Effects of Drowning on the Body

Effects of Drowning on the Body According to the new definition adopted by the WHO in 2002, Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning is defined as death from asphyxia that occurs within the first 24 hours of submersion in water. Near drowning refers to survival that lasts beyond 24 hours after a submersion episode. Hence, it connotes an immersion episode of sufficient severity to warrant medical attention that may lead to morbidity and death. Drowning is, by definition, fatal, but near drowning may also be fatal. (2) Drowning is the seventh leading cause of accidental death in the United States. Though the exact incidence in India can only be a crude estimate, one keeps coming across incidences of drowning fatalities. Many boating accidents lead to fatalities, possibly due to concomitant accidental injuries or trapping in submerged boat. Motor vehicle accidents with a fall in streams or ponds are also being reported with similar settings. Drowning can also occur in scuba divers but may be associated with cardiac event or arterial gas embolism. Other possibilities to be kept in mind include hypothermia, contaminated breathing gas, oxygen induced seizures. Even community swimming pool and home bathtubs and buckets are known to be adequate for young children to drown accidentally. Majority of such events are due to unsupervised swimming, esp in shallow pools or pools with inadequate safety measures. One look for features of closed head injury or occult neck fractures while management of such cases. Intentional hyperventilation before breath-hold diving is associated with drowning episodes.(3) Weak swimmers attempting to rescue other persons may themselves be at risk of drowning. Males are more likely than females to be involved in submersion injuries. This is consistent with increased risk-taking behavior in boys, especially in adolescence.(4) CAUSES OF DROWNING Alcohol consumption, which impairs coordination and judgement Failure to observe water safety rules e.g. having no life preserver or unsupervised swimming. Sustaining a head and neck injury while involved with a water sport Boating accidents Fatigue or exhaustion, muscle and stomach cramps Diving accidents including scuba diving Medical event while in the water e.g. seizure, stroke, and heart attack Suicide attempt Illicit drug use Incapacitating marine animal bite or sting Entanglement in underwater growth Drowning and near-drowning events must be thought of as primary versus secondary events. Secondary causes of drowning include seizures, head or spine trauma, cardiac arrhythmias, hypothermia, syncope, apnea, and hypoglycemia. PATHOPHYSIOLOGY Drowning occurs when a person is submerged in water. The principal physiologic consequences of immersion injury are prolonged hypoxemia and acidosis, as a result of immersion in any fluid medium. The most important contribution to morbidity and mortality resulting from near drowning is hypoxemia and its consequent metabolic effects. Immersion may produce panic with its respiratory responses or may produce breath holding in the individual. Beyond the breakpoint for breath-hold, the victim reflexly attempts to breathe and aspirates water. Asphyxia leads to relaxation of the airway, which permits the lungs to take in water in many individuals (wet drowning). Approximately 10-15% of individuals develop water-induced spasm of the air passage, laryngospasm, which is maintained until cardiac arrest occurs and inspiratory efforts have ceased. These victims do not aspirate any appreciable fluid (dry drowning). It is still controversial whether such a drowning occurs or not.(5) Wet drowning is caused by inhaling large amounts of water into the lungs. Wet drowning in fresh water differs from salt water drowning in terms of the mechanism for causing suffocation. However, in both cases water inhalation leads to damage to the lungs and interfere with the bodys ability to exchange gases. If fresh water is inhaled, it passes from the lungs to the bloodstream and destroys red blood cells. If salt water is inhaled, the salt causes fluid from the body to enter the lung tissue displacing the air. The pathophysiology of near drowning is intimately related to the multiorgan effects secondary to hypoxemia and ischemic acidosis. Depending upon the degree of hypoxemia and resultant acidosis, the person may develop cardiac arrest and central nervous system (CNS) ischemia.CNS damage may occur because of hypoxemia sustained during the drowning episode per se or may occur secondarily because of pulmonary damage and subsequent hypoxemia. Additional CNS insult may result from concomitant head or spinal cord injury. Although differences observed between freshwater and saltwater aspirations in electrolyte and fluid imbalances are frequently discussed, they rarely of clinical significance for people experiencing near drowning. Most patients aspirate less than 4 ml/kg of fluid. 11 ml/kg is required for alterations in blood volume, and more than 22 ml/kg of aspiration is required before significant electrolyte changes develop. Regardless, most patients are hypovolemic at presentation because of increased capillary permeability from hypoxia resulting in losses of fluid from the intravascular compartment. Hyponatremia may develop from swallowing large amounts of fresh water. The temperature of the water, not the patient, determines whether the submersion is categorized as a cold or warm drowning. Warm-water drowning occurs at a temperature greater than or equal to 20Â °C, cold-water drowning occurs in water temperatures less than 20Â °C, and very cold-water drowning refers to temperatures less than or equal to 5Â °C. Hypothermia reduces the persons ability to respond to immersion, finally leading to helplessness or unconsciousness. Pulmonary Effects Aspiration of only 1-3 ml/kg of fluid can result in significantly impaired gas exchange. Fresh water moves rapidly across the alveolar-capillary membrane into the microcirculation. It causes disruption of alveolar surfactant, producing alveolar instability, atelectasis, and decreased compliance with marked ventilation/perfusion (V/Q) mismatching. As much as 75% of blood flow may circulate through hypoventilated lungs which acts as a shunt. Salt water, which is hyperosmolar, increases the osmotic gradient, and therefore draws fluid into the alveoli. Surfactant washout occurs, and protein-rich fluid exudates rapidly into the alveoli and pulmonary interstitium. Compliance is reduced, alveolar-capillary basement membrane is damaged directly, and shunt occurs. This results in rapid induction of serious hypoxia. Both mechanisms cause pronounced injury to the alveoli/capillary unit resulting in pulmonary edema. Fluid-induced bronchospasm also may contribute to hypoxia. Increased airway resistance secondary to plugging of the patients airway with debris (vomitus, sand, silt, diatoms, or algae), as well as release of inflammatory mediators, result in vasoconstriction and reactive exudation, which impairs gas exchange. A high risk of death exists secondary to the development of adult respiratory distress syndrome (ARDS), which has been termed postimmersion syndrome or secondary drowning. Late effects include pneumonia, abscess formation, and inflammatory damage to alveolar capillary membranes. Postobstructive pulmonary edema following laryngeal spasm and hypoxic neuronal injury with resultant neurogenic pulmonary edema also may play roles. Cardiovascular Effects Hypovolemia is secondary to fluid losses from increased capillary permeability. Profound hypotension may occur during and after the initial resuscitation period. Ischemic metabolic acidosis due to lactic acid accumulation impairs cardiac function. This may often be a large component especially when the victim struggles violently trying to save himself. In addition, hypoxemia may directly damage the myocardium. Myocardial dysfunction result from ventricular dysrhythmias and asystole, decreasing cardiac output. Pulmonary hypertension may result from the release of pulmonary inflammatory mediators, which increase the right ventricular afterload, thus decreasing contractility. CNS Effects If hypoxemia and decreased cardiac output persists long enough, anoxic brain damage can ensue. Improvement in the management of pulmonary dysfunction caused by near drowning has left CNS injury the major determinant of subsequent survival and long-term morbidity. Hypothermia Thermal conduction of water is 25-30 times that of air. The temperature of thermally neutral water, in which a nude individuals heat production balances heat loss, is 33Â °C. Physical exertion increases heat loss secondary to convection/conduction. A significant risk of hypothermia usually develops in water temperatures less than 25Â °C. Other Effects The clinical course may be complicated by multiple organ failure resulting from prolonged hypoxia. Disseminated intravascular coagulation, hepatic and renal insufficiency, metabolic acidosis, and gastrointestinal injuries must be considered and appropriately managed. CLINICAL FEATURES (6) History All aspects leading to the submersion episode should be determined. Most patients are found after having been submerged in water for an unobserved period. Rarely does a patient present with the classic story of a novice swimmer stranded in water, frantically struggling and flapping arms in desperation. It is important to extract certain relevant factors in the beginning of resuscitative efforts, which include submersion time, associated trauma (especially cervical spine and head), drug or alcohol ingestion, type of water, degree of water contamination, water temperature, and response to initial resuscitation maneuvers. Pertinent past medical history must be obtained to look for secondary causes of drowning, particularly trauma, seizures, cardiac disease, syncope, exhaustion, alcohol and drug use, hypothermia, diabetes mellitus, psychiatric history with suicidal tendencies or panic disorder, poor neuromuscular control such as severe arthritis or neuromuscular disorder. Physical Examination The clinical presentation of people who experience submersion injuries varies greatly. A victim of a submersion incident may be classified initially into one of the following four groups: a) Asymptomatic b) Symptomatic, manifesting with: Altered vital signs (eg, hypothermia, tachycardia, bradycardia) Anxious appearance Tachypnea, dyspnea, or hypoxia Metabolic acidosis (may exist in asymptomatic patients as well) Altered level of consciousness, neurologic deficit. Vomiting. c) Cardiopulmonary arrest, manifesting as: Apnea Asystole, ventricular tachycardia or fibrillation, bradycardia Immersion syndrome d) Obviously dead, as noted by: Normothermic with asystole Apnea No apparent CNS function Rigor mortis Dependent lividity The following clinical conditions need to be excluded Spinal Cord Injuries Head trauma Cardiac Arrhythmias Seizures Laboratory workup An electrocardiogram is indicated if there is evidence of significant tachycardia, bradycardia, or dysrhythmia or risk of underlying cardiac disease. Arterial blood gas analysis is probably the most reliable clinical parameter in patients who are asymptomatic or mildly symptomatic. A surprising degree of hypoxia can exist without clinical signs. Draw blood for serum glucose levels, complete blood cell count, serum electrolyte levels, liver enzymes, lactate level, and coagulation profile, if indicated. Continuous pulse oximetry and cardiorespiratory monitoring may be needed. Chest radiography should be done for evidence of aspiration, pulmonary edema, or segmental atelectasis suggesting foreign body aspiration. Acute renal impairment is known to occur frequently in near drowning, and while usually mild, severe renal impairment requiring dialysis may occur. If initial tests show elevated serum creatinine, marked metabolic acidosis, abnormal urinalysis, or significant lymphocytosis, serial estimations of serum creatinine should be performed. Cervical spine radiograph or computerized tomography (CT) scanning is helpful in individuals with history of trauma, neck pain, or if doubt exists about the circumstances surrounding the submersion injury. Non contrast head CT scanning is helpful in an individual with altered mental status and a suggestive or unclear history of head trauma. Treatment Pre Hospital Care Optimal pre-hospital care is the most significant determinant of outcome in the management of immersion victims. The patient should be removed from water at the earliest opportunity. If spinal trauma is suspected the individual should be moved the least amount possible, with attention to cervical spine stabilization. The primary aims of treatment of the near drowning cases should be in the order of priority, as below.(7) Effective immediate relief of hypoxia. Restoration of cardiovascular stability. Prevention of heat loss. Speedy evacuation to hospital. As in any rescue initiative, initial treatment should be geared toward ensuring patency of the airway, breathing, and circulation. Initiate rescue breathing immediately, if feasible even while the patient is still in the water. Chest compressions are not effective in the water and waste valuable time. The Heimlich maneuver has not been shown to be effective in removing aspirated water. In the patient with an altered mental status, the airway should be checked for foreign material and vomitus and debris visible in the oropharynx should be removed with a finger-sweep maneuver. Higher pressures may be required for ventilation because of the poor compliance resulting from pulmonary edema. Supplemental 100% oxygen by mask should be administered as soon as available. The degree of hypoxemia may be difficult to determine on clinical observation. Begin rewarming; wet clothing is ideally removed before the victim is wrapped in warming blankets. Hospital Care (7-9) Even those victims who appear normal on arrival at hospital can deteriorate rapidly. An accurate and rapid initial assessment of the victim is essentialInitial management of near drowning should place emphasis on basic life support algorithms and on immediate resuscitation and treatment of respiratory failure, with establishment of an adequate airway and cardiopulmonary resuscitation, if necessary. Associated injuries must be considered, as in any other form of accidental injury. Consider potential spinal injuries, especially in diving accidents. The need for hospitalization is determined on clinical evaluation. Provide all victims of a submersion injury with supplemental oxygen during their evaluations. Noninvasive continuous pulse oximetry is valuable. Patients with completely normal findings on examination and trivial history may be discharged after a 6-hour observational period. Admit any patient with respiratory symptoms, altered oxygenation by pulse oximetry or blood gas analysis, or altered mental status. The most critical role in management is prompt correction of hypoxemia and acidosis. Immediate use of supplemental oxygen with laryngeal mask or other devices achieving high fractional inspired oxygen should be instituted. Consider intubation and mechanical ventilation in any patient with poor respiratory effort, altered sensorium, severe hypoxemia, severe acidosis, significant respiratory distress, if a patient is unable to maintain a PaO2 of greater than 60-70 mm Hg (>80 mm Hg in children) on 100% oxygen by face mask or PaCO2 is > 45 mm Hg. Endotracheal intubation and mechanical ventilation may be indicated in awake individuals unable to maintain adequate oxygenation on oxygen, by mask or via continuous positive airway pressure (CPAP) or in whom airway protection is warranted. Intubated victims of submersion injury may require 5-10cm H2O PEEP may improve oxygenationpositive end expiratory pressure (PEEP) with mechanical ventilation to maintain adequate oxygenation. PEEP has been shown to improve ventilation patterns in the noncompliant lung in several ways, including 1) shifting interstitial pulmonary water into the capillaries, 2) increasing lung volume via prevention of expiratory airway collapse, 3] providing better alveolar ventilation and decreasing capillary blood flow, and 4) increasing the diameter of both small and large airways to improve distribution of ventilation. Pulmonary insufficiency due to drowning may warrant use of surfactant, though its efficacy to be used routinely in all cases has not been demonstrated. Bronchoscopy may be necessary for removal of significant inhaled foreign bodies, such as water debris or aspirated food Intravascular volume depletion is common, secondary to pulmonary edema and intracompartmental fluid shifts, regardless of the type of fluid aspirated. Rapid volume expansion may be indicated using isotonic saline. Ventricular dysrhythmias (typically, ventricular tachycardia or ventricular fibrillation), bradycardia, and asystole may occur as a result of acidosis and hypoxemia, rather than due to electrolyte imbalances. Inotropic support may be required using dopamine or dobutamine. Central venous pressure monitoring may be warranted. Most acidosis is restored after correction of volume depletion and oxygenation. Sodium bicarbonate may be administered in cases of severe acidosis that do not correct using the above measures, but only administer it after adequate ventilation has been established. Most immersion victims become hypothermic gradually and are at risk for ventricular fibrillation and neurologic injury. Re-warming method is dependent on the degree of hypothermia and the patients response. Aggressively rewarm hypothermic patients to restore normal body temperature. Core rewarming with warmed oxygen, continuous bladder lavage with fluid at 40Â °C, and intravenous infusion of isotonic fluids at 40Â °C should be initiated during resuscitation. Warm peritoneal lavage may be required for core rewarming in severely hypothermic patients. Place a nasogastric tube for removal of swallowed water and debris and to assist in rewarming efforts. Urinary catheterization for ongoing urine output measurement may be warranted to assess urine output. The benefits of resuscitative efforts should be continuously reassessed in such situations. Initiate appropriate treatment of hypoglycemia and other electrolyte imbalances, seizures, bronchospasm, cold-induced bronchorrhea, dysrhythmias and hypotension as necessary. Corticosteroids have been shown to be of no benefit in the management of near drowning. Routine antibiotic prophylaxis is not indicated unless the patient was submerged in grossly contaminated water or sewage. Patient disposal depends on the history, presence of associated injuries, and degree of immersion injury. Victims, who only have mild symptoms that improve during observation and have no abnormalities on arterial blood gas studies or pulse oximetry and chest radiograph, should be observed for a more prolonged period of time in the emergency department (about 6 hours). Certain patients may display mild to moderately severe hypoxemia that is corrected easily with oxygen. Admit these patients to the hospital for observation and discharge only after resolution of hypoxemia, if they have no further complications. All patients requiring intubation and mechanical ventilation should be admitted to the Intensive Care Unit. Varying degrees of neurologic as well as pulmonary insults typically complicate their courses. COMPLICATIONS Immediate complications are secondary to hypoxia and acidosis. The immediate threat is the effect on the cardiovascular system. Hypoxia and acidosis may lead to cardiac dysrhythmias, including ventricular fibrillation and asystole. Myocardial damage may lead to cardiogenic shock. Monitor and maintain intravascular volume and blood pressure. Central venous pressure (CVP) monitoring is useful in those patients requiring intensive care. Aspiration of fresh or salt water alters the function of surfactant, causing injury to the alveoli and pulmonary capillaries. Increased capillary permeability can worsen the hypoxia. Continuous pulse oximetry is useful. The early use of supplemental oxygen with high levels of positive end-expiratory pressure is helpful in reversing hypoxemia. Central nervous system effects depend on the severity and duration of hypoxia. Post hypoxic cerebral hypo perfusion may occur. Cerebral edema and intracranial hypertension secondary to hypoxic neuronal injury is frequently observed, but studies have shown that invasive monitoring of intracranial pressure is neither useful nor necessary in near-drowning incidents. Near-drowning patients frequently develop pneumonia, often due to secondary bacterial infections. Whether prophylactic antibiotics are beneficial is still controversial. Chemical pneumonitis also is not infrequent, especially if the submersion occurs in chlorinated or severely contaminated pools. PROGNOSIS The most significant impact on morbidity and mortality occurs before the patient arrives at the hospital. The prognosis is related directly to the duration and magnitude of hypoxia. Poor survival is associated with the need for continued cardiopulmonary resuscitation efforts on arrival to the hospital. Many survivors have long-term neurologic sequelae. If they recover from the pulmonary effects of the submersion, patients who are fully awake on arrival to the hospital generally do very well. Neuro-protective effects only seem to occur if the hypothermia occurs at the time of submersion and only with very rapid cooling in water less than 5Â °C. PREVENTION In most instances, drowning and near drowning can be prevented with simple safety measures and common sense. Most young children enter a swimming pool directly adjacent to their home or one with inadequate fencing or unlatched gates or doors. Adult supervision is essential in the prevention of drowning. Because lapses of supervision are inevitable, other safety precautions must be in place. The use of adequate fencing around swimming pools decreases the number of immersion injuries significantly. The enclosure may be a wall or fence at least 4 feet tall that completely surrounds a pool on all four sides. Doors and gates to the pool should be self-closing and self-latching. The use of personal flotation devices may reduce the incidence of drowning among children when playing in natural bodies of water or when boating. Pool owners should be trained on basic life support. Both children and adults should be instructed to never swim alone or unsupervised. Alcohol and drugs should not be used when operating or riding in motorized watercraft.

But everyman has his price Essay

‘ But everyman has his price.’ Show the part that corruption plays in the action of A Man for All Seasons. The statement ‘everyman has his price’ suggests that all humans are capable of being corrupted. Humans then succumb to certain temptations: greed, power, deception, bribery, betrayal and self-interest. Often men fall prey to such temptations in search of material comfort at the expense of spiritual comfort. More himself comments upon these temptations in the text: â€Å"But since in fact we see that avarice, anger, envy, pride, sloth, trust and stupidity commonly profit far beyond humility, charity, fortitude, justice and thought and have to choose, to be human at all† He says that not to succumb to these, would make one a hero or at least more than a common man. More did not aim to live up to being a hero, but he stood by his moral codes and did not succumb to such temptations. Throughout the play, attempts are made to corrupt More. Such attempts to corrupt morals and religious beliefs occur mainly because of the Kings desire to remarry. Henry married his brothers widow which was disallowed by the Catholic Church-however the Pope eventually gave dispensation for the marriage of Henry and Catherine to take place. Now Henry wants a divorce, to enable him to marry Anne Boleyn and to secure an heir. This creates a dilemma and the King wants the backing of More, which we see when Henry is speaking with More â€Å"Touching this matter of my divorce, Thomas; have you thought of it since we last talked† Up until this time the Catholic Church had predominated in society and nobody had questioned its authority. Martin Luther and John Calvin were two of the primary instigators, who started a movement against the Catholic Church, because they hated the Churches ‘sale of indulgences’. For his stand Martin Luther was excommunicated from the Catholic Church in 1521. He then set up his own Church, which, in 1529 was renamed, from Lutherans to Protestants, when they protested against attempts to limit their teachings. In this respect it suited Henry’s present needs to side with the reformation, to gain his divorce and thereby making himself head of the Church of England, enabling him to become his own authority. The only reason why the King needs Mores support in his divorce is because More is honest and people recognise this honesty and integrity: â€Å"Because you are honest, what’s more you’re known to be honest† Henry attempts to use the power of kingship to persuade More to agree with him, â€Å"I have no wife†¦and those that say she is my wife are not only liars†¦but traitors† The power he has means that if someone were to oppose him, he would simply dispose of them. Henry uses the word traitor because traitors are executed. All this fails to persuade More, his moral stand is too strong. He is trying to emphasise what a good king he is by showing what he is doing is for his country. â€Å"†¦And all the Popes back to St. Peter, shall not become between me and my duty† He is, on one hand, witty, pleasant and a man of elegant appearance, but he is also self-opinionated, brutal and corrupt. As he has little success persuading More with these tactics, he tries to convince More that the original marriage was sinful: â€Å"Thomas, Thomas, does a man need a Pope to tell him when he’s sinned. It was a sin, Thomas, I admit it, I repent†¦.† He further tries to convince More by reasoning that all the sons Catherine has borne have, have died and this has been his punishment. Henrys argument insinuates that God has punished him, and therefore the Pope was wrong for allowing the union. â€Å"†¦It was no marriage; she was my brothers widow. Leviticus: thou shalt no uncover the nakedness of thy brothers’ wife† Which uses Biblical text to provide further evidence that the Pope was wrong. More was a devout Catholic and believed the Pope to be a direct descendant of Peter, Christ’s disciple and therefore the Popes authority went without question â€Å"†¦The theory is that he is also the Vicar of God, the descendant of St. Peter, our only link with God† â€Å"†¦The King in Parliament cannot bestow the supremacy of the Church because it is a spiritual supremacy.† Although More may sympathise with the kings argument we understand from what he says his devotion to the Church and Catholicism. Henry tries to challenge Mores belief saying this is a ‘tenuous link’. More clarifies his position further â€Å"†¦Why it’s a theory yes, you can’t see it, can’t touch it†¦But what matters to me is not whether its true or not but that I believe it to be true†¦Ã¢â‚¬ , thus showing he cannot disobey Rome. More will not break his principals, although in the end he leads his family into poverty. Alice and Margaret want More to agree with the King and to forget his principles. Their reason for this is for their family safety. Alice tries to convince her husband to capitulate with the King â€Å"You can fit the cap to anyone you want† and accuses him of being ‘cruel’ to the household. More asks Alice to remove his chain: â€Å"Hell’s fire-God’s blood and body no!† â€Å"†¦Is this wisdom to betray your ability, abandon practice, forget your station and your duty to your kin and behave like a printed book!† Alice is scared of loosing her position and becoming a pauper and because of this she tries to corrupt More. More is only human and Alice only wants her husband to do what she feels is best for the family and the country therefore she will not remove the chain. More, though, is acting like ‘a printed book’ and he will not accept bribes or money from the Church. Margaret knows that Sir Thomas is going to resign anyway and to show her love and respect for her father, she removes the chain although she knows it will lead to her poverty. More feels it necessary to resign because it was his way of resisting severing the connection with Rome and Chapuys encourages Mores resignation saying he could not believe that More ‘will allow himself to be associated with the recent actions of King Henry’. More too, does not want to be associated with the corrupted King. Chapuys is not really interested in Mores moral stance; his concern is for the furtherance of Spain. (Catherine is Spanish and a divorce would sever Spanish interests in England). When he mentions that Northumberland and Yorkshire are ready to resist I deduce his intentions are political and not concerned with Mores moral integrity. When Chapuys tells More: ‘Beyond that point, Sir Thomas, one is not merely ‘compromised,’ one is in truth corrupted,† he is using verbal bribery to ensure his resignation. More will not go against his principals; he does not want to stand trial for treason. He is careful not to accept any bribes. Chapuys brings a letter from Charles 1st, which More refuses to accept as it could be seen as an allegiance with Spain. More feels that if he were to take money offered by the Bishops, the King would have more evidence against him. â€Å"If the King takes that matter any further, with me or the Church, it will be very bad, if I even appear to have been in the pay of the Church† Other characters also appear to corrupt, often in their attempts to please the King. Cromwell is a very corruptive character. He shows allegiance to the King – but only for his personal satisfaction: â€Å"Sir Thomas is going to be a slippery fish, Richard; we need a net with a fine mesh† Cromwell is being corruptive in trying to discredit More. Cromwell uses metaphors â€Å"Raising the storm† and â€Å"to come out of harbour† to accuse More of causing conflict in standing by his morals. The common man also refers to social movement as ‘canals’ and â€Å"Against the current of their times.† This movement is also shown with the River Thames used as a waterway that takes the characters along. This metaphor again is used by the Boatman to show how More is getting deeper into his position and the feud is getting heavy, ‘silt’, but More is trying to keep straight: â€Å"There’s a channel there getting deeper all the time† Cromwell is trying to set More up so that he can be more acquainted with the King. He accuses More for using God to â€Å"provide a noble motive for his frivolous self conceit.† Cromwell asks Rich to help, but Norfolk defends More because he has realised that Cromwell is only trying to corrupt him and his family, therefore Norfolk wants nothing to do with this. Norfolk consequently is not corrupt, he just does not have a strong moral code to abide by. Wolsey, however, tries to persuade More to support him in getting Henry’s marriage to Catherine annulled. Again More adheres to his moral code, taking care not to criticise the King or say anything that would put him in danger: â€Å"A dispensation was given so that the King might marry Queen Catherine, for states reasons. Now we are to ask the Pope to-dispense with his dispensation, also for sate reasons?† Wolsey’s corruption is not for his personal gain. Catherine has been unable to bear Henry a son, and Wolsey feels that for the sake of the Royal succession, Henry should remarry so that he may have an heir. â€Å"The King needs a son†¦let him die without an heir and we’ll have them back again† (referring to the War of the Roses). Wolsey feels that ‘certain measures perhaps regrettable, perhaps not-there is much in the Church that needs reformation Thomas-alright, regrettable! But necessary, to get us an heir!† therefore he justifies his corruption (if you can justify corruption) because it ultimately would benefit the country. More answers this: â€Å"When statesmen forsake their own private conscience for the sake of their own public duties†¦they lead their country by short route to chaos† More does not agree with Wolsey and even these reasons are unacceptable. Of all the character in the play, More is the only one who does not succumb to corruption. It would have been the easy option for More agree and comply with the King, but the strength of his religious and personal morals meant more to him. He was respected for these attributes and did not want to loose this. He also felt that ultimately God was his judge. This play is about political dalliance rather than fast moving action, â€Å"The interval started early in the year 1530 and it’s now the middle of May 1532.Two years.† It is about corruptive persuasion that More resists and ultimately leads to his execution. This is shown at the beginning of act 2: The political dalliance of the play is instigated by More not giving in to coercion, persuasion or even temptation. Ultimately, according to his own definition, More is a hero: â€Å"If we lived in a State where virtue was profitable, common sense would make us good, and greed would make us saintly. And we’d live like animals or angels in the happy land that needs no heroes.† He lived up to his rules and the rules of his religion, however unhappy he has made those around him. ‘Everyman has his price’ except More, or was it his life that was the price he had to pay?

Information about the KU Writing and Math Centers Essay

Thank you for your letter asking me about studying at Kaplan University. This is very nice place and students feel here very comfortable and confident as they have plenty of possibilities to learn as many new skills as they may want and have time for. To make life of its students a little simpler, the University has established two Centers, which offer a large variety of services. That is why I am writing to you to give all necessary information about the system of student assistance at Kaplan University. The University two Centers are always ready to provide the students with any relevant assistance. There is the Kaplan University Writing Center and the Kaplan University Math Center which are both very helpful during the study. For example, you are working on any writing task like research, survey or just essay you may find it useful to attend Writing Center. This Center purpose is to help students develop their writing skills and technique. The Center staff has developed particular guidance sections outlining basic steps of working on writing task. There are four sections for those who are looking for grammar help or advice on more advanced level of idea generation. The section with the APA writing style guidance is there to help students make their work have a decent scientific style and be free of plagiarism. All these guidance sections are in PDF file format and can be downloaded or printed as often as you need. Writing Center may also give a feedback to your written work. For that you will have to submit your paper by clicking a yellow notepad icon. Once your paper is reviewed, which usually takes about 2 days, you receive an e-mail message and may get the reviewed paper by downloading it from the submission page. In case you are toiling at some math problems and need somebody to give you essential hints or just want to train your knowledge University Math Center is there to help you. As well as Writing Center, Math Center provides with the wide range of information starting from elementary math operations to the complicated equations solving. You can get not only information on certain math problems but also train you solving skills and check your progress either in a particular area or on the whole module. There are specific mathematics modules dealing with particular math operations, so you can work on them one by one or choose any in which you prefer to improve you knowledge. It has to be pointed out that the Centers have the option of communication with a tutor. Thus, Writing Center has a live-chat option where you can meet your tutor and ask him/her any questions related to your written work. However, you won’t have to ask about spelling or grammar issues, while the purpose of such instruction session is to give you more essential help and make your writing skills more advanced and efficient so that you can use them in your further study. Such live sessions are available for 15 hours per week from Monday to Wednesday in the evenings (6 pm -11 pm ET). Math Center Tutor is available also in the evenings from 8 pm to 11 pm on the same days plus Thursday. Just same as writing instructors math tutor will not solve or check your problems or equations; he/she will try to make you comprehend modules concepts and acquire necessary solving skills. I must admit that both University Centers are extremely helpful for those who want to be a better student. The principle of their assistance service is not to do the work for you but to teach you essential techniques and fundamental skills, basing on which one can make progress in study and achieve successful results. Their aim is your clear understanding of the learning material and ability of self-sufficient work. Unfortunately, I have not been for a long time here, and I have not had a chance to use any of these centers yet. However, the time when I’ll have to write my research is approaching and I plan to visit Writing Center soon. What I hope to get there is the information of what are the effective ways of collecting information, thesis formulation, arguments development and other essential points to write an outstanding paper. I am sure center instructors will be of indispensable assistance to me as I am a freshman and I’d advice this service to all my mates. I hope you will find this information useful and in case you need more information, please feel free to contact me. Sincerely, Full Name (insert your full name here) Class and Section Number (insert your class and section number here)

Annotated Bibliography On Database Management Systems

The ability to store information has always been important for our survival. In the beginning, information used to be shared by word of mouth. Then, with the invention of writing, data slowly started to be stored in books kept in libraries, sorted in specific order that made them easily accessible. Finally, the invention of the computers led to the evolution of databases. Databases are important, because thanks to them humans are able to store and later on retrieve information. The way in which databases arise is very simple. It all begins as a list in a word-processing system. As the size of the list increases, the data starts to appear inconsistent. If this occurs, Database Management Systems come to help, due to the fact they can store a large amount of information in a number of tables linked to each other. Programs such as Access are able to add new data to a database or make changes to already existing data from the database; they are even able to delete information. These features assist people in analyzing and categorizing information in the following way: Tables lie in the core of any given database. Thanks to them, the possibility of redundancy is greatly reduced. A database can consist of a number of different tables which enables the researcher to break information down into smaller (and easier to analyse) pieces. Just like spread sheets, they consist of rows (also called records) and columns (fields). By using records, researchers are able to combineShow MoreRelatedAnnotated Bibliography On Database Management System1650 Words   |  7 PagesThere are many restrictions on the write and read operations in database management system. These restrictions show the measurable effect on the each and every transaction in the database management system and which are due to some specific operations. The transactions are not only read that data from database all the time but sometime some transaction need to delete the data items from database and create the data items into database. Such type of transactions show high impact on concurrenc y controlRead MoreAnnotated Bibliography On Database Management System Essay1014 Words   |  5 PagesPearson Cape Town Campus Introduction to Databases project Student Number: MB2014-0413 Teacher: Andrew Davies Due Date: 23/09/2016 Contents Page Page 1†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦..Cover Page Page 2†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Contents Page Page 3-5†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.Question 1 Page 6-12†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Optional Access Screenshots Page 13-18†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.Question 2 Page 19†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦References and Bibliography Question 1 1.1) Database Database is defined as a set of related data inRead MoreThe Concept Of Reference Management As Seen The Eyes Of Author Dianne Ridley1289 Words   |  6 Pagesthis study will be to discuss the concept of reference management as seen in the eyes of author Dianne Ridley. Micro finance and economics in rural areas Microfinance also known as microcredit is the provision of financial services to small businesses or groups of entrepreneurs in an effort to eradicate poverty. This is most common to developing or third world countries and is provided to people who don’t qualify for the formal banking system, in other words people without collateral, credit historyRead MoreA Research On Environmental Management And Conservation1637 Words   |  7 PagesThe following annotated bibliography covers a breath of topics under the major topic theme Environmental Management and Conservation. It was created as a starting point for building my knowledge of GIS tools used in environmental management and conservation for my concept map. The authors present an exploratory study using purposive testing among four different groups (scientist, non-scientist, agency manager and social scientist) included in the Coastal Landscape Analysis Modelling Study (CLAMS)Read MoreAnnotated Bibliography1329 Words   |  6 Pagesï » ¿ Annotated Bibliography Galen College of Nursing Annotated Bibliography Mayo Clinic (2011). Personal health record: A tool for managing your health. Retrieved from http://www.mayoclinic.com/health/personal-health-record/MY00665 This source talks about how electronic health records makes it easy to gather and manage medical information in a secure location (Mayo Clinic, 2001, pg. 1). They explain what a health record is and what goes into it. The advantages and disadvantages toRead MoreManaging Information Security Risks: The Octave Approach1635 Words   |  6 PagesAddison-Wesley Professional, 2008 (ISBN: 978-0321509178). In this book Allen et al discusses the risk management plans for IT managers. The book notes that there is no silver bullet for information security risks. The best practices are what should be used in handling the IT risks. Berber, M.; von Solms, R.; Overbeek, P. Formalizing Information Security Requirements. Information Management and Computer Security 9, 1 (2001): 32-37. In this paper, Berber et al discusses ways of formalizing informationRead MoreInformation Systems For Business Professionals1810 Words   |  8 PagesCOIT20274: Information Systems for Business Professionals (T3, 2015) Annotated Bibliography Assignment 1 Rahul Joshi S0280273 Due date 11 December 2015 Date Submitted 11 December 2015 Tutor Dr. Robert Wu Central Queensland University Sydney, Australia Introduction: This report is prepared for Ms Toni Carlos, an owner of small business called EIA (Education In Australia). The business was establishedRead MoreUnderstanding Nursing Practices: An Assignment1480 Words   |  6 PagesA: Von Bertalaniffy. (1969). General System Theory: Foundations, Development, Applications (Revised Edition). George Braziller Inc. 0807604534. Everett M. Rogers: (1997). Diffusion of Innovations Theory. HYPERLINK http://www.tcw.utwente.nl/theorieenoverzicht/Theory clusters/Communication and Information http://www.tcw.utwente.nl/theorieenoverzicht/Theory clusters/Communication and Information Technology B: Drack, Manfred. (2007). On the Making of a System Theory of Life: Paul A Weiss and LudwigRead MoreA New Event Planner Entrepreneur, And New Computer Technology Essay1231 Words   |  5 Pagesinformation in an annotated bibliography. As a new event planner entrepreneur, I conducted research on what’s trending in the event planning industry and my top trends were creativity, event-driven marketing (EDM), and new computer technology. An extension of the project required an archive-based qualitative approach to one of the trends. I chose to conduct research on EDM based on the following factors: 1) EDM presented a distinct approach to direct marketing and traditional database marketing whichRead MoreImpact of Ict on Society2585 Words   |  11 PagesSISAT School of Information Systems Technology Faculty of Informatics ISIT900 Fundamentals of Contemporary Technologies Impact of ICT on Society Table of Contents PART A 1 1. Introduction 1 2. The annotations 1 2.1 Scholarly journal articles 1 2.2 Conference papers 1 2.3 Newspaper articles 1 2.4 Internet sources 1 3. Conclusion 2 Annotated Bibliographies 3 PART B (Endnote) 6 4. Introduction 6 5. The Endnote advantages 6 6. The Endnote disadvantages 7 7. The Recommendations 8