The Twilight Saga 3: Eclipse Chapter 15. WAGER

I STARED AT HIM FOR A LONG MINUTE, SPEECHLESS. I could not think of one thing to say to him. As he watched my dumbfounded expression, the seriousness left his face. â€Å"Okay,† he said, grinning. â€Å"That's all.† â€Å"Jake -† It felt like there was something big sticking in my throat. I tried to clear the obstruction. â€Å"I can't – I mean I don't . . . I have to go.† I turned, but he grabbed my shoulders and spun me around. â€Å"No, wait. I know that, Bella. But, look, answer me this, all right? Do you want me to go away and never see you again? Be honest.† It was hard to concentrate on his question, so it took a minute to answer. â€Å"No, I don't want that,† I finally admitted. Jacob grinned again. â€Å"See.† â€Å"But I don't want you around for the same reason that you want me around,† I objected. â€Å"Tell me exactly why you want me around, then.† I thought carefully. â€Å"I miss you when you're not there. When you're happy,† I qualified carefully, â€Å"it makes me happy. But I could say the same thing about Charlie, Jacob. You're family. I love you, but I'm not in love with you.† He nodded, unruffled. â€Å"But you do want me around.† â€Å"Yes.† I sighed. He was impossible to discourage. â€Å"Then I'll stick around.† â€Å"You're a glutton for punishment,† I grumbled. â€Å"Yep.† He stroked the tips of his fingers across my right cheek. I slapped his hand away. â€Å"Do you think you could behave yourself a little better, at least?† I asked, irritated. â€Å"No, I don't. You decide, Bella. You can have me the way I am – bad behavior included – or not at all.† I stared at him, frustrated. â€Å"That's mean.† â€Å"So are you.† That pulled me up short, and I took an involuntary step back. He was right. If I wasn't mean – and greedy, too – I would tell him I didn't want to be friends and walk away. It was wrong to try to keep my friend when that would hurt him. I didn't know what I was doing here, but I was suddenly sure that it wasn't good. â€Å"You're right,† I whispered. He laughed. â€Å"I forgive you. Just try not to get too mad at me. Because I recently decided that I'm not giving up. There really is something irresistible about a lost cause.† â€Å"Jacob.† I stared into his dark eyes, trying to make him take me seriously. â€Å"I love him, Jacob. He's my whole life.† â€Å"You love me, too,† he reminded me. He held up his hand when I started to protest. â€Å"Not the same way, I know. But he's not your whole life, either. Not anymore. Maybe he was once, but he left. And now he's just going to have to deal with the consequence of that choice – me.† I shook my head. â€Å"You're impossible.† Suddenly, he was serious. He took my chin in his hand, holding it firmly so that I couldn't look away from his intent gaze. â€Å"Until your heart stops beating, Bella,† he said. â€Å"I'll be here – fighting. Don't forget that you have options.† â€Å"I don't want options,† I disagreed, trying to yank my chin free unsuccessfully. â€Å"And my heartbeats are numbered, Jacob. The time is almost gone.† His eyes narrowed. â€Å"All the more reason to fight – fight harder now, while I can,† he whispered. He still had my chin – his fingers holding too tight, till it hurt – and I saw the resolve form abruptly in his eyes. â€Å"N -† I started to object, but it was too late. His lips crushed mine, stopping my protest. He kissed me angrily, roughly, his other hand gripping tight around the back of my neck, making escape impossible. I shoved against his chest with all my strength, but he didn't even seem to notice. His mouth was soft, despite the anger, his lips molding to mine in a warm, unfamiliar way. I grabbed at his face, trying to push it away, failing again. He seemed to notice this time, though, and it aggravated him. His lips forced mine open, and I could feel his hot breath in my mouth. Acting on instinct, I let my hands drop to my side, and shut down. I opened my eyes and didn't fight, didn't feel . . . just waited for him to stop. It worked. The anger seemed to evaporate, and he pulled back to look at me. He pressed his lips softly to mine again, once, twice . . . a third time. I pretended I was a statue and waited. Finally, he let go of my face and leaned away. â€Å"Are you done now?† I asked in an expressionless voice. â€Å"Yes,† he sighed. He started to smile, closing his eyes. I pulled my arm back and then let it snap forward, punching him in the mouth with as much power as I could force out of my body. There was a crunching sound. â€Å"Ow! OW!† I screamed, frantically hopping up and down in agony while I clutched my hand to my chest. It was broken, I could feel it. Jacob stared at me in shock. â€Å"Are you all right?† â€Å"No, dammit! You broke my hand!† â€Å"Bella, you broke your hand. Now stop dancing around and let me look at it.† â€Å"Don't touch me! I'm going home right now!† â€Å"I'll get my car,† he said calmly. He wasn't even rubbing his jaw like they did in the movies. How pathetic. â€Å"No, thanks,† I hissed. â€Å"I'd rather walk.† I turned toward the road. It was only a few miles to the border. As soon as I got away from him, Alice would see me. She'd send somebody to pick me up. â€Å"Just let me drive you home,† Jacob insisted. Unbelievably, he had the nerve to wrap his arm around my waist. I jerked away from him. â€Å"Fine!† I growled. â€Å"Do! I can't wait to see what Edward does to you! I hope he snaps your neck, you pushy, obnoxious, moronic DOG!† Jacob rolled his eyes. He walked me to the passenger side of his car and helped me in. When he got in the driver's side, he was whistling. â€Å"Didn't I hurt you at all?† I asked, furious and annoyed. â€Å"Are you kidding? If you hadn't started screaming, I might not have figured out that you were trying to punch me. I may not be made out of stone, but I'm not that soft.† â€Å"I hate you, Jacob Black.† â€Å"That's good. Hate is a passionate emotion.† â€Å"I'll give you passionate,† I muttered under my breath. â€Å"Murder, the ultimate crime of passion.† â€Å"Oh, c'mon,† he said, all cheery and looking like he was about to start whistling again. â€Å"That had to be better than kissing a rock.† â€Å"Not even remotely close,† I told him coldly. He pursed his lips. â€Å"You could just be saying that.† â€Å"But I'm not.† That seemed to bother him for a second, but then he perked up. â€Å"You're just mad. I don't have any experience with this kind of thing, but I thought it was pretty incredible myself.† â€Å"Ugh,† I groaned. â€Å"You're going to think about it tonight. When he thinks you're asleep, you'll be thinking about your options.† â€Å"If I think about you tonight, it will be because I'm having a nightmare.† He slowed the car to a crawl, turning to stare at me with his dark eyes wide and earnest. â€Å"Just think about how it could be, Bella,† he urged in a soft, eager voice. â€Å"You wouldn't have to change anything for me. You know Charlie would be happy if you picked me. I could protect you just as well as your vampire can – maybe better. And I would make you happy, Bella. There's so much I could give you that he can't. I'll bet he couldn't even kiss you like that – because he would hurt you. I would never, never hurt you, Bella.† I held up my injured hand. He sighed. â€Å"That wasn't my fault. You should have known better.† â€Å"Jacob, I can't be happy without him.† â€Å"You've never tried,† he disagreed. â€Å"When he left, you spent all your energy holding on to him. You could be happy if you let go. You could be happy with me.† â€Å"I don't want to be happy with anyone but him,† I insisted. â€Å"You'll never be able to be as sure of him as you are of me. He left you once, he could do it again.† â€Å"No, he will not,† I said through my teeth. The pain of the memory bit into me like the lash of a whip. It made me want to hurt him back. â€Å"You left me once,† I reminded him in a cold voice, thinking of the weeks he'd hidden from me, the words he'd said to me in the woods beside his home. . . . â€Å"I never did,† he argued hotly. â€Å"They told me I couldn't tell you – that it wasn't safe for you if we were together. But I never left, never! I used to run around your house at night – like I do now. Just making sure you were okay.† I wasn't about to let him make me feel bad for him now. â€Å"Take me home. My hand hurts.† He sighed, and started driving at a normal speed, watching the road. â€Å"Just think about it, Bella.† â€Å"No,† I said stubbornly. â€Å"You will. Tonight. And I'll be thinking about you while you're thinking about me.† â€Å"Like I said, a nightmare.† He grinned over at me. â€Å"You kissed me back.† I gasped, unthinkingly balling my hands up into fists again, hissing when my broken hand reacted. â€Å"Are you okay?† he asked. â€Å"I did not.† â€Å"I think I can tell the difference.† â€Å"Obviously you can't – that was not kissing back, that was trying to get you the hell off of me, you idiot.† He laughed a low, throaty laugh. â€Å"Touchy. Almost overly defensive, I would say.† I took a deep breath. There was no point in arguing with him; he would twist anything I said. I concentrated on my hand, trying to stretch out my fingers, to ascertain where the broken parts were. Sharp pains stabbed along my knuckles. I groaned. â€Å"I'm really sorry about your hand,† Jacob said, sounding almost sincere. â€Å"Next time you want to hit me, use a baseball bat or a crowbar, okay?† â€Å"Don't think I'll forget that,† I muttered. I didn't realize where we were going until we were on my road. â€Å"Why are you taking me here?† I demanded. He looked at me blankly. â€Å"I thought you said you were going home?† â€Å"Ugh. I guess you can't take me to Edward's house, can you?† I ground my teeth in frustration. Pain twisted across his face, and I could see that this affected him more than anything else I'd said. â€Å"This is your home, Bella,† he said quietly. â€Å"Yes, but do any doctors live here?† I asked, holding up my hand again. â€Å"Oh.† He thought about that for a minute. â€Å"I'll take you to the hospital. Or Charlie can.† â€Å"I don't want to go to the hospital. It's embarrassing and unnecessary.† He let the Rabbit idle in front of the house, deliberating with an unsure expression. Charlie's cruiser was in the driveway. I sighed. â€Å"Go home, Jacob.† I climbed out of the car awkwardly, heading for the house. The engine cut off behind me, and I was less surprised than annoyed to find Jacob beside me again. â€Å"What are you going to do?† he asked. â€Å"I am going to get some ice on my hand, and then I am going to call Edward and tell him to come and get me and take me to Carlisle so that he can fix my hand. Then, if you're still here, I am going to go hunt up a crowbar.† He didn't answer. He opened the front door and held it for me. We walked silently past the front room where Charlie was lying on the sofa. â€Å"Hey, kids,† he said, sitting forward. â€Å"Nice to see you here, Jake.† â€Å"Hey, Charlie,† Jacob answered casually, pausing. I stalked on to the kitchen. â€Å"What's wrong with her?† Charlie wondered. â€Å"She thinks she broke her hand,† I heard Jacob tell him. I went to the freezer and pulled out a tray of ice cubes. â€Å"How did she do that?† As my father, I thought Charlie ought to sound a bit less amused and a bit more concerned. Jacob laughed. â€Å"She hit me.† Charlie laughed, too, and I scowled while I beat the tray against the edge of the sink. The ice scattered inside the basin, and I grabbed a handful with my good hand and wrapped the cubes in the dishcloth on the counter. â€Å"Why did she hit you?† â€Å"Because I kissed her,† Jacob said, unashamed. â€Å"Good for you, kid,† Charlie congratulated him. I ground my teeth and went for the phone. I dialed Edward's cell. â€Å"Bella?† he answered on the first ring. He sounded more than relieved – he was delighted. I could hear the Volvo's engine in the background; he was already in the car – that was good. â€Å"You left the phone . . . I'm sorry, did Jacob drive you home?† â€Å"Yes,† I grumbled. â€Å"Will you come and get me, please?† â€Å"I'm on my way,† he said at once. â€Å"What's wrong?† â€Å"I want Carlisle to look at my hand. I think it's broken.† It had gone quiet in the front room, and I wondered when Jacob would bolt. I smiled a grim smile, imagining his discomfort. â€Å"What happened?† Edward demanded, his voice going flat. â€Å"I punched Jacob,† I admitted. â€Å"Good,† Edward said bleakly. â€Å"Though I'm sorry you're hurt.† I laughed once, because he sounded as pleased as Charlie had. â€Å"I wish I'd hurt him.† I sighed in frustration. â€Å"I didn't do any damage at all.† â€Å"I can fix that,† he offered. â€Å"I was hoping you would say that.† There was a slight pause. â€Å"That doesn't sound like you,† he said, wary now. â€Å"What did he do?† â€Å"He kissed me,† I growled. All I heard on the other end of the line was the sound of an engine accelerating. In the other room, Charlie spoke again. â€Å"Maybe you ought to take off, Jake,† he suggested. â€Å"I think I'll hang out here, if you don't mind.† â€Å"Your funeral,† Charlie muttered. â€Å"Is the dog still there?† Edward finally spoke again. â€Å"Yes.† â€Å"I'm around the corner,† he said darkly, and the line disconnected. As I hung up the phone, smiling, I heard the sound of his car racing down the street. The brakes protested loudly as he slammed to a stop out front. I went to get the door. â€Å"How's your hand?† Charlie asked as I walked by. Charlie looked uncomfortable. Jacob lolled next to him on the sofa, perfectly at ease. I lifted the ice pack to show it off. â€Å"It's swelling.† â€Å"Maybe you should pick on people your own size,† Charlie suggested. â€Å"Maybe,† I agreed. I walked on to open the door. Edward was waiting. â€Å"Let me see,† he murmured. He examined my hand gently, so carefully that it caused me no pain at all. His hands were almost as cold as the ice, and they felt good against my skin. â€Å"I think you're right about the break,† he said. â€Å"I'm proud of you. You must have put some force behind this.† â€Å"As much as I have.† I sighed. â€Å"Not enough, apparently.† He kissed my hand softly. â€Å"I'll take care of it,† he promised. And then he called, â€Å"Jacob,† his voice still quiet and even. â€Å"Now, now,† Charlie cautioned. I heard Charlie heave himself off of the sofa. Jacob got to the hall first, and much more quietly, but Charlie was not far behind him. Jacob's expression was alert and eager. â€Å"I don't want any fighting, do you understand?† Charlie looked only at Edward when he spoke. â€Å"I can go put my badge on if that makes my request more official.† â€Å"That won't be necessary,† Edward said in a restrained tone. â€Å"Why don't you arrest me, Dad?† I suggested. â€Å"I'm the one throwing punches.† Charlie raised an eyebrow. â€Å"Do you want to press charges, Jake?† â€Å"No.† Jacob grinned, incorrigible. â€Å"I'll take the trade any day.† Edward grimaced. â€Å"Dad, don't you have a baseball bat somewhere in your room? I want to borrow it for a minute.† Charlie looked at me evenly. â€Å"Enough, Bella.† â€Å"Let's go have Carlisle look at your hand before you wind up in a jail cell,† Edward said. He put his arm around me and pulled me toward the door. â€Å"Fine,† I said, leaning against him. I wasn't so angry anymore, now that Edward was with me. I felt comforted, and my hand didn't bother me as much. We were walking down the sidewalk when I heard Charlie whispering anxiously behind me. â€Å"What are you doing? Are you crazy?† â€Å"Give me a minute, Charlie,† Jacob answered. â€Å"Don't worry, I'll be right back.† I looked back and Jacob was following us, stopping to close the door in Charlie's surprised and uneasy face. Edward ignored him at first, leading me to the car. He helped me inside, shut the door, and then turned to face Jacob on the sidewalk. I leaned anxiously through the open window. Charlie was visible in the house, peeking through the drapes in the front room. Jacob's stance was casual, his arms folded across his chest, but the muscles in his jaw were tight. Edward spoke in a voice so peaceful and gentle that it made the words strangely more threatening. â€Å"I'm not going to kill you now, because it would upset Bella.† â€Å"Hmph,† I grumbled. Edward turned slightly to throw me a quick smile. His face was still calm. â€Å"It would bother you in the morning,† he said, brushing his fingers across my cheek. Then he turned back to Jacob. â€Å"But if you ever bring her back damaged again – and I don't care whose fault it is; I don't care if she merely trips, or if a meteor falls out of the sky and hits her in the head – if you return her to me in less than the perfect condition that I left her in, you will be running with three legs. Do you understand that, mongrel?† Jacob rolled his eyes. â€Å"Who's going back?† I muttered. Edward continued as if he hadn't heard me. â€Å"And if you ever kiss her again, I will break your jaw for her,† he promised, his voice still gentle and velvet and deadly. â€Å"What if she wants me to?† Jacob drawled, arrogant. â€Å"Hah!† I snorted. â€Å"If that's what she wants, then I won't object.† Edward shrugged, untroubled. â€Å"You might want to wait for her to say it, rather than trust your interpretation of body language – but it's your face.† Jacob grinned. â€Å"You wish,† I grumbled. â€Å"Yes, he does,† Edward murmured. â€Å"Well, if you're done rummaging through my head,† Jacob said with a thick edge of annoyance, â€Å"why don't you go take care of her hand?† â€Å"One more thing,† Edward said slowly. â€Å"I'll be fighting for her, too. You should know that. I'm not taking anything for granted, and I'll be fighting twice as hard as you will.† â€Å"Good,† Jacob growled. â€Å"It's no fun beating someone who forfeits.† â€Å"She is mine.† Edward's low voice was suddenly dark, not as composed as before. â€Å"I didn't say I would fightfair.† â€Å"Neither did I.† â€Å"Best of luck.† Jacob nodded. â€Å"Yes, may the best man win.† â€Å"That sounds about right . . . pup.† Jacob grimaced briefly, then he composed his face and leaned around Edward to smile at me. I glowered back. â€Å"I hope your hand feels better soon. I'm really sorry you're hurt.† Childishly, I turned my face away from him. I didn't look up again as Edward walked around the car and climbed into the driver's side, so I didn't know if Jacob went back into the house or continued to stand there, watching me. â€Å"How do you feel?† Edward asked as we drove away. â€Å"Irritated.† He chuckled. â€Å"I meant your hand.† I shrugged. â€Å"I've had worse.† â€Å"True,† he agreed, and frowned. Edward drove around the house to the garage. Emmett and Rosalie were there, Rosalie's perfect legs, recognizable even sheathed in jeans, were sticking out from under the bottom of Emmett's huge Jeep. Emmett was sitting beside her, one hand reached under the Jeep toward her. It took me a moment to realize that he was acting as the jack. Emmett watched curiously as Edward helped me carefully out of the car. His eyes zeroed in on the hand I cradled against my chest. Emmett grinned. â€Å"Fall down again, Bella?† I glared at him fiercely. â€Å"No, Emmett. I punched a werewolf in the face.† Emmett blinked, and then burst into a roar of laughter. As Edward led me past them, Rosalie spoke from under the car. â€Å"Jasper's going to win the bet,† she said smugly. Emmett's laughter stopped at once, and he studied me with appraising eyes. â€Å"What bet?† I demanded, pausing. â€Å"Let's get you to Carlisle,† Edward urged. He was staring at Emmett. His head shook infinitesimally. â€Å"What bet?† I insisted as I turned on him. â€Å"Thanks, Rosalie,† he muttered as he tightened his arm around my waist and pulled me toward the house. â€Å"Edward . . . ,† I grumbled. â€Å"It's infantile,† he shrugged. â€Å"Emmett and Jasper like to gamble.† â€Å"Emmett will tell me.† I tried to turn, but his arm was like iron around me. He sighed. â€Å"They're betting on how many times you . . . slip up in the first year.† â€Å"Oh.† I grimaced, trying to hide my sudden horror as I realized what he meant. â€Å"They have a bet about how many people I'll kill?† â€Å"Yes,† he admitted unwillingly. â€Å"Rosalie thinks your temper will turn the odds in Jasper's favor.† I felt a little high. â€Å"Jasper's betting high.† â€Å"It will make him feel better if you have a hard time adjusting. He's tired of being the weakest link.† â€Å"Sure. Of course it will. I guess I could throw in a few extra homicides, if it makes Jasper happy. Why not?† I was babbling, my voice a blank monotone. In my head, I was seeing newspaper headlines, lists of names. . . . He squeezed me. â€Å"You don't need to worry about it now. In fact, you don't have to worry about it ever, if you don't want to.† I groaned, and Edward, thinking it was the pain in my hand that bothered me, pulled me faster toward the house. My hand was broken, but there wasn't any serious damage, just a tiny fissure in one knuckle. I didn't want a cast, and Carlisle said I'd be fine in a brace if I promised to keep it on. I promised. Edward could tell I was out of it as Carlisle worked to fit a brace carefully to my hand. He worried aloud a few times that I was in pain, but I assured him that that wasn't it. As if I needed – or even had room for – one more thing to worry about. All of Jasper's stories about newly created vampires had been percolating in my head since he'd explained his past. Now those stories jumped into sharp focus with the news of his and Emmett's wager. I wondered randomly what they were betting. What was a motivating prize when you had everything? I'd always known that I would be different. I hoped that I would be as strong as Edward said I would be. Strong and fast and, most of all, beautiful. Someone who could stand next to Edward and feel like she belonged there. I'd been trying not to think too much about the other things that I would be. Wild. Bloodthirsty. Maybe I would not be able to stop myself from killing people. Strangers, people who had never harmed me. People like the growing number of victims in Seattle, who'd had families and friends and futures. People who'd had lives. And I could be the monster who took that away from them. But, in truth, I could handle that part – because I trusted Edward, trusted him absolutely, to keep me from doing anything I would regret. I knew he'd take me to Antarctica and hunt penguins if I asked him to. And I would do whatever it took to be a good person. A good vampire. That thought would have made me giggle, if not for this new worry. Because, if I really were somehow like that – like the nightmarish images of newborns that Jasper had painted in my head – could I possibly be me? And if all I wanted was to kill people, what would happen to the things I wanted now? Edward was so obsessed with me not missing anything while I was human. Usually, it seemed kind of silly. There weren't many human experiences that I worried about missing. As long as I got to be with Edward, what else could I ask for? I stared at his face while he watched Carlisle fix my hand. There was nothing in this world that I wanted more than him. Would that, could that, change? Was there a human experience that I was not willing to give up?

James Loewen

To describe this work overall is rather a monumental task because there aren’t many other books out there like this one.   Lies My Teacher Told Me by James Loewen takes on really two tasks.   One is to question and answer the concept of why students dislike history classes.   The second is to prove the idea that much of what students learn in American history classes is wrong and that there are many omissions.   The author can be described as a teacher who challenges the role of revisionist history in American schools. He says that much of American history alienates children of color by ignoring the fact that many of the people who contributed greatly to this country were indeed, non-white.   Because of the nature of textbooks in American high schools, much of college history classes are taken up â€Å"fixing† the subject matter that students have learned in high school history classes. Being a college history professor, he asserts this with confidence.   Loewen does not deny the importance of knowing history for one minute, but he does question what we know.   Loewen is a university professor of history at the University of Vermont, and his study in preparation for writing this book consisted of studying twelve textbooks covering a range in American history.   He set about to â€Å"analyze the process of textbook creation and adoption to explain what causes textbooks to be as bad as they are† and the effects of using them. So, why is history boring according to Loewen?   History is made up of nothing but stories which should not be boring, but textbook companies have left out anything that â€Å"might reflect badly upon our national character† (Loewen).   As Loewen says, there is no sense of drama in history taught in schools, and there is every sense that things will work out in the end.   This alone makes history boring.   It is also boring because â€Å"textbooks almost never use the present to illuminate the past† (Loewen).   Therefore, students have a difficult time understanding the relevance to their daily lives. History is portrayed as a â€Å"morality play,† in which the touchy areas are never taught or discussed.   Publishers tend not to acknowledge problems of today or use the past to shed some light.   They also never speak of the factors that contributed to problems; rather a â€Å"blame the victim† approach is used.   As Loewen says, â€Å"While there is nothing wrong with optimism, it does become something of a burden for students of color, children of working class parents, girls who notice an absence of women who made history, or any group that has not already been outstandingly successful† (Loewen).   This â€Å"burden† turns students off to history because it does not accurately address any of these things nor does it tell the full stories. Textbooks ignore many historical realities for a variety of reasons.   The biggest reason is that publishers believe that students must develop a sense of nationalism or patriotism.   To acknowledge troubling areas in our nation’s history is to run the risk that patriotism will not be developed.   A â€Å"happy† view of history leads Americans to believe that everything is okay, so students are not troubled.   This view of history embraces the American idea of individualism rather than looking at the many factors that affected lack of equal opportunity.   Textbooks make us believe that equal opportunity was and is an option for all. As for other reasons, Loewen does a thorough job pointing these out.   Facts are presented â€Å"as one damn thing after another† (Loewen).   Books â€Å"suppress causation† (Loewen).   In fact, many of the facts included are flat out wrong and many of the books are clones of each other, which means the facts are wrong over and over again.   They rarely include primary source documents, which Loewen compares to students taking a course in poetry without reading a poem.   Plus the books are just so darn big that students hate carrying them and reading them. In his Table of Contents he discusses all the false information or omissions based on his study of textbooks, such as the study of Christopher Columbus, Thanksgiving, Native Americans, the invisibility of racism, the absence of social class, the disappearance of the recent past, and the myth of progress to name a few.   These chapters contain much needed information about the true stories. The results of his study conclude that students are bored with or alienated from history or both.   They are also not able to use the past in order to think about the future.   He proposes this book partly in order to discuss how to assess all the various sources of knowledge about history and to help teachers think about how to learn history more accurately. As he ponders the idea of â€Å"truth† in revisionist history in every chapter, I will use one chapter as an example.   In the chapter entitled hero Making Heroes, examples are given of how textbooks leave important ideas or at least controversial ones out of the books.   For example, Loewen tells us that Helen Keller was a radical socialist.   Books leave out all mention of Woodrow Wilson’s racism and the fact that there was a new surge of racial violence in this country after his presidency. And last but not least, discussion of Christopher Columbus has been totally slanted.   He took land from the Native Americans and engaged in slave trade or forced labor.   He alone destroyed entire nations of Native Americans.   Only six of twelve textbooks even mentioned the idea of forced labor at all.   And yet, most of what is taught does none of these things. Loewen concludes with the statement that â€Å"students will start learning history when they see the point of doing so, when it seems interesting and important to them, and when they believe history might relate to their lives and futures† (Loewen). I believe the author does accomplish his goals.   He absolutely adequately sums up why students hate history.   The study of history seems all about facts and dates that have no relation to each other or to our lives.   History books are chock full of names and dates but not material that challenges the student to really think about and analyze history.   These facts are expected to be taken at face value and not to be questioned.   Any controversy is left out of books.   Students need to be taught history in a more meaningful way so that they can use the past to illuminate the future or even the future to illuminate the past. To me, understanding is the only reason to teach anything, not rote memorization of facts that aren’t even true.   I understand that standardized testing puts a lot of pressure on history teachers, but American schools should at least be able to find a way to present both sides of issues.   Students could truly be more interested in history that way.   Teaching only the wonderful qualities in American history and ignoring the disturbing parts is not a way to push students to become leaders of tomorrow.   If one truly wants to fix problems, one must first identify what the problems are.   For example, in terms of equal opportunity, it is important for students to realize that phrase was always a dream propagated by white people. People of color in this country have never had even a remote chance to thrive the way white people have.   Therefore, current practices like affirmative action might not seem so terrible if they understand the history all the way down the line.   There has always been affirmative action; it was just only for white people.   Now that we give it a name and make it policy to benefit nonwhite people, society is up in arms.   Teaching about the historical laws and rules that made it impossible to receive a fair chance if one was non-white is at least a step in the right direction.   Maybe that would help illuminate the present by using the past.   It would also highlight high level skills like synthesis and critical thinking. I detest the idea of revisionist history.   I understand that there are places where a thorough understanding is just not possible.   For example, teaching about our genocide of the Native Americans to elementary students is not a good idea.   However, we can teach about such things from primary source documents.   Falsities do not have to be taught.   We certainly do not need to reinforce the idea that Indians have all vanished or that they live in teepees still.   If all else fails, leave the study of these people or events out of history classes where students are too young to understand the ramifications. Loewen would not propose this as it would be yet another omission.   Loewen’s book should be required reading for any person planning on teaching anything.   Loewen gives a very thorough account of the many inaccuracies and omissions that are currently taught.   A lot of people have not had enough history after high school to even realize that this is the case or to put all the information together, to synthesize it in such a way that the light bulb finally comes on. And while it is much easier to take the safe route, that one is rarely the best.   In this culture we need more critical thinkers, not more people who can memorize facts.   In this information age, it is more crucial than ever to teach others how to think, not what to think.   Any fact we will ever need is at our fingertips on the Internet.   What we aren’t taught is how to analyze and evaluate or how to come to a conclusion based on thorough understanding of both sides (informed decisions).   In addition, teaching the truth of some of these historical inaccuracies might go a long way in helping racial inequities or other avenues where we â€Å"blame the victim† in our culture.   Certainly we would change our definition of America, but we might be more apt to become part of the solution. Works Cited Loewen, James, Lies My Teacher Told Me, Simon and Schuster, 1995.

How does Shakespeare present love and hate Essay

Shakespeare wrote the play of two lovers’, Romeo and Juliet. Thought to be, one of the greatest, tragic love stories of all time, however, throughout the play, Shakespeare contrasts love with hate at every possible moment. The two themes, love and hate, are like twins separated at birth, brought up in different backgrounds, a totally different society. Combining these two themes, creates curiosity into how ‘a pair of star crossed lovers’ and an ancient feud of two rivalry family’s, can come to together to present, a great and unforgettable love, with fate bringing them to their death. At the beginning of each act, there is a chorus. This device, is used to inform the audience of the events to follow in the next act, it is written in the sonnet form, which was popular at the time the play was written. Writing in this form, creates suspense and leaves the audience anxious to see the next act. At the beginning of act 1 the prologue reads, â€Å"from forth the fatal loins of these 2 foes. A pair of star crossed lovers take their life† here we have love and hate side by side from the beginning. It tells the audience that, regardless of the hate of the two families, a pair of young lovers will do whatever it takes to be together. The prologue is very formal and solemn, it is written like this to create tension. So when the play begins, two servants, from the house of Capulet enter, they talk about fighting and raping the Montague’s, â€Å"I will push Montague’s heads from the wall, and thrust his maids to the wall†. So straight away the audience immediately sees hatred being portrayed. Then they see some Montague servants, and decide to start a fight, â€Å"I will frown as I pass by, and let them take it as they list†. A fight then begins. However when Benvolio enters the mood drastically changes, as we begin to see the first signs of love and peace, as he tries to break up the fight. â€Å"Part fools! Put up your swords you no not what you do.† No sooner have  these words of peace been spoken, hate is brought straight back into play, with the entrance of Tybalt! Who forces Benvolio to fight. Then enters Capulet and Lady Capulet, and Montague and Lady Montague. Here we see the love and hate intertwining with the men wanting to fight, but their wives are holding them back, during which the prince enters. Immediately the fighting stops. Here you see the superiority of the prince as he threatens everyone, â€Å"if you ever disturb our streets again, your lives shall pay the forfeit of the peace†. All this of course happening in the street, creating chaos amongst the town. This presents the feud being not just between the two families, but the whole town, as we are shown, during the fight, with citizens of the town willing to join in fighting both Montague’s and Capulet’s, â€Å"Clubs, bills, and partisans! Strike! Beat them down! Down with the capulets! Down with the Montague’s!† Which portrays more hatred! During the play we see a lot of respect being portrayed, a lot of it within the two families, for instance in act 1 scene 1 when Benvolio is talking to his uncle (Montague)†My noble uncle† although this is perceived as respect, it could also be perceived as love. Whereas in act 1 scene 5 when Tybalt is arguing with his uncle (Capulet) although he shows him respect by listening to his wishes, he has hate burning inside of him, this both for his uncle and Romeo, â€Å"Patience performance with wilful choler meeting Makes my flesh tremble in their different greeting†. There is also respect shown for the Prince, â€Å"the prince came, who parted either†. At the time the play was written, arranged marriage was very common. People did not marry for love, but for wealth. Juliet’s parents arranged for Juliet to marry. They shouldn’t have, as Juliet was only young and was very vulnerable. Juliet was also still a child and still growing up, she wasn’t ready to marry, but her mother and father thought at Juliet’s age ‘happy mothers are made’. The play is set in Verona, Shakespeare set it there, because he was trying to describe an exotic place, were the audience could believe a tragic love story might happen. During the play we come across many types of love, The Montague’s love for their son is one of them. We are shown of their concern  for Romeo, very early on in the play, â€Å"Could we but learn from whence his sorrows grow, we would as willingly give cure as know.† Another type of love is Benvolio’s love for his cousin, â€Å"so please you, step aside; I’ll no his grievance, or be much denied.† All these types of love were within the family. One, which was not, was Romeo’s ‘supposed’ love for Rosaline, â€Å"I do love a women†. At the end of act 1 scene 1, Romeo enters and explains of his undying love for Rosaline, the only problem is, she does not like Romeo and rejects his love, â€Å"she’ll not be hit with cupids arrow†. In act 1 scene 2, Benvolio suggests that Romeo should go to the Montague’s masked ball to take his mind off Rosaline, so he can compare other beautiful girls with Rosaline, and realise that she’s not that nice after all, â€Å"At this same ancient feast of Capulet’s†¦and I will make thee think thy swan a crow.† Romeo agrees to go but only so he can admire Rosaline, â€Å"I’ll go along, no such sight to be shown, But to rejoice in splendour of mine own.† When at the masked ball, Romeo catches his first glance of Juliet, he immediately falls in love with her, without a second thought for Rosaline, â€Å"did my heart love till now?† Forswear it, sight! For I ne’er saw true beauty till this night.† Romeo speaks in sonnet form, which is typical for lovers, and uses rhyming couplets, â€Å"so shows a snowy dove trooping with crows, as yonder lady o’er her fellows shows.† Straight after this, Shakespeare brings hate back into the play with Tybalt. Tybalt despises the Montague’s, so when Tybalt hears Romeo’s voice at ‘his’ party, â€Å"This by his voice, should be a Montague. Fetch me my rapier, boy.† The mood changes rapidly back to hate. Tybalt informs Capulet, who tells him to ignore him. Tybalt is furious by his uncle’s wishes, and swears revenge on Romeo, â€Å"I will withdraw, but this intrusion shall, now seeming sweet, convert to bitterest gall.† In the flash of an eye lid, the hate is turned back into love when Romeo approaches Juliet. Romeo uses parts of the petrachan tradition. He uses lots of imagery related to religion. â€Å"This holy shrine, the gentle sin is this† The love that is being portrayed towards Juliet is true love, unlike his ‘supposed ‘ love for Rosaline. We believe Rosaline was a ‘crush’ as he had never actually spoken to Rosaline, only gazed at her from afar. Shakespeare uses dramatic irony, when presenting Romeo and Juliet’s first meeting, in that the audience no what is happening but the  characters don’t i.e. the audience no that they are from rivalry families but Romeo and Juliet do not, as it is a masked ball. The nurse, who brought Juliet up, was more like a mother than her real one. When she calls for Juliet, Romeo asks her who this beautiful girl is that he has fallen madly in love with, when he realise he is in love with his only enemy, â€Å"My life is my foe’s debt† he feels like he has no power, and Juliet’s response is much the same, â€Å"my only love sprung from my only hate. Too early seen unknown, and known too late.† The only people she hates brought the only person she loves, into the world, and now that she knows who he is, it’s too late to change anything, because it was love at first sight. In conclusion, Shakespeare contrasted both love and hate during act 1 scene 1 and act 1 scene 5, to create a strong beginning to the play. He presented love and hate in many different ways, but always alongside each other, intertwining throughout. He keeps these two themes combined together, through the rest of the play.

Common Welfare Essay Example | Topics and Well Written Essays - 1250 words

Common Welfare - Essay Example One of the first elements that define common welfare is with regards to the fact that the very same values that are used to fulfilling interpersonal relationships are also used towards fulfilling the needs of broader society; namely cooperation, appreciation, democracy, confidence building, and solidarity. With respect to the way in which this would work within and implementation level, it must be understood that this particular aspect of the theory is inarguable and must be accepted due to the fact that it is been proven to work throughout society and to be true as a whole. A secondary core element of this economic and social theory is that a fundamental shift must be made away from seeking profit and dominance within a given market alone. Instead, individuals should seek to maximize the common good. With respect to this particular approach, it must be denoted that this is an idyllic vision of the way in which a business interactions should take place; and one that is unlikely to su cceed in the real world. A third core element of the common welfare approach is the understanding that a regulatory framework is needed in order to encourage the shift away from a competition and profit based approach. This could foreseeable be engaged; however, the costs of implementing such a system, with respect to the lost efficiency that this would necessarily entail, could be massive. A fourth key factor of the theory is that the more effective/better the common welfare is, the more legal advantages will be passed along to the company in question; i.e. lower taxes, reduced customs/duties, loan rates etc. Although this may be true, the ultimate time that would take for the common welfare approach to signify a total and complete change to the entire economy could be far longer than might be expected; thereby leading to a breakdown in the system. A fifth cornerstone that is noted is that the financial balance sheet, the gold standard that has been used to measure success within p revious models, must become a secondary balance sheet alongside the common welfare balance sheet. The difficulty in this is that elements of common welfare are extremely difficult to measure; as compared to their more numeric and quantitative economic counterparts. This calls into question the efficiency or effectiveness of that such an approach could engender. Items 6 points to the fact that once a company is free of the drive to continue to promote profitability, it can then focus upon growing to the optimal size; keeping in mind that this optimal size does not necessarily denote complete domination of the market. The shortcoming that is inherent within this particular approach is the fact that such an approach decreases the incentive that a firm has to continue to provide a high quality of goods/services and merely seeks to survive. Item 7 discusses the way that cooperation and solidarity can become evidenced within firms that espouse the common welfare approach. This may indeed be true; however, once again, the incentive to cooperate and work together to

Mentorship Preparation Essay Example | Topics and Well Written Essays - 3000 words

Mentorship Preparation - Essay Example In this paper, we would be discussing on the nurse mentoring a patient in a sexual health clinic. Integration of the mentor's role into the health care system has increased access to comprehensive health care in combination with the fulfillment of the client's need for prescription medications (Bailey, 1999; Le Bar, 1986). In the UK, resourcing issues such as a reduced number of doctors and the demand for the delivery of cost effective care, have led to plans to extend the role of mentors into prescribing as a potential way of meeting these demands. Nurses may teach individual clients in one-to-one teaching episodes. For example the nurse may teach about wound care while changing a client's dressing or may teach about diet, exercise, and other lifestyle behaviors that minimize the risk of a heart attack for a client who has a cardiac problem. The nurse may also be involved in teaching family members or other support people who are caring for the client. Nurses working in obstetric and pediatric areas teach parents and sometimes grandparents how to care for children. Because of decreased length of hospital stays, time constraints on client education may occur. Nurses need to provide client education that will ensure the client's safe transition from one level of care to another and make appropriate plans for follow-up education in the client's home. Discharge plans must include both information about what the client has been taught before transfer or discharge and what remains for the client to learn to perform self-care in the home or other residence. Nurses are often involved in community health education programs. Such teaching activities may be voluntary as part of the nurse's involvement in an organization such as the Red Cross or Planned Parenthood, or they may be compensated as part of the nurse's work role. Community teaching activities may be aimed at large groups of people who have an interest in some aspect of health, such as nutrition classes, CPR or cardiac risk factor reduction classes, and bicycle or swimming safety programs. Community education programs can also be designed for small groups or individual learners such as childbirth classes or family planning classes. Nurses are also involved in the instruction of professional colleagues. Nurses in nursing practice settings are often involved in the clinical instruction of nursing students. Experienced nurses may function as preceptors for new graduate nurses or for newly employed nurses. Nurses with specialized knowledge and experience may share that knowledge and experience with nurses who are new to that practice area (Courteney & Butler, 1999). Such specialized courses include acute care nursing, perioperative nursing and quality improvement/quality assurance. Nurses may also be involved in teaching other health professionals. Nurses may participate in the education of medical students or allied health students. In this capacity, the nurse educator is often clarifying the role of the nurse for other health professionals or how the nurse can assist them in their care of the client. The nurse may also teach health care colleagues knowledge or skills that are considered the domain of nursing. For a nurse who acts as a mentor, the areas for client education (NICE, 2002) include, promotion of health, increasing a person's level of wellness, growth and development topics, fertility control, hygiene, nutrition, exercise,

Fieldwork GPS report Essay Example | Topics and Well Written Essays - 1000 words

Fieldwork GPS report - Essay Example The first type is the Total Station, which is classic equipment and is not only a GPS system. The other two types of equipment used are the Trimble Juno SB handheld and Leica antenna. These two types of equipment are used in similar ways to position points, but the Leica antenna is more accurate and expensive. On the other hand, the Trimble is cheaper than the Leica antenna. This report will show how the devices can be used and a comparison between all three based on the results each type of equipment’s accuracy. Aim: To understand how GPS systems work by using different types of equipment, and to know which device is most accurate. List of equipment: GPS Leica antenna Total Station GPS Trimble Juno SB handheld Explanation and results of fieldwork: (Figure 1: Wild Park area from Google maps) The field work was conducted at Wild Park in Brighton (Figure 1). The first step was set two points as references by using Leica antenna GPS devices. The benefit of these two points is to make the work more accurate. The group started with using a handheld Trimble for each student. Firstly, we opened the device and added information to it. We then made a line across the valley. Finally, each student took random points to show the land in the valley. The map for the points was done using the geographical information system ARCGIS programme, and the results are shown on this one map for the points and contours as well as a 3d map (Figure 3): (Figure 2: Contours map of Trimble device) (Figure 3: 3d map of Trimble handheld points using ARCGIS programme) The second lot of work was done through using a Lieca antenna device. For this step, we only used one piece of equipment. We started by taking points across the valley. Then, random points were taken. The map used ARCGIS programme; one map is a contours map (Figure 4) and the other is a 3d map (Figure 5). (Figure 4: Contours map of antenna GPS points) (Figure 5: 3d map of antenna points) The last piece of equipment used w as a total station. Through this device, two lines across the valley were taken. One line went across the valley, while the other line went the length of the valley. The points of the total station are presented in a diagram by using Excel and the ArcGIS programme of the Wild Park valley (Figure 6 and 7). (Figure 6: Diagram from Excel file of total station points) (Figure 7: Image of total station points using the ARCGIS programme) Discussion and comparisons between the three devices and methods: The Trimble Juno handheld and antenna dGPS devices used a GPS system to show the points on the map. The system used three satellites to present the easting, northing, and latitude, or X, Y and Z of the points. The accuracy of the position of points will be more accurate when the device uses an accurate clock and can read the signal from the satellite even when the weather is not good. The total station does not use the GPS system, and the accuracy of the points depends on the control points and if the devices have sets on it very well or not. From the points in the Excel file, the maps, which were drawn using an Arc map or arc scene programmes, and type of reading of equipment, I will make a comparison between the devices. Firstly, the Lieca antenna dGPS equipment or differential GPS is a receiver antenna (rover) that receives a signal from a station base that is reserved in a big area. The advantage from this way of using a GPS

Repo 105 Lehman Brothers Term Paper Example | Topics and Well Written Essays - 1750 words

Repo 105 Lehman Brothers - Term Paper Example The Repo 105 has been a practice being conducted by several companies in the current world of business in order to gain financial support or other favors from the stakeholders. However, this research paper aims to explore the usage of Repo 105 by Lehman Brothers that steered to its bankruptcy. In particular, the paper makes a focus on the perceived fraud in Lehman Brothers, the response from the corporation and the government, the core issue behind the fraud, and the suggested steps that could have prevented such a misconduct to occur. The purpose of the paper is to establish the financial viability of the accounting responsibilities of the organizations and the impacts associated with poor accounting and financial concepts and decisions. This exhibits the importance of morality and transparency of the overall business and corporate world. Lehman Brothers Holding Inc. was among the largest firm globally offering financial services. In fact, it was the fourth largest investment bank the United States before the declaration of its bankruptcy. It offered services such as sale of equity and fixed incomes, trading, investment banking, private banking and equity, investment management, and financial research. Lehman Brothers filed for bankruptcy on September 15, 2008, thereby breaking the world records for being the largest with $619 billion in debts and $639 billions for their assets. Their asset surpassed the previous corporate giants such as Enron and WorldCom that had followed the similar trend of bankruptcy. Lehman Brothers was the largest victim of the induced 2008’s financial crisis of the US that affects the global financial markets. Its collapse contributed to more injuries in the 2008 financial crisis, as it steered the erosion of more money from global equity markets, which caused the decrease of the market capitalization efforts. For

Summary of a book chapter Assignment Example | Topics and Well Written Essays - 500 words - 6

Summary of a book chapter - Assignment Example A strong economic and military power are critical to the formation of such a liberal global market economy. According to the hegemonic theory, the absence of a dominant economic and military power can make it difficult to enforce liberal rules. Thus, the international markets cannot operate without the existence of a liberal dominant power. Chances of a global market economy falling are high when there is no integration of such a hegemon. In addition, the risk of deteriorating economic relations into self-interested, nationalistic and protectionist competition can be profound. The debate presents that the dominant power manipulates a global market in attempts to foster a world economy grounded in a free trade. The free trade benefits all the nations that participate in such a global market. For instance, the US military in Western Europe helped in neutralizing Soviet threat. Marxism initiated a debate regarding the development and underdevelopment in nations that are still developing. The Marxists reacted to the economic liberal concept. Thus, this debate begins from a liberal perspective of problems related to development. It is apparent from this debate that asking of pertinent questions regarding development was never possible before 1950s. In some cases, individuals could ask questions that concerned the colonial development since a number of developing nations had European states controlling them. Development of colonies was not strictly a global concern, but an imperial issue. The beginning of decolonization by 1950s marked the introduction of agendum on researching about development on a global scale. Such developments led to new states including Africa and Asia becoming part of the UN and was able to raise their concerns regarding development. Mainstream perspective appears to be a dominant discourse that defines all, which appertains to develop ment. Economic liberals raised several debates on varied issues. In this

Managerial decision making process Essay Example | Topics and Well Written Essays - 1750 words

Managerial decision making process - Essay Example Performance evaluation is an important task in any organization because by evaluating the performance the productivity level of an individual is measured.Promotion, salary packages, increment in compensation and growth of the individual are also based on the performance evaluation therefore organization must ensure that they have proper performance evaluation method that considers important characteristics and traits of the individual so that right candidate is promoted and get his reward of hard work. Also by promoting the right individual, his motivation level would also increase thus it would further increase the productivity. There are different factors that an organization use to evaluate the performance of an individual however the following criterion are the most common considered by organization to evaluate the performance of an individual Knowledge of the individual Expertise in the field Productivity level Performance Tasks completed by the individual Completion of work wit hin the deadline Skills to work as a team player These are the most common factors that are considered in evaluating the performance of an individual, but the criteria may vary from one organization to another. Main concerns with the given company’s current evaluation form The main problems with the existing company’s evaluation form and method are as follows: In evaluating performance, the behavior of an individual with his co-workers and supervisors is highly considered. The extent to which an individual keeps his desk or office clean is considered an important aspect. Task completed on time is not considered as an important characteristic to evaluate the performance of the individual. The knowledge and abilities of an individual are ignored. Most Commonly-Used Sets Of Criteria Which Should Be Evaluated In A Performance Evaluation There are several commonly used sets of criteria used in order to evaluate the performance of an individual and these criteria are as foll ows: Performance of the individual Goals and targets achieved by the individual Efforts put in by the individual Productivity of the individual Ambitions Leadership qualities Motivation level Technical skills and knowledge Team work and team player Advantage of using same performance evaluation method One of the main advantages of using one performance evaluation method for every employee is that it evaluates the performance of different employees in the organization using same criteria therefore it is easy to identify the performance level of different individuals and thus it becomes easier for the management to analyze and reward them and promote them. RELATIVE VALUE OF THE COMMONLY-USED SETS OF EVALUATION CRITERIA already IDENTIFIED There are drastic differences in the criteria used by the company and the criteria that are most commonly used in organizations around the world. The existing system of the organization focuses more on the behavior of the performance, rather than the contribution of the individual towards organization goals and objectives. Organizations around the world focus on the productivity and performance of the individual, whereas this company focuses on relationship with co-workers and managers. Result indexes, such as turnover, quantity and quality of work produced by the employee, are also used for appraisal purposes around the world, which are ignored by the company. Advantages Of Including Supervisors, Peers, And Subordinates In The Evaluation Process Most of the people in the organization review the employee’s performance than just their immediate supervisor. The 360-degree feedback evaluation allows the employer to understand what the performance of the employees is and how the supervisors, peers, subordinates and the external customers viewed the employee’s performance. This evaluation technique provides feedback from all levels of the

Business Entity Regulations Paper Essay Example | Topics and Well Written Essays - 500 words

Business Entity Regulations Paper - Essay Example Next comes the most important part. If it is in the form of sole proprietorship or general partnership, the entity might not require registrations but if it in the form of Corporations, LLCs or LLPs or limited partnerships, it requires business filings with the Kansas Secretary of State. Also, if the business is in the form of partnership (limited or limited liability), non-profit, limited liability company or an corporation, the entity has to be registered with the State of Kansas. The business entity is granted an Employer Identification Number (EIN) which is a federal tax identification number. It is essential for the employers to have EIN before they hire any person. Apart from these mandatory factors, the entity also has to be registered for the state taxes and try and obtain businesses licenses and permits from the state as well as the local governments to function legally. Last but not the least, for the start-ups, guidance are provided to hire the employees at the first place. The annual filling report can be obtained electronically or online. At the outset, the name of the business entity and the identification number of business identification as per Secretary of State’s record has to be entered. The business entity (Lario Oil and Natural Gas in this case) should have delinquent and active status to file online. Also the business entity must possess credit card facility and checking account. As the Lario Oil and Gas Company is a profit entity, it has to pay a flat fee of USD 50. The due date for the annual report can be found by conducting a business entity search or contacting the office of the Secretary of State. The other important aspect of the procedure is that the online option is applicable only to the companies having addresses at the United States and Canada. If the company has address in any of the other nations, it has to mail the annual report in paper document to the

Impression on professionalism in physical therapy core-values self Essay

Impression on professionalism in physical therapy core-values self assessment - Essay Example According to the study conducted under the ‘excellence core value, there were several indicators such as demonstration plus investment in physical therapy, importance of using several material evidence to enhance professional decisions, involvement in collaborative efforts to promote quality health plus education, and others in which the scores were 4 or 5. Under the ‘professional duty’ core value, the author achieved consistency by scoring 4 or 5 levels. The indicators, in this case, included demonstration of beneficence, promotion of physical therapy profession and others. The high rating on these indicators attributes to immense knowledge and experience. The researcher is aware of these indicators and the core values connected to the sample indicators, therefore; he showed consistency of scores. The teller is aware of his professional obligations thus he applies his knowledge of physical therapy to meet these obligations. Under the ‘accountability’ core value, he scored a 3 on the indicator concerning acknowledgement and acceptance of consequences. On the sample indicator of ‘clients requirements above those of therapists’ the score was at level 3. There was the same score for an indicator concerning cultural bias plus gender.   The author scored low under the integrity core value on the indicator entailing the limits of his expertise. Other low scores emanated from indicators of political activism and involvement in social justice matters. The low scores attribute to the knowledge and awareness in those areas.

Imperialism from 1700 to 1900 Essay Example for Free

Imperialism from 1700 to 1900 Essay From 1700 to 1900, the world was expanding. Many countries took on a expansionism type known as imperialism. Countries such as England used the British East India Company to conquer parts of Asia. America used imperialism to spread their rule westward, known as Manifest Destiny. They both used this tactic as migration. During these encounters, many factors stayed the same, but also differed in some ways. In the 19th century, the Americas were finally free of British control, and decided to spread their nation westward, past the Appalachian mountains to the pacific ocean. These people who traveled were called pioneers, exploring the frontier of America. Along the way, they came across Native American civilizations and tribes. Although the Native Americans were welcoming, the pioneers took advantage of them, through their resources. They eventually lead to the endangerment of the buffalo. They depleted many other of their resources, which caused the Native Americans and pioneers to attack one another. Battles such as Little Bighorn and the Wounded Knee massacre are just two known ones. The pioneers ended up killing off many of the natives, which was known as the French and Indian war, and although many Native Americans still survived those attacks, to this day most of them are force to live on reservations. The Americans then started giving away land in the midwest, that used to be owned by these tribes. The Homestead Act encouraged people to go out west and take land given by the government. The land was typically 100 plus acres. The British initially entered India in the 18th century with the East India Company with the sole thought of its trading and financial benefits. By the beginning of the 19th century, however, ulterior motives started to appear. The British were, technically, the ruling governors of India, but before then, had only been concerned with making money. Now, however, the British began trying to expand their territory and the idea of responsible trusteeship came about. The British, along their conquests, destroyed much of Indian culture and replaced it with their own. The British did however, like the idea of the caste system in separating the people, and so let that remain in tack to remain in control of the population. India became a major trade hub in Asia due to this. British rule also modernized India, bring new  technologies and such there, known as cultural diffusion. And so, the Natives had to stay on their reservations while America expanded. America continued their idea of Manifest Destiny all the way to the Pacific. As for the British, the Indian culture was destroyed and changed to the British way of life.

Marketing Plan of Nestle

Marketing Plan of Nestle Nestle is the leading FMCG company of Switzerland established by Henri Nestle. Nestle is serving worldwide with its more than 500 factories in 86 countries comprising almost all continents. Nestlà ©s product portfolio is more than 500 products all over the world serving best to their customers. Henri Nestlà © endowed his company with the symbol derived from his name. His family coat of arms, the nest with a mother bird protecting her young, became the Companys logo and a symbol of the Companys care and attitude to life-long nutrition. The Nestlà © nest represents the nourishment, security and sense of family that are so essential to life Launched on the North American market in 2003, Nestlà © PURE LIFE is destined to become the worlds top and most widely distributed brand by 2010. Nestle is also willing and has goal to achieve the $1 Billion enterprise by 2014. Nestle Pure Life is a premium drinking water, produced to the highest standard of safety and purity. The company is seeking to provide customer with pure drinking water on suitable prices make the product as convenient as possible. According to their claim that they provide the best food throughout the world Nestle is leading brand in water market and has left behind many local brands which were working before the launching of Nestle Pure Life. Now it has maximum market share in developed and major cities of Pakistan like Lahore, Karachi, Islamabad, Multan, Hyderabad and many others. As we have discussed earlier that Nestle is going to become the fully market leader of water market in Pakistan, signs are clearly visible to achieve the set point of Nestle. Nestle Pure Life is also the star product of Nestle Pakistan and most probably all over the world where Nestle Pure Life exist. Here you can see the market share chart for the product and after that there is a Boston Consultancy Group Matrix is shown which would describe the ranking of Nestle Pure Life in product portfolio of Nestle Pakistan. Nestlà ©s business objective is to manufacture and market the Companys products in such a way as to create value that can be sustained over the long term for shareholders, employees, consumers, and business partners. Nestlà © recognizes that its consumers have a sincere and legitimate interest in the behavior, beliefs, and actions of the Company behind brands in which they place their trust and that without its consumers the Company would not exist. Nestlà © continues to maintain its commitment to follow and respect all applicable local laws in each of its markets. According to our observation and market survey, we have concluded that as such there is not set demographic techniques to set the specific target market. Because, water is something that everyone uses. Everyone can use any size of bottle that Nestle is offering. There are some variations that can be made throw OUR OBSERVATION but not from the company Nestle Pure Life comes in four different sizes. These four are targeting different types of people and lifestyles. The smallest size of Nestle Pure Life Water of 0.5L. This size is being heavily used by the consumers in place of soft drink. University and Colleges are also included in its target market of this size. But the product is used by everyone in the society also. It is not only specified people that have been discussed above. The second size of the Nestle Pure Life Water which is about 1.5L. This size is being used in mostly meetings. You can say that any kind of organizational meeting or any other social meeting, this product i s being used. The third size of the Nestle Pure Life which is used in mostly houses and offices in the waiting area. The fully household product and also using in executive rooms in offices with the dispensers. This Nestle Pure Life Water Bottle is also very helpful in many dispensers available in the market with good options We can easily observe that Nestle itself is not taking active part in social welfare. And on the other hand, we see the lower prices of the product as compared to the other FMCGs Companys products like Unilever, Colgate. Palmolive and Procter and Gamble. If we look at the prices, we can observe that Nestle is also using its name for the promotional activities and pricing strategies also. They have to maintain their level of efficiency and always provide the best at best price. Nestle cares about the customers. As the time is of inflation, nestle is trying to overcome the pricing problems to the extent they can do. Nestlà ©s point of view is Only by understanding their needs can we serve our consumers to the fullest Profit earning is the core aim of every company but in case of nestle their profit margin is small just for the sake of customers trust and happiness. Only a few amount of profit is collected from pure life water. Nestle always strive to give superior product at low rates . Nestle is also one of the leader of retaining their customers. This is one reason of their success. They use the simple formula for the price that is Cost + Profit. The main reason is Pure Water which is the name of this product. Rests of the water products are using chemicals which can be harmful for the human body but Nestle Pure Life is the only water product which is pure in nature. That is also the unique selling point of Nestle Pure Life. This is the most powerful point that is in the mind of the customers while purchasing any water bottle in their routine life. The brand name is also very important for the consumers. The slogan of Nestle is Good Food Good Life. That is very attractive slogan people can attract from. It puts the perception in the minds of people that theyre being offered good products for their healthy lifestyle. If you look at the logo of Nestle, youll get to know that a bird is feeding the children. Obviously a mother cant deceive the children. Nestle pure life is a brand of nestle which explains a big symbol of quality to customers. Nestle Pure Life shows in their ads about the purity of water and the water need for you r body. In its launching advertisement, the company advertises Nestle Pure Life very successfully. In that advertisement, a lady is drinking Nestle Pure Life Water and then it goes towards inside the body to show the functions of pure water. That was the awesome commercial that boosted the sale of Nestle Pure Life. Nestle is also advertising on famous websites like you can observe that whenever you will login to your face book account, the ads of Nestle will be there. There are number of sign boards and banners you will see in the cities to aware people about the products of Nestle. Thus, Nestle is using all types of media to advertise their products in anyway. When Nestle Pure Life was launched, they distributed the free samples of 0.5L bottles for market testing and for their advertising purpose. Then a short walk was also arranged for the sake of good health and seminars was also conducted to make sure about the pure water needed your body. To understand the depth of Positioning, we will divide into three steps The final aspect of the micro environment is publics, which is any group that has an interest in or impact on the organizations ability to meet its goals. For example, financial publics can hinder a companys ability to obtain funds affecting the level of credit a company has. Media publics include newspapers and magazines that can publish articles of interest regarding the company and editorials that may influence customers opinions and our mostly products are selling on the public advertisement because the people are the too much concision about their health. Government publics can affect the company by passing legislation and laws that put restrictions on the companys actions. Citizen-action publics include environmental groups and minority group and can question the actions of a company and put them in the public spotlight. Local publics are neighborhood and community of the organizations and will also question a companys impact on the local area and the level of responsibility of their actions. The general public can greatly affect the company as any change in their attitude, whether positive or negative, can cause sales to go up or down because the general public is often the companys customer base. And finally, the internal publics impacts include all those who are employed within the company and deal with the organization and construction of the companys product. Each market impact has different characteristics and causes they find important. This can be beneficial to a marketer as they can decide who their product would benefit most and tailor their marketing plan to attract that segment. Demography covers many aspects that are important to marketers including family dynamics, geographic shifts, work force changes, and levels of diversity in any given area. Another aspect of the macro environment is the economic environment. This refers to the purchasing power of potential customers and the ways in which people spend their money. Within this area are two different economies, subsistence and industrialized. Subsistence economies are based more in agriculture and consume their own industrial output. Industrial economies have markets that are diverse and carry many different types of goods. Each is important to the marketer because each has a highly different spending pattern as well as different distribution of wealth. The natural impacts: The natural environment is another important impact of the macro environment for the organization. This includes the natural resources that a company uses as inputs and affects their marketing activities. The concern in this area is the increased pollution, shortages of raw materials and increased governmental intervention. As raw materials become increasingly scarcer, the ability to create a companys product gets much harder. Also, pollution can go as far as negatively affecting a companys reputation if they are known for damaging the environment. The last concern, government intervention can make it increasingly harder for a company to fulfill their goals as requirements get more stringent. The technical impacts: The technological environment is perhaps one of the fastest changing factors in the macro environment. This includes all developments from antibiotics and surgery to nuclear missiles and chemical weapons to automobiles and credit cards. As these markets develop it can create new markets and new uses for products. It also requires a company to stay ahead of others and update their own technology as it becomes outdated. They must stay informed of trends so they can be part of the next big thing, rather than becoming outdated and suffering the consequences financially. The political impacts: The political environment includes all laws, government agencies, and groups that influence or limit other organizations and individuals within a society. It is important for marketers to be aware of these restrictions as they can be complex. Some products are regulated by both state and federal laws. There are even restrictions for some products as to who the target market may be, for example, cigarettes should not be marketed to younger children. There are also many restrictions on subliminal messages and monopolies. As laws and regulations change often, this is a very important aspect for a marketer to monitor. The final aspect of the macro environment is the cultural environment, which consists of institutions and basic values and beliefs of a group of people. The values can also be further categorized into core beliefs, which passed on from generation to generation and very difficult to change, and secondary beliefs, which tend to be easier to influence. As a marketer, it is important to know the difference between the two and to focus your marketing campaign to reflect the values of a target audience. Nestle is the world leader in FMCG industry. People trust on the products launched by the company even the product is facing some problems. Nestle was doing its good job in past but now it is facing some problems of low quality of their products. Nestle is sued by someone they claim that they are doing unethical business. They are mixing unhygienic things which can cause damage to customers health. Its example is that their water is not pure and good for health. You can see dust partials in Nestle mineral water when you keep it in sunlight that shows its product quality is down. Now they have to do more making their strong position in market because when you lose your image in customers eye then it is difficult to renew their image. Marketing plan of Nestle Marketing plan of Nestle MARKETING PLAN OF NESTLE NESTLE Nestle had setup its first plant in 1961 in Moga (Punjab). The company is acknowledged as one of the leading companies in the FMCG sector with â€Å"Top rated wealth creators of India â€Å". It is progressively evolving into food, beverage, nutrition, health, wellness, and touching lives of people. Nestle India has strong brands like Maggi, Nescafe, Cerelac, Lactogen, Kit, Kat Polo, Milo and Polo. It has set up â€Å"Cafe Nescafe â€Å"and â€Å"Coffee Corners† in mini metros. Nestle is leveraging the vast consumer base in India. There has been continuous focus on values. NESCAFE In Hebrew, the word â€Å"NES† means Miracle â€Å"CAFE† means Coffee so together its a miracle with coffee. Nescafe believes in innovation, improvement, thrust on value for money. Nescafe leads the market of instant coffee with Rs.361 crore. The companys beverage products generate 22% of the companys total revenue. Nescafe has pushed into more diverse media. Global Coffee market s segregated into three segments: Instant Coffee Roast And Ground Coffee Chicory Despite the ever increasing choice available to the consumer, Nescafe original maintains its position as not only the nations favourite coffee, but also the leading hot beverage brand overall. In 1930, the chairman of Nestle in Switzerland was approached by the Brazilian coffee institute and asked to develop coffee that was soluble in hot water and retained its flavour. From these beginings came not only the worlds first instant coffee, but also the emergence of a classic brand of the millennium. After years of painstaking research, scientists at the Nestle research laboratory in Switzerland finally achieved the desired results, and on April 1, 1938, Nescafe was launched in Switzerland. Nescafe original holds the pre-eminent position with a 36.5% retail share of the instant coffee market. The coffee sector s led by Nescafe brands which account for 55% of all instant coffee sales n the UK. BUSINESS STATEMENT Nescafe business objective , and that of management and employees at all levels , is to manufacture and market the Companys products in such a way as to create value that can be sustained over the long term for shareholders , employees , consumers , business partners and the large national economies in which Nescafe operates. Nescafe is conscious of the fact that the success of a corporation is a reflection of the professionalism, conduct and the responsible attitude of its management and employees. It continues to maintain its commitment to follow and respect all applicable local laws in each of its markets. It s conscious of the fact that the success of a corporation is a reflection of the professionalism, conduct and the responsible attitude of its management and the employees. Therefore recruitment of the right people and ongoing training and development are crucial. MARKETING OBJECTIVES We are going to use the method SMART: Specific: The objectives have to be clear. For example, in each shop, the company of â€Å"NESCAFE† must achieve the selling objectives. The turnover to reach will not be the same in the different shop because we make the selling objectives according to size of the shop, the frequentation, the type of the clients. Measurable: The company has to follow the different targets in the sales outlets and if each Shop allowed reaching the objectives. To measure the sales we can calculate the sales by day In order to understand how the client bought the product. With these data we can improve The strategy and the sales. The commercials can ask to the supermarket to put the product in A different way or to make more promotion. Achievable: The targets have to be realist. At the beginning the turnover would grow slowly and after the promotion, it would have a faster expansion. If we reach to win clients from Our main competitor (in a first time) and from the others tea brand (in a second time), the Sales would grow increasingly. The firm should have a long terms vision and should bereactive in front of decisions or problems which can occur. Relevant: the objectives have to be founded on fact and not on suppositions. The firm has to Respect its general strategy and its image. The firm should take into consideration the sales Of its competitors in order to be based on relevant objectives. Timed target: each objective should have a deadline. It can allow measuring the different Sales of the day, of the week, of the month, according to these data, the firm can change the Objectives or makes promotion to reach these objectives. INDUSTRY ANALYSIS TRENDS: In 2005, the tea industry reached the $1.7 billion category and it is expected to continue growing indefinitely (Mintel 2005). Market analyst believe the tea industry will continue to boom and is not expected to reach saturation level in the near future. The favourable movement in the tea industry can be attributed to two major factors: (a) Consumers need for convenience and time-saving services; and (b) the positive press given to tea. For the last decade, the health benefits of tea have gained wide coverage in the media. Studies continue to show the beneficial properties of tea, with health benefits ranging from lower cholesterol levels to improve arterial health and decreasing chance of cancer. This positive press has definitely catapulted the demand for tea. Consumers believe that tea is very good for the body, thus, it is more logical to drink more tea and less soda pop and other drinks. Consumer considers Nestea as a healthy habit. COMPETITOR: One of the major competitor for Nescafe tea in the world tea markets Lipton tea. Moreover the alliance between Unilever and PepsiCo is expected to enable Lipton to strengthen its global position. Lipton tea is going above and above these days, so the competition would be strong. There are other tea also, like Tetley who s gaining good market. CUSTOMER PROFILE: There are two major target markets for ready-to-drink tea. One group s the consumers on the go. These are the employees, students, and other consumers who lead a busy lifestyle. Thus, there is a need for products that are accessible and readily available. Convenience has dominated the market, particularly the food and beverage industry. The other group is made up of health conscious consumers, specifically the baby boomers who patronize anything healthy. SWOT ANALYSIS Strengths Great leap forward in media. Sustained improvement in customer service levels. Global leader in instant coffee the company has a clear global lead in the important coffee sector, which is growing significantly in emerging markets, accounting for 21% of global value in 2007. It has solid financial base. Nestle has a number of cost-saving programmes in place and as a result ,has been able to place itself in a position where it is able to afford sizeable investment in brand development. Weaknesses Agencies spent all their time fighting each other. Adopted a pricing strategy higher than competitors. The mass-market positioning of Nescafe, presents significant difficulties in terms of tapping into the growing demand for premium coffee products. Nescafe has developed only minimal presence in tea, a sector which is benefiting notably from the rise in consumer health-consciousness. Opportunities Shortage of tea supply unlikely. Consumers are living a healthier lifestyle. Growth in tea market due to promotional efforts of healthy attributes of tea. Euro monitor International forecasts that Asia-Pacific will be the fastest growing market for hot drinks over the 2007-2012 periods. As Nescafes largest regional market, Asia-Pacific therefore presents significant opportunities for the company n spite of poor conditions in major Western European markets. It could further develop its confectionary brands n other hot drinks along the lines of existing products. Threats High quality tea prices will increase moderately. Tea market is very competitive and relative elastic. Sluggish prospects in developed markets market maturity and aggressive competition amongst retailers are set to constrain hot drinks growth severely in major developed markets during the forecast period. Increasing transport and raw material costs, mainly relating to rising bean, oil and packaging prices, are placing significant pressure on margins in the companys beverage operations. MARKETING STRATEGIES Nescafe FMCG giants wants to be a â€Å"preferred client†. Strike balance between tapping into local knowledge of markets and disseminating global practice. Communication efforts are directed effectively and with maximum return on investment. To work with the limited number of agencies so that they really know the business. Encourage its agencies and employees by making changes in remuneration. Nescafe has even in the past resorted to low-key market penetration strategies. Nescafe can take advantage of the positive press on the health benefits of tea to boost the sales of its tea product line. The company can use recent studies on the health benefits of tea as the basis of its press releases and advertising campaigns. TARGET MARKET We want to touch the target group n a progressive way. At the beginning, it is important to touch the consumers of black tea, fruit tea and health tea. In second time, we should attract consumers of the main competitor â€Å"LIPTON TEA†. The next step will be to touch the tea drinkers in general and at the end, the consumers of coffee. We can argue for the coffee drinkers that the black tea is as strong as the coffee and good for the health. DISTRIBUTION CHANNEL Mc cann and publicis mojo is the lead global agency of Nescafe. Products are sold throughout India and also are exported to Russia, Hungary and several other countries. Visibility and availability of product had been supported by smaller stock keeping units. MARKETING MIX Product Nestea will be a high quality product offered as specially blended Black tea as well as Fruit and Herbs. Contents of the Nestea black are: 40 bags, 80 bags, 150 bags, 250 bags (Family pack) The amount of bag refers to different target groups. 40 bags for singles, 80 bags for couples, 150 bags and 250 bags are Family packs. Contents of Nestea fruit and Nestea herbal is 25 bags. This is standard size, very common on the tea market (comparison with competitors) The different tastes offered will be: Peppermint, citrus fruit, mango and peach, apple, vanilla. Place Tea is imported from India because the company is able to get high quality for a reasonable price. The final product will be distributed to Retailers such as supermarkets and small shops so the end consumer has easy access to it. Place in supermarkets: The fruit and herbal tea boxes should be placed on the top of the shelves in the supermarkets. Beneath them on the middle and lower levels the black tea should be placed according to the content of tea bags. 40 bags should be placed higher than the ones containing more bags. Price Nestea price would be Content Price Nestea Black 40 bags Rs. 40.99 Nestea Black 80 bags Rs. 78.99 Nestea Black 150 bags Rs. 145.99 Nestea Black 250 bags Rs. 235.99 Peppermint 25 bags Rs. 49.99 Mango Peach 25 bags Rs. 39.99 Apple 25 bags Rs. 40.99 Vanilla 25 bags Rs. 41.99 Promotion The promotion is the most important point to launch our products because we want to be able to compete with our biggest competitor â€Å"Lipton Tea†. We are going to set up original events in order to attract new customers and consumers of the other tea brands. Promotion in supermarkets: We want to set up a stand in the supermarket in order to make tasting to the supermarkets clients. The stand should represent the brand with the colour of the company During the launch of our product, all the customers at the supermarket will receive a sample of â€Å"Nestea† for free at the cashers including a voucher which explains the game to win a trip to London. Promotional offers during the year: If a client buys a box of 150 bags, he will get a free cup or a spoon. If he buys a box of 250 bags, he will get a free box of vanilla tea. The top companies markets spend 40% of their budget on TV. FINANCIAL PROJECTIONS Updated General Fund Projection for FY 2008 There are no specific fiscal actions that result from acceptance of this report. The Fiscal impact of the FY 2008 budget projection will be considered as part of the FY 2008 budget process. As a result of updating the FY 2008 current level of services, the estimated deficit faced by the County is between $201.6 million and $238 million, which is, at the high range, $36.4 million above our August estimate. Between now and June, the projected County deficit could also change as a result of new information, and State and/or Federal budget impacts. As part of the County Executives FY 2008 Recommended Budget, the Administration is likely to propose modified solutions to address the deficit above the original $201.6 million CATEGORY FALL 2006 PROJECTIONS FEBRUARY 2007 PROJECTIONS VARIANCE % Salaries and Benefits $1,079,122,529 $1,104,392,402 $25,269,873 2.3% Services and Supplies $980,299,690 $985,905,536 $5,605,846 0.6% Other Charges $14,975,229 $13,419,939 ($1,555,290) (10.4%) Operating/Equity Transfers $312,285,789 $319,670,115 $7,384,326 2.4% Expenditure Transfers/Reimbursements ($191,727,494) ($203,671,731) ($11,944,237) 6.2% Total Net Expenditures $2,194,955,743 $2,219,716,262 $24,760,519 1.1% Total Revenues $1,993,330,215 $1,992,472,684 ($857,531) 0% Net Cost ($201,625,528) ($232,176,299) ($25,618,050) 12.7% CONCLUSION This new product will definitely help Nescafe to grow better and better. The only thing that the strategies used should be according to the plan. As according to the plan first preference should be the customers taste. The competitors are strong so in the starting we should be on our toes. Ultimately the goal s to make it big and really big. This Nestea will definitely make a change to NESCAFE. BIBLIOGRAPHY www.foodeditorials.com www.nescafe.com www.nestle.in/nestle_india_landing.aspx www.ciims.net/2008/09/nescafe_atack_green ­_tea_market.html www.allbusiness.com/marketingmarketing/236907-1.html en.wikipedia.org/wiki/nestle

Chronic Opiod Use after Hysterectomy

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