Tuesday, December 31, 2019
The Evolution Of Video Games Essay - 872 Words
Speech Outline Speech Title: The Evolution of Video Games Specific Purpose: To inform my audience on how video games has progressed over time. Central Idea: Video games has evolved over time by the enhancement of technology, quality, and its appeal to a more diverse group of people. I. INTRODUCTION Attention Getter: I will start out with a joke. What do you call two Pac mans? 2Pac! Reveal Topic: My topic is about how video games first became what it is today and how it has progressed over time. Credibility Statement: Iââ¬â¢m qualified to talk about this subject because I have been an online gamer for years. How the Topic Relates to the Audience: Almost everyone, even if they have never picked up a controller can see the significant changes in the gaming industry. Since it has expanded over time catering not only to teenage boys, but also statistics show that 40 percent of the gaming industry include females and the average male gamer is thirty one years old. Preview: Video games has evolved over time by the enhancement of technology, quality, and its appeal to a more diverse group of people. II. BODY First off, video games has evolved over time by the enhancement of technology. A. Technology 1. Technology today a. People can play with others despite their geographical location and become a part of a new society and make friendships that can last a lifetime. b. Artificial intelligence c. Portability- people can now game anywhere at any time through aShow MoreRelatedEvolution of Video Games1676 Words à |à 7 Pages1. INTRODUCTION: 1. a What is Video Game? Video game is an electronic game seeking human interaction through an engaging user interface that is being fetched by a video device. Traditionally the term video in video game is referred as a raster display device, but it now implies any type of display device [monitors, TV etc] that can produce two or three-dimensional images. 1. b How does it work? The electronic systems used to play video games are referred to as platforms. The most famous platformsRead MoreThe Evolution Of Video Games1325 Words à |à 6 Pages The Evolution of Video Games Video games have been around for over 60 years and are still evolving over time. But just how did these video games advance over these 60 plus years? According to our research, video games started out in the 1950ââ¬â¢s-1960ââ¬â¢s with basic technology such as low quality graphics, basic controls, and third person play. But from the 2000ââ¬â¢s on, video games evolved from basic technology to more advanced technology such as high quality graphics, more advanced controls, and firstRead MoreThe Evolution Of Video Games1164 Words à |à 5 PagesThe Evolution of Video Games FULL OUTLINE Specific Purpose: To inform my guidance about the evolution of video games. Central Idea: Video games have evolved over time as technology has advanced from 8-bit 2D graphics to the high quality of games they have become today. Introduction: I. As a kid we all had that favorite video game, whether it was Super Mario Bros., Pokà ©mon, or Crash Bandicoot. II. As we have grown up we have watched the video games we used to play evolve to what is out thereRead MoreThe Evolution Of Video Games2345 Words à |à 10 PagesJohn Reynolds 4/28/2016 Research paper: The Evolution of Videogames. What is the definition of videogame? According to the dictionary, it is a game played by electronically manipulating images produced by a computer program on a television screen or other display screen. I have loved to play video games ever since I was a little kid. I still remember the first video game I ever had, it was called Sega Genesis 2. It was one of my all-time favorite games. I was so sad the day it died because of itsRead MoreInformative Speech Evolution of Video Games Essay945 Words à |à 4 Pagesworld of video games. Ever since then technology has grown incredibly now making a fun hobby out of it that people can really enjoy. I myself have made it a hobby and try to keep up with all the latest devolvementââ¬â¢s in the gaming world. Some of my fondest memories are from when I was about 4 years old and I would wake up and go play Mario with my grandpa on my old Nintendo 64. Today Iââ¬â¢m going to explain the past of video gaming, where we are today and what is to come of the video games in the futureRead MoreCriminal Justice and the Game of Online Violence: A Review of the Evolution of Perspectives of Video Game Violence and Its Causes1274 Words à |à 5 Pagesï » ¿Criminal Justice and the Game of Online Violence A Review of the Evolution of Perspectives of Video Game Violence and its Causes March 4, 2012 ABSTRACT: Four articles are reviewed in reverse chronological order because they demonstrate an interesting trend in how online computer usage and gaming is being thought of as a contributor to violence and other types of anti-social behavior. In looking at this trend, it can be seen how reviewers of all types are looking more broadly at this emergingRead MoreThe Evolution Of Playstation On The Game1301 Words à |à 6 Pages The Evolution of PlayStation Joshua McMunn Craven Community College The evolution of the PlayStation has changed dramatically over the past twenty two years. Some of the major changes is how the gamer puts in the game; to put it into the PlayStation one the gamer has to hit a button so you can insert the game. To insert a game into the PlayStation four all the gamer has to do is slide the game right in. Another thing that is different between the two systems is how the user saves his progressRead MoreEssay Video Games Speech Outline728 Words à |à 3 PagesPersuasive Speech Outline Matt King CMST 220 Video Game Speech 6-12-13 * Attention grabber/introduction - Slaying dragons, defending your planet from alien invasion, or bouncing on the heads of koopas and saving the same princess who gets caught every time? Sound Familiar? If youââ¬â¢re anything like me you have tried all of these. Of course not literally but Iââ¬â¢m sure you have all played a video game that has let you do something crazy and exciting you couldnââ¬â¢t normally do. * Can I getRead MoreImportance Of Advancements In Technology758 Words à |à 4 Pagesgamer, there are certain types of technology I canââ¬â¢t do without. While, I donââ¬â¢t consider myself a hardcore gamer, I do play a wide variety of video games from first-person shooters, massively multiplayer online role-playing games (MMORPG) and Japanese role-playing games (JRPG), to platform games and turn-based tactics (TBT), and so on. My interest in video games overall is partially because of my interest in technology and future technologies, which is why out of all the readings provided this semesterRead MoreGaming: How Gaming Has Evolved Over Time. The Evolution1284 Words à |à 6 PagesGaming: How Gaming Has Evolved Over Time The evolution of the gaming world continues to strive for further evolvement by expanding the way games are experienced. From the beginning with the start of a game that just depicted a story in words, to changing the way games can be controlled by gamers, we see them evolve even in story concepts. Games provide more choices of action in the ever-growing number of games and game consoles. Starting from no graphics at all and progressing to 3D and reaching
Sunday, December 22, 2019
Home Schools V.S. Public Schools Essay - 2756 Words
Home Schools V.S. Public Schools How would your life be different if you were home schooled? Perhaps you were. If not though, do you think that you would be on the same academic path that you are on now? In the case of Evenstar Perez, it made her life very different. Evenstar started out going to a public school from first grade through fifth, but it wasnââ¬â¢t until she entered into sixth grade that she began to be home schooled. Evenstar mentioned, ââ¬Å"At first the transition was difficult because I was so used to the public schools system of doing things, but later I became better adapted.â⬠When asked what advantages she felt she gained from her home school experience, Evenstar replied, ââ¬Å"A lot.â⬠She then went on to explain how sheâ⬠¦show more contentâ⬠¦Students who are home schooled get better individual attention, academic freedom, and in return, get a better education than students who attend public schools. Cremin mentioned that home schools were the original method used to educate young students and, in fact, during colonial times, it was the leading structure of education (qtd. in Cai 1). Public schools that later developed ended up depleting the number of home schooled students due to the better financial accommodations, however, recently the number of home school students has been increasing by 10% more students each year (Cai 1). According to Cizek, the amount of home school educators who are conservative constitute for 75% of the home school educators population, and the other 25% of home school educators are liberal in their ideas and can often include such sects as atheists and libertarians (qtd. in Cai 2). There are many different ways to incorporate an education into a home schooled environment. For example, there is a method of teaching at home called the ââ¬Ëschool at homeââ¬â¢ technique, which is where the educator sets up the setting at home to be just like that of a public school where the curriculum can consist of all sorts of activities, such as, on-line course work, a curriculum that comes packaged, and even a time schedule to keep the student moving along at a steady pace (Cai 2). There is also a method called ââ¬Ëunlearningââ¬â¢ whereShow MoreRelatedThe Civil Rights Movement Of America1609 Words à |à 7 Pagesthe original documents that condemn racism/genocide. There also was the National Association for the Advancement of Colored People ,NAACP. They were an anti-racist corporation that initiated federal court cases against segregation, especially in schools. This was crucial to the movement because desegregated neighborhoods would mean that everyone is equa l, which is what they were really struggling to make people understand. Also, education is the forum of reform. ââ¬Å" During the war, membership in theRead MoreLifestyle Auditing1284 Words à |à 6 Pagestaxpayers colluding with tax collecting officials hence posing a great challenge to public service as the government cannot collect enough money to finance setting up of schools, hospitals and other infrastructure for its citizens. public servants continue to waste the money collected through dubious payments to ghost companies, over-invoicing, and other diversionary actions, the cash crunch will only get worse. Public servants continues to waste taxpayers money which are more so collected throughRead MoreThe Rights Opportunity Commission ( Eeoc )1519 Words à |à 7 Pagesissue amongst the people of the nation. Equal opportunities is defined as the treatment of others equally without the discrimination of their sex, race or age. Actions have been made to help prevent this from ever happening. In 1964, Congress passed Public Law 88-352 (78 Stat. 241). This civil rights act ââ¬Å"forbade discrimination based on sex and race in hiring, promoting, and firing. ... Title VII of the act created the Equal Employment Opportunity Commission (EEOC) to implement the law.â⬠Morris DeesRead MoreCuban Health Care . Introduction. Healthcare Is The ââ¬Å"Efforts1209 Words à |à 5 PagesHealthcare Under the oppression of Batistaââ¬â¢s dictatorship, Cubaââ¬â¢s healthcare was close to non-existent. The upper-class went to clinics that were privately funded and the middle and lower class were forced to go to busy, run-down clinics. ââ¬Å"Havana was home to almost half the countryââ¬â¢s physiciansâ⬠¦ the disparity between rural and urban health was marked. Cuba had only 1 rural hospital, only 11% of farm worker families drank milk, and rural infant mortality stood at 100 per 1000 live birthsâ⬠(NIH GOV).Read MoreDr. Martin Luther King Jr. Essay1918 Words à |à 8 Pageswould ââ¬Å"be judged not by the color of their skin but by the content of their character.â⬠They believed that the economic gulf between blacks and whites is roughly the same as it was 50 years ago, but that the gap has narrowed on measures such as high school completion and life expectancy. Gender equality is achieved when men and women share the same rights and opportunities across all sectors of society, including economic participation and making decisions, when the different behaviours, aspirationsRead MoreCensorship Is Ficial Examination And Suppression Of Certain Books2335 Words à |à 10 Pagesmay think that it has been eradicated. In todayââ¬â¢s day and age, it s running rampant, especially in young adult literature. In 2014, 331 books were challenged. A lot of the books that were censored or challenged were by parents, public libraries, private and public schools. 35% were challenged by parents. The reasons those books were challenged is because the topics of homosexuality, suicide, being sexually explicit, drugs/smoking/alcohol, and being unsuited for the age group. (2014 Books ChallengesRead MoreLiterature Review Write Up with Cover Page4074 Words à |à 17 PagesVending Machine Food Environment Assessment Literature Review Erin Fitzharris University of Iowa-School of Public Health Susan Klein Iowa State University Extension Carol Voss Iowa Department of Public Health Fit for Life Program Summer 2008 1 The food environment has only recently been studied as an important contributor to the dietary decisions people make every day; decisions which ultimately impact both short- and long-term health outcomes. The built environment, or the surroundingsRead MoreThe Life And Times Of The Wicked Witch Of West1848 Words à |à 8 Pagesthe teachers teaching at a prestigious all boysââ¬â¢ school. Galinda becomes interested in the major sorcery as soon as she founds out that she can switch roommates if she chooses that major. Boq has fallen in love with Galinda and plans to tell her but then his plan doesnââ¬â¢t go as planned and now is going to meet up with Galinda in the garden made by Elphaba. He confesses his love to Galinda but the least she says sheââ¬â¢ll do is acknowledge him in public and Boq takes this as a win. Elphaba run into eachotherRead MoreDifference Between Law Enforcement And Crime Enforcement2549 Words à |à 11 Pageseveryone and they all work in different ways. They all have different structures and are for different situations. These programs are there to help everyone for their own good and for the good of the wonderful place they live in. Police officer Napa CA v.s Police officer Los Angeles CA Each position offers different requirements some might be similar but depending on what you would want to become they have slightly different requirements. not every job is the same not every person does it the same wayRead MoreThe History of African American Discrimination and the Civil Rights Movement2340 Words à |à 9 Pageshospitals, imparted medical aid and aided black veterans. The staff parleyed employment contracts for ex-slaves and helped resolve labor disagreements. Former slaves were aided in achieving legalized marriages or tracing lost relatives. Thousands of schools for blacks were created with the help of the bureau, including Howard University in Washington, D.C., Fisk University in Nashville, Tennessee, and Hampton University in Hampton, Virginia. Bureau agents, who performed in essence as social workers were
Saturday, December 14, 2019
Autism Awareness Free Essays
string(139) " right manner to experiences in the environment, for example staying away from fire or snuggling up with pleasure in a cozy throw blanket\." Autism Awareness Angi Reid Sisk ESE Instructor Pillar October 24, 2011 Autism Awareness Autism is a disability that affects thousands of children today. The causes are yet to be known but there are many theories floating around as to how children develop this disorder. More importantly than how they have gotten the diagnosis, is what can be done do to help them thrive in their educational environment. We will write a custom essay sample on Autism Awareness or any similar topic only for you Order Now Many of these children are staring school and are faced with an entirely new set of challenges other than adjusting to life in a home setting. There are many common characteristics that children with autism exhibit; educators must be aware of these traits and understand the best way to deal with them and other needs required by the students due to this disability. It is vital to be knowledgeable in the best teaching strategies and have access to support services and aids available to give children with this disorder the tools needed to achieve success along with their non-disabled peers. Autism has six distinct characteristics that involve students with the disability, (Turnbull and Wehmeyer, 2009). Several characteristics accompany students with autism that can drastically impact their progression in a general classroom environment. One common characteristic that children on the autism spectrum face is difficulty with speech. Children with autism are likely to develop speech more slowly than other children. In some children they may never start talking and with others they could develop speech and then lose it suddenly or over a period of time. Students with autism may experience the lack of social language skills; they can also exhibit lack of eye contact and unusual facial expressions. These deficiencies are not done intentionally, but because students with autism have an inability to communicate on the same level as their other peers, (Brittish Columbia; Ministry of Education, 2000). For the students who have developed speech it can differ in other ways such as odd pitch tones or repetitive speech patterns. In the past studies were done and showed that only about fifty percent of individuals with autism would acquire full use of complete accomplished speech, (Turnbull and Wehmeyer, 2009). Today those statistics have drastically increased and show that with appropriate therapy including help from speech pathologists and other trained educators; the number of individuals that increase effective speech has grown to eighty five to ninety percent especially with early intervention. Speech therapists can help children with severe language impairments develop great communication skills and give them the needed skills to better communicate with their peers, (Powers, 2000). Social development is another common characteristic that students with autism share. Many find this characteristic to be the most alarming trait that children with autism share. Social interaction between autistic students and their classmates and teacher can be extremely difficult. This often occurs because these students may not have the ability to socialize well with others and could also exhibit other attributes like poor eye contact and can be resistive to comforting from others including their parents. Autistic students have difficulty understanding the feelings of others and how to distinguish that those feelings are separate from their own. They also have a hard time being empathetic and understanding the needs of their classmates and instructors, (Turnbull and Wehmeyer, 2009). Commonly children with autism can have a hard time establishing relationships in school settings because they tend to interact with others awkwardly and in a rigid manner, British Colombia: Ministry of Education, 2000). Most children with autism do not begin exhibiting the strong lack in social interaction until around the age of two years, (Powers, 2000). The progression that children make socially depends widely on their cognitive development; children who are less cognitively impaired ten to react better in social situations. Repetitive or stereotypical behavior is very common and can range from motor movements to repeated verbalizations. Autistic children can have very powerful interests and preferences that may be quite different from other students in their classroom. Sometimes distress can be caused accidentally by disrupting a studentââ¬â¢s routine, (Powers, 2000). Unfortunately these behaviors can have a large impact on students learning process and the way that they handle themselves in a classroom. Situations or happenings that can seem insignificant to us can throw them completely off and impede their quality of learning. One reason for this is because students with autism can be insistent with routines being the same and can have obsessions with certain objects or belongings, (Turnbull and Wehmeyer, 2009). On many occasions autistic students will have a hard time with transition from their house to the school environment because of the urgency for the structured routine that they thrive on at home. This characteristic can display stereotyped behaviors such as lining up toys or objects or repetitive flapping of their bodies or toys. Students with autism also have challenges with sensory and movement behavior. Children with these issues can react very differently to their peers and various situations in the classroom. Children facing sensory problems may not respond the same to environmental stimuli. They may not have a reaction to something that is hot in the same way that a child without sensory problems would react. On the other hand they could over respond to the stimulant, (Autism Society of North Carolina, 2009). This characteristic could also cause students to exhibit hypersensitivity to light or certain taste, smells, or how objects feel, (Turnbull and Wehmeyer, 2009). Sensory issues can cause problems with intervention and teachers should always be aware of the risks that therapy can bring to students due to sensory differences, (Volkmar and Weisner, 2009). Environmental stimuli can be very disturbing and even painful at time for children with autism. This can apply to limited types of sensory input or all forms of it; this can be caused by a disorder with the childââ¬â¢s sensory processing, An individualââ¬â¢s tactile system which includes the skin and brain allows a person to perceive and respond in the right manner to experiences in the environment, for example staying away from fire or snuggling up with pleasure in a cozy throw blanket. You read "Autism Awareness" in category "Papers" When autistic students have problems or disturbances in their tactile systems they may do the opposite. They may withdraw from trying to be comforted or from affection; this is called tactile defensive. These responses are a result of a tactile misconception and can lead to other behavioral problems. (British Colombia: Ministry of Education, 2000). Problem behaviors is a commonly shared by autistic children. This can be aggression toward oneself or others. This happens more often when the student is frustrated or in a situation that cause over stimulation or confusion, (Autism Society of North Carolina, 2009). This can cause major disturbances in a classroom setting if the student shows violence toward the teacher or their other classmates. Even if he child is not aggressive toward others, there is the worry of them hurting themselves by biting, scratching, and in more severe cases head banging. Teachers can help to control these situations by modeling the appropriate behavior and helping the students with the right way to handle stress and positive reinforcers, (Turnbull and Wehmeyer, 2009). Student with autism that are entering the schools system have many needs and all of these f actors should be taken into consideration for the optimal success of any child with a disability in a general curriculum classroom. One important need for a student is their physical space and how it is cohesive to their comfort ability. The environment where a child with autism learns is extremely important because students on the spectrum have a hard time regulating their focus and attention especially in complex classroom settings, (Volkmar and Weisner, 2009). The nature of the environment of a childââ¬â¢s classroom when faced with a disability can either help them progress or encumber their educational experience. It is important that the class be appealing for all of the students attending but equally as important that it not be distracting for a student with autism. Organization of the room is key in getting the child to engage with his or her peers and to do this in a manner that is comfortable to them. There should be a special place for the student to remove themselves if needed that has a serene and calming meaning it should be free from clutter and other things that could over stimulate. Obvious distractions such as computer screens should be kept out of eye sight so the focus can remain on the teacher. Predictability is also an important need to address with students with autism. A good way to address these needs is by having set routines where the student knows what to expect next. The teacher could use bells or timers to help the student know when to transition or to signal other daily reminders. Making transitions and moving from one exercise to another can be difficult and cause stress to the student which can be eased by incorporating simple techniques into the classroom which give the student a sense of security. Students with disabilities have a need for more one on one interaction in the classroom because they have hard time processing information as quickly as the other students. This need can be addressed by having a well trained para-professional that can help the student complete school work and other tasks assigned during the day. An aid can help the students to make the right decisions for positive behavior and can provide overall assistance in areas of need. Positive reinforcement is greatly needed on a daily basis and can be very encouraging to student with a disability. Focusing on the students strengths are a great way to motivate and help them excel in other areas. Collaborating with families is a good way to see what kind of methods work at home and then try to incorporate them into the classroom. Encouraging the student to participate in all of the activities along with the rest of their classmates will show that you believe in them and expect the best from them. A huge need for children with autism is help with social interaction. It is not that they do not want to make friend, it is that they do not possess the skills to know how. It is not an easy task to influence a child with autismââ¬â¢s social development. Social settings can cause distress so they need to be handled correctly and it helps to limit their social experiences to shorter time limits so that the experience does not become unpleasant, (Powers, 2000). When children have a good relationship with their teacher they are shown to have better relationships with their peers, (Turnbull and Wehmeyer, 2009). Environmental stimuli have a large affect on the outcome that a student with autism has in the classroom. Teachers need to be aware of their responses to certain stimuli and learn what bothers the student and try to accommodate these needs whenever possible. Factors such as sound and lighting should be considered into the planning of the classroom and the configuration of the room. A need for extra time is a must for students with any type of disability. The teacher should always give the student extra time to complete assignments and class activities. The student may need extra time to process general information and request that you give them pertaining to instruction. Extra time will allow them to process the information more clearly. When children begin school especially primary grades after they have left preschool, they are faced with new challenges and expectations based on increased ââ¬Å"psychological and physical maturityâ⬠, (Volkmar and Wiesmer, 2009). Students are provoked to work more independently and there is much more self directed learning occurring in the classroom. It is possible and is happening more frequently now that students with ASDââ¬â¢S are functioning well in school with the help from all of the options available now. There are fully inclusive classes and programs that supply mainstream teaching along with special education services. When teachers make accommodations for students with autism it helps them to function on a more appropriate level. Students with autism can have a difficult time with various sounds and lights that they hear and see throughout the course of their school day. Ear plugs or noise cancelling headsets can be very beneficial in helping them eliminate some of these disturbing factors, (Stokes, 2011). When students leave the classroom to go to lunch or other activities they are introduced to sounds that they are not familiar with; these components will help in these situations. Another great tool and accommodation for students are visual or graphic schedules. These are good tools to let the students know what activity come when and in what sequential memory order they are to perform them in, (Powers, 2000). These schedules should be composed from left to right or top to bottom so they are not confusing to understand and have very clear graphics. Students with autism can become very involved in computers and it can give them a sense of calmness and really help to educate them on various subjects. Computers like visual charts give a clear and concise message for the activity being focused on. Computers can also be used as a reward and a bonus for good behavior. If the children are exposed to computers at home it gives them a sense of familiarity at school. Another way that educators can accommodate their students is by collaborating with the special education teacher on tips and strategies on the best methods to implement in the classroom and positive reinforcers that can help the teacher help the child to put forth their best effort. Special education teachers can also spend time with the paraprofessional or the aid to help them in specific instruction on how to help the students on individual learning skill sets. A crisis plan is a tool that all teachers who have students with disabilities in their classrooms need on file. These are put into place in case a child has an emotional outburst or some other type of emergency during the day that would call for immediate assistance, (Stokes, 2011). This plan should cover everything from sensory issues to obsessive compulsive factors and how to address them in the best possible way. This plan should be collaboration between the parents, administrative staff, the special education teacher, and the general classroom teacher. This plan could coincide with the IEP plan which addresses learning goals and outcomes. Both of these plans in conjunction with each other make a great tool for the teacher. Autism affects so many live today; almost everyone has contact with or knows someone affected with this disability. Education and early intervention is the key to giving students with this disability the best opportunity for success. Understanding all of the characteristics for this disability can greatly help the educator to understand and meet the needs of their students and achieve success. All students deserve the right to an education in the most least restrictive environment with the best services available. If educators use their resources and work in collaboration with the families and other support systems; their students will learn in a positive and stable environment. Reference Page Autism Society of North Carolina, (2011). Common Characteristics of Children with Autism Disorders. British Colombia Ministry of Education. Special Programs Branch, (2000). Teaching Students With Autism: A Resource Guide For Schools. Powers, M. D. (2000). Children With Autism, A Parents Guide. Second edition Stokes, S. , (2011). Interventions and Strategies for Success Turnbull, A. , Turnbull, R. and Wehmeyer, M. (2009). Exceptional Lives: Special Education in Todays Schools. Sixth Edition Volkmar, F. and Wiesnar, L. (2009). A Practical Giude to Autism: What Every Parent, Family member, and Teacher Needs to Know. How to cite Autism Awareness, Papers
Friday, December 6, 2019
Strategic Information System for Business -Myassignmenthelp.com
Question: Discuss About The Strategic Information System For Business? Answer: Introducation In the assignment regarding the strategic information systems, the attempt has been made to write the literature review on the usage, problems, historical development, and the adaptability of the software of accounting system application in Australia. At the same time attempt has been made for generalizing the discussion such as discussing the accounting softwares in general so that it can be used in any of the company. Nevertheless, here the topic is emphasized on the environment of the university (Barnett, et al., 2013). Hence, here the main focus is on the usage of the accounting softwares in the Australian Universities.In doing so, research has been conducted thoroughly over the topic.As per the given process of research mainly in the phase of the literature review efforts are put in the best way for using the examples of the business practice from scholarly journal papers, books, conferences, and the professional magazines for supporting the arguments that are given in the research (Beynon-Davies, 2013). The current organizational structure that is being followed the Australian University under consideration is highly hierarchical with varied degree of complexity at each of the hierarchical levels. The strategic information system that needs to be implemented needs to cater to all the functional modules of the University. The integrated approach to the information system requirement of the organization is the key to implementing a strategically viable SIS (Cai, 2014). There are several operational challenges that are currently the part of the all the problems faced by the university that dictates the need for the deployment of the strategic information system. Due to the hierarchical structure of the organizational structure that has well differentiated sets of functional requirement at each of the hierarchy levels, data consistency has always been a challenge (Goldberg, et al., 2014). For instance, the accounts related information that is maintained by the organization should ideally relate to the student details data that is maintained by the admissions department. Since the various operations that are being done on the same data set, managing the data inconsistencies is a huge challenge that is faced by the University system (Hinkelmann Pasquini, 2014, August). In the context of the University, the functional requirements that the strategic information system is expected to cater to revolves around the very fundamental organizational structure. As an implication of this, this nature of the system acquisition method that is to be employed needs to consider the various alternatives that are available in the form of commercial software, custom software and Enterprise resource planning system (ERP) (Horkoff, et al., 2014). In the university due to the fact that system would be accessed by a variety of system administrators and users, which in fact would be very specialized and context dependent. Moreover the size of the target users to the system would also play a vital role in the system acquisition methodology adopted in this case (Hovelja, Vasilecas Vavpotic, 2015). Considering all these factors in addition to the fact that due to the handling of a considerable amount of the sensitive data that would be handled by the various functional units of the organization, the use of an ERP system is recommended. The use of the ERP would be a preferable trade off from the cost vs. data security point of view. The use if the ERP would ensure that the veritably hierarchical system that is in place with regard to the organizational structure is preserved (Kasemsap, 2015). This would also enable the selective access and visibility to the various data sets to the users and module administrators. After the deployment of the intended strategic information system, there could be various challenges with regard to the control problems in the form of the handling and maintenance of the master data sets. This would require an elaborate and well implemented plan for the use of the various data sets in a manner that reduces the chances for data inconsistencies in future and could provide a proper resolution, if such condition does come up (Li, Hsieh Rai, 2013). With regard to the various frauds and other tampering that could be done to the system is the possibility of unauthorized access to the data on the system. While most of this would need the physical access to the concerned system module yet it is indeed possible to gain access using other maliciously intent means In the context of the business research for conducting the proper literature review, this stage of the review is of concern and has to adopt the correct methodology.Thefollowing figure gives the brief idea on how theliterature review is conducted and progressed further: It was explained by (Lu, et al., 2013) that it is actually necessary for continuing the search during the research process as it is the strengthening process. As the findings of this research will be weighed and judged with respect to the various other similar researches.Three successive movementshas been found in information technology as per views of (Mayeh, Ramayah Popa, 2014)which has made an attempt for handling the reality of the IT silos remarkably.The meaning of IT silos is that many diversified functionsof the business within the same organization or the company which have the tendency to work independently rather together and during that there are certain features which crawl in. In General Australian companies and in particular universities will not have any exceptions from these movements as the same thing was faced by them as it was common for all.It was mainly realized when there was a development of Bespoke accounting software. As a lot of calculation work is involved in the accounting occurrence of manual errors is quite common, sothe first step was kept forward in developing this software so that it becomes a paperless office and the automation in theorganizations and in the universities will be easy (Shapira, Gk Salehi, 2016). Soon, instead of using the tailor-made or bespoke software, universities started giving preference for using the shelf software like Peachtree and Tally. A lot of general things are included in accounting software so it was necessary for developing the accounting software that is standardized such as Tally and Peachtree. The advantage of using shelf software is that the companies can start using it after purchasing the licenses within a weeks time. For developing the Bespoke software, it took months, while the accounting software that is prepackaged took only 2 weeks for customization before it was bought for the full usage (Trad Kalpi?, 2014). This problem was due to the absence of the centrally defined core of the business intelligence which can define the business logic unambiguously. The accounting department will have their own view regarding certain processes, logic or the data so when there is a situation of exchange of information between the departments there are certain conflicts which arise.As there was an independent application developed in silos with respect to each department it was considered to be the root cause for thebroad integrity and the uniformity problems in the organization (Valentine Stewart, 2015, January). References Barnett, N.J., Parry, G., Saad, M., Newnes, L.B. and Goh, Y.M., 2013. Servitization: is a paradigm shift in the business model and service enterprise required?.Strategic Change,22(3?4), pp.145-156. Beynon-Davies, P., 2013.Business information systems. Palgrave Macmillan. Cai, C., 2014. Study on applying the computer network technology to construct the enterprise information system.BioTechnology: An Indian Journal,10(11). Goldberg, E.M., Sullivan, C.S., Goldwasser, B. and Braud, L.A., NetSuite Inc., 2014.Concise communication of real-time business information in an enterprise network. U.S. Patent 8,838,465. Hinkelmann, K. and Pasquini, A., 2014, August. Supporting Business and IT Alignment by Modeling Business and IT Strategy and Its Relations to Enterprise Architecture. InEnterprise Systems Conference (ES), 2014(pp. 149-154). IEEE. Horkoff, J., Barone, D., Jiang, L., Yu, E., Amyot, D., Borgida, A. and Mylopoulos, J., 2014. Strategic business modeling: representation and reasoning.Software Systems Modeling,13(3), pp.1015-1041. Hovelja, T., Vasilecas, O. and Vavpotic, D., 2015. Exploring the infulences of use of information system development methodologies elements on strategic business goals in enterprises.Technological and Economic Development of Economy. Kasemsap, K., 2015. The role of information system within enterprise architecture and their impact on business performance.Technology, innovation, and enterprise transformation, pp.262-284. Li, X., Hsieh, J.P.A. and Rai, A., 2013. Motivational differences across post-acceptance information system usage behaviors: An investigation in the business intelligence systems context.Information systems research,24(3), pp.659-682. Lu, Y., Panetto, H., Ni, Y. and Gu, X., 2013. Ontology alignment for networked enterprise information system interoperability in supply chain environment.International Journal of Computer Integrated Manufacturing,26(1-2), pp.140-151. Mayeh, M., Ramayah, T. and Popa, S., 2014. The Role of Absorptive Capacity in the Usage of a Complex Information System: The Case of the Enterprise Information System.J. UCS,20(6), pp.826-841. Shapira, P., Gk, A. and Salehi, F., 2016. Graphene enterprise: mapping innovation and business development in a strategic emerging technology.Journal of Nanoparticle Research,18(9), p.269. Trad, A. and Kalpi?, D., 2014. The Selection and Training Framework (STF) for Managers in Business Innovation Transformation Projects-Business enterprise architecture integration.Procedia Technology,16, pp.755-767. Valentine, E. and Stewart, G., 2015, January. Enterprise Business Technology Governance: Three Competencies to Build Board Digital Leadership Capability. InSystem Sciences (HICSS), 2015 48th Hawaii International Conference on(pp. 4513-4522). IEEE.
Friday, November 29, 2019
7 Tips So You Never Suffer from Exam Anxiety Again
Spring semester is nearing its end and students are beginning to settle into their favorite cubicle to prepare for finals. Itââ¬â¢s second nature for students to study and prepare for tests and exams that have become routine since middle school. But that doesnââ¬â¢t mean they donââ¬â¢t still get nervous. And for some individuals, the anxiety can be severe. If youââ¬â¢re one of those unlucky individuals, here are 7 tips that will help with your exam anxiety: 1. Meditate Meditation is one of the most effective ways to give your mind a break. Allot yourself 15 minutes every day to do so and clear your mind. It will help your reduce pre-exam stress and keep calm when youââ¬â¢re studying for exams. 2. Listen to classical music Students often study while listening to music, but most probably arenââ¬â¢t aware of the benefits of listening to classical music. A number of academic studies have shown that listening to classical music actually benefits helps boost your brainpower and elevate your mood. If youââ¬â¢ve never tried it before, give it a try! 3. Set aside time for yourself Being prepared for your exam is key to doing well on your exam, but that doesnââ¬â¢t mean you should lock yourself in your room and study 24/7. Itââ¬â¢s important to give yourself a break and do something for yourself as well. Go grab a quick meal with your friends, or treat yourself to an hour of Netflix! Just remember this is not an excuse to procrastinate! 4. Exercise Research has proven that exercise can help with your memory and brainpower. You donââ¬â¢t have to go to the gym, or run 3 miles, but make sure you go out and get some air! A 15 minute stroll outside now and again will d you some good. 5. Play with Puppies Many colleges these days host Puppy De-stresser parties during finals week on campus, so make sure you head over! Puppies are full of love and their cuteness will melt all your stress away. No puppies at school? Check out these puppy videos - itll do the trick! 6. Eating Dark Chocolate Ever wondered why you binge on chocolate when youââ¬â¢re stressed? Itââ¬â¢s because chocolate stimulates the release of endorphins to help you fight stress. Dark chocolate specifically helps fight the stress hormone cortisol, resulting in an overall relaxing effect on the body. 7. Sleep Sleep is extremely important, especially for those who have exam anxiety. Lack of sleep clouds your mind and often damages your resilience. Allowing your brain and body to rest is how you turn your short-term memories from studying to long-term memories that you can recall during a test. Choosing where to go to college is an incredibly important decision. Make an informed choice by talking to current students on ourmentorship platform. Access 60,000+ successfulcollege application filesuploaded by college students (they get paid when you view them). is a community of students helping students. Our goal is to bring much-needed transparency to higher education.
Monday, November 25, 2019
Biography of Georges Seurat, Father of Pointillism
Biography of Georges Seurat, Father of Pointillism Georges Seurat (December 2, 1859 ââ¬â March 29, 1891) was a French painter of the post-impressionist era. Heââ¬â¢s best known for developing the techniques of pointillism and chromoluminarism, and one of his iconic paintings was instrumental in ushering in the era of Neo-Impressionism. Fast Facts: Georges Seurat Full Name:à Georges-Pierre SeuratOccupation: ArtistKnown For: Creating the techniques of pointillism and chromoluminarism, with scenes emphasizing smooth lines and colors blended by visual observation, not mixed pigmentsBorn: December 2, 1859 in Paris, FranceDied: March 29, 1891 in Paris, FrancePartner: Madeleine Knobloch (1868-1903)Children: Pierre-Georges (1890-1891), unnamed child (died at birth, 1891)Notable Works:à Bathers at Asnià ¨res, A Sunday Afternoon on the Island of La Grande Jatte, The Channel of Gravelines, Petit Fort Philippe Early Life Georges Seurat was the third and youngest child of Antoine Chrysostome Seurat and Ernestine Seurat (nà ©e Faivre). The couple already had a son, Ãâ°mile Augustin, and a daughter, Marie-Berthe. Thanks to Antoineââ¬â¢s success in property speculation, the family enjoyed considerable wealth. Antoine lived separately from his family, visiting them weekly rather than living under the same roof. Georges Seurat began studying art early; his first studies occurred at the Ãâ°cole Municipale de Sculpture et Dessin, an art academy run by the sculptor Justin Lequien near the Seurat familyââ¬â¢s home in Paris. In 1878, he moved to the Ãâ°cole des Beaux-Arts, where his studies followed the typical courses of the time, focusing on copying and drawing from existing works. He finished his artistic training in 1879 and left for a year of military service. Early Career and Innovation When he returned from his military service, Seurat shared a studio with his friend and fellow artist Edmond Aman-Jean, where he worked to master the art of monochrome drawing. In 1883, he had his first work exhibited: a crayon drawing of Aman-Jean. The same year, he spent most of his time working on his first major painting, Bathers at Asnià ¨res. Final Study for Bathers at Asnieres by Georges Seurat. Francis G. Mayer / Getty Images Although Bathers at Asnià ¨res had some impressionistic influences, specifically in its use of light and color, it broke from that tradition with its textures and outlined figures. His process also departed from impressionism, as he sketched out several drafts of the piece before actually starting to work on the final canvas itself. The painting was rejected by the Paris Salon; instead, Seurat showed it in May 1884 at the Groupe des Artistes Indà ©pendants. Among that society, he met and befriended several other artists. However, the societyââ¬â¢s disorganization soon frustrated Seurat and some of his friends, and together, they split from the Indà ©pendants to create a new artistsââ¬â¢ society of their own, called the Socià ©tà © des Artistes Indà ©pendants. Georges Seurat was heavily influenced by contemporary ideas about color theory, which he tried to apply to his own works. He subscribed to the idea of a scientific approach to painting with color: that there was a natural law to the way colors worked together to evoke emotion in art, similar to how musical tones worked together in harmony or dissonance. Seurat believed that he could create a new artistic ââ¬Å"languageâ⬠using perception, color, and lines. He called this theoretical visual language ââ¬Å"chromoluminarism;â⬠today, itââ¬â¢s included under the term divisionism, referring to how the technique requires the eye to combine adjacent colors, rather than the artist mixing pigments before painting. Family Life and Famous Work Right on the heels of the debut of Bathers at Asnià ¨res, Seurat began work on his next piece, which would come to be his most famous and enduring legacy. A Sunday Afternoon on the Island of La Grande Jatte depicts members of different social classes all spending a leisure afternoon at a park on the waterfront of the Seine in Paris. Sunday on the Island of la Grande Jatte by Georges Seurat. To create the painting, Seurat used his color and pointillism techniques, using tiny dots of individual colors overlapping and adjacent to each other so that they would be ââ¬Å"blendedâ⬠by viewersââ¬â¢ eyes, rather than mixing the paints themselves. He also prepared for the painting by spending significant time at the park he depicted, sketching his surroundings. The resulting painting measures 10 feet wide and currently is displayed at the Art Institute of Chicago. A smaller, related study, Study for A Sunday Afternoon on the Island of La Grande Jatte, resides in New York City in the Metropolitan Museum of Art. Although Seurat never married, he had a significant romantic relationship with Madeleine Knobloch, an artistââ¬â¢s model. She was the model for his 1889/1890 painting Jeune femme se poudrant, but they took pains to conceal their relationship for some time. In 1889, she moved into Seurats apartment, and she became pregnant sometime in 1889. The couple moved to a new apartment to accommodate their family, and Knobloch gave birth to their son, Pierre-Georges, on February 16, 1890. Final Years and Legacy During the summer of 1890, Seurat spent most of his time at the commune of Graveline, along the coast. He was incredibly prolific that summer, producing four canvas paintings, eight oil panels, and several drawings. Out of his works from that time period, the most notable was his painting The Channel of Gravelines, Petit Fort Philippe. The Channel at Gravelines, in the Direction of the Sea by Georges Seurat. Francis G. Mayer / Getty Images Georges Seurat began working on another painting, The Circus, but he did not live to continue innovating and working. In March 1891 he fell ill, and on March 29, he died at his parentsââ¬â¢ home in Paris. The nature of the illness that caused his death is unknown; theories include meningitis, diptheria, and pneumonia. Whatever the illness was, he passed it on to his son Pierre-Georges, who died weeks later. Madeleine Knobloch was pregnant at the time, but their second child did not survive long after birth. Seurat was buried on March 31, 1891 at Cimetià ¨re du Pà ¨re-Lachaise, the largest cemetery in Paris. He left behind a legacy of significant artistic innovation, despite dying at the very young age of 31. Seuratââ¬â¢s use of color and his work with pointillism have been his most enduring artistic legacies. In 1984, nearly a century after his death, Seuratââ¬â¢s most famous painting became the inspiration for a Broadway musical by Stephen Sondheim and James Lapine. Sunday in the Park with George is inspired by the painting, and the first act of the musical depicts Seurat himself in a highly fictionalized way, imagining his creative process. The musical focuses more on his artistic pursuits but also does depict a fictionalized version of his personal life, notably in the character of his mistress ââ¬Å"Dot,â⬠who seems to be an avatar for Madeleine Knobloch. Art students still study Georges Seurat today, and his influence on other artists began not long after his death. The cubist movement looked at his linear structures and form, which then influenced their ongoing artistic developments. And of course, even young children in the modern world learn about pointillism, usually through A Sunday Afternoon. Despite his short life, Georges Seurat established himself as a key and permanent player in the art world. Sources Courthion, Pierre. ââ¬Å"Georges Seurat: French Painter.â⬠Encyclopaedia Britannica, https://www.britannica.com/biography/Georges-Seurat.Georges Seurat, 1859ââ¬â1891. New York: Metropolitan Museum of Art. 1991Jooren, Marieke; Veldink, Suzanne; Berger, Helewise.à Seurat. Krà ¶ller-Mà ¼ller Museum, 2014.
Thursday, November 21, 2019
Health Care Ethics Assignment Example | Topics and Well Written Essays - 500 words - 2
Health Care Ethics - Assignment Example The surgical group from Manhattan identifies the value attached to time that is why they have posted doctorsââ¬â¢ schedule on their website, and it refreshes after every ten minutes. Current lifestyle has forced middle-class people to be busy time after time. Therefore, with a website that shows the schedule for the appointment is a win of their market. This will make both the patients and doctors to be time conscious and enhance the reputation of the surgical group. Renaming trade-off: If the practices are renamed to include River Valley Associates then the brand of the hospital will grow beyond its territory. However, this is a long-term process since it will consume a considerable amount of time for the brand (practices) to become famous. Not renaming trade-off: There will be confusion among the clients (patients) if the practices are renamed and in severe circumstances client will consider certain services are not offered in that hospital and opt going to another hospital. Therefore, by not changing clients will not be confused, and perhaps market the new practices to other members of the community. New innovation in a market always faces a challenge of breaking through the market, but how the challenges are addressed is what that matters. In this case of health saving account plan, some of the factors to be considered include; culture, and level of income. Culture has to do with the employeesââ¬â¢ attitude towards saving and since this health saving for coverage, it should be marketed intensively. To overcome the problem of saving culture, the hospital can diversify the level of services based on employeeââ¬â¢s capability of saving. This too will have conquered the challenge arising due to the difference in the level of income. Analyzing the cost implication of these two groups, the level of return will be a key element to be considered.
Wednesday, November 20, 2019
Government and Non-Profit Organizations Essay Example | Topics and Well Written Essays - 250 words
Government and Non-Profit Organizations - Essay Example This will not only provide joint support but will initiate some other ways of improving tourism among the youths and the local people. Some of the governmental agencies which the organization can partner with include Ministry of sports and youth affairs, Ministry of tourism, as well as institutions of higher learning in Kenya. The above mentioned government agencies will be highly meaningful in giving support to the realization of the organization goal in various ways. Ministry of sports and youth affairs is in charge of sporting activities in the country as well as establishing the well-being of youths in the country. It therefore has the influence of youths towards visiting the parks. Ministry of tourism is in charge of promoting tourism in the national and international arena. This will provide an avenue for marketing the organization and formulating policies to the local people as well as to the youths hence creating awareness (Jones, 2005). Institutions of higher learning comprising of universities and middle colleges can arrange tour activities such as picnics and adventures to the Nairobi National Park as they are the centre of excellence where many youths are. Despite the efforts by Nairobi National Park to increase the number of local tourist, there are perceived conflicts which are to arise as it partners with government and other agencies. One of the potential conflicts is on the fee to be charged in the entrance. Most young adults do not have enough money to cater for the higher fees charged hence will conflict with the agencies which may introduce small fees. Additionally, the agencies may want to dominate through imposing policies against the organization. The clash in polices will pose a conflict between the organization and government
Monday, November 18, 2019
Successful security management Research Paper Example | Topics and Well Written Essays - 2250 words - 1
Successful security management - Research Paper Example The various area of security that needs attention include: Dalton (2003) traces the roots of contemporary corporate security back to the role of the night watchman prior to the 1960s. In this guise the job of security personnel within businesses entailed little more than acting as a lookout with a primary role of early warning in case of incidents such as fire. Throughout the 1960s and into the latter half of the 20th century this limited early role began to expand and fire watches began to take on more classical security duties including controlling access and egress from properties, patrolling and maintaining perimeter fences and general guarding duties (Gill, 2006). Dalton terms this the ââ¬ËGreen Shack Eraââ¬â¢ as activities were typically based out of such shacks located by the main gate (Gill, 2006). While security management progressed at varying speeds within industries different and between individual organizations a growing role for security departments within the corporate world was apparent. For the most part it moved out of the so-called green shacks and into offices embarking on what Dalton describes as the ââ¬ËPhysical Security Eraââ¬â¢ (Gill, 2006). With the arrival of the physical security era corporate security continued to perform duties such as security patrols but in addition took on responsibilities for responding to medical emergencies, controlling traffic, monitoring equipment, escorting employees and staffing front desks (Gill, 2006). This entirely defensive approach to corporate security could be considered the trademark of the physical security era and to an extent it remains the ethos behind security departments in many large businesses today (Gill, 2006). One of the effects of globalization has been a proliferation in the number of threats which face large organizations with exposure to operational risks all over the world. This in turn has made the job of protecting businesses much more complicated and means the
Saturday, November 16, 2019
The Challenges Faced By Environmental Management Systems Business Essay
The Challenges Faced By Environmental Management Systems Business Essay This research is about the Environmental Management System (ISO 14001) and does the packaging companies adopted (ISO 14001) because as we know packaging industry is one of the industry that generate massive amount of waste. Thus this waste must be managed carefully to reduce the impact to the environment. Further investigation will be carry out into the role that the packaging companies played towards the current environmental issues. Basically an Environmental Management System is a management system that can helps an organization to manage its environmental impacts and also a way which can minimize such impacts effectively in the long run. The packaging industry is an industry that responsible to enclosing or protecting certain products for distribution, longer duration of storage and also for marketing purposes to attract consumers. The environmental issue has been always the world agenda since early of 1992 when a group of international organisations for examples the United Nations Conference in Environmental and Development, World Health Organization and also the Non- Governmental Organization setting standards to maintain sustainable environment. The term sustainable environment was used by the well known Brundtland Commission which is now widely been quoted as development that meets the needs of present without compromising the ability of future generations to meet their own needs. The Environmental Management System (ISO 14001) is one of the standards in the ISO (International Organization for Standardization) family tree and the British Standard BS 7750 was the first standard to be created at that time. According to Krut and Gleckman (1998): This international association of national standard- setting bodies was set up to facilitate international commerce by standardizing technical specifications. It works closely with the International Electrotechnical Commission (IEC). In many areas, from ATM cards to telecommunication bandwidths to plumping supplies, business and the public experience significant advantages from ISO and IEC activity. (Kurt and Gleckman, 1998, pp.2). Although the issues of environmental being a great debate from different group of people especially the environmentalist but there is still lack of awareness among the public itself. This is also due to the lack of commitment from the local government to convey this important message to the public. This topic was chosen because the researcher took the subject of Environmental Issues in Business before and found that in order to sustain in a business first we have to understand well about what is the Sustainable Environment and how does it affect a business in the long run. Research Aims Objectives The aim of this research is to examine the Environmental Management System (ISO 14001) practices in packaging companies located in North East of England. This followed by 3 objectives to fit with the aim above and there are: to identify the reasons of the adoption of the Environmental Management System, to identify the problems companies faced when getting certified to ISO 14001, and lastly to examine the companys performance before and after adopting the Environmental Management System. Literature Review In this section will discuss about the previous research has been done to this topic and also demonstrate to the reader how well does the researcher knows about this particular topic of Environmental Management System (ISO 14001). Saunders, Lewis and Thornhill (2007, p.57) commented that reviewing the literature critically will provide the foundation on which your research is built and also the main purpose is to help the researcher to develop a good understanding and insight into relevant previous research and the trend that have emerged. There are plenty of books, journals and articles discussing about the environmental issues, how does the industrial sector can minimize their waste by adopting the Environmental Management System and also why businesses needs to play an important role towards the sustainability of the environment. No doubt all human being living in this world today does created much of their own waste (motor cars and the consumptions of CFCs in air conditioners or refrigerators) to the environment itself but the waste and pollutions created from the industrial sector are much more severe. According to Whitelaw (1997): If we look back to the to the Industrial Revolution, we might see this as the period when the inventiveness and innovation of human beings, and the resultant mechanization of manufacturing processes began to have negative impacts upon the environment. Prior to this period, any negative environmental impacts tended to be localized for example, forest were cut down without any future regard. (Whitelaw, 1997, pp. 2). Another author does agree with the same argument above and stated that: Businesses are the core of the environmental debate and are central both to the pollution problem and to the solutionthe activities of industry provide employment, and investments drive economic growth. However, in doing so, be it because of the resources that they consumer, the processes they apply or the products that they manufacture, business activities are a major contributor to environmental destruction. (Welford, 1994, pp. 3). One of the solutions for businesses to minimize their wastage is to implement the Environmental Management System (EMS) and getting certification of ISO 14001. Jorgensen (2000) defined the EMS: An EMS is part of the enterprises overall management system. It includes the organizational structure, planning activities, responsibilities, practices, procedures, processes and resources for implementing and maintaining environmental management. It includes those aspects of management that plan, develop, implement, achieve, review, maintain and improve the enterprises environmental policy, objectives and targets. (Jorgensen, 2000, pp.75). Implementing the EMS does not only helps businesses to reduce their wastage but also will improve the environmental performance and this can lead to a better corporate image of the businesses itself. According to Jorgensen (2000): EMS offers a structured and systematic method to incorporate environmental care in all aspects of business. The aim is not only to comply with environmental regulations and minimize the (financial) risks of liabilities and costs but to improve the environmental performance continuously and through this improve corporate image and gain competitive advantage. (Jorgensen, 2000, pp. 75). There are many large organizations for example BT Group in UK which takes the environmental management very seriously into their business. According to BT Group: In 1990 the BT Board made a commitment to optimise environmental management across the company. Since then, we have made real strides towards our goal of world class environmental management. Climate change is higher than ever on the agenda for government and business. BTs response to this is a new plan which takes some ambitious steps to cut our emissions of carbon dioxide. Having already reduced our carbon footprint by 58% in the UK, we have now set a target to achieve an 80% reduction in our carbon intensity worldwide by 2020. BT consumes 0.7% of the UKs entire electricity, so we think we can make an important difference. We have pledged to reduce the amount of carbon we emit as a business and help others to do the same. We are encouraging our suppliers, customers and employees to take action. We also believe that communications technology can be harnessed to help address climate change. (http://www.btplc.com/Societyandenvironment/Environmentandclimatechange/Environmentandclimatec hange.htm, no date). Further discussion of the objectives and more detailed literature review will be covered in the later part of this research project. Methodology Research Approach Strategy The research approach that will be use to apply in this topic is the Inductive Approach. Saunders, Lewis and Thornhill (2007, p. 118) commented that the purpose (Inductive Approach) here would be to get a feel of what was going on, so as to understand better the nature of the problem. This approach is best to be combining with the qualitative data and is being suggested to use different kind of methods to collect the data in order to get different point of view. (Saunders, Lewis and Thornhill, 2007, p.119). Since the environmental issues can be categorized under the real life context, the Case Study Strategy is more suitable to use in this research as the case study strategy is based on a real life context investigation. Types of information required Information that is required for this research is to find out how the environmental issues affect the business sector especially the packaging companies in the north east of England (regulations that needs to be follow, government, investor and also the public pressure), did the business owners take any initiative to protect the environment, some useful data from the Environment Agency in UK, why those companies choose to adopt the EMS or get certified for ISO 14001 (corporate image, attract more investors and consumers, able to help the companies in certain way or just for the seek for adopting it) and lastly to compare the performance before and after adopting the EMS and also to create awareness to the companies that the importance of sustainable environment/business. Data collection The main data collection for this research project will be from conducting an interview with around 8 packaging companies that are located in the North East of England. The length of each interview will be approximately 15-25 minutes. Voice recording, video recording and notes taking will be acquire to form a transcript at the later part for this research. Semi- structured interviews is the type of interview to be use in this research as questions from interview can be omit or vary according to the background of the company and also the background of the interviewee. Secondary Data The secondary data collection is also one of the ways to collect data for the research project. Secondary data consists of 3 types and there are Documentary Secondary Data, Multiple Source- Secondary Data and the Survey Secondary Data. In order to meet the objectives in this research project, reports and database from the potential companies are very valuable and in addition the journals, articles, newspaper and also books publication could also be sources for this research. Documentary Secondary Data and the Multiple Source- Secondary Data will be used in the research. Methods/Strategy linked to project objectives
Wednesday, November 13, 2019
Why we dropped the Atomic Bomb Essay -- essays papers
Why we dropped the Atomic Bomb The dropping of the atomic bombs on Hiroshima and Nagasaki in August of 1945 was a definite turning point in the Pacific War of World War II. Earlier that year, Germany had been defeated and the world then turned its attention to the Pacific war. Most history books state the argument that the dropping of the atomic bombs on Japan was necessary to stop the war in order to save thousands of lives of American troops that were planning to invade Japan. "Had the bombs not been employed (so the "wisdom" goes), an enormous number of American troops would have perished in an inevitable amphibious operation against the Japanese mainland."(McManus 1) This paper will demonstrate that Japan was willing to surrender before the bombs were used, and there were other hidden reasons for using the bombs. If you ask a high school graduate what the result of the atomic bombs on Japan was, he or she would most certainly answer the immediate surrender of all Japanese forces. That should be satisfactory enough to not question the issue any further. If you ask the same student wether the Japanese would have surrendered without the bombs, he or she will hesitate and will probably not be able to give an answer. The reason for this is that the history text books at school teach students a black and white fact: the atomic bombs were the only way to make the Japanese surrender. According to Francis E. Kazemek: "most texts focus on abstract facts and figures, offering little discussion of the reality of the bombing."(Kazemek 2) The atomic bomb should not be considered as the only decisive factor for the Japanese surrender, but as the straw that broke the camel's back. After the attack on Pearl Harbor, the Japanese empire continued to expand rapidly during the first half of 1942. Its empire extended from Manchuria and the Aleutian Islands to the north, New Guinea to the south, Burma to the west and the Marshall Islands to the east. Nevertheless, the tide turned against Japan when Germany was defeated in May 1945 and the Americans took over the Marian Islands in 1944.(Long 1) The Americans needed the Marian Islands as an air base to be able to bomb Japan directly. Winston Churchill wrote in his personal narrative of the Second World War, "The time at last had come to strike at the enemy's homeland."(Churchill 540) Before then, J... ...as with the war in the Pacific. The Japanese were not easy to fight and deal with. The fact that the Japanese wanted to have peace talks before the bombs were used makes it clear that there were different reasons for using the bombs. Ending the war with Japan as soon as possible was important to stop Stalin from claiming territories in the far east. The United States had seen what Stalin was doing in Europe, and did not want Stalin any stronger. The fact that the bomb had been successfully tested, and had cost the United States billions compelled the President to use it. The racist feelings towards the Japanese the decision to drop the bombs easier. Nevertheless, many people share what Brigadier General Paul W. Tibbet, pilot of the Enola Gay, had to say:"Those of us who gained that victory have nothing to be ashamed of neither do we offer any apology. Some suffered, some died. The million or so of us remaining will die believing that we made the world a better place as a result of our efforts to secure peace that has held for almost 50 years. Many of us believe peace will prevail through the strength and resolve of the United States of America."(Airmen Memorial Museum)
Monday, November 11, 2019
Graham Greeneââ¬â¢s four fundamental requirements Essay
Westerhoff narrates about Graham Greeneââ¬â¢s four fundamental requirements for leading a spiritual life. (1) willingness to embrace suffering of world while enduring oneââ¬â¢s own (2) a life of solitude and silence (3) introspection of deep restlessness within spirit (4) to see the image of God (Christ) within the community of faith. (John. H. Westerhoff 1994, 30) To preach or to teach, expertise level of human knowledge and understanding is required in order to communicate verbally without hurting others. There were no instances in Bible where Jesus hurted disciples or followers. Jesus was above solutions and problems and that is why offered a formulae by saying ââ¬Å"Take my yokeâ⬠which means accepting oneââ¬â¢s own suffering along with worldââ¬â¢s suffering. ââ¬Å"My burden is lightâ⬠(St. Matt. 11:29) which includes a fact that Jesus carries the burden along with those who are practicing Jesus teachings. Spiritual life with God can be compared with a grape wine climber as Jesus said ââ¬Å" I am the true vineâ⬠(St. John 15:1) ââ¬Å"Abide in me and I in youâ⬠(St. John 15:4) . A constant communication with God or clinging to the word of God leads to spiritual formation. ââ¬Å"If ye abide in me, and my words abide in you, ye shall ask what ye will, and it shall be done unto youâ⬠. (St. John15:7). Communication with God through prayer is explained by Urban Holmes in the book ââ¬Å"A History of Spiritualityâ⬠(John H. Westerhoff 1994, 53) wherein knowing God in two different methods. (1) Kataphatic means knowing God indirectly in which relationship with God is mediated (2) apophatic means, knowing God directly and where there is no mediation. Speculative-kataphatic encourages rationalism. Further this school of prayer is based on imaginary senses and even includes writing of conversations with God, while affective-kataphatic encourages pietism which is more charismatic and includes all the bodily expressions and senses in complete contact with God (e. g. clapping, moving body, shouting etc). ,. Speculative-apophatic leads to encratism while affective-apophatic leads to quietism. The four symbols of four categories are : speculative-kataphatic = ââ¬Å"Sâ⬠, speculative-apophatic = ââ¬Å"Tâ⬠, affective-kataphatic = ââ¬Å"Fâ⬠, affective-kataphatic = ââ¬Å"Nâ⬠. These categories offered by Jung are applicable in prayer and devotion according to the personal preferences. Schools of spirituality can only be applied as an aid for spiritual growth. Prayer purifies souls, castes away unhealthy minds and thoughts and brings closer to God who is an embodiment of love. (St. John 3:16) (I Corinthians 13). God also said ââ¬Å"Seek ye first the kingdom of God, and all these things shall be added unto youâ⬠. Seeking God amidst of daily lives and chores. Karl Rahner, the Jesuit priest-theologian, in a letter to God, discusses about tiring hours of activities in a day and how the time is not allocated to God and lays emphasis on how important it is to be in relation with God. Further states that for the entire mankind seeking Godââ¬â¢s guidance and support amidst of daily life, is another way of practicing Godââ¬â¢s presence. Conclusion Prayer is the only means and a wonderful gift of God to be in constant relation with God. Prayer is a strong weapon that has been used by several preachers in the past such as King Martin Luther, D.L. Moody, John Wesley, David Livingstone and several holy and pious preachers. The present international evangelists and Bible preachers include Dr. Billy Graham (BGEA)and Charles Stanley (In Touch Ministries) who believe concretely in the power of prayer. The preachers who dedicate hours of prayer to God, receive visionary experiences, divine power to deliver gospel of God. Preachers have to maintain a dual relation, one with God and second with those who are receiving the gospel/word of God.
Friday, November 8, 2019
Gerardus Mercator essays
Gerardus Mercator essays On March fifth, 1512, a boy soon to be one of the greatest influences on the exploration of our planet, was born. Originally named Gerard de Cremere, Gerardus Mercator first studied at Hertogenbosch in the Netherlands, then in 1530, at the age of 18, entered the University of Louvain, studying humanities and philosophy. From there he graduated with an M.A. in 1532. After graduating, Mercator began to have worries on how to reconcile the account of the origin of the universe given in the Bible with that given by Aristotle. Although traveling to many places, including Antwerp and Mechelen, the only result he obtained from his travels was that he became deeply interested in geography. Mercator returned to Louvain after realizing his true passion, and studied mathematics under Gemma Frisius, instrument making and engraving under Gaspar Myrica, and learned how top apply mathematics to geography and astronomy, and in 1534 married Barbara Schellekens, by whom he had six children. By the time he was 24, Mercator was a superb engraver, an outstanding calligrapher, and a highly skilled instrument maker. In 1535 1536, Mercator, working with Myrica and Frisius, constructed a terrestrial globe. In 1537 they constructed a globe of the stars. Mercator, from 1537 1540, produced maps of Palestine, Flanders, and the world with a new projection. In 1544 Mercator was charged with heresy partly due to his Protestant beliefs, but also because of the fact that he traveled so widely to acquire information for his maps, suspicions were aroused. After spending seven months in prison, he was released, mainly due to strong support from the University of Louvain. Then in 1552, he moved to Duisburg and opened a cartographic workshop. Once in Duisburg, Mercator completed a project to produce a new map of Europe (1554) and taught mathematics from 1559 to 1562. In 1564, more maps followed: one of Lorraine and one of the British Isle...
Wednesday, November 6, 2019
The Secret of Quiche Maya Essays
The Secret of Quiche Maya Essays The Secret of Quiche Maya Essay The Secret of Quiche Maya Essay When creation begins, according to Popol Vuh, there is nothing but the sky and the darkness. The face of the earth is not yet formed and the seas cover the surface. The Gods are the only ones who exist at this point in time. ââ¬Å"Whatever might be is simply not there: only murmurs, ripples, in the dark, in the night.â⬠(Tedlock 72) This shows the emptiness of the universe and the need for creation by the Gods.In the first decision about creation there are many aspects of the Gods present. Three of these, Thunderbolt Hurricane, Newborn Thunderbolt and Raw Thunderbolt are aspects of one God, Heart of Sky. Plumed Snake consisted of many entities: the Bearers, Begetters, Sovereign Plumed Snake, the Maker and the Modeler, all of which were the water. ââ¬Å"So there were three of them, as Heart of Sky who came to Sovereign Plumed Serpent, when the dawn of life was conceivedâ⬠¦Ã¢â¬ (Tedlock 73) So Heart of Sky along with Sovereign Plumed Serpent discus ses the creation about to unfold and how they should go about it. They discuss the options and rules for creation before they begin. The Gods here represent the sky and the ultimate creator.When the Mayans go to create the world they begin by speaking the word ââ¬Å"Earthâ⬠. When they do this, the seas begin to recede and the mountains rise above the sea. Trees begin to grow on the mountainsides. ââ¬Å"Now they planned the animals of the mountains, all the guardians of the forests, and creatures of the mountains: the deer, birds, pumas, jaguars, serpents, rattlesnakes, yellowbites, and guardians of the bushesâ⬠¦when this deed had been done, all of them had received a place to sleep and a place to stay.â⬠(Tedlock 76, 77)The motive for creating humans was to have someone to speak the names of the Gods and praise their works. They wanted to be ââ¬Å"â⬠¦invoked and remembered on the face of the Earth.â⬠(Tedlock 79) The animals they had created could not speak and so could not sing their praises. Another motive was that someone was needed for the ââ¬Å"time of planting and the dawnâ⬠¦So now let us try to make a giver of praise, giver of respect, provider, and nurturer.â⬠(Tedlock 79)The early humans were created out of earth and mud. They crumbled easily, could not turn their heads and spoke nonsense at first then not at all. They dissolved in water and had no mind of their own. The Gods dissolved them and started over. The next humans were made of wood and were humans in looks and speech. They multiplied with daughters and sons but, ââ¬Å"There was nothing in their hearts and nothing in their minds, no memory of their mason and builder. They just went and walked wherever they wanted. The Gods were angry about this and destroyed them with a mighty flood.â⬠(Tedlock 84)The Popol Vuh is a representation of the Mayan culture and beliefs. This manifests that they are polytheistic in nature, where they believe in many gods, an d that these gods were the ones that created them. According to the Popol Vuh, Mayans see destruction as a way of life, since it leads to the creation of new things. In the Popol Vuh, it can be seen that in order to come up with the ââ¬Å"perfect human creation,â⬠the gods underwent several destruction procedures at the times where their creations have gone wrong. The Mayan concept of creation was like other concept of creation of other cultures, where there was nothingness at first, only the gods exist. And out of their boredom, they decided to create living creatures, something that would keep them company, creatures that would acknowledge their power.The Popol Vuh was able to serve two major purposes. The first one was before the year 1550 when it was written for the first time in a European language and therefore made available to the world. Thus, before 1550 it was a communication device that gave information and of course was used to entertain the native Indians when the re was a gathering. More than that, it gave the natives of Central America a sense of identity. This then translates to unity, a backbone for nation building. It can be said that the magnificent Mayan civilization would not have been possible without having the social glue that holds people together and organize them into their social ranks. The myth contained in Popol Vuh allowed them to accept why things are the way they are. This also gave them a thing to look forward to since the Popol Vuh includes in its multiple books the exploits of their past leaders. This can serve as a motivational force for the present leadership of that time to do good for they are assured of immortality when historical accounts are handed down from generation to generation.The second major purpose of the Popol Vuh is the rich information it provides for the people in the modern age. Specifically, it will surely help in peeling away the layers of the enigma that shrouds the sudden and total collapse of t he Mayan civilization. By unlocking it by way of translation, the world is now privileged to look deeper and far into the ancient world of the Mayans. Ditchburn was able to trace back the connection between the Popol Vuh and that great Mayan civilization and he wrote, ââ¬Å"In the sixteenth century, the territory immediately to the south of Mexico, which is now the Republic of Guatemala, was inhabited by various independent nations which were descended from the ancient Mayaâ⬠¦Ã¢â¬ (2003). So whoever was the original author of the Popol Vuh manuscript was able to record what happened during the last days of the Mayan civilization. It is now up to the anthropologist to look at the evidence and offer some clue to finally solve the mystery. To give a clear perspective of why this is so important, Arthur Demarest put it succinctly, ââ¬Å"The rise of civilization in a rainforest was baffling [â⬠¦] The rain forest setting of the Maya continues to challenge our interpretations a nd understanding of this environment (2004).The Popol Vuh may have been created as a form of resistance to the Spanish, since at that time, Spanish invaders came and seized their lands. If you look closely at the text where the Mayan gods destroy the men they created because they werenââ¬â¢t doing what they wanted, it could be associated with how the invaders do things. They force the Mayans to do things, and when the Mayans resisted, they get harmed, and worse, they get killed.The myth and saga found in the multiple books of Popol Vuh helps to see the ancient world in a different light. Together with the majestic temples and public structures built by the Mayans and the pieces of history found in the Popol Vuh it does not cease to amaze any serious student of history the capabilities of ancient peoples. This in turn inspires future anthropologist and archaeologist to not only continue digging but also to continue looking for lost treasures not only in terms of objects but also l iterary works such as the Popol Vuh.
Monday, November 4, 2019
Research Proposal-Intimate Partner Violence Proposal
-Intimate Partner Violence - Research Proposal Example This situation raises further concern because some hospital and clinic-based research bids have also shown that there is an association between increased IPV risk and pregnancy. As such, it becomes necessary for the obstetric-gynecologic nursing department to make rigorous screening so as to handle the health threat posed by IPV. Research has therefore been focused on the significance, completeness, acceptability and accuracy of different screening instruments and methods. Better screening methods and approaches have been identified, but the exercise of screening has not yet attained perfection due to non-disclosure. The problem is disproportionately high among immigrant minorities and this affects implementation of intervention measures to curb IPV. In order to enhance screening there is a need to find out factors that cause non-disclosure, which in turn, affects results obtained and used in decision-making and policy formulation. The determination of these factors will be a helpful step towards finding countermeasures that will help improve the screening process. This paper proposes an approach towards solving the non-disclosure challenge and its underlying causes as well as countermeasures. Key words: Intimate Partner Violence (IPV), Immigrants, Minorities. ... pleteness, acceptability and accuracy of different screening instruments and methods have, either indirectly or directly been the focus of obstetric research. These questions have increased awareness on IPV prevalence, accuracy of screening among various groups and optimal approaches and tools to screening of IPV in the obstetric-gynecologic field (Liebschutz & Chuang, 2002). The results from research bids elicited by such questions have informed the formulation of effective screening of IPV among various groups and appropriateness of methods applied. In spite of improving effectiveness in screening and approaches to screening, nursing practitioners in obstetric-gynecologic nursing have become cognizant of the fact that there are still many cases of ineffective screening. This occurs due to non-disclosure, which is elicited by multiple factors. Cases of ineffective screening are prevalent within immigrant and minority groups and occur to a lesser extent within mainstream populations (Kaguyutan & Shetty, 2002; Pendleton, 2003). Specific factors that influence revelation of information during screening are prominently cited in most pieces of literature on IPV. However, there is a lack of a substantial body of research into the component factors and their relative influence on information revelation during screening and the outcomes of screening. Additionally, there is no comprehensive body of research in to how the factors that influence information revelation and screening can be positively influenced to favor screening. Indeed, effectively ascertaining the significance, completeness, acceptability and accuracy of different screening instruments, is not sufficient in helping improve the screening process (Marks et al., 1998). This is because no matter how effective a
Saturday, November 2, 2019
Homeworrk Questions Assignment Example | Topics and Well Written Essays - 250 words
Homeworrk Questions - Assignment Example The birthright citizenship principle entails getting the citizenship of the United States through circumstances involving birth. Birthright citizenship is provided due to the jus soli. The United States citizenship is given directly to any individual who is born within the country, and is under the authority of jurisdiction of the United States. The US jurisdiction additionally covers the US Virgin Islands, Marianas and Puerto Rico. The birthright citizenship is also granted to children born outside the US to US citizens. Immigrant acculturation entails the aspects of cultural and social change that develops after contact between several cultures. The interaction cultures leads to the changes in cultures, social organizations and customs. Effective immigrant acculturation results into improved health conditions; mainly due to enhanced nutrition and healthcare access. The media is very instrumental in driving cultural integration, hence improves acculturation. Cultural integration is improved through the mediaââ¬â¢s capabilities of information and ideas exchanges; for examples, the exchanges in the performing arts like poetry or
Thursday, October 31, 2019
An Ethical Dilema Essay Example | Topics and Well Written Essays - 750 words
An Ethical Dilema - Essay Example The person spent hours using the company phone lines in setting up of doctorââ¬â¢s appointment or making phone calls to their friends who are from different side of business on company time. Even when the person was in state of using internet in office computer, he had an interest in surfing to different social networking sites on companyââ¬â¢s valuable time. His friend was obsessed with his behavior because it resulted in low performance. The same colleague used to have longer conversations with other colleagues which were irrelevant and had nothing to do with business. The situation did not offered his friend to report this unethical behavior to his supervisor because the person was his dearest friend and he did not wanted the company to take actions against his colleague. Due to his positive nature, the colleague started to continue the behavior excessively and always made his friend involved in his conversations. This also had a negative impact on his performance as he was unable to meet deadlines with the work. Answer 2: If I put myself in the role of an employee that had to deal with his colleagueââ¬â¢s unethical behavior, I would have reviewed code of conduct and the companyââ¬â¢s philosophy regarding the attitude of that employee. I would consult with my other colleagues the particular situation without revealing the name of any person in the scenario. This would help me understand rules of the company regarding an unethical behavior to conduct personal business on companyââ¬â¢s time. Then simply I would pay visit to my colleague and let him know of his unethical behavior which is ruining the culture and philosophy of the organization. I would make him understand that his particular behavior is inflicting my performance curve with greater margins. I would make him realize that the company pays its employees for the work they have performed instead of doing personal business (Rhodes, 1986). If still the matter persisted with consistency, I would approach an ombudsperson that is charged with the duty of handling informal complaints from the working staff. This would allow me to make complaints against any employee regarding their behavior without revealing my name. These complaints are made confidential and the company assures employeesââ¬â¢ anonymity in the case. This is also considered as the whistle blowing concept in which an employee has a right to share the wrongdoing practices happening within the firm to his manager and supervisor. This act would only be possible if actions made by a colleague are recognized as an unethical behavior. I would not be taking actions if the behavior would not have resulted in decrease in my performance (Garber, 2008). Answer 3: Ethical dilemmas often do not have clear responses unless the person has broken the law or regulations that are governed by the organization. The concept of integrity is to make correct choice between right and wrong. Individuals can make good decisions in this case if they have been prepared for the particular situation or their ethical base is strong. A person who commits to integrity will find himself in a right situation before it requires action against an ethical dilemma. In the above case of ethical dilemma, an employee had to make corrections with the colleagueââ¬â¢s behavior. He had to make up his mind that the behavior he was pursuing was unethical and is resulting in low
Tuesday, October 29, 2019
Education for Students with Exceptional Needs Essay Example for Free
Education for Students with Exceptional Needs Essay Education is a detrimental factor to oneââ¬â¢s success. Through formal education an individualââ¬â¢s knowledge is maximized and nurtured. It is because formal education hones the human mind to think critically and helps human mind in improving its decision making ability. Education also allows individuals to learn about history that enable them to better understand the present and face the challenges of the future. Education helps individuals receive information from the external world. The things people learn through formal education are the very foundation that permits them to move up in the world and seek better jobs. While it is true that hands-on-experience is an important aspect to get to the top, formal education and training are also essential to be qualified for top positions. Raw talents are important but they also need honing and the best way to hone them is through experience and assistance through schooling. Education is a must for everyone. Individuals with exceptional needs should also be given equal opportunity to learn and gain knowledge. Teaching students with exceptional needs is indeed a challenge (Adams, 2006). Teachers who wish to impart their services to these individuals should be equipped, trained, and should posses great patience and care. I believe that the experiences and learning that I am gaining from the university would significantly help me to become a better teacher for these individuals. My major helps me understand that the field of special education is an evolving and changing discipline. It is based on philosophies and it involves studying evidence-based principles and theories, which could be complicated without the guidance of experienced professors. In addition, teachers must learn how to communicate effectively with students and parents so that students will have a more enriched learning experience. I have always been taught that sharing knowledge to others is one of the best ways to help people. Teachers are heroes, they say. I do not want to become a hero but I simply want to help others. Individuals with exceptional needs have to be helped so that they could also learn to stand on their own. Giving them education is one way to support these people. It will help the students reach their full potential and give them more confidence. This will also empower parents and give them less worry regarding their children. Sincerity is an important trait of a person working for individuals with exceptional needs. I sincerely want to help them that is why I chose this field as my career. I believe that pursuing a career on the field of special education would give me the opportunity to help others. As a rehabilitation service major, I know that I will be able to impart my knowledge to these individuals and help them in my own little way. Many teachers are not very enthusiastic in pursuing a career in special education since this is a very challenging task. On the contrary, I am one of those who enjoy facing challenges. Since there are only few who choose the path on special education, I decided that I will be one of the few who could make a difference to these individuals with exceptional needs. I also believe that all people could actually learn. However, since each person is unique, appropriate instructional support is needed especially for individuals with exceptional needs. Thus, training is needed to become a suitable teacher for these individuals. That is why I highly appreciate all the things that I learn in the university because I know that the knowledge will help me in my future career.
Saturday, October 26, 2019
Management of Melanoma Brain Metastases (MBM)
Management of Melanoma Brain Metastases (MBM) Abstract: Melanoma is the third most common cause of brain metastases, after lung and breast cancer. Common clinical manifestations include headache, neurologic deficits, cognitive impairment and seizures. The management of melanoma brain metastases (MBM) can be broadly divided into symptom control and therapeutic strategies. Supportive treatment includes corticosteroids to reduce peritumoral edema, antiepileptics for seizure control and medications to preserve cognitive function. Until recently the therapeutic strategies focused on local treatment including surgery, whole brain radiation therapy (WBRT), and stereotactic radiation (SRS). Historically, systemic therapy has had limited utility. Immunotherapeutic drugs like anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and anti-programmed cell death protein 1 (PD1) and agents targeting BRAF- MEK pathway have revolutionized the systemic treatment of MBM. Recent clinical trials with these agents have shown activity against MBM and incre asingly being used in clinical practice. In this article, we will discuss epidemiology, biology of MBM and the role of surgery, WBRT, SRS in this patient population. An overview of the currently available systemic therapeutic agents that includes immunotherapy and targeted tyrosine kinase inhibitors (TKIs) and a practical multidisciplinary management algorithm to guide the practicing oncologist will be outlined. Introduction: Recent advances in the management of advanced melanoma have resulted in improved 5-year survival rates, however, MBM remain a significant cause of morbidity and mortality. Approximately 20% of metastatic melanoma patients have brain metastases at diagnosis.à Overall about 50% of stage IV melanoma patients will develop symptomatic brain metastases (1-3). Cerebral hemispheres are the site of 80% of brain lesions from melanoma followed by the cerebellum (15%) and brainstem (5%)(4).Common clinical manifestations include headache, neurologic deficits, cognitive impairment and seizures. Until recently, patients with MBM had a dismal prognosis with a median overall survival (OS) of 6 months (5). The management of MBM can be broadly divided into supportive management and therapeutic strategies. Supportive treatment includes steroids to reduce peritumoral edema, antiepileptics for seizure control and medications to preserve cognitive function. Traditionally, therapeutic strategies focused on local treatment including surgery, WBRT, and SRS. Historically, systemic therapy has had limited utility in the management of MBM. However, the treatment paradigm has changed considerably with the advent of targeted therapy and immunotherapy. Approximately 50% of advanced melanoma patients harbor a BRAF mutation and a number of targeted agents for this mutation and downstream pathway have shown promise in the management of metastatic melanoma. Immunotherapeutic agents like anti- CTLA-4 and anti- PD-1 have shown clinical efficacy in MBM and now constitute first line treatment options for metastatic melanoma. Biology of brain metastases: Until recently MBM were believed to have the highest mutational discordance compared to the primary site (6).à However, Chen et al. reported molecular profiling that included hot spot mutations, global mRNA expression patterns, quantitative analysis of protein expression and activation by reverse protein array (RPPA) analysis of 16 patients (7). In this study, authors reported complete concordance in mutational profile between intracranial and extracranial sites. Despite these similarities crucial differences in the expression of PI3K/AKT pathway were noted by RPPA. Another study compared the expression of BRAF mutation in different sites of metastases in advanced melanoma and showed greater mutational concordance (16/20 patients) in brain compared to other visceral/subcutaneous metastases (8). These studies provide an initial understanding of the molecular characteristics of MBM. With the advent of immunotherapy, tumor microenvironment and immune infiltration has been a focus of intense research. Brain has been traditionally thought of as an immune privileged organ but recent studies have established the existence of a neuro-immune axis and questioned this belief(9). Our understanding of this unique interplay between the immune system and central nervous system has dramatically evolved over time. Berghoff et al. investigated the expression of PD-1, PD-L1, CD3, CD8, CD45RO, forkhead box protein 3 (FoxP3), CD20, and BRAF V600E by immunohistochemistry in MBM samples (10). Varying degrees of tumor infiltrating lymphocytes (TILs) were reported in this study, 33 out of 43 specimens stained positive for CD3(+) T-lymphocytes, 39 for CD8(+) T-lymphocytes, 32 for CD45RO (+)memory T-lymphocytes, 27 for PD-1(+), 21 for FoxP3(+) T regulatory lymphocytes, and 19 for CD20(+) lymphocytes.à Significant tumoral PD-L1 expression (>5%) was observed in 9 specimens while 22 sam ples stained positive for PD-L1 suggesting role of immunotherapeutic agents in MBM. Prognostic indices Although the median OS of MBM is dismal, approximately 5% patients are long term survivors(2). Hence prognostic factors that predict outcomes and can guide the treatment decisions and enrollment in clinical trials are of value. Several large single center series have examined various primary tumor, brain metastases, and patient characteristics predictive of survival (2, 11, 12). Age, performance status, number of brain metastases, extra-cranial metastases, time from primary tumor diagnosis, presence of neurologic symptoms and elevated LDH are factors that determine survival. (13). Sperduto et al proposed a new disease basedscoring index based on 483 newly diagnosed MBM patients from 8 different centers (14). On multivariate analysis, performance status and number of BMs were prognostic for survival in MBM. The outcomes of ds-GPA MBM varied from GPA class I with survival of 3.4 months to GPA class IV with survival of 13.2 months. These prognostic indices have inherent limitations. All of them were evaluated retrospectively, had only overall survival as the end point, did not include molecular and genetic profile of the primary malignancy, and did not take systemic therapy into consideration (15). A large single institutional experience of 366 patients treated to 1,336 brain metastases has also shed some light on the interplay of important prognostic variables in patients with MBM. In this series, characteristics associated with survival included younger age, lack of extracranial metastases, performance status, and treatment with BRAF inhibitors or immunotherapies. This work specifically highlights the importance of modern out outcomes in patients who are eligible for and receive newer targeted therapies. For example, the 12-month survival estimate for patients treated with BRAF inhibitors was 37% compared to 23% for those patients who did not receive these therapies (p=0.01). Moreover, the 12-month survival e stimate for patients treated with immunotherapies was 47% compared to 22% for those patients who did not receive these therapies (p=0.04). Clearly, further work is needed to define the impact of mutation, targeted drugs and immunotherapy in the current era. Diagnosis: The neurologic symptoms associated with brain metastases include headaches, seizures, cranial nerve deficits to motor or sensory deficits. All melanoma patients with neurologic symptoms worrisome for MBM should undergo a gadolinium enhanced magnetic resonance imaging (MRI) of the brain, if no contraindications exist. Guidelines recommend routine MRI of brain with and without gadolinium contrast for patients with stage IV melanoma due to the high prevalence of asymptomatic brain metastases(16). Computed tomography of brain with and without contrast can be used as an alternate imaging. Management: The options available for management of brain metastases include surgery, WBRT, SRS, systemic therapy and symptom management. The management plan to treat these patients should take into account the overall prognosis, performance status and morbidity associated with the treatment. 5.1 Management of symptoms: Supportive care for patients with brain metastases is typically to control the cerebral edema with steroids. Due to minimalmineralocorticoid effect and long half-life, dexamethasone is the steroid of choice, however, other steroids at an equivalent dose can be used and tapered gradually over a two week period(17). A randomized trial in 1990s compared different doses of dexamethasone ranging from 4 mg/day to 16 mg/day and concluded that 4-8 mg/day would provide same degree of clinical improvement in 1 week (18). Routine use of prophylactic anti-epileptics in patients with brain metastases is not recommended(19). When patients have seizures several anti-epileptics are available including phenytoin, carbamazepine, valproic acid and levetiracetam. Non-enzyme inducing agents like levetiracetam are preferred to avoid interactions with systemic agents. 5.2 Neurosurgical Options: Surgery has traditionally been used for management of solitary brain metastases, or large symptomatic brain lesions. Multiple retrospective studies have reported improved survival with surgery compared to best supportive care(13, 20-22). Younger patients with good performance status, fairly well-controlled extracranial disease, solitary brain metastasis, lesions in accessible locations and of small size generally have better outcomes with surgery (21, 23). Surgery is usually followed by radiation boost to the surgical bed by either WBRT or SRS, with an intention of sterilizing the surrounding tissues and preventing local recurrence. Two randomized trials comparing adjuvant WBRT to surgery alone have shown improvement in outcomes(24, 25). Patchell et al. evaluated the role of WBRT post-resection of a single brain metastasis compared to surgery alone(25). Postoperative WBRT resulted in a significant reduction in local and distant intracranial failure. However, no difference in the over all survival or time duration of functional independence was noted. Similar results were seen in the EORTC 22952-26001 study with decreased 2-year intracranial and resection site recurrence without significant survival benefit. Multiple retrospective reports of post-operative SRS have shown improved patient outcomes however prospective data is awaited (26, 27). Bindal et al. showed benefit of resection in select group with multiple metastases in a retrospective review of 56 patients(28).à In practice, surgery plays an important role in debulking or removal of life-threatening lesions. Surgery also provides immediate relief from intracranial hypertension by eliminating the mass effect, and symptomatic hydrocephalus by reestablishing the flow of cerebrospinal fluid (CSF). 5.3 Whole brain radiation therapy: Melanoma brain metastases lesions are generally considered radio-resistant compared to other histologies (29). Randomized trials with WBRT have reported survival in the range of 2.4 to 4.8 months.(30) The ideal dose and number of fractions, balancing the intracranial control and cognitive decline, has been subject to intense debate.à WBRT fraction sizes of âⰠ¤ 3 Gy do not lead to significant neuro-cognitive decline. A retrospective study compared higher dose of radiation, 40 Gy in 20 fractions with 30 Gy in 10 fractions(31). The 40 Gy group had overall survival of 5.6 months compared to 3.1 months. However most of these trials were not melanoma specific and included patients with all tumor types. Patients who are symptomatic with change in mentation, headaches and seizures but are deemed unfit for surgery or SRS due to large number of metastases, poor performance and uncontrolled extracranial metastases are generally treated with WBRT(32). 5.4 Stereotactic radiation therapy: Stereotactic radiation has been increasingly used in the management of MBM in the last two decades. SRS in MBM results in local control rates of 50-75% at 1 year(33-35). SRS is generally limited to lesions smaller than 4 cm in diameter (36).à In a retrospective review of 333 patients treated with SRS showed a sustained tumor control rate of 73%(35). The 12-month cumulative incidence of local failure was 14% in another single institution experience of 191 patients treated to 793 MBM.à Number of brain metastases that can be treated with SRS has been intensely investigated. SRS for solitary brain metastasis was compared to surgery plus WBRT in a phase III trial that closed prematurely due to poor accrual. The overall survival, freedom from local recurrence and neurological death rates were similar in both groups(37).à Several studies have evaluated the role of SRS in patients with 1-3 brain metastases (38, 39). Aoyama et al. compared SRS alone with SRS followed by WBRT in patie nts with 1-4 brain metastases(38). No difference in neurocognitive function and survival was observed. SRS-alone arm had increased local and distant intracranial failure. A phase III trial compared WBRT followed by SRS to WBRT alone, in 333 patients with 1-3 brain metastases from different histologies that included only 13 MBM patents (40). Performance status at six months improved significantly with addition of SRS to WBRT. SRS for patients with 5-10 brain lesions was evaluated in a multi-institution prospective observational Japanese study of 1194 patients(41). The overall survival, neuro-cognitive function and post SRS complications did not differ for patients with 5-10 brain lesions compared to 2-4 brain lesions(42). 5.5 Systemic therapy: Traditional systemic therapy had a limited role in MBM due to challenges of drug delivery in the brain from blood brain barrier (BBB) with its tight junctions and efflux pumps (P-gp and MRP transport proteins) (43). The concept of localized disruption of BBB at the site of brain metastases has been proposed, as demonstrated on MRI by contrast enhancement (44). Chemotherapy: Chemotherapy agents have not shown good activity in MBM. Dacarbazine which is the approved chemotherapy for metastatic melanoma does not cross the BBB(45). A number of studies evaluated the role of alkylating agents with good BBB penetration such as temozolomide (TMZ), lomustine and fotemustine in MBM patients. In a phase II trial Agarwala et al. enrolled 151 MBM patients with no local radiation therapy for BM to receive TMZ (46). TMZ use showed a modest intracranial response of 6%, median PFS of 4.3-5.2 weeks and median OS of 3.2 months. Two phase II trials of WBRT with TMZ(47, 48); or thalidomide, WBRT with TMZ (49) failed to improve the response rates significantly. Lomustine in combination with TMZ showed modest efficacy in a phase I/II study(50).à Intracranial activity of fotemustine was first reported in a phase III trial of fotemustine versus dacarbazine for metastatic melanoma (51). This led to a randomized phase III trial that compared fotemustine plus WBRT to fotemustine alone in MBM (52). The response rates were 7.4% for fotemustine alone and 10% for fotemustine plus WBRT. Fotemustine is not currently approved by FDA for use in MBM due to delayed thrombocytopenia and leukopenia(53). Targeted therapy: BRAF, NRAS and KIT are three common, mutually exclusive driver mutations seen in metastatic melanoma (54, 55). Of these three, BRAF mutation is the most common mutation seen in approximately 40-50% of patients with advanced melanoma. The presence of BRAF, NRAS increases the risk of CNS metastases seen in patients withà advanced melanoma. Prior studies have reported 24% CNS metastases rate in BRAF and 23% CNS metastases incidence in NRAS mutant melanoma compared to 12% rate in those who lack these mutations(56). Dabrafenib and vemurafenib target BRAF V600 mutation and FDA approved for metastatic melanoma. A phase I trial of dabrafenib in ten patients with untreated asymptomatic brain metastases, intracranial response was seen in 8 patients (four CR, four PR) (57). This impressive 80% response rate prompted the phase II trial of dabrafenib in BRAF mutant melanoma brain metastases (BREAK-MB) (58). This multicenter open label study accrued 172 patients asymptomatic brain metastases with BRAFV600E or BRAFV600K mutation and one measurable lesion (defined as atleast 1 cm in diameter). Cohort A consisted of 89 patients who were radiation naive and cohort B consisted of 83 patients who had failed prior radiation therapy for BM. BRAFV600E patients had an intracranial response rate (IRR) of 39% (29/74) in cohort A and 31% (20/65) in cohort B, PFS of 16.1 weeks in cohort A and 16.6 weeks in cohort B with OS of 33.1 weeks in cohort A and 31.4 weeks in cohort B. BRAFV600K patients had a lower IRR of 7%(1/15) in cohort A and 22% (4/18) in cohort B. This trial supports the efficacy of dabrafenib in BRAF mutant MBM patients, especially those with BRAFV600E mutations with acceptable toxicity. In an open label study of 24 non-resectable, untreated MBM patients harboring BRAFV600 mutation, treatment with vemurafenib resulted in tumor regression of more than 30% (7/19)and partial response was seen in 3 patients. Median PFS and OS was 3.9 and 5.3 months respectively in this study. In a phase II study, 146 BRAF mutant MBM patients were treated with vemurafenib(59). The first cohort included 90 patients with untreated BM, the second cohort comprised of 56 patients with previously treated BM.à Complete response was noted in 2 patients, with 14 PRs, and a best objective response rate of 18%. In previously untreated MBM, the median intracranial PFS and OS were 3.7 months and 8.9 months respectively. Previously treated MBM had similar PFS and OS of 4.0 months and 9.6 months respectively. There is no prospective data of safety and efficacy of combination of BRAF inhibitors and radiation therapy. Most reports are retrospective in nature with increased incidence of dermatitis seen in extracranial skin associated with concurrent use of BRAF inhibitors and radiation (60). Rompoti et al. reported five patients with MBM treated with combined radiation and BRAF inhibitor(61). Two patients underwent SRS and three received WBRT. Patients treated with SRS did not experience any skin adverse effects while all three patients treated with WBRT noted grade1/2 dermatitis. A retrospective analysis evaluated effectiveness of vemurafenib and radiation in BRAFV600 MBM (62). All of them received vemurafenib, six patients underwent SRS, two received WBRT, one received SRS and WBRT and three underwent surgery and radiation. Thirty-six of the 48 index lesions responded with 23 (48%) CRs and 13(27%) PRs. Major limitations were the retrospective nature of the study, small number, and pretreat ed patients with radiation and systemic therapy including ipilimumab. Several small retrospective case series have reported outcomes of MBM treated with targeted agents and SRS/WBRT (Table-1). A recent study of 19 patients with BRAF mutations undergoing SRS and concurrent BRAF directed therapies has shown impressively few local failures (12-month cumulative incidence of 1%). Additional studies of combination therapy are clearly warranted. Immunotherapy: Melanoma is an immunogenic malignancy (63) with a high mutational burden that results in high number of neo-antigen(64). It has been proposed that the relatively high neo-antigen burden makes this malignancy more susceptible to immunotherapy. However, the brain has traditionally been considered an immunologically privileged site due to the presence of the BBB. Recent studies on the intracranial tumor microenvironment as elucidated above have suggested otherwise, showing CD8 T-cells, CD 20+ cells, T-regulator cells and PD-L1 expression within intracranial tumor(10). The intracranial activity of interleukin-2 (IL-2, one of the first immune modulatory agents) was reported in two retrospective reviews(65, 66).à A response rate of 5.6% was seen in 37 patients with untreated brain metastases within a larger group of 1069 metastatic melanoma and renal cell carcinoma patients treated with high dose IL-2(65). In a second report, two of the 15 brain metastases patients treated with high dose IL-2 showed CR (66). No prospective trials were initiated with high dose IL-2 due to concerns for cerebral edema and neurotoxicity. Two pathways that have revolutionized the management of advanced melanoma are those involving CTLA-4 and PD-1/PD-L1.à The CTLA-4 receptor is expressed exclusively on T-cells and downregulates the interaction between antigen presenting cells and T-cells. Ipilimumab is a fully human monoclonal antibody against the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)(67). The pivotal phase III trial that compared ipilimumab with or without gp 100 peptide vaccine to gp 100 vaccine as a single agent allowed enrollment of patients with asymptomatic and/or previously treated MBM (68). A non-significant trend towards better survival in the MBM subgroup was noted among the patients treated with either ipilimumab alone or ipilimumab plus gp 100 compared to gp 100 alone(69). In an expanded access program (EAP) in Italy, 146 MBM patients received ipilimumab and a global response rate of 12% was seen (70). An American EAP reported a 1-year overall survival rate of 20% among 165 MBM patients tr eated with ipilimumab (71). Margolin et al. conducted an open label phase II clinical trial of ipilimumab for MBM (72). The trial enrolled 72 patients 51 patients in cohort A (those who were not on steroids for cerebral edema) and cohort B of 21 patients (on treatment with steroids). According to the WHO criteria, the response rate was 18% (9/51) in cohort A compared to 5% (1/21) in cohort B, and by immune-related response criteria the response rate was 25% (12/51) in cohort A and 10% (2/21) in cohort B. The median OS was 7.0 months and 3.7 months in cohort A and cohort B respectively. The study concluded that ipilimumab can be used safely in MBM patients. An Italian phase II trial tested a combination of ipilimumab and fotemustine in patients with advanced melanoma including asymptomatic MBM patients (73). A total of 20 patients (out of 83 patients) had asymptomatic MBM, and among these patients the study reported a PFS of 3.0 months and 3-year OS rate of 27.8% (74). A randomized, 3 arm, phase III trial of fotemustine, versus fotemustine plus ipilimumab, versus ipilimumab plus nivolumab (NIBIT-M2) is currently recruiting patients (75). Several retrospective studies have evaluated the safety of combining ipilimumab and radiation therapy (SRS or WBRT), and prospective trial data is forthcoming (76-78). PD-1 receptors are expressed on several cells including T-cells and antigen presenting cells. Their interaction with PD-L1 ligands on tumor cells leads to T-cell exhaustion and downregulation of tumor-specific immune response(79). Nivolumab and pembrolizumab are two anti-PD-1 antibodies that are currently approved for the management of advanced melanoma, and several others are under evaluation. An open label, single-center, phase II clinical trial is currently enrolling patients with untreated brain metastases from melanoma or non-small cell lung cancer (80). In a published early analysis, a response rate of 22% (4 patients) was reported in a total of 18 MBM patients and the responses were durable. Authors noted a high concordance between systemic and brain metastasis responses. Additionally, 11% (2 patients) had stable disease. Intriguingly all responders lacked a BRAF mutation. Relatedly, 4 patients were not evaluable either due to rapid progression necessitating BRAF-targeted ther apy (3 patients), or intralesional hemorrhage (1 patient). Toxicities in the MBM cohort included grade 3 transaminitis (1 patient), as well as grade 1-2 seizures (3 patients) and grade 3 cognitive dysfunction (1 patient) from peritumoral edema. Leptomeningeal disease in melanoma à Leptomeningeal disease (LMD) is a subset of metastatic with extraordinarily poor prognosis and median survival of 8 weeks(81, 82). About 5% of malignant LMD originates from melanoma (Kesari) and up to 23% of melanoma cases develop LMD(1, 83). Primary leptomeningeal melanoma also exists as a separate clinical entity and should be a consideration in the context of a person with multiple congenital melanocytic nevi(84). Diagnosis of LMD is usually made based on the combination of neurologic symptoms along with corresponding leptomeningeal enhancement on MRI. While cytology from cerebrospinal fluid (CSF) is considered to be the gold standard for LMD diagnosis, sensitivity of this testing ranges from 50% to 80%, depending on number of lumbar punctures performed (85). Like with MBM, treatment of LMD with chemotherapy has low response rates(86). The clinical course of LMD is more treacherous in melanoma in other malignancies given the propensity for melanoma LMD to hemorrhage(87). Molec ular characterization of melanoma LMD suggests a higher percentage of BRAF mutations in comparison to the general melanoma population (68% v 45%), based on a single center melanoma LMD cohort of 60 patients(76). Several case reports have been published highlighting complete and partial responses as well as prolonged ongoing survival beyond 15-18 months with BRAF inhibitors (86). Immunotherapy approaches, including intrathecal IL-2, adoptive cell therapies with tumor infiltrating lymphocytes (TILs) and cytotoxic T-lymphocytes (CTLs), and immune checkpoint inhibitors, have also reported prolonged survival in comparison to historic medians (86). A single center study of 38 patients with melanoma LMD who were treated with intrathecal IL-2 reported a median survival of 9.1 months, and the best 15% of patients reached a median survival over 24 months(88). Ongoing survival over 18 months in a melanoma LMD case was reported with WBRT followed by ipilimumab, an immune checkpoint CTLA-4 inhib itor; in this case, treatment with ipililumab resulted in complete radiologic response(89). A phase II trial of combination immunotherapy with ipilimumab and nivolumab, a PD-1 inhibitor, in melanoma LMD has recently opened to accrual(90). In summary, these early data suggest that both targeted therapy and immunotherapy have efficacy in melanoma LMD and can result in durable responses well over a year. Upcoming trials addressing melanoma LMD with newer therapies will likely yield significantly improved survival data over the next decade. Conclusion: Despite significant recent improvement in the outcomes of patients with melanoma, brain metastases remain a major determinant of mortality and morbidity in melanoma patients, and patients with MBM remain in the worst prognostic category. The vast majority of clinical trials with newer agents exclude patients with MBM, thus data on the effectiveness of new drugs in the context of MBM is still lacking. Understanding the biology of MBM and its clinical response to newer agent and particularly combinations of agents and strategies is crucial to increasing the longevity of the poorest-risk melanoma. Appropriate care of MBM begins with diagnosis. In melanoma, the brain is a common site of metastatic spread, both early and late. It is crucial to begin screening patients for MBM at diagnosis, and NCCN guidelines have recently been updated to reflect this changing diagnostic paradigm. The frequency at which to repeat imaging is still not known. Several therapeutic options now exist for the treatment of MBM (A proposed algorithm is provided in Figure-1). Surgical resection, radiation therapy, targeted therapy and immunotherapy all show some degree of efficacy with MBM.à Even in cases of LMD, perhaps the worst subset of MBM in terms of survival, treatment with targeted therapy and immunotherapy can induce prolonged survivals from historic means. Initial reports involving combinations of these therapies, such as radiotherapy with either targeted therapy or immunotherapy, appear promising, but will need to be systematically studied in cohorts with larger numbers. Equally important will be the parallel investigation of predictive markers in MBM with these therapies and combinations. Thus, whenever possible, patients with a new diagnosis of brain metastases should be enrolled in appropriate clinical trials. If an appropriate clinical trial is unavailable, treatment decisions should be made with input from a multidisciplinary t eam including radiation oncologists, neurosurgeons, and medical oncologists.
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