Chronic Opiod Use after Hysterectomy

Chronic Opiod Use after Hysterectomy Specific Aims The rapid increase in the incidence of opioid-related overdoses and deaths has become a big public health threat in the United States. This opioid epidemic affects more women than men due to higher opioid prescribing and dose, longer period use, and more opioid dependence in women.1 From 1999 to 2010, the rate of opioid overdose caused death increased 5-fold among women.2 Besides the illicit purchase for some women, the initial exposure to opioids for many others may likewise come from the regular medical treatment as prescription opioids are widely used for pain management after surgery.3 As such, the critical research gap on opioids use is that the evidence is insufficient to draw conclusions about optimal strategies for initiation and titration of opioid therapy.4 Several observational studies have investigated the patterns of opioid use for noncancer pain in patients pre and post-surgery, and identified the risk factors of chronic opioid use post-surgery.5-11 Most of these studie s examined the prediction of baseline demographic and clinical characteristics of patients for prolonged opioid postoperative use and suggested that surgery is a risk factor for chronic opioid postoperative use.5-9 Only two studies examined the initial opioid exposure within 6 or 7 days of the surgery date and results are controversial.10,11 One study reported that initial exposure of opioid poses 44% increase risk of chronic postoperative opioid use and another one suggested that this risk would be low and statistically insignificant.10,11 Similar investigation has not been done specifically for hysterectomy, the most frequently performed non-obstetric surgeries in the United States for women of reproductive age.3,12 Pain has been demonstrated as a common symptom before and after hysterectomy.13,14 A small cross-sectional study has examined the predictors for opioid prescription in women of productive age and identified that opioid use was significantly associated with hysterectomy status and pain-related dysfunction.15 Another cross-sectional survey study reported that 32% patients had chronic pain after hysterectomy.14 Neither chronic opioid postoperative use nor initial opioid exposure for acute surgery pain was examined in these two studies.14,15 Filling this gap in knowledge is critical since identifying the risk factors of chronic opioid postoperative use could lead to optimized initial opioid prescribing for acute pain management and reduced chronic opioid postoperative use and improved women health. Our long-term goal is to help reduce chronic use of opioids and optimize the pain management in women after obstetric and gynecologic surgery through identification and dissemination the safer initial opioid prescribing for acute post-operative pain. Our objective here, which is the next step in our long-term goal, is to compare the patters of opioid use pre and post hysterectomy and determine the important risk factors that associate with chronic use of opioids in women post hysterectomy. The national OptumInsight Clinformatics data offers an essential resource to investigate these aims. The availability of clinical diagnoses and pharmacy medical dispensing offers a significant advantage for investigating drug utilization with corresponding clinical conditions in large population. Our team is well suited to conduct this research given extensive expertise in contemporary pharmacoepidemiology, many years of experience on opioid abuse research, prior drug utilization studies using large claims data, and clinical expertise from obstetric and gynecologic physicians. Our specific aims are to investigate patterns and predictors of chronic opioid use in women pre and post hysterectomy with the following analyses: Aim 1: To characterize the patterns of chronic opioid use in women after hysterectomy. Aim 2: To determine the significant risk factors for chronic use of opioids in women after hysterectomy. The first specific aim for this study is to identify patients who chronically take opioids during six months post hysterectomy, and investigate the time and geographical patterns of chronic opioid use in women after hysterectomy. The pattern of chronic opioid use pre- and post-surgery will also be compared in women with varied age, comorbidities, co-medications, as well as types and doses of initial opioid prescribing. The second specific aim is to determine the risk factors that significantly relate to chronic opioid use, and determine if characteristics of initial filled opioid prescriptions significantly associate with the chronic use of opioids after adjusting for other potential risk factors. Many pain related studies have demonstrated that long term opioid prescribing was significantly predicted by patients clinical characteristics and psychosocial factors, including pain conditions, psychiatric disorders, frequency of medical visits, smoking, and pain-related dysfunction.16-18 Therefore, the adjusted covariates in this study would include both demographic and clinical characteristics. B. Significance and Innovation Currently the United States is experiencing an unprecedented opioid epidemic. According to the Centers for Disease Control and Prevention (CDC), opioid-related deaths increased 200% overall from 2000 to 2014.19 During 2014, about 1.9 million people had an addiction of opioids, with overall 47,055 overdose deaths, 18,243 overdose deaths in women, and 18,893 overdose deaths related to prescription pain relievers.20,21 Based on the data reported by the CDC, women are more likely to have chronic pain, be prescribed opioids with higher dose and longer period, and hence progress to dependence.22 Although opioid abuse is a public health crisis, opioid analgesics are still the mainstay for treatment for acute pain after major surgery. In 2014, total 245 million prescriptions for opioids were dispensed from U.S. retail pharmacies.23,24 During 1998-2010, approximately 7.4 million hysterectomies were performed, making hysterectomy one of the most frequently performed surgeries for women in the United States.25 With over 60% of hysterectomies performed abdominally and up to 85% of patients experiencing moderate-to-severe pain after hysterectomy, postoperative pain management becomes very important.26,27 Evidence suggests that intense and long-lasting postsurgical pain can increase postsurgical morbidity, delay recovery, and lead to chronic pain.28 Opioids such as morphine, meperidine, and oxycodone are widely used postoperatively to reduce and manage pain in patients after hysterectomy.29 Women with hysterectomy and high levels of pain-related dysfunction were almost twice as likely to have opioid prescription. More than 85% of women with hysterectomy and a high level of pain-related dysfunction were found to use opioid.15 Hormonal disturbance, hyperalgesia, and iatrogenic effects are potential adverse effects from op ioid use in women after hysterectomy.14,15 The interaction of opioid-induced adverse effects and post-hysterectomy hormonal dysregulation may intensify pain and promote continued use of opioids.15 There are no known studies that evaluate the connection between acute and chronic postsurgical opiate prescription in women experienced hysterectomy. In consideration of the current opioid epidemic it is important to understand how post-surgical pain is managed, and if this setting presents increased risk of opioid addiction among certain groups, or related to particular prescribing practices. The goal of this proposed study is to examine whether opioids prescribed in women following hysterectomy is associated with chronic use of opioids, and to evaluate which factors may predict patterns of opioid use that indicate overuse or addiction. Accordingly, this study first aims to describe the incidence pattern of chronic opioid use in women post hysterectomy. The second aim is to explore the significant risk factors and determine if the characteristics of initial opioid prescribing significantly associate with chronic opioid use after adjusting for other potential risk factors. This study will reveal important insights regarding post-surgical pain management for a common procedure, and determine if certain patient or treatment characteristics increase the risk of chronic opioid use in this setting. We expect that this research will provide evidence for the need to improve clinical practice towards optimized pain management and reduced chronic opioid use in women after hysterectomy through identification the specific opioid, drug type (short-acting or long-acting), and doses that significantly associate with chronic opioid use in women after hysterectomy. Our study will provide sufficient evidence to draw conclusion about optimal strategies for initiation and titration of post-surgery opioid therapy, and enhance evidence-based medicine for opioid use in Rhode Island, and also the United State. This award would enhance my capabilities on handling interdisciplinary studies and further help me to develop my own research projects and seek for external funding. Innovation Our proposed observational studies based on the administrative claims data will allow for investigation of time trends and geographic variation of drug use in large population and address for well-characterized clinical conditions. Our approach will employ state of the art, innovative pharmacoepidemiologic study designs and statistical models, to improve the precision of outcome definition and minimize measured and unmeasured confounding and bias in our estimation of significant predictors for chronic opioid use after hysterectomy. The unintended outcomes from adverse drug effects make the prospective trials unethical. In this circumstance, a well-designed, retrospective observational study with sufficient sample size offers an efficient design to determine if there is an adequate signal for impropriate opioid prescribing to women post obstetrics and Gynecology surgery. The generalizability of study results are guaranteed due to the nationwide large health plan data that the analyses are based upon. C. Approach Data Sources Study data will be derived from the national OptumInsight Clinformatics Data MartTM, a research database spanning January 01, 2010 through December 31, 2013. The Optum Research Database includes about 23 million beneficiaries from the nationwide commercial health insurer, United Healthcare. The data contains health care utilization with transactional reimbursement data from outpatient pharmacy dispensing, inpatient and outpatient services.30 It links administrative enrollment data with the important medical codes including the national drug code (NDC) for pharmacy dispensing, the Current Procedural Terminology (CPT) code for medical procedure, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for diagnosis. The claims data in this database have been adjudicated, ascertained, and deidentified for research purpose. The University of Rhode Island (URI) and OptumInsight Inc have approved utilization of these data. URI already licenses thi s database that it is freely available for faculties to use. Study Population This study will include adult women who receive the hysterectomy surgery between July 01 2010 and June 31 2013 and have at least 6 months of continuous prior coverage under this health insurance plan. This continuous 6-month coverage provides a baseline for defining new drug users, as well as baseline clinical characteristics, such as comorbidities and co-medications. The hysterectomy procedures will be derived from the ICD-9-CM diagnostic codes 68.3x-68.7x, and 68.9x, where 68.3x indicates a subtotal abdominal hysterectomy, 68.4x indicates a total abdominal hysterectomy, 68.5x indicates a vaginal hysterectomy, 68.6x indicates a radical abdominal hysterectomy, 68.7x indicates a radical vaginal hysterectomy, and 68.9x indicates other and unspecified hysterectomy.13,31 Patients with pelvic evisceration (ICD-9-CM: 68.8x) will be excluded. We also will exclude patients with any cancer diagnoses, including malignant neoplasm of the female genitourinary organs-cancer (ICD-9-CM: 179-184), a nd carcinoma in situ of female genitourinary system (ICD-9-CM: 233). Exposure Assessment Opioids in this study include the following medications: codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone. Tramadol and propoxyphene, considered as weak opioids or already off market, will not be included.11,15 The exposure group involves adult women who receive the hysterectomy surgery and fill more than one prescription for opioids on the day of hospital discharge or within 7 days after hysterectomy surgery, provided that they have no exposure to opioids for at least 6 months prior to hysterectomy.11 The 7 days of window is based on the assumption that a filled prescription during this period would likely to treat acute postoperative pain caused by hysterectomy. A comparison group, defined as the patients with no opioids use on the day of hospital discharge or within 7 days after hysterectomy surgery, will serve as a control to make a comparison of risks for chronic use of opioids. The control patients also have no exposure to opioids for at least 6 months prior to hysterectomy. The exposure of opioids will be identified using NDC codes from pharmacy claims data. In this study, exposure assessment includes all characteristics of the initial filled opioid prescription at the day of hospital discharge from hysterectomy or during 7 days post-hysterectomy. The different type of opioids (classified as long or short acting), number of supply days, and oral morphine equivalent daily dose (milligrams) will be assessed and analyzed. Outcome Assessment Since the study focuses on the risk of chronic opioid use after initial exposure to opioids following hysterectomy, patients were followed from the 8th day after hysterectomy to the first day of outcome occurrence. The outcome, chronic use of opioids after hysterectomy, will be defined using trajectory models.11 in which patients with similar patterns of medication filling during follow-up will be grouped together. The trajectory model was initially generated for the purpose of the assessment of medication adherence.32,33 In order to classify the trajectory groups for opioid use during the defined follow-up window, we first generate 6 dichotomous variables to indicate if a study participant fills a prescription of an opioid medication during each of 6 consecutive 30 day follow-up periods.11 we then model these 6 binary indicators of using opioids in each 30 day follow-up period as a longitudinal response in a logistic group-based trajectory.34,35 With a trajectory model, we will estimate the probability of membership of patients in each group, and the probability of the certain opioid exposure over time as a smooth function of time. We will fit the model using 2 to 4 opioid exposure groups with comparison of the Bayesian Information Criterion.36 The number of groups will be chosen based on the value of the Bayesian Information Criterion. In each group, a third-order polynomial (including linear, squared, and cubic terms) of time will be used to model the probability of being exposed to opioids. Patien ts will be assigned to different trajectory groups, which are generated from these models and have highest probability of the membership. Based on the model results, the group of patients with the highest probability of filling opioids over time will be defined as the chronic use. Other trajectory groups were classified as nonchronic users. The trajectory models provide new advanced approaches to utilize the observed data to determine distinct filling patterns of opioids in our study population during the year after hysterectomy surgery. It classifies patients into groups with similar opioid exposure patterns without relying on a priori and subjective cutoff line for the definition of chronic opioid use. The trajectory models will be conducted using SAS Proc Traj (SAS, version 9.4, SAS Institute Inc., Cary, NC, USA). Patterns of Chronic Opioid Use After chronic opioid use is defined using trajectory models, we will compare the frequency of the incidence of chronic opioid use over time from 2010 to 2013. The secular trend will be analyzed using Joinpoint regression program (National Cancer Institute, Calverton, MD) to identify the joint points and slopes. The rates of chronic opioid use in women post hysterectomy will also be compared with varied age, comorbidities, co-medications, as well as characteristics of initial opioids exposure, including opioid types and doses. The geographic variation of chronic opioid use will be mapped and analyzed using ArcGIS 10.5 geographic information systems software (ESRI, Redlands, CA). The opioid prescription policies and socioeconomic status in different states will be compared with the geographic variation of chronic opioid use. Predictors of Chronic Opioid Use We will identify the predictors of chronic opioid use at baseline or the time of the initial opioid prescription. A previous study demonstrated that hysterectomy, older age, and higher levels of pain-related dysfunction were associated with opioid prescription.15 Potential predictors in this study would include age, year of surgery, smoking, illicit substance abuse, alcohol abuse, hysterectomy type, psychotropic medication use, pre-operative depression, pre-operative pain condition, primary indication for hysterectomy, co-medications, and characteristics of the initial opioid exposure. Although the benefits of minimally invasive surgical procedures have been documented,37 hysterectomies performed for benign indications in 2010 in the US still consisted of 40.1% total or subtotal abdominal hysterectomies, 30.5% laparoscopic hysterectomy, 19.9% vaginal hysterectomy, and 9.5% robotic-assisted hysterectomy.21,25 Hysterectomy type has been related to the initial opioid prescription,15 how ever, the results from randomized clinical trials showed that abdominal hysterectomies didnt increase postoperative chronic pain.38,39 The primary indication for hysterectomy is defined based on the following algorithm: (i) precancerous conditions will be assigned the primary indication if endometrial cystic hyperplasia or carcinoma in situ of female genitourinary system is listed as an indication associated with hysterectomy surgery; (ii) whichever is listed first of endometriosis, uterine prolapse, or uterine leiomyoma will be assigned the primary diagnosis associated with hysterectomy if cancer or a precancerous condition is not listed; (iii) endometrial cystic hyperplasia is combined with in situ under precancerous and that pain and bleeding were included as reported reasons for hysterectomy, and (iv) other was assigned the leading for the remaining diagnoses.19 Over 60% of patients have reported pain as pre-operative symptoms for hysterectomy.39 After hysterectomy, the prevalent pain was reduced to 4.7% to 31.9% during 1-2 years after surgery, while new onset pain at follow-up was reported in 1-14.9% patients and increased pain was in 2.9-5% of patients with pre-operative pelvic pain.39 Therefore, in our study, we plan to assess pre- and post-operative pain, as well as the pain conditions, including pelvic pain, back pain, fibromyalgia, and migraine or other headache syndromes using ICD-9-CM codes. Patients with pharmacy claims for opioids or diagnoses for opioid abuse (ICD-9-CM: 304.xx) during the 6-month baseline period will be identified as opioid users prior to hysterectomy. Preoperative depression that has been found significantly associated with postoperative chronic pain,40 will be identified using diagnoses, as well as medication use at baseline. Antipsychotropic medication use will be obtained using prescription information. The psychiatric comorbidity, will be assessed using prescription information instead of ICD-9-CM codes for greater specificity.11 Co-medications refer to the use of other medications on postoperative pain management. The postoperative use of Nonsteroidal anti-inflammatory drugs (NSAIDs) or Acetaminophen with opioids has been found safe and effective on pain relieve with reduced opioid dose.41 All potential predictors, including characteristics of initial opioid use, will be adjusted in multivariate analyses to identify the significant predictors for chronic use of opioids in patients post hysterectomy. Statistical Analysis Statistical tests and modeling will be conducted to identify potential significant risk factors for chronic use of prescribed opioids in women post-hysterectomy. Categorical variables will be examined and compared using Chi square or the Fisher exact test. Continuous variables will be compared using the student t test. The covariates will be selected from all demographic and clinical variables using statistical modeling. A univariate analysis will be performed with the initial opioid exposure variable and then with each covariate added one at a time to monitor the change of the estimate of the major exposure variable. The covariates that modify the estimate of opioid exposure (variable >5%) or significantly predict the chronic use of opioids will be selected for further multivariate analysis. To account for many confounding factors, we will also utilize propensity score matching method to combine all confounding factors into a propensity score. The patients with initial opioid exposu re will be 1:5 matched with the patients without initial opioid exposure using the propensity score with a caliper of 0.01. A multivariate conditional logistic regression model will be utilized to measure the adjusted odds ratio of initial opioid exposure on chronic opioid use in two matched groups. A probability of type 1 error (alpha) = 0.05 will be considered to be the threshold of statistical significance. Tukey-Kramer method will be applied to correct the inflated p value due to multiple comparisons. Statistical analysis will be performed using SAS software (version 9.4, Cary, NC). Sensitivity Studies In order to address unmeasured confounding factors, sensitivity analyses will be conducted in two sections: subgroup analyses and instrumental variables. Subgroup analysis In order to investigate the effects of initial opioid exposure in women post hysterectomy, multivariate analysis will be conducted in the following subgroups: women with postoperative chronic pain, women without postoperative chronic pain, women with postoperative NSAIDs use, women without postoperative NSAIDs use, women with postoperative Acetaminophen use, and women without postoperative Acetaminophen use. Interactions between the drug exposure and the important factors will be examined in the multivariate analyses. Subgroup analyses will likewise be conducted if the interaction is statistically significant. Instrumental Variable We plan to use propensity score matching to address all measurable confounding factors and generate two balanced comparison groups. However, the unmeasurable confounding factors, like confounding by indication, may still impact the study validity. Instrumental variable is an advanced methodology that has been utilized in pharmocoepidemiological studies to control for the unmeasurable confounding factors, such as confounding by indication. In the sensitivity study, we will use the physicians preference as an instrumental variable and reexamine the initial opioid exposure on chronic use of opioids post hysterectomy. D. Timeline Table. Study Timeline of the Study. Time Period Study Progress Before 07/01/2017 Obtain IRB approval and Optum data use permission 07/01/2017 08/01/2017 Complete data cleaning, manipulating, and variable editing. 08/01/2017 10/01/2017 Complete analyses for demographic and clinical characteristics 10/01/2017 01/31/2018 Complete trajectory modeling to determine chronic opioid use. Analyze the time and geographic trends. 02/01/2018 02/28/2018 Submit an abstract to the annual meeting of International Society of Pharmacoepidemiology (ISPE) 03/01/2018 06/30/2018 Complete analyses for specific aim 1 07/01/2018 01/31/2019 Complete predictive modeling as described in specific aim 2 02/01/2019 02/28/2019 Submit an R21 to NIH, and an abstract to the annual meeting of ISPE 03/01/2019 06/30/2019 Compete analyses for specific aim 2, including all sensitivity studies. Submit a final paper to a high impact journal 09/01/2017 12/15/2017 Complete course PHP 2090 01/01/2018 05/15/2018 Complete course PHP 2470

Military Commander & the Law Essay

Both in the civilian and the military population, the issue of legal drinking age has been a contentious issue. The proposal to lower the minimum drinking age among members of the military in different states has attracted a lot of debate all over the United States. The basic argument has been individuals who are able to defend the country and participate in combat missions in Afghanistan and Iraq among other areas are responsible enough to be allowed to legally buy and consume alcoholic drinks irrespective of the age. However, any debate that deals with changes in the law is always a controversial issue. There are a large number of people in support of the lowering of the drinking age in the military to 18 years irrespective of the laws in the state in which the military base is located. On the other hand, it has been opposed by a large number of individuals and groups (Bray & Hourani, 2007). However, it is important to note that if an individual is mature enough to take part in military duties, he is mature enough to drinking and therefore the drinking age in the military should be lowered to 18 years. Surveys carried out in the United States have always indicated that majority of Americans support the abolishment of legal drinking age limits in the military. The Americans are generally for the argument that all individuals in active duties in the armed forces should not be limited by the law to consume beer. Being a democratic country, the policy makers have no option but act according to the will of the majority. In the past, all military officials in active duty were allowed to consume alcohol in their military bases irrespective of the laws limiting the drinking age in the state. This changed in the 1980s when the congress enacted laws that required the states and federal laws on legal drinking age be enforced in the military bases (Powers, 2009). Since then, there have been suggestions to abolish this law in different states. The basic argument has always been if the individual is man enough to be in a battlefield, he should be able to handle beer responsibly. Common sense indicates that an individual is recruited and allowed to work in the military because they are adults and therefore should not be limited by the law (Hoellwarth, 2007). An 18 years individual in the United States has attained the majority age and is considered to have the ability to make informed decisions such as participating in general elections. The person can also take a weapon to defend his country. Does it make sense really for such a person to be denied the right to consume alcohol? I don’t think so. The common believe that tolerance to alcohol increases with age is not necessarily true. There are cases where younger people have been found to be more tolerant. Moreover, tolerance to alcohol is an issue of responsibility and discipline rather than age. Many young people serving in the US military are more responsible that some senior members of the society (Jacobson, et al, 2008). In conclusion, it does not make sense the limit the military personnel from consuming alcohol based on their age. The fact that they are mature enough to take part in combat missions and defend their country suggests that they are mature enough to control their drinking. Moreover, majority of the Americans are in support of abolishing legal drinking age in the military. Reference Bray R. M & Hourani L. L. (2007). â€Å"Substance use trends among active duty military personnel: findings from the United States Department of Defense Health Related Behavior Surveys,† 1980-2005. Addiction; 102(7):1092-101 Gittins, R. A. (1996). The Military Commander & the Law, ISBN 0788172603, DIANE Publishing Hoellwarth, J. (2007). Corps lowers drinking age to 18 in some cases, Retrieved on July 22, 2010 from: http://www. marinecorpstimes. com/news/2007/05/marine_alcohol_070511/ Jacobson I. G, Ryan MAK, Hooper TI, Smith TC, et al. (2008). â€Å"Alcohol use and alcohol-related problems before and after military combat deployment. † JAMA; 300:663–675. Powers, R. (2009). U. S. Military: Military Drinking Age. Retrieved on July 22, 2010 from: http://usmilitary. about. com/library/polls/blmildrinkingage. htm

An Easy Free Printable Snowman Dot to Dot for Christmas

A Comprehensive Treatment Plan Based Off Diagnosis Of The...

Upon discussions and consultations with general dentistry, periodontics, prosthodontics, and endodontic professors, we have drawn a comprehensive treatment plan based off diagnosis of the problems at hand. Periodontitis, loss of tooth structure due to bruxism, fistula, and periapical abscess were the findings. Based from the presentation of patient, it is apparent patient is at high risk of periodontal issues and of caries. Included in appendix, are the clinical photos, radiographs, periodontal charts, study casts, and treatment plans. Scaling and Root Planning (SRP), prophylaxis, root canal therapy (RCT), post and core, porcelain fused metal crown, and night guard were the major treatments. While broken teeth and possible caries†¦show more content†¦2), Autologous platelet concentrates (APC) for bisphosphonate-related osteonecrosis of the jaw treatment and prevention. A systematic review of the literature is a quality paper. Massimo et al. focused on finding out the differe nce between the group exposed to APC vs. the group Not exposed to APC, in regard to surgical dental treatments, in terms of a) improving success of surgical treatment of BRONJ, b) reducing the incidence of BRONJC after oral surgery procedures, furthermore, 1) improving healing of bone and soft tissue at the surgical site, 2) reducing incidence of any other post-surgical complication and side-effect, 3) improving patient’s quality of life by reducing pain, swelling, and other common symptoms, in the post-surgical period, increasing treatment acceptance by patient, in patient under bisphosphonate treatment world-wide. This paper analyzed original clinical studies including prospective and retrospective, on surgical treatment and prevention. The meta-analysis combined 2 case series and 1 case control but excludes case report and non-outcome study. The studies included address the review question, have appropriate study design, with clear search strategy, The article utilized Cochrane Central Register of Controlled Trials, MEDLINE, and Scopus bibliographic databases that were not limited to just English studies. Also, Del Fabbro et al.Show MoreRelatedAlcohol Use Disorder Identification Test1569 Words   |  6 Pagespropelled by unique problems and conditions. Generally, many people will look for therapy because of sense of dissatisfaction with emotional pain or life. Sometimes it can be from immediate distress that is related to a definite crisis like addiction, separation or a loss, maybe on ongoing difficulty in part of their lives like work or relationship. For some people it might be due to suffering strong sadness, worry or fear. 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Chapter One The Duel And The Dinner - 1336 Words

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Ellis1377 Words   |  6 Pagesinfluenced and were influenced by the unstable era in which they happened to live in. Through the six chapters and preface, Ellis examines the key revolutionary leaders, the problems they faced, their ideas and thoughts on these issues, and how they were human and capable of failure, not just legendary figures destined for success. Ellis describes the many ongoing motives for the Hamilton-Burr duel, the political ideas and compromises on handling the new nation’s economy, the controversy on the issueRead More Joseph J. Ellis Founding Brothers : The Revoluntary Generation654 Words   |  3 Pagescombines our founding fathers weakness’ and strongest abilities in just six chapters. His six chapters tell the stories of: The duel between Alexander Hamilton and Aaron Burr. This entertaining chapter describes how duels were undertaken and played out in that time, and helps the reader understand both mens motives. The dinner which Thomas Jefferson held for Alexander Hamilton and James Madison in June 1790. This featured one of the greatest political compromises in American history. The silenceRead MoreThe Revolutionary Generation, By Joseph J. Ellis1730 Words   |  7 PagesAmerican author and historian. Born July 18, 1943 in Washington, D.C., Ellis would grow up to be one of the best, well-known scholars of America. He began his college education at Yale University, then at the College of William Mary. Ellis works include Founding Brothers: The Revolutionary Generation, American Sphinx, and His Excellency: George Washington. His books have brought his name into one of remembrance as his books have gone on to win the Pulitzer Prize, National Book Award, and NewRead MoreFounding Brothers1172 Words   |  5 Pagesthe New Constitution states on the asset side bountiful continent an ocean away from European conflict; young population of nearly 4 million, about half of it sixteen years of age or younger and to grow exponentionally and on the liabilities side no one established republican government on the scale of the US and judgment of the most respected authorities was that it couldn’t be done, second dominant intellectual legacy of Revolution, in the Declaration of Independence, stigmatized all politicalRead MoreThe Revolutionary Generation : Joseph J. Ellis1516 Words   |  7 Pagesare divided into six chapters which are The Duel, The Dinner, The Silence, The Farewell, The Collaborators, and The Friendship (The Founding Brothers). As you read the chapter names you see how it all started terribly; they really did not care for each other, but they had to settle their differences in order to keep the United States strong. Chapter one The Duel details about the argument that turned into a duel between Alexander Hamilton and Aaron Burr. This fight was one for the books as you readRead MoreNotes On The Brothers Notes836 Words   |  4 PagesMadeline Wilson Founding Brothers Notes Chapter One: The Duel †¢ Hamilton Vs. Burr o Burr was vice president of the us †¢ Morning of July 11, 1804 †¢ Plains of Weehawken o Actually occurred on a small ledge popular for duels due to its seclusion †¢ Dr. David Hosack and associate Nathaniel Pendleton accompanied Hamilton †¢ Burr brought William Van Ness, his associate, with him. †¢ Burr had dark hair, dark skin and dark eyes †¢ Unlike Hamilton who had a fair complexion, red hair and blue eyes. †¢ Burr hadRead MoreFounding Fathers Reflections : The Generation1398 Words   |  6 PagesErin Tran Period 4 Founding Fathers Reflections Preface: The Generation In the first few pages of this chapter, I thought it was interesting that Ellis really goes into detail about hindsight and far sight saying that because of hindsight, many of the founders could only see the goal of being independent. However there were some that saw the plentiful amount of resources and the potential America had to form a government. But all of the Founding Fathers were not sure that they would winRead MoreAp Us Questions1624 Words   |  7 Pageslives illuminate? (Hint: there are four.) Theme One: The diversity of the personalities that were represented. Theme Two: All of the founding fathers knew each other personally. Theme Three: The subject of slavery was not talked about so that peace was maintained in the republic. Theme Four: The founding fathers knew what they would be doing for the country and their importance in the change of history. The Duel 5. How did the characters and the duel represent political development of the early

De Niros Game Free Essays

De Niro’s Game â€Å"De Niro’s Game† by Rawi Hage is a coming of age story about a boy named Bassam from war torn Lebanon. The main settings are the headings of the three parts of the novel; Roma, Beirut and Paris. The settings help to illustrate character development, the novel’s themes and are important symbols throughout. We will write a custom essay sample on De Niros Game or any similar topic only for you Order Now The first section of the novel is entitled â€Å"Roma,† but the events all occur in Beirut. Bassam never goes to Roma, however it is always present in the novel and an important symbol throughout. Roma is a place that Bassam has wanted to go his entire life. Roma symbolizes Bassam’s hope for a better life. He fantasizes that it is a perfect place, almost a heaven. When a little girl from his neighborhood dies he says â€Å"I went to the little girl’s funeral, the little girl who was on her way to Roma. † pg. 25. While visiting his friend George he says that they â€Å"whispered conspiracies, exchanged money, drank beer, rolled hash in soft, white paper and I praised Roma. † pg. 34. In the Roma section Bassam is younger and more innocent than in the other sections. Bassam is still a petty criminal. He only commits small crimes such as vandalism and drug use. The fact that the first section is called Roma, yet it is not in Roma, is a form of foreshadowing, suggesting this fantasy may never become reality. The second part of the novel is called â€Å"Beirut. † This section is the turning point of Bassam’s life. In this section Bassam stops dreaming about Roma. Beirut symbolizes Bassam’s loss of innocence. He starts committing major crimes, such as murdering the militiaman ‘Rambo. ’ Bassam starts to learn about the brutality of the war and the slaughter being committed by the militia. Beirut is a symbol of the horror in the world. In Beirut, Bassam realizes how harsh reality and the war are. Soon after realizing this he says â€Å"Ten thousand coffins had slipped underground and the living still danced above ground with firearms in their hands† pg. 88. At one point Bassam says â€Å"From the roof I could see West Beirut on fire. The Israelis bombarded the inhabitants for days, orange light glowed in the night, machine gun bullets left the ground and darted into the air in red arches. The city burned and drowned in sirens, loud blood and death† pg. 163. Not only does Bassam learn about the horrific things going on in the war but he also witnesses his best friend George killing himself, because George cannot go on knowing that he has committed such heinous crimes against humanity. Because of the war Bassam is betrayed by his best friend, tortured by the militia for a crime he did not commit and is forced to realize that the militia and war are not good, but rather morally wrong and pointless. Part III, of the novel is called Paris. Bassam escapes from Beirut and goes to Paris searching for George’s father. After Bassam finds Georges family, they soon betray him. Paris is a symbol of Bassam’s complete and utter hopelessness. In Paris Bassam thinks â€Å"I had no plans, and realized that I could not think of any. Other than Rhea, no one in Paris knew me, no one was expecting me for dinner, nor to walk in a funeral procession, nor to work, eat, carry the wounded, speed around on motorcycles† pg. 215. He has almost no place in Beirut and even less of a place in Paris. Paris symbolizes that Bassam is ruined by the war in Lebanon. Bassam is an outsider in Paris because of his twisted morals and values that were corrupted due to the war. He reads â€Å"The Outsider† by Albert Camus, which talks about the meaninglessness of existence and realizes there are many similarities between him and the character in the book. No matter where he goes, Bassam will always be an outsider. Paris helps Bassam develop as a person, realizing that things are horrible everywhere, and he cannot escape his past. Near the end of the novel, Bassam says â€Å"And so I drifted for hours, trying and failing to reconcile Paris with the phantasm of my youth, with the books I had read, with my teachers stories† pg. 204. Bassam realizes Roma is a fantasy. Setting and place are vital literary devices in â€Å"De Niro’s Game†. The settings are linked to the themes, in that Beirut is a city destroyed by war as Bassam is destroyed by war, and due to his journey through Paris he realizes his dreams of Roma are unattainable. The changes in setting also parallel and mark the stages of his coming of age. In Roma Bassam was a boy, in Beirut his transformation began and in Paris, Bassam became a man. While Bassam is in no way a perfect or even good person, he has made a transformation into adulthood. Without the setting his transformation into manhood would have been less clear and with How to cite De Niros Game, Essay examples

Australian Corporate Laws

Question: Discuss about the Australian Corporate Law. Answer: Introduction There are different businesses opened up by various individuals and their primary goal is to ensure customer satisfaction and generate income. The choice of a business depends on an individual and the availability of the clients. The employees employed in the organizations should be treated with dignity for them to continue working as required. Moreover, the managers should motivate them from time to time for them to gain the morale to work. The productivity of a business depends on the workers effort and the management commitment to the organization. The marketing of the products and services is also essential so as to create awareness to the public. The employees have their rights and they should not be mistreated by the employers at any time. The salaries should be paid as agreed and the working environment should also be friendly to enable them to perform their tasks. The discussion below outlines the business structures and employee rights. Main Body Moreover, Kate owns a business of selling womens shoes and is growing rapidly as it is becoming more successful. She is a sole trader and needs to update her business structure to a more appropriate one. Kate has been doing all the activities on herself without any other persons help. As a sole proprietor she has been enjoying all the profits alone as she manages the enterprise alone. The losses in the business it is upon her to know when to recover them and also minimize them and continue running the business. There are no documents that are needed for one to engage in sole proprietorship structure. It is the responsibility of Kate to take care of any liabilities that arises while carrying out the business. The best structure for Kate to upgrade the business to is the partnership. She will be required to partner with an individual or another organization so that they can undertake the business together. However, each partner will have the responsibility of reporting their share of t he enterprise profits. The individuals will also be liable for the debts or other liabilities that the business will be responsible for from time to time (Spadaccini, 2007). In addition to that, there are a number of advantages and disadvantages of the partnership structure. First of all, there is more capital to run the business as each of the partners will contribute an amount of cash. It will be easy to buy the stock for the enterprise and also expand it to have other branches to serve the customers. Secondly, the decision making will be easier as the individuals will come with various ways to improve the business. It is because two heads or more are better than one in coming up with a solution towards something. The primary goal of the persons will be to come up with ways that will enable the company to earn more profits so that when shared on can get a big value. The strategies will be laid down to enable the organization to achieve its goals and objectives. Thirdly, the profits obtained from the business are divided among the partners. It is carried out after all the enterprise stock is bought and money for other activities is set aside (Smith, 201 3). Fourthly, the management of the business is easier as all the persons help in managing all the activities. The individuals are allocated duties and responsibilities that they should perform. It makes it easy to organize the enterprise and its employees who help in various activities. Moreover, there are no shareholders who can interfere with the governing the business. The management is highly flexible as long as all the partners agree on the same thing that needs to be undertaken. The fifth is that there is the shared responsibility of managing the business and one takes part in perfecting the area they are best in or where they are talented. The partners have various skills that are of help in the organization formed and they will be highly beneficial to the business (Cockburn, 2011). However, there are disadvantages of the partnership form of business structure. First of all, there are disagreements between the partners. It occurs when the individuals have different ideas on running the business or other interests. They highly cause harm to the businesses and also the relationship among the persons. It is advisable that the people involved should draft a deed of partnership while engaging in the partnership. It ensures that every individual is aware of the procedures that will take place during the disagreements and what will happen if the agreement is dissolved. Secondly, there are issues during the profit sharing where some partners are not putting any effort in running or managing the business. Most of the people are reluctant and only wait to reap the rewards after others have worked hard. All the persons involved are supposed to work together and show commitment to the work. Thirdly, the partners must pay the taxes as required by the law and the returns shou ld be done yearly. It is not different to the sole trader and the taxation laws are well stipulated and must be followed. Fourthly, all the partners share the liability and other financial risks of the enterprise. They are not subjected to a particular person and all the people must be accountable. The circumstances are sometimes not liked by many persons. Lastly, the agreements set must be followed and no one has the freedom to do what they want like in a sole trader structure (Spadaccini, 2007). On the other hand, Myra is the director of Kids Clothes Pty Ltd and the only shareholder and the organization makes cheap children clothing. It has been profitable in the past but later on started running at a loss. She later paid herself huge bonuses and transferred the other assets to a new company known as Clothing for Kids Pty Ltd. The workers are still employed by Kids Clothes and it has no any assets. It owes them some thousand dollars; superannuation and long service leave rights. The employees have possible legal grounds that they can use to claim their entitlements from the Clothing Kids Pty Ltd. First of all, they had been employed by Myra and signed the contract form that outlined their duties and salary amount. Moreover, it includes the right to leave over a period of time while working in the organization. The contract form will be useful at the court of law to show the agreement they had entered into with Kids Clothes Pty Ltd (Werhane et al, 2004). Secondly, their employer transferred all the assets to the Clothing for Kids Pty Ltd that were being utilized in the Kids Clothes. They have the right to claim as they had worked hard to accumulate the assets and their rights have not been addressed. The management of Clothing for Kids Pty Ltd is responsible to settle what the Kids Clothes owes its employees. The assets should be utilized in paying the debts that the Kids Clothes never paid its workers. Moreover, they should also get the superannuation and the long service leave. The law stipulates the rights of the employees and they are entitled to leave and the regular payment towards future pension. The assets transferred to the other company are highly valuable to the employees and they have the right to use them. The managers of Clothing for Kids Pty Ltd should recognize the efforts of the workers and grant them their entitlements. They should also have enquired whether the Kids Clothes had any debts with the workers or any peo ple before accepting the assets. It is against the law to accept valuables that have disputes among other parties. The requests of the employees should be addressed by the Clothing For Kids Pty Ltd (Repa Nolo Press, 2014). Moreover, action should be taken against Myra personally for her misconduct. She neglected her duties as the director and did adhere to the employee rights. On the other hand, she transferred all the organization assets to another company without any formal notice to the workers. She would have informed them about the progress of the business and the changes taking place. Myra also owes them thousands of dollars that had accumulated over the holiday. They had also been granted the superannuation and long service leave as required by the law. She had violated the law and must face various charges at the court of law (Busse, 2004). Conclusion In conclusion, the rights of the employees are protected by the law and no any employer should go against them. They should adhere to them to avoid any complications or fines at the court of law. The workers should sue Myra at the court of law for her negligence and not performing her duties as required by law. She contravened the Corporations Act that outlines the duties and responsibilities of the directors of companies. Myra is liable for the activities that happen in the company and should act accordingly to solve the issues affecting the workers who she relies on to improve the organization. The employees should be highly treated with respect and dignity as they play a major role in a company. They help in improving the productivity and generating income for an organization. References Busse, R. C. (2004).Employees' rights: Your practical handbook to workplace law. Naperville, Ill: Sphinx Pub. Campbell, D., Campbell, C. T. (2009).Legal aspects of doing business in North America. Salzburg, Austria: Yorkhill Law Publishing. Cockburn, R. (2011).Small business tax planning: All you need to know from start-up to retirement. Petersfield : Harriman House Gray, D. A. (2004).Start run a profitable business. London: Kogan Page. Lewis, J. (2008).Seeking inner peace and financial freedom: Stepping stones in a chaotic world. New York: iUniverse. Mancuso, A. (2015).How to form your own California corporation. Berkeley, California : Nolo McCulloch, K. J., Prentice-Hall, Inc. (2002).Termination of employment: Employer and employee rights. Englewood Cliffs, N.J: Prentice-Hall. Orakwue, O. (2007).Two dozen businesses you can start and run in Canada, the USA and elsewhere. Toronto: Obrake Books. Repa, B. K., Nolo Press. (2014).Your rights in the workplace. Berkeley, California : Nolo Spadaccini, M. (2007).Business structures. Irvine, CA: Entrepreneur Press. Smith, H. (2013).Learn small business start-up in 7 days. Richmond, Vic: Wiley. Werhane, P. H., Radin, T. J., Bowie, N. E., Wiley InterScience (Online service). (2004).Employment and employee rights. Malden, MA: Blackwell Pub.