Interventions For Substance Abuse Amongst Young People

INTRODUCTION Despite the fact that young people are most often the healthiest group of people in the population (Emmelkamp, and Vedel, 2006), there is concern about the extent to which this group engages in risk-taking behaviours, including the consumption of drugs and alcohol and the abuse of these substances. Such activities expose them to problems ranging from the individual health level to the costs incurred during rehabilitation (Berglund, Thelander & Jonsson, 2003). Rehabilitation needs often include mental health and psychiatric solutions due to the mental health and social problems caused by drinking and the consumption of illegal drugs. In the UK, the use of psychoactive substances has become a major activity among the youth population. For example, it has been shown that 50% of young people in the age bracket 16-24 years have used an illicit drug on at least one occasion in their lives. This project also exposed that the most commonly used drug is cannabis which is used by 40% of youths aged 16-19 years and a shocking 47% of 20-24 year olds. Amphetamine then follows which is used by 18-14% of the above age groups. Between 2011 and 2012, 20,688 young people accessed substance misuse services, with the majority of this number accessing services for abuse of cannabis (64%) or alcohol (29%) (National Drug Treatment Monitoring System, 2012). Over half of the users were aged 16 to 18 (53%), whilst the rest were aged under 16 (National Drug Treatment Monitoring System, 2012). About two thirds (64%) of the young people who accessed specialist substance misuse services in 2010-11 were male. Overall, females accessing subst ance misuse services for young people are younger with 19% of males aged under 15 years compared to 27% of females. Almost half of the young people entering specialist substance misuse services are recorded as being in mainstream education, such as schools and further education colleges, followed by a further 19% in alternative education, such as schooling delivered in a pupil referral unit or home setting. A further 19% are recorded as not in education or employment. However, it should be noted that education and employment status was reported for only new young people entering specialist services during the year. Therefore, the total will be lower than that of all young people (National Drug Treatment Monitoring System, 2012). Referrals to drug and alcohol treatment services commonly come from youth offending teams, although around 14% of referrals come from mainstream education institutions and 7% are made up of self-referrals. Perhaps surprisingly referrals from the Child and Adolescent Mental Health service (CAHMS) make up only 3% of referrals (National Drug Treatment Monitoring System, 2012). These figures paint a perhaps surprising picture. For example, more young people are referred to specialist drug and alcohol services from mainstream education than specialist educational centres, suggesting that substance abuse could be far rifer amongst young people as might be expected. It could be argued that failure of school authorities to take a more effective preventative approach to drug and alcohol abuse may be contributing to the overall problem. These figures also suggest that immediate attention and intervention must be offered to young people to reduce negative outcomes associated with such high drug use. The statistics reveal that there is a high rate of drug and substance abuse among young people in the UK. The high of level concern about the use of illicit drugs and substances has an effect on health, educational and political discussions in the UK. The government’s national strategy for ten years on drug misuse views young people as a critical priority group in need of quick prevention and treatment intervention (Keegan and Moss, 2008) and recognises the need to improve our understanding of the role played by illicit drugs and substances in the lives of such young people. Educators, health practitioners and policy makers should have comprehensive understanding when it comes to discussions involving the abuse of illicit drugs. For example, the Government must take into account factors such as a lack of understanding amongst young people as to the laws that govern different classes of illegal drugs. Abuse of alcohol and other drugs leads to the destruction of cognitive and emotional development in young people and exposes them to an increased possibility of accidental injury or even death. Finally, there is also a risk of users becoming drug dependent. Abuse of drugs and alcohol by young people can also lead to such negative consequences as coronary heart diseases, lung cancer, AIDS, violent crime, child abuse and unemployment (Gurnack, Atkinson & Osgood, 2002). As a result, individuals indulging in the use of alcohol and other drugs incur tremendous costs in their individual lives, their family lives and even their future careers. Society is also not exempt as it pays a price in different ways. For instance, society incurs extra costs in health care, drug and alcohol treatment, law enforcement and supporting the seriously affected families who have been rendered helpless by the situation. There are many reasons why young people become involved in substance abuse. From a sociology perspective it has been argued that the recreational abuse of drugs has become ‘normalised’ (Parker, Measham and Aldridge, 1995) among certain groups of young people. However, Shiner and Newburn (1997) have argued that this theory is reductionist and simplifies the reasons behind a young person’s choice to abuse drugs. In reality, the reasons as to why a young person may begin to abuse drugs can range from having poor adult role models who may also use drugs and alcohol as a way of coping or even a genetic predisposition toward poor self-regulatory behaviours (Spooner and Hall, 2002). Evidence shows that adolescent alcohol and drug abuse is not influenced by a single factor but a large number of factors which are not necessarily confined to any single part of the an adolescent’s world (Connors, Donovan & DiClemente, 2001). Environment The environment in which a person lives is very instrumental when it comes to the kind of life that people lead, especially young people. If the environment is for example characterized by pronounced unemployment then young people in such an environment will indulge in activities that make them forget even for a moment the realities of the unemployment situation. If, for example, in their immediate environment young people face the situation of a large supply of drugs and everyone around them is abusing drugs or alcohol, then it is easy for such young people to adopt this kind of lifestyle and become drink or drug abusers. The above explanation shows that the kind of environment a young person stays in has a very direct influence on the habits that are finally adopted by this group of young people. Curiosity Young people naturally have the tendency to try new things and to find out how it feels doing something new. Young people in the United Kingdom are not an exception and most of them usually try drinking and drugs just to explore and find out what the experience is like. This however results in the young people becoming victims of the consequences that follow (Woo and Keatinge, 2008). The Defence Mechanism A good number of young people use drugs specifically to assist them in easing trauma that may result from unsatisfactory relationships and also physical or emotional abuse that may arise from families or homes that lack happiness. Promotion and Availability There is always a great amount of pressure from advertisement of alcohol over the media. The colourful nature of these promotions is often very enticing and mostly misleading. In the promotions or commercials, alcohol is glamorised hence the young people are influenced to indulge and as a result end up facing the dire consequences. This review will analyse the different interventions utilised when working with young people who abuse drugs and alcohol. These include those carried out by mental health workers, religion-orientated interventions, community based interventions and more psychiatric, medication based interventions. Motivational based interventions are also discussed. Aims and Objectives The aim of this project will be to review and critically evaluate the literature regarding different interventions for young people who abuse drugs and alcohol in the UK. To achieve this aim the project has set the following objectives: To critically examine the interventions for young people (aged 16 to 21) who use drugs and alcohol in UK, with the aim of providing recommendations to improve the care given to the youths who are addicted or at risk of substance abuse. To use secondary data to identify the importance of different interventions in dealing with young people (age 16 to 21) who use drugs and alcohol in the UK. Rationale Interventions for young people aged 16 to 21 who use drugs and alcohol has elicited varied opinions from professionals involved in their care. This has been a result of the often complex and varied needs of young people with substance abuse issues, such as mental health issues (Weaver et al., 2003), social exclusion (Fakhoury and Priebe, 2006) and involvement with the criminal justice system (Hamdi and Knight, 2012; Lundholm et al., 2013). Therefore, there is often disagreement on where the intervention should focus primarily. Various strategies have been advanced to address the involvement of young adults in drugs and substance abuse. For example, medication by mental health nurses in cases of addiction (Bennett and Holloway, 2005). However, due to the variety of interventions available for treating young people with substance abuse disorder, it is important to continuously review the literature in this area and pin point the most effective interventions for treating this group of individuals. [Client must write some words here on why they have chosen this topic (this is essential according to the assignment brief).] SEARCH STRATEGY In preparation for this critical literature review, a number of sources including journals, articles and health text books were used. The search was conducted using computerised databases which enabled access to literature on interventions for young people who abuse drugs and alcohol. Examples of such databases are given below: The Department of Health NHS Evidence (National Institute for Health and Clinical Excellence, 2012). PsycINFO (American Psychological Association, 2013). PubMed (National Center for Biotechnology Information, 2013). Google Scholar (Google, 2013). net (EMAP Publishing, 2013). Nursing and Midwifery Council publications (Nursing and Midwifery Council, 2010). Royal College of Psychiatrists useful resources (Royal College of Psychiatrists, 2013). Royal College of Nursing library services (Royal College of Nursing, 2013). These databases contained numerous useful sources such as journal articles, recommendations, guidelines and reviews that were used to gather evidence relevant to interventions for young people who abuse drugs and alcohol. Search terms used included; ‘drugs and substance abuse’, ‘alcohol abuse’, ‘effects of alcohol abuse’, and ‘intervention measures for drugs and substance abuse[1]’. It was not uncommon for a search to produce many results. Therefore, for any search that produced more than 50 results, the first 50 results were observed to pick out the most relevant and interesting studies. The remaining results were not looked at because of time constraints[2]. In addition to searching for relevant sources through online databases, reference lists within articles were also utilised to search for other relevant sources. Inclusion Criteria For an effective review of the subject area, there was a need to select relevant articles to achieve the set objectives. Therefore, only sources relevant to intervention for young people who abuse drugs and alcohol, papers published in the English language and papers published after the year 1999 were selected. Although sources pertaining to studies carried out in the USA were still considered relevant, a priority was given to sources from the UK. If a source had used an adult sample but was still considered relevant and useful then it was considered for inclusion. Exclusion Criteria General papers on drugs and substance abuse not specific to youths, papers published in languages other than English and published before the year 1999 were not included. An example search strategy when using one of these sources, the British Nursing Index, is given below. Search Strategy Example: British Nursing Index (BNI). Through citing the term ‘intervention for young people who abuse drugs and alcohol’, 5,000 articles were gathered without limiters. Limiters such as ‘role of mental health nurses’ and ‘only book and journals concerned with drugs and substance abuse’ were applied to the second search, which reduced the output to 2,034 books and journals. In the third search, additional limiters such as year of publication (2000-2012) were applied, which then reduced the number of books and journals to 734. After all further limiters were applied, such as articles that only used an age group of 16 to 21 years as participants, 70 journals and books were chosen for further analysis. Only 23 articles were considered relevant for this review and analysis due to their in depth exploration of the subject and their meeting of inclusion and exclusion criteria. LITERATURE REVIEW Interventions for substance abuse serve a number of purposes including reducing use of illicit or non-prescribed drugs and curbing problems related to drug misuse, including health, social, psychological and legal problems and last but not least tackling the dangers associated with drug misuse, including the risks of HIV, hepatitis B and C and other blood-borne infections and the risks of drug-related death. Prevention and intervention are usually categorised into primary (direct prevention), secondary (early identification of the problem and subsequent treatment) and tertiary levels (late identification and treatment). Furthermore, interventions are now often categorised into population wide interventions, selective interventions aimed at only high risk groups and early interventions for at-risk groups (Cuijpers, 2003). The nature of interventions has also evolved over the years. Twenty to thirty years ago the emphasis was on providing young people with information and buffering moral values whereas in the more modern era, a social dimension has been added and young people are taught resistance skills to avoid peer pressure (Gilvarry, 2000). Alcohol related deaths are rife in the UK, with 8,748 alcohol related deaths in the UK in 2011 (Office for National Statistics, 2013). However, there were 1,883 noted drug related deaths in 2010, a decrease of 299 from 2009 (Ghodse et al. 2012). These statistics reflect the importance of interventions for drug abusers, which could be protecting some individuals from the most extreme consequence of substance abuse. Mental Health Interventions Research has evidenced that Major Depressive Disorder (American Psychiatric Association, 1994) is often co-morbid in young people who abuse drugs and alcohol (Sutcliffe et al., 2009; Marshall and Werb, 2010; Marmorstein, Iacono and Malone, 2010). Due to the potentially devastating effects of depression at both the individual (Galaif et al., 2011; Petrie and Brook, 2011) and societal level (Sobocki et al., 2006), substance abuse is viewed as something that must be dealt with swiftly and effectively. This co-morbidity of mental illness and substance abuse means that mental health nurses are often involved in interventions with young people. Mental illness is a psychological anomaly that is generally associated with distress or disability that is usually not considered to be a component of an individual’s normal development (Nursing and Midwifery Council, 2008). Despite the fact that standard guideline criteria are used all over the world to define mental illness, diagnosis and i ntervention is often incredibly complex, especially when substance abuse is also a factor. Community services are offered to people with such problems through assessment by different psychiatrists and clinical psychologists, or sometimes social workers. All these professionals use methods of observation and inquiries through asking questions to help establish any given patient’s condition. Mental health nurses are often at the front line in providing care and support in both hospitals and the community. In the United Kingdom, mental health nurses play a great role in taking care of young people with mental disorders and mental illnesses that may have developed as a result of substance abuse (Department of Health, 2012). They offer counselling services in order to help people focus on their goals or outcomes; help people develop strategies that support self-care and enable individuals and their families to take responsibility for and participate in decisions about their health. They provide a range of services including education, research and knowledge sharing and e vidence informed practices. They also perform the role of addiction counsellors in order to provide intake co-ordination, assessment, treatment and follow-up care for youths with addictions, mental illness and mental health problems using common assessment tools. They can provide health promotion, prevention and early detection of problematic substance use; use core competencies and knowledge in addictions and a full range of withdrawal management services including detoxification services using best practice treatment protocols, outreach, prescribing, counselling, and harm reduction However, mental health nurses are often faced with challenges that hinder them from successfully achieving their goals. Challenges include non co-operation of the patients’ families and also the complex nature of patient problems (Nursing and Midwifery Council, 2008). In a comprehensive review, RachBeisel, Scott and Dixon (1999) found that there was a much higher prevalence of substance abuse amongst individuals with mental illness and that the course of mental illness was significantly negatively influenced by the abuse of illegal substances. These findings highlight a key issue in mental health interventions for young people who abuse substances, namely that it is important to determine the relationship between the substance abuse and mental illness before allocating a suitable intervention. For example, if a young person has developed a mental illness as a result of abusing substances, a mental health focused intervention may not be appropriate as it would not be treating the root of the problem or the reason why the young person started to use illegal substances in the first place. Psychiatric and Medical Interventions Psychiatric and medical based interventions refer to the treatment of substance abuse in a young person by a psychiatrist who is medically trained and able to provide an additional dimension of treatment than a psychologist or mental health worker is able to. An example of this is the prescription of methadone, a synthetic opiate that is used to help young people withdraw safely from heroin use. The National Institute for Health and Clinical Excellence (2007) recommend a psycho-social approach when treating individuals with substance abuse disorder and advocate the use of medication. However, use of medication with young people who are suffering from substance abuse disorders should be used with care due to the risk of dangerous side effects (Webster, 2005). Motivational Interventions Motivational interventions are brief interventions used by professionals to enhance a young person’s motivation to change and stop abusing substances (Tevyaw and Monti, 2004). In a review of the effectiveness of motivational interviewing (Smedslund et al., 2011) it was found that although motivational interviewing techniques were more effective at reducing the extent of future substance abuse when compared to no intervention, the technique was no more effective when compared to other types of intervention. For example, motivational interviewing was no better at reducing extent of substance abuse that simply assessing a patient and providing feedback. The authors reviewed 59 studies that had been accessed from a range of online databases. This is a reasonable number of studies as the body of literature on motivational interviewing as an intervention for substance abuse is quite limited. However, the authors failed to collect evidence on other measures of efficacy such as a redu ction in future criminal prosecution for drug offences or improvement in overall quality of life. The efficacy of motivational interviewing has been studied in young people in particular by McCambridge and Strang (2003). 200 young people from inner city London were randomly allocated to either a motivational interviewing condition or a non-intervention education control condition. All participants were aged between 16 and 20 and were using illegal drugs at the time of the study. The motivational interviewing intervention consisted of a brief, one hour face-to-face interview and self-reported changes in the use of cigarettes, cannabis, alcohol and other drugs was used as the outcome measure both immediately after the interview and at a three month follow up point. It was found that in comparison to the control group, young people who received motivational interviewing as a brief intervention reduced their use of cigarettes, alcohol and cannabis. Although these results initially seem in favour of motivational interviewing as an intervention for young people who have substance abuse issues, it should be noted that self-report measures are very open to bias and it is possible that the reported reduced use of drugs and alcohol was much higher than the actual reduction in use. This was reflected in a follow up study by the same authors 12 months later (McCambridge and Strang, 2005) where it was found that the difference in reduction in substance use between the experimental and control groups found after three months had completely disappeared. This result suggests that although motivational interviewing may be an effective short term intervention for treating young people with substance abuse issues, it has no enduring effectiveness over a long period of time. This may be due to a lack of follow-up support for young people and the brief nature of the intervention. Community-Based Interventions Community drug and alcohol services offer interventions such as comprehensive assessment and recovery care planning, support and care co-ordination, advice and information, stabilisation, counselling and relapse prevention and motivational interviewing (Nursing and Midwifery Council, 2008). Hepatitis B vaccinations, Hepatitis C testing and referral to treatment for these diseases, are also essential due to the risk of infections through needle sharing. Like most interventions, these community services are aimed at promoting recovery from addiction and enabling the achievement of individual goals, helping individuals to remain healthy, until, with appropriate support, they can achieve a drug-free life. This may involve stabilising service users on prescribed substitute medication to improve withdrawal symptoms and to reduce cravings. In their review of community-based interventions, Jones et al. (2006) found a limit on the effectiveness of such interventions, especially when it came to long term and enduring effect for reducing substance abuse. The results suggested that a change in community-based interventions was needed. Morgenstern et al. (2001) found a very high level of satisfaction among community based substance abuse counsellors who had received training in delivering cognitive behavioural therapy (CBT) to clients. This suggests that perhaps one way of increasing the effectiveness of community-based interventions would be to equip community-based workers with a wider range of skills with which they can help young people suffering from substance abuse. Supporting this recommendation was a study by Waldron and Kaminer (2004) who found that use of CBT was associated with clinically significant reductions in substance abuse amongst adolescents. Religious Interventions Some interventions are religious in nature. For instance, the United Methodist Church follows a holistic approach which stresses prevention, involvement, treatment, community organization, and advocacy of abstinence. The church could be argued to have a progressive role by offering a spiritual perception on the issue of substance abuse. Another popular religious based approach to tacking alcohol abuse in particular is the 12-step program offered by Alcoholics Anonymous. Individuals are commonly encouraged or possibly even required cut any acquaintances with friends who still use alcohol. The 12-step programme motivates addicts to stop consuming alcohol or other drugs and also it helps to scrutinize and modify the habits related to their cause of addiction. Numerous programs accentuate that recovery is a long-lasting process with no culmination. For drugs which are legal such as alcohol, complete abstinence is recommended rather than attempts at moderation which may cause relapses. Fi orentine and Hillhouse (2000) found that participants in a 12-step program stayed in future treatment for a much longer period of time and were much more likely to be able to complete a 24-week intervention programme. It was also found that a combination of a 12-step program and an alternative substance abuse intervention was more effective than either treatment alone. This suggests that providing young people with interventions in isolation may not be the most effective way of helping them overcome their substance abuse. However, literature on religious based interventions tends to focus on adults and although still applicable to the treatment of young people in many ways, young people may be put off by the religious nature of these 12-step programmes and may be intimidated by the group nature of the treatment. In support of this criticism, Engle and MacGowan (2009) found that only two out of 13 adolescent group treatments of substance abuse could be categorised as showing potentia l efficacy in treating young people with these problems. Family-Oriented Interventions It has been argued that the family has a central role in both increasing and reducing the risk of problem behaviours in young people such as substance abuse (Vimpani and Spooner, 2003). A review by Velleman, Templeton and Copello (2005) echoed this view that the family can have both a positive or negative impact on a young person’s risk of substance abuse. Kumpfer, Alvarado and Whiteside (2003) have identified that support for families based within the home, family education and skills training, improving parental behaviour and time-limited family therapy are all highly effective forms of family-based interventions for young people with substance abuse issues. However, as research has shown that the family can also play a role in increasing risk of substance abuse, professionals must be confident that family therapy is suitable and not run the risk of worsening a young person’s relationship with their family and in turn worsening their substance abuse. School-Based Interventions Education about the use of drugs and alcohol within schools has been advocated as a preventative intervention for young people at risk of substance abuse disorder. Fletcher, Bonell and Hargreaves (2008) found that interventions focused around encouraging a positive school environment and improving young peoples’ relationships was associated with a reduction in risky substance abuse. However, part of this conclusion was based on the review of observational studies, which are open to bias and subjectivity. CONCLUSIONS AND FUTURE RECOMMENDATIONS This essay has reviewed a number of sources regarding the efficacy and suitability of certain interventions for young people with substance abuse issues. A key limitation of much of the literature is the tendency to put emphasis on drugs as a generic material with very little distinction is made between different types of illicit substances. With the very varied effects of different drugs on the user, it could be argued that the specific reasons for a young person’s drug usage will have an impact on the effects that a drug has. For example, stimulant drugs will most likely be used for nervous system arousal, while other drugs such as alcohol and cannabis are sedatives and cause nervous system depression. These kinds of drugs can be termed as instrumental drugs since the reasons behind their usage correspond to the effect of the different kind of drug that is used (Brick, 2008). Therefore, it might be useful for professionals to base their interventions on the types of substanc e abused. From the above literature review it is evident that there is need for mental healthcare especially to help young people who are adversely affected by the use of drugs and other substance abuse. Some youths suffer from psychiatric disorders as a result of indulgence in drugs and substance abuse. Others experience mental problems that need serious rehabilitation measures taken in order to counter such problems hence emphasis should be laid on the care that is to be given to the young people affected by any of the above problems caused by the abuse of drugs and other substances. Therefore, mental health interventions remain an important intervention for young people. A number of recommended adjustments in healthcare to cater for young people struggling with abuse have been identified. For example, there should be an increased application of various musical strategies in helping patients suffering from various mental health conditions as a result of substance abuse (Connors, Donovan & DiClemente, 2001), as this kind of intervention appears to be lacking in use with young people. Another main limitation in research that aims to measure the effectiveness of intervention measures is the lack of control that researchers have. It would be considered unethical if young people with drug abuse problems were randomly allocated to intervention procedures, especially if one was chosen as a control condition and was not believed to be effective in treating substance abuse issues. This means that it can be difficult to compare intervention methods. Another limitation lies in the types of measure researchers’ use to measure effectiveness of intervention methods. For example, a self-report measure may be used to assess whether young people have either stopped or at least reduced their intake of illicit substances. This type of questionnaire may also be used to see if the young people are seeing a positive result from receiving an intervention. However, self-report measures are open to social desirability bias meaning that many young people may fabricate their answer s in order to either please the professionals who are involved with helping them or to conceal ongoing substance abuse. The review has also emphasized the causes or triggers of alcohol and drug abuse among young people in the United Kingdom showing that the environment a young person stays in is one of the greatest factors that lead to indulgence in alcohol, drug and substance abuse. Other factors like enjoyment, peer pressure, promotions in the media and rebellion are also causes of alcohol, drug and substance abuse among the youth in the United Kingdom (Gurnack, Atkinson and Osgood, 2002). More focus on these root causes could help improve prevention and reduce the need for later intervention, which has a poor track record of success. Finally, there is need according to the literature review to improve media perception of mental health patients in order to help alleviate the conditions of psychiatric disorders that are caused by the indulgence of young people in alcohol, drug and substance abuse (Berglund and Thelander, 2003). This doesn’t indicate failure in the mental nursing services but it just implies that mental health workers and psychiatrists need reinforcement in order to positively contribute to successful intervention (Califano, 2007). This suggestion is based on the need for a more holistic approach when it comes to treating young people with substance abuse issues, where the effect on all areas of their life including their mental health must be taken into account during intervention. Strengths of this Critical Literature Review Secondary data was reviewed in this project, which provided larger scope on choices of information for the project. In addition this review was able to identify key areas for improvement of health condition interventions for youths affected by substance abuse. Limitations of this Critical Literature Review This literature review was small in scale, since word and time limits were set. Although 23 articles were selected for review, this number could have been improved. 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(1997) Definitely, maybe notThe normalisation of recreational drug use amongst young people. Sociology, 31(3), pp. 511-529. Smedslund, G., Berg, R.C., Hammerstrom, K.T., Steiro, A., Leiknes, K.A., Dahl, H.M. and Karlsen, K. (2011) Motivational interviewing for substance abuse. Cochrane Database for Systematic Reviews, Issue 5. Sobocki, P., Jonsson, B., Angst, J. and Rehnberg, C. (2006) Cost of depression in Europe. The Journal of Mental Health Policy and Economics, 9(2), pp. 87. Spooner, C. and Hall, W. (2002) Preventing drug misuse by young people: we need to do more than ‘just say no.’ Addiction, 97(5), 478-481. Sutcliffe, C.G., German, D., Sirirojn, B., Latkin, C., Aramrattana, A., Sherman, S.G. and Celentano, D. (2009) Patterns of methamphetamine use and symptoms of depression among young adults in Northern Thailand. Drug and Alcohol Dependence, 101(3), pp. 146-151. Tevyaw, T.O. and Monti, P.M. (2004) Motivational enhancement and other brief interventions for adolescent substance abuse: foundations, applications and evaluations. Addiction, 99, pp. 63-75. Velleman, R.D.B., Templeton, L.J. and Copello, A.G. (2005) The role of the family in preventing and intervening with substance use and misuse: a comprehensive review of family interventions, with a focus on young people. Drug and Alcohol Review, 24, pp. 93-109. Vimpani, G. and Spooner, C. (2003) Minimising substance misuse by strategies to strengthen families. Drug and Alcohol Review, 22, pp. 251-254. Waldron, H.B. and Kaminer, Y. (2004) On the learning curve: The emerging evidence supporting cognitive-behavioural therapies for adolescent substance abuse. Addiction, 99, pp. 93-105. Weaver, T., Madden, P., Charles, V., Stimson, G., Renton, A., Tyrer, P., Barnes, T., Bench, C., Middleton, H., Wright, N., Paterson, S., Shanahan, W., Seivewright, N. and Ford, C. 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APPENDICES Appendix A Search Term: â€Å"Drugs and substance abuse.† SourceNumber of Relevant Hits Department of Health0 NHS Evidence5597 PsychINFO22 PubMed2337 Google Scholar1,070,000 Nursing.net4435 Nursing and Midwifery Council59 Royal College of Psychiatrists477 Royal College of Nursing library services1,753 Search Term: â€Å"Alcohol Abuse.† SourceNumber of Relevant Hits Department of Health0 NHS Evidence6893 PsychINFO92 PubMed87,995 Google Scholar1,480,000 Nursing.net1760 Nursing and Midwifery Council138 Royal College of Psychiatrists629 Royal College of Nursing library services1,654 Search Term: â€Å"Effects of alcohol abuse.† SourceNumber of Relevant Hits Department of Health0 NHS Evidence5476 PsychINFO31 PubMed21,363 Google Scholar1,430,000 Nursing.net8502 Nursing and Midwifery Council40 Royal College of Psychiatrists531 Royal College of Nursing library services2,590 Search term: â€Å"Intervention measures for drugs and substance abuse.† SourceNumber of Relevant Hits Department of Health0 NHS Evidence3169 PsychINFO3 PubMed215 Google Scholar174,000 Nursing.net7672 Nursing and Midwifery Council23 Royal College of Psychiatrists302 Royal College of Nursing library services3,250 Appendix B TitleFirst AuthorPublication Year 1Drug treatment and twelve-step program participation: the additive effects of integrated recovery activities.Fiorentine2000 2A critical review of adolescent substance abuse group treatments.Engle2009 3Co-occuring severe mental illness and substance use disorders: A review of recent research.RachBeisel1999 4Statistics for young people in specialist drug and alcohol services in England 2011-12National Drug Treatment Monitoring System2012 5Substance abuse in young people.Gilvarry2000 6The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomised trial.McCambridge2004 7The role of the family in preventing and interviewing with substance use and misuse: a comprehensive review of family intervention, with a focus on young people.Velleman2005 8School effects on young people’s drug use: a systematic review of interv ention and observational studies.Fletcher2008 9A review of community-based interventions to reduce substance misuse among vulnerable and disadvantaged young people.Jones2006 10Motivational enhancement and other brief interventions for adolescent substance abuse: foundations, applications and evaluations.Tevyaw2004 11Motivational interviewing for substance abuse.Smedslund2011 12On the learning curve: the emerging evidence supporting cognitive-behavioural therapies for adolescent substance abuse.Waldron2004 13Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: within treatment and posttreatment findings.Morgenstern2001 14Family-based interventions for substance use and misuse prevention.Kumpfer2003 15Deterioration over time in effect of Motivational Interviewing in reducing drug consumption and related risk among young people.McCambridge2005 16Drug misuse: psychosocial interventions: full guideline.National Institute for Health and C linical Excellence2007 17Substance abuse treatment and the stages of change: Selecting and planning interventions.Connors2001

Economic impact of genetically modified foods Essay

Genetic engineering has resulted to the production of genetically modified foods. It entails altering the genetic make up of plants using a set of technologies. Genes are combined from different organisms through recombinant DNA technology. Genetic engineering results to enhanced food tastes and quality. It reduces the time for maturation and can be used to increase nutrients and yields of crops. Again the crops produced are stress tolerant and they are resistant to disease and pests and herbicides. Genes are taken from one species and inserted into another to produce quality products. Genetically modified foods were first established in the 1990s with most products being Soya, cottonseed and wheat. The process could involve taking DNA from favorable organisms and inserting in a plant or crop. Biotechnology can be used to solve difficult crop production challenges where the farmers using it do not have to worry about the quality of their products. The technique is environmentally friendly and hence poses no threat to the surrounding. It does not involve emission of pollutants to the atmosphere. Farmers using biotechnology in their crop production increase their incomes and acquire economic, environmental and social benefits. (Giannakas K & Yiannanaka, 90) Although some people fear consuming genetically modified crops extensive research has been done on them to ensure that they pose no health risk to consumers. They are similar to those produced using traditional methods of breeding. Prominent scientists have also cleared the concerns that GM would be a risk to the environment. To them GM is a safe way of improving agriculture. International organizations also support this viewpoint for instance Food and Agriculture Organization (F. A. O) of the United Nations and the European Commission. Therefore people should not fear consuming GM foods as they are safe. Land is a fixed resource which can only be modified by increasing its utility. Measures ought to be taken to ensure that idle land is put to effective use. However care should be taken to ensure that harmful effects do not occur to the environment. For instance cutting trees to plant GM crops would have negative effects on the climate. Trees control the levels of carbon dioxide and consequently global warming. Population on the other hand grows at higher rates and concerns that food shortages would arise, led to the introduction of biotechnology. Through genetic modification of crops the problems of land shortages or water resources can be well contained. Smaller areas of land can be used to produce large outputs. Genetically modified foods can help farmers produce more food products which is healthy and with fewer resources. Continued research by bio-technicians is done to ensure production meets the consumer’s specific demands. It can establish plants that are drought resistant and hence can survive hostile conditions. Genetically Modified crops can increase the incomes of countries tremendously. Developing countries can adopt GM technology as it will increase the GDP Gross Domestic Product. This income can be used to improve the infrastructure facilities in the less developed countries and this would see them embrace economic growth and development. Investment in improving the transportation network would improve the basis for other industries which can now easily transport their raw materials and finished goods to appropriate destinations. (Carpenter J & Gianessi L, 67) Trade will be promoted by using GM products. Most developing countries do not have a diversified economy and they over rely on agriculture. Agriculture is a critical industry which is affected by climatic changes, pesticides and other factors like invasion by animals. With Genetic Modification one is guaranteed of quality products. Developing countries use their agricultural products to earn foreign exchange through external trading processes like exports. Problems faced by farmers are rejection of their products by foreign consumers on the basis of poor quality. GM products are enhanced to ensure that they are of high quality and consequently will not be rejected. GM products require less use of pesticides as they are not very prone to such use. This further reduces the cost of production on farmers who will not have to buy pesticides. A reduction of costs is an economic gain to farmers. Such costs would reduce the profits that farmers could have got. Extensive use of Genetically Modified soyabeans increases their contribution to reduce pesticide application. Farmers can decrease the need for tillage which can cause reduction in soil erosion and thus reduce the water treatment costs that consumers incur annually. (Giannakas K & Yiannanaka, 85) GM crop production has led to the growth of the food industry to very high levels. The demand can be categorized into consumer levels, retailing level and food processors. Using Genetically Modified products is a safe way of enhancing people’s way of life substantially by improving their health care and their environment. It supplements the traditional cross breeding methods and hence is not a new venture. It is just a modification. Poverty in developing countries can be eliminated with the use of GM. Since most of Less Developed countries have not embraced technological advancement in the agricultural industry they rely on natural processes in their production. Natural processes pose a great threat as fluctuations are bound to occur affecting the quality and quantity of products produced. GM would see such farmers at better positions to handle the impact of natural calamities of crop production in terms of quantity and quality. Hunger would be a thing of the past if GM was completely embraced. With increased crop yields the poverty levels of people in developing countries would be eliminated. They would trade the surplus both internally and externally to earn incomes which they can use to raise their living standards. With abundant food production health related problems can be solved and this further reduces the costs that would have been incurred seeking health facilities. Use of GM would ensure that there is a sustainable agricultural system. Its use in cotton production for instance in India where the greatest challenge to cotton production is insect and pest invasion can be beneficial. Implementation of GM cotton production increased the production rates to unprecedented rates. The prior losses caused by reduced quantity due to insects and pests became a thing of the past. The GM product is more resistant to the pest and can cause a reduction of pesticides by higher levels while increasing the yields to approximately 80%. This translates to savings on insecticides. Other factors held constant of prices of GM cotton were relatively the same with those of non GM then there would be increased revenues earned. Sustainable agriculture is the key to food security. Population levels are projected to the distribution of resources among nations affect the way the market forces operate. Unequal distribution of resources precipitates variations of needs between the rich and the poor. Since the poor lack resources to advance in technology so that they can shift from agricultural production to industry. Adoption of the genetically modified crops would increase the production of crop yields. Food shortages in the developing countries affect the developed countries who feel the responsibility of assisting them through donations. Bio-technological aspects are driven by the need to solve issues that are critical in the society. Development of a GM rice project would work to help reduce the rates of blindness caused by deficiencies in vitamin A. Again crops that provide other important nutrients like iron can be GM controlled. Provision of foods with effective nutrients can help improve the health standards of people. With a decrease in the demand for pesticides the firms that produce them would face stiff competition which would see their prices reduced. This will be a negative impact to pesticide producing companies. They may be forced to lay off some of their employees and at extreme situations they may close down. GM food has great potential to provide health to humans especially in developing countries. For instance use of GM banana to prevent the some diseases like hepatitis B virus. Invention of genetically modified crops that can be used for medicinal purposes would be a positive advancement. Adjusting the crop to enable it accommodate important chemicals would reduce the costs of offering medical care. Quality and better products are produced using GM and these products can survive under a wide range of climate. This would ensure more production of such goods which can be used for consumption as well as for exports and local markets. GM products are more attractive to consumers since they have been modified to suit different needs. More preference would mean higher sales when goods are placed in the markets and consequently more incomes. (Carter A. nd Guillaume G, 20) Growing GM crops without use of spray chemicals makes the crop easier for farmers to grow at reduced costs. The indirect costs would be reduced for instance the cost of labour used in spraying the pesticides as well as the environmental hazards created. Other benefits of using GM are that it is possible to enhance the quality of crops by emphasizing on the positive ones while removing the undesirable qualities. Using genetic technology is faster than using conventional breeding. Water use is also effectively reduced when pesticides are not used. GM reduces the work that would have been done if it was considered. (Carpenter J & Gianessi L, 70) Genetic engineering instills fear in people but such fears are uncalled for as they are based on prejudice and exaggerations. It has seen many people rise from poverty to grace. GM cultivation is among the most economically viable form of farming. It has led to the reduction in the emission of greenhouse gases which are responsible for global warming. This is due to the fact that the pesticides use is minimal. Production of fertilizers emits hazardous gases like nitric acid which cause the greenhouse effects. Farmers using GM crops in developing countries can afford to educate their children as well as provide for their families. Educating children especially in the developing countries is a step to breaking the vicious cycle of poverty. This is because with the investment in education overeliance in agriculture would be reduced. With GM, crops can be made to grow at shorter periods with increased desirable qualities. Drought resistant crops can be use to alleviate the famine problems in developing countries. With shorter spans of maturity crops can be used for commercial purposes earning farmers incomes. GM products can be enhanced to stay fresh for longer to allow for effective transportation. This can be done to flowers and fruits which are quite perishable. The costs of preservation can be reduced as it would not be required with the same intensity it could have been, had GM production not been considered. Again, wastage is reduced when ‘fresh’ periods are prolonged. Production of GM products can be cheaper due to the fact that they can be made firm hence consist lesser amount of water and require less amount of water when harvesting and consequently less energy in processing them to other products. For instance, tomato puree in Britain. Less energy in production caused lesser costs to the producers who charged lower prices to consumers. GM Soya helps save costs of using herbicides as weeds are controlled. (Falck-Zepeda et al, 2) Critics raise concerns that since pollen grains of GM can easily be carried to other plants through insects or wind, eventually all crops will be genetically modified. To them this will be a disastrous effect. Countries which could have greatly gained from GM, have not embraced the idea. Some, especially from the developing countries, were quick to note that GM did not help their farmers. Contamination is therefore bound to occur where GM soyabean pollen grains may be contaminated with GM maize pollens. Concerns are however raised that the profits are the main reasons for advocating for GM. Companies that engage in expensive and extensive research do so with their own vested interests of earning more income. It is argued that the motive behind their implementation is to make money and the argument placed before that GM was to help solve the food shortages. Extensive research ought to be carried out to establish the actual impact of GM so that consumers are well aware of the products they consume. Crop losses that are incurred when pests invade crops are minimized using GM because it ensures reduced insects and pests. This translates to higher revenues acquired, as there are less financial losses. Consumers are attracted to such products, as they are not linked with exposure to chemicals from pesticides. Some people shy away from crops exposed to pesticides for health reasons and they would have an option if GM crops were embraced. Another advantage of GM is that it is herbicide tolerant. Naturally it may be harder or difficult to remove weeds through tilling in some farms precipitating the need to use herbicides to control the weeds. Tilling is a time consumingactivity as well as expensive. When spraying such herbicides, care must be taken, as it would affect the entire group. All crops might be destroyed or they could be negatively affected when spraying the herbicides. GM products are not affected by the herbicides and hence their production will be better placed. They are also resistant to some disease causing organisms like fungi, bacteria and viruses. Ensuring that the plants are disease resistant will ensure the plants survival. (Falck-Zepeda et al, 2) Genetically Modified products can be made cold tolerant so that genes from a cold water fish can be used to produce crops that are more tolerant to cold temperatures. With the rise in population and fixed land for cultivation, there is need to utilize the drought stricken areas to increase their utility. GM crops are more drought resistant so that crop production is increased and it will be a step forward in ensuring that food security was attained. Land that was formerly inhabitable due to salinity or drought can be reclaimed. ( IFT, 45) The malnutrition problem in third world countries that is responsible for childhood deaths can be reduced with utilization of GM products that are enriched with appropriate vitamins. Since people in developing countries rely on the staple foods, which are mostly starch, they lack the necessary nutrients to fight malnutrition. Malnourished children are not able to successfully pursue their education and are therefore a problem to the whole country. If the developing countries suffering from this problem can embrace the Genetically Modified rice or other products that have such nutrients, their economy would grow eventually. ‘A healthy nation is wealthy nation. ’ Sicknesses associated with lack of appropriate nutrients require finances for treatment and such costs can be reduced. (Domingo L, 1749) Other concerns raised against GM production are fears that the cost of the GM products may rise uncontrollably especially if the genetic engineering firms who have invested a lot in research were to be given patent rights. They could only exist to perpetuate inequalities between the rich who could easily afford them and the poor who lack the means to attain them. Governments of respective countries ought to be keen in establishing the regulations governing the effects and approval of new GM varieties in their countries. However the tests done to verify the impacts of GM crops are run by governments but they are conducted by the GM companies themselves. The results could therefore be interfered with to give false information depending on vested interests. Gene modification is a complex activity that could cause allergies to people as they entail induction of proteins and new genes. Again the genes may be incompatible resulting to absurd effects and this raises concerns that the toxic effects could arise with the interruption of the native genetic structure. GM crops are resistant to antibiotics and there are worries that this would eventually be transferred to human beings thus affecting their health. Since GM crops are pest resistant they may lead to the extinction of some species. Chemical based farming affects wildlife especially in the farms. Birds and insects that influence the natural arable processes in the farm could have their existence affected if weeds are completely eliminated. Critics of GM foods argue that genetic engineering is not the solution to the food related problems especially in developing countries. Most people are not malnourished because of food shortages but because of its inaccessibility. Unequal distribution of resources is the main reason why some people cannot afford necessities like food. Governments of respective countries should handle the inequality issue in their country.

Points of change and contention over funding Essay

Smiling perhaps is very common among all the cultures of the world. A smile can start or end a war. A smile could even be immortalized and glorified just like Da Vinci’s Mona Lisa. Basically, a smile has some unexplainable power to make any situation somewhat lighter. However, misusing a smile could also spark disputes. The complexity and the potential of a smile is explored by profit-oriented groups. And as it turns out, a smile could really attract profit. Prioritizing how to smile is just as essential as planning the whole business. This simple yet effective practice is what some of the business sector is overlooking. People work hard for their money, not to mention life is getting more complicated as time passes. So it is just understandable that people would be carefully thinking—sometimes even over-thinking how would they spend their money. A smile could wash away that fear of spending. A smile is the business sector’s way of communicating that the customers are being valued. Moreover, a smile is the business sector’s way of saying that it is a pleasure providing the customers with quality product and service. If we would observe the evolution of the market, enterprising people were initially offering very basic products, then things got more complex as time passed by. Let us take for example food, in the earlier years of the market almost any variety of food, as long as it is edible, proven delicious, and safe for consumption people would buy them. However, we could just observe the how the food industry had evolved. People now are considering the packaging, nutrition facts, taste, and other details. In sophisticated restaurants, presentation is being considered as just as important as taste. This overload of details to analyze is likely to intimidate the consumers. However, if a smile is incorporated in the presentation of the food, the consumer’ thinking would circle back to the basics. A smile would tell the consumers that the food is edible, delicious, and safe for consumption. And as an added effect, a smile would suggest that eating the food would be an enjoyable experience. This analogy of putting a smile in the food business could be easily translated in the language of other business fields. It would just be as effective if a computer salesperson would smile as he or she would explain how a complicated computer program would work for the consumer. In relation to the previous paragraph, the business groups, particularly the corporations, even professionals, are being perceived by the public in a negative tone. Professional and business groups are being regarded as merely profit-driven. Incorporating the practice of smiling into businesses and professional endeavors is one likely solution to the problem. A smile is a message that tell the consumers that a business would not exist without them. In a profound sense, a smile is the way of professional and the business sectors way of expressing their gratitude. To simpler statement, a smile is the best way to make a person relax. In addition to that, a smile is one of the most effective tool in difficult situation. It just requires common sense to assume that any endeavor would have more chance of success if done with a smile. Moreover, smiling requires no financial investment, yet it could help increase profit. Of course, it would not hurt if we flex a few facial muscles. Work Cited True Profit Systems. The Real Value of a Smile. Retrieved 16 July 2008

Computed Tomography Dosimetry and Dose Risks Research Paper

Computed Tomography Dosimetry and Dose Risks - Research Paper Example Cardiac DECT scan was performed by using potential clinical protocol (GSI 15 imaging protocol, 64 sections at 0.625-mm collimation, alternating energy between 80 kVp and 140 kVp, 640 mA, 0.6-second tube rotation). Absorbed organ doses were measured by using an adult male breast (female breast attached) anthropomorphic phantom and metal oxide semiconductor field effect transistor detectors (MOSFET), and were obtained also by the computational method based on the Monte Carlo simulation (Im-PACT calculator). The MOSFET dosimeters were evaluated for reproducibility, linearity, energy, and angular dependence. Our results indicated that the MOSFET dosimeter has excellent linearity within diagnostic dose ranges, but in low dose regions, the values are less reliable. The energy dependence was about 7% at tube potentials from 80 kV to 140 kV. The results from performing GSI 15 protocol Im-PACT calculator showed that the breast, lung, stomach, and esophagus had the highest recorded absorbed or gan doses. For the same organs, the MOSFET does measurements were consistently lower than the calculated doses by Im-PACT. The estimates of radiation risk in this study are relatively small for any individual patient. The X-ray Computed Tomography technology has become the method of choice for most diagnostic imaging procedures due to the remarkable advances over the past few decades, contributing to the improvement of diagnostic image quality and the reduction of examination time and cost (AAPM 23, 2008, the International Commission on Radiological Protection Publication (ICRP) 103, 2007, Huda et al, 2008). This has led to a rapid increase in using the CT scanners around the world. In the United States alone, 62 million CT scans were performed in 2006, of which 4 million were for children (Brenner & Hall, 2007). In Japan, there are 91 scanners per million people (Coach, 2008).  

Two summary pages of Recruitment and Retention Essay

Two summary pages of Recruitment and Retention - Essay Example In short, the authors identify the main problems in Panda Express HR management as ineffectiveness of recruitment process and lack of employees’ loyalty. On the one hand, the selection process of new employees reveals its weakness, since the company possesses low educational requirements for their candidates. In this context, the status of the company is low for job seekers. For instance, the necessity to work on the weekends does not attract them to enter hiring process. Although, the main task for the company’s recruitment is to find a person who will share its corporate culture and reveal loyalty. In this situation, the authors reveal the necessity to provide the full amount of information for each candidate who wants to become General Manager in Panda Express. On another hand, the authors raise retention issue in order to discuss the company’s capability to maintain staff’s loyalty. In fact, the core reason of numerous symptoms of employee’s discontent is the maintenance of inadequate information on the working conditions. Currently, newcomers frequently suffer from the imbalance between work and life on their jobs and choose the latter one by leaving Panda Express. In this case, the basic assumption for authors’ recommendations is the need to reevaluate corporate duties and responsibilities. For this purpose, the role of General Manager is the key one for the company. Thus, the recommendations are divided into three main groups: introducing this position with 2 year degree, changing salary, and reliance on managerial potential. Firstly, the authors assume that lowering the threshold for passing to General Manager from 4 year to 2 year degree will increase the motivation of college newcomers to develop within the company. In this context, replacement of high salary offer to high bonus system is crucial, since it encourages striving and taking care of each achievement on this

U09d1 Sarah and Michael Case Study Essay Example | Topics and Well Written Essays - 500 words

U09d1 Sarah and Michael Case Study - Essay Example s good, there is a conflict on interest in the case as the couple have already decided how they would prefer to spend their last days and it is a personal will rather than one forced by others. It is also clear by law that an individual has the rights to make a decision for how they aim to spend their last few days. This is one of the few issues that have been presented in the case. Secondly, the end – of – life directive enables the medical assistance to discuss the wish of the parents with the children. This however is a major issue as the cases are generally very sensitive and discussing this with the children can prove to be very difficult. This is mainly because the amount of stress, trauma and emotional distress that children and family members go through when an elderly person is ill is very high. Hence it would be difficult for the health care providers to convey the news as well as the family members to hear the news of the will of the parents. This again causes a second of ethics in the case (Garrett, Baillie, & Garrett, 2009). Considering the end of life decision in my life or for someone I know, I feel that it is incorrect to allow anyone to take the decision to end the life of others. This is inappropriate and is completely inhuman. A person should be given the right to live as long as they can and as long as their body is able to accept the life. Using technology to keep a person alive or trying to kill a person against the flow of nature is not right and should not be accepted anywhere in the world. Life is given to all and mercy killing is not ethical in any manner and should not be permitted. Giving an end – of – life decision for someone irrespective of whether it is a mother or father of brother or sister is incorrect and is against the law of nature. Hence it is essential that this is not provided as an option ever as according to the ACA code of Ethics it has clearly been presented that, ‘counsellors must strive to take measures

Ethical Issues in Google Essay Example | Topics and Well Written Essays - 1250 words

Ethical Issues in Google - Essay Example Ethic primarily comprises moral principles that help an individual to justify and distinguish good behaviour from bad ones. Organisation ethics is defined as a set of principles and guidelines that govern organisational decision and practices (Pojman, 1989). The paper aims at analysing ethical issues relevant to Google while briefly highlighting ethical theories and examples thereof. Organisational behaviour is significantly affected by organisational ethics. Ethic is gaining importance at large corporations such as Google because, with growing organisational complexities, the ethical dilemma at companies is also increasing rapidly. From the perspective of organisational behaviour, four ethical theories were ascertained to be appropriate for discussing the relevance of ethics at Google. These theories are the utilitarian ethical theory, virtue ethics, rights-based ethics and justice based ethics (Peterson, 2002). Utilitarian theory of ethics was originally posited by Jeremy Bentham, which however was later advanced by authors such as John Stuart Mill. The theory implies that self-interest should be overlooked and impartial judgment should be made when the interest of a number of individuals is associated with a particular action. Consequently, it is also known as the rule-based theory. In other words, utilitarian ethics is focused on the impact of an action’s outcome on various stakeholders. These stakeholders can be either internal or external to an organization. Utilitarian ethics emphasizes on a maximization of stakeholders’ wealth while minimizing potential damage. From organizational perspective, utilitarian ethical approach delivers long-term benefits to a firm by means of goodwill (Freeman, 1994). One example of the violation of utilitarian ethics by Google can be the strategy it adopted while entering China. China being one of the most populous countries presents an enormous opportunity for growth for Google but the Chinese government insists that all digital activities of its citizens require national monitoring for political control.  Ã‚  

United Arab Emirates Law and How It Bacame United Essay

United Arab Emirates Law and How It Bacame United - Essay Example in the history of this strategic region, which later on flourished through the rearing of camels at the latter stages of the second millennium BC (Adias-uae.com). Additionally, at the beginning of the 1st century AD, overland caravan traffic begun between Syria and Southern Iraq cities. Furthermore, the existence of water prone transport to the important port of Omana, which is presently referred to as Umm al-Qaiwain, which later on ended up to India, came up. These routes played integral roles to the region since they were alternative transport zones to the Red Sea, which was mostly used by the Romans (UAE Interact). During the mid 19th Century, the United Arab Emirates economy was varied as a result of different population living in different areas and possessed different resources. Several industries came up in the UAE, including pearl fishing, dates, trade, fishing, handicraft and grazing. At this particular instance, the Bedouins and the fishermen enjoyed a simplistic type of li fe. The preceding years saw an important evolution in Abu Dhabi and Dubai due to pearl fishing and trade (Noack, 2007). The discovery of oil in Abu Dhabi in 1962 saw major transformation in the UAE. The oil boosted the economy of the UAE which ultimately made the Trucial States to gain political and national power, thus imposing adverse pressure on Britain, forcing it to withdraw from the region by 1968. This significant freedom made the rulers of the Emirates to hold a round table meeting and agree to form a union known as the United Arab Emirates in July 1971. The United Arab Emirates was formally established in on 2nd December 1971. Initially, the union was composed of six emirates of Abu Dhabi, Dubai, Sharjah, Ajman Umm al-Quwain and Fujairah. Amazingly, Ras al-Khaimah joined the union... United Arab Emirates Law and How It Bacame United Though each emirate is governed by a hereditary emir, the seven emirates are governed by a single national president. The seven emirates are; Abu Dhabi, Dubai, Sharjah, Ajman, Fujairah, Umm al-Quwain and Ras al-Khaimah. Abu Dhabi serves as the capital as well as being the state’s center of political, industrial and cultural activities. In 1971, prior to independence, the United Arab Emirates was referred to as the Trucial States or Trucial Oman. This was in reference to the truce entered between the local sheikhs, hereditary rulers and the United Kingdom in the 19th century. This paper is going to highlight the United Arab Emirates Law and how the seven principle emirates became united and formed a union called United Arab Emirates. United Arab Emirates History and Formation Sascha Noack asserts that archaeological evidence has some reasonable proof that there were settlements from as early as 4000BC. However, a population of high culture developed around 2500BC. Historical in dications suggest that the population has a major composition of Bedouins and fishermen. Prior to 1820 before the conclusion of a contract between the Great Britain and the Sheikhdoms of Abu Dhabi, Sharja, Dubai, Ajman, Fujairah, Umm al-Quwain and Ras al-Khaimah, the area was commonly referred to as Pirate Coast. while the UAE has a federal system of government, each emirate has its own ruler, has some degree of autonomy and can make its own laws, so long as they comply with the federal law.

H&M Communication Campaign Case Study Example | Topics and Well Written Essays - 2000 words

H&M Communication Campaign - Case Study Example The realisation of that potential, however, is contingent upon the formulation and implementation of a market plan as which would create consumer awareness of the brand, on the one hand, and incite the purchasing decision on the other. This necessitates the capitalisation upon both Madonna and H&M's already existent market appeal and pre-existing consumer loyalty and trust. To ensure the popularisation of the brand, it is imperative that M by Madonna engage in a marketing communication campaign designed to disseminate information about the line and to familiarise the consumer fashion market with it. The primary goal of the campaign is to increase market awareness of the line, with campaign success measured in terms of message penetration as evidenced through sales figures. The campaign will be comprised of a mix of advertising and public relations, supported with direct mail. Paid advertisements will target the defined global consumer segment and public relations, the launching of the lines in various markets. Advertising will consist of magazine, billboards (outdoor advertising) and TV. Public relations will consist of the distribution of promotion packages at the launch events, with the former being highly publicised events featuring celebrity guests. M By Madonna offers the trendy young consumer an entire fashion range at an affordable price. Realising the importance of dress as a statement about who one is and where one is heading, the line extends consumers the opportunity to look fashionable and expensive' without having to pay dearly for it. 3 Background Founded in 1947, H&M has grown from a small Swedish fashion outlet to one of the world's largest fashion retailers, with over 1,300 stores and operations in 24 countries. Always associated with the youth market, H&M provides both male and female fashion consumers with trendy, often jet-setting, fashions and high quality products at affordable prices (Nolan, 2006). As such, it provides the youth market with the haut couture look at retail prices. The Madonna-H&M venture is a potentially promising addition to the youth fashion market. The resultant line, M By Madonna, provides the youth consumer with an entire range of youth clothing and accessories, suitable for wear at the office, at university/school, for leisure, formal and casual occasions. It is, in other words, a highly varied, multi-purpose line. M By Madonna combines between youthfulness and elegance and, as such, provides the fashion consumer with timeless, multi-purpose and multi-occasion designs. Distributed to fashion stores across the world, not to mention H&M outlets in March 2007, the line has tremendous market potential should the campaign succeed in capitalising upon both H&M and Madonna's market reputations and consumer appeals. 4 Situation Analysis 4.1 Goals The primary goal of this communication campaign is to create consumer awareness of them by Madonna line and disseminate relevant information regarding points of purchase, whether physical (stores) or virtual (web) locations. The secondary goal is to raise the visibility level of M By Madonna, in what has often been referred to as an increasingly retail-crowded consumer market environment and to establish awareness of the line as the optimal youth fashion choice. Other goals can be expressed as follows: Positioning of the line Branding Influencing positive consumer perceptions of he fashion line, thereby inciting the purchase

Marketing research Essay Example | Topics and Well Written Essays - 750 words

Marketing research - Essay Example Australian population statistics report indicated that population density was 2.9 people per square kilometer, in June 2010, compared to 2.6 people per square kilometer in 2005 (Anderson, 2011). Reports also indicated that Australian Capital cities had the highest population density of 150 people per square kilometer, in June 2010. The city of Canberra had the largest population followed by Victoria with 24 people per square kilometer (Anderson, 2011). The Northern region had the lowest population density of 0.2 people per square kilometer. Low population density in the Northern Territory is as a result of its large arid and semiarid areas, distance from earlier settlements, and more recent settlements. Australia’s Capital cities and their population include Sydney (3,502,301), Melbourne (3,160,171), Brisbane (1,508,161), Perth (1,176,542), Gold Coast (376,533), Canberra (309,799), Newcastle (279,975), Central Coast (255,429), Wollongong (228,846), Geelong (130,194), Hobart (1 26,048), and Townsville (119,504) among other cities (Anderson, 2011). Australia’s economy is one of the world’s fastest growing economies. According to nominal GDP, it is ranked a 13th largest economy and the 17th according to GDP (PPP) (Anderson, 2011). Australia is rich in natural resources, therefore; most of the imports are usually manufactured products such as computer accessories, telecommunication equipment, aircrafts, vehicle parts and accessories, and medicinal and pharmaceutical equipment. China is Australia’s leading source of imports. Major imports from China include computers, communication equipment, clothing, games and sporting gadgets, televisions and furniture (Australian Bureau of Statistics, 2012). Other sources of import include New Zealand, United States, Japan, European Union and Singapore. Import of commodities usually require the involvement of Customs authorities in both Australia and the source of import, and these goods are subject to trade agreements, import quotas and tariffs (Australian Bureau of Statistics, 2012). Rich in mineral resources and fertile land, Australia is the world’s leading exporter of mineral ores such as gold and iron-ore, agricultural products such as wool and wheat, and energy in the form of coal and natural liquefiable natural gas (Australian Bureau of Statistics, 2011). Other exports include gold, beef, meat, alumina, live sheep, diamonds, mineral sands, lead, uranium, refined zinc ores, bauxite, and transport and machinery equipment. The mining and agricultural sectors account for 57 percent of Australia’s exports. Its exports were valued at AUD 24166 million, in September 2012 and averaged AUD 8217.4 million per every financial year. China became Australia’s largest export market, in 2009. Australia exported about 266.2 million tons of gold and iron-ore to China, in 2009 (Australian Bureau of Statistics, 2011). This represented a 45.2 percent increase in export ov er the same period. Other leading export markets include European Union, Japan, United States, and South Korea. Economists have established that, over the past two decades, Australia has enjoyed continuous economic growth. In 2010, Australia’s Gross Domestic Product (GDP) was estimated at US$882.344 billion. This represented a 3.94 percent increase from 2009. According to the World Bank reports, in 2011, Australian GPD was worth US$1371.76 billion (Australian

Is Eurozone sustainable for the UK to join Literature review

Is Eurozone sustainable for the UK to join - Literature review Example Over the past few years, there has been a considerable debate about the stand that the United Kingdom has taken towards Eurozone. This study explores the topic, ‘Is Eurozone sustainable for the UK to join’. By taking a detailed look at the reasons because of which UK did not join and the reasons due to which the other countries joined, this study would try to analyze the perspective of the UK with regards to Eurozone. A Brief History of Eurozone For many decades, European leaders and diplomats have discussed and debated the concept of a monetary integration of European countries. The arguments were multiple, while some thought that the common currency could prove to be an alternative to the US dollar, some other felt that a single currency would provide many different advantages (Zimmerman, 1995). For some leaders, it meant political symbolism and for some others, it meant the rise a new and improved economic model (Vujic, 2004). After a long era of discussions and debates, the Eurozone came into existence in1999 and the Euro became the legal currency for the member nations (Kleimeier and Sander, 2002). The adoption of a single currency would mean that all the member countries would have a single monetary policy, and would not continue to have separate policies. To regulate this, the European Central Bank came into existence which lays down the Europe wide monetary policies and handles decisions related to interest rates, exchange rates and so on. (Salvatore, 2002). Therefore, if any particular country wants to introduce a separate economy policy, it has to rely on the policies of the European Central Bank as it has become the sole authority of Eurozone. Having a single currency has both advantages and disadvantages and the existence of the Eurozone over the ten years has proved this. The Euro has seen success during the period of 2003-2005, where as it suffered from the loss of its stand during the economic recession that happened during 2008-2009. In recent times, there have been some apprehensions about the stability of the Euro, in the light of the results of the recession where some members of the Eurozone saw major economic crises. Why did the UK Not Join Eurozone? The United Kingdom is one of the most prominent nations of the European Union. Yet, it took a stance on not joining Eurozone. The currency of the United Kingdom continues to be pound sterling and the possibilities of its joining Eurozone look bleak in the near future (Layard, 2002). The Maastricht Treaty (The treaty on European Union) saw the negotiation of an ‘opt-out’ from the common currency (Leblond, 2004). The government that came into power post the 2010 election in the United Kingdom also decided that it would not join the Euro as long as it was in governance. In addition, the UK also has carried out many public opinion polls to take a stance on the whether it should join the Eurozone and the polls in 2005, 2008 and 2009 also demonstrated the opposition to joining the UK. The past three governments of the United Kingdom also took strong stand on not joining the Eurozone. Pr ime Minister Tony Blair set forth ‘five economic tests’ (tests that would help in determining criteria such as the currency

Is Our Country Too Small to Sustain so Many Professional Sports Teams Essay Example for Free

Is Our Country Too Small to Sustain so Many Professional Sports Teams Essay Is our country too small to sustain so many professional sports teams? This question is being asked and written about a lot lately. New Zealand sport is fairly strong in places but there are a lot of negatives. But many great sporting triumphs have come out our tiny sports crazy country. But it is debatable wether or not provincial sport is going well at the moment. Teams are dropping out of competitions and are running out of money. On the other hand our country has had some great sporting milestones and our provincial sport is a stepping-stone for some of our world-class athletes to make their mark on the world. Firstly many provincial teams are losing money or are in debt. This either forces teams to drop out of an upcoming season or completely fold. For example the Otago Nuggets had to drop out of the NBL (National Basketball League) in 2009 because of financial reasons. But thanks to their major sponsor Oceania Gold they are back in the League. The Otago Rugby Football Union who over four years lost nearly $4 million and have just announced they may go into liquidation and miss the 2012 ITM Cup. This all starts because unions are spending more money to buy players, coaches, staff, flights and accommodation than what they can afford. With teams going into debt they cannot afford to buy their star players, buying star players maybe good for the team in the short run but can end badly in the long run. This is bad because with a team pulling out does not give locals the chance to get recognised on the big stage where their career could start. This is also bad for big sports fans in a region, as they do not have a team to support. With all the negative points there are positives like there is so many sporting milestones being reached. For such a small country we compete very well against the rest of the world, in some cases we are even world champions. This makes me proud to be a New Zealander. E. g. The All Blacks finally won the rugby world cup after a 24-year drought, 3 times loosing to France. Or the New Zealand Breakers winning the Australian National Basketball League and becoming the first New Zealand team to win an Australian competition beating the Warriors in the NRL for rugby league and the Phoenix in the A-league for soccer. Or The Silver Ferns Beating the world champions in the final of the netball in the commonwealth games and finally the Kiwis who won the last Rugby League World Cup showing that national sport in New Zealand is very strong. It is important having strong national teams as it is a good reputation to have as a country, and for such a sports crazy nation it is good to see New Zealand win. Lastly, for great sportsmen and women provincial level is where is all begins on their journey to greatness. Many great sportsmen have been recognised from sports in New Zealand. E. g. Brendon McCullum who plays cricket for Otago and New Zealand got a contract for US$900,000 by an Indian cricket club, the Kolkata Night Riders. McCullum is now one of the best Twenty/Twenty players in the world. Another example is Kirk Penny. Penny had a great season for the New Zealand Breakers basketball team. A European club, Madrid Fuenlabrada signed him and he is now making his mark in Spain. This is important as it helps world-class athletes from New Zealand be known to the rest of the world. In conclusion we see that professional sport in New Zealand has its downsides being that teams are going broke or defunct but many positives like our national teams doing well and New Zealand players being recognised worldwide. We can see there are many positives and negatives but most professional sports in New Zealand are strong and I believe New Zealand sport is great.

Effects of Paraneoplastic LEMS on Neuromuscular Junction

Effects of Paraneoplastic LEMS on Neuromuscular Junction Qing Zhi Tan Effects of Paraneoplastic  Lambert-Eaton Myasthenic Syndrome on the Neuromuscular Junction IntroductionThe Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disease. It is characterised by muscle weakness of the proximal lowerlimbs as a result of auto-antibodies produced against the voltage-gated calcium channels (VGCC) found on the presynaptic membrane of the neuromuscular junction(1). Most of the time, LEMS is classified as a paraneoplastic syndrome as it is often associated with cancer (small cell lung cancer in particular) (2, 3). One of the earliest descriptions of this disease was reported by Anderson and his colleagues in the year 1953, describing a 47-year-old patient with bronchial carcinoma presenting with progressive muscle weakness(4). Upon examining this patient, Anderson wrote: His (the patients) muscle power was generally weaker than his muscle bulk would suggest, especially the muscles of the shoulder girdle, hip girdle, trunk, and anterior compartments of the legs.(4) Since then, much research has been done to find out more about this disease. It is now known that the auto-antibodies are primarily directed against the P/Q-type VGCCs at the neuromuscular junction (1-3, 5, 6). This report will discuss the effects of LEMS on the neuromuscular junction. Voltage-Gated Calcium ChannelsIt would be useful to first understand the structure of the voltage-gated calcium channels (VGCC). In general, VGCCs are made up of 5 subunits (ÃŽÂ ±1, ÃŽÂ ±2, ÃŽÂ ², ÃŽÂ ´, ÃŽÂ ³) and can be divided, according to the electrophysiological and pharmacological properties of their ÃŽÂ ±1 subunit, into 5 different subtypes (L, N, P/Q, R and T-type)(2, 7). The structure of a typical VGCC is shown in Figure 1 below. As mentioned before, the LEMS auto-antibodies are mainly directed against the P/Q-type VGCCs (1-3, 5, 6). The ÃŽÂ ±1 subunit of the P/Q-type VGCCs is known as ÃŽÂ ±1A(8). This ÃŽÂ ±1A subunit forms the channel which allows the movement of Ca2+ ions into the synaptic knob(8), and can be further broken down into 4 identical domains (I, II, III, IV), each possessing 6 transmembrane segments (S1-S6)(2, 8) (see Figure 2). What Happens at The Neuromuscular Junction?Now that we have understood the basic structure of the VGCCs, let us move on to its role and how it is affected by the pathogenesis of LEMS. The neuromuscular junction is made up of the pre-synaptic membrane, the synaptic cleft and the post-synaptic membrane (5, 9, 10). P/Q-type VGCCs present on the surface of the pre-synaptic membrane play a vital role in allowing synaptic transmissions to cross the neuromuscular junction (7, 9). In studies conducted by multiple different researchers, anti-P/Q-type VGCC auto-antibodies were found in more than 85% of LEMS patients (3, 6, 11). Japanese researchers Masaharu Takamori and his colleagues even went a step further to determine the specific immunodominant sites within the P/Q-type VGCC in which the auto-antibodies would bind. In their study, they found that majority of their test subjects had auto-antibodies directed against domains II and IV of the ÃŽÂ ±1A subunit in the P/Q-type VGCC(12)(highlighted in red in Figure 2). Depolarisation of the pre-synaptic membrane occurs when stimulated by an action potential initiated by a nerve impulse(13). This membrane depolarisation causes the VGCCs to open, allowing the local influx of calcium ions (Ca2+)into the synaptic knob(13). The increase in Ca2+ concentration will stimulate the exocytosis of vesicles containing the neurotransmitter Acetylcholine (ACh) into the synaptic cleft(13). ACh then goes on to bind to the nicotinic acetylcholine receptors found on the motor end plate which will trigger an action potential and subsequently causing muscle contraction.(10, 13) In patients with LEMS, the LEMS auto-antibodies would bind to the VGCC present on the pre-synaptic membrane of the neuromuscular junction(5). This causes the VGCC to lose its ability to function as an ion channel, thus inhibiting the influx of Ca2+ into the synaptic knob during membrane depolarisation(5). Since the exocytosis of synaptic vesicles are dependent on Ca2+ (14), it is believed that a decrease in Ca2+ influx would result in a reduction in synaptic vesicle exocytosis(5, 13, 15). A recent study conducted in 2015 confirmed the phenomenon in which the LEMS IgG directly causes a reduction in the exocytosis of synaptic vesicles (16). They did this by using fluorescence imaging techniques to observe the exocytosis of synaptic vesicles in rat neurons incubated with LEMS IgG (16). Pooled IgG from healthy individuals were used in comparison and as a control (16). Hence, it is evident that the muscle weakness seen in LEMS patients is a direct consequence of reduced exocytosis of ACh-containing synaptic vesicles. In summary, the Lambert-Eaton myasthenic syndrome is an autoimmune disease that causes muscle weakness in patients. The reduction in muscle power is due to insufficient ACh release at the neuromuscular junction. In 85% of these patients, this is caused by auto-antibodies inactivating the P/Q-type VGCCs on the presynaptic membrane. Going Beyond VGCCs So, what happens in the remaining 10-15% of LEMS patients that do not have anti-P/Q-type VGCC antibodies? Many scientists have asked the same question and investigations have been carried out to find alternative mechanisms in the pathogenesis of LEMS in seronegative patients. (The term seronegative is used to describe patients with undetectable anti-P/Q-type antibodies.) In the absence of anti-P/Q-type VGCC antibodies, it is almost impossible that LEMS would have the same pathogenesis in seronegative patients. Yet, it is found that there are no significant differences in the electrophysiological and clinical characteristics between the seronegative and seropositive patients(17, 18). One possible explanation for this phenomenon is that there might be auto-antibodies directed against a different molecule involved in the synaptic transmission; hence causing seronegative patients to have the same clinical and electrophysical features albeit having no anti-P/Q-type VGCC antibodies. To date, many auto-antibodies with different target molecules have been found in LEMS patients. One of the earliest to be discovered is an auto-antibody to synaptotagmin, which is a protein involved in synaptic vesicle exocytosis (2, 5, 13, 15, 19). Furthermore, antibodies to the M1-type presynaptic muscarinic ACh receptor (M1-mAChR) have also been discovered(20). The M1-mAChR is a G-protein coupled receptor that regulates ACh release at the neuromuscular junction(5, 20). We will not be going into the specifics of these antibodies in this report as the mechanisms involved are largely complicated. ConclusionEven though LEMS is a rare autoimmune disease, the prevalence of LEMS as a paraneoplastic syndrome in patients with small cell lung cancer (SCLC) is extremely high. More than half of LEMS patients have SCLC and more often than not, the diagnosis of LEMS precedes the diagnosis of SCLC(21). Therefore, LEMS could potentially play a crucial role in allowing certain cancers to be detected at an earlier stage. Hence, understanding the pathophysiology of this disease would not only prove useful in discovering better treatments for LEMS patients but also aid the early detection of cancer. References: 1.Weiss N, Koschak A. Pathologies of Calcium Channels. Weiss N, Koschak A, editors: Berlin, Heidelberg : Springer Berlin Heidelberg : Imprint: Springer; 2014. 2.Takamori M. An autoimmune channelopathy associated with cancer: Lambert-Eaton myasthenic syndrome. Intern Med. 1999;38(2):86-96. 3.Lennon VA, Kryzer TJ, Griesmann GE, OSuilleabhain PE, Windebank AJ, Woppmann A, et al. Calcium-Channel Antibodies in the Lambert-Eaton Syndrome and Other Paraneoplastic Syndromes. New England Journal of Medicine. 1995;332(22):1467-75. 4.Anderson HJ, Churchill-Davidson HC, Richardson AT. BRONCHIAL NEOPLASM WITH MYASTHENIA. The Lancet. 1953;262(6799):1291-3. 5.Hulsbrink R, Hashemolhosseini S. Lambert-Eaton myasthenic syndrome diagnosis, pathogenesis and therapy. Clin Neurophysiol. 2014;125(12):2328-36. 6.Motomura M, Lang B, Johnston I, Palace J, Vincent A, Newsom-Davis J. Incidence of serum anti-P/Q-type and anti-N-type calcium channel autoantibodies in the Lambert-Eaton myasthenic syndrome. Journal of the Neurological Sciences. 1997;147(1):35-42. 7.Catterall WA. Voltage-gated calcium channels. Cold Spring Harbor perspectives in biology. 2011;3(8):a003947. 8.Structure and Regulation of Voltage-Gated Ca2+ Channels. Annual Review of Cell and Developmental Biology. 2000;16(1):521-55. 9.Hughes BW, Kusner LL, Kaminski HJ. Molecular architecture of the neuromuscular junction. Muscle Nerve. 2006;33(4):445-61. 10.Martini F, Nath JL, Bartholomew EF. Fundamentals of anatomy physiology. San Francisco: Benjamin Cummings; 2012. 11.Motomura M, Johnston I, Lang B, Vincent A, Newsom-Davis J. An improved diagnostic assay for Lambert-Eaton myasthenic syndrome. Journal of Neurology, Neurosurgery Psychiatry. 1995;58(1):85-7. 12.Takamori M, Iwasa K, Komai K. Antigenic Sites of the Voltage-gated Calcium Channel in Lambert-Eaton Myasthenic Syndromea. Annals of the New York Academy of Sciences. 1998;841(1):625-35. 13.Lang B, Newsom-Davis J. Immunopathology of the Lambert-Eaton myasthenic syndrome. Springer seminars in immunopathology. 1995;17(1):3-15. 14.Mechanisms of Synaptic Vesicle Exocytosis. Annual Review of Cell and Developmental Biology. 2000;16(1):19-49. 15.Takamori M. Lambert-Eaton myasthenic syndrome as an autoimmune calcium channelopathy. Biochem Biophys Res Commun. 2004;322(4):1347-51. 16.Spillane J, Ermolyuk Y, Cano-Jaimez M, Lang B, Vincent A, Volynski KE, et al. Lambert-Eaton syndrome IgG inhibits transmitter release via P/Q Ca2+ channels. Neurology. 2015;84(6):575-9. 17.Oh SJ, Hatanaka Y, Claussen GC, Sher E. Electrophysiological differences in seropositive and seronegative Lambert-Eaton myasthenic syndrome. Muscle Nerve. 2007;35(2):178-83. 18.Nakao YK, Motomura M, Fukudome T, Fukuda T, Shiraishi H, Yoshimura T, et al. Seronegative Lambert-Eaton myasthenic syndrome: study of 110 Japanese patients. Neurology. 2002;59(11):1773. 19.Takamori M, Hamada T, Komai K, Takahashi M, Yoshida A. Synaptotagmin can cause an immune-mediated model of Lambert-Eaton myasthenic syndrome in rats. Annals of neurology. 1994;35(1):74-80. 20.Takamori M. Lambert-Eaton myasthenic syndrome: Search for alternative autoimmune targets and possible compensatory mechanisms based on presynaptic calcium homeostasis. Journal of Neuroimmunology. 2008;201-202:145-52. 21.Titulaer MJ, Verschuuren JJGM. Lambert-Eaton Myasthenic Syndrome. Annals of the New York Academy of Sciences. 2008;1132(1):129-34.