from the outside back in. This makes me think of you because many times throughout your life you have alienated yourself. You just look from the outside as time passes by and sometimes you feel like going back in, and being an insider again but you dont. The phrase Im looking at you through the glass; dont know how much time is passed. Oh God it feels like forever makes me think of you a lot. Because you are always thinking about how quickly time passes by. It seems like you have been alienating yourself for a long time now, it feels like forever. The next song on your CD is Tears in Heaven by Eric Clapton. I just had to add this one. I know that you are really sensitive about your brothers death and all, and you dont like talking about it. However, I think that the sooner you face reality the better it will be for you and everyone. This song was made for his son who died. He was very meaningful to Eric Clapton just like your brother Allie was to you. I know you so well, that I am sure that you have wondered about many of the things that this song is stressing about. Such as if Allie would remember your name, and if it would all be the same. Also, there is a bigger picture to it. I remember about an specific conversation with your sister Phoebe you told me about. She asked you to name one thing you really liked and you said you really liked Allie. I think you should listen to lines such as Cause I know I dont belong here in heaven and Cause I know I just cant stay here in heaven. The bigger picture that these lines are showing and I am trying to prove to you is that as much as you love Allie you have to let him go. You are both in different worlds now, and wherever he is, you dont belong there. At least not yet. Holden, you should really get on with your life and just keep with you all of the good memories you have with Allie but let him go. It is the best thing to do. I am sure you will enjoy quite a lot the next song I picked out for you. It is a classic by the great band Pink Floyd. This one is called Another Brick in the Wall. You might have heard of it already. The meaning of the song is to say that in school they treat us all the same and they do not respect that everyone is a separate and different individual. Pink Floyd is saying that this is all false control and they are putting all the students together and trying to make them all the same, therefore losing their individualities. I can tell that you will agree with these lines, and that they will really kill you. When they say All in all its just another brick in the wall, the meaning is that every single one of us students are just a tiny brick of the wall of hypocrisy, superficiality, and shallowness that they are trying to build. They are the ones that you every so often refer to as the phonies. That is what I think this song is criticizing, phonies who try to make everyone be the same. They try to make everyone be like them. Hopefully there are still people out there, like me and you, who are going to fight this and knock down this wall of phonies. The next song I picked is called Boys Dont Cry by The Cure. It makes me think of you and Jane. When I listen to it, I think of how you like Jane so much and she is the only girl that you truly care about but you wont tell her. Just like the song is describing, you often say I would You mention things that you would do, such as give her a buzz, and visit her, and ask her on a date. However, you never do any of it. The line boys dont cry is obviously making a critic to some boys like you, who would rather hide their feelings and appearing tough instead of telling the truth and possibly crying. I love the line I try and laugh about it hiding the tears in my eyes and the one I try to laugh about it; cover it all up with lies. Both of these lines are very strong. They also show things that you do. You often act all nonchalant and like giving Jane a buzz is just something you would do any day. However, I think it is much deeper than that. You are scared of being rejected by her because she is the only one you care about. So, you just act casual and cool about it and lie and hide your feels for her. The next song, The Permanent Rain by The Dangerous Summer follows the same line as the one before. I think that just like the singer is saying, I wont let this die, you shouldnt let what you have with Jane die. You and her both have a really strong connection and bond. I think it would be very sad if you did not do anything about it. I think you should go and tell her how you feel. It is really the best thing to do. When he says, I know its not helping to hear me say: I wish it was me in the car the other day really makes me think of you as well. Even though you have never actually told her about it, you have wondered for a long time about her and Stradlater in his teachers car. You wonder about what happened and you cannot help but wish that it were you with her in the car instead of Stradlater. Finally, when the line You know it meant a lot, but I was just a kid comes up it seems like it was written for you. You were both too young to fully understand the connection that you both h ad. Now, I think you are old and mature enough to understand it and your relationship with Jane should mean even more if you tell her how you feel. The next song, however, is not about Jane. It is about High School, hence the name High School Low by Say Anything. Just like you, the guy in the song is sixteen. He is also worrying about things such as the whole high school experience, and girls. I find there is even a connection to you when he says, My teacher says that Im brilliant. It reminds me of how Mr. Spencer would try and get the best out of you. He did not say you were brilliant, however, he acknowledge that you had so much more potential than the one you were showing with your poor grades and test scores. The passage about looking at pictures of himself when he was a child can also be compared to you. I know that you have often thought about how it is such a horrible experience having to grow up and all, but we will get to this topic later. To do with the whole grades issue, he also says My grades look pretty damn low. I want to motivate myself, but how the hell am I supposed to work. This is something that is so similar to you that it could have come out of your mouth. At the same time that you realize that your grades are low and you need to make an effort, you dont know how to. You are confused about what you should do that would motivate yourself. I remember you told me that when your psychoanalyst asked you if you would apply yourself when you got back to school in September you said you did not know. I mean of course you want to, but as you said it yourself, you are not able to tell how you are going to behave. One phrase that is constantly repeated is take me away. Just like you, this boy wants to run away from these high school days and from all the phoniness and move on to a better part of life; be it the past or the future. Speaking of phonies, this is what my next chosen song is about. It is called Mutiny! by Set Your Goals. This song is clearly criticizing people. In my opinion, it is criticizing the phonies. What leads me to think this way is when things such as superior, you are inferior and heroes have betrayed are said. This is talking about people who think that they are better than other s when they really are nothing special. It is also talking about how people can just betray you and change all of the sudden. Finally, the line I will find the line and cross it every time reminds me of you. It reminds me of how you many times alienate yourself as a form of protection. Therefore, I think that crossing the line is a symbol for you of that crazy red hunting hat you wear. You wear it to prove your point and to show people that you dont care and youre fine with being different. This is nothing else but a way of crossing the line. The next song I chose is called Flake and it is by Jack Johnson. In case you dont know, a flake is someone who says that they will go somewhere or do something and then they dont. Am I the only one who sees a resemblance here to you?! Yes, I am going to start talking about Jane again. You seriously have to stop saying that you will call her, unless you are actually planning on doing it. Otherwise, you are just flaking. The strong line It seems to me that maybe pretty much always means no is what I feel sometimes when you start talking to me about her. You say that you might call her if you feel like it. Now, I am starting to see it as something you just have to say to feel good about yourself, to show that you have the power to call her. I think you should not flake Jane. Besides that, it is a great song and I really love the instrumental and the beat for it. I am sure you will love it too! The next song I picked is a slow one. I find it truly beautiful. It is called Cannonball by Damien Rice. It is also a love song. What I think it is talking about is about someone whom he really loves but that he cannot be with for a reason or another. He talks about how he remembers the girl all the time, and the things that remind him of her. I think that the way he feels about this girl is just like how you feel about Jane. It reminds me of how you remember her because of little things such as how she always kept her kings on the back. This song also brings up the issue you have of lying and it claims that the issues he had to face in life when dealing with love are the ones that made him be like that. It also reminds me of you when he mentions that It is not hard to fall when you float like a cannonball because you can often be very heavy and therefore you sink into your issues like a cannonball sinking down in an ocean. My favorite like on this song, however, has to be the last one. It says when you know that you just dont know. I think it is talking about when people are confused and how it takes courage, to even admit that you are lost. Speed of Sound by Coldplay is also sort of a slow song. The main point to this song is that it is talking about time. I think that Coldplay is trying to show how everything moves so fast, like the speed of sound. Time goes by too quickly, Holden. I know you have already realized that before, considering how you have told me countless times and made me notice that once we notice everything has already happened. This song could have been sung by someone who is waiting on a platform and they are noticing how fast things happen. It also talks about the issues we all have with dealing with this fast-moving time. Be prepared because this next song I am about to introduce to you will kill you. I am serious. It is called Forever Young and it is by Alphaville. It is impossible for me to listen to it and not think of you. The main point to this song is the fact that we all get old. The singer obviously wants to be forever young just like you! You tend to resist the natural process of maturity and growing up. It seems like you want to be forever young without having any responsibilities or having to deal with any problems of adulthood. I think this is mostly because you are scared. You are scared of what awaits for you, and it all sort of mystify you. That is why you invent that you do not want to be an adult because it is a world of phoniness. It is your way of running away from the fact that you are actually scared of growing up because you do not have a clue of what any of it is like. A line on this song that I find really interesting is Some are like water, some are like the heat, some are a melody and some are the beat. I think that this line is talking about the people that make our life what it is. The people that are there for us. I think that water is a symbol for the people that are a bit colder and the heat for the ones who are warm. The people who are a melody are the ones, like Jane, who come every once in a while and they completely change how you were before, just like the melody of a song. The melodies of someones life are not always there, but we can never be the same after they leave. Finally, the beat is a symbol for the people who are there to support you in your life constantly, just like the beat in a song. It is also impossible to be the same without the beats of our life, such as Phoebe, because they are the ones that we can call whenever we need. I think you will really enjoy the next song I picked. It is called Marching Bands of Manhattan by Death Cab for Cutie. First of all, the main reason of why it reminds me of you is the whole New York experience. I know how much that city describes you. I am sorry but I will have to bring old Jane up once again. I think that this song is mostly talking about how he wants to be with someone that doesnt know how they feel. I think that this is your type of song, and I hope you will like it. If you like it, you should look up more songs by Death Cab for Cutie, they all send like this and have wonderful lyrics. Well, this is pretty much all, I hope you enjoyed the songs I chose and you will take some of the advice I gave you. Remember to get back to me and tell me what you thought of them. Oh! Also, I hope you like the cover for the CD! I know how crazy you have been about those ducks on Central Park and I just thought you would enjoy that. Love, Deb P.S. The two other songs I added were songs I found searching on the internet that were inspired by The Catcher in the Rye and I thought that they would be interesting to add.

Difficult Intubation And Post Tonsillectomy Bleeding

Difficult Intubation And Post Tonsillectomy Bleeding A six year old boy with Downs syndrome is on his way to the childrens hospital by ambulance with post-tonsillectomy bleeding. He underwent adeno-tonsillectomy because of recurrent tonsillitis and enlarged adenoids under general anesthesia the day before, some 22 hours ago. Despite being overweight at 37 kilograms and enlarged adenoids he did not suffer from sleep apnea. Prior to his original surgery, the child was uncooperative necessitating an inhalation induction with some struggling. Venous access was difficult even post induction requiring several attempts, and finally being achieved in the left saphenous vein at the ankle. Because of possible atlanto-occipital instability associated with Downs syndrome, laryngoscopy was performed with C-spine precautions. Direct laryngoscopy presented a Grade 3 view due to an enlarged tongue. Bag-mask-ventilation with an oro-pharyngeal airway was easy throughout the preintubation phase. Indirect laryngoscopy using the GlideScopeÂÂ ® revealed a Grade 1 view followed by the placement of a styletted, uncuffed 5 mm ID oral RAE tube. Adeno-tonsillectomy was performed i n the usual fashion and the child was discharged home after an uneventful 20 hour overnight observation period. Apparently, while momentarily unattended at home, the boy ate a hard tea biscuit. The child immediately experienced a sharp pain and an intra oral bleeding started. The emergency physician on duty is confronted with an overweight boy, sitting on a stretcher and spitting blood frequently into a kidney basin. The child is in moderate distress with the following vital signs (HR 152, BP 97/57). The child will not tolerate nasal prong oxygen and the pulse oximeter reading is 94% on room air. Auscultation of the chest is clear. Examination of the mouth reveals brisk bleeding in the right tonsillar bed. An attempt to start an intravenous line in the right saphenous vein is not successful, but blood is obtained for a CBC, coagulation parameters and a cross match for blood. The child is then transferred to the operating room. 45.2 INTRODUCTION: 45.2.1 What is the incidence, Morbidity and Mortality of pediatric post-tonsillectomy bleeding? Tonsillectomy is one of the most frequently performed surgical procedures in children. Rates in children aged 0-14 vary considerably within and between countries. In 1998, they varied from 19 per 10,000 children in Canada to 118 per 10,000 in Northern Ireland, so a very common procedure in both countries (1). The most common post-tonsillectomy complications include postoperative nausea and vomiting and pain. Dehydration may occur in children due to delayed and poor oral intake, nausea and fever. Delayed post-operative bleeding is the most significant complication and though uncommon, is not rare (2). Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature varying widely from 0 to 11.5 percent (3). Typically, however, the rate ranges between 2.9 and 3.4% (4). Mortality rates are rarely reported in the literature. Two large studies reported 0 out of 15,996, and 1 out of 16,381 tonsillectomies in 1979 and 1970 (5). On the other hand, there are many published case reports. Sixty-seven percent of post-adeno-tonsillectomy bleeding originates in the tonsillar fossa and 27% in the nasopharynx. There are two major time frames for post operative bleeding. Most often, the bleeding occurs within the first 24 hours after surgery (primary bleeding) (5). Primary bleeding is generally related to surgical technique, and incidence is declining. Twenty five percent of all post tonsillectomy hemorrhage occurs after 24 hours. This secondary bleeding is not related to surgical technique, is rare and of unchanged prevalence over the years (5). It is mainly observed between the 5th and 10th postoperative day, although it may occur at any time (6). Infection of the tonsillar bed with clot sloughing is believed to be the major cause of secondary bleeding. It tends to occur more commonly in older pediatric patients, because the indication for tonsillectomy in this age group is usually related to recurrent infections rather than airway obstruction, the most common indication in the younger pediatric age group.(5). Since tonsillectomy is usually performed to improve the quality of life in otherwise healthy, young children, any death is unacceptable. 45.3 PATIENT EVALUATION: 45.3.1 What are the initial clinical steps one should take in the patient with post-tonsillectomy bleeding? The diagnosis of post-tonsillectomy bleeding is usually made by a quick history. Parents or patients will mention right away the previous surgery. Differential diagnosis is blunt or sharp trauma to the oropharynx. Rare cases are bleeding tumors of the oropharynx, like hemangioma. The child will present with fresh blood in the mouth and frequent swallowing of blood. Nausea with or without emesis of fresh blood is common. Newer and more potent antiemetic medications may mask or suppress vomiting. Therefore, the amount of blood swallowed may be underestimated. It is not uncommon for children to have been bleeding silently for a prolonged period of time with extensive blood loss. The child is often restless, diaphoretic and pale. The vital signs may show an increased heart rate, because of pain and hypovolemia. In awake children, hypotension following blood loss is a very late sign and then indicates significant hypovolemia. Intravenous access must be established as soon as possible followed by initial volume resuscitation with crystalloid or colloid solutions or. A blood sample for baseline hematocrit or hemoglobin is necessary as well as for blood type and cross match. An intra oral examination will show blood and blood clots. A bleeding source may be seen in the tonsillar bed. Bleeding from the tonsillar bed may initially be controlled using pharyngeal packs and cautery. But children with post tonsillectomy bleeding should be taken back to the operating room for exploration and surgical hemostasis. Repeated attempts to stop bleeding on the ward or in the emergency department should be avoided, except if exsanguination is imminent. A questionnaire of children undergoing tonsillectomy with or without postoperative bleeding showed an increased incidence of post-traumatic stress disorder if the children with bleeding were treated on the ward compared to children without bleeding or if the bleeding was treated in the operating room (7). 45.4 AIRWAY MANAGEMENT 45.4.1 How is the airway usually managed in post-tonsillectomy bleeding? Large volumes of blood may be swallowed, and blood or blood clots are often present in the oral cavity of these children. Despite the fact that the aspiration of blood is not similar in severity to aspiration of gastric acid, it remains an undesirable occurrence. In addition to hypovolemia, patients with post tonsillectomy bleeding present two major problems: Aspiration: These patients must be considered to have a full stomach and are at an increased risk of aspiration. Difficult airway: Blood and blood clots may impair visualization to the vocal cords. In addition swelling of the oropharynx may have occurred because of surgery or infection. This may lead to a changed laryngeal anatomy. Because of the risk of aspiration, a mask induction maintaining spontaneous breathing is not desirable and a rapid sequence induction should be considered. The efficacy and use of cricoid pressure, especially in children is currently controversial. It is noteworthy that cricoid pressure can distort the laryngeal anatomy and worsen the view of the larynx. In addition, it can induce vomiting in the partially anesthetized patient. The blood and blood clots in the oropharynx can impair vision during laryngoscopy or cause plugging of the endotracheal tube. A working suction apparatus is lifesaving and must be prepared in duplicate. One should be a large bore, rigid surgical suction and the other mounted with a flexible endotracheal suction catheter. If one becomes blocked with a blood clot, another is readily available. If large amounts of clot are present, it may be necessary during the initial laryngoscopy to manually remove them with a finger or gauze. A Magill forceps should be available to grab clots deeper in the pharynx, recognizing that these clots may be too fragile to be grasped and removed from the oral cavity using the Forceps. A past history of difficult laryngoscopy is helpful, although this never precludes preparations for a difficult and failed airway. Different sized curved and straight blades as well as a flex tip blade (McCoy laryngoscope) should be readily available. Different sized cuffed endotracheal tubes, with one size up and down of the calculated size must be prepared. They should be preloaded with a well lubricated intubating stylet, as is standard for a rapid sequence induction. A tracheal introducer (Bougie) may be helpful in the presence of a grade 3 view. If the epiglottis is visible, but no laryngeal entrance can be appreciated, a stroke of chest compression may help find the glottic opening by creating air bubbles. The pediatric lightwand represents an elegant technique for intubation in the case of a glottic view obscured by secretions or blood. The extremely bright light can shine easily through blood and blood clots. However experience is necessary when using this device. Indirect laryngoscopy using the video-laryngoscope (GlideScopeÂÂ ® or the AirtraqÂÂ ®) can be difficult. Blood and secretions may block the optical lenses and impair the view to the vocal cords. The lens in the AirtraqÂÂ ® with its position between the lightsource on one side and the guide channel for the endotracheal tube on the other side might be more protected than the lens of the GlideScopeÂÂ ®. Case reports or studies, however, have not been published in this regard. The laryngeal mask plays an accepted role as an alternative airway device in managing the difficult pediatric airway (see Chapter 42). It is used frequently in primary adeno-tonsillectomies. It can be placed quickly and can be used as a conduit for a flexible bronchoscope to guide intubation if required. On the positive side, a laryngeal mask may briefly tamponade the bleeding site, and therefore protect the airway and the optical lens of the bronchoscope. Though, on the other hand, it may not provide sufficient airway protection in situations with increased risk of aspiration like post tonsillectomy bleeding. A case report recently described the successful use of a laryngeal mask for a failed intubation in a post tonsillectomy bleed (8). The use of a flexible bronchoscope alone is not recommended in cases of oropharyngeal bleeding. Experts recommend that the practitioner should rely on the alternative techniques with which they have the most experience and skill. Preparation for the unexpected is essential. An experienced otolaryngologist or other qualified rigid laryngoscopist/bronchoscopist should be in the OR for all of these cases. If direct laryngoscopy fails, a rigid device wielded by the otolaryngologist may just be successful. An appropriately sized, lubricated and tested rigid laryngoscope/bronchoscope connected to a light source and suction must be readily available at the head of the child. Preparation for a surgical airway is also essential (e.g. tracheotomy tray opened and ready). To reduce the risk of postoperative nausea and vomiting the stomach content of the child should be suctioned using an orogastric tube at the end of the procedure, recognizing that this does not guarantee an empty stomach as much of the blood may be clotted. 45.4.2 What are the airway management options for this patient? This patient presents several issues regarding anesthesia induction and airway management: high risk of aspiration difficult intravenous access suspected atlanto-occipital instability known difficult direct laryngoscopy with easy facemask ventilation expected difficult view of the larynx due to blood and secretions Several options for the anesthetic and airway management of this child need to be weighed and considered in light of their risks and benefits: Intravenous induction versus inhalation induction without IV access: This child is undergoing a second surgical procedure within 24 hours. Due to the frightening emergency situation, pain, bleeding and his mental impairment he is distressed and uncooperative. While a smooth inhalation induction with a facemask was preferred for his first surgery, a stomach potentially full of blood mitigates against this approach and for a rapid sequence induction to minimize the duration of an unprotected airway. One might even hope for a rapid venous access following a mask induction to permit medication administration but we know in this case that is not likely. Anesthesia induction with cervical spine precautions versus no C-spine precautions: Downs syndrome is associated with atlanto-occipital instability in up to 20% of cases. It can occur in children as young as 4 years of age. The large head of the Downs child coupled with this atlanto-occipital instability places them at increased risk for cervical spine injury during anesthetic induction. Radiographic findings of cervical spinal instability in Downs syndrome remain controversial. Lateral radiographs of the neck in flexion and extension do not reliably detect atlanto-occipital instability. Due to impaired cognition and anxiety, positioning of the patient can be difficult. Old lateral neck radiographs are not available for this child. Due to the emergency situation, a current neck radiograph is not possible. Therefore cervical spine precautions should be performed. Extreme neck extension should be avoided in this child. Awake tracheotomy versus anesthesia induction with attempted laryngoscopy: The fact that this child has a known difficult direct laryngoscopy together with a documented Grade 3 view favors an awake tracheotomy under local anesthesia. This approach would maintain a protected airway at all times. Awake tracheotomy in adults and children are challenging. Optimal surgical positioning with neck extension is crucial for successful procedure. It is not expected, that this child will tolerate this procedure. This fact, together with the required c-spine precautions would exclude an awake tracheotomy as an option for this child. The plan is to perform an intravenous rapid sequence induction employing indirect laryngoscopy to place an endotracheal tube. Preparations for rigid laryngoscopy are in place and the surgeon is prepared to embark immediately with a surgical airway (in this case a triple set up). 45.4.3 How should you prepare for this case? Following the failed attempt to start an intravenous line in the emergency department, the child was brought to the operating room. As previously outlined, venous access is crucial for induction and fluid resuscitation. Placement of a central line in the awake child is a possible option. For internal jugular vein access, the head may need to be rotated with increased risk associated with the presumed atlanto-occipital instability. The subclavian approach has the risk of a pneumothorax. An ultrasound guided femoral vein approach is an alternative. On the other hand, several studies have shown that an intraosseos cannula can be placed within 60 seconds and that this line provides an excellent access for the administration of medications and fluids. Because of the risks associated with central line placement, the child was prepared for an intraosseous cannula. The right leg was prepped with antiseptic solution, and local anesthetic injected at the tibial plateau. An intraosseous canula was placed without incident. A normal saline solution flowed freely permitting the administration of 20ml.kg-1 bodyweight. Atropine 0.1 mg IV was administered to reduce additional secretions and mitigate vagal responses secondary to laryngoscopy. The usual monitors were applied (pulse oximetry, noninvasive blood pressure and EKG). The surgeon was prepared as was his equipment; the rescue airway cart was in the room. 45.4.4 Management of this child Concurrent with the placement of the intraosseous canula, the child was prepared for a rapid sequence induction. The child was denotrogenated with 100% FiO2 for 3 minutes employing a facemask that was reasonably tolerated with much cajoling. Considering the possibility of significant hypovolemia a 50/50 mix of Ketamine and Propofol (ketofol) was selected for induction and Succinylcholine for neuromuscular blockade. Cricoid pressure during induction was not applied to avoid stimulating vomiting in the already agitated child. It was applied after the child was deeply anesthetized. As soon as the child was deeply asleep and paralyzed, the mouth was suctioned easily and several clots were removed with the Magill Forceps. Again the brisk bleeding from the right tonsillar bed was noted. Since the previous direct laryngoscopy showed a Grade 3 view, a repeated direct laryngoscopy was not attempted. Because the oral cavity seemed to be free of clot, it was decided to proceed with indirect laryngoscopy with the GlidescopeÂÂ ®. Unfortunately, blood obscured the lens and following a prolonged laryngoscopy the attempt to intubate was abandoned. Oxygen saturations fell from 100% to 94% and despite the risk of aspiration, mask ventilation was begun and cricoid pressure was maintained.The saturations recovered nicely. At this point, faced with a failed intubation, rather than a failed airway it was decided to insert a ProSealÂÂ ® laryngeal mask. The oral cavity was once again suctioned with a rigid catheter under direct laryngoscopy and a number 3.0 ProsealÂÂ ® laryngeal mask was easily placed. No air leak was noted and pressure controlled ventilation with a pressure limit of 15 cm H2O was started. A number 5.5 uncuffed endotracheal tube was loaded on a pediatric flexible bronchoscope. Using the LMA ProSealÂÂ ® as a conduit, the bronchoscope was advanced into the trachea. Blood and secretions where present in the LMA and in the trachea but did not obscure the view through the bronchoscope. The ETT was placed easily. With a small air leak at 20 cm H2O airway pressure, it was decided not to change the ETT over a pediatric Cook airway exchanger to a cuffed ETT. Since the LMA did not obscure the surgeons view, it was decided to leave the LMA in place and remove it together with the endo tracheal tube at the end of the procedure after emerge of anesthesia. With a secured airway, the ENT surgeon cauterized the tonsillar bed, and the bleeding artery could be ligated. At the end of the procedure, a large bore nasogastric tube was placed through the suction port of the ProsealÂÂ ® laryngeal mask and the stomach suctioned. The child was taken to the pediatric ICU where he was extubated fully awake one hour later. 45.5 OTHER CONSIDERATIONS 45.5 1 What is the current thinking with respect to the surgical management of post-tonsillectomy bleeding? Life threatening post-tonsillectomy bleeding requires an aggressive approach to surgical management. Initially pressure on the bleeding tonsillar fossa with a clamped gauze or the index finger may give sufficient time to start an intravenous line for blood work and cross match, and to provide for fluid resuscitation or blood transfusion if indicated. If intraoperative localization of the bleeding source is time consuming and local treatment is ineffective, ligation of the external carotid artery at an early stage may be required. Aberrant arterial blood supply to the tonsillar region deriving from the internal carotid artery or the carotid bulb may be present. In cases such as these, packing of the pharynx and angiographic embolization of the feeding artery may be necessary(9). 45.5.2 Are there specific measures that one ought to employ to reduce the postoperative morbidity and mortality of patients following tonsillectomy? The focus on post-tonsillectomy bleeding is on preventive measures, both by the surgeon and the anesthesia practitioner. Tonsillectomy technique: In comparison to the cold knife technique, hot techniques employing bipolar diathermy or coblation tonsillectomy are associated with an increased rate of secondary bleeding (4, 9). The duration, frequency and surgical extent of these techniques are linked to the amount of damage to the surrounding tissue. This damage leads to deeper zones of local necrosis which is vulnerable to bacteria- and enzyme-containing saliva, and therefore at increased risk of secondary bleeding (4, 5). Effects of postoperative, nonsteroidal, antiinflammatory drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit platelet cyclo-oxygenase (COX). A recent meta-analysis showed an increased risk of re-operation for hemostasis post-tonsillectomy if conventional NSAIDs such as ketorolac, ibuprofen or ketoprofen were used for postoperative pain control in children (10). On the other hand ketorolac has been proven to be an effective treatment for post tonsillectomy pain, and as a non-opioid delivers an intraoperative opioid sparing effect and leads to a reduction in postoperative respiratory depression, nausea and vomiting. A most recent meta-analysis did not find an altered number of perioperative bleeding events in patients given an NSAID (11). Still, the use of these drugs should be discussed with the surgeon and used with precautions. Effects of dexamethasone for postoperative nausea and vomiting (PONV): Postoperative nausea and vomiting increases the risk of primary hemorrhage and unexpected postoperative hospital admission. Dexamethasone has antiemetic properties in the perioperative setting. However, dexamethasone may inhibit wound healing, attenuate the inflammatory response to local infection and as a result perhaps increase the risk of postoperative bleeding. A recent study in children undergoing tonsillectomy and administered dexamethasone was prematurely terminated because of an increased bleeding rate (12). Similar to NSAIDs, the use of dexamethasone should be discussed with the surgeon und used with caution. Tonsillectomy as outpatient surgery: Traditionally, tonsillectomy has been associated with a hospital inpatient admission. Economic imperatives have pushed hospitals to perform tonsillectomies as outpatient day surgery procedures. The evidence has shown that this can be safely performed with the following exceptions: age under 3 years medical disorders that increase anesthetic and surgical risk craniofacial abnormalities abnormal coagulation, with or without an identifiable bleeding disorder obstructive sleep apnea acute peritonsillar abscess family conditions that prevent easy and rapid return to a medical facility Patients should always be observed for a minimum of 6 hours. They should be able to tolerate oral fluids and be pain free of prior to discharge. As an alternative to hospital admission, a 23 hour overnight observation period can be considered. 45.6 SUMMARY Post-tonsillectomy bleeding is a rare event, which occurs most often within 24 hours following tonsillectomy. However, it may be delayed for up to 14 days postoperatively. The amount and severity of bleeding along with the need to ensure patient comfort and a still surgical field most often make operative revision under general anesthesia necessary. The insidious and continuous nature of the bleeding may lead to significant hypovolemia which is often difficult to assess. Blood work and cross match as well as preoperative intravenous access with fluid resuscitation are crucial in the management of these children. Aspiration and a difficult airway are ever-present risks during the induction of anesthesia in these patients. Rapid sequence induction with direct laryngoscopy and endotracheal intubation is the accepted first choice in the management of these children. An array of pediatric airway management devices need to be immediately available. Blood and secretions can obscure the laryngeal view and can make some devices more useful than others. A surgeon experienced in rigid broncoscopy and establishment of a surgical airway must be present during anesthesia induction. Cautious use of nonsteroidal inflammatory drugs and steroids is advocated. Any death related to a tonsillectomy is a unacceptable bleeding in otherwise healthy children.

Apartheid, Globalization, and South Africa Essay -- Outsourcing, Offsho

Introduction In 1991 President Frederik Willem de Klerk of South Africa succumbed to the pressures of international economic sanctions, officially repealed the apartheid laws and called for the drafting of a new constitution. Just three years later, Nelson Mandela became the President of South Africa in the country’s first multi-racial election. Apartheid’s end may never have come, however, were it not for the improved efficiency of communication between states, the increased economic interdependency between those states, and the emergence of international non-governmental organizations (INGOs) that make national borders all but invisible and chip away at Westphalian sovereignty. The existence of such factors allowed for International Organizations (IOs) such as the United Nations to call state governments’ attention to the crimes against humanity committed in South Africa each day, and it allowed those governments to act effectively. Yet the Black, Coloured, and Asian pe ople of South Africa are not singing globalization’s praises. In point of fact, historically globalization has done far more harm than good to the natives of South Africa. Globalization is by no means a fundamentally new phenomena but rather a thickening of preexisting networks of interdependence. (Keohane and Nye 2000). After the industrial revolution in Europe and the surge in international trade in the mid 1800s globalization soon took hold of South Africa. The discovery of diamonds in the territory in approximately 1900 increased the land’s value significantly as it could be exploited by the colonists to generate substantial monetary gains. Following the Boer War with English invaders thirsty to share in the profits of the mineral rich land, the ... ...tiglitz suggests, the supranationals need to remove conditionality from their loan agreements and pay closer attention to the domestic needs of the countries they aim to help. Superpowers like the United States need to practice what they preach, and stop protecting their own markets while plundering others. (Stiglitz, 2001) Only this fused effort of dedication and hard work by the ANC with increased aid from IOs based on less one-sided terms will pave the way to sustainable equality in South Africa. The plateauing environmental degradation is an example of this process. In this case, South Africa observed a shift from sharp degradation to the â€Å"sustainable development† they sought. Sovereignty has been all but lost in South Africa in the past decade, and its people and land suffered. Its gradual restoration will pave the way to recovery and eventual prosperity. Apartheid, Globalization, and South Africa Essay -- Outsourcing, Offsho Introduction In 1991 President Frederik Willem de Klerk of South Africa succumbed to the pressures of international economic sanctions, officially repealed the apartheid laws and called for the drafting of a new constitution. Just three years later, Nelson Mandela became the President of South Africa in the country’s first multi-racial election. Apartheid’s end may never have come, however, were it not for the improved efficiency of communication between states, the increased economic interdependency between those states, and the emergence of international non-governmental organizations (INGOs) that make national borders all but invisible and chip away at Westphalian sovereignty. The existence of such factors allowed for International Organizations (IOs) such as the United Nations to call state governments’ attention to the crimes against humanity committed in South Africa each day, and it allowed those governments to act effectively. Yet the Black, Coloured, and Asian pe ople of South Africa are not singing globalization’s praises. In point of fact, historically globalization has done far more harm than good to the natives of South Africa. Globalization is by no means a fundamentally new phenomena but rather a thickening of preexisting networks of interdependence. (Keohane and Nye 2000). After the industrial revolution in Europe and the surge in international trade in the mid 1800s globalization soon took hold of South Africa. The discovery of diamonds in the territory in approximately 1900 increased the land’s value significantly as it could be exploited by the colonists to generate substantial monetary gains. Following the Boer War with English invaders thirsty to share in the profits of the mineral rich land, the ... ...tiglitz suggests, the supranationals need to remove conditionality from their loan agreements and pay closer attention to the domestic needs of the countries they aim to help. Superpowers like the United States need to practice what they preach, and stop protecting their own markets while plundering others. (Stiglitz, 2001) Only this fused effort of dedication and hard work by the ANC with increased aid from IOs based on less one-sided terms will pave the way to sustainable equality in South Africa. The plateauing environmental degradation is an example of this process. In this case, South Africa observed a shift from sharp degradation to the â€Å"sustainable development† they sought. Sovereignty has been all but lost in South Africa in the past decade, and its people and land suffered. Its gradual restoration will pave the way to recovery and eventual prosperity.

Battle of the Buldge :: World War II History

Battle of the Buldge The Battle of the Buldge was the last of the German attacks. It lasted from December 16,1944 to January 28, 1945. The Battle of the Buldge was the largest land battle of World War 2. More then a million men participated in this battle, 600,000 germans, 500,000 Americans and 55,000 British armies were fighting. Towards the end of 1944, World War 2 was coming to an end. The German forces were weakening. Hitler's armies were on the run. The Allies had regained land that was previously taken over by the Nazis, such as Paris, Casablanca and Tripolia. Hitler decided that a surprise attack against the allies could turn the tide of the war. He built up large armies with newly built tanks, artillery and airplanes. Hitler's last attack had to work or he would be defeated. The plan was to march 85 miles from Southern Belgium to Luxembourg and attack the allies by surprise. He would attack during the Christmas season in the Ardennes Forest, an area where there were only a few allied shoulders. T he invasion was designed to split the American and British armies in half. However it did not succeed. The German armies caught the allies by surprise. They had some success in the beginning and were able to take a lot of land from the allies and captured many allied soldiers. The allied forces fought Hitler's armies bravely. They held on to their ground wherever they could. They slowed down the German armies until American and English reinforcements arrived to fight the Germans. The German army was no match for the allied forces. They were running out of fuel, men and ammunition. After fierce battles the German forces were pushed back and gave up all the land they had conquered in the beginning of the

Mission of God Essay -- The Bible, Genesis

Mission of God When one comes across the question â€Å"Who is God for them?† they could present a lot of definitions on what they think God is. To some, they would revere God as the Supreme Being that has created the whole universe in seven days. Some would note that He is the Loving, Caring, Sympathetic and Ever-Forgiving God that watches over us and guides us away from the darkness of our hearts. Many would state that He is the only Divine Being that everyone must obey and worship. This answer many vary if one comes from another religion, but all would agree that this God is a very special being that connects each and every one of us. But if one is asked the question â€Å"What do you think is God’s Personal Mission to us and to the world?† the answers may be unclear and even not be answered at all. This paper would try to answer this particular question by identifying and discussing the Mission of God through the passages in the Old and New Testament and the themes corresp onding to this Mission. This paper would also discuss the implications of the Mission of God to the contemporary Australian Church as an example of discussing the effects it has on the teachings of the Church. According to Jennings (2003), the mission of God can be traced from the first book of the Old Testament; the Book of Genesis. In summary, the first book tells readers how God began to create the world and the lives of the first humans He has watched, tested and protected. But looking closely in the first few chapters of the book, God presented his plans and mission for the world he has created in the first eleven chapters of this particular book. Jennings cited that God’s love is concentrated to His creations, especially in man; specifying his mission that He... ...rst travels after the time of Christ and how he came across the will of God and His mission. Most leaders in Jerusalem question the Gentiles and why they are accepted in the Church. But James, another disciple of Christ, remembered Jesus’s teachings from the books of Law, Prophets and Psalms from the Old Testament and prevented a massive argument from brewing between the Jews and Gentiles. Both authors speculate on how James got to remember this particular teaching of Christ but they both agree that James noted that the Word of God in form of the Gospel is not meant just for Jews but also for the Gentiles and other races that flock God’s church. (Wills, 1979) ; (Peters, 1972) Now that the mission of God is properly outlined in both the Old and New Testaments of the Bible, what are its implications upon the different churches that studied and valued its teachings?

Knowledge Of Biomechanical Restrictions Ankle Health And Social Care Essay

The knee bend is a often used exercising in the strength and conditioning community and is regarded as an first-class manner to develop the lower limb muscular structure. This is in no little portion down to the biomechanical and neuromuscular similarities that the knee bend exercising has in relation to many athletic motions ( Escamilla et al. , 2001 ) . The knee bend is besides used in many rehabilitation protocols as it is a closed kinetic concatenation exercising ( Escamilla et al. , 1998 ; Stuart, Meglan, Lutz, Growney, & A ; An, 1996 ) where the distal section is fixed ( Yack, Collins, & A ; Whieldon, 1993 ) . The knee bend is besides a mention point for most strength and conditioning managers when measuring maximum lower limb strength and this is besides the instance in competitory power-lifting and weightlifting ( Escamilla, Fleisig, Lowry, Barrentine, & A ; Andrews, 2001 ) . Squat preparation has been shown to correlate strongly with improved sprinting, perpendicular leap an d other athletic abilities ( Wisloff, Castagna, Helgerud, Jones, & A ; Hoff, 2004 ; CHELLY et al. , 2009 ) and so strength and conditioning managers would be wise to proliferate good motion in this exercising. It is non merely in athletic preparation that the knee bend should be regarded as of import but besides in mundane life because the specificity of the crouching motion to undertakings such as picking up immature kids and bundles is innately similar, as are infinite other avocations and undertakings ( Schonefield, 2010 ) intending the ability to crouch allows people to retain functional independency in life. During chunky public presentation the mortise joint articulation contributes considerable support and helps to bring forth the important degrees of power required for this motion ( Hung & A ; Gross, 1999 ) . Besides failing or instability at the mortise joint has antecedently been implicated in the generation of defective motion forms during the knee bend happening specifically that failing of the gastrocnemius, tibialis front tooth or buttocks may increase likeliness of both foot pronation gesture and so diminishing the ability to command articulatio genus valgus ( Bell, Padua, & A ; Clark, 2008 ) . However it was noted by Schonefield ( 2010 ) that the degree of kinematic informations on the mortise joint articulation and its importance to the crouching motion is scarce. Most writers have decided to concentrate their attendings on the biomechanics of the spinal column, hip or articulatio genus composite during crouching undertakings ( Schonefield, 2010 ) and so some recommendations will be made within this paper for future research. The incidence of ankle hurt in athletics is highest in tribunal and squad athleticss such as rugger, football, hoops and volleyball ( Fong, 2007 ) . A systematic reappraisal paper by Fong ( 2007 ) looked at 227 surveies that had detailed ankle hurt rates across 70 different athleticss over a 28 twelvemonth period and found that in athleticss hurts the mortise joint was the 2nd most injured organic structure site after the articulatio genus ( Fong, 2007 ) . The chief constituents that encompass the mortise joint are the superior tibiofibular articulation and the talo-crural articulation. The superior tibiofibular articulation ( STFJ ) is prone to locking when it is working as portion of a kinetic concatenation and this can take to stop scope restrictions of talocrural dorsiflexion ( Phelps, James, & A ; Matthijs, 2003 ) . The talo-crural articulation ( appendix 1 ) which passively dorsiflexes up to 30Â ° and plantar flexes up to 50Â ° is made up of the talar dome resting on the roof of the mortice, which is junction of the shinbone, calf bone and median and sidelong malleoli. Talocrural dorsiflexion is seen as normal between 11Â ° and 25 Â ° and inflexible between 4.3Â ° and 11.2Â ° ( mention this please ) . The mortise joint composite besides has a huge web of back uping ligaments and sinews and in entire the mortise joint and pes contains 26 castanetss. In order to crouch the metatarsals will dorsiflex and kidnap as the mortise joint goes into dorsiflexion and so follows subtalar joint abduction doing calcaneal eversion which leads to internal rotary motion of the shinbone and thighbone making knee flexure and therefore motion in the sagittal plane. The flexibleness of the calf musculus composite will restrict the sum of dorsiflexion attained, which in bend bounds the remainder of the concatenation or causes compensations someplace else. The induction of a squatting motion is thought to happen from a muscular response that initiate hip and knee flexure along with ankle dorsiflexion to interrupt unsloped position ( Dionisio, Almeida, Duarte, & A ; Hirata, 2008 ) . At this point an automatic response of the tibialis anterior additions ankle joint dorsiflexion torsion and disrupts the postural equilibrium ( Cheron, Bengoetxea, Pozzo, Bourgeois, & A ; Draye, 1997 ) . At this point moderate gastrocnemius activity has been observed appare ntly to command the degree of dorsiflexion at the mortise joint ( Dahlkvist, Mayo, & A ; Seedhom, 1982 ; Escamilla et al. , 2001 ; Escamilla et al. , 1998 ) contending the theory that the musculus is eccentrically controlling dorsiflexion. This theory nevertheless may non keep true due to the fact that the gastrocnemius is a biarticular musculus and may so shorten at the articulatio genus whilst lengthening at the mortise joint and frailty versa for the ascent stage ( Escamilla, 2001 ) . Indeed gastrocnemius activity has been found to be comparatively low in crouching motions and is highest at near to top out knee flexure ( Donnelly, Berg, & A ; Fiske, 2006 ) which correlates with the fact that the gastrocnemius force arm extremum at this point ( Escamilla et al. , 2001 ) . Ankle angular speeds have been seen to be reasonably low and rather changeless throughout both the acclivity and descent stages of the knee bend ( Escamilla et al. , 2001 ) . Stance is an of import factor in crouching public presentation and muscular enlisting forms and no clear victor has been found in the race to domination with foot place even in the powerlifting universe. Escamilla et Al ( 2001 ) examined how 3 differing stances affected joint minute and angular speeds utilizing a 3 dimensional biomechanical analysis but besides comparing against a 2-D theoretical account, happening important differences in wider stances. This was interesting because the ankle joint minutes and section angles calculated in old 2-D literature were based on utilizing a individual camera to therefore position the joint moving in merely the sagittal plane which can merely go on when the pess point forwards and so as the stance breadth increased so would the degrees of erroneous informations biomechanically from the mortise joint articulation ( Escamilla et al. , 2001 ) presuming topics have to turn their pess out. Potentially this means unless the stance was standardized to insulate sagittal motion in all literature so it is extremely likely to be inaccurate. The motion of the articulatio genuss relative to the mortise joints in the z-axis was besides studied in the Escamilla et Al ( 2001 ) paper and they found that the articulatio genuss translated frontward over the pess 21.7 AÂ ± 4.4 centimeter during the narrow stance, 18.0 AÂ ± 2.6 centimeter during the medium stance, and 16.0 AÂ ± 4.6 centimeter during the broad stance. It has been antecedently reported that increased frontward motion of the articulatio genuss during crouching causes shearing forces at the articulatio genus ( Ariel, 1974 ) . This besides highlights the importance of ankle dorsiflexion scope of gesture during crouching motions when using a broad or average stance, which was categorized by Escamilla et Al ( 2001 ) as 121-153 % shoulder width apart ( set broad stance breadth in! ) . In this survey the most important differences in joint minutes and minute weaponries were seen at the mortise joint articulation ( Escamilla et al. , 2001 ) and unsurprisingly the greatest differences occurred between the narrow and broad stances ( appendix 2 ) . The greatest mortise joint articulation minutes were seen at maximal knee flexure ( Escamilla et al. , 2001 ) which was in line with old literature where gastrocnemius activity besides peaked at this point ( Isear, Erickson, & A ; Worrell, 1997 ) in all chance antagonizing the mortise joint minutes. A recent survey, albeit looking at quality of motion steps and the sidelong measure down test, saw that topics with inhibited public presentation in these trials had limited ankle dorsiflexion ( RABIN & A ; KOZOL, 2010 ) and so compensations are likely to be happening elsewhere. McLaughlin et Al ( 1977 ) have recommended maintaining the shinbone every bit perpendicular as possible to restrict the possible articulatio genus shearing forces in the knee bend ( McLaughlin, Dillman, & A ; Lardner, 1977 ) and so a later survey by Fry et Al ( 2003 ) compared kinetic belongingss when articulatio genus anterior motion was restricted. The 7 topics were weight trained work forces who had all squatted on a regular basis earlier and each performed 3 knee bends both impeded and unimpeded with consequences demoing important differences in both hip and articulatio genus torsions under restricted articulatio genus conditions. The restricted knee bend produced greater torsion values at the hip compared to the articulatio genus and besides showed a more inclined bole and trunk every bit good as a more perpendicular shinbone ( Fry, Smith, & A ; Schilling, 2003 ) . The limitation ( figure 1 ) so causes a alteration in the hip minute arm, which is a necessary compensation to let the Centre of mass to remain over the base of support, the pess. This inordinate forward tilt is hence necessary when there is a limitation in anterior knee motion and significantly has besides been noted as a common mistake for novice lifters executing the barbell knee bend exercising ( Chandler & A ; Stone, 1991 ) . It has been seen that less skilled homesteaders tended to tilt frontward more, therefore making greater bole torsions ( McLaughlin et al. , 1977 ) but it has besides been seen that lumbar spinal column shearing forces are significantly increased in lifters exposing a outstanding forward tilt ( Russell & A ; Phillips, 1989 ) . It can be moderately assumed that the big hip torsions seen when anterior articulatio genus motion is restricted are transferred to the lumbar spinal column making a possible hurt site and hapless biomechanical modeling. Surveies have antecedently shown that the experts in crouching have superior kinematics due to a more vertical bole, less horizo ntal hip supplanting and superior dynamicss through less bole torsions than less experient lifters ( McCaw & A ; Melrose, 1999 ; McLaughlin et al. , 1977 ) . One cause for restricted anterior articulatio genus motion in knee bend could be gastrocnemius equinus forestalling dorsiflexion and this is a wholly under researched country. It has been researched in spastic and neurologically impaired persons but non every bit much in non-spastic populations as a cause of limited dorsiflexion. This stringency causes an inability to dorsiflex through the tibiotalar articulation and can besides take to other symptoms of the bow and mid pes ( DiGiovanni et al. , 2002 ) . Heel rises have been used by jocks to help in the gym based motion such as knee bend and Olympic raising fluctuations. A diminution board is such a device and this puts lesser demands on the mortise joint in dorsiflexion compared to normal floor based knee bends ( Frohm, Halvorsen, & A ; Thorstensson, 2007 ) . This has been postulated as a method for the intervention of tendinopathies at the patellar but this is when utilizing bizarre motions ( Frohm et al. , 2007 ) to make maximal force at the articulatio genus and non for general knee bend. One possible drawback with heel rises is that the when utilizing a heel raise the pes becomes more plantarflexed coupled with calcaneal inversion. This means that during crouching when tibial internal rotary motion is required it is hard to achieve whilst the pes is somewhat inversed and as the shinbone is already in a somewhat externally rotated place. Tibial external rotary motion has been implicated as one of the causes of dynamic articulatio genus valgus in the knee bend exercising ( Bell et al. , 2008 ) which is regarded as a important hazard factor in anterior cruciate ligament showing ( Chaudhari & A ; Andriacchi, 2006 ; Hewett et al. , 2005 ) . The median supplanting of the articulatio genus ( MKD ) is thought to be influenced by specific strength or flexibleness shortages in muscular structure at the hip and mortise joint ( Hirth & A ; Padua, 2007 ) such as stringency of sidelong gastrocnemius, soleus and peroneals which may add to tibal abduction and external rotary motion ( Bell et al. , 2008 ) . Once once more though, the research detailing the existent comparative parts of the mortise joint and hip is non seen. This is one country where clinicians may make up one's mind to utilize a heel rise to distinguish the cause of MKD between hip muscular structure and lower limb muscular structure when MKD is seen when utilizing a heel rise under the calcaneous when bilaterally crouching ( Bell et al. , 2008 ) . A surve y by Bell et Al ( 2008 ) looked at the lower limb causes of MKD and found that topics with inordinate MKD had 20 % less inactive mortise joint dorsiflexion scope of gesture with a flexed articulatio genus ( Bell et al. , 2008 ) . It should be noted that the topics in this survey were non wholly from athletic or physically active backgrounds with a significantly greater proportion ( n=30, men=7, women=30 ) being adult females. The presence of an increased articulatio genus valgus when decreased mortise joint dorsiflexion scope of gesture is present facilitates the demand for farther survey into this country as a showing tool for ACL hurt bar ( Fong, Blackburn, Norcross, McGrath, & A ; Padua, 2011 ) . Outside of crouching forms, jocks with limited mortise joint dorsiflexion have been seen to incur much greater extremum landing forces after dropping or jumping ( Blackburn & A ; Padua, 2008 ; Devita & A ; Skelly, 1992 ) which is coupled with much less articulatio genus and hip supplanting. Reduced ankle dorsiflexion scope of gesture was besides associated with patellar sinew tendinopathies ( P & lt ; 0.05 ) in volleyball participants due to the resulting limited calf bizarre contraction ability ( Malliaras, Cook, & A ; Kent, 2006 ) . Another similar status to patellar tendinopathy that has been implicated with limited mortise joint dorsiflexion is Morbud Osgood Schlatters ( MOS ) in athleticss active kids. This status is caused by grip apophysitis of the tibial tubercle caused by insistent strain and chronic avulsion of the secondary ossification Centre of the tibial tubercle ( EHRENBORG, 1962 ) although the exact description and causing is still debated. This insistent pulling gest ure comes from the quadriceps musculus during featuring activities ( Sarcevic, 2008 ) . Sarcevic ( 2008 ) theorized that limited mortise joint dorsiflexion caused compensatory actions such as increased articulatio genus flexure, tibial internal rotary motion and foot pronation during the stance stage of running ( Sarcevic, 2008 ) . In this paper 42 of the 45 topics had a dorsiflexion angle of less than 10Â ° and besides had clinical diagnosing of MOS. This is simply a theory though and farther research should concentrate on using a control group to compare and therefore make causal relationships. The importance of ankle dorsiflexion scope of gesture is non merely critical for crouching motions and set downing but besides for the bar of by and large enfeebling conditions such as plantarfasciitis. Plantarfasciitis is comparatively common in physically active and athletic populations ( Kibler, Goldberg, & A ; Chandler, 1991 ) and is by and large seen as redness of the facia on the sole of the pes giving anterior heel hurting. It has been seen that when ankle dorsiflexion is limited, inordinate pronation of the pes will happen to counterbalance, thereby increasing tensile tonss on the plantar aponeurosis ( Kibler et al. , 1991 ; WRIGHT & A ; RENNELS, 1964 ) . The hazard of plantartfasciitis additions as the scope of dorsiflexion lessenings and providentially those who spend a longer sum of clip on their pess are once more at a greater hazard ( Riddle, Pulisic, Pidcoe, & A ; Johnson, 2003 ) . One of the causes of a limited dorsiflexion may be the inability of the shinbone to posterior glide decently on the flexible joint like scree ( Denegar & A ; Miller, III, 2002 ) . Lots of research is available that highlights the effectivity of anterior to posterior mobilizations of the scree on the shinbone to increase ankle dorsiflexion scope of gesture ( Landrum, Kelln, Parente, Ingersoll, & A ; Hertel, 2008 ; van der Wees et al. , 2006 ; Vicenzino, Branjerdporn, Teys, & A ; Jordan, 2006 ) . This research was by and large performed on topics with chronic mortise joint sprain and or, instability. One of the theories postulated for the effectivity of the front tooth to posterior mobilization technique is the theory of the lockup of the scree, whereby the scree is subluxated anteriorly on the shinbone ( Mulligan B R. , 1999 ) and even though there is small published quantifiable grounds of this theory it is worthwhile cognition for the strength and conditioning manager who identifies a dorsiflexion restriction. In another paper topics who suffered recurrent mortise joint sprains and were so diagnosed with chronic mortise joint instability ( CAI ) had significantly less dorsiflexion compared to a control group when jogging ( Drewes, McKeon, Casey Kerrigan, & A ; Hertel, 2009 ) . This shortage was so postulated as a important hazard factor in jocks with CAI with recommendations to see a clinician proposed ( Drewes et al. , 2009 ) . It should besides be noted that during this survey used a 10 camera gesture analysis system intending a 3-D analysis was undertaken on topics.

A description of a tranditional ELT classroom in Korea

It’s a Friday afternoon. After he looks through the schedule to find out which class he has to instruct next, Mr Jo is checking up the word quiz papers which will be used to see whether they have reviewed the words that they learned from the last English class.Now he enters the door of the classroom, and tells the students running, chatting, sitting on the desk to prepare for the class. After settling down the class, he begins to check if everyone is present. And the teacher is giving out the word quiz papers and telling them to write down on the sheet the words that he will say. Right after speaking ten words he wants to check up, he has students swtch their papers, and score them, Next, the teacher gathers up all the papers and puts them aside, and he is moving to the next segment.Mr. Jo points out a student and asks her what grammar points she was instructed in the last class. Unfortuantely she doesn’t remember what she learned, so Mr. Jo warns her that if she doesnà ¢â‚¬â„¢t reivew what she learns next time, she will have a penalty for that.For students to refresh their memory of what they have learned, he starts to go over the points again. Finishing the review, he has the students open up the textbook and begins to cover the reading passage. The teacher reads all the sentences and translates them one by one as usual. Whenever he runs into a grammar point that might be new to the students, the teacher explains it in Korean, and encourages them to take notes on their textbook.After he goes through all the passage, the teacher gives them some homework to write all the sentences and to translate them to Korean on the notebook, and also asks the students to solve all the questions on the grammar and reading sections.Getting back to his desk, he piles up the quiz sheets and starts to go through the number that each student has scored today. Now he is getting ready for another class of the same level as he has just been through.