Wednesday, July 31, 2019

Survival Guide Hari Raya

Personal Trainer & Nutritionist have been a personal trainer and nutritionist for over 6 years. I got my certification from A. F. T. A in the USA Speaker conduct various health and corporate wellness seminars. Some of my clients include Nestle, Node's, Bank Engage, Patrons Malaysia, Bursa Malaysia and other clients in both the private and public sector TV Host am a regular TV guest on various talk shows discussing health, diet, nutrition and other wellness topics. Brand Ambassador As part of my job, have been fortunate to represent brands such as Aids, Nestle and Fitness Concept.Web Entrepreneur love the web. We launched Cooked. Com, a Malaysian calorie database, eBooks and are very active in providing tips on our website – Shakespearian. Com, Backbone and Twitter Shakespearian. Com 0 201 0 4 WEIGHT LOSS FAQ Shakespearian. Com 0 201 0 General Hair Array FAQ 5 Before share my 20 hair array weight loss survival tips, lets look at some general FAQ How much to eat during array? To tally up to you but try to follow some of the 20 tips I am going to share with you Nina bit. Will you gain weight over hair array? Most probably. Its opposite to Ramadan.Where 90% lose weight during Ramadan, 90% of you will gain weight during the first few days of seawall. All I can say is that it is K to indulge and reward yourself after a long month of fasting. But, don't worry. Your goal this array should be to minimize weight gain! If you have lost egg during pupas, keep weight gain below egg. But how can I lose weight during hair array? Yes, you don't want to be in the 90% group. In fact, everyone who reads and understands my eBooks should be in the 10% â€Å"l am going to lose weight this array† group. K there are two parts to this: ; First 10 days: These are the hardest as festivities are at their peak and everyone is in the leaps germ mode. During this period, your AOL (if any) should be to minimize weight gain. ; Last 20 days: Again since open houses are mostly limit ed to the weekends, you MUST make sure that your week days are as healthy as possible. If you have 5 good days and 2 bad days, you should be K. Get back on track! So in combination, to lose weight over the 30 days of array, make sure your exercise & diet routine get back on track, especially during weekdays as weekends are filled with tempting open houses.Make me proud! Should you exercise during array? Totally up to you but not very convenient when you are on the road and everyone else is indulging In Megan and shakeups. So for me, I don't exercise during the first week. Once I return to work, it is a good time to restart my exercise program. That said, there is no need to reward your self for 30 days. 10 crazy days and 20 healthy eating days is fine with me. Can start the â€Å"How to lose egg in seeks† program during array? Yup, but would advice you NOT to start it until you are back into your normal routine.The â€Å"How to lose egg in 5 weeks† program requires you to have control over your day. When you Bali camping or are in the midst of hair array, you probably lose control! But hey, if you feel you are ready and motivated, oh can get started anywhere, any time! Any guidelines before I start to exercise again? If you have not been exercising throughout Ramadan (like me), you can't continue where you left off. The lack of exercise during Ramadan has affected your strength and cardiovascular fitness. Here are some guidelines to help you get back on track: ; Start slow!Keep the intensity within moderate levels. ; Make sure to eat your pre and post exercise meals (a must for weight training) ; Pace yourself. It will time to rebuild your fitness and strength. ; your body. If you can't cope, stop. You don't want to get injured now, do you? Arrival Guide: 20 Hair Array Tips to Keep That weight Off Listen to 6 20 HAIR ARRAY TIPS TO KEEP THAT WEIGHT OFF! Celebrate Array! Don't be one of those people who bring you. Hair array is a celebration. A rew ard for all the fasting you have committed yourself to for 30 days. Reward yourself.Its K to let go for a few days. 7 Yes, the first few days are special and all the great food is just too tempting but hey, after a few days its time to head back to reality and keep your intake in check. My advice, take it easy. Pace yourself. 8 Do you know how many calories are in leman, longing or all those shih-Mimi? It takes 20 minutes Eat slowly. It takes about 20 minutes for you to feel full. Never start with desserts! Always start with a proper meal. Go for rice, meats, vegetables or whatever makes up a balanced meal. 9 â€Å"Stretch† Your Buffet.Opposed to a served meal, buffets allow you to control your portions and choices BUT some relative will nag you for not eating enough or making enough â€Å"rounds†. My tip: Take small portions and frequent trips. This gives people the impression that you are eating a lot. 10 Never start with desserts. They are packed with sugars and fat s. If you want desserts, reduce the calories from your main course. Milk before you hit the road. What? More food? Well yes and no. During this festivity, most of you will be hitting the road when visiting friends and family but with all the traffic & delays, its important to keep your hunger in check.A quick glass of low-fat milk (or any other balanced snack) before you leave home keeps your cravings in check. This helps you to avoid unnecessary calories. Know your r ay calories. If you are serious about keeping your array weight gain in check, make sure that you are aware of all your array-food calories. Well you should! Otherwise, you lose control over your weight. How many cookies do you need? Ah yes, the humiliation cookies or biscuit array. They are everywhere you go and loaded with sugar (calories). Do the math: Lets say an average cookies packs some 35 calories.If you eat 10 cookies per open house and visit xx houses per day, that works out to be a whooping 21 ,OOH calories or 2. Egg! How to reward? By enjoying all the delicious leman, rending and other yummy but know your limits. You don't need 30 day of feasting! Yes idolatry is 30 days long but that doesn't mean you have to eat-all-you-can every single day. Stick to 10 vs. 20 days. If you need to indulge in array food and o all out, stick to 10 out of the 30 days of seawall. Example: First 2 days of array + weekends. Its K to say â€Å"No†. As a guest, we always feel obligated to well eat.

Tuesday, July 30, 2019

Accountable Care Organizations, Bundled Payments, and Health Reform Essay

With the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, health care reform has become the law. The legislation will extend health care coverage to more citizens, stabilize health insurance markets, enhance regulation and consumer protection, and improve the affordability and quality of health care in the United States. Changes in payment system of health care proposed by PPACA have led to the development of Accountable Care Organization (ACO). This paper will address how ACOs and the bundled payments system will impact the future of health care. See more: Strategic Management Process Essay The ACO is a health care organization which provides accountability for quality, cost, and care for medical beneficiaries with single entity providers that are responsible for delivering care. The ACO-model builds on the Medicare Physician Group Practice Demonstration and the Medicare Health Care Quality Demonstration, established by the Medicare Prescription Drugs Improvement and Modernization Act of 2003. Under the Affordable Care Act, the U.S. Department of Health and Human Service (HHS) released new rules that benefit doctors, hospitals, and other health care providers of better care for Medicare patients through ACOs on March 31, 2011(U.S. Department of Health & Human Services, 2001). According to the Centers for Medicare & Medicaid Services’ (CMS) administrator Donald Berwick, MD, â€Å"An ACO will be rewarded for providing better care and investing in the health and lives of patients. ACOs are not just a new way to pay for care but a new model for the organization and delivery of care† (Penton Media., 2011). The new model, which is called the â€Å"Pioneer Accountable Care Organization,† is to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries  (Medicare Parts A and B) and reduce unnecessary costs through establishing a shared savings program, which promotes accountability for Medicare FFS beneficiaries. It requires coordinating care for services provided under Medicare FFS and encourages investments in infrastructure, and it redesigns care processes. Regarding the differences, the Pioneer ACO payment model incorporates a population-based payment in the third year of the ACO’s Participation Agreement. This population-based payment will replace fifty percent of the FFS payments (McDermott & Emery, 2011). The Pioneer ACO model is estimated to save Medicare as much as $430 million over three years by coordinating with private payers to reduce costs for Medicare beneficiaries and improve health outcomes. An ACO may engage in either a Shared Savings Program or in the Pioneer ACO model. In addition, the Pioneer ACO model is separated from the Medicare Shared Savings Program for Medicare beneficiaries by the Advance Payment Initiative (Center for Medicare and Medicaid Innovation Center, 2011). ACOs require the ability to manage cost and quality for patients across the continued extent of care and across different associational settings. They also require the capability to plan budgets and resources needed to allocate payments, and the commensurable size of primary care providers for Medicare patients’ populations assigned to the ACOs (at least 5,000 Medicare or 15,000 commercial patients). According to the Journal of the American Medical Association, doctors Shortell and Casalino recommend a three-tiered system of qualification for ACOs (Shortell, S. and Casalino, L., 2010). The tiers will be based on the degree of financial risk acceptable for ACOs and the degree of financial rewards that can be completed by performance targets. In the first tier, ACOs will receive FFS payment with shared savings for providing quality care at lower than the expenditure targets. In the second tier, ACOs will receive bundled payments and episode of care based payments for managing costs and achieving benchmarks. They will be accountable for care that meets these criteria. In the third tier, ACOs will receive partial and global capitation payments. Under a three tiered structure, ACO providers will submit a three-year plan to the HHS or CMS for achieving qualification status at the varied levels. The U.S Department of Health and Human Services (HHS) announced the â€Å"Bundling Payment for Care Improvement Initiative† to coordinate payments for services delivered across an episode of care, such as a cardiac bypass or a hip replacement, on August 23, 2011 (Vendome Group, LLC, 2011). The definition of bundled payments refers to a single payment for all care related to an entire treatment or condition. Bundled payments, also called episode-base payments or case-rate payments are considered as a mechanism for improving both cost and quality, such as currently exist with Geisinger Proven Care and the Prometheus Payment system (Dark,Cedric., 2011). Bundled Payments do benefit physicians and hospitals if patients complete their medical treatments within a certain time period because it will save the physicians and hospitals additional costs. However, it is a disadvantage for physicians and hospitals if the treatment takes longer than the traditional time because it will cost more money to care for patients. Unfortunately, its emphasis is less about improving care and more about reducing the financing for medical care (Gorman Health Group Blog, 2011). This means hospitals, physicians, and other practitioners will have to take their own approach to improving the delivery of healthcare, which should benefit Medicare patients. The goal of the initiative is to increase efficiency of care, improve quality of care, and lower costs. This initiative consists of four different bundled payment models. The first three bundled payment models are retrospective payment arrangements based on patients’ historical data. However, the fourth model is proposed for the future. Centers for Medicare & Medicaid Services (CMS) make a single bundled payment to the hospital for all services during inpatient stays for hospitals, physicians, and other medical professional specialists. In the first model, the episode of care is the length of time the inpatient stays in the acute care hospital. Medicare pays the hospital a discounted payment based on the payment rates established under the Inpatient Prospective Payment System (IPPS), which starts at zero percent for the first six months and then rises to a minimum of two percent in the third year, based on the IPPS. Physicians are paid under the Medicare Physician  Fee Schedule. Hospitals and physicians are to share in any costs. This model benefits Medicare patients by reducing their costs, but not hospitals and physicians because they must share in any expenditures. The second model, which is also based on IPPS, is different from the first model because it includes inpatient and post-acute care from either 30 or 90 days following discharge. This bundled payment includes physicians’ services, post-acute care, readmissions, and other related services, which can be clinical laboratory services, medical equipment, prosthetics, orthotics, other supplies, and Part B drugs. The minimum discount is three percent for the first 30 to 90 days after discharge and two percent for more than 90 days. The Medicare enrollee is to share the costs if the total payments are less than the target price. However, the provider will be responsible for payment coverage if the total payments exceed the target costs. This model uses an incentive discount for Medicare patients to spend less time in rehabilitation versus the first model which has no early rehabilitation discount. However, this model does not give an advantage to hospitals and physicians because it encourages Medicare patients to leave medical services sooner. The third model begins at discharge from an acute facility if less than 30 days are spent in rehabilitation. These bundled payments are the same as the second model with the exception of a discounted rate, which Medicare enrollees are required to set up instead of CMS, since CMS has not indicated an expected discount for medical service (Becker, Epstein & Green, P.C, 2011). In the fourth model, which is the only perspective model, hospitals will receive a single bundled payment from CMS that covers all medical services by hospital, physicians, and other medical professional specialists. The minimum discount will be three percent of the estimated total costs for the episode care (Proskauer Rose, 2011). The bundled payments are more hospital-centric than ACOs’ program. However, ACOs’ focus will be on how hospitals and physicians will share reimbursements in a post-fee-for-service payment system. Therefore, Medicare beneficiaries will benefit the most but hospitals and physicians will not. Future ACOs include: Integrated Delivery Systems, Multispecialty Group Practice (MSGP), Hospital Medical Staff Organization (HMSO), Physician-Hospital Organizations (PHO), Interdependent Practice Organization (IPO), and the Health Plan Provider Organization or Network (Charles DeShazer, 2011). However, most physicians work in very small practices that would not likely have the resources to develop the capacities to be an ACO. In an ACO-based health care organization, these small practices would either merge into new or already existing specialty group practice, or would engage in an ACO that facilitates clinical integration among small practices. Many physicians may still prefer smaller practices, and under comprehensive healthcare reform may continue to exist. In ACOs completely based on the quality and cost of care, the market may decide whether virtually integrated systems can succeed in competition with systems where physicians are merged into large group practices. Moreover, specialist physicians are creating medium sized or even larger single specialized groups. However, a single specialty group cannot serve as an ACO for full patients care but can be an essential element of an ACO or can be a crucial source of medical care through referrals. In Integrated delivery systems (IDS), medical care is coordinated and reimbursed within the system to make patient care more efficient while improving access to and the quality of the care received. Some examples are: Cleveland Clinic, Henry Ford Health System, Mayo Clinic, Scott & White Clinic, and so on. However, a recent report indicates that challenges may still remain. IDS face lack of compensation from health insurance providers for care coordination services as well as difficulties in finding specialty care, such as mental health care and changes in management and physician cultures in adopting the new organization (United States Government Accountability Office, 2011). The promising advantages of the multispecialty group practice (MSGP) model were recognized in 1932. As stated in the Physician’s Advocate(2008), â€Å"These advantages include having the resources to redesign care processes, take advantage of economies of scale to implement electronic medical records, form health care teams, obtain database feedback on performance gaps, and make the changes needed to improve care† (Physician’s Advocate, 2008). Some evidence indicates that multispecialty group practices do make the most of recommended care management processes like electronic information technology, as well as sharing in quality improvement medical services. Therefore, MSGPs provide better quality care for preventive measures involving screening tests and diabetes management than smaller forms of practices. Moreover, studies also indicate lower Medicare spending on patients related to multispecialty or hospital associated groups than other patients. However, it is unlikely that MSGPs will become the major organization form in the United States health care system since it is so expensive to implement. HMSO, more than 800,000 physicians that currently practice in the United States are members of hospital medical staffs (Carroll, 2011). The hospital medical staff organization can serve as ACOs for either inpatient or outpatient care. Studies indicate that most physicians have primary relationships with a single hospital to form a stronger partnership entity between physicians and their primary hospital (Fisher and et al., 2006). Hospitals have resources to support adopting electronic medical records (EMR), provide performance and accountability data, and assist quality improvement support for physicians. Bundled payments for specific medical conditions or episodes of sickness, such as a coronary artery bypass graft (CABG), hip or knee replacement (Massachusetts Medical Society, 2008) will provide incentives for hospitals and physicians to work together to reduce Medicare costs (Welch, WP and ME Miller, 1994). This model will have future advantages for chronic illness treatment as we ll as episodes of care since physicians and hospitals work together closely to monitor patients’ long term care. However, the HMSOs encounter challenges including leadership of the diverse cultures of hospitals and physicians and legal restrictions to obtain sharing (Primary Care Associates., 2008). An alternative of the MSGP model is the PHO. Hospitals and physicians work together to ensure cost-effective and steady system delivery of medical services and the provisions of the health care services to the patients. There are approximately one thousand PHOs in the United States and most are managed organizations with the goals of achieving and managing the quality  and cost of care (Nixon Peabody LLP., 2010). Under the Affordable Care Act, the contracting PHO model can emerge into an entity that will manage the quality and cost of care. Without meeting the needs of all physicians, this model has the advantage and the incentive of improving performance. With the HMSOs, the hospital will provide resources for EMR, performance reporting, quality improvement, and process management support. However, PHOs must be clinically integrated to avoid anti-trust laws (Casalino, Lawrence P., 2006). A fifth model is the Interdependent Practice Organization (IPO), which is an advancement for those physicians who practice in small organizations or who do not wish to be part of larger organizations for delivering care. The interdependent practice organization is based on an association of physicians in numerous independent practices. IPOs are capable of providing high quality, better care, although most of these organizations are loosely organized (Rittenhouse and et al., 2004). The future IPO model requires strong leadership, administration, and enough patients across individual practices to support financing of technology infrastructure and management systems. IPO models might be attractive to physicians practicing in rural areas. With given sufficient incentives, existing IPOs can became independent organizations by strengthening their management structure and developing a solid shared culture of performance improvement. These requirements are challenges since IPOs are composed of many small practices. The last model, the Health Plan-Provider Organization or Network (HPPO/HPPN) is similar to the IPO. It is based on an association of independent physician practices. The health plan will be the major financial assets to encourage a more cost-effective health care delivery system. Many have capabilities in disease management, electronic information technology implementation, and quality improvement entities that can be used effectively in collaboration with physicians. Some physician practices may participate with health plans rather than local hospitals. Health plans can be part of a smaller physician’s practice and become the unit of accountability of performance. However, the success of this model will depend on an individual physician’s leadership (Shortell and et al., 2008). The Centers for Medicare & Medicaid Services (CMS) released final rules and new opportunities for financial support for doctors, hospitals, and health care providers to work together to improve the care of Medicare patients by adopting ACOs on October 20, 2011. The new rules provide for a new voluntary Medicare Shared Savings Program. Providers will be able to participate in an ACO and share in the savings with Medicare. ACOs will reward providers for reducing the costs and meeting quality measures, such as reducing hospital readmissions or emergency room visits. Providers will begin to share in savings based on how they perform in thirty-three quality measurements in the second and third performance years. Medicare beneficiaries will be a part of the ACO system when they form. Moreover, community health centers and Rural Health Clinics (RHCs) will be allowed to participate in the ACO programs (Galewitz, Phil and Jenny Gold., 2011). To appeal to providers, CMS will provide physician-owned and rural providers early access to the expected saving of up to $170 million dollars, so providers can start ACOs right away. At the same time, the Antitrust Division of the Department of Justice issued the entire final rules that will allow providers to participate in the Medicare Shared Savings Program. In addition, the final rules will no longer require a mandatory antitrust review for collaborations as a condition of entry into Shared Saving Program (Department of Justice, 2011). Electronic health record (EHR) usage is no longer a condition of participation to prompt more RHCs and other programs to join (Center for Medicare and Medicaid Innovation Center, 2011). Moreover, CMS will assist agencies in monitoring the care and quality of performance of ACOs. The program will save up to $940 million dollars over four years (U.S. Department of Health & Human Services, 2001). Patients or Medicare beneficiaries are encouraged to select an ACO as their medical center. ACOs can be used for result-based payments, public report purposes, and claim-based payments which retrospectively allow patients to join who have not adopted ACOs. This advances patients’ choices and encourages ACOs to coordinate their patients’ care to treat patients equally. Because physicians are not required to be part of ACOs, physicians  can still be paid with the Shared Saving Programs used by Medicare, Medicaid, and other commercial health plans. They also can be eligible to achieve quality-based rewards. In addition, physicians and hospitals that are part of ACOs can have both obtainable rewards for improving quality and controlling costs; however, there is more inevitable risk. Furthermore, bundled payments for certain services and procedures, using a combination of capitation, result-based payments, and readmissions, gain sharing between physicians and hospitals tha t can be adopted within ACOs. Physicians also can benefit from the assistance that ACOs can provide with electronic health records and with implementation of established processes to improve quality and efficiency. Health reform will be needed in laws and regulations for the Stark law, anti-kickback statuses, fraud and abuse, anti-trusts, scope of practices, and the corporate practice of medicine. However, the final rules were relaxed and established waivers for the physicians’ self-referral law, the federal anti-kickback status, and certain penalties to encourage the participation in the Medicare Shared Saving Program and the Advance Payment Initiative (FierceHealthcare, 2011). Therefore, more medical providers will be regulated by the programs. In the past, healthcare leadership has relied on organizational structure to deliver higher quality at lower costs, which has not succeeded in improving neither efficiency nor performance. In fact, they have increased the problems that they intended to address. Neither diagnostic related groups (DRG) nor Health Managed Organizations created a shared achievement for all parties. Provider profit motivation lacked the pressure of medical beneficiaries to protect quality while minimizing costs. While each DRG and resource based relative-value unit encouraged providers to focus on provision without interventions, HMOs and other managed providers encouraged providers to minimize intervention, regardless of whether managing could delay the quality or completeness of patient care (Numberof, 2011). Ignoring the minimal role that patient demand plays in driving market completion among providers, the current and past medical health care system has decreased accountability for quality of medical care. ACOs were established to fix the inadequate accountability for wasteful  spending and quality of patient care. The PPACA provisions are consumer based solutions; however, they do not allow patients to have fully informed choices about their coverage and medical care (Numberof, 2011). Employers, who contract with insurers, apply with providers; therefore, accomplishment is limited. However, many physicians are reluctant to assume accountability for patient outcomes, since they admit that outcome is directly under the behavioral control of the patient. Furthermore, it seems that provider contracts could be integrated to a successful ACO in a shared savings program; providers continue to receive funding for each service they perform. Even with the possibility of a bonus from shared-savings, maintaining the FFS system boosts providers into continuing delivering an excess of services. In addition, ACOs, which are a single untested model, are largely hospital based. Eligibility requirements are larger and more involved for ACO organizations. Larger organizations are able to consolidate their markets; however, this consolidation may result in less competition. Therefore, large delivery organizations may become too big to fail but will increase advantages for patients. Without competition, the organizations might have little incentive to reduce the costs or improve quality of medical care. Enduring health reform has to cover the uninsured without exception or conditions. As Victor Fuchs, professor at Stanford University mentions â€Å"It [Enduring health reform] must improve efficiency in medical practice by providing physicians with the information, infrastructure, and incentive they need to deliver cost effective care† (Fuchs, 2010). Information will come from the electronic health records, a process that will be amped up by the HITECH Act, which is part of the American Recovery and Reinvestment Act of 2009 (Leyva, Carlos and Deborah Leyva, 2009). Electronic health records will benefit providers with more accurate real-time data on patients as well as provide analyses on drug responses and provide support to improve the quality of medical care. Health information Exchange (HIE) can enhance information from a wide databases and allow that information to be shared through various technology by providers. This allows related patient information to be shared withi n EMR with the provider who needs that information (Southern New Hampshire Health System, 2011). Furthermore, the  Patients Centered Outcomes Research Institute (PCORI) will offer physicians and patients new information of varied medical technology. Atul Grover, chief advocacy officer for the Association of American Medical Colleges, notes â€Å"It will be an evidence synthesis that really considers different populations and different diseases and tries to get more information to clinicians as they go about doing their daily work† (Marathon Medical Communications, Inc, 2010). The integration of the PCORI will enhance information so that physicians and patients can choose the appropriate test and treatment based on the patients’ condition. Moreover, infrastructure reform will enhance horizontal collocation within providers and monitor patients consistently. Health care reform strengthens greater integration through the redesign of delivery systems such as medical homes and ACOs for physicians. Recent studies suggest that better coordination of care can reduce readmission rates for major chronic sicknesses (Hernandez, AF, 2011). In addition, the PPACA will give incentives for hospitals to support proven practices that essentially reduce their rates (Foster, 2010). Likewise, the PPACA’s pilot program involving bundling payments will bring physicians and hospitals an incentive to allocate care for patients with chronic illnesses. Most essentially, PPACA admits that health reform that brings ACOs as the delivery system is an ongoing process requiring continuous adjustment. The PCORI will develop new medical tests, drugs, and other treatment that will provide continuously updated information for physicians and patients. Over the next decade, similarly, the Innovation Center in the Centers for Medicare and Medicaid will be establishing and evaluating new policies and programs that will enhance the quality of care for Medicare beneficiaries and reduce costs. PPACA not only will expand health care coverage to millions of Americans but also will enact many policies to reduce the amount of costs for health care by bringing ACOs as the delivery system, which will reduce the costs of health care over time. By enacting ACOs as a Primary Care Provider (PCP), PPACA provides the most effective medical care support possible. Moreover, by adopting the bundled payment approach, physicians, hospitals, and other providers will be able to reduce the costs for Medicare beneficiaries.  Therefore, the public should embrace the new health care proposal to reduce their costs and improve the quality of their medical care. References Becker, Epstein & Green, P.C (2011) â€Å"HEALTH REFORM: CMS Innovation Center Announces Four Models in Bundled Payments for Care Improvement Initiative,† Retrieved from Carroll, Aaron. (2011, June 3). â€Å"Meme-busting: Doctors are all leaving Canada to practice in the U.S.,† Retrieved from Casalino, Lawrence P. (2006) â€Å"The Federal Trade Commission, Clinical Integration, and the Organization of Physician Practice,† Journal of Health Policy, Politics, and Law, Retrieved from Center for Medicare and Medicaid Innovation Center (2011) â€Å"Pioneer ACO Application,† Retrieved from Center for Med icare and Medicaid Innovation Center (2011) â€Å"final ACO rule,† Retrieved from Department of Justice, the Antitrust Division and the Federal Trade Commission (2011) â€Å"Background Documents,† Retrieved from DeShazer, Charles. (2011) â€Å"Accountable Care Organization (ACO) Tutorial,† Retrieved from Dark, Cedric (2011) â€Å"Quality over Quantity: Reforming Payment,† Retrieved from FierceHealthcare, (2011) â€Å"CMS, OIG to relax self-referral, anti-kickback laws with ACO waivers,† Retrieved from Foster, David. (2010) â€Å"Healthcare Reform: Pending Changes to Reimbursement for 30-Day Readmission,† Retrieved from Fuchs, Victor (2010) â€Å"Health Care Reform,† Retrieved from

Monday, July 29, 2019

Campaign Advertising Essay -- Advertising

(Local monthly glossy magazine): This magazine targets 31% of the local population making it an ideal media outlet for a local event like the Fitness-Challenge kick off. Since the Fitness Challenge focuses on eliminating childhood obesity, parents will be the main target audience. According to the U.S. census bureau 32% of American families with a child under the age of 12 have a stay at home mother. Only 3% of American families with an elementary age child have a stay at home dad. Taking these statistics into account our campaign will cater towards behaviors and needs of the â€Å"stay at home mom†. Out of the local population that reads â€Å"Our community†, 70 percent are women ages 31-60 years old. This age range and gender covers our target audience therefore making advertisements through this media outlet very effective. A half page ad would cost the campaign 4,000 dollars, a small price for so much exposure. Since the magazine only prints every month, readers tend to flip through the pages mul tiple times, maximizing frequency. $4000 KABC (NBC affiliate) With 40 percent of the local population as regular viewers, advertisements on this program will significantly increase awareness of the Fitness Challenge. Women ages 35-55 represent an astounding 72 percent of viewers. Awareness of the challenge requires introduction of the event concept and benefits. Running at least 30 non-primetime ads two months before the Challenge will familiarize the target audience with the event without bombarding them with information. Thirty prime-time ads will run the month before the event to maximize advertising exposure of the Fitness Challenge Kick off. Cost: Non-primetime-$3750\ Prime-time- $9000 WPTG (urban ra... ... middle of paper ... targeted stay at home moms, dads also hold decision power when it comes to their children’s health. Billboards displaying advertisements for the Fitness Challenge kick off, offer an enormous amount of exposure for the event. Boards strategically placed a long high traffic roadways catch the eyes of interested fathers on their way home from the workplace. Most working individuals drive the same route to and from work meaning that they encounter the same billboard messages twice daily. Therefore the frequency that one individual encounters the ad on a daily basis must equal or surpass two. Multiply this by 2 months and the number of impressions falls well over 100. Cost: 2 months- $ 5000 Total Cost: $31,205 Even after creating a campaign media plan that encompasses multiplatform advertising our budget of $50,000 remains $18795 higher than required funds.

Sunday, July 28, 2019

Accounting Concepts Essay Example | Topics and Well Written Essays - 1500 words

Accounting Concepts - Essay Example Under the money measurement concept, these items can be recorded as a land worth $100,000, a building (containing 10 rooms and conference hall) worth $500,000, 250 chairs at $50 each, and so on The money measurement concept assumes that money is a stable unit of measurement and therefore the value of money does not change with time. Going concern concept The going concern concept implies that accounting transactions are recorded keeping the view that the business will exist for a long period of time. More precisely, a business enterprise is considered to be a going concern but not a liquidated one. As per the going concern concept, asset valuation is done at historical cost or replacement cost. The going concern concept is a fundamental principle to the preparation of financial statements (Rajasekaran 2011, p.18). In case of short term business projects like building construction, the business comes to an end once the construction of the particular building is completed. In contrast, some business entities that operate in the automobile or consumable goods industry exist for a long period and they will continue their business activities in the foreseeable future. According to this concept, business enterprises treat prepaid expenses as assets in their balance sheets even though they are not saleable practically. Dual aspect concept Dual aspect concept is one of the fundamental accounting concepts and assumes that every transaction has a two-fold aspect – giving certain benefits and receiving certain benefits. The underlying principle of the double entry system is that every debit has an equal and corresponding amount of credit (Johnston & Johnston 2006, p.54). From the accounting equation (Assets = Liabilities+Capital), it is... The object evidence concept says that all accounting activities must be objective evidence based. In other words, there should be adequate verifiable documents to support the reliability of every transaction recorded in the books of accounts. This is the very essential for auditors to verify the reliability of accounts prepared. It is to be noted that the verifiable evidences must be objective but not subjective. For instance, a business entity has to keep receipts for the building rent paid. From the above discussion, it is clear that all the ten accounting concepts explained are greatly beneficial for accountants to prepare universally comparable, understandable, reliable, and relevant set of accounts. These accounting concepts give a standard structure to books of accounts prepared globally. â€Å"The accrual concept is an accounting system which recognises revenues and expenses as they are earned or incurred, respectively, without regard to the date of receipt or payment†. In simpler words, revenue is recorded in the books of accounts on its realisation but not its actual receipt. In the same way, expenses have to be recognised when they are incurred but not when the payment is made actually. To illustrate, a business unit paid $5,000 in rent for the building and machinery a year whereas it had owed only $4,500 in rent. That means the company prepaid $500 in rent. At the end of the accounting period, the prepaid rent is recorded on the asset side of the balance sheet.

Rana Plaza building collapse Essay Example | Topics and Well Written Essays - 1000 words

Rana Plaza building collapse - Essay Example Every structure is design specific observing the building codes and laws accurately. Rana Plaza buildings failure to observe building codes rendered it a failure. Gomes reports on an article open security published on 9 May 2013 that in Bangladesh, any permission for constructing high-rise building is obtainable through bribes, and the building built without procuring suitable materials. Unsuitable materials in most cases comprise substandard materials lacking the desired strength to withstand the forces and pressures exerted and imposed by the structure. That automatically leads to an eventual failure and collapse of the structure. In addition to the substandard materials used, the load bearing columns were found to have been erected haphazardly. Live loads in a structure exerts pressure it as well as the dead loads. The workers form part of the live loads exerting a weight on the structure. The overcrowded workers at Rana Plaza building exerted more loading than the structure could bear. That could lead to an eventual collapse. An early assessment conducted by NGO Asian Disaster Preparedness Center reveals the building was built primarily and purely for retail purposes. However, the building hosted three garment factories with electrical generators. The generators together shook and vibrated the poorly constructed building exerting a weight estimated to be six times more than the intended weight bearing capacity of the building. The excess loading on the structure led to its eventual collapse. Industrial police asked the garment factory owners at Rana Plaza to keep the factories shut and only proceed further procedures after consulting with expert structural engineer. The bosses failed to respond to the directives and forced the workers in threatening them of pay cut. The presence of the workers in the already weak building exerted more pressure on it thereby causing the collapse. The bosses ignored calls by the employees who saw cracks on the

Saturday, July 27, 2019

The Roman Catholic Church Essay Example | Topics and Well Written Essays - 1250 words

The Roman Catholic Church - Essay Example Roman Catholics are seen as Christians in their communion to the Pope. Over the world, there are over a billion members following the Catholic Church. In the following essay, we will describe in Part I the organization of the Roman Catholic Church through, then in part II we will discuss about the role of this religion in one's life with the role of the Pope, the Saints and the Bible. Finally, in Part III, we will compare the Roman Catholic Church with Islam. Roman Catholicism - as other Christian denominations, Judaism and Islam - is a monotheistic religion. The Catholic Church believes that God is one, eternal, all-powerful, all-knowing and omnipresent. However, the Roman Catholic Church is also a Trinitarian religion, meaning that even though God is only one in nature, essence and being, He exists in three divine persons: the Son, the Father and the Holy Spirit. They are all identical in essence but differ in their relationship to one another which constitutes the Holy Trinity. Faith in God is the keystone, the most fundamental Catholic belief but also faith in the relationship of these three divine entities as being one. Roman Catholics believe that the Son, the second divine person, has been incarnated as Jesus Christ. Born of the Virgin Mary, he is considered by Catholics to be truly divine and as the same time truly human, teaching how to live through his words and his acts and revealing God as love. Even though Roman Catholicism is composed of numerous places of worship such as cathedrals, churches, chapels and oratories, there is no particular rule for Christians to worship in these places. They can worship in any place as God is omnipresent. However, within these places are held the Eucharistic liturgy - the Celebration of the Mystery of Christ, especially the Paschal Mystery of his death and resurrection - which is considered as the high point of its activity and the source of its life and strength. Within these places of worship, Catholics are particularly focused on the altar, the tabernacle, the place in which chrism and other holy oils are kept, the seat of the bishop or priest, and the baptismal font. The Christian Roman Church recognizes and administers seven sacraments, considered as gifts from Christ to his Church: Baptism, Confirmation, Eucharist, Reconciliation, Anointing of the Sick, Holy Orders and Matrimony. Not every person will receive every sacrament, but they are considered by the Roman Catholic Church as necessary to salvation, conferring each sacrament's special graces, forgiveness of sins, adoption as children of God, conformation to Christ, and membership of the Church. There are numerous holidays and days of observance through the year for Roman Catholics. However, we will only insist on some major events in this essay. Christmas Eve and Christmas day celebrates the arrival of May and Joseph in Bethlehem and the birth of Jesus Christ. Ash Wednesday is an observance to begin the 40 day season of the Lent, a time of reflection and preparation for Holy Week and Easter, a time of intense devotion, it is observed by fasting, frequent worship and acts of charity. Easter commemorates the resurrection of Jesus Christ after his crucifixion. Good Friday is a remembrance of the crucifixion of Christ. Finally, Sundays are considered as days of observance commemorating the rest of God after creating earth during six

Friday, July 26, 2019

Strategic Plan Stakeholders Essay Example | Topics and Well Written Essays - 250 words

Strategic Plan Stakeholders - Essay Example The reasons underlying the development of a document on strategic planning is for the organization to eradicate ill politics emanating from the stakeholders. This may result whenever a certain group within or outside the business perceives biasness. A planning document entails the organization’s objectives and goals. Further, it describes to the stakeholders the essential approaches that business entity targets to implement to accrue the long term plans. Through the implementation of a planning document, the organization gains the ability to pursue its goals since every stakeholder will be knowledgeable of the perceived outcomes thus devoting his support to the planning process (p. 2). Reasonably, the development sets a pace for the organization to meet all its stakeholder needs. Organizations devote their strategic development plans towards achieving beneficial outcomes. Therefore, the documented approach will serve to the effect of ensuring efficiency in delegation of tasks, team-building, and a unified focus towards the set goals and objectives. The document acquaints an organization with a prospectus for scanning the environment. This influences a positive approach towards development of the organization’s mission. Arguably, the documented approach describes the organization’s vision (p. 3). Lastly, it is an essential resolution to a democratic process of inserting decisions harvested from the organization’s internal and external

Thursday, July 25, 2019

Coach case Essay Example | Topics and Well Written Essays - 500 words

Coach case - Essay Example This model focused on providing indirect sales to other third parties thus increasing the number of sales of products and thus increasing its brand awareness in the market. These two strategies enabled Coach Company to attain its two primary strategic objectives which were to increase the global distribution of its products and to also improve the store sales productivity. Therefore, through these two strategies, the company has been able to attain competitive advantage over its major rivals, however, it was not certain whether the firm could match some of its prime rivals such as Dolce and Gabbana, and Versace. Coach Company has the principal strength of adequately competing with its competitors on its highly unique and superior luxury goods. Besides the company’s products has an innovative styling that has played a huge role in attracting new customers. Comparatively, Coach Company products are available at major outlets and sold at price less than 50% or more than its chief competitors in the luxury industry. In addition, the company has delivered extra services to the customers such as customer care to cater for their queries whenever they occur. As a result, the company has experienced increased customer satisfaction and loyalty from its customers. Equally important, Coach engaged in strategic associations with other major company such as Movado thereby broadening their market segment. This concept of outsourcing has not only enabled them to cut their maintenance costs but to lower their manufacturing costs as well. This has therefore increased their competitive advantages in the luxury industry. The companies has also various internal weaknesses which should be managed appropriately. For instance, the luxury industry is characterized by rampant change in the fashion trends. This has thus led the factory outlet stores to outperform the retail price stores. Therefore, the company’s products and brand are diluted due to the

Wednesday, July 24, 2019

The Localization of Management in China Essay Example | Topics and Well Written Essays - 11250 words

The Localization of Management in China - Essay Example 3.8 HR Departments 37 3.9 Chinese Characteristics 46 Chapter 3 - Structure 49 Chapter 4 - Research Methodology 50 A.- Research Framework 50 B.- Research Procedure 52 C.- Research Methods 52 4.1 Primary Research 53 4.2 Secondary Sources- Surveys 53 4.3 Reliability of Material 54 4.5 Qualitative and Quantitative Research 55 Bibliography 60 List of Tables and Figures Table 1 20 Table 2 25 Table 3 33 Table 4 47 Table 5... The localization of management in China has to be examined with understanding the implications and considerations for foreign companies which requires a number of critical considerations. The roots of the issue are inherent in the understanding of China, as this is core of the management operation. This process requires that the companies involved in an understanding the dynamics of the operation should consider understanding the culture of the country as other factors are the rooted within the question. Thus, the main hypothesis represents: Chapter Two: Introduction: In order to understand the implications as well as considerations of the localization of management in China, one must realize that over one-fifth of the world's population live there. China has recorded double digit economic growth throughout the 1990s, and 2000s, and is well on its way to becoming the number one economy in the world (Kai-Alexander, 2002, p. 3). The importance of the country's huge domestic market has been, and is attracting business investment, which has implications for both the firms entering as well as already in the market. The foregoing also has implications for the Chinese national employed in the managerial level. A key factor in understanding the cultural dimensions of the Chinese is the historical turmoil that the country has undergone.

Tuesday, July 23, 2019

Online Customer Service Essay Example | Topics and Well Written Essays - 2750 words

Online Customer Service - Essay Example However, as the businesses grew, information regarding each customer became difficult as a result of customer growth base. To cope up with the growing customer bases, marketing segmentation and customer grouping was started, where customers were put in slots that could fit into their needs. Grouping of customers and putting them into slots enhanced the expectations of customers, but this also compromises some other desires of the customers since other services are tailor made to groups, not individuals2. In order to meet these challenges, relationship management begun to surface in 1980’s where this idea was to work efficiently with a direct relationship with the customer. Most of the firms realized that this could make them to know more about their customers and provide services that were tailor-made to match their desires. By doing this, firms were able to add value to their customers and themselves. Relationship Management is a group of terms and methodologies that illustra te how businesses should endeavor  and  strive for quality customer service, long term relationship with customers, and provision of quality goods and services. The argument behind good customer relationship include, sense of control, reduction of risks, provide more security, feeling a sense of control and reduction of costs of being a custo The rise of social customer The rise of customer requires that companies should change into a fully fledged social enterprise that values openness and succeeds on the collaboration with customers. The livelihood of the social business is a combination of consistent and immediate flow of information which involves every employee and spans every level of the company3. This means philosophically the customer’s needs at the heart of the vision of the company so as to equip the entire labor force with the right tools so as to ensure that there is customer satisfaction either directly or indirectly. This means operationally that there is a n investment in systems, guidelines and training that will enhance immediate communication between the workers and customers. A social business will have to pay attention and engage a variety of media-email, telephone, mobile and web. Several customers are going for social media to research, rave and rant about their experiences. By amplifying and aggregating experiences of the customers, social media has the ability to either make or break the reputation of the company. Studies have indicated that over 40% of the adults use the web to share their complaints about the services and products. Social media has the ability to bring down the company into its knees if not well managed. Social media has pushed customer service to the front of tactical thinking.  In order to stay in the competition, it is extremely beneficial for companies to know about the needs of a social customer. Use of Social Media Companies in the contemporary business environment are moving closer to its customers , and have taken some steps in resolving the problems encountered by its customers. There is a massive opportunities for various companies in the social web4. Removal of communication obstacles between a business and its customers, social web maintains one-on-one, small-scale relationship with the customers contrary to the setting of large-scale

Meaning of Life and Happiness Essay Example for Free

Meaning of Life and Happiness Essay I do not think that there is a single person in the world who can say that knows what happiness actually is and, more importantly, that knows how to achieve it. We sometimes get the glimpse of pure happiness but those moments are so rare and so intense that we only recognise them too late. Each of us understands this feeling in a different way†¦I, for instance, see it as the one that can make you feel that there is no worry in life and nothing and nobody can hurt you anymore. For me, it is when you feel like you can do anything and forget about the past, the future, just enjoying the mere present. In my case, it is one of two feelings that can make you cry with all your heart†¦because it is too much for you to express in plain words or pointless gestures. â€Å"Tears are words that the heart can’t express† a wise man once said and could have never said it better, as happiness is that joy which is so strong that sometimes even hurts. However, I never remember the recipe for happiness and even if I did I do not think it would work again because one of its components is also hazard. Still, this does nt make me stop searching for it and devote it everything I do, I am and I achieve. Likewise, each person I’ve ever met, consciously or not, did the same†¦we want to get something, to become someone. Why? Not because that would make us feel miserable, but fulfilled and maybe a little bit more: happy. Hence, I strongly believe that happiness is the main purpose of our lives, the whole aim of our ephemeral existence. We are born happy and we want to die the same; this is the true ideal that we all crave for reaching. Money, wealth, knowledge mean nothing, without someone who cares about what you have achieved. Human beings, whether they like admitting it or not, need other human beings to share their secrets with, to share their joy or sorrow; as genuine joy can only become happiness if there is another person by your side. In other words, happiness is, in my opinion, the actual meaning of life; and life seems so complicated especially because we seldom get to its core, we almost never get to know what happiness feels like†¦and afterwards all that remains is an unclear memory of the moment and a wish of feeling it again.

Monday, July 22, 2019

Edgar Allan Poe Essay Example for Free

Edgar Allan Poe Essay A famous author who initiated the start of detective stories and could spook his readers out with his tales of horror was born in January 19,1809. He was a wonderful short story writer and a poet. One of his masterpieces that he is well known for is known as â€Å"The Raven.† I’m sure by now you’ve guessed that I’m speaking of the â€Å"Father of the Detective stories† known as Edgar Allan Poe. Poe’s work reflected his own bitter and mysterious life. In most of his writing there is a blur between what is real and what if fiction because many of his narrators are on some sort of drugs. Edgar was a romantic writer, and his style was gothic. Edgar Allan Poe was a romantic in his writing. He was a part of the American renaissance movement and it is apparent he along with many other American writers rejected the British form of writing. He seemed to embrace that writing should express emotions. It shouldn’t just follow a certain rubric of rules but effuse from the heart. The tell-tale signs of a romantic writer are strong idealism and rejection of classicism. These characteristics are vividly found in his work known as â€Å"Ligeia†. In this story the narrator is an opium addict who marries a woman named Ligeia. He finds her to be very intriguing. He sees her as a beautiful woman with a mysterious personality. Unfortunately, she dies and he ends up marrying a stereotypical woman named Rowena. She is the complete opposite of Ligea in that she is exactly the way all the women of his era are supposed to be like. At the end of the story this woman also dies but then Ligea returns to the author through Rowena’s dead body. The romantic writer uses many examples to illustrate his preference for Romanticism over British literature and Classicism. The preference of the author for his first wife is an example of strong idealism and rejection of classicism. For instance, the writer describes his wife as an extraordinary being†¦almost inhuman: â€Å"She came and departed as a shadow.† Then he goes on to talk about her eyes and mentions that they are much bigger than normal eyes should be. He has a soft spot for her unique features and admires her intelligence. It is because she is different from the norm of women, he finds her attractive. She is a symbol of rebellion to the rules of classicism and her characteristics paint the art of romanticism. He then contrasts her â€Å"Singular yet placid cast of beauty† with the â€Å"fair-haired† and â€Å"blue-eyed† classical beauty of Rowena. It is apparent he prefers his first wife over the latter one because he repeatedly compares the two but compliments the first one. Poe then goes on to demonstrate strong idealism in his work. Idealism was basically a term used to define the optimistic nature of American writers in the good nature of mankind. In this story the fact that the narrator’s first wife comes back to life through the body of his second wife is a symbol of optimism. The author had described his wife as a woman who had wisdom of divine matters. He believed in her wisdom so much that he was sure she had used it to resurrect herself. It is also useful to know that the author was an opium addict. His point of view may have been distorted with hallucinations but the opium usage itself is an example of strong idealism. It is through this usage he is able to find his favorite wife come back to life simply because he willed for her to return to him. Her return could even be literal after she claims that, â€Å"Man doth not yield him to the angels, nor unto death utterly, save only through the weakness of his feeble will† (Lombardi). So maybe she was really there and if she was then this is a fine example of idealism. Considering, idealism is the hope of having a very unlikely event occur because of someone’s optimism. One more example of idealism in Ligeia is no significance of time or space. The American writers wanted to be very distinct from the old literature and wanted to cut off from them. As a result, they made time and space irrelevant to their work as a rebellion to rules. This explains why readers are never told how or when the author met his first wife or at what time she was reincarnated. For example, Poe says â€Å"I cannot, for my soul, remember how, when, or even precisely where, I first became acquainted with the lady Ligeia. (Deter) In addition, the author is so caught up the description of Ligeia he doesn’t remember the beginning of his relationship with her or what the ending to her is. She seems to consume him to the point that time and space don’t matter to him. Does she even have an ending? Considering she comes back to life as if manipulating time is one of her skills. All of these details just add to how much of a romantic writer Edgar Allan Poe really is. Poe used a very gothic style of writing. His work was usually dramatic, suspenseful and melodic. â€Å"The Raven† is a perfect example of these writing techniques. For instance, in â€Å"The Raven† the setting of the story is in his apartment in a lonely December night. The narrator is missing his lover, Lenore, who died. He is trying to distract himself by delving into the realms of his books but is sadly failing in all his attempts. Then a Raven appears at his window and knows of one word, â€Å"Nevermore.† He asks the Raven if he would see his lover again, but it replies â€Å"Nevermore.† The Raven angers the author and he tells it to leave to which the Raven gives the same answer, â€Å"Nevermore†. This poem is very meaningful and pretty much defines the themes and styles that Edgar loved to promote in his work. One thing to be noted when reading this poem aloud is that repeating Nevermore aloud after each stanza is a purposeful tactic. Edgar’s melodic instincts shine through this technique. He does this to emphasize the unity of effect and so that each stanza reflects the meaning of the poem as a whole. In addition, the â€Å"O†Ã¢â‚¬â„¢s in â€Å"Lenore† and â€Å"Nevermore† are too emphasized so that the unity of effect occurs once more. Moreover, this woman has left him and she is no more so the two words are parallels to the emotions of the author at the moment. They signify his loneliness. Edgar’s poetry is always well thought-out and he is always on a mission to have relatable but dramatic themes that will suck his readers in. In this poem he combines the theme of beauty with death. The beauty is represented by the memory of his beloved lover but who has met the ugly reality of death. He asks the Raven whether he will meet her in heaven but is hit by the cruel answer â€Å"Nevermore†. This blatantly ugly reality is what makes his poem have an even more gothic and depressing touch.

Sunday, July 21, 2019

Modification of the 4-Quinolone Scaffold

Modification of the 4-Quinolone Scaffold Discovery: Quinolones are antibacterial agents that are of major importance in the antibacterial field as the can act as the model antibiotic. This is due to their broad range of activity, the high potency and good bioavailability with both intravenous and oral administration possible. This is coupled with high serum levels and a distribution within tissues that specifies concentration levels and results in, theoretically, few occurrences of unwanted side effects.1 The timeline for the development of this class of antibacterial agents begins with the isolation of the bactericidal naphthyridine, nalidixic acid, in the 1960s by George Lesher as the first synthetic quinolone antibiotic. Nalidixic acid is illustrated in Figure 1 below and is a by-product that was isolated from a chloroquine synthesis.2 Figure 1: Nalidixic Acid The clinical use for naldixic acid was to treat urinary tract infections (UTIs) caused by gram negative organisms. The successive generations of quinolones had activity against both gram negative and gram positive bacteria as well as anaerobic bacteria. This development lead to fluoroquinolones which are latest in quinolone antimicrobials. The clinical uses for the quinolones today include respiratory tract infections, bacterial meningitis and gastrointestinal infections as well as the historical use of treating UTIs. The development of fluoroquinolones resulted in a more extended spectrum of activity and improved pharmacokinetics then the first generation of quinolones.3,4 Structure: The general quinolone class of molecules is comprised of 4-quinolone and 1,8-napthyridine ring structures. The naphthyridine ring structures differ slightly from the 4-quinolone core due to the presence of two nitrogen atoms in the rings of the molecule (Figure 2). The substituents R5, R6, R7 and R1 were added to improve the activity of the quinolone core before the development of highly potent fluoroquinolones.1 Figure 2: General Structure of 4-Quinolones The first fluoroquinolone to be developed was Flumequine; illustrated in Figure 3. It had a fluoro-group at the 6 position and was the first compound to show that modifications of the quinolone core could results in improved activity against the gram-positive bacteria that nalidixic acid had no effect on.1 Figure 3: The first fluoroquinolone- Flumequine Mechanism of Action: Inhibition of bacterial DNA gyrase (topoisomerase II) and topoisomerase IV is achieved by quinolones. These enzymes play a vital role in the uncoiling of DNA. DNA gyrase acts as the target in gram negative microbes and topoisomerase IV as the target in gram positive microbes for quinolone activity. The widely-accepted mechanism of action is that quinolones bind to complexes, formed between DNA and one of the enzymes, to generate a Quinolone-DNA-Enzyme complex that inhibits DNA replication. The binding of quinolones and topoisomerase is enabled by a water-metal ion bridge. The inhibition is bacteriostatic as replication is reversible.   Eventually apoptosis occurs due to the fragmentation of the DNA ends of the complex. This results in bactericidal inhibition. The most common form of resistance to the quinolones is due to specific mutations in the topoisomerase II and IV that interfere with the water-metal ion bridge interaction.2,3 Development: Quinolones are grouped into generations depending the activity of the molecules. The first generation showed activity against gram negative bacteria that caused UTIs. The second generation showed enhanced activity against gram negative bacteria and improved activity against gram positive. This enabled the list of conditions that quinolones could treat to expand. This generation displayed improved pharmacokinetics; due to the use of a C7-piperdinyl substituent. The third generation provided improvement in efficacy in inhibiting gram positive and anaerobic pathogens. 3,5 The fourth generation of drugs observed dramatically increased activity against DNA gyrase and gram positive microbes, improved pharmacokinetics and pharmacodynamics. The major changes were the addition the fluoro-group at the C-6 position and a ring substituent at C-7. Norfloxacin (1), second generation, was the first broad spectrum quinolone with ciprofloxacin (2) the first quinolone to have activity observed beyond the treatment of UTIs.2 Currently, Garenoxacin (3), fourth generation, is of interest due to its distinct carbon-carbon bond at position C7 and its broad spectrum of activity.3 Figure 4:Generations of quinolone drugs. Three modified quinolone cores have acted as templates for drugs that are on the commercial market. The cores were 4-oxo-1,4-dihydroquinolone (4), 7-oxo-2,3-dihydro-7H-pyrido-[1,2,3-d,e]-1,4-benzoxazine (5) and 4-oxo-1,4-dihydro-[1,8]-naphthyridine (6). These selected cores are illustrated in Figure 5.3 Figure 5: Cores used as templates for commercial drugs Retrosynthesis: Scheme 1: Retrosynthesis of 4-Quinolone core6 A carbon-carbon disconnection between the ketone and the aromatic ring, the reverse would be a Friedel-Crafts reaction.   The double bond is opened and the hydroxyl group that is added is converted to a carbonyl group. The final disconnection, N-C, results in the starting materials; a keto ester and the substituted aniline. Synthesis: Several synthetic approaches have been taken to generate the 4-quinolone core. The Gerster-Hayakwa and Chu-Mitscher reactions are used specifically for the synthesis of the drug Levofloxacin. The Chu-Li route was established primarily for 9-cyclopropylpyrimidinones. The Gould-Jacobs reaction, Grohe-Heitzer cycloacylation and Conrad-Limpach-Knorr are appropriate methods of synthesising the generic 4-quinolone core.3 The Conrad-Limpach-Knorr synthesis will generate quinolones but this reaction will give different products depending of the whether it is kinetically or thermodynamically controlled. Aniline and 3-keto ester are mixed and at room temp the keto group joins the nitrogen of the aniline giving an enamino ester (kinetic product) and cyclisation at 250 °C results in a 4-quinolone. Thermodynamically controlling this reaction, by carrying it out at 140 °C, results in an amido-ketone dominating regardless of the less reactive ester on the keto ester being the centre of the first nucleophile attack. Ring closure results in a 2-quinolone.7 Scheme 2: Conrad-Limpach-Knorr Synthesis (kinetically controlled) As the substrate for the cyclisation needs to be the high-energy tautomer and cyclisation causes loss of aromaticity in the ring, solvents with high boiling points are generally used in this synthesis.8 The reactions are encouraged by electron-donating substituents in the aromatic ring including methoxy or amino groups. These give increased yields in the condensation and ring closure steps. A CF3 group can act as an acceptor at C-4.9 The short reaction sequence limits possibility of loss of yield. Rational Drug Design: Illustrated in Scheme 3 is the process of rational drug design. Computational screening is used to identify the target and generate the lead compound. This is modified considering the biological aspects, the 3D structure, the QSAR and reactivity of the compound. This generates a new lead which is optimised and put forward for preclinical trial. Scheme 3: Rational Drug Design Process10 Nilsen et al. used endochin as a lead for optimisation in a rational drug design study. The target selected was the multiple stages of the life cycle of malaria. Endochin is potent against malaria but is not active in vivo due to rapid and extensive metabolisation. Optimisation was required to form endochin-like quinolones (ELQ) that retained the activity of endochin but were biologically active. The aims for optimisation was to improve metabolic stability and aqueous solubility as well as eradicate cross-resistance.11 Figure 6: Structural Representation of Endochin The EQLs were synthesised by converting the quinolones to quinolines, followed by nucleophilic displacement. The quinoline undergoes Suzuki-Miyaura coupling with a boronic ester and finally the protecting group is removed (Scheme 4 A). An OCF3 group was also added to the side chain for further optimisation (Scheme 4 B). Scheme 4: Synthesis of ELQ An orally active class of quinolones were synthesised; 4(1H)-quinolone-3-diarylethers. The initial lead, ELQ-233 (Figure 7: ELQ-233Figure 7), displayed low nano-molar IC50 values. The optimisation step was to introduce an aryl group at C-3. A lipophilic diphenylether side chain was used as it had been previously reported as integral in other antimalarial drugs. This was to work with the methyl group at C-2 to cause out of plane movement of the sterically large aromatic ring, altering the à Ã¢â€š ¬Ãƒ ¢Ã‹â€ Ã¢â‚¬â„¢Ãƒ Ã¢â€š ¬ stacking from the numerous H-bonds. This variation would not be perused as ELQ-233 was equipotent to endochin. Figure 7: ELQ-233 Due to the success of adding a fluoro group to the quinolone, to further build on the optimisation of endochin, a fluorine was added at C-6 on a second optimised molecule (7) along with a methoxy group at C-7 (as is in the endochin structure); illustrated in Figure 8.11 The methoxy group is a useful substituent due to its lipophilic and hydrophilic components in close proximity. Figure 8: Illustration of Compound 7 However, both ELQ-233 and 7 were metabolically unstable and therefore did not fulfil the optimisation requirements. Table 1: Values obtained for the optimised molecules Compound cLogP EC50 (nm) Endochin 3.35 3.8 ELQ-233 3.70 8.4 7 3.73 40 8 5.66 2.2 Further derivatives were generated and the pattern that emerged indicated that the substitution pattern on the aromatic ring influenced the reactivity with malaria. This result led to the rational design of further ELQ derivatives. Straight-forward reactions were continued to be used. The boronic ester with a varying diarylether side chain undergoes palladium mediated coupling with the quinolone then a demethylation occurs using hydrobromic acid to give the desired product. Repositioning the OCF3 group to the side chain increased the efficacy and the metabolic stability. The compounds that was found to be metabolically stable and potent had a chloro-group at C-6 and OCH3 ­at C-7. Figure 9: Structural representation of compound 8 Although compound 8 was the most potent compound, the high logP value is a disadvantage as it does not follow Lipinskis Rule of Five which is the basis for most developed drugs. To improve solubility and allow for lower dosages of 8, bioisoteres of the side chain were employed. The OCF3 was replaced by CF, Cl and F by Nielson et al. and displayed subnanomolar activity. Other options would be to double the terminal OCF3 group, double the substituents on the diaryl side chain, convert the diphenyl ether side chain to a dipyridine ether side chain or replace a phenyl ring in the side chain with a cyclopropane group. Phenyl rings can be replaced by a heteroaromatic ring or a saturated ring to improve efficacy, lipophilicity and specificity of binding. The introduction of a pyridine ring should reduce the metabolism of the phenyl ring and toxicity of metabolites.12 In heterocycles, metabolism can be more complicated with hetero-atoms being oxidized and/or ring opening reactions possible- slowing metabolism. Cyclopropane was explored as derivative of the phenyl ring resulting in compounds with reduced molecular weights and lower lipophilicities. It also limits the conformations available and increase yields of ELQs.11 Scheme 5 below are the same coupling reactions that are stated by Nielson et al. but with the suggested changes to further improve the lea d. Caution must be taken when adding substituents to the side chain so that Lipinskis rule of five is obeyed; there must be no more than 5 hydrogen bond donors or 10 hydrogen bond acceptors and the molecule should be below 500 Da. Scheme 5: Suggested further optimised lead molecules Rational drug design is an advantageous modification method as it is a streamline process when compared with SAR or QSAR as there is no trial and error, all leads and derivatives are prepared having been predicted by computational means previously. The computational aspect allows for all compounds and potential targets to be envisaged in 3D before they are synthesized. This computed information is then stored on large databases which can assist future drug development work. Rational drug design can be an expensive technique as a specialized team is required with knowledge in biology, chemistry and computer science. Costs rise due to payment of wages for the team and the specialized equipment and computer software that is vital. Although the computational aspect of this method is beneficial it can also be a disadvantage as not all predicted compounds can be synthesized and if the compounds are synthesized they may not act as predicted when in vivo.   Specifically, in this ratio nal drug design study, the reactions utilised readily available reagents that were also inexpensive. They were straight-forward reactions that gave high yields and could be scaled up. These are vital as the cost of antimalarial drugs must be kept down so that all people can afford to access it.11 Structure-Activity Relationship (SAR): SAR studies examine how the structure of the molecule effects the activity. SAR considers structural characteristics and relates them the activity therefore it is necessary to have a well characterized database to compared the results against. The basic principle of SAR, that structure determines properties and reactivities in a biological system, is of importance when determining toxicological properties. This is of huge significance for quinolone development as they must be nontoxic in vivo while remaining bacteriosidal.13 Figure 10: Areas SAR Studies consider13 These studies examine which modifications are possible to the core ( Figure 11) and which substituents cannot be modified without negatively interfering with the activity and potency of the drug.   There can be qualitative and quantitative aspects to these studies. The quantitative considerations are part of a quantitative structure activity relationship (QSAR) which will be discussed later. Figure 11: Quinolone core positions for the SAR study Table 2: Important Positons on the Quinolone core-SAR Study results14 Position Influence On: Preferred substituent: Effect of substituent: 1 The pharmacokinetics and has control on overall potency. Cyclopropyl increase activity against gram negative microbes 5 Activity against gram-positive bacteria. NH2 and CH3 moiety improve activity against gram-positive bacteria 7 Spectrum of activity and pharmacokinetics. 5/6 membered N heterocycle (aminopyrrolidines and piperazines) Alkyl group Aminopyrrolidines: increase activity against gram-positive bacteria Piperazines: increase activity against gram-negative bacteria. Alkyl: enhance gram- positive potency and lengthen the serum half-life 8 Pharmacokinetics and specific activity on anaerobes. CF, CCl and COMe improve activity against anaerobic bacteria. alter specific interaction of the agent in vivo. SAR studies reveal that a hydrogen at R2 is preferred. Any larger moiety would likely cause steric hindrance with the adjacent carboxyl group at C-3 and the oxygen at C-4. These substituents are vital for activity as these positions are where binding to DNA bases occur before the sites are made available for other hydrogen bonding to proceed by DNA gyrase. A small molecule is best for potency at R6. This is usually a fluorine group in later generations of quinolones as it produces molecules of between 5 to 100 times greater potency that when a hydrogen is positioned at R6.14 Ciprofloxacin (Figure 12) is one of the original patented quinolone anti-bacterial agents. It is first generation as it has moderate activity towards gram negative bacteria, poor pharmacokinetics and poor bioavailability. Figure 12: Structural representation of Ciprofloxacin However, using the results of the SAR, Ciprofloxacin can be further optimized. Scheme 6 utilizes straight-forward reactions to attach an -NH2 moiety to the core at positon 5 where the SAR study indicates it has the greatest influence. Firstly, nitration of the aromatic ring occurs, followed by a reduction of the nitro group to an aniline with palladium on carbon. Scheme 6: Further optimisation based on SAR Study Results The new lead is still in agreement with the SAR results as the carboxyl and oxygen are present at C-3 and C-4 respectively. The preferred substituent as stated in Table 2 are also used throughout the reaction scheme; the piperazine is at position 7, the fluoro group at positon 6 and the cyclopropyl group at positon 1. These substituents can positively influence the spectrum of activity the potency and the overall pharmacokinetics of the molecule. The addition of extra hydrogen bond acceptors/donors must be limited so as not to disobey Lipinskis rule of five by having more than 5 hydrogen bond donors or 10 hydrogen bond acceptors. These reactions, like the rational drug design reactions, utilize readily available, generally inexpensive reagents which is important to keep the cost of the anti-malarial drug down. Palladium is an exception as it is a rare metal but cheaper alternatives could be used for this step such as Raney Nickel although this generates intermediates before the aniline is formed unlike the direct formation when the palladium catalyst is used.15 SAR studies can represent molecules as 2D, atoms and bonds, or 3D, steric effects and electrostatics. 3D is best for when the receipt-mediated mechanism is known. Successful SAR studies also need appropriate methods of analysis which depend on whether quantitative or qualitative analysis is being perused and if the mechanism is known. The ideal SAR model should have adequate molecules for fair statistical analysis, a wide range of activities and an even distribution of molecules in each compound class. This model is rarely found when toxicology is considered.13 Quantitative Structure-Activity Relationships (QSAR): The basic principle of QSAR is that similar molecules have adequate similar mechanistic elements so that a common rate-determining step is shared among them and that they have comparable energy requirements for activity. This principle is taken further and the assumption is that differences in reaction rates results in differences in activity or potency.13 Lipophilic, electronic and steric effects are considered in QSAR studies. QSAR provides an equation that quantifies the SAR and allows for predictions about which property has an important role in the distribution/ mechanism of the drug. Predictions cut down on the volume of analogues to be synthesised. Equations are only applicable to compounds of the same structural class. Outliers indicate when a feature is important and can produce new leads. The QSAR may not give accurate predictions as the parameters have covariance on each other; the predicted model may vary in vivo.6 Lipophilicity/Hydrophobicity: This can be considered as the lipophilicity of the molecule or the lipophilicity of the substituents attached. Partition Coefficient, P, is the parameter associated with the lipophilicity of the molecule and is measured by Equation 1. Equation 1: Representation of the lipophilicity parameter. Solvents chosen to represent the Central nervous system The activity of a molecule can be related to the P value as a molecule must be able to cross membranes and be transported through the body to its target site which is dependent on its lipophilicity. Varying substituents on the core can alter the P value in whichever direction is more beneficial for the activity of the molecule. From SAR studies increased quinolone activity occurs when a lipophilic substituent, such as a halogen, is attached at C-6. Simple reactions, including nitration and chlorination (Scheme 7), will add these substituents to the core, again using cheap and readily available reagents. In general, increasing lead hydrophobicity increases activity (Figure 13). This does not go to infinity as there is a point at which the lead is to hydrophobic to be transported in vivo.6 LogP should not be more than 5 per Lipinskis rule of 5; high enough to bind, low enough to be released. Scheme 7: Addition of lipophilic substituents to the quinolone core to alter the P value Figure 13: Linear relationship between biological activity 1/C and lipophilicity6 Electronics: This parameter can influence ionisation and polarity which alters how a drug passes through a membrane or how strongly it binds to a receptor. Hammett substitution constant (à Ã†â€™) is the measure of the electron withdrawing or donating ability for substituents on an aromatic ring. à Ã†â€™ affects the equilibrium and the value is dependent on induction/resonance effects and whether the substituent is para or meta directing. Ortho is not considered due to sterics.6 Table 3:Substituents that can alter the à Ã†â€™ parameter Electron Donating Group (para): Electron Withdrawing Group (meta): -NH2 -NO2 -OH -CONH2 Halogen -CN Generally, electron-withdrawing substituent, positive à Ã†â€™ values, increase activity (Table 3). Simple reactions like those illustrated in Scheme 7 are used to attach the à Ã†â€™-influencing substituents to the quinolone. Sterics: Drug molecules must approach and successfully bind to a receptor and the sterics of the molecule can alter this approach. Bulk can result in nonbinding as the drug is sterically hindered from approaching the target site. It can also limit the available conformations so that only the most efficient arrangement binds to the receptor. Table 4: Parameters for measurements of steric effects6 Measure of Steric Effect: Key Feature: Other Factors: Tafts Steric Factor (Es) Quantifies steric feature of substituents Limited to use on certain substituents Molar Refractivity (MR) Measures volume occupied by atom(s) Corrects for ease of polarisation. Verloop Steric Parameter Computer programme calculates steric values For use with any substituent Using the quinolone core, modifications can be made so that the sterics prevent rapid metabolisation of a drug molecule in vivo which will extend its half-life and lead to better activity. Binding the quinolone to a large side chain restricts it from binding to smaller sites which Nilsen et al. conclude lead to better selectivity.11 Scheme 8 illustrates the addition of bulky side chains that can give better selectivity as they will only approach the sites they fit into. Furthermore, the double bond linkage and aromatic rings restrict the conformation that the molecule can adopt, increasing selectivity. Bulky side chains can prevent rapid metabolism occurring. When adding bulk, caution must be taken to ensure the molecule stays below the recommended 500 Da. Scheme 8: Reactions to alter the sterics of a quinolone core16 3D-QSAR: 3D-QSAR considers the relative spatial arrangement of model compounds and aims to correlate the features across molecules that affect activity and are required for ligand binding. 3D-QSAR studies the geometry, pharmacophore and molecular field. Key assumptions of 3D-QSAR13: The model compound and not its metabolite cause the biological response. The studied conformation is bioactive. Solvent effects are not considered The system is in equilibrium All compounds bind in the same manner to the one target. 3D-QSAR puts compounds with common configurations in a 3D grid, calculates the interaction and tabulates the results. An equation is then created based on the relationship between the calculations and the reported values. This verifies QSAR results. Conformers are superimposed to display the common ligand-binding orientation to the receptor. Probe atoms calculate steric and electrostatic fields.13 3D-QSAR studies on 1,3,5-triazine, quinolone derivatives, determined less bulky groups on the heteroatom ring, more bulk on the aro

Saturday, July 20, 2019

Paper Cranes :: Creative Writing Essays

Paper Cranes 1. From the Menninger Institute's seven criteria for emotional maturity: The capacity to find more satisfaction in giving than receiving. The capacity to relate to other people in a consistent manner with mutual satisfaction and helpfulness. The capacity to love. 2. In the opening scene of the film L.I.E., the main character, Howie, a fifteen-year-old boy with baggie jeans and hair that does a chipmunk tail flip at the top of his forehead, jumps up to stand on the railing of an overpass on the Long Island Expressway. Arms extended to the sides, he tightrope walks to the left. He stops, turns, and begins back. Then stops again and lifts one foot so he's balanced only on the tip of one sneaker, on a metal beam the width of a cassette tape. We, the audience, see him from behind: a thin figure in too-big clothes, car after car after car whizzing by beneath him, all oblivious to the boy who, with just the slightest sudden gust, could land, crumpled, on their roof. As you watch, all you want to do is wrap your arms around the boy and hug him to the ground, to safety, to chiding words about what could've happened, and keep on hugging him. And as you watch the rest of the movie, that feeling never leaves: Howie only seems more and more alone. You see th e already motherless Howie abandoned by his father, abandoned by the boy he'd thought was his best friend, bullied at school, until the only person left to listen to him at all is a middle-aged man who also happens to be a pedophile. At first I was outraged that the director portrayed this pedophile as the only person willing to put a supportive arm around Howie's shoulder. After all, aren't pedophiles scum? But then I realized that maybe that was the point. It's easy to judge. And it's easy to keep speeding home, aware only of the other metal boxes zooming along next to you in tenuous synchrony. 3. When I was little I got fevers. They were uncomfortable fevers that made it so all I could think about was feeling nauseous and anticipating the moment when I would feel well enough to eat the promised popsicle. But the worst part was at night, when I'd float somewhere in and out of consciousness: since I wasn't always sure if I was sleeping or not, I wasn't sure when I was dreaming or not, either.

Savagery, Power and Fear :: miscellaneous

Savagery, Power and Fear MLA Research Paper Savagery, Power And Fear And how it’s ties in with Lord Of The Flies Young children who are left unattended will slowly loose their civilization, which will turn into, Savagery, Power, and Fear. Civilization is when man meets his basic needs in a healthy manner. Savagery is when people revert back to their lost human instincts. Power, in the case of Lord Of the Flies it’s a position of ascendancy over others: AUTHORITY. Fear is an unpleasant often strong emotion caused by expectation or awareness of danger. Lord of the Flies shows a great amount of uncivilization through out the whole novel. Through all the characters for example when the boys create the Lord of The flies, which is â€Å"the bloody, severed sow’s head that Jack impales on a stake in the forest glade as an offering to the beast. This complicated symbol is most important image in the novel when Simon confronts the sow’s head in the glade and it seems to speak to him, telling him that evil lies within every human heart and promising to have some â€Å"fun† with him (This â€Å"fun† foreshadows Simon’s death in the following chapter.) In this way, the Lord of the Flies becomes a physical manifestation of the beast, a symbol of the power of evil, and a kind of Satan figure who evokes the beast within each human being. Looking at the novel in the context of biblical parallels, the Lord of the Flies recalls the devil, just as Simon recalls Jesus. In fact, the name â€Å" Lord of the Flies† is a literal translation of the bible name Beelzebub, a powerful demon in hell s ometimes thought to be the devil himself.† (Spark notes) This is very uncivilized. Savagery is most often found when young children or any human if put in the same position lose the instincts of human ways. This is portrayed through the book Lord Of The Flies. The beast is one way this is shown. â€Å" The imaginary beast that frightens all the boys stands for the primal instinct of savagery that exists within all human beings. The boys are afraid of the beast, but only Simon reaches the realization that they fear the beast because it exists within each of them. As the boys grow more savage, their belief in the beast grows stronger. By the end of the novel, the boys’ behavior is what brings the beast into existences, so the more savagely they act, the more real the beast seems to become.

Friday, July 19, 2019

The Glass Menagerie :: essays research papers

The play the Glass Menagerie supports the theme of illusions. A menagerie, a zoo, refers to a group of inhuman creatures. Since the creatures are glass, they are very fragile and not real. The title specifically refers to Laura’s collection of glass animals mainly horses. To escape the harshness of reality, Laura spends hours playing with the menagerie; this is an imaginary world for her. It is not only Laura, it is all of the Wingfields, they are all fragile enough to break easily. They burn with the slow and impeccable fires of human desperation.   Ã‚  Ã‚  Ã‚  Ã‚  The Glass Menagerie is a sad story of hopelessness and tragedy, a story of human nature and how it affects people's lives. The story itself may not seem tragic but the social downfall of the Wingfield's in itself is tragic. Williams shows the Southern family in decline, with certain members holding desperately to past visions of grandeur. Amanda Wingfield desperately clings to her romanticized memories of her southern past. Williams makes it clear that her memories are just mere illusions. The south has a tragic history, just like Amanda and Rose.   Ã‚  Ã‚  Ã‚  Ã‚  As you read into the play, you understand that the Wingfield's live in a life of fantasy wrapped in tragedy. Many aspects of their life, I believe, are very depressing and heartbreaking.   Ã‚  Ã‚  Ã‚  Ã‚  Such is the case of Amanda Wingfield. A southern girl, who had the opportunity to marry very rich husbands. She takes a wrong turn and marries a drunk who deserts he, there is no coming back from the one mistake. Everyday she reminisces about her past life and how glorious it once was. Tennessee Williams uses this as a perfect way to compare their present life to their past, creating a feeling of misery and pain.   Ã‚  Ã‚  Ã‚  Ã‚  These feelings of misery and hopelessness are enforced by her children's sorrows and wretched lives. As Laura develops a inferiority complex after going to school for one day, the reader develops a sense of compassion.

Thursday, July 18, 2019

Salvador Dali

Salvador Dali Salvador Dali, one of the most famous artists of the 20th century, was very active even in the latter part of his life. He not only painted, but also showed to be creative in the artistic world in general. He traveled, and along the way learned different techniques of painting, but always went back to paint as he described it ‘hand painted dream photographs’. (Sandoval, 1998) Dali emerged as a leader of the Surrealist movement, where he was the most faithful and only true surrealist, although he was later expelled from because of his political views and more traditional work. During this time he created a painting, Persistence of Memory (1931), which is still on of the best-known surrealist works. (Sandoval, 1998) Dali’s work was different to others since all of his discoveries and inventions are reflected in his work and appear in them in a scarcely transposed form. He and Gala later moved to the United States, during World War II, were he devoted himself to self-publicity and began to paint pictures of religious themes. One of these paintings includes, The Crucifixion of St John of the Cross, (1951). During this time, he also showed the world that he was not only a great painter, but had other talents as well. For example, he designed jewelry, apartments, clothing, costumes, shop interiors, and stage sets. Along with this he also worked for Vogue and Haper’s Bazaar. (Neret, 1997) This also led him to take part in the production of films such as, ‘An Andalusian Dog’ and ‘The Golden Age’, where he worked in collaboration with Bunuel. (Folkes, 1999) Gigantism was predominant in Dali’s late work. The paintings that he created during this part of his life were a combination of all of the styles, which he had worked on. They include: Surrealism, â€Å"quintessential pompierism†, pointillism, action painting, Tachisme, geometric abstraction, Pop art, Op art, and psychedelic art. (Neret, 1997) Some of these pictures include, The Discovery of America by Christopher Columbus (1958-59), and Tuna Fishing (1966-67). Stereoscopy was also used by Dali in some of his paintings such as, Dali from the Back, Painting Gala from the Back, Etermalized by Six Virtual Corneas Provisionally Reflected in Six real Mirrors (1972-73) or Dali Lifting the Skin of the Mediterranean Sea to Show Gala the Birth of Venus (1977), to name a couple, to paint his last visual poems. Neret, 1997) Dali also had a couple of exhibits in the final stage of his life. Some of these included exhibits in Rome and Venice, nuclear mysticism, in 1951, and at the National Gallery, in Washington, DC, in 1956. Dali continued to work on paintings and books, and continued to travel to promote his latest creations, until the death of his wife G ala in 1982. A year later the creation of his perfume known as â€Å"Dali† came out along with his last painting, The Swallow’s Tail. Neret, 1997) He then lived in isolation from the world for a few years in Torre Galatea, when he began to endure some health issues. A few years later, January 23, 1989, Dali died of heart failure. References Folkes, S. T. (1999) Salvador Dali, Life. History. Art. Retrieved February 29, 2004, from: http://www. seven7. demon. co. uk/dali/history. htm Neret, G. (1997). Salvador Dali. San Diego, CA: Thunder Bay Press Sandoval, J. (1998) Dada and Surrealism: Salvador Dali Biography. Retrieved February 29, 2004, from: http://www. duke. edu Salvador Dali Salvador Feline Action Dali lived to be among the most versatile and creative artists of the twentieth century. Dali was born on the 1 lath of March 1904 in Spain and he was one of history greatest surrealist and broad-minded artists. Surrealism is defined as opening up one's mind and accessing an unconscious world, through an area of art. During his childhood, Dali soon discovered that he was on the earth solely for the reason to be an artist. Dali earned a reputation as a malicious being, as he was expelled from his school for extravagant behavior.Dali had portrayed his ideas ND thoughts on a canvas, through his own understanding of discovering a new world based on the unconscious mind. His paintings also display a charisma and attraction for Classical and Renaissance art. This was clearly visible as his later works evinces hyper-realistic style and religious symbolism. Dali was often associated with the Surrealist movement, despite his removal from the group in 1934 due to his unr eceptive political views.Salvador Dali is one of the most celebrated artists of the surrealist movement; being known for his conspicuous surrealist work as well as his minting techniques resounding that of Renaissance art. Dali was born in Figures, Catalonia, Spain and belonged to a very prosperous family. Dali was ten years old when he had his first drawing lesson whilst demonstrating hysterical yet rage-filled outbursts towards his family and playmates. Pursuing his interest in art, he entered the Madrid School of Fine Arts in 1921.Dali was in his early ass in 1920, when he first heard about a group of experimental artists in Paris. As it was depicted as strange, they had to invent a new word to describe their art: surreal. Surrealism began as a iterate and artistic movement. Andre Breton, a French Poet, had inspired many others after him, by discovering this new form of art. It was a revolutionary response to the devastation of the First World War. It was also inspired by the psy choanalytical concepts of Sigmund Freud. Freud believed that all of us possess an inner unconscious world, in which our emotional and sexual feelings are oppressed and the only way to express ourselves is to release emotions without censoring what comes out' [1]. Dalais artistic profession commenced when he was expelled from the Madrid School of Fine Arts in 1924. By that time, Dali was already exhibiting work locally. He was invited by Andre Breton to Join the surrealists, when he moved to Paris.For the next several years, Dali had incorporated his illustrative theories into his paintings, displaying his thoughts about the psychological state of paranoia and its importance as a subject. He called this method the ‘paranoia-critical activity, which is a surrealist method used to help an artist enter their subconscious through a systematic irrational thought and a self-persuaded paranoid state. Around this period, Dali had also developed a short surrealist film that was directed by Luis Bungee, called Un Chine Nodal (An Andalusia Dog).Dali became so infamous because the subject matter of the film was so sexually and politically shocking. Dali had produced many important works during this period, which included William Tell (1930), The Persistence of Memory (1931), Dormouse, Coeval, and Lion invisible and the Birth of Liquid Desires (1932), Breton had dismissed Dali from the Surrealist group in 1934 as a result of his differing views on General Franco and fascism. Dali had then moved to Italy in 1937, and practiced more traditional painting styles. Meanwhile, he had married Gala, the first wife of the founders of the surrealist movement.Gala was perhaps the most important and influential figure in Dalais life. His paintings during the sass and sass focused more on religious themes, reproducing his enduring attraction of the supernatural. He had rendered many traditional still-like objects into his work. He continued employing his ‘paranoia- critical' method. In 1955, he returned to Spain, becoming rather withdrawn. Regardless he continued to paint until his death in the 1980. Salvador Dali influenced the manner of which modern artists use the method of ‘revealing the gap teen reality and illusion' [2].His artwork provides a glimpse into the intimate world of an individual's subconscious. His outstanding yet somewhat grotesque dreamless and paintings effortlessly evoke emotion from a viewer. His work delivers a disconcerting impression of psychological hallucinations. Drawing on Dalais belief of unearthing the subconscious, many second generation surrealists such as Joseph Cornwall, and other abstract expressionists continued to incorporate Dalais influence in their work. Arguably, the twentieth century's most eccentric and successful artist was thought to have been referring to Dali.He is truly one of history greatest surrealists. As a Spanish-Catalan painter, entering the Madrid school of fine arts was Dalais first step t o becoming a great artist. Discovering surrealism had changed Dalais life forever, Joining great surrealists such as Andre Breton. He developed painting methods, illustrating his theories of psychological state of paranoia and its importance as a subject matter. Salvador Feline Action Dali was the most influential contributor to the surrealist movement, leaving behind an impact on modern art. Salvador Dali Vanishes† sees UN Ecuador whiz poor el artists Salvador Feline Action Dali. Cosec © Salvador Dali y est. Ecuador porous De com pià ±ata. Us USA el still De surrealist, per us Trojan sees realists. Poor example, en â€Å"The Image Vanishes,† Mira realists, per hack UN concept De surrealist. Edema ¤s, you jocose Dali porous me gusts el rate De Dali. Me gusts us Trojan y rate porous us still surrealist sees Ã'Ëœnice y creative. Tamaki ©n me gusts us rate porous De us ideas y el significant deter ¤s De cad painter. Ho, SE upped encounter e]employ De us rate en SST. Petersburg, Florida; Berlin Germany; Paris, France; Catalina, Spawn.Salvador Feline Action Dali is a Spanish artist that is considered the personification of surrealism. Dali was born in 1904 in Catalina, Spain. He spent the early part of his life with his rich parent's and attended the Academy of Fine Arts in Madrid. Then, he moved away to Join the Surrealist movement in 1934. He spent most of his live d oing this in Madrid, Spain; Paris, France; and New York. The style that he used was surrealism, but he painted his portraits and other paintings realistically. Surrealism is the type of style that is not realistic and expresses the power of imagination. â€Å"TheImage Vanishes† is a painting made by the artist, Salvador Feline Action Dali. I chose Salvador Dali and this painting because of how he paints. He uses the surrealistic style, but his work is realistic. For example, en â€Å"The Image Vanishes,† it looks realistic, but it uses a surrealistic concept. In addition, I chose Dali because I like the art of Dali. I like his work and art because of his surrealistic style is unique and creative. Also, I like his art because of his ideas and the significance behind each painting. Today, examples of his art can be found in SST. Petersburg, Florida; Berlin Germany; Paris, France; Catalina, Spawn.