Pediatric Dengue Shock Syndrome Essay Example

Pediatric Dengue Shock Syndrome Essay Example Pediatric Dengue Shock Syndrome Essay Pediatric Dengue Shock Syndrome Essay Michelle de Vera,1 M. D. , and Marissa M. Alejandria,2 M. D. ABSTRACT Background: The cornerstone of therapy for dengue shock syndrome (DSS) remains to be the prompt and aggressive restoration of circulating plasma volume. Two common types of intravenous uids currently used in DSS are crystalloids and colloids. The debate is ongoing on whether one is superior to the other in critically ill patients. Objective: This systematic review aims to compare the therapeutic effects of colloids versus crystalloids in reducing the recurrence of shock, the requirement for rescue uids, the need for diuretics, the total volume of intravenous uids given, the hematocrit level and pulse rates, and mortality rates of children with DSS. Search strategy: We searched Medline 1966 to August 2008, the Cochrane Controlled Trials Register (The Cochrane Library Issue 1, 2008), and the Philippines Herdin database 1964 to 2008. Local journals were handsearched and reference lists were examined. Researchers and experts in the eld were contacted for unpublished or ongoing trials. Selection criteria: The studies included were randomized controlled trials comparing colloids versus crystalloids in children less than 18 years with a diagnosis of DSS. Data collection and analysis: Two reviewers independently did trial selection and assessment of methodologic quality using the Cochrane Infectious Diseases Group criteria. Two reviewers independently extracted the data and analyzed it using Review Manager Version 5. Results: Of eight studies initially reviewed, four studies ful lled the selection criteria (N=694, colloids=410, crystalloids=284). Colloids and crystalloids did not differ signi cantly in decreasing the risk for recurrence of shock (RR 0. 92, 95% CI 0. 62 to 1. 38), the need for rescue uids (RR 0. 90, 95% CI 0. 70 to 1. 16), total volume of intravenous uids given (WMD 0. 80, 95% CI -1. 68 to 3. 28) and the need for diuretics (RR=1. 17, 95% CI 0. 84 to 1. 64). However, there were signi cant improvements from baseline in the hematocrit levels (WMD -3. 37, 95% CI -5. 94 to -0. 0) and pulse rates (WMD -3. 37, 95% CI -5. 94 to -0. 8) of patients who were given colloids. Tests for heterogeneity were not signi cant. Allergic type reactions were seen in patients given colloids. One child died in the colloid group. Conclusion: Colloids decreased the hematocrit and pulse rates of children with DSS after the rst two hours of uid resuscitation. However, no signi cant advantage was found over cr ystalloids in reducing the recurrence of shock, the need for rescue colloids, the total amount of uids, the need for diuretics, and in reducing mortality. KEYWORDS: Meta-analysis, Crystalloids, Colloids, Pediatric, Dengue shock syndrome Department of Pediatrics, The Medical City Department of Clinical Epidemiology, UP College of Medicine 1 2 *Best Paper, The Medical City Interdepartmental Research Forum, 2008 14 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids of lifesaving F luid resuscitation is oneshock thecritically ill cornerstones in managing in patients. Physicians have an array of intravenous uids to choose from, however, the debate continues on which type of uid would be most bene cial. One condition that would bene t most from smart uid choice is dengue shock syndrome (DSS). DSS is the most serious manifestation of dengue hemorrhagic fever (DHF). The burden of disease is greatest in Asia, where in many countries dengue is a leading cause of pediatric hospitalization. An estimated 500,000 patients with severe dengue require hospitalization each year, a large proportion of which are children. At least 2. 5% of patients die, although case fatality could be twice as high. 1 The major pathophysiological event seen in DSS is the acute increase in vascular permeability leading to the loss of plasma from the vascular compartment. Thus, the key to its management is the rapid restoration of the circulating intravenous blood volume. Two common types of intravenous uids currently used in DSS are crystalloids and colloids. Crystalloids are uids based on a solution of sterile water incorporated with electrolytes that are formulated to be hypertonic, hypotonic, or isotonic in com parison to the human plasma. The most common formulations include 0. 9% isotonic saline which is designed to approximate closely the human plasma, and lactated Ringer’s solution, almost similar to isotonic saline, but with the addition of lactate. Colloidal uids are also water- and electrolytecontaining solutions, but with the addition of a substance that does not easily diffuse through a semipermeable membrane owing to its high molecular weight. Albumin preparations contain human serum albumin, the largest component of colloid osmotic pressure in the human blood. The hetastarches, which are 6% hetastarch and 10% pentastarch, are derived from a polysaccharide that is incorporated in a uid with different molecular weights. Dextran solutions use synthetically derived dextran proteins. Gelatin solutions have true gelatin component designed to be biologically compatible. 3 The current guidelines in the management of DSS include administration of crystalloid intravenous uids at a rate of 10-20mL/kg over an hour upon presentation of unstable vital signs or manifestations of shock. Shifting to colloidal solution is warranted if there is evidence of hemoconcentration despite administration of about 1 liter of initial intravenous uids, as shown in Appendix 1. Once improvement is seen, colloids should be shifted back to crystalloids. The increased vascular permeability in DSS, combined with the capability of crystalloid uids to seep through easily, predisposes a patient to receive massive volumes until hemodynamic stability is achieved. This led to the belief that colloids, with their higher molecular weight and ability to maintain or improve the colloid osmotic pressure, will require less amount to achieve improvement, and can thus be a better alternative to crystalloids during the early resuscitative phase in DSS. The studies that have investigated the bene ts of colloids over crystalloids in patients with shock are limited. The large, multi-center, double-blind, randomized controlled trial Saline vs Albumin Fluid Evaluation conducted in 2004 compared the colloid albumin and the crystalloid isotonic saline for uid resuscitation in 6,997 intensive care unit patients. In the said trial, albumin and saline were comparable in terms of 28-day all cause mortality. 4 Likewise, a systematic review of the use of colloids and crystalloids for uid resuscitation in critically ill patients found no evidence that colloids, compared with crystalloids, reduced the risk of dying. Despite the increasing numbers of patients with DSS who are mostly children, there are only a few studies that compared the use of colloids and crystalloids in these patients. 6-9 OBJECTIVES The purpose of this systematic review is to synthesize the available data from clinical trials comparing colloids and crystalloids in resuscitating children with DSS. It aims to estimate the effects of colloids compared to crystalloids on the following param eters in children with DSS: Recurrence of shock. Requirement for rescue intravenous uids. Mortality. Total volume of intravenous uid given. 15 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Need for diuretics. Change in hematocrit level. Change in pulse rate. This systematic review aims to compare the adverse effects associated with the administration of colloids versus crystalloids in children with DSS. experts, and researchers in the eld for additional information on unpublished and ongoing trials. There was no language restriction. Methods of the review: Two reviewers independently assessed the eligibility of potentially relevant trials based on the selection criteria. The reviewers independently assessed the methodologic quality of each trial using the Cochrane Infectious Diseases Group criteria. Studies were assessed as â€Å"high quality† if randomization and allocation concealment were adequate, blinding maneuvers were performed, and intent-to-treat analysis was done. Studies were assessed as â€Å"fair quality† if any subtle biases were present: unclear allocation concealment; absence of blinding; and no intent-to-treat analysis. Studies were considered â€Å"low-quality† if any of the following biases was seen: inadequate randomization and allocation concealment and/or signi cant differences between the treatment group and control group in terms of known predictors of outcome; obvious differences in the general quality of care received by subjects in both groups; marked difference in drop-out rates; and outcome detection methods were different for both groups. Two reviewers independently abstracted data from the studies including baseline characteristics of patients, inclusion and exclusion criteria, types of intervention or study uids, and dosing regimen. The information on each outcome measure and the number of affected patients were also obtained. Data were analyzed using the Review Manager (RevMan) Version 5. 0. For dichotomous data, the risk ratio, or the probability that an event will occur, was determined for each comparison. The need for diuretics, need for rescue uid, and recurrence of shock were all considered dichotomous outcomes. For continuous data, the weighted mean differences were determined. The decrease in hematocrit and pulse rate from baseline and the total volume of intravenous uids administered were all analyzed as continuous data. Missing data such as standard deviations were derived using the 95% con dence intervals provided. SEARCH METHODOLOGY Criteria for considering studies for this review: Studies included in this review were randomized controlled trials in which children less than 18 years of age were given either colloid or crystalloid intravenous uid within the rst 2 hours after being diagnosed with DSS. The diagnosis of DSS was based on the World Health Organization (WHO) criteria, as shown in Appendix 2, which included hemoconcentration associated with the characteristic plasma leakage, presence of circulatory compromise as evidenced by narrowing of pulse pressure, hypotension, decreased perfusion, and decreased urine output. The primary outcome measures included the number of episodes of shock, the requirement for rescue intravenous uids, and mortality. The secondary outcome measures included the change from the baseline in pulse rate, the change from the baseline of hematocrit, the need for diuretics, the total volume of intravenous uid given, and adverse effects. Search strategy: We searched the following databases for relevant studies: Medline 1966 to June 2008; the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2008); and the Herdin database of the Philippines 1964-2008. The search strategy combined the terms â€Å"pediatrics†, â€Å"child†, â€Å"children†, â€Å"dengue†, â€Å"dengue hemorrhagic fever†, â€Å"dengue shock†, and â€Å"intravenous uids† with the Cochrane Highly Sensitive Search Strategy phases one and two as contained in the Cochrane Reviewer’s Handbook, as shown in Appendix 3. Conference proceedings and local journals were handsearched for potentially relevant trials. The reference lists of articles were examined to identify additional relevant studies. We also searched institutional libraries, including libraries in universities, hospitals, and pharmaceutical companies. We contacted colleagues, 16 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Study Flow Diagram Potentially relevant randomized controlled trials identified through Medline, Herdin, and CENTRAL searches (n=4) Trials excluded (n=2) Included patients with septic shock (n=1) Assessed difference between clinical and laboratory diagnosis of dengue (n=1) Articles obtained from colleagues (n=2) Trial excluded (n=1) Used both colloids and crystalloids in a single patient (n=1) Links to related articles and other references examined (n=2) Trial excluded (n=1) Compared colloid with blood plasma (n=1) Randomized controlled trials comparing colloids and crystalloids in pediatric dengue shock (n=4) The formula for grouping data and imputing group means and group standard deviations were obtained from the Cochrane Handbook of Systematic Reviews. 0 We assessed heterogeneity using the chi-square test for heterogeneity (P value 50% indicated moderate degree of heterogeneity; a value of 75% indicated large degree of heterogeneity across trials. For outcome measures with signi cant heterogeneity, the sources of heterogeneity were explored by doing sensitivity analysis according to methodologic quality. excluded two trials: one trial was on the assessment of the differences between the clinical and laboratory diagnosis of dengue, and the other trial included patients with septic shock. On review of the reference lists of relevant articles, two more trials were identi ed: one ful lled the selection criteria while the other was excluded since it used both colloids and crystalloids for each study participant. We obtained two additional studies from colleagues. One trial was excluded because it compared a colloid with blood plasma. Included studies: Four randomized controlled trials on the use of colloids and crystalloids in children with DSS were included with a combined sample size of 694 (colloids=410, crystalloids=284). -9 All the trials used WHO criteria for the diagnosis of DSS. 2 Participants: The patients were under 18 years old, with ages ranging from 1-15 years. All patients were Asians: 655 were Vietnamese and 39 were Indonesian. In all the studies, none of the patients received any intravenous uids prior to the study. 17 RESULTS Search results: As shown in the study ow diagram, we identi ed four potentially relevant randomized controlled trials on the use o f colloids and crystalloids through Medline and CENTRAL searches. We Philippine Journal of Microbiology and Infectious Diseases Vol. 9, Issue 1, January-June 2010 Colloids Table 1. Characteristics of Included Studies Author, Year Nhan 2001 7 Study Population 230 Vietnamese children clinically diagnosed DHF DHF grade III = 222 DHF grade IV = 8 1-15 years old Intervention Study uids Lactated Ringer’s solution, isotonic saline, dextran, gelatin Fluid rate DHF grade III: 20mL/kg for 1 hr DHF grade IV: 20ml/kg for 15min, then 20mL/kg over the following hour Study uids Lactated Ringer’s solution, starch, dextran Fluid rate 15mL/kg for 1 hr, then 10mL/kg for the 2nd hr Outcomes Data presented are those of DHF grade III patients only: PPRT, reshock rate, time to 1st episode of reshock, change from baseline of hematocrit and pulse rate, volume of uid infused, requirement for rescue uid, volume of rescue uid used, requirement for diuretic, mortality Change from baseline of hematocrit; total volume of rescue uid used after initial resuscitation, total volume of uid given, requirement for further uid resuscitation, requirement for diuretic, mortality, length of hospital stay; depth of pleural effusion, new bleeding after study entry, clinical uid overload, volume of ascites Change from baseline of hematocrit, cardiac index, pulse rate and pulse pressure, requirement for further uid resuscitation, requirement for diuretic, duration of shock, episodes of reshock, mortality Change from the baseline of hematocrit, hemoglobin, pulse rate and pulse pressure; total volume of uid given, episodes of reshock, mortality Adverse Reactions None stated Wills 20056 51 2 Vietnamese children with clinical DSS Moderate shock = 383 Severe shock = 129 2-15 years old Allergic type reactions, transient high fever and rigors without cardio-respiratory compromise; urticarial rashes Dung 19998 50 Vietnamese children with clinical DSS 5-15 years old Study uids Lactated Ringer’s solution, isotonic saline, dextran, gelatin Fluid rate 20mL/kg for 1 hr, then 10mL/kg for the 2nd hr Study uids Lactated Ringer’s solution, gelatin Fluid rate 20mL/kg as initial volume of uid resuscitation None stated Prasetyo20089 39 Indonesian children with clinical DSS 1-13 years Adverse reactions in coagulation, liver and renal functions and acid-base equilibrium; severe allergic type reactions DHF: dengue hemorrhagic fever DSS: dengue shock syndrome PPRT: pulse pressure recovery time One study included both DHF grades III and IV patients9, while two studies presented data on DHF grade III patients only. 7-8 The study by Wills (2005) grouped patients into those with moderate and severe shock. The subset of patients with severe shock was not given the chance to receive crystalloid uids and was not included in this review. Children were excluded in the study if they had severe hemorrhagic manifestation for which transfusion was likely7, chronic disorders7, malnutrition9, and heart, renal, liver, and lung diseases. 9 Interventions: The colloids used were dextran 706-8, gelatin7-8, and hydroxyethyl starch. 6,9 The crystalloids used were lactated Ringer’s solution69 and isotonic saline. 7-8 In three studies6-8, the study uids were administered initially at 20mL/kg for 1 hr for DHF grade III patients and 20ml/kg for 15min. Subsequently, uids were given depending on each study’s protocol: 20mL/kg over the following hour for DHF grade IV patients7; 15mL/kg for 1 hour, then 10mL/kg for the 2nd hour6; and 20mL/kg for 1 hour, then 10mL/kg for the 2nd hour. The study by Prasetyo9 administered an initial volume of 20mL/kg to all patients. Table 2. Characteristics of Excluded Studies Author, Year Hung 2006 Martinez-Vega 2006 Tatura 2008 Upadhyay 2005 Reason for Exclusion The study used both colloids and crystalloids in all patients with DSS. The study did not compare colloids and crystalloids; it was based on the assessment of the difference between clinical and laboratory diagnosis of dengue. The study compared gelatin solution with blood plasma. The study participants were children with septic shock. 18 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Table 3. Methodological Quality of Included Studies Author Year Dung 19998 Randomization Adequate Allocation Concealment Adequate-treatment pack numbers contained in opaque envelopes Adequate-treatment pack numbers contained in opaque envelopes Computer generated random numbers, treatment packs prepared by independent staff Not stated Blinding Double-blind each treatment bottle covered in black tape Double-blind Double-blind Intent-to-treat Analysis Not stated Nhan 20017 Wills 20056 Sequential randomization Adequate, strati ed by pulse pressure Random assignment, strati ed to DHF 3 or 4 Yes Yes Prasetyo 20089 Not stated Not stated Outcomes: The outcomes measured included the following: changes from baseline of hematocrit6-9 and pulse rate7-9; total volume of rescue uid used after initial resuscitation6,7 and requirement for further uid resuscitation6-8; total volume of intravenous uids given6,7,9; requirement for diuretics6-8; and number of patients with recurrences of shock. -9 Other parameters evaluated were the following: change in hemoglobin9, pulse pressure8,9 and pulse pressure recovery time7; cardiac index8; duration of shock8; time to rst episode of reshock7; length of hospital stay in days6; and mortality. 6-9 The study by Prasetyo further determined disorders of blood coagulation, liver and renal function parameters, and acid-base equilibrium. 9 The study by Wills reported depth of pleural effusion, new bleeding after study entry, clinical uid overload, and volume of ascites. 6 Two studies determined severe allergic type reactions after intravenous uid infusion. 6,9 The characteristics of the included studies are summarized in Table 1. Excluded studies: Trials that did not compare rystalloids and colloids or were not used on pediatric patients with DSS were excluded from this review. 11-14 The characteristics of the excluded studies are summarized in Table 2. Methodological quality of included studies: Two studies were assessed as â€Å"high quality. †6. 7 The study by Prasetyo had unclear alloc ation concealment and did not mention blinding or intent-to-treat analysis, as shown in Table 3. The study by Dung also did not state whether intent-to-treat analysis was done. Both were rated as fair quality. Despite randomization, the study of Nhan had unequal distribution of more severely ill patients: dextran group had fewer patients with very low pulse pressure, but had patients with lowest mean pulse rate at presentation. Primary outcomes: The meta-analysis of the trials showed no statistically signi cant difference in reducing the risk for recurrence of shock (3 trials, RR 0. 92, 95% CI 0. 62 to 1. 38) and the need for rescue colloids (2 trials, RR 0. 90, 95% CI 0. 70 to 1. 16) after the initial resuscitation. Test for heterogeneity was not signi cant for both outcomes, as shown in Figures 1 and 2. Figure 1. Number of Patients Who Had Recurrence of Shock After the Initial Fluid Resuscitation Study or Subgroup Dung 1999 Nhan 2001 Prasetyo 2008 Total (95% CI) Colloid Crystalloid Risk Ratio Events Total Events Total Weight M-H, Fixed, 95% CI 2 31 1 25 111 19 155 2 32 3 25 5. 4% 111 86. 7% 20 7. 9% 156 100. 0% 1. 00 [0. 15, 6. 55] 0. 97 [0. 64, 1. 47] 0. 35 [0. 04, 3. 09] 0. 92 [0. 62, 1. 38] Risk Ratio M-H, Fixed, 95% CI Total events 34 37 Heterogeneity: Chi? = 0. 82, df = 2 (P = 0. 66); I? = 0% Test for overall effect: Z = 0. 40 (P = 0. 69) 0. 005 0. 1 1 10 200 Favours colloids Favours crystalloids Favours experimental Favours control 19 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Figure 2. Number of Patients Who Needed Rescue Colloids After the Initial Fluid Resuscitation Study or Subgroup Nhan 2001 Wills 2005 Total (95% CI) colloid crystalloid Risk Ratio Events Total Events Total Weight M-H, Fixed, 95% CI 32 74 111 255 366 37 40 111 41. 0% 128 59. 0% 239 100. 0% 0. 86 [0. 58, 1. 28] 0. 93 [0. 7, 1. 28] 0. 90 [0. 70, 1. 16] Risk Ratio M-H, Fixed, 95% CI 77 Total events 106 Heterogeneity: Chi? = 0. 08, df = 1 (P = 0. 78); I? = 0% Test for overall effect: Z = 0. 81 (P = 0. 42) 0. 01 0. 1 1 10 100 Favours colloids Favours crystalloids Favours experimental Favours control All study participants recovered fully, ex cept for one child in the colloid group (starch) who died of profound shock and gastrointestinal bleeding. 6 Secondary outcomes: There was no signi cant difference between patients who received colloids and crystalloids in terms of the total volume of intravenous uids given during resuscitation (WMD 0. 80 ml/kg, 95% CI -1. 68 to 3. 8) and the need for diuretics (RR=1. 17, 95% CI 0. 84 to 1. 64). The test for heterogeneity was not signi cant, as shown in Figures 3 and 4. Hemodynamic variables: On the other hand, there was a signi cant improvement in hematocrit levels from the baseline after the rst two hours of uid resuscitation (WMD -7. 87, 95% CI -8. 52 to 7. 22), but with a large degree of heterogeneity, as shown in Figure 5. Sensitivity analysis removing the study of Wills (2005), which used median instead of mean, removed the heterogeneity and a statistically signi cant reduction in hematocrit levels remained (WMD -3. 37, 95% CI -5. 94 to -0. 80), as shown in Figure 5a. The study of Wills (2005) also showed a signi cant reduction in the median hematocrit levels two hours after the initial resuscitation (25% for the dextran group versus 9% for the Ringer’s lactate group, p 35% Improvement IV therapy by crystalloid, successively reducing the ow from 10 to 6, 6 to 3ml/kg/hr Discontinue after 24-48 hrs Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 25 Colloids Appendix 2. World Health Organization Criteria for the Diagnosis of Dengue Fever and Dengue Hemorrhagic Fever DF/DHF DF Grade* Symptoms Fever with two or more of the following signs, headache, retro-orbital pain, myalgia, arthralgia I Above signs plus positive tourniquet test Above signs plus spontaneous bleeding Laboratory Leukopenia occasionally. Thrombocytopenia, may be present, no evidence of plasma loss Thrombocytopenia 100,000, Hct rise 20% Thrombocytopenia 100,000, Hct rise 20% Thrombocytopenia 100,000, Hct rise 20% DHF DHF II DHF III Above signs plus circulatory failure (weak pulse, hypotension, restlessness) Profound shock with undetectable blood pressure and pulse DHF IV Thrombocytopenia 100,000, Hct rise 20% *DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS) 26 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Appendix 3. Search Strategy Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 27

Overview of Animal Cruelty

Overview of Animal Cruelty The term animal cruelty gets thrown around a lot, but an animal activists definition of animal cruelty may be very different from that of a hunter, a vivisector or a farmer. There is also a legal definition of animal cruelty that varies by state in the U.S., to confuse things further. Essentially, though, animal cruelty boils down to inhumane acts against animals of all walks of life, including starving domesticated pets, torturing any creatures and excessive killing of animals for sport. Animal Cruelty Law in the United States In the United States, there is no federal animal cruelty law. While some federal laws, like the Animal Welfare Act, the Marine Mammal Protection Act or the Endangered Species Act restrict when or how certain animals in certain situations may be harmed or killed, these federal laws do not cover the more typical case, such as the person who intentionally kills the neighbors dog. Every state has an animal cruelty statute, and some offer stronger protections than others. Hence, the legal definition of animal cruelty will vary according to which state you are in, and some places have very large exemptions. For example, most states have exemptions for wildlife, animals in laboratories, and common agricultural practices, such as debeaking or castration. Some states exempt rodeos, zoos, circuses and pest control. However, some states may also have separate laws banning practices like cockfighting, dog fighting or horse slaughter - activities observed as inhumane by the majority of Americans. Where the legal definition is lacking, at least for animal rights activists, is in protecting all creatures from unnecessary suffering at the hands of mankind.   In any case, if someone is found guilty of animal cruelty, penalties also vary by state. Most states provide for the seizure of the animal victims and reimbursement for expenses for the animals care, and while some allow counseling or community service as part of the sentencing, twenty-three states have felony penalties of over a year in prison for animal cruelty. For more information, the Animal Legal and Historic Center provides an excellent, detailed overview of animal cruelty statutes in the U.S. To find your states animal cruelty statute, go to the Centers site and choose your state from the drop-down menu on the left. The Common Understanding Animal cruelty cases make headlines around the country every day, whether its the person who kills the neighbors cat, the hoarder of sick and dying animals, or the family whose starving, freezing dog is tied up outside in the middle of winter. These acts would likely constitute animal cruelty under any states animal cruelty statute, and would also fit with the publics common understanding of the term. However, when it comes to animals other than cats and dogs, peoples concept of the term animal cruelty varies greatly. Most animal activists would say that traditional agricultural practices such as debeaking, tail docking, castration, and confinement on factory farms are animal cruelty. Although some people do agree, as evidenced by the passage of Prop 2 in California, factory farmers and most other states animal cruelty laws havent yet adopted these same values. While some might base their definition of animal cruelty on how much the animal suffers or feels pain during death, the amount of suffering is not relevant for animal rights activists because the animals are deprived of their right to live and exist free of human use and abuse. Some may also base their definition on which type of animal is involved or how intelligent they perceive that animal to be. The slaughter of dogs, horses or whales for meat may be the epitome of animal cruelty to some, while the killing of cows, pigs, and chickens are acceptable to those same individuals. Similarly, to some, the killing of animals for fur or cosmetics testing may constitute unacceptable animal cruelty while the killing of animals for food is acceptable. Among the general public, the more culturally beloved the animal is and the more unusual the harm is, the more likely they are to be outraged and label the harm to that animal as animal cruelty. To animal activists, a much wider range of harms is called animal cruelty. Animal rights activists would argue that cruelty is cruelty, regardless of how common or legal the harm is.

Biology - Wood Frog Essay Example | Topics and Well Written Essays - 1000 words

Biology - Wood Frog - Essay Example For example, it has a moderate size up to two inches or two to three inches long ("Wood Frog - Rana Sylvatica: Minnesota DNR" ), and it has a smooth, moist and reddish skin. Moreover, it is cold blooded and can tolerate a large temperature and saves the water inside the body for the later usage for example, in some cases, up to 65% of the whole body water. Additionally, wood frog has webbed feet just as other amphibians but it does not have fully webbed feet. Moreover, it has a vertebra that is why it is usually identified as vertebrates; it also has notochord which identifies for the Chordates. It can live in water as well as in soil and it can lay eggs in water as well as in the soil. Furthermore, its eggs does not have any membrane which makes them amphibians, males and female frogs gather in ponds for reproduction, skin coloration is brown, and they also go to ponds and water lands for breeding. Moreover, its sound can be heard in the first periods of the spring and they have dar k pitch under their eyes The relationship between the wood frog and other organisms can be reflected by the fact that wood frog belongs to Kingdom Animal which is the broadest category of classification. This is because of the fact that most of the animals that are categorized as â€Å"animals† have some specific characteristics which are common to them. For example, organisms that are characterized as â€Å"animals† are eukaryotic i.e. the animals that have developed cell membrane and complex cell structures, for example plants, fungi etc. Moreover, organisms in Kingdom Animal are â€Å"motile† which means that they can freely move from one place to the other. The examples include snack, lion, deer etc. These are all animals and have common characteristics with the wood frog because they are all under Kingdom Animal. The second category of classification is the Phylum which is Phylum Chordates in case of the wood frog. Furthermore, the animals in Phylum Chordat es are identified with their Notochord which they have at least for some period of their lives, a hollow dorsal nerve chord, and an anal tail etc. Besides this, notochord is the flexible and rod shaped body which is found in the early embryos and, in some cases, becomes the axial support of the body. Similarly, the animals in Phylum Chordates include Hagfish, Star fish and lancelet etc. and these animals have the common characteristic with the wood frog that they all have notochord, a hollow dorsal nerve chord and an anal tail. In this way, wood frog is more closely related and associated with the animals of Phylum Chordates because they have many common characteristics. The third category of classification includes Class which is Amphibians in case of wood frog. The basic characteristics of amphibians are that their eggs are not surrounded by membranes, they have four limbs and they are cold blooded. For example, toads, salamanders etc. are the vertebrate chordates that have same c haracteristics as wood frog. In this way, wood frog is far more linked and has similarity with animal chordates such as salamanders, toads because they are in the same class and have similar characteristics. Similarly, wood frog is also associated with many other amphibians due to their order which is anura and family which is Ranidae. Moreover the common genre and species

The Art and Craft of Rap Music Essay Example | Topics and Well Written Essays - 3000 words

The Art and Craft of Rap Music - Essay Example Then, the four most infuential rap albums of all time are discussed, chosen primarily based upon their influence in redefining the genre as it existed prior to the album. Some of the largest names in the rap music business are discussed and analyzed with particular respect to their technical and artistic merits, as well as their social impact upon the world. Since its conception in the early seventies, rap music has been more than just a genre of music. It has become a street culture with elements that promote self expression and participation. Whether you call it rap or hip hop, it is the medium for urban-based creativity and expression of culture. This paper discusses the history and influence of rap, offering insight into a genre that is highly publicized on a global level but often ignored. The beginning of hip hop has often been discussed and debated among those in the music scene. On one hand, it seems to be widely accepted that the birth date of rap was 1979, when Sugar Hill Gang released Rappers Delight, but the hip hop scene more likely began to form in the Bronx in 1971. The founder of hip-hop was rapper and first break-beat deejay Kool Herc. Sugar Hill Gang seem to be used as a starting point as they hold the title for the introduction of rap music on vinyl, the youth cult for rap music had established itself many years prior to 1979. Soon after the conception of rap as an idea, Grandmaster Flash invented scratching; spinning a record back and forth creating a scratching sound. These innovations made by Kool Herc, Grand Wizard Theodore, Grandmaster Flash, Afrika Bambaataa and other like- minded DJs of the era were the spearhead of an underground cultural movement that is now recognized as hip-hop. Hip hop quickly became recognized as a form of urban based creativity and expression of culture, the turntables enabled artists to be creative with musical sounds. The turntable is an instrument that gives artists control over mainstream music, by proffering a "simple tool to make their art," (Byi, 1998) constituting a sense of rebellion through scratching and distorting a track. Not only does deejaying give artists a sense of upheaval, but also liberation and freedom, the DJ, Q-Bert explained this phenomenon in an interview, "the art of scratching is like a miracle- how you grab any recorded sound and manipulate it to say whatever you wantI wanted to speak the universal language of music, so I chose the musical instrument of the future: the turntable" (Byi, 1998) In the beginning, hip-hop was mainly seen at parties where a DJ would loop samples from records and allow people to battle over these tracks; from here hip-hop culture grew. Deejays often used a microphone to engage the crowd. Over time, individuals other than the Deejay joined in, delivering a message in a catchy rhyme form. By drawing attention not only to the message itself, but also how the message was conveyed, these individuals became performers in their own right, taking a place alongside Deejays and B-Boys; the emcee was born. People were rapping on the streets, and battles could be seen in warehouses on a Saturday night where budding rappers would get on the stage and rap against each other in a knock out style competition. It was the lack of financial resources that prevented this music from being

A Retrospect of the Hong Kong Handover Essay Example for Free

A Retrospect of the Hong Kong Handover Essay Slide 2 Hong Kong’s handover to the Chinese government after 150 years of British colonial rule is a major historical event My paper analyzes whether or not China handled Hong Kong well 10 years after the Handover occurred. It also aims to look at the changes that have taken place since the Handover, and how they have affected the situation in Hong Kong. Important questions regarding this issue are:   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   After 10 years, did China handle Hong Kong well?   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Has China fulfilled its promise to maintain Hong Kongs status quo as a leader in Asian economy?   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Have the policies and changes that the Handover has brought been beneficial to the people of Hong Kong? My position is that China did a good job in the sense that they did not do harm to Hong Kong and was able to preserve the liberal economic and political spirit of the place. My conclusions are based on the following parameters: One, the economic situation of the territory, and two, the political situation of the territory. Slide 3 Background of the Issue Why was the Handover a source of anxiety to Hong Kong citizens?   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The Hong Kong way of life is different than that of Mainland Chinas   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   China is under a Communist System while Hong Kong adopts a free market economy The Impact of the Hong Kong handover can be brought to light with the following facts: Geography Hong Kong is a small piece of coastal island below Mainland China. Its strategic location made it an important port for the trading of goods and is regarded as an ideal base for military and tactical operations. When it comes to its economy, Hong Kong is a force to contend with. Hong Kong: Is one the modern world’s most important financial hubs Enjoys one of the world’s highest gross domestic products Provides jobs to millions in Mainland China as well as in neighboring countries Slide 4 Aftermath of the Handover Accounts of life in Hong Kong right after the Handover were promising. Generally, it was â€Å"life as usual†. The general consensus is that the Handover did not cause the major political and economic upheavals that many feared it would. While there was a slowing down in the economy, it was not at the level expected. The changes were milder and subtler than expected The reaction of the business community to the Handover reflects the reaction of the locals: Businesses were able to ride the change without much difficulty. Multinational companies based in Hong Kong have been loyal, and were able to transcend political upheavals. Slide 5 The most important policies implemented after the Handover included â€Å"One country, two policies† and â€Å"Hong Kong people administering Hong Kong†. China also increased public spending and reduced tax. These policies have allowed Hong Kong’s Special Administrative Region (SAR) government a free hand to implement decisions with respect to Hong Kong’s political and economic environment. Such a moves also proved to be effective because it kept businesses in Hong Kong. Hong Kong’s Performance under China’s rule has been on the large part, successful. The following are evidence of China’s good handling of the Hong Kong Handover: Hong Kong was one of the least affected during the Asian economic depressions Hong Kong was one of the first to bounce back from the depression. Hong Kong survived the health problems of SARS, bird flu and mad cow disease.

Society’s Treatment of Women Revealed in The Yellow Wallpaper

Society’s Treatment of Women Revealed in The Yellow Wallpaper      Ã‚  Ã‚  Ã‚  Ã‚   Charlotte Perkins Gilman had problems. Most of those problems resulted from her nervous condition that was previously termed â€Å"melancholia.† She did not give in – Gilman was a fighter. Instead of bowing to the disease, she wrote â€Å"The Yellow Wallpaper,† a story intended to help other women suffering from a similar fate. Although this explanation reveals why Gilman wrote the book, it does not reveal the true intention of the story. This is not merely the tale of an insane woman. The narrator’s insanity is a symbol for Gilman’s commentary on the evils of social conformity with relevance to the role of women in society. The narrator comes to realize the inhumanity in society’s treatment of women, and, as a result of her awakening, she cannot help but visualize her own torment brought on by the old yellow wallpaper that hangs around her, a faded cage. The narrator’s name is left a mystery in order to give her u niversal appeal. The narrator could be and is every wife, every mother, every daughter, every woman. Gilman uses imagery and literary devices to convey her moral of the mistreatment of women in the 19th century.      The first striking image that readers of "The Yellow Wallpaper" are presented with is not that of a room, it is not of the house, but of the character of John, the husband. John is described as a man of a "practical and ext... ...21-530. King, Jeanette, and Pam Morris. "On Not Reading Between the Lines: Models of Reading in 'The Yellow Wallpaper.'" Studies in Short Fiction 26.1 (Winter 1989): 23-32. Knight, Denise D. "The Reincarnation of Jane: 'Through This' - Gilman's Companion to 'The Yellow Wallpaper.'" Women's Studies 20 (1992): 287-302. Rigney, Barbara Hill. Madness and Sexual Politics in the Feminist Novel: Studies in Bronte, Woolf, Lessing, and Atwood. Madison, WI: The University of Wisconsin Press, 1978. Russell, Denise. Women, Madness and Medicine. Cambridge, MA: Polity Press, 1995. Showalter, Elaine. The Female Malady: Women, Madness, and English Culture, 1830-1980. New York: Pantheon Books, 1985.   

“Same-Sex Marriage Should Not Be Legalized”

PONTICIFICA UNIVERSIDAD CATOLICA MDRE Y MAESTRA. RECINTO SANTO TOMAS DE AQUINO. Academic Writing ILE-322 Student Name: Leslie Herrera. ID Number: 2009-5699 Teacher: Emilia Gracia Final Draft: Essay 3. â€Å"Same-Sex Marriage Should Not Be Legalized†. July 18th 2012. Same-Sex Marriage Should Not Be Legalized. As we know, same-sex marriage has been discussed and argued for a long time. Within the controversial topic of gay rights, there’s no area more controversial than same-sex marriage. And all of us ask ourselves if same-sex marriage should be legal or not. But the fact is that we have to start thinking about it as a moral and religious topic.The government shouldn’t legalize the same-sex marriage because the legal definition of marriage is the civil union between a man and a woman, marriage is a religious rite, and also those couples will be able to adopt children if they are given the right to marry. Same-sex marriage is also known as gay marriage. Same-sex ma rriage is between two people of the same gender. The Netherlands became the first country to legalize same-sex marriage in 2001; in the United States of America, the first state to legalize same-sex marriage was Massachusetts, on May 17, 2004. According to ProCon. rg (2011), as of May 10, 2012, same-sex marriage has been legalized in eight states such as: Massachusetts, Connecticut, Lowa, Vermont, New Hampshire, New York, Washington, Maryland, and the District of Columbia which will be effective on January 1, 2013. This has become an even more controversial topic since these current legalizations of same-sex marriage. One argument against same-sex marriage is that the legal definition of marriage is the civil union between a man and a woman. â€Å"The institution of marriage has traditionally been defined as between a man and a woman† (ProCon. rg, 2011, Con Gay Marriage,  ¶1). Further, if any government gives the right to marry same-sex couples this traditional institution of marriage will weaken. â€Å"Marriage runs contrary to two of the primary goals of the lesbian and gay movement: the affirmation of gay identity and culture and the validation of many forms of relationships† (ProCon. org, 2011, Con Gay Marriage,  ¶8). Therefore, same-sex marriage is totally the opposite of the traditional institution of marriage; those are two things that cannot have the same rights, and actually God made us to be heterosexual no homosexual.In addition, marriage is a religious rite. â€Å"Gay marriage is not compatible with the beliefs, sacred texts, and traditions of many religious groups† (ProCon. org, 2011, Con Gay Marriage,  ¶4). In fact, we know that most of the religions are opposing same-sex marriage, because they are always guided by the Bible and God’s commandments and his teachings. â€Å"Marriage was established by the Creator with its own nature, essential properties and purpose. No ideology can erase from the human spirit the certainty that marriage exists solely between a man and a woman† (ProCon. org, 2011, Con Gay Marriage,  ¶12).If same-sex is legalized, churches and other religious institutions would be forced to change their rules in order to marry same-sex marriage couples. Furthermore, one of the biggest problems for society and probably the most important for new generations is that same-sex marriage would be that those couples will be able to adopt children if they are given the right to marry. â€Å"The institution of marriage as a union of man and woman, uniquely involving the procreation and rearing of children within a family, is as old as the book of Genesis† (ProCon. org, 2011, Con Gay Marriage,  ¶1).Children need both a mother and a father, because they learn a lot from each of them. â€Å"Girls who are raised apart from their fathers are reportedly at higher risk for early sexual activity and teenage pregnancy. Children without a mother are deprived of the emotional s ecurity and unique advice that mothers provide† (ProCon. org, 2011, Con Gay Marriage,  ¶6). Besides, same-sex marriage will intensify to the assimilation of homosexuals into a heterosexual culture. And probably that one of the facts that can affects the society the most, because if that happened our moral and religious values would be lost.The supporters and people who are for the same-sex marriage argue that they should have the right to civil marriage because of same marriage benefits, such as: health insurance and public acceptance which heterosexual couples have. Nevertheless, that argument of the supporters is irrelevant, because each person can have his or her own health insurance that provides their workplace, so they don’t need a family or spouse health insurance to have the same benefits as traditional marriage. On other hand, if the government were to legalize same-sex marriage the public acceptance is not guaranteed.Because people are that decided in what t hey are going to believe, maybe some people will accept this and a larger group of people disagrees. Therefore, the government don’t have to legalized the same-sex marriage in order to people accept homosexual family or marriage or to receive health insurance. Hence, no government should legalize same-sex marriage for all the facts that this action may involve, for example, those couples will be able to adopt children and also because of moral and religious values.Accordingly about what we have read, the legalization of same-sex marriage is an unmoral and unreligious action. I think that promoting homosexuality with government-backed same-sex marriage it would hurt our children, the generations that are growing, the country, and also the entire world. If a homosexual man or woman wants to get married, the only thing they need to do is choose not to be homosexual and marry someone of the opposite sex. Reference Pro. Con. org. (2011, January 9). Should gay marriage be legal?. G ay Marriage. Retrieved from http://www. gaymariage. procon. org