Health Care System: Private or Public Essay

Main Argument: Is America’s health-care system better than Canada’s? Thoresen, S. T. , & Fielding, A. (2011). Universal health care in Thailand: Concerns among the health care workforce. Health Policy, 99(1), 17-22. Retrieved from https://0-www-clinicalkey-com. catalog. lib. cmich. edu/ Stian H. Thoresen and Angela Fielding, authors of the article â€Å"Universal health care in Thailand: Concerns among the health care workforce†, write about the controversial topic of public health care from the Thai health care professionals perspective. The article is based off of interviews with health care professionals who work in dealing with patients who are covered by public health care. One quote, â€Å"Health care professionals at public hospitals, particularly in rural areas, have experienced up to a doubling in the number of daily out-patients; many with superficial symptoms,† is what Thoresen and Fielding were under the impression of after the interviews. They also followed up with another quote stating, â€Å"While the improved access to health care provisions was welcomed, questions regarding the appropriateness of seeking medical advice were raised. This specific article is perfect for my topic in a number of ways. Thoresen and Fielding bring up their findings perfectly because they use their interviews with professionals who work in public health care to back up their argument. This would be a great source for my paper because not only is it a real life example of public health care, it is another country with public health care which would show that the point is to not bash the Canadian health care system, but to show an international comparison. The two authors stated, â€Å"There are potentials for health care professionals to congregate in the private sector and urban areas where workloads are perceived to be less demanding. † Relating back to a previous quote, it was understood that public health care equals more health care facilities populated with patients, whereas with private, it seems it is not so crowded which can lead one to believe that patients are only seeking care when absolutely needed. Thoresen and Fielding bring up a debatable argument that is universal to all (private and public health care owners) and present their findings appropriately. Funds have been set in place to build what he explained as a â€Å"public-private partnership†. This type of health care system is all made possible because of a philanthropy type fund from different organizations. Dolan explains, â€Å"The fund will rely on $87 million in loans from Morgan Stanley in exchange for tax credits to build 500 new affordable housing units and eight new health centers serving 75,000 people. † Dolan’s article, â€Å"U. S. news: Public-private fund aims at health care, housing gap†, would fit in my paper as an example how people can make the best out of private health care. Private versus public health care is so controversial due to the fact that one party, whether it be the patients or professionals, are going to suffer expense wise. Of course private health care is more costly for the average person than public health care; Dolan explains a way for both the people of private health care, as well as health care services to get a fair end of the deal. He explains the idea well due to the fact that solves the problem by bringing up an existing way to help out with private health care. Quotes from this article could easily be included into the topic of my paper. Dolan, rather than a farfetched idea like switching to private health care overnight, approaches the argument with more encouragement. Culyer, A. J. (1989). The normative economics of health care finance and provision. Oxford Journals, 5(1), 34-58. A. J. Culyer, writer of the article â€Å"The normative economics of health care finance and provision†, better explains many fine points of public health care. Culyer explains that while many believe that public health care comes along with a lot of excess spending, the real crisis is the â€Å"underfunding†. Since the government acts as the main source of funding for health care, it actually can work against the common good of the people. A. J. states that the concern of underfunding has given rise to bring up proposals for reform which includes a greater role for private insurance, out-of-pocket payments, and private health care. Although A. J. Culyer’s article is wrote in response to the medical ‘crisis’ of the UK, it still would act as a great example to show positive aspects of private health care. It is true that many believe that public health care has a lot of excess spending, but apparently, a big problem in this particular type of health care is the underfunding. Culyer’s article would be crucial in my paper because he proposes another example that would make one question public health care. It is true that the government is the main source of funds in public health care, but when assets are going towards other organizations as well money can become split up and threatened. Culyer incorporates this idea without coming off too strong, but rather makes the public health care system questionable.  Berman, M. (n. d. ). Although the main focus has been the benefits of private health care, Micah Berman offers insight on why public health care works for some countries. This article is written specifically on focuses of the U. S. health care reform in 2011. The cost of medical care in the U. S. and the Affordable Act of 2010 are two of the main topics discussed in the article. The author’s main point is that the U. S. should focus on the prevention of chronic disease, instead of treatment when those diseases appear. Berman genuinely believes that this type of reform would cut medical costs drastically. The point of my paper is not to come off demanding but informational with many sources which is why another side to the health care system is essential. Micah Berman has one quote in the article that really caught my attention, â€Å"We don’t have a health care system in America. We have a sick care system. If you get sick, you get care. But precious little is spent to keep people healthy in the first place. † It may be true that the U. S. has some of the best health care services and technology in the world, but it may also have some of the most demanding patients as well. People seem to be so focused on what types of characteristic a better health care, or in their hopes, a cheaper health care, would have, that they forget to take care of themselves in the process.

What killed audiolingualism

Audiologists is one of the nine 20th century language teaching approaches which was based on contrastive analysis about behaviorism and structuralism, and was created as a reaction to the reading approach that was lacking of emphasis on oral- aural skills. The results of this approach, dialogues approach, were generally regarded a great success. The small groups of learners and high motivation were the caveats that undoubtedly contributed to the success of the approach.However, successful as it was, Audiologists reached its end in the sass and is no longer seed today. There are some reasons as to why this approach collapsed. The first reason was the emergence of error analysis that makes audiologists received attacks from many linguists. Chomsky attack on behaviorism view on which audiologists is based is very well-known. He also proposed that people have innate system- generally known as Universal Grammar- within them that provides them with ability to construct their own grammar.T he error in audiologists was also viewed not as something to be avoided. Error Is a good thing through which learners' mind is shown. There was another attack as well saying this approach, especially in the late sass, failed to follow the learners' needs In a way that the learners needed advanced academic skills more than they need oral skill because of the university requirement for enrollment at U.S and British (grab, 1991). That audiologists banned students from using Al because It will Interfere with their LA acquisition also received critics because some linguists viewed Al not as a hindrance, but as an important resource In decision making In writing Another reason that killed audiologists Is the negligence of the caveat that audiologists be taught In small class with highly motivated students.This negligence occurred because of several reasons; people's amazement toward how successful audiologists was that they Implemented It anywhere hoping to get the same success, and the b oredom that students felt due to the monotonousness for using drilling so often that they lose their motivation. This monotonousness was one thing that led Harmer (1991) to suggest that It not be used too frequently and too long. It Is human nature to get ordered and It Is Inevitable.In Dalton, the level of emergency also became the significant factor In a way that former learners with dialogues method viewed LA as an urgent need. Some needed It for World War 2, some-especially those who lived In one place with two language-needed It to be mediating language because It was the only way to communicate. However, LA learning today Is not because It Is urgently needed. Most of the time, It Is Just learned because It Is In the curriculum. However, despite all reasons mentioned above, It Is not that Audiologists Is a bad teaching approach.The alma of this paper, and also the alma of learning language teaching approach, Is not to Judge any approach. There Is no such thing called the best o r the worst method. Audiologists Itself Is not a bad approach since, at some point In history, It has been very successful. Thus, Audiologists, Just Like any other approaches, Is not for us to discredit. The task for all language teachers Is to find the method that Is most suitable and most effective for the learners. What killed audiologists By realization also viewed not as something to be avoided.Error is a good thing through which especially in the late sass, failed to follow the learners' needs in a way that the audiologists banned students from using Al because it will interfere with their LA but as an important resource in decision making in writing Another reason that killed audiologists is the negligence of the caveat that audiologists be taught in several reasons; people's amazement toward how successful audiologists was that they implemented it anywhere hoping to get the same success, and the boredom suggest that it not be used too frequently and too long.It is human natu re to get bored and it is inevitable. In addition, the level of emergency also became the significant factor in a way that former learners with dialogues method viewed LA as an urgent need. Some needed it for World War 2, some-especially those who lived in one place with two language-needed it to be mediating language because it was the only way to communicate. However, LA learning today is not because it is urgently needed. Most of the time, it is Just learned because it is in the curriculum.However, despite all reasons mentioned above, it is not that Audiologists is a bad teaching approach. The aim of this paper, and also the aim of learning language teaching approach, is not to Judge any approach. There is no such thing called the best or the worst method. Audiologists itself is not a bad approach since, at some point in history, it has been very successful. Thus, Audiologists, Just like any other approaches, is not for us to discredit. The task for all language teachers is to fi nd the method that is most suitable and most effective for the learners.

A Story About WWF Essays - American Christians, WWE Hall Of Fame

A story about WWF "Welcome everybody to 'Raw IS War'! Tonight's main event is Sting verses Shawn Michaels for the WWF World Heavyweight Championship. Before we begin, here is a little information on the challenger, Sting," announced Vince McCann. "He hails from Death Valley, California. At 7 feet tall and over 300 pounds, he is the biggest wrestler in the WWF. He is the 'Man from the dark side'," Jim Ross stated. "Ladies and Gentlemen..... here is your challenger........ Sting!" The crowd cheers as Sting walks down the ramp. He is stopped at the bottom of the ramp to be interviewed by Gene Oakerland. "Sting, if I can ask you one question. Why do you want the title so badly?" " Well Gene, ever since I was a child, the championship belt has been held by disrespecting degenerates. I feel it's time for a real champion get the belt. That is why I'm here, I'm the people's cham....." Before sting could finish his sentence he is attacked by HHH. HHH's partner distracted the referee long enough for him to deliver the devastating 'Piledriver'. With Sting's head exposed, HHH drops to the ground and drives Sting's exposed head on the cement floor. The force was enough to break his neck. Sting was knocked out from the force of the impact. When he awoke, he was in an ambulance. "Where am I? Somebody please tell me where I am," Sting pleaded. The paramedic treated him to calm down. "I can't move! I can't move" he would say. It took about half an hour to Sharp Hospital. Two doctors were waiting for him when he arrived. The immediately took him to the operating room. It was here that Sting found out that he had suffered a broken spine. The doctor ordered an experimental operation. It was a highly dangerous operation. One mess up could kill the superstar. It took five hours to complete the difficult operation. Sting was wheeled into his private room. To make him feel more at home, the room was decorated with WWF merchandise. When Sting woke up, he had a sharp pain in his neck. The doctor gave him some medicine to help. It worked a little bit. About three hours after he woke up, a doctor came in and told him that he probably never be able to wrestle again. Sting heart sunk. He didn't want to hear that. It was about seven in the morning when Sting went to sleep. It had been nearly ten hours since he arrived at the hospital. For the first two months, all he did was sleep. The medicine they were giving him making him very sleepy. When he was awake, he would move his hand a little. The slight movement of his hands made the doctors extremely happy. They now were sure that he wasn't paralyzed. It took him another fours months before he could move his arm perfectly. With the confidence he had gained, he tried to walk out of bed. As soon as he was off the bed, he feel flat on his face. Sting was soon transferred to the San Diego Rehabilitation Center . For the first few months, he would just sit in bed thinking of ways to get back HHH. One Sunday, he happened to watch church on t.v. He saw a man who claimed that God cured him of paralysis. Sting started to pray immediately. "Dear Lord, It's me Sting. I know you are really busy and all but if you could, I would really like to wrestle again. Amen." Sting recited this prayer for the next two weeks. On the fifteenth day, he tried to move his feet

Organizational Communication Concepts and Skills Assignment

Organizational Communication Concepts and Skills - Assignment Example Therefore, if the organization tends to neglect socializing the employees, then in such cases the employees must themselves socialize. There are two distinct communication network taking place in organizational environment. They are formal as well as informal network. The formal network is making communication following the hierarchical structure of the organization. On the other hand, the informal network comprises communication following the grapevine (Cairo University, 2012). It is a well known fact that successful communication in an organization enhances the efficiency, minimizes the turnover of the employees and also helps in the development of the office atmosphere. The chief objective of this discussion is to propose a new communication structure for an organization. The five different concepts that the discussion shall evaluate are active listening, organizational culture, and conflict resolution, leadership strategies as well as formal and informal communication. Analysis o f the Concepts Important For Successful Communication within an Organization Active Listening It is a well known fact that effective listening is significant for improving communication. However, the managers are not always found to be listening since active listening is not considered to be a natural procedure. Mental as well as physical efforts are needed on part of the listener. Intra-organizational listening can be considered as an influential competitive tool (Helms & Haynes, 1992). In the context of the business world, listening is considered to be a significant element of effectual communication in an organization. While communicating with the members of the organization, listening will assist in avoiding any kind of confusions, comprehending the work lucidly and thus creating a positive connection with whom the communication is initiated. The communication experts have agreed to the fact that active listening as a major factor which comprises behaviors such as empathetic bod y language, posing useful questions, validating employee expression via considerate conversation turn-taking along with rephrasing for ensuring mutual understanding. Active listening generally comprises the focus of the consultants upon the clients with an indication that they are listening closely to the issue presented and the client’s interpretation of this aspect (The University of Maine, 2012). For a communication to be effective and successful, it is vital for the listeners to motivate themselves to listen. They are supposed to decide precisely why they are listening. Active listening offers numerous advantages to the organization. It leads to save in time by means of people’s defenses and gain significant information without repeating the same conversation always. It permits the organization to evaluate a situation accurately (Kuboto, Mishima, & Nagata, 2004). However, one of the facts regarding active listening is that it is not an easy skill to be attained. It might as well require alterations in one’s own basic attitudes. Active listening carries an element of personal risk. Creating an attitude of sincere interest in the speaker is not an easy task. It can hence be created by being willing to risk viewing the world from the speaker’s point of view (Rogers & Farson, 2010). Organizational Culture Organizational culture is considered to be a significant component in the context of organizational communication. Culture is generally comprehended as how people make sense of

History 2 Essay Example | Topics and Well Written Essays - 500 words - 1

History 2 - Essay Example This happened in the march of 1985. It was as a result of the emergence of younger communists. These people had radical thinking and were fed up with the years of stagnation in the Soviet Union both politically and economically. Gorbachev had a team of reform-oriented technocrats who thought that economic development was at a very slow pace in USSR (Brown, 1996). With these things in mind and a hope to achieve rapid economic development, Gorbachev introduced programs like glasnost that is political openness and perestroika, which meant Economic restructuring (R.English, 2000). Adding to it was the policy named Uskoreniye, which meant gearing up of economic development. These policies came up in 1986 (Brown, 1996). These can be marked as the main weapons that led to the dismantling of the great Soviet Union (Helene, 1992). As the conservatives at that time did not agree with Gorbachev regarding these reforms by the name of economic restructuring, he introduced glasnost stating that th e transformations in the economy would be difficult to achieve without corresponding changes in the political scenario in the nation (R.English, 2000). Gorbachev thought that these reforms would speed up the Economic development of USSR and was confident that he would have people’s support by having their views in a wide range of openness through glasnost. However Glasnost resulted in an unexpected situation where freedom of speech became much more prominent and the fourth estate’s domination started (David, 1994). This gave the opportunity for press to be more comfortable in expressing the loopholes in Soviet Union and the hidden truths that were never known to people. Many political prisoners were released as a result and USSR was a topic that was free to explore by many foreign sources as well (David, 1994). Many topics that were hidden in the past were now brought to light. People started to become aware of the

Healthcare Programs Essay Example | Topics and Well Written Essays - 1000 words

Healthcare Programs - Essay Example TRICARE represents the healthcare program utilizing military healthcare systems as the main providers. This program is funded and supported through civilian providers and facilities, and includes provision of healthcare services to military personnel and their families of the USA, past or presently active. The introduction of tricare was primarily a strategy in the eighties and the nineties, in response to the increased healthcare costs in the USA, as well as the changes in the modernization trends. Tricare was perceived to be a feasible and economic way to save costs while improving access and choice to healthcare services. The development of TRICARE has expanded significantly, and has now come to be a part of 40% of the USA hospitals. Increasingly high numbers of healthcare personnel and providers now form a part of the TRICARE provision team. (Carrato, 2003) The effectiveness of Tricare is very evident if comparing to other healthcare systems such as CHAMPVA. The differences run from basic infrastructures of the plans. While TRICARE, formerly CHAMPUS, is a medical insurance program carried out by the department of defense, CHAMPVA is run through VA. The members differ with regards to their status as retired or non retired from military services, tricare being entertaining to the retired personnel. CHAMPVA restricts itself to those who are either 100% disabled personnel, or either dead. This does not to be so for tricare patients. CHAMPVA does not entertain veterans, which forms a large part of the tricare members. Also, CHAMPVA has rules about access and obtaining of prescriptions. The above mentioned differences help to understand some of the key differences that make tricare a much superior healthcare program over others. (Tricare for life, 2001) Tricare has many services at its disposal, which are both comprehensive as well as targeted in their approach to diseases. The triple option benefit in the system allows the enrollment of many people with a wide range of healthcare services. Now it has become active in the advanced medical areas of cancers, along with including age old programs of immunizations etc. The scope of tricare therefore is very vast, with much promise of improvement. Tricare gives these services through a range of programs, which include the Prime Preventive Services, the Pharmacy Program, and Dental Coverage etc. Tricare has proven its worth through its impressive reports of its performances. Perhaps the most demonstrative of Tricare's effectiveness is looking at the claims processing capacity and the speed with which these are carried out. Around 755 of the claims are addressed within 21 days of being placed, an impressive statement of the quality and the efficiency of Tricare. (Bailey, 1999) With the pr ojected increase of health costs by7.3% by the year 2011, Tricare's potential role in reducing these costs is highly promising. (Carrato, 2003) One of the proof that tricare has shown constant delivery with respect to healthcare is its successful maintenance of its enrollment fee. The active duty members have almost no costs for care, which is provided in the military settings. Pay for a service is very high

Ibarra & Hansens Are you a Collaborative Leader Article

Ibarra & Hansens Are you a Collaborative Leader - Article Example The employees could also use the video broadcast and express their views. Beinoff kicked off the debate by grabbing an iPad and commenting on the Chatter, soon employees from their offices started commenting back. The debate lasted for weeks thus allowing Beinoff the opportunity to align the employees to the mission and create an open culture for salesforce.com. Command and control policies hinder collaboration in many organizations. A survey of â€Å"best performing CEOs in the world† done early 2010 revealed that collaborative leaders require strong skills such as acting as connector, ensuring diversity of talent, guiding teams and modeling collaboration at the top (Ibarra and Hanse 3). According to Malcolm Gladwell, collaborative leaders play a global connector role by linking the employees, the ideas and resources. David Kenny, President of Akamai Technologies is one of such leaders who spend time travelling in order to meet with business partners, customers and employees around the world. Collaborative leaders can attain insightful ideas such as macroeconomic issues and impact of climate change through collaborating with business partners. Collaborative leaders will make global connections in order to spot business opportunities and model the top managers on the business expectations. Collaboratibve leaders will attend to conferences outside their professional specialty and meet people outside the organization like external partners (Ibarra and Hanse 4). According to previous research, diverse teams will produce better results. Collaborative leaders will engage diversity in their teams in order to enhance creativity. Such teams should consider the diversity in terms of nationality, age and time dedicated to visiting emerging markets. For instance, nonnative English speakers may be disadvantaged in Multinational companies in emerging markets. Danone of France has

Explain why you feel college students do or don not benefits from Essay

Explain why you feel college students do or don not benefits from participation in extracurricular activities - Essay Example There are numerous oppurtunities to suit individual tastes and requirements. It is better to be sincerely involved and dedicated to one or two activities rather than be a ‘Jack of all trades and master of none’. Academics are the most important and a student should maintain a balance between the academics and the extra curricular activities. College still want good academic results although a lot of importance is laid on the other activities. Admission officers believe that what you do says a lot about you. Your academic mark sheet give details about your studies but the write up on your extra –curricular activities tell them of the sort of person you are. Every human being has hidden talents which need a platform to evoke from within. Such activities provide an excellent opportunity to realize your own strengths and perhaps even weaknesses. Different academic clubs and societies within the campus help students to work within a group and understand the group dynamics. For instance, for one who is the only child at home, interacting and working with others in a group teaches patience and adjustments. It has been found that students who are involved in extra curricular activities perform better in studies, have a pleasing nature, can relate better with the peer group. It instills in them a sense of confidence. It teaches them how to carry themselves in life. Employers these days lay a lot of stress on extra curricular activities as it ensures the all-round growth of a student. In conclusion I would like to state that life beyond academics only helps to enhance the personality of a student, provided he/she is selective. It empowers a student to make his own decisions. It helps him gain vital experience and skills necessary to guide him into his future path. So participate, bloom and shine! Let your extra curricular activities speak volumes about

Promote good sleep hygiene Essay Example | Topics and Well Written Essays - 750 words

Promote good sleep hygiene - Essay Example The National Sleep Foundation (2011) also lays down that inadequate sleep contributes to different problems related to depression. UMass Boston should keep all these problems in sight before implementing an educational program for the students regarding sleep hygiene. UMass Boston health office should ensure that the students are getting an excellent sleep before coming to the school. This would help in improving the academic performance of many of the students in the college. Frederick Danner and Brandon Phillips (2008) in â€Å"Adolescent sleep, school start times, and teen motor vehicle crashes† state that adolescents are not getting enough sleep as they are growing up and this leads to several problems in the society. Teenagers tend to drive while being drowsy and this leads to many traffic problems in the society. Keeping this in mind the UMass Boston health office can provide the students with the information about driving without sleep. Driving while being drowsy poses the risk of accidents to these teenagers and the health office should inform the students about the risks involved. Mary Carskadon in a research at Brown University found that students who got enough sleep in their daily routine were able to perform well in their academic settings. The research clearly showed that students who went to bed earlier in their daily routine were able to grasp A’s and B’s whereas the ones who slept less were amongst the low achievers in the class (Carpenter 2001).Moreover Kyla Wahlstrom (2002) stated that students who did not get enough sleep showed signs of inattentiveness and poor performance in the class. All these signs clearly show that the UMass Boston health office should take a step to inform the students about the possible consequences that they may face if they do not get enough sleep. Sleep is also related to the cognitive skills of an individual as shown by many researches. June Pilcher and Walter (1997) carried out an experiment to find out the relation between the cognitive skills and sleep. The experiment was conducted on 44 college students who either were sleep deprived for 24 hours or slept for 8 hours. These college students were asked to perform a cognitive skill test after which they had to complete 2 questionnaires with regard to the efforts that they made during the test. The result clearly showed that the individuals who did not get sleep properly were not able to perform well in their academic settings. The cognitive skills of the ones who slept properly were higher than the ones who did not sleep properly. The students who did not sleep properly were not able to perform at the cognitive task whereas those who slept well were completely different as they were able to perform well. Moreover the questionnaires helped to assess the awareness of the students and it was found that the sleep deprived students rated their performance to be high than the non-deprived ones which clearly means that they are not aware about the effects of sleep on their academics. Sleep education at UMass Boston can help the students to get over these common problems so that they can concentrate on their skills and improve upon their cognitive performance (Pilcher & Walter 1997). Maintaining Sleep hygiene is a solution to all the problems that individuals in academic settings suffer from. Sleep related problems are seen to be suffered by many students because of which they cannot perform well in th

Company Analysis and Evaluation Case Study Example | Topics and Well Written Essays - 2250 words

Company Analysis and Evaluation - Case Study Example The Collins Foods Group is a private company based in Australia with a joint ownership by private investors and management together with employees forming 52% and 48% of ownership respectively. The company's main business includes retail outlets for food service i.e. KFC in Queensland and sizzler in Australia. Collins Food group in Queensland operates from Brisbane where it operates one hundred and fourteen retail outlets and twenty six Sizzler restaurants in within Australia. The earliest KFC restaurant in Australia was established in 1968 and opened in 1969, while the earliest Sizzler was established in 1984 and opened in 1985. KFC has been growing since its establishment and this can be seen in terms of the increased number of retail outlets, more employee, increased profits etc. The company seeks to attain a continuous development in each and every area of its operation as its mission statement describes it "Establish Collins Foods Group as leading restaurant holding company, whi ch operates premier brands where people love to eat and are proud to work." KFC also seeks to better the community in which it operates through its commitment to participate in activities that enhance the community. KFC has a principle that "if you take care of your people they will take care of your customers. If you take care of your customers they will take care of your business" Figure 1: Collins Food Group Pty Limited SWOT Analysis Strengths Weaknesses Opportunities Threats Strong capital base Internal controls for some of our outlets are wanting The state is focusing on subsidizing hotel industry to boost tourism The world economic crisis that has catalyzed inflation and have seen financial industries raised lending rates Strong brand The company is understaffed Internet marketing will help us to reach out the whole global market and hence expanded market Technological advancement may introduce new challenges that may affect the normal business processes. Competent top management and subordinate personnel The regular personnel review might not be very reliable There are many upcoming training and management consultant firms from which the company can outsource this services Big competitors may shift focus and wipe out part of our market position Wide distribution channels A significant percentage of employee turnover Hotel industry expanding providing opportunities to penetrate new markets The upcoming retail food service providers are poaching experienced employees from our company Efficient quality control procedures In case the financial crisis continues to bite people will continue to cut down on their spending habits Efficient staff appraisal system Track record in excellent customer care devoid of top management approval Competitors in the industry might be reluctant to implement new technology Figure 2: Balanced scorecard: Critical Success Factors (CSFs) Analysis Critical success Factor Categories Critical success factors (CSTs) Measurement of the CSFs Understanding of market Sensitivity to volatile market needs Number of active customers Understanding our competitors and their decision making Attainment of a competitive edge above our competitors Innovative response to the needs of the customers Number of new customers Consumer

Silence Family Essay Example for Free

Silence Family Essay Silence are the words that are not said, rather then the words that are chosen. It is the fear of the truth as well as hiding from it. In the novel Obasan by Joy Kogawa, silence is a part of a culture and is a larger part of a family. The character Naomi allows silence to over come her life, which allows her to remain tortured inside the internment camp of her own body. Although the family is living in another country, the traditions to Japan are still very strong. In the U. S. silence is generally looked upon as passive while Japan it traditionally signals pensiveness, alertness, and sensitivity. Growing up with Obasan and her Uncle, Naomi was raised and taught to respect silence. Naomi remains extremely quiet about her childhood under the guidance of her aunt. A major truth she hides is her molestation. She was taught not to lash back at adults and to do what they say. At this moment, she learned dis-trust. The incidents with him happened more than once, yet she remained silent. This, for Naomi, drew her apart from her mother, leaving something between them that could not be discussed or mentioned. Before this event, they had sort of a silent communication, and now she misses that. This is similar to the hen and chick incident where the mother hen pecks at the baby chicks. She now can see a tare between mother and daughter she couldn’t see before. â€Å"†¦They are the eyes that protect, shielding what’s hidden most deeply in the heart of a child†(p. 59). There was no longer this link between her and her mother after the shame of her losing innocence. Naomi remains silent for so long that, â€Å"silence within her small body has grown large and powerful,† (p. 14) just as it did for Obasan. She lives her life miserable after all she has been through but must remain silent about. Unlike Aunt Emily, Obasan believes that speaking about and confronting the fact that the Canadians interned the Japanese will not bring about justice but only sadness, an emotion she does not express because â€Å"the language of er grief is silence. She has learned it well, its idioms, and its nuances. † (p. 14) Being raised by Obasan created the life Naomi has now. She lives in a world where she has no love in her life, or anyone to be honest with. But for Naomi the silence could not continue when she seeks for the truth about her mother which she had all along. Naomi learns about her mother’s tragedy through the letters between Grandma a nd Grandpa Kato she received from Emily. She has known that her mother’s grave had been found but Naomi never knew that her mother was badly hurt in the bombings of Nagasaki when she was helping her cousin Setsuko with her new baby Chieko, who looked just like Emily. After the bombing Naomi’s mother and the baby were both in the hospital. Naomi’s mother was badly injured and the baby had leukemia. Since the baby looked like Naomi there was a connection to her and for the first time the communication between Naomi and her mother are open again. This allows Naomi to begin speaking to her, even though she was not there. But after reading those letters Naomi broke the silence because now she knows the truth and she can finally communicate. In Obasan, Naomi is tortured by the silence of the truth. She is unable to speak of what is true and can not find out what is real due to the absence of her mother and having to be risen by her Obasan. After she does learn the truth, she does not feel tortured any more because she can find the comfort of communication with her mother, a connection she has missed for years.

The following information outlines Brilliant Decisions Associations tender Essay Example for Free

The following information outlines Brilliant Decisions Associations tender Essay Introduction Within this tender for contract, Brilliant Decisions Association has outlined its aims, objectives, and aspirations for providing the City of Leeds with a modern, flexible, and state of the art health facility. The facility which our consortium will be replacing, Leeds General Infirmary, has suffered from under investment for many years. The resulting consequences have produced a health facility which fell short of the communities needs and expectations, and will continue to do so for many years unless investment is acquired. The following information outlines Brilliant Decisions Associations tender for contract for the development of a new health facility for the City of Leeds. Objectives Brilliant Decisions Association is a consortium of national and international businesses with a strategic interest in the strength and success of the Citys economy, financial sector and employment. Our consortium will provide a high quality, privately financed hospital to provide the community with a modern, flexible, state of the art hospital. We believe by providing a new health facility, the community will not only experience sufficiently increased level of care, but increased employment prospects, and improved services. These services, such as the improved transport links a new health facility will provide to the community, will provide increased access to the city and the local community, increase custom to retail outlets which will improve the strength of the communitys finances. Brilliant Decisions Association has many aspirations for the new health facility which it will deliver to the City of Leeds and the local community surrounding the hospital upon completion of the project. We believe the new health facility will be the most modern and state of the art in the country, providing flexible services to meet the needs and demands of the local community and providing the community with a wide range of employment opportunities in which they can progress through into management. We understand that no matter how efficient the new health facility is, we need the support of the local community for it to be a centre of excellence. Brilliant Decisions Association has very strong ethical views on the impact that a new health facility will have on the local community and because of this, we have a number of key areas which we will endeavour to meet with the development of the new hospital. The new health facility is going to be developed in a green field site located in the local community area. We recognise that building on this land will be difficult to accept for the local residents but we are going to develop the hospital to encompass many of the natural aspects of the green field site. We will have many open areas and gardens around the hospital for patient and visitors to walk around. We will develop any land which is not developed into the main infrastructure of the hospital by planting many trees, plants and shrubs to make the hospital less of an eyesore and to encourage the natural wild life to inhabit these areas. The new health facility will be of the highest standards in terms of quality of buildings and the internal infrastructure. The quality of buildings and dà ¯Ã‚ ¿Ã‚ ½cor which will be used will be professionally constructed so as to provide a safe environment for our staff, patients and visitors. A stringent fire safety procedure will be in place to protect the safety of our staff and patients. Our staff will be heavily trained with regular re-training exercises in the health and safety laws and regulations which govern the safety of the hospital, patients and themselves. There will be clearly visible fire and health and safety notices to inform staff and patients of emergency exits and their responsibilities. Brilliant Decision Association will endeavour to employ only quality trained staff to provide our patients with the highest quality of care available to enable the health facility to match our aims and aspirations. * To secure the most advantageous deal for ourselves, building a new hospital, we believe the cost of these advisors will be in the region of à ¯Ã‚ ¿Ã‚ ½14.000.000 on the à ¯Ã‚ ¿Ã‚ ½164.000.000 contract. The consultancy cost figures are in the higher percentage range, around 8-9% so that we do not go under budget for this expenditure. * Based on two future PFI scheme hospitals, they will have a throughput of patients per bed of 88 and 100 per year. We will aim to have a throughput of 90 in line with these future hospitals. * We feel that we can best achieve our objectives by offering a new hospital with buildings of high quality. With a new hospital there are a minimum of limitations as to what can be done, and this will hopefully appeal to the NHS trust. This is of course the option that would satisfy the shareholders in our member companies as well as it will increase their return. * Ancillary staff will be contracted to out to work with existing employees. Because we are pushing for a re-development, TUPE rules wont apply to current staff and all employees can be paid the same and the same conditions can apply to all staff. * We could introduce charges for parking; this could be an area which could provide our shareholders with a large increase in profits. Clamping could also be considered with the release fee waived if we believed it was under exceptional circumstances. Charging for televisions, radio usage and the use of bedside phones should be considered to further increase profits. Vending machines around the hospital could also be used for profit maximisation. We could aim to receive 50% return on the items purchased. * To change this public opinion/perception, we will implement an advertising campaign identifying the opportunities for the population and the district i.e. job creation and investment. We will also identify and reaffirm that it is the only and best option so that we can obtain public support for the hospital. Exhibition portfolio Issue no. 1 Use of consultants, lawyers and accountants We will utilise the expertise of the most qualified consultants, lawyers and accountants to secure the contract and provide us with the maximum profit. The cost of advisors in PFI schemes in the past has been between 2.8% and 8.7%. To secure the most advantageous deal for ourselves we estimate that the cost of these advisors will be in the region of à ¯Ã‚ ¿Ã‚ ½14.000.000 on the à ¯Ã‚ ¿Ã‚ ½164.000.000 contract. As a company we believe this expenditure is justified if we secure the contract. The consultancy cost figures are in the higher percentage range, around 8-9% so that we do not go under budget for this expenditure. As with previous PFI schemes there have been varying public opinions on the financing of their local hospitals under the PFI initiative. We could use these consultants to put to rest the public concerns. This will be discussed later in issue six. Pros and Cons for developing a new Hospital: Pros larger contract = more profits employ own staff (ancillary staff) = cheaper wages Cons Time needed to build and develop = long wait for return on investment Greenfield site No road or rail links = these would have to be constructed taking up valuable time Pros and Cons for the Refurbishment of a previous hospital: Pros Shorter development time Cons Less profit Limitations on employing own staff Poor transport links Poor emergency access as in built up area Issue no.2 Number and throughput of beds The population in the area is expected to significantly increase over the next 15 years. The area of growth that will be the largest will be that of the elderly population. If we were to aim to provide a bed for each elderly member of the public, our profit margins will decrease significantly to satisfy the increased demand. To accommodate for these future demands, we will aim to improve the throughput of beds as in other PFI financed hospitals, above the NHS average of 56-57 patients per year per bed. With these other PFI schemes, they have experienced a 20-40% bed loss when building a new hospital after the reconfiguration of services, an area in which we could investigate in order to save money and increase our profits. Based on two future PFI scheme hospitals, they will have a throughput of patients per bed of 88 and 100 per year. We will aim to have a throughput of 90 in line with these future hospitals. Pros and Cons for reducing the number of beds: PROs * Less cost * More profit CONs * Not able to cope with patients demand * Could affect success for the contract Issue no. 3 Quality of the buildings Alternatives to be considered When considering the quality of the buildings, there are several issues that need to be reviewed. First of all, we need to decide between (a) rebuilding and refurbishing the City General Infirmary (b) building a new hospital We also need to decide whether the hospital, existing or new, should be of (I) poor quality (II) average quality (III) high quality Evaluation of strengths and weaknesses Rebuilding and refurbishing the City General Infirmary: Strengths As the buildings already exist, the costs will be lower compared to building a new hospital. With less construction work needed, the chance of overdue work will be smaller resulting in less chance of being penalized. The lower costs of construction work means that the 20% profit expected by builders will be a lower amount. Weaknesses The existing buildings may cause limitations as to what can be done and likely problems with issues like size can be impossible to overcome. Building a new hospital: Strengths There are no limitations as to what can be done in terms of size, technology etc., enabling us to accommodate all the needs the NHS trust may have. Weaknesses A new hospital involves extensive construction work which will affect the cost. Because of the amount of work required, the risk of penalties due to overdue completion is high. Extensive construction work also means payment to builders will be a large figure. Poor Quality Strengths The costs will be low. Less work needs to be done. Less work means that there is a smaller chance of overdue construction work and penalties. As the cost for poor quality construction work will be low, so will the profits paid out to the builders. Weaknesses As lease agreements for PFI hospitals have a typical duration of 25 years, maintenance of the hospital will be the consortiums responsibility for a long period of time. Any savings we might make now for not investing in quality might become costly in future as shoddy construction work normally doesnt have high durability. Low quality buildings might put the health and safety of future employees, patients and visitors at risk. The chance of winning the contract may be smaller if we only offer a hospital of poor quality. Conclusion After evaluating the range of alternatives, we feel that we can best achieve our objectives by offering a new hospital with buildings of high quality. With a new hospital there are a minimum of limitations as to what can be done, and this will hopefully appeal to the NHS trust. This is of course the option that would satisfy the shareholders in our member companies as well as it will increase their return. Although going with a new hospital and the high quality option will be more costly then the other alternatives, we believe it will increase our chances of winning the contract, and future maintenance expenses will be kept to a minimum. Making a high quality hospital can also be good publicity for the consortium. Issue no. 4 Ancillary services The problem has been defined and recognised. This is concerned with the decision on whether to contract out ancillary services or to provide the service within the scheme. These are the two feasible alternatives. To complete the decision making process, the alternatives will be evaluated and the best alternative will be selected. The consortium has the opportunity to make a maximising choice. This is defined as the decision making the best choice of various alternatives. The decision making condition is that of Uncertainty. The decision maker is not able to predict the outcome of the decision, a range of possible outcomes may be identified and evaluated but there is in-sufficient information to derive outcome probabilities. The problem raises some financial issues. Contracting out the ancillary services is the most profitable course of action for the consortium. Using self-provided employees is less profitable because there pay and working conditions are protected by the TUPE (Transfer of Undertakings) rules. If external ancillary staff were employed, they wouldnt be protected by the TUPE so the consortium could cut costs by paying staff at a lower level. There is also the possibility of a hospital development rather than a refurbishment which would mean that TUPE would not apply to the staff. This would mean that the pay level could be reduced to cut costs and produce a larger level of annual profit. The financial decision raises some ethical issues also. Previous consortia have encountered problems when ancillary staff have been hired and are working with self-provided employees. The ancillary staff are paid at a lower rate then the self-provided staff because self-provided staff are protected by TUPE rules. There will be two sets of staff performing the same operations within the hospital but being paid at two different rates. This could lead to poor team-work between the two different sets of staff. This could lead to in-efficiency and poor performance of staff. Strikes could be encountered and this has been experienced by previous consortia. A strike could increase the workload of self-provided staff who may not be able to cope. The question has to be asked on whether it is ethically right and fair to set the level of pay to two different levels for the same job. The two main issues to contend with before a decision is made the financial and ethical factors. The advantages of hiring ancillary staff are that it is more profitable and are not protected by the TUPE rules so the conditions provided dont have to meet certain standards. However, the hiring of ancillary staff may disrupt the running of the hospital. Strikes could be encountered and the relationship between the ancillary staff and the self-provided staff would not be ideal leading to poor performance of staff. There is also the possibility of a development in contrast to a refurbishment which would mean that self-provided staff wouldnt be protected by TUPE rules. After evaluation of the possible alternatives, it has been decided that the best course of action is to provide staff ourselves. The hiring of ancillary staff would be too much of a disruption for the running of the hospital. With the possibility of a development, self-provided staff wouldnt be protected by TUPE rules. This would mean that self-provided staff would be just as profitable as hiring ancillary staff. Business Decision Analysis model: An analytical decision model can be used to help evaluate and interpret which decision will provide the best outcome. As decision makers, we are operating under the conditions of Uncertainty. The Stochastic model can be used because it incorporates the estimates of probability. A model can be created to help determine which decision will produce the best outcome. The problems encountered with a stochastic model are that it can be difficult to create estimates of the probabilities. The probabilities will be derived using the Subjective method. Under this method, the decision maker uses opinion, intuition, judgement and past experience. The probability tree below conveys the estimates associated with the alternatives concerned with the financial possibilities; ANCILLARY (1High profit) REFURBISHMENT CONSORTIUM SELF PROVIDED (2Lower profit) DEVELOPMENT ANCILLARY (3High profit) SELF PROVIDED (4High profit) Outcome number Probability 1 (0.6 x 0.5) = 30% 2 (0.6 x 0.5) = 30% 3 (0.4 x 0.5) = 20% 4 (0.4 x 0.5) = 20% The decision tree above shows four possible outcomes from the alternatives. The two types of outcome is high and low profit. There is a higher chance of refurbishment rather than development because that is the original proposition. But the development does have its advantages to the government so this should have a reasonable amount of probability associated with it. From these two original options, the consortium can contract out staff or self-provide staff. There is a 50% chance of the consortium choosing each option. These two options will produce a financial outcome. The table above shows these financial outcomes and the probability associated with them. The table shows that choosing ancillary services provides a 50% of profit. This is a 30% probability from the refurbishment and a 20% probability from the development. The development also provides an extra 20% probability of profit from the development because there is no TUPE protection for self-provided staff. This shows that there is a 70% chance of profit from the alternative of choosing ancillary staff, which is the reason why this alternative has been chosen. However, it has been taken into account that these probabilities are estimates and there is room for marginal error. Issue no. 5 Charges for parking and television There are a number of options that could be considered so as maximise shareholder profits, many already employed in other PFI hospitals. We could introduce charges for parking; this could be an area which could provide our shareholders with a large increase in profits. Clamping could also be considered with the release fee waived if we believed it was under exceptional circumstances. Charging for televisions, radio usage and the use of bedside phones should be considered to further increase profits. Vending machines around the hospital could also be used for profit maximisation. We could aim to receive 50% return on the items purchased. Issue no. 6 Opposition to PFI financed hospital Within the local population, there is an 81% objection rate to a PFI financed hospital. They will however accept this proposal when they realise it is the only real option for development of their health services. To change this public opinion/perception, we could implement an advertising campaign identifying the opportunities for the population and the district i.e. job creation and investment. We could also identify and reaffirm that it is the only and best option so that we can obtain public support for the hospital. We could use the services of the consultants/advisors to either carry out this advertising campaign or advise the company how we should do it and get another company in to do it. The second option would cost more money and would reduce our profits. Refinancing We intend to refinance the deal as soon as the risky phase of the construction is complete. We are doing so in order to increase the return on profits for our shareholders. Theoretical decisions During the decision making process we aimed to use the rational model of decision-making. This process had the potential to be successful because: * Goals were known the goal or aim is to win the contract to build and run a new hospital under the PFI Initiative * Information/resources were available through the Department of Health website and other available information it was possible to research previous PFI schemes and what they offer * Prediction is feasible the outcome of the decision will hopefully mean that we will win the contract and this is a feasible prediction as we have as much chance as any other group to win the contract The Rational Model: 1 Identify and design the problem 2 Gather and sort the information 3 Generate the broadest possible range of alternatives 4 Evaluate the strengths and weaknesses of alternatives 5 Select the optimal alternative 6 Implement and monitor the effectiveness The Rational Model applied to our decision-making: 1 Create and submit a promising tender for contract to build and run a Hospital under the PFI Scheme by exceeding present expectations of similar schemes in order to win the contract. 2 Researched previous PFI schemes in order to improve the performance and meet expectations 3 Choose whether the best option would be to build a new hospital or refurbish a previous hospital 4 Identify the six issues in terms of which decision to take pros and cons of each alternative 5 To build a new Hospital in order to increase the chances of providing a better service, whilst benefiting the community, the NHS and our needs, in order to win the contract 6 Submit the tender for contract and wait to see if the contract has been won by ourselves The constraints of the decision making process meant that as a group we may have satisficed rather than maximised due to constraints such as limited availability of resources and time limitations (deadline needing to be met). After attempting to take the Rational approach it can be seen that the decision making process ended up being Bounded Rational as we ended up satisficing the end result. Despite attempting to be rational during the decision making process the actual processes was much more chaotic and Cohen et als (1972) Garbage Can Model is more appropriate to the way in which our decisions were made. The Garbage Can Model: Cohen et al identify that there are 4 independent processes affecting decision-making. These four processes all coincide with each other randomly until the decision is made. Our decision-making was chaotic but eventually as the 4 processes merged the decision was made. * Problems create a proposal that appeals to the local community and the requirements of the NHS to win the contract. * Solutions win the contract * Participants we are a group of business men and women leading a consortium of companies * Choice Opportunities To build a new hospital or refurbish the existing hospital. Factors affecting the decision-making Process: Risk and Uncertainty * Risk the contract will be won by another group choices have to be made about the hospital i.e. new or refurbishment in order to attract the interest and win the contract. * Uncertainty the results of the decision are uncertain as we do not know what the competitors proposals contain. Ethics: When building something as important a hospital the needs of the patients are top priority and the requirements of the staff to provide a safe and workable environment. Societal ethics, professional ethics and individual ethics are important factors in the decision-making process. During the decision-making process the group was not affected by Groupthink or risky-shift. Bibliography Whittaker. L, BDA Lecture notes. www.dh.gov.uk

Pain Sensation: Nociceptive receptors and transduction

Pain Sensation: Nociceptive receptors and transduction Pain is a subsystem of somatic sensation which includes a wide range of unpleasant sensory and emotional experiences usually associated with actual or potential tissue damage (Das et al., 2005). Over the years, by means of the evolutive process of natural selection, nature has made sure that pain is a bodily signal we cannot ignore. As a matter of fact, sensitivity and reactivity to noxious stimuli are essential to the well-being and survival of an organism. In dangerous circumstances pain tells the subject to get out of that situation immediatly, this is its main function. Without these attributes provided by pain mechanisms, the organism would have no means to prevent or minimize dangerous circumstances (individuals congenitally insensitive to pain are easily injured and most of them die at an early age1). While most of the sensory and somatosensory modalities are primarily informative, pain is a protective modality. Pain perception (also called nociception) doesnt come from excessive stimulation of the same receptors that generate somatic sensations, as someone could even think, it is a properly devoted subsystem. Nociception (from the Latin nocere, to hurt) in fact depends on specifically dedicated receptors and, due to its vital importance, this kind of information travels through redundant pathways. Pain also differs from the classical senses (hearing, smell, taste, touch, and vision) because it is both a discriminative sensation and a graded emotional experience. In the big picture, pain appears as a more complex whole experience than simple somatic sensation; that is why there are still many obscure aspects not completely understood, especially in the field of pain physiology and pharmacology. For this and other reasons, even nowadays, nociception remains an extremely active area of scientific research. 2. Pain Sensation Nociceptive receptors and transduction Pain sensation begins with relatively unspecialized free nerve cell endings called nociceptors. Like other somatic sensory receptors, they transduce a variety of noxious stimuli into receptor potentials, which in turn trigger action potentials in the pain nerve fibers (afferents). These action potentials are transmitted to the spinal cord and then, through the brainstem, to the thalamus and the somatic sensory cortex according to specific pathways2. Nociceptors are widespread distributed, they also show different degrees of sensitiveness and specialization. There are nociceptors in the skin, in the joints and also in visceral organs, but none of them is found inside the central nervous system (CNS)1. In contrast with somatic sensory receptors (responsible for the perception of innocuous mechanical stimuli), the axons associated with nociceptors conduct relatively slowly, being only lightly myelinated or, more commonly, unmyelinated2. Thus, according to the different kind of axon, there are faster or slower pain pathways. In particular, pain receptors can fall into four major categories depending on their response to the different types of stimulation caused by the damage: mechanosensitive nociceptors: respond to mechanical stimulation and have A-delta fibers, bigger axons with faster conduction velocity; mechanothermal nociceptors: respond to thermal stimuli, A-delta fibers; chemical nociceptors: respond to chemical substances, A-delta fibers; polymodal nociceptors: respond to high intensity stimuli of the previous three types and have C fibers, smaller and unmyelinated axons with slower conduction velocity. The cell bodies of these primary pain-neurons are located in the dorsal root ganglia (for body afferents) and in the trigeminal ganglia (for face afferents)1,2. The transduction of nociceptive signals, which starts with the nociceptive receptors, is a complex task. Tissue damage results in the release of a variety of chemical substances which triggers the response of nociceptors. Some of these substances activate the transmembrane transient receptor potential (TRP) channels, which in turn initiate action potentials2. Another characteristic feature of nociceptors is their tendency to be sensitized by prolonged stimulation, making them respond to other sensations as well in certain circumstances. This prolonged stimulation increases the release of chemical substances, making nociceptors sensitized and reducing their response threshold. Actually, within a few seconds after the injury, an area of some centimeters around the injured site shows reddening caused by vasodilation. This inflammation becomes maximal after about ten minutes and this region shows a lowered pain threshold (hyperalgesia) in response to additional noxious stimuli. This effect is also referred to as peripheral sensitization, in contrast to central sensitization that can occur at higher levels in the dorsal horn1. Although it is still unknown whether nociceptors respond directly to the noxious stimulus or indirectly by means of one or more endogenous chemical intermediaries released from the traumatized tissue, the activation of nociceptors initiates the process by which pain is experienced: these receptors relay information to the CNS about the intensity and location of the painful stimulus. Pain classification The result of sudden painful stimulation can be divided into two categories of sequential sensations separated by a short time interval. A sharp first pain, immediately after the damage, its followed some seconds later by additional, diffuse and longer-lasting second pain sensation. The temporal interval between these two separate sensations is due to the difference between fast transmitting A-delta fibers and slow transmitting C fibers. This phenomenon is also known as double pain sensation. Pain has also been classified into three major types1: Pricking pain: is also called fast pain or sensory pain (first pain) and arises mainly from the skin, carried by A-delta fibers which permit discrimination and localization of the pain. Burning pain: is caused by inflammation, burned skin and is carried by C fibers. This type of pain is a more diffuse, slower to onset, and longer in duration (second pain). Like pricking pain, burning pain arises mainly from the skin, but it is not distinctly localized. Aching pain: is a sore pain which arises mainly from the viscera and somatic deep structures. This pain is carried by the C fibers from the deep structures to the spinal cord and is not distinctly localized. Pain pathways The neural pathway that conveys pain (and temperature) information from the periphery of the body to the higher centers of the CNS is often referred as the anterolateral system (or ventrolateral column). This pathway is physically separated from the system that conveys mechanosensory information like touch and pressure (dorsal column-medial lemniscus pathway). However, even though the dorsal route has been always considered a touch pathway functionally separate from the anterolateral pathway, recent reports indicate that the dorsal column can carry noxious information from the viscera and widespread skin regions as well1. Anyway, the main difference between these two systems remains the site of decussation: while the dorsal column is an ipsilateral tract until the medulla (where synapses and decussates), the anterolateral system makes early synaptic connections and decussates right away in the spinal cord, becoming a contralateral tract. Composing the anterolateral system, there are three major ascending tracts: the neospinothalamic tract (the main, central pain pathway, phylogenetically younger, with few synapses), the paleospinothalamic tract and the archispinothalamic tract (which constitute minor parallel pain pathways, phylogenetically older and multisynaptic tracts)1. Every pain tract is made of three kinds of pseudounipolar neurons: first-order, from free nerve endings (nociceptors) to the dorsal horns of the spinal cord; second-order, from the dorsal horns to the thalamus; and third-order, from the thalamus to the primary somatic sensory cortex. The cell bodies of first-order neurons are located in the dorsal root ganglia (DRG) for all three pathways. a) The neospinothalamic tract (central pathway) constitutes the classical anterolateral system. This pathway is responsible for the immediate awareness of a painful sensation and for the understanding of the exact location of the painful stimulus. The first-order nociceptive afferents enter the spinal cord via the dorsal roots of the DRG and, when these projecting axons reach the dorsal horns of the spinal cord, they branch into ascending and descending collaterals, forming the tract of Lissauer2. Once within the dorsal horn, these afferents make synaptic connections with second-order neurons located in Rexeds laminae (layer I to V). Axons of these second-order neurons then cross the midline of the spinal cord, decussating in the anterior white commissure, and ascend to the brainstem in the contralateral (anterolateral) quadrant. Most of the pain fibers from lower extremities of the body and below the neck terminate, through the brainstem, in the ventral posterior lateral nucleus (VPL) of the thalamus. The VPL, which serves as a relay station, is thought to be mainly concerned with discriminatory functions1. Finally, here axons of second-order neurons synapse with third-order neurons that send the signal to the primary and secondary somatosensory cortex (SCI and SCII, respectively). Unlike the rest of bodily afferents, first-order nociceptive neurons from the head, face and intraoral structures have somata in the trigeminal ganglion. Trigeminal fibers enter the pons, descend to the medulla (forming the spinal trigeminal tract) and make synaptic connections in the spinal trigeminal nucleus, then cross the midline and ascend as trigeminothalamic tract (or trigeminal lemniscus). Axons from the second-order neurons terminate in a variety of targets in the brainstem and thalamus, but the discriminative aspects of facial pain are thought to be mediated by projections to the ventral posterior medial nucleus (VPM) of the thalamus and by projections (from here) to primary and secondary somatosensory cortex2. All of the fibers terminating in VPL and VPM are somatotopically oriented and still here the information supplied by different somatosensory receptors remains segregated. Axons from the thalamus synapse with third-order neurons of the SCI, which includes Brodmanns Areas 3a, 3b, 1 and 2. Each of these cortical areas contains a separate and complete representation of the body: they are somatotopically organized maps representing the human body (from the foot up to the face) in a medial to lateral arrangement2. b) The paleospinothalamic tract is a parallel pathway where the emotional response to pain is mediated1. This tract also activates brainstem nuclei which are the origin of descending pain-suppression pathways which regulate the sesation of noxious inputs at the spinal cord level. In the paleospinothalamic tract the majority of the first-order nociceptive neurons make synaptic connections with second-order neurons in Rexeds layer II (substantia gelatinosa). These second-order neurons also receive input from mechanoreceptors and thermoreceptors, and thats why the anterolateral system is also responsible for temperature perception1. The nerve cells that compose the paleospinothalamic tract are multireceptive or wide dynamic range nociceptors. Most of their axons cross and ascend in the spinal cord primarily in the anterior region and thus form the anterior spinal thalamic tract (AST). These second-order fibers contain several tracts and each of them makes a synaptic connection in different locations: in the mesencephalic reticular formation (MFR) and in the periaqueductal gray (PAG), forming the spinoreticular tract; in the tectum, also known as the spinotectal or spinomedullary tract; in the midline thalamic nuclei, forming the spinothalamic tract. Altogether these three fiber tracts are thus known as the paleospinothalamic tract, which is in part bilateral, because some of the ascending fibers do not cross to the opposite side of the cord1. Finally, from the thalamic nuclei, these fibers synapse bilaterally in the somatosensory cortex. Pain is a complex experience processed by a diverse and distributed network of neurons and brain regions. In addition to the sensory-discriminative aspects (carried by the neospinothalamic tract) there are also affective-motivational components of pain2. In the paleospinothalamic pathway there are extensive connections between the thalamic nuclei and the limbic areas such as the cingulate gyrus and the insular cortex. The insular cortex integrates the sensory input with the cognitive components. The limbic structures (amygdala, superior colliculus) project to the hypothalamus and initiate visceral responses to the pain. The thalamic nuclei also projects to the frontal cortex, which in turn is linked to the limbic structures involved in processing the emotional components of pain1. c) The archispinothalamic tract is another parallel pathway, phylogenetically the oldest that carries noxious information1. The characteristics of this tract are very similar to the ones found in the previous pathway. First-order nociceptive neurons make synaptic connections in Rexeds layer II (substantia gelatinosa). From here, second-order fibers ascend and descend in the spinal cord surrounding the grey matter to end synapsing with cells in the reticular formation and in the periaqueductal gray. Further diffuse multisynaptic pathways ascend to the diverse nuclei of thalamus and send collaterals to the hypothalamus as well as the limbic system nuclei. These fibers, like for the paleospinothalamic tract, mediate visceral, emotional and autonomic reactions to painful stimuli. In short, because of the importance of warning signals of dangerous circumstances, several nociception pathways are involved to transmitting these signals and some of them are redundant. The neospinothalamic tract conducts fast pain (via A-delta fibers) and provides information of the exact location of the noxious stimulus. The multisynaptic paleospinothalamic and archispinothalamic tracts conduct slow pain (via C fibers), a pain which is chronic and harder to localize. Through these patways, pain activates many different brain areas which link together sensation, perception, emotion, memory and motor reaction1. 3. Pain Modulation When talking about pain, we always have to consider and keep in mind the discrepancy between the objective reality of a painful stimulus and the subjective rsponse to it. Modern studies have provided considerable insight into how circumsatnces affect pain perception-interpretation and, ultimately, into the pharmacology of the pain system2. For many years it has been suggested that somewhere in the CNS there should be some neuronal circuits modulating incoming painful informations. Evidence for an intrinsic analgesia system was demonstrated by intracranial electrical stimulation of certain brain sites1,3. The circuit consisting of the periaqueductal gray matter (PAG), the raphe nuclei (RN), the locus coeruleus (LC) and the caudate nucleus (CN) contributes to the descending pain suppression mechanism, which inhibits incoming pain information at the spinal cord level6. Stimulation of such areas produce analgesia without behavioral suppression; indeed, touch, pressure and temperature sensation remain intact1. At the interneuronal level, opiate receptors activation causes hyperpolarization of the neurons, which in turn results in the inhibition of firing and in the release of substance P (a neurotransmitter involved in pain transmission) that blocks pain transmission1. In addition to descending projections, also local interactions between mechanoreceptive afferents and neural circuits within the dorsal horn can modulate the transmission of nociceptive informations to higher centers2. Observations by Melzack and Wall led to the idea that concomitant activation of the large myelinated fibers associated with low-threshold mechanoreceptors can mediate the flow of pain. This mechanism, also known as Gate Control Theory13, predicts that (at the spinal cord level) non-noxious stimulation will produce presynaptic inhibition on dorsal root nociceptor fibers and thus blocking incoming noxious information from reaching the CNS1 (i.e. non-painful input closes the gates to other painful inputs, which results in prevention and suppression of pain sensation). This explains also why if you, for example, stub a toe, a natural and effective reaction is to vigorously rub the site of injury for a couple of minutes2. However, there are many different factors that can influence the way we understand pain. Doubtless, three of these are: drugs, prior injuries and, more broadly speaking, circumstances. a) Drugs The brain has a neuronal circuit and endogenous substances to modulate pain. There are two primary types of drugs that work on the brain: analgesics and anesthetics1. The term analgesic refers to a drug that relieves pain without loss of consciousness, whereas the term anesthetic refers to a drug that depresses the CNS. Anesthetics are characterized by the absence of perception for all sensory modalities, including loss of consciousness, but without loss of vital functions. The areas that produce analgesia when stimulated are also responsive to exogenously administered opiate drugs2. As a matter of fact, the most effective clinically used drugs for producing temporary relief from pain are the opioid family, which includes morphine and heroin1. Unluckily, several side effects resulting from opiate use include tolerance and drug dependence (addiction). In general, these drugs modulate the incoming pain information as well as relieve pain temporarily, and are also known as opiate producing analgesia (OA). Opioidergic neurotransmission is found throughout the brain and spinal cord and appears to influence many CNS functions: opioids exert marked effects on mood, cognition and motivation1 (e.g. producing euphoria). The analgesic action of opiates implied the existence of specific brain and spinal cord receptors for these drugs long before the receptors were actually found. Since such receptors are unlikely to have evolved in response to the exogenous administration of opium and its derivates, the convinction grew that endogenous opiate-like compounds must exist in order to explain the evolution of these receptors in the body2. Nowadays, three classes of opioid receptors have been identified: ÃŽÂ ¼ (mu), ÃŽÂ ´ (delta) and ÃŽÂ º (kappa). All three classes are widely distributed in the brain, and particularly in the PAG, which is the site for higher cortical control of pain modulation in humans8. Moreover, three major classes of endogenous opioid peptides that interact with them have been recognized in the CNS: ÃŽÂ ²-endorphins, enkephalins and the dynorphins. Enkephalins are considered the putative ligands for the ÃŽÂ ´ receptors, ÃŽÂ ² endorphins for the ÃŽÂ ¼-receptors, and dynorphins for the ÃŽÂ º receptors1. The opioid peptides modulate nociceptive input mainly in two ways: blocking neurotransmitter release by inhibiting Ca2+ influx into the presynaptic terminal; or opening potassium channels, which hyperpolarizes neurons and inhibits spike activity. The various types of opioid receptors are distributed differently within the central and peripheral nervous system and this can explain many unwanted side effects following opiate treatments1. (For example, ÃŽÂ ¼-receptors are widespread in the brain stem parabrachial nuclei, which is a respiratory center. Inhibition of these neurons elicits also respiratory depression). In addition to opiates, the other big family of analgesia producing drugs is represented by the cannabinoids. Like opiates, cannabinoids produce analgesia when microinjected in the PAG and pain itself serves as a trigger for endocannabinoid release3. Results from the study by Walker et al. (1999) indicate that anandamide (an endogenous cannabinoid) fulfills the requirements for a nonopiate mediator of endogenous pain suppression and these data support the existence of endogenous cannabinergic circuitry in the dorsal and lateral PAG. Even if the opiate and cannabinoid mechanisms partially overlap anatomically, the endogenous opiate system is activaetd by intense and prolonged stimuli (such as high threshold electrical stimulation), while endogenous cannabinoids occur mostly in tonic pain suppression, during tests that do not produce significant stress or fear3. Cannabinoids have been used to treat pain for centuries and cannabis is still used despite its illegal status in most parts of the world. The spontaneous and stimulated release of anandamide in a pain-suppression circuit suggests that such drugs may form the basis of a modern pharmacotherapy for pain, particularly in instances where opiates are ineffective3. b) Previous injury A curious effect, well known and documented in clinical literature, is referred to as phantom limb sensation. Following the amputation of an extremity, nearly all patients have an illusion that the missing limb is still present. Although this illusion usually diminishes over time, it persists in some degree throughout the amputees life, and can often be reactivated2. A reasonable explanation for this phenomenon is that the central sensory processing apparatus continues to operate indipendently of the periphery, giving rise to these bizarre sensations. Indeed, considerable functional reorganization of the somatotopic maps in the primary somatosensory cortex occurs immediately after the amputation and tends to evolve for several years2. Neurons that have lost their original inputs respond to tactile stimulation of other (near) body parts, and so it is not unusual for the patient to perceive a phantom limb as a whole and intact, but displaced from the real location. These and further ev idences suggested then that a full representation of the body exists indipendently of the peripheral elements that are mapped2. Anyways, the major problem following phantom limbs phenomena is constituted by the fact that up to 85% of the amputated patients develop also phantom pain4. The description of this common unease can vary from a tingling or burning sensation to some more serious and debilitating issues. Phantom pain, in fact, is one of the more frequent causes of chronic pain syndromes and is extraordinarily difficult to treat2. Neverthless there is no really effective treatment, a study by Jahangiri et al. (1994) demonstrated that preoperative epidural infusion of morphine, bupivacaine and clonidine significantly reduces the incidence of phantom limb pain and phantom limb sensation. Moreover, this kind of treatment has been shown as safe for use on general surgical wards with a low incidence of minor side-effetcs4. Other than amputations, pain perception may also be modulated in certain stressful situations. Exposure to a variety of painful or stressful events produces an analgesic reaction, and this phenomenon is called stress induced analgesia (SIA). It has been considered that SIA can provide insights into both the psychological and physiological factors that activate endogenous pain control and opiate systems1. (For example, soldiers wounded in battle or athletes injured in sports events sometimes report that they do not feel pain during the battle or game; however, they will experience the pain later after the battle or as game has ended). Some studies demonstrated in animals that electrical shocks cause stress-induced analgesia3 and it has been suggested that endogenous drugs, (opiates or cannabinoids) released in response to stress, inhibit pain by activating the midbrain descending system1. Based on these and other experiments, it is assumed that the stress experienced by the soldiers and the athletes suppressed the pain which they would later perceive. c) Circumstances The experience of pain is highly variable between individuals: this highly subjective perception has a complex and often non linear relationship between nociceptive input and pain sensation5. From human experimentation we know that a variety of pain modulatory mechanisms exist in the nervous system, and these systems can be accessed either pharmacologically or through contextual and cognitive manipulation7,6. Various mental processes such as attention, emotional state, past experiences, memories, beliefs and feelings have been shown to influence pain perception and bias nociceptive processing in the humain brain9. All these top-down factors can be grouped together in the category of circumstances that either enhance or diminish pain sensation in regard to dedicated modulatory circuits. Among the cognitive variables influencing pain, the brain mechanisms underlying attentional control have been probably the most extensively studied5. A number of reports show the important role of attentional state in modulating the activity of primary somatosensory areas7. Thus, pain is perceived as less intense when individuals are distracted from it, as proved in an interesting study by Das et colleagues (2005). This research provides strong evidence supporting virtual reality (VR) based games in providing analgesia and positive influence on children with acute burn injuries, with minimal side effects10. VR can be considered an intermediary between reality and computer technology, and its ability to immerse the user interacting with the artificial environment is central in this kind of approach. However, attentional processes interact with mechanisms supporting the formation of expectations about pain and reappraisal of the experience5. The ability to predict the likelihood of an aversive event is an important adaptive capacity11. Our subjective sensory experiences are thought to be heavily shaped by interactions between expectations and incoming sensory information12 and this cognitive factor is important also for pain perception: positive expectations (i.e., expectations for decreased pain) produce a reduction in perceived pain that rivals the effects of a clearly analgesic dose of morphine12. These evidences provide also a neural mechanism that can, in part, explain the positive impact of optimism in chronic disease states. In fact, perceived control, attentional control and the descending pain modulatory system are involved in the placebo-induced analgesia, which is a clinical example of cognitive pain modulation that decreases pain intensity and cerebral responses to pa in5. Such top-down modulatory mechanism is a robust and clinically important phenomenon, which can be demonstrated in approximately one-third of the population9. Moreover, placebo analgesia requires the activation of endogenous opioid-mediated inhibition and neuroimaging techniques showed that there is also overlapping among brain sites activated by opioids and those that are activated during placebo analgesia9. Also the emotional state driven by the (experimental) context alters the attitude of patients and can produce powerful effects on pain perception7. In general, negative emotions increase pain, whereas positive ones decrease it14,7. Neverthless the brain mechanisms underlying these effects remain largely unknown, the prefrontal cortex, as well as parahippocampal and brainstem structures, are thought to be involved in the emotional regulation of pain14. According to Roy et al. (2009) cognitive and emotional processes induced by pleasant or unpleasant pictures interact with pain perception and modulate the responses to painful electrical stimulations in the right insula, paracentral lobule, parahippocampal gyrus, thalamus, and amygdala14. Not only, recent studies suggested that emotionally laden images representing human pain had a unique capacity to enhance pain reports15, in the suggestive perspective that search for the neural bases of human empathy with huge social implications. Thus, even though is well-established that mood selectively alters the affective-reactive response to pain (also called pain tolerance), the interpretation for some of these studies is sometimes difficult, since they do not always clearly dissociate changes in mood from changes in attention7. In fact, other studies showed that emotions can have a direct effect on attention to pain, leading to what is called attentional bias toward pain-related informations, which does not ensure the absence of covariate processes7. In the end, the available data indicate that emotion and selective attention may both interact modulating pain perception and cortical responses. But the observations that emotional manipulations alter pain unpleasantness more than pain sensation, while attention alters both pain sensation and unpleasantness, suggest that different modulatory circuits are involved7 and that they act through at least partially distinct mechanisms, which can be separated by appropriate experimental settings15. All this multiplicity of mechanisms underlying the emotional modulation of pain is reflective of the strong and reciprocal interrelations between pain and emotions, and emphasizes even more the powerful effects that emotions can have on pain perception14. 4. Conclusions In conclusion, in the CNS, much of the information from the nociceptive afferent fibers results from excitatory discharges of multireceptive neurons. The pain information in the CNS is controlled by ascending and descending inhibitory systems that can exert both facilitatory and inhibitory effects on the activity of neurons using endogenous opioids or other substances as mediators. In addition, a powerful inhibition of pain-related information occurs in the spinal cord. These inhibitory systems can be activated by brain stimulation, intracerebral microinjection of morphine, and peripheral nerve stimulation1. However, pain is an extremely complex perceptual and cognitive experience that is influenced also by many top down factors such as past sensations, expectations, the context within which the noxious stimulus occurs, the attentional and emotional state. Therefore, for all these reasons, the response to pain can often vary considerably from subject to subject. Case Report: Use of Valproate in Kleine Levin Syndrome Case Report: Use of Valproate in Kleine Levin Syndrome Successful use of Valproate in Kleine Levin Syndrome: a case report and review of cases reported from India Abstract Kleine-Levin Syndrome (KLS) is characterized by recurrent episodes of hypersomnia and other symptoms and it is a really challenging for the physician, since its causes are not yet clear, and available treatment options are not having adequate support. Here we are reporting a case with successful use of Valproate in KLS and also reviewing the cases reported from India. Introduction Kleine-Levin Syndrome (KLS) is a rare disorder which mainly affects adolescent boys and characterized by recurrent episodes of hypersomnia, and sometime along with hyperphagia, behavioral and cognitive disturbances, and hypersexuality (Yao et al., 2013). Several medications (stimulants, lithium, valproate, antipsychotics, antidepressants) have been reported to provide variable benefit in different symptoms, with lithium being the most widely used drug (Arnulf et al., 2005 2012). We are presenting a case of KLS, who had complete remission with valproate and also reviewing the cases reported from India. Case details: A 17 year old single male student of 12th standard, presented to our psychiatric outpatient clinic in September 2004 with hypersomnolence, low mood, decreased appetite and interest in studies, social and sexual disinhibition (such as singing obscene songs loudly at home, and touching unconsenting females’ including mother’s body parts- limbs, face and genitalia). Onset was acute, without any elicitable precipitating factor and course was episodic with average 7-10 days episode in every month for last four months and he maintained completely well in interepisodic period. Provisional diagnosis of recurrent depressive disorder (brief episodes) was kept and he was started on Sertraline (50 mg), on which he responded well. He remained asymptomatic for nearly nine months, but started having similar episodes again from mid 2005, due to which Sertraline was gradually hiked up to 150 mg/day, but of no use. Hence he was admitted in our inpatient setting in March, 2006 for diagnostic evaluation and further management. After detailed evaluation, it was found that his sadness was not pervasive and depressive cognitions and associated disturbances were not present and hypersomnia remained predominant complaint as initially he was sleeping 16-20 hours per day. He was also not responding with these medications, hence differential diagnosis of KLS vs. depression was kept and later finalized to KLS. His heamogram, renal functions, liver functions, blood sugar, routine urine, thyroid functions were within normal limits and chest X ray, ECG, EEG, and MRI brain were nor mal. In view of good literature support Lithium was started from 600 mg/day and hiked to 900 mg/day (serum level 0.8 mEq/liter). On which he has shown significant improvement initially for six month but later again started experiencing similar symptoms. He also had three episodes of fall, unresponsiveness and epileptiform discharge in EEG twice. Hence in view of seizure disorder and lack of response, Neurologist’s consultation was sought, who opined to start antiepileptic medication. Hence lithium was switched to Valproate (750 mg/day) in December 2006, on which he maintained completely well for 4 years, except brief reemergence of symptoms on discontinuing Valproate, which improved completely on resuming the medication. Valproate was gradually tapered and stopped in January 2011 on insistence of patient and family with discussing its pros and cons. Now index case has been maintaining well off Valproate for last three years without any episode of hypersomnolence, sexual disin hibition, sadness, or epileptic seizure. Discussion Based on historical reports by Kliene and Levin, KLS was essentially described and termed by Critchley (1962). Thereafter many researchers have reported their cases and reviewed cases with KLS (Arnulf et al., 2005 2012). Here we are reporting a case with KLS, who responded well with Valproate, after diagnostic dilemma and different psychotropic medications and also reviewing the other cases reported from India. In our electronic search for Indian studies on Kliene-levin syndrome, by using PUBMED and Google Scholar, we could find 15 cases reported from India (Aggarwal et al., 2011; Mendhekar et al., 2001; Prabhakaran et al., 1970; Shukla et al., 1982; Sagar et al., 1990; Narayanan et al., 1972; Agrawal Agrawal, 1979; Malhotra et al., 1997; Gupta et al., 2011). Of them 13 were males and 2 females, similar to male preponderance reported in the literature (Arnulf et al., 2005 2012). While presenting to psychiatric services their age was between 9 to 26 years and they had onset between 7 to 24 years of age. In two-third of patients (10 out of 15 patients) it was preceded with fever and their episodes of somnolence were lasted from 3 days to 10 weeks. Hypersomnia and hyperphagia were present in all, while two-third of patients also had social and sexual disinhibition (11 out of 15 patients). Other symptoms were cognitive disturbances (low intelligence quotient, impaired memory, confusion, and a cademic decline), irrelevant talk, and perceptual disturbances. Nearly one-third of patients improved spontaneously without any medication, while rest was given lithium, carbamazepine, methyl amphetamine, dextro amphetamine, and modafinil. Longest asymptomatic follow-up period is reported for 2 years (Aggarwal et al., 2011) (as depicted in table-1). Though literature supported lithium for higher response rate (Arnulf et al., 2005 2012), but index patient had remarkable response with Valproate, not with lithium, like earlier two reports (Crumley, 1997; Adlakha Chokroverty, 2009). Like earlier report (Adlakha Chokroverty, 2009), index patient also improved on lower dose of Valproate (divalproate 750 mg vs. 500 mg Valproate). Compared to other cases reported from India (Aggarwal et al., 2011; Gupta et al., 2011), index patient had longest follow-up (7 years) and remained asymptomatic in this period, except small exacerbation on discontinuation of Valproate treatment, which improved completely on resuming the drug. Similar to our patient, anticonvulsants (like Valproate) are the preferred treatment for KLS patient, and may also offer benefits in case of comorbid epilepsy (Yao et al., 2013). Valproate may be a good alternative to lithium in terms of efficacy as well as side effect profile. References Yao, C.C., Lin, Y., Liu, H.C., Lee, C.S., 2013. Effects of various drug therapies on Kleine–Levin syndrome: a case report. Gen Hosp Psychiatry. 35, 102.e7-102.e9. Arnulf, I., Zeitzer, J.M., File, J., Farber, N., Mignot, E., 2005. Kleine-Levin syndrome: a systematic review of 186 cases in the literature. Brain. 128, 2763-76. Arnulf, I., Rico, T.J., Mignot, E., 2012. Diagnosis, disease course, and management of patients with Kleine-Levin syndrome. Lancet Neurol. 11, 918-28. Critchley, M., 1962. Periodic hypersomnia and megaphagia in adolescent males. Brain. 85, 627–56. Aggarwal, A., Garg, A., Jiloha, R.C., 2011. Kleine-Levine syndrome in an adolescent female and response to modafinil. Ann Indian Acad Neurol. 14, 50-2. Mendhekar, D.N., Jiloha, R.C., Gupta, D., 2001. Kleine-levin syndrome : a report of two cases. Ind J Psychiatry. 43, 276-8. Prabhakaran, N., Murthy, G.K., Mallya, U.L., 1970. A Case of Kleine-Levin Syndrome in India. Br J Psychiatry. 117, 517-519. Shukla, G.D., Bajpai, H.S., Mishra, D.N., 1982. Kleine-levin syndrome: a case report from India. Br J Psychiatry. 141, 97-98. Sagar, R.S., Khandelwal, S.K., Gupta, S., 1990. Interepisodic morbidity in Kleine-Levin syndrome. Br J Psychiatry. 157, 139-141. Narayanan, H.S., Narayanan Reddy, G.N., Rama Rao, B.S., 1972. A case of Kleine-levine syndrome. Ind J Psychiatry. 14, 356-358. Agrawal, A.K., Agrawal, A.K., 1979. Kleine-levin syndrome: a case report. Ind J Psychiatry. 21, 286-287. Malhotra, S.M., Das, M.K., Gupta, N., Muralidharan, R, 1997. A Clinical Study of Kleine-levin syndrome evidence for hypothalamic-pituitary axis dysfunction. Biol Psychaitry. 42, 299-301. Gupta, R., Lahan, V., Srivastava, M., 2011. Kleine-Levin syndrome and idiopathic hypersomnia: Spectrum disorders. Ind J Psychol Med. 33, 194-8. Crumley, F.E., 1997. Valproic acid for Kleine-Levin syndrome. J Am Acad Child Adolesc Psychiatry. 36, 868-9. Adlakha, A., Chokroverty, S., 2009. An adult onset patient with Kleine-Levin syndrome responding to valproate. Sleep Med. 10, 391-3. Table-1: Reported cases with Kleine Levin syndrome from India