Life of Quaid E Azam

ACCF/AHA Pocket Guideline Adapted from the 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy November 2011 Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons  © 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc.The following material was adapted from the 2011 ACCF/AHA Guidelines for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (J Am Coll Cardiol 2011;XX:XX–XX). This pocket guideline is available on the World Wide Web sites of the American College of Cardiology (www. cardiosource. org) and the American Heart Association (my. americanheart. org). For copies of this document, please contact Elsevier Inc. Reprint Department, e-mail: [ema il  protected] com; phone: 212-633-3813; fax: 212-633-3820.Permissions: Multiple copies, modification, alteration, enhancement, and/ ordistribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at [email  protected] com. Contents 1. Introduction †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 2. Clinical Definition †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦ 6 3. Genetic Testing Strategies/Family Screening †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 4. Genotype-Positive/Phenotype-Negative Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 5. Echocardiography †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 10 6. Stress Testing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 14 7. Cardiac Magnetic Resonance †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 15 8. Detection of Concomitant Coronary Disease †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 9. Asymptomatic Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 19 10.Pharmacologic Management†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 21 11. Invasive Therapies †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 26 12. Pacing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 29 13. Sudden Cardiac Death Risk Stratification †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 30 14. Selection of Patients for Implantable Cardioverter-Defibrillators †¦ 32 15. Participation in Competitive or Recreational Sports and Physical Activity †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 16. Management of Atrial Fibrillation †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 38 17. Pregnancy/Delivery †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 41 2 1. Introduction The impetus for the guidelines is based on an appreciation of the frequency of this clinical entity and a realization that many aspects of clinical management, including the use of diagnostic modalities, genetic testing, utilization of implantable cardioverter-defibrillators (ICDs), and therapies for refractory symptoms lack consensus.The discussion and recommendations about the various diagnostic modalities apply to patients with established HCM and to a variable extent to patients with a high index of suspicion of the disease. Classification of Recommendations The ACCF/AHA classifications of recommendations and levels of evidence are utilized, and described in more detail in Table 1. 3 Applying Classification of Recommendations and LevelRecommendations and Level of Evidence Table 1. Applying Classification of of Evidence Table 1. Applying Classification of Recommendations and Level of Evidence S i z e Class I Benefit >>> Risk f T r e a T m eSni T ee f ffe c T e a T z o Tr Class IIb Class IIa Benefit >>> Risk Benefit Risk Additional studies with broad Additional studies with objectives objectives needed focused needed; additional registryreasonable to perIt Is data would be helpful Class IIa Class I Benefit >> RiskRisk Benefit >>> Additional studies with Procedure/Treatment focused objectives needed should be performed/ Procedure/Treatment should be performed/ administered It administered Is reasonable to perform procedure/administer treatment n Recommendation favor n Recommendation in thatProcedure/Treatment form procedure/administer may be ConsIdered treatment n n Rec ommendation Recommendation’s eSTimaTe of cerTainTy (PreciSion) of TreaTmenT effecT a populations d* ived from multiple zed clinical trials analyses Recommendation that level a procedure or treatment Multiple populations is useful/effective evaluated* n Sufficient evidence from Data randomized multiple multiplederived from trials randomized clinical trials or meta-analyses or meta-analyses n of procedure or procedure treatment treatment is useful/effective being useful/effective n Sufficient evidence from n Some conflicting evidence n favor usefulness/efficacy less of treatment or procedure well established being useful/effective conflicting evidence evidence from multiple from multiple randomized randomized trials or trials or meta-analyses meta-analyses in favor of treatment or procedure usefulness/efficacy less being useful/effective well established conflicting evidence from single evidence from single randomized trial randomized trial oror nonrandomized studies nonrandomi zed studies in favor usefulness/efficacy less of treatment or procedure well established being useful/effective opinion, case studies, or opinion, case studies, standard of care care or standard of may/might be considered is reasonable may/might be reasonable can be useful/effective/beneficial usefulness/effectiveness is is probably recommended unknown/unclear/uncertain or indicated or not well established n n Some Greater multiple randomized trials from multiple randomized or or meta-analyses trialsmeta-analyses b populations d* ived from a ndomized trial ndomized studiesRecommendation that level b procedure or treatment Limited populations is useful/effective evaluated* n Evidence from single Data derived or randomized trialfrom a single randomized trial nonrandomized studies or nonrandomized studies n n Recommendation in that n Recommendation favor n n Recommendation Recommendation’s of procedure or procedure treatment treatment being useful/effective is useful/effective n Some conflicting single n Evidence from n n Some Greater evidence from trial or randomized single randomized trial or nonrandomized studies nonrandomized studies n Recommendation favor n Recommendation in that C ited populations d* sensus opinion ts, case studies, ard of careRecommendation that level C procedure or treatment is Very limited populations useful/effective evaluated* n Only expert opinion, case Only consensus opinion studies, or standard of care of experts, case studies, or standard of care n n n Recommendation Recommendation’s of procedure or procedure is treatment treatment useful/effective being useful/effective n Only expert expert n Only divergingopinion, case studies, or studies, opinion, casestandard of care or standard of care is reasonable should can be useful/effective/beneficial is recommended is probably recommended is indicated oris useful/effective/beneficial indicated n n Only diverging expert Only diverging expert d phrases for commendations shou ld Suggested phrases for writing recommendations is recommended is ndicated is useful/effective/beneficial s treatment/strategy A is Comparative recommended/indicated in effectiveness phrases†  preference to treatment B treatment/strategy A is probably treatment/strategy A is recommended/indicated in in recommended/indicated preference to to treatment B preference treatment B it is reasonableshould be chosen treatment A to choose treatment A over treatment B over treatment B treatment/strategy A is probably recommended/indicated in preference to treatment B it is reasonable to choose treatment A over treatment B ive ess phrases†  4 treatment A should be chosen over treatment B e T menT e ffe c T A recommendation with Level of Evidence B or CClass IIIIIb Benefit Class No orBenefit > Risk Class III Harm Procedure/ Additional studies with broad test treatment objectives needed; additional Cor III: Not No Proven be helpful noregistry data would Benefit benefit Helpful Class II I No Benefit or Class III Harm Procedure/ test Cor III: Not no benefit Helpful Cor III: harm treatment No Proven Benefit does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. Procedure/Treatment Cor III: Excess Cost Harmful harm be w/o Benefit to Patients may ConsIdered or Harmful n n Recommendation’s Recommendation that Excess Cost Harmful w/o Benefit to Patients or Harmful Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †  For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. n procedure or treatment is usefulness/efficacy less not useful/effective and may well established be harmful conflicting n Greater n evidence from multiple Sufficient evidence fromRecommendation that procedure or treatment is not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses Recommendation that procedure or treatment is not useful/effective and may be harmful Evidence from single randomized trial or nonrandomized studies Recommendation that procedure or treatment is not useful/effective and may be harmful Only expert opinion, case studies, or standard of care COR III: Harm potentially harmful causes harm associated with excess morbidity/mortality should not be performed/ be done administered/ other n multiple randomizedor randomized trials trials or meta-analyses meta-analyses n n Recommendation’s Recommendatio n that n sefulness/efficacy less procedure or treatment is well established not useful/effective and may be harmful conflicting n Greater n evidence from single Evidence from single randomized trial randomized trial oror nonrandomized studies nonrandomized studies n Recommendation’s Recommendation that usefulness/efficacy less procedure or treatment is well established not useful/effective and may n Only diverging expert be harmful opinion, case studies, or n Only expert opinion, case standard of care studies, or standard of care n n n n COR III: COR III: may/might be considered Nomay/might be reasonable Benefit Harm usefulness/effectiveness is is not potentially unknown/unclear/uncertain recommended harmful or indicated not well established harm is not causes associated with excess morbidity/mortality should not be done COR III: No Benefit is not recommended is not indicated should not be performed/ be done administered/ is not useful/ other beneficial/ is not useful/ effect ive bene? cial/ effective should not be done s not useful/ beneficial/ effective 5 2. Clinical Definition The generally accepted definition of hypertrophic cardiomyopathy (HCM), is a disease state characterized by unexplained left ventricular (LV) hypertrophy associated with nondilated ventricular chambers in the absence of another cardiac or systemic disease that itself would be capable of producing the magnitude of hypertrophy evident in a given patient. Clinically, HCM is usually recognized by maximal LV wall thickness ? 15 mm, with wall thickness of 13 to 14 mm considered borderline, particularly in the presence of other compelling information (e. g. , family history of HCM), based on echocardiography.In terms of LV wall-thickness measurements, the literature has been largely focused on echocardiography, although cardiovascular magnetic resonance (CMR) is now used with increasing frequency in HCM. In the case of children, increased LV wall thickness is defined as wall thickness ? 2 standard deviations above the mean (z score ? 2) for age, sex, or body size. However, it should be underscored that in principle, any degree of wall thickness is compatible with the presence of the HCM genetic substrate and that an emerging subgroup within the broad clinical spectrum is composed of family members with disease-causing sarcomere mutations but without evidence of the disease phenotype (i. e. , LV hypertrophy). 6 3. Genetic Testing Strategies/Family Screening Class I 1.Evaluation of familial inheritance and genetic counseling is recommended as part of the assessment of patients with HCM. (Level of Evidence: B) 2. Patients who undergo genetic testing should also undergo counseling by someone knowledgeable in the genetics of cardiovascular disease so that results and their clinical significance can be appropriately reviewed with the patient. (Level of Evidence: B) 3. Screening (clinical, with or without genetic testing) is recommended in first-degree relatives of pati ents with HCM. (Level of Evidence: B) 4. Genetic testing for HCM and other genetic causes of unexplained cardiac hypertrophy is recommended in patients with an typical clinical presentation of HCM or when another genetic condition is suspected to be the cause. (Level of Evidence: B) 7 Class IIa 1. Genetic testing is reasonable in the index patient to facilitate the identification of first-degree family members at risk for developing HCM. (Level of Evidence: B) Class IIb 1. The usefulness of genetic testing in the assessment of risk of sudden cardiac death (SCD) in HCM is uncertain. (Level of Evidence: B) Class III: 1. Genetic testing is not indicated in relatives when pathogenic mutation. (Level of Evidence: B) 2. Ongoing clinical screening is not indicated in genotype-negative relatives in families with HCM. Level of Evidence: B) No Benefit the index patient does not have a definitive 8 4. Genotype-Positive/Phenotype-Negative Patients Class I 1. In individuals with pathogenic mutat ions who do not express the HCM phenotype, it is recommended to perform serial electrocardiogram, transthoracic echocardiogram (TTE), and clinical assessment at periodic intervals (12 to 18 months in children and adolescents and about every 5 years in adults), based on the patient’s age and change in clinical status. (Level of Evidence: B) 9 5. Echocardiography Class I 1. A TTE is recommended in the initial evaluation of all patients with suspected HCM. (Level of Evidence: B) 2.A TTE is recommended as a component of the screening algorithm for family members of patients with HCM unless the family member is genotype negative in a family with known definitive mutations. (Level of Evidence: B) 3. Periodic (12 to 18 months) TTE screening is recommended for children of patients with HCM, starting by age 12 or earlier if a growth spurt or signs of puberty are evident and/or when there are plans for engaging in intense competitive sports or there is a family history of SCD. (Level o f Evidence: C) 4. Repeat TTE is recommended for the evaluation of patients with HCM with a change in clinical status or new cardiovascular event. (Level of Evidence: B) 5. A transesophageal echocardiogram (TEE) is recommended for the intraoperative guidance of surgical myectomy. (Level of Evidence: B) 10 6.TTE or TEE with intracoronary contrast injection of the candidate’s septal perforator(s) is recommended for the intraprocedural guidance of alcohol septal ablation. (Level of Evidence: B) 7. TTE should be used to evaluate the effects of surgical myectomy or alcohol septal ablation for obstructive HCM. (Level of Evidence: C) Class IIa 1. TTE studies performed every 1 to 2 years can be useful in the serial evaluation of symptomatically stable patients with HCM to assess the degree of myocardial hypertrophy, dynamic obstruction, and myocardial function. (Level of Evidence: C) 2. Exercise TTE can be useful in the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting outflow tract obstruction in patients with HCM. (Level of Evidence: B) 11 3.TEE can be useful if TTE is inconclusive for clinical decision making about medical therapy and in situations such as planning for myectomy, exclusion of subaortic membrane or mitral regurgitation secondary to structural abnormalities of the mitral valve apparatus, or in assessment for the feasibility of alcohol septal ablation. (Level of Evidence: C) 4. TTE combined with the injection of an intravenous contrast agent is reasonable if the diagnosis of apical HCM or apical infarction or severity of hypertrophy is in doubt, particularly when other imaging modalities such as CMR are not readily available, not diagnostic, or contraindicated. (Level of Evidence: C) 5.Serial TTE studies are reasonable for clinically unaffected patients who have a first-degree relative with HCM when genetic status is unknown. Such follow-up may be considered every 12 to 18 months f or children or adolescents from high-risk families and every 5 years for adult family members. (Level of Evidence: C) 12 Class III: 1. TTE studies should not be performed more HCM when it is unlikely that any changes have occurred that would have an impact on clinical decision making. (Level of Evidence: C) 2. Routine TEE and/or contrast echocardiography is not recommended when TTE images are diagnostic of HCM and/or there is no suspicion of fixed obstruction or intrinsic mitral valve pathology. (Level of Evidence: C)No Benefit frequently than every 12 months in patients with 13 6. Stress Testing Class IIa 1. Treadmill exercise testing is reasonable to determine functional capacity and response to therapy in patients with HCM. (Level of Evidence: C) 2. Treadmill testing with monitoring of an electrocardiogram and blood pressure is reasonable for SCD risk stratification in patients with HCM. (Level of Evidence: B) 3. In patients with HCM who do not have a resting peak instantaneous g radient of greater than or equal to 50 mm Hg, exercise echocardiography is reasonable for the detection and quantification of exercise-induced dynamic LVOT obstruction. (Level of Evidence: B) 14 7. Cardiac Magnetic Resonance Class I 1.CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis. (Level of Evidence: B) 2. CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography. (Level of Evidence: B) Class IIa 1. CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive. (Level of Evidence: B) 15 Class IIb 1.In selected patients with known HCM, when SCD risk stratification is inconclusive after docume ntation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement may be considered in resolving clinical decision making. (Level of Evidence: C) 2. CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy. (Level of Evidence: C) 16 8. Detection of Concomitant Coronary Disease Class I 1. Coronary arteriography (invasive or computed tomographic imaging) is indicated in patients with HCM with chest discomfort who have an intermediate to high likelihood of coronary artery disease (CAD) when the identification of concomitant CAD will change management strategies. (Level of Evidence: C) Class IIa 1.Assessment of coronary anatomy with computed tomographic angiography is reasonable for patients with HCM with chest discomfort and a low likelihood of CAD to assess for possible concomitant CAD. (Level of E vidence: C) 2. Assessment of ischemia or perfusion abnormalities suggestive of CAD with single-photon emission computed tomography or positron emission tomography myocardial perfusion imaging (because of excellent negative predictive value) is reasonable in patients with HCM with chest discomfort and a low likelihood of CAD to rule out possible concomitant CAD. (Level of Evidence: C) 17 Class III: 1. Routine single-photon emission computed echocardiography is not indicated for detection of â€Å"silent† CAD-related ischemia in patients with HCM who are asymptomatic. (Level of Evidence: C) 2.Assessment for the presence of blunted flow reserve (microvascular ischemia) using quantitative myocardial blood flow measurements by positron emission tomography is not indicated for the assessment of prognosis in patients with HCM. (Level of Evidence: C) No Benefit tomography myocardial perfussion imaging or stress 18 9. Asymptomatic Patients Class I 1. For patients with HCM, it is recom mended that comorbidities that may contribute to cardiovascular disease (e. g. , hypertension, diabetes, hyperlipidemia, obesity) be treated in compliance with relevant existing guidelines. (Level of Evidence: C) Class IIa 1. Low-intensity aerobic exercise is reasonable as part of a healthy lifestyle for patients with HCM. (Level of Evidence: C) Class IIb 1.The usefulness of beta blockade and calcium channel blockers to alter clinical outcome is not well established for the management of asymptomatic patients with HCM with or without obstruction. (Level of Evidence: C) Class III: Harm 1. Septal reduction therapy should not be performed for asymptomatic adult and pediatric patients with HCM with normal effort tolerance regardless of the severity of obstruction. (Level of Evidence: C) 2. In patients with HCM with resting or provocable outflow tract obstruction, regardless of symptom status, pure vasodilators and high-dose diuretics are potentially harmful. (Level of Evidence: C) 19 Fi gure 1. Treatment Algorithm HCM PatientsACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; DM, diabetes mellitus; EF, ejection fraction; GL, guidelines; HCM, hypertrophic cardiomyopathy; HTN, hypertension; and LV, left ventricular. Treat comorbidities according to GL [HTN, Lipids, DM] Obstructive Physiology No Heart Failure Symptoms or Angina No Yes Yes Avoid vasodilator therapy and highdose diuretics Systolic Function Annual clinical evaluation No Heart Failure Symptoms or Angina LV EF 50 mm Hg) for whom standard medical therapy has failed. (Level of Evidence: C) 4.When surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation, when performed in experienced centers, can be beneficial in eligible adult patients with HCM with LVOT obstruction and severe drug-refractory symptoms (usually New York Heart Association functional classes III or IV). (Level of Evidence: B) 26 Class IIb 1. Alcohol septal ablation, when performed in experienced centers, may be considered as an alternative to surgical myectomy for eligible adult patients with HCM with severe drug-refractory symptoms and LVOT obstruction when, after a balanced and thorough discussion, the patient expresses a preference for septal ablation. (Level of Evidence: B) 2. The effectiveness of alcohol septal ablation is uncertain in patients with HCM with marked (i. e. , >30 mm) septal hypertrophy, and therefore the procedure is generally discouraged in such patients. (Level of Evidence: C) Class III: Harm 1.Septal reduction therapy should not be done for adult patients with HCM who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on optimal medical therapy. (Level of Evidence: C) 2. Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with HCM. (Level of Evidence : C) 27 3. Mitral valve replacement for relief of LVOT obstruction should not be performed in patients with HCM in whom septal reduction therapy is an option. (Level of Evidence: C) 4. Alcohol septal ablation should not be done in patients with HCM with concomitant disease that independently warrants surgical correction (e. g. coronary artery bypass grafting for CAD, mitral valve repair for ruptured chordae) in whom surgical myectomy can be performed as part of the operation. (Level of Evidence: C) 5. Alcohol septal ablation should not be done in patients with HCM who are less than 21 years of age and is discouraged in adults less than 40 years of age if myectomy is a viable option. (Level of Evidence: C) 28 12. Pacing Class IIa 1. In patients with HCM who have had a dualchamber device implanted for non-HCM indications, it is reasonable to consider a trial of dual-chamber atrial-ventricular pacing (from the right ventricular apex) for the relief of symptoms attributable to LVOT obst ruction. (Level of Evidence: B) Class IIb 1.Permanent pacing may be considered in medically refractory symptomatic patients with obstructive HCM who are suboptimal candidates for septal reduction therapy. (Level of Evidence: B) Class III: 1. Permanent pacemaker implantation for the performed in patients with HCM who are asymptomatic or whose symptoms are medically controlled. (Level of Evidence: C) 2. Permanent pacemaker implantation should not be performed as a first-line therapy to relieve symptoms in medically refractory symptomatic patients with HCM and LVOT obstruction in patients who are candidates for septal reduction. (Level of Evidence: B) No Benefit purpose of reducing gradient should not be 29 13. Sudden Cardiac Death Risk Stratification Class I 1.All patients with HCM should undergo comprehensive SCD risk stratification at initial evaluation to determine the presence of: (Level of Evidence: B) a. A personal history for ventricular fibrillation, sustained ventricular tach ycardia, or SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * b. A family history for SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * c. Unexplained syncope. d. Documented nonsustained ventricular tachycardia (NSVT) defined as 3 or more beats at greater than or equal to120 bpm on ambulatory (Holter) electrocardiogram. e. Maximal LV wall thickness greater than or equal to 30 mm. Appropriate ICD discharge is defined as ICD therapy triggered by VT or ventricular fibrillation, documented by stored intracardiac electrogram or cycle-length data, in conjunction with the patient’s symptoms immediately before and after device discharge. 30 Class IIa 1. It is reasonable to assess blood pressure response during exercise as part of SCD risk stratification in patients with HCM. (Level of Evidence: B) 2. SCD risk stratification is reasonable on a periodic basis (every 12 to 24 months) for patients with HCM who have not under gone ICD implantation but would otherwise be eligible in the event that risk factors are identified (12 to 24 months). (Level of Evidence: C)Class IIb 1. The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: a. CMR imaging with late gadolinium enhacement. (Level of Evidence: C) b. Double and compound mutations (i. e. , >1). (Level of Evidence: C) c. Marked LVOT obstruction. (Level of Evidence: B) Class III: Harm 1. Invasive electrophysiologic testing as routine SCD risk stratification in patients with HCM should not be performed. (Level of Evidence: C) 31 14. Selection of Patients for Implantable Cardioverter-Defibrillators Class I 1.The decision to place an ICD in patients with HCM should include application of individual clinical judgment, as well as a thorough discussion of the strength of evidence, benefits, and risks to allow the informed patient’s active participation in decision making. (Level of Evidence: C) 2. ICD placement is recommended for patients with HCM with prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. (Level of Evidence: B) Class IIa 1. It is reasonable to recommend an ICD for patients with HCM with: a. Sudden death presumably caused by HCM in 1 or more first-degree relatives. (Level of Evidence: C) b. A maximum LV wall thickness greater than or equal to 30 mm. (Level of Evidence: C) c. One or more recent, unexplained syncopal episodes. (Level of Evidence: C) 2.An ICD can be useful in select patients with NSVT (particularly those 30 mm or Recent unexplained syncope No Yes ICD reasonable Nonsustained VT or Abnormal BP response Yes Other SCD Risk Modifiers* Present? Yes No ICD can be useful Legend Class I Class IIa No ICD not recommended Class IIb Class III Role of ICD uncertainRegardless of the level of recommendatio n put forth in these guidelines, the decision for placement of an ICD must involve prudent application of individual clinical judgment, thorough discussions of the strength of evidence, the benefits, and the risks (including but not limited to inappropriate discharges, lead and procedural complications) to allow active participation of the fully informed patient in ultimate decision making. BP indicates blood pressure; ICD, implantable cardioverter-defibrillator; LV, left ventricular; SCD, sudden cardiac death; SD, sudden death; and VT, ventricular tachycardia. 35 15. Participation in Competitive or Recreational Sports and Physical ActivityClass IIa 1. It is reasonable for patients with HCM to participate in low-intensity competitive sports (e. g. , golf and bowling). (Level of Evidence: C) 2. It is reasonable for patients with HCM to participate in a range of recreational sporting activities as outlined in Table 2. (Level of Evidence: C) Class III: Harm 1. Patients with HCM should not participate in intense competitive sports regardless of age, sex, race, presence or absence of LVOT obstruction, prior septal reduction therapy, or implantation of a cardioverterdefibrillator for high-risk status. (Level of Evidence: C) 36 Table 2. Recommendations for the Acceptability of Recreational Noncompetitive) Sports Activities and Exercise in Patients With HCM* Intensity Level High Basketball (full court) Basketball (half court) Body building†¡ Gymnastics Ice hockey†¡ Racquetball/squash Rock climbing†¡ Running (sprinting) Skiing Soccer Tennis (singles) Touch (flag) football Windsurfing § Moderate Baseball/softball Biking Modest hiking Motorcycling†¡ Jogging Sailing § Surfing § Swimming (laps) § Tennis (doubles) Treadmill/stationary bicycle Weightlifting (free weights)†¡|| Hiking 2 4 4 3 3 3 2 5 4 5 1 3 (downhill)†¡ Skiing (cross-country) 0 0 1 2 0 0 1 0 2 2 0 0 1 1 Eligibility Scale for HCM†  Intensity Level Low Bowling Golf Hor seback riding†¡ Scuba diving § Skating ¶ Snorkeling § Weights (nonfree weights) Brisk walking 5 5 3 0 5 5 4 5 Eligibility Scale for HCM†  *Recreational sports are categorized according to high, moderate, and low levels of exercise and graded on a relative scale (from 0 to 5) for eligibility, with 0 to 1 indicating generally not advised or strongly discouraged; 4 to 5, probably permitted; and 2 to 3, intermediate and to be assessed clinically on an individual basis. The designations of high, moderate, and low levels of exercise are equivalent to an estimated >6, 4 to 6, and

Challenging Obstacle

Ray Pyle November 18, 2012 Essay #5 College Entry Essay 9:40-Sect. 46; 11:10-Sect. 69 Most Challenging Obstacle: The Death of My Father Most people would say that high school and resisting peer pressure would be the most difficult task that they have ever faced. Well the most challenging obstacle that I had to overcome was the death of my father. My life was turned upside down when it all happened. It greatly impacted me on a physical and mental level. Luckily this challenge taught me to cherish life. It even brought me closer to God and to understand that he has a plan for all of us.It pushed me to become more determined and motivated in any activity I partake in. Our family is much closer now then we were before. His death opened my eyes and my mind to accept the idea that you must live life to the fullest. Not only did it teach me to live life but it showed me how to be confident, strong, respectable to everyone and everything, and how to appreciate the little things in life. This would definitely be the hardest obstacle that I ever had to face in my life. Ever since that faithful day my views on life have changed dramatically. Now I have become more an optimistic individual.Yes, I am more optimistic because now I see the true beauty of the world that I always overlooked. When I see pictures of nature it releases a feeling of sanctity or even solace. I don’t take life for granted anymore, now I strongly believe that every life is precious even the pesky bugs. His leaving revealed that instead of rushing life I should stop every once in a while and take a gander at nature. Like a moment to soak it all in and embrace the true beauty that so much people fail to see. Now I live in the moment instead of worrying what the future brings.This ordeal has brought me a lot more near to God. In my prayers I learned that God needed him and that my father had fulfilled his purpose. I know it sound cliche but it is the truth and no one can tell me differently. Inste ad of resorting to drug I turned to God and he helped me through the pain. In a way God has taken the role of a fatherly figure and I am grateful. I go to church more often and I feel more alive and refreshed. This trial has shown me the love that God has to offer and how he will take care of you when your love ones are gone.God has become an important factor in my life after my dad died. My determination is at the highest point it could be. I have this motivation to strive to become the best I can. I do these things to make my father proud and to honor his legacy. To be honest, if my father was alive today I wouldn’t have fathom the idea of taking Advanced Placement courses. I would have relied on my dad to do everything for me including finding and paying for my college. Now I can proudly say that with this newfound determination I can succeed on my own.For once in my life I am actually studying and pushing myself to the limit on how much I can learn and retain. I was able to turn such a negative situation into a positive by using it to fuel my dreams. When all was finished this traumatic event created a feeling of togetherness. Our family became tighter and closer together. Now we set up family nights where it would either be Mexican night meaning we make Mexican dishes or game night where we battle it out on the Wii. On certain Saturday’s we all would go out to any restaurant mostly Chili’s and sit-down and talk about how our week was.In a sense we come together and evaluate our week and sometimes we even reminisce about him. It is better to remember the good times than to remember what happened that cold December night. His death brought our family together and taught individual to enjoy the times we have left on Earth because you never know when it is your time. The experience I gained was how to be confident in everything I do. I learned how to be strong in times of great distress. I now have the utmost respect for every living thin g. Also, his death allowed me to see how important life is and how we must make the most of it.You always live like it is you last day and always be willing to aid those in need. My father passing away gave me lesson that I hope to pass onto my children. Seeing my father go would have to be the hardest thing that I ever had to overcome. Thanks to God I am standing here stronger than ever. Instead of using this as an excuse I am using this as fuel to empower me. This situation has impacted me physical and mental but I won’t ever let it hold me down. In my heart I know that my father will never accept less so I will aim for the highest peak and ride it out to the end.

Two Tail Hypothesis Scholarship Essay Example | Topics and Well Written Essays - 500 words

Two Tail Hypothesis - Scholarship Essay Example The analysis can be used by the manager to study if there is the significant difference between position and extrinsic job satisfaction in the company. This would enable the manager to make a plan on which strategy to use either Hourly Employee or Salaried Employee in respect of job satisfaction. Since ÃŽ ±=0.05 and confidence level is 95%; t- statistic=-54.60, the critical value is  ±1.96 we reject null hypothesis because p-value 1.67 E-91 is less than 0.05 and adopt alternative hypothesis. The t-test is used when the sample is small; it can be used to test the difference in population mean, that is when the population is n≠¤30 and the standard deviation of the population is estimated from the standard deviation of the sample. Whereas z-test is used when the population means is known together with standard deviation. Researchers do not have enough time to study the whole population. To study the entire population would be tedious and time-consuming; therefore, representative sample from the population is appropriate in the data collection. In statistical inferences, conclusions are drawn about the attribute of the population, e.g. the standard deviation or mean based on sample data analysis. Supposing there was a need to calculate the average weight of the population of youths in America, it would be unreasonable except at massive cost to weigh up each individual and calculate the mean weight. Another scenario is that testing process may be very destructive such that sampling becomes the only sufficient way.

Mental health and mental disorder module(psychososial studies Degree) Essay

Mental health and mental disorder module(psychososial studies Degree) - Essay Example The existence of mental disease and the legality of the psychiatric specialization are not universally acknowledged. Some specialists, especially Doctor Thomas Szasz, Professor Emeritus of Psychiatry at Syracuse, seriously stand up against the practice of use of the definition "mental illness." The anti-psychiatry movement frequently refers to what it means by "myth of mental illness" and dispute against a biological cause for mental disorders, or also states that all human experience has a biological origin and so no type of behaviour can be called a disease per se. In this particular work I would like to study depression from the general point of view and from the point of view of Thomas Szasz in order to prove or disprove his position. So, is depression a disease or a myth? Depression is the most widespread disease of XX century. During all the past and in present century depression was considered as a normal condition of artistic, creative people. We heard more than once:  «I am in depression, live me along ". Nowadays, depression is a dangerous disease, which causes unfeigned suffering. However there are some scientists who do not agree with it, they are Thomas Szasz and his colleagues Jeffrey A. Schaler and Ron Leifer. 1. The first point: â€Å"A disease scientifically is defined as a biological abnormality that affects living tissues. Trees can be diseased, plants, animals, and humans. A real disease is typhoid fever, we call it a literal disease. Spring fever sounds like a disease but it is not a disease. The whale is a real animal, but it is not a fish, it is a metaphorical fish. So when we say depression is not a disease, we do not minimize the human phenomenon suffering. It exists like the whale exists but it is not a disease.† (Thomas S. Szasz Cybercenter for Liberty and Responsibility, 1998). 2. The second point: â€Å"Treatment has got nothing to do with

People and Church of Nicaragua Case Study Example | Topics and Well Written Essays - 250 words

People and Church of Nicaragua - Case Study Example People and Church of Nicaragua had huge expectations from Pope Paul II’s visit to the state in 1983. When the people led regime became autocratic and denied the common man its right to survive and prosper, the Marxist revolutionaries started fighting for the welfare of the people. The Church of the ‘poor’ also aligned with the Marxist revolutionaries and proactively supported their cause (Gutià ©rrez, 1973; Belli, 1988). The Pope’s visit was therefore highly significant for the Nicaragua Church as well as for the people because they saw it as intangible support and a means to convince the government for social reforms that would benefit the common man (Foroohar, 1989; Williams, 1985). But unfortunately, Pope’s visit was a huge let down for Nicaragua’s people and the Church. The major objective of the visit of Pope John Paul II was to proclaim that Catholic Church did not support communists. The huge congregation assembled at the Plaza was hop eful that Pope would lend support to the people’s revolution and decry the mass carnage by government led death squad. But Pope’s silence on the issue was a big disillusion for the priests and public but later wrote a letter ‘denouncing Popular Church’(Dew, 1983:632). He neither condoled the deaths of priests, nuns and innocent people nor made any effort to talk with Nicarguan priests so that could put their case personally. Despite people’s incessant chant, ‘Holy Father, we beg you for a prayer for our loved ones who have been murdered’, Pope was unmoved (Boyt, 1983). Pope’s agenda to his Nicaragua visit was politically inclined and defied wider human welfare. The priests’ fears came true and they along with people of Nicaragua became the innocent victims of oppressive regime that got the approval from the highest authority of Catholic Church, when Pope remained silent on the issue in his visit.

Leadership is simply about 'getting the job done'. Discuss in relation Essay

Leadership is simply about 'getting the job done'. Discuss in relation to concepts and conflicts - Essay Example On average, a manager’s job would be to administer things as per the managerial continuity and integrity. This paper will examine the existing theoretical concepts in relation to leadership. Also, conflicts might arise in the case all the theories are applied in one go. The paper would examine the possible conflicts too. Key Concepts Introduction: The following discussion would cover the key concepts in relation to management and how a job should be executed. It also focuses on management and corporate strategy in relation to leadership. Discussion: If a job is to be done, it is not likely that one does it single-handedly in today’s complex socio-psychological environment. He or she would need a team, hence the formation of workgroups. In a workgroup, the goals must be shared, group values must be specified, decision must be based on consensus and evaluation must be constantly done. Moreover, in order to get the job done, some other ethical values like mutual trust, ded icated participation and respect for each other must be ushered (McGregor, Bennis and Schein, 1966). In doing the job, the leader must understand the relationship between behaviour and performance among his or her subordinates. Reinforcement Theory explicates the concept as such that a rewarded behaviour is more likely to be repeated while a behaviour that is punished is less likely to be repeated. The concept of reward and punishment is necessary and thus simply getting the job done may be insufficient (Keller, 1969). Figure - 1 Goal setting is also important because neither the leader nor his or her subordinates are supposed to know what to do if no goal is set at all (Brenda Devis, 1988). Again, according to Adam’s Equity Theory, the extent of equity that an individual would observe in relation to a work situation would proportionally affect his or her job performance and satisfaction (Kinicki, 2009). However, management in the real world cannot be completely based on theo ries only. To get the job done, the leader must handle general management and show skills in operational systems. A manager uses management tools to manage people and resources, while the leader is supposed to use the same tools innovatively. This is beyond simply completing the job. The fundamental questions like â€Å"What is management?† and â€Å"What is business?† should be explored with support from practical experiences. Techniques and tools like networks of critical path, cash flow and inventory control add more dimensions to decision making (Payne, Chelsom and Reavill, 2004). In getting the job done, the leader must not remain in the constraints of that job only. He or she must understand business failure or success is primarily dependent on how diverse areas of function in management can be combined to deliver and produce value to the different stakeholders. Corporate strategy in the form of functional integration is imperative in orchestration with the compl ex and dynamic corporate environment (Johnson, Scholes and Whittington, 2005) Summary: The key concepts in relation to leadership and ‘getting the job done’ are discussed. Stress has been put on: 1. Workgroup functionality 2. Reinforcement Th

Principles of social crime prevention have little to offer in the Essay

Principles of social crime prevention have little to offer in the development of effective crime prevention practices. Critically discuss - Essay Example A detailed discussion of the situational approach to crime prevention, presented further on, shifts accents from social context of crime prevention to a more subjective nature of crime. Prior social context was considered by the crime prevention theorists as a determinant one; starting from 80s more subjective and situational aspects were considered (Lawrence, 2000). Moreover, there is made an attempt to find similarities and differences between these two approaches, to evaluate their efficiency in modern practices of crime prevention. Chicago School is a famous developer of social approach to crime prevention. The main suggestion of Chicago School is that crime is always caused by social force (Melville, Morgan, Norris and Walkington, 2006, p. 70). The primary goal of this theory was to develop welfare in the society through the expansion of welfare states, where no triggers of crime existed (Garland and Sparks, 2000, p. 195). Chicago School has made a significant contribution to crime prevention practices. Social theoretical approach applied by this school, made this study an outstanding laboratory for sociological research in the context of social relationships and influence caused by urbanism. Chicago School made an emphasis on the contextual considerations of crime. In terms of socio-cultural context crime can appear and can be prevented as well. Park and Burgess are sociologists who worked out basic claims of social crime prevention. Their main idea is a concurrent existence of five concentric zones in the process of cities’ development (The Chicago School I). The most risky zone is the â€Å"zone in transition† (Garland and Sparks, 2000, p. 189). Another claim of these sociologists can’t be discussed without arguing. Chicago School sociologists underline that well-being of the society is determined by their living conditions. In other

The history of the trumpet Essay Example | Topics and Well Written Essays - 1000 words

The history of the trumpet - Essay Example However, this is only the recorded history and the presence of trumpet can be older. Initially trumpet was not used as a musical instrument, but for martial and religious purposes. Historically, trumpets were of grand importance as militarily, they were employed by trumpeters for delivering commands to troops present at far away distances. Bugle, a form of trumpet is used in place of trumpet in today’s military just as a conventional instrument. Trumpet as a musical instrument go through betterment during the middle Ages and Renaissance (Downey 29). The technique of designing and crafting the trumpet also got better with time. This paper elaborates the historical presence and importance of trumpet and traces it back to its origin. Trumpet has got the reputation of highest register in terms of brass musical instruments. Historically, trumpet is among the oldest most musical instruments. When a trumpet is used, a buzzing sound is created that is made by blowing air with the supp ort of a whistling posture of the lips. The trumpet that is found today is made up with brass tubing that is a quality that it gained after the fifteenth century. It is present in many forms nowadays and is used as a musical instrument while its historic form was not altogether musical (Tarr 62). During the sixteenth century, military and courts both used the trumpets for their own purposes. Usage of trumpet started becoming famous in Germany during the sixteenth century. The ending of this century marks the usage of trumpet in musical terms and before this, it was mostly used for courtly and military reasons. Initially, the trumpeters made use of low pitched sounds, but later on, they also made use of high pitched sounds. The musicians also started to use diversified harmonic series (Brownlow 78). The seventeenth and eighteenth centuries saw the heighted version of the trumpet. Famous composers like Leopold and Michael were famous in terms of their musical compositions. For courtly purposes, the D and C keys in trumpets were employed while for military purposes, Eb and F keys in trumpets were employed. Diverse registers of trumpets were played by the musicians of the era (Barclay 46). When the valves were introduced to the trumpet, the interest of musicians in the usage of trumpet increased. In the nineteenth century, the trumpet was no more a common musical instrument as it became an orchestral instrument. At this time, the F key in trumpet along with crooks were employed that made the trumpet more interesting as a musical instrument (Tarr 93). The shape and form of trumpet had improvements with the passage of time. The valves took the place of crooks with the time and improvement of the trumpet as a musical instrument. The size of the trumpet also saw transformations. The improvements in the trumpet enabled the musicians to play the trumpet with much ease and sound (Wallace & McGrattan 116). The trumpet’s first known form was Alphorn that was constru cted by means of a tree trunk. The trumpet has high pitched sound and big appearance. It was generally employed for flocking cattle, beckoning groups of people, religious preaching and war related messages by military. The 17th century that was also called baroque era saw the transformation of Alphorn into trumpet (Smither 358). The initial trumpets were called natural trumpets, which was constructed by means of metal. Previously, tree trunk was used in place of metal. The trumpets that were created then were in form of elongated cylindrical tubes having a

Legal Process Paper Essay Example | Topics and Well Written Essays - 750 words - 1

Legal Process Paper - Essay Example 06(b)[3] of the statute, the notice must include the date, place and the circumstances of the alleged unlawful employment practice so that the employer may be apprised of the nature of the charges against it. However, the name of the charging party need not be included. If the EEOC totally fails to notify an employer of the charges, the courts, as the District Court did in EEOC v. St. Annes Hospital of Chicago, Inc.,have ruled that the EEOC could not bring a suit on that charge. The Supreme Court in Shell Oil Co. v. EEOC held that notice was adequate, even while not technically perfect. The legislative history of Title VII is clear that untimely notice by the EEOC should not be an absolute bar to court action by the aggrieved party. Also under Section 706(b), the EEOC is required to investigate the charge of discrimination to determine if reasonable cause exists to believe that the charge is true. If no reasonable cause exists, the EEOC shall dismiss the charge and promptly notify the charging and charged party of the dismissal. If reasonable cause exists, the EEOC â€Å"shall endeavor to eliminate any such alleged unlawful employment practices by informal methods of conference, conciliation and persuasion.† If those efforts fail, the EEOC may bring a civil suit against the employer in federal court under Section 706(f). If the EEOC does not bring suit within 180 days of the filing of the charge either by choice or because it dismissed the charge, the charging party may request notification, commonly referred to as a â€Å"right to sue† letter. Upon receipt of that letter, the charging party has 90 days to sue. Thus, a charging party may not sue until she received a notice of dismissal by the EEOC or a right to sue letter. The charging party may demand a right to sue letter, even before the EEOC has made its reasonable cause determination, so long as the demand for the letter is 180 days after the EEOC charge is filed. However, the right to sue letter can be

Proposal Assignment Example | Topics and Well Written Essays - 750 words - 1

Proposal - Assignment Example The market has become so dynamic and requires every player to change tact and not stick with some of the old ways. We seriously need to rethink our policy on publicity matters. We will need to have a public relations department headed by a professional and given adequate staffing to help with selling the company brand. There is need for an all-out campaign aimed at improving the image of the company and giving it a more modern touch. We should realize that we have not done better than hold onto the clientele base we had more than 10 years ago when some of our competitors had either not emerged or were still very young in the industry. Younger generations do not identify with our brand. Our publicity approach should contain a mix of the social media and radio/TV adverts which both the old and young generations can identify with. We don’t want to continue losing clients instead of retaining and adding more, because that is known to be the surest route to collapse. There is need to set aside physical and monetary machinery to implement the publicity agenda. It is going to cost us quite some money as we start on it, but continued publicity measures will be less costly. Any amount of resources that will be spent in the pursuit of lost glory, it will be worth it. We are never going to regret having spent enormous sums of money towards improving the company’s brand it is the only way to expand our customer base beyond what we have currently. Let us strive not to succumb to competition, but learn to live with it and be able to handle its dynamics. We will need to work as a team to be able to achieve this. We have to walk together to deliver the best brand possible. It will require sacrifice on the part of each and every one of us, but this will take immense support of the company’s top management. All we will ask of the management is an enabling environment for

Corellation Between Spirituality, Emotions Essay Example for Free

Corellation Between Spirituality, Emotions Essay Abstract   The purpose of this paper is to describe the changes during pregnancy, which is influenced by various factors like lifestyle modification, emotions and spirituality. The paper first discusses in detail about the stress and emotional changes, which occurs during pregnancy and its impact on both child and mother. These results are also supported with proper evidence from various research.   Secondly, paper discusses about how lifestyle modification in pregnant women affects the child and mother and these results are supported by evidence from various research.   Finally, the paper discusses about the spiritual believes and its impact on pregnant women. INTRODUCTION Pregnancy is a life event for which most women look forward too. The symptoms of pregnancy might sometimes be distressing but ultimately, it is all worthwhile. Women’s life changes completely during this period. This is the most stressful as well as memorable period in a women’s life. Proper planning before pregnancy to overcome the physical and emotional changes is highly essential. Since, lifestyle modification, stress, anxiety and diet changes produce major impacts in pregnant women and the fetus, the need for proper life style modification during pregnancy is recommended by all physicians. This paper discusses the impact of three major factors Stress, life style modification and spirituality in pregnant women with empirical evidence from various research studies. STRESS AND RELATED IMPACTS IN PREGNANT WOMEN   Expectant women are subject to stress due to several factors, which includes physical changes during pregnancy, environmental changes, lifestyle changes and several other factors. Pregnant women besides physical changes also experience emotional changes at time of pregnancy. Mood swings are common and women will face emotional ups and downs in early pregnancy because of hormonal changes. Its is common for pregnant women to cry or get angry and upset for no apparent reason.    Pregnancy Changes related to stress During first trimester, the pregnant women spend most of their time by realizing the fact that they are pregnant. They experience themselves inwardly and try to understand and overcome the fears about the pregnancy. This must be the case only when the women experiencing the first pregnancy. In later pregnancy, they become more familiar with the changes. At first pregnancy, pregnant women are subjected to many fear such as fear about discontinuing the job, lifestyle changes, responsibility, economical constrains etc. Insecure feelings are common during the early stage of pregnancy. Mood swings grows higher leading to unusual behaviors. The pregnant woman may laugh or cry for irrelevant things. These are often related to hormonal changes in the body. However, researchers believe that hormonal changes during pregnancy augment the force of the feelings and do not causes mood change. Few researchers has identified that the amount of anxiety is heavier in pregnant women who bears a boy baby, for which the reasons are unidentified. In the second trimester, the expectant mother slowly comes out of fear and anxiety, which they experienced during the first trimester and starts feeling better as by now they start experiencing the movement of the baby. During this period, the understanding between the husband and wife starts growing and slowly they accept the existence of baby. The woman starts showing changes physically as she gain weight, also fear and anxiety grows rapidly during this period as fear of miscarriage or disaster to the baby or to herself develops. Speaking out about the fear to her husband or to someone close would relive herself from stress. During the last stage of pregnancy, the pregnant mother experience more fear and stress. As they grow larger in size, they experience low self-esteem and expect more attention from all the dear ones especially from her husband. They fear more regarding delivery complications.    Physical stress during pregnancy and its impact Physical strain during pregnancy is equal to emotional strain. High physical stress during pregnancy is not advisable as it has possibility of inducing preterm delivery among pregnant women. â€Å"In a research conducted by Mozurkewich and Colleague among the employees of pregnant women in U.S who had performed increased physical work has given birth before their deliver date. In another study conducted among the women in France has shown similar results.    Stress and its impact on diet Stress, tension, low energy, exhaustion and other emotional changes can influence the diet preference by the pregnant women. According to the study conducted by the ‘Johns Hopkins Bloomberg School of Public Health’, â€Å"the diet of the expectant mother would affect the growth of the fetus and the wellbeing of the infant. According to this study which was conducted by ‘Kristen Hurley, Janet DiPietro, Kathleen Costigan and Laura Caulfield’, â€Å"Mother who experienced more fatigue during the pregnancy period consumed more amount of energy rich foods and zinc and consumed less folate. Expectant mothers who felt more stressed munched more amount of snacks and carbohydrate foods and also consumed lots of foods which is rich in fat, protein, iron and zinc. Worried feelings were connected with poorer consumption of vitamin C. Mothers who were stressed by pregnancy experience ate less meat.†Ã‚   â€Å"While pregnant women eating more amount of food may lead to increase in micronutrients and decrease the intake of other important nutrients like folate and vitamin C†, says, ‘Laura Caulfield, Ph.D. an associate professor at the Bloomberg School of Public Health’s Centre for Human Nutrition’.    Stress and its effect on the fetus Stress during pregnancy can bring about several changes in mother and child’s health. It affects the heart rate of the pregnant women. It also brings about blood pressure and anxiety in women. â€Å"According to Catherine Monk of Columbia University, emotional changes during pregnancy result in heart problems in pregnant women and have major effect on the fetus.†Ã‚   Earlier research has shown that stress during pregnancy leads to under weight babies and premature babies. Researcher has found that heart rate of mother is associated to heart rate of the fetus and when mother is stressed or worried, it affects the infant directly. Researchers from John Hopkins University and National Institute of Child Health Development (NICHD) in their research have found that emotional changes during pregnancy have direct impact on child’s behavior. Mother with increased emotion and fear of pregnancy has children with poor behavior skills and emotional disorder.  Ã‚  Ã‚   â€Å"According to Janet A. DiPietro, PhD, a developmental psychologist and professor at John Hopkins Bloomberg School of Public Health, increased stress during pregnancy results in chemical changes which manipulate the organ growth and development of the fetus.† Thus, it is essential for a pregnant women to be free from stress and emotions during and after pregnancy to give birth to a healthy baby and to maintain her own health. LIFESTYLE CHANGES AND ITS IMPACT IN EXPECTANT MOTHER Lifestyle modification during pregnancy affects both mother and child especially when seems to be negative. Expectant mothers who are involved in habits such as Cigarette, alcohol, caffeine etc are under risk of developing breast cancer, delivery complications and pass the risk of behavioral disorder to their child. Apart from this diet, modification and exercise pattern also has impact on child’s growth. Expectant mother with eating disorder or overeating habits are prone to low-birth weight or over weight babies. Alteration in diet with inadequate nutrients or over nutrition leads to gestational diabetes. The child born to such parents develops Type I diabetes and are also at risk of developing cardiovascular problems. Lower folate consumption before and during the time of pregnancy would lead to birth defect and neurological problems. Hence, proper nutrition intake before and after pregnancy is essential. Consumption of Alcohol at the time of pregnancy leads to abortion, affects the fetus development, causes serious birth defects particularly the intellectual growth of the child. Hence, it is advisable to avoid alcohol consumption before and during pregnancy. Pregnant women who drink heavily are at risk of giving birth to child with alcohol syndrome i.e. a syndrome, which has major effect on mental and physical health. Similarly, pregnant women who consumes higher amount of caffeine are also at risk of developing miscarriage and birth defects. In addition, heavy exposure to chemicals can lead to birth defects. Various studies have shown that exposure to hazardous chemicals as solvents at work place have resulted in increase in the risk of abortion or birth defects. Apart from these, exercise during pregnancy is highly essential. Exercise during pregnancy strengthens the lower back and lower abdomen. Lack of proper exercise would result in caesarian and delivery complications. Exercise can reduce the labor complications and the risk of delivery. Regular exercise and walking would be more effective if followed in the second and third trimester. It helps the pregnant women to be relieved out of constipation, discomfort due to increased weight, fatigue, backaches etc    Diet modification during pregnancy affects the child and the offspring A research study conducted by â€Å"Children’s hospital Oakland Research Institute by David Martin, M.D, Dr. Jennifer Cropley and Catherine Suter from Victor Chang Heart Institute in Sydney, November 2006, has found that, ‘ mother’s diet during pregnancy   dose not only affect the health of her child but also affects the health of the grandchildren by changing the behavior of specific gene.† The researchers has performed the study on Avy mouse (yellow in color) which posses gene similar to human genes. The researchers during the research has used two group of pregnant mouse of which one group was fed with usual diet consumed by human and the other group was provided with supplements such as folate, vitamin, zinc etc along with the normal diet during the middle of the pregnancy. The similar experiments were followed for the offspring’s. The results of the study revealed that mouse without the supplement diet in both the experiments has shown considerable alteration in the gene resulting in the change of color from yellow to brown and were also found to be unhealthy and are at risk of cancer. Though it is, the known fact that mother’s diet would have considerable impact on the child’s health this is the first study, which has compared the correlation between mother’s diet and its impact in offspring. According to ‘Kenneth Beckman, Ph.D. Assistance Scientist at CHORI and a member of Project Export Centre of excellence in Nutritional Genomics, said, â€Å"The supplements provided during the pregnancy of the mother benefited the grand children even when the mother of the grandchild did not consume diet with supplements. Thus, maternal diet could have long lasting implications which extends for generations and even centuries.† Overeating and its impact on child  Ã‚   According to the research from ‘Oregon Health and Science University, September 2006’, â€Å"overeating during pregnancy may lead to several health problems to the child.†   Ã¢â‚¬Å"The researcher Kevin Grove, Ph.D., a scientist in ONPRC’s Division of Neuroscience in his research has confirmed that grandchildren off the expectant mother who overeat are at risk for liver damage and at a risk for early commencement of diabetes and obesity. Apart from this considerable change take place in the hypothalamus of the brain, which is responsible for the weight regulation.   He also states that children who are born to mother who consumes lots of fatty foods may be at a risk of diabetes and obesity.† The researchers have noted that pregnant female monkeys who were used for the research when provided with high fatty food passed on liver damage and pancreas damage to their offspring’s. The results were similar to humans when expectant women consumed high fatty food. It is clear from the above study that the need for a balanced diet among pregnant women is highly essential to prevent all health related problems to the child and the offspring. Another study conducted by world health organization there is a considerable increase in obesity related heart disease and metabolic disease among the present generation. Though the increase in obesity among present generation is because they consume high amount of fatty foods like sugar and saturated fats, on the other hand the obesity is also associated with increased consumption of energy rich food during pregnancy and during breast-feeding is one more reason for obesity among children’s. For several years it is has been stated that undernourished mother during pregnancy give birth to low birth weight babies which in turn affects the infant with heart related problems as it grows. However, latest studies reveals that apart form undernourished mother even the child born for mother who during pregnancy expose to energy rich food are also prone to heart disease. The study also revels that maternal diet has direct impact on child’s desire for food and maternal diet with increased energy food results in heart disease and other diseases like diabetes and hypertension in the later part of life. In such cases, the child develops abnormalities in aorta and in kidney resulting in severe disease as they grow up.    Smoking affects the child and grandchild Pregnant women may pass down the habit of smoking and its related disease to their child and to their grandchildren for continued generation.   Research study from Australia in 1982 has revealed the fact that children born to mothers who smoked during the time pregnancy started smoking before the age of 15 when compared to the children’s who were born to the mother who were non-smokers. At the same time, children’s of mothers who were smokers and gave up smoking at the time of pregnancy has shown similar results as children’s of mother who was non-smoker.   Thus, pregnant women are highly recommended to avoid smoking during pregnancy. Different study conducted by ‘Keck School of Medicine of University of California, states that use of tobacco and nicotine by the mother during pregnancy would result in lung diseases such as asthma to her children and grandchildren. The author Frank D. Gilliland, Professor of preventive medicine Keck School of Medicine states that smoking pregnant women will pass down long-term impact of lung disease in generations continuing for centuries. The research result shows that children’s and grandchildren’s of smoking mother at the time of pregnancy experienced problems of asthma from the age of five. Although the child of smoking mother did not experience any problem, the grandchild was highly prone to developing asthma. The researchers have also found that the nicotine present in the tobacco affects the DNA of the infant and affects the immune system of the baby. It is also found that nicotine from the tobacco affects the formation of the egg in the girl child as it grows. Thus, from above research studies it is clear that lifestyle modification in pregnant women would bring major impact in both child and mother. Few research has also proved that even grandchildren’s and further generation are affected by irregular dietary habits and alcohol and smoking habits. SPIRITUALITY AND ITS IMPACT ON EXPECTANT MOTHER Fasting seems to be one of spiritual activity, which has influenced most of the religious people especially Hindus and Muslims. People by fasting show their gratitude and love towards God. However, fasting when continued for more that two or three days leads to Lower Glycemic Index, reduces the protein and fat level in blood, increases the uric acid content, and possibly reduces the RBC and hemoglobin levels in the blood. If this is the case for normal people, when women with pregnancy undergoes fasting the results would be more drastic leading to ill health to both mother and child. As pregnancy is a crucial period and the mother is expected to consume the right amount of nutrition to maintain her health and the babies’ health, fasting during such period has to be avoided. According to a ‘Physician Gabriel Cousens, â€Å"fasting means to withdraw from that which is poisonous to the intellect, body and spirit. This can also be described as removal of corporal, emotional and psychological pollutant from our life, more willingly than merely staying away from or interrupting eating. Starving oneself for religious purposes typically involves taking away thyself from worldly duties.† On the other hand, in spite of the awareness for the need for proper nutrition some expectant mothers as being more religious blindly believes that by following rituals like fasting would bring God’s love and blessings to the child. Especially Muslim women’s during the period of Ramadan even if pregnant presume that fasting is obligatory for healthy wellbeing of child and mother. However, Islam is not too harsh on Muslim women’s who are pregnant. For that reason, no religion would be cruel to advice fasting during pregnancy. In Islam, the culture itself has prohibited such activity. Qur’an, has stated the following people not to fast during Ramadan, â€Å"pregnant women in her last trimester and also to avoid fasting by expectant mother if its is harmful to the mother and the child, women who is breast feeding, menstruating women and women who are in nifas.†Ã‚   According to Hadith, â€Å"the religion also states that if a expectant mother or the breast-feeding mother is subjected to health problems due to fasting, in such case they can fast the equivalent amount of days in another period of time.† Fasting are starving in the name of god is not ideal and it only spoils the health of the mother and baby. As pregnancy is an imperative period in women’s life attachment between mother and child grows right from the time of conception and develops with intake of right nutrition at right time. Impacts of fasting in Expectant women During pregnancy, the mother has to eat for two hence at this time going without food or starving without food due to spiritual reasons would affect both the child and mother. On the other hand, avoiding food at instance help the mother to remove the toxins from her body. Toxins loaded in the kidney, lungs, bladder, skin, intestinal track, respiratory track etc can be removed when avoiding food at some instances. However, this depends on the body condition of the women. In such cases the pregnant women has to take the advice of her doctor regarding her dietary habits. The culture of Islam states that fasting during first and second trimester of pregnancy is safer. This is also supported by the statement provided by ‘Dr. Shahid Athar; â€Å"according to him expectant based on health conditions can fast during the 1st and 2nd trimesters with the guidance and supervision from her obstetrician.† In a study conducted in Africa by researchers from Austin, nearly 89.5% of expectant women were fasting during the month of Ramadan. The result showed that blood glucose level in expectant mother who were fasting were significantly less than the normal amount which has resulted in gestational diabetes among these women. As no carbohydrate is available for producing glucose during the fasting period ketosis occur to avoid the loss of protein, which results in fall in insulin level and augmented weight loss. The research has proved that continuous fasting in pregnant women increase the risk of gestational diabetes, which results in over weight babies, caesarian, and stillbirth. Proper diet management under medical supervision and frequent blood testing for blood sugar can prevent gestational diabetes in pregnant women. Another research by â€Å"Kellymon has proved that fasting leads to dehydration, which thereby decreases the milk supply due to the decreased fluid level in the body.†   Ã‚  Ã‚  Ã‚   Another study by Centre for Advance for health in 2000 has revealed that pregnant mothers who starved during the first 14 weeks of pregnancy has given birth to child who are at high risk of heart disease. Form the research studies it is clear that fasting in the name of spirituality has shown adverse effect on both the child and mother. Although the belief of the expectant mother has to be considered, health related issues due to fasting have to be given priority. Since, the effect of fasting affects not only the mother but also the child, such beliefs has to be considered. The impacts of fasting last on child’s health for longer period and even it grows for several generations. CONCLUSION   As pregnancy is a crucial period in women’s life special attention and care during this period is more important. Pregnant women in general should be away from stress and try to keep them relaxed and peaceful. Excess stress can create severe impact on women’s health and in child’s health and also can lead to preterm delivery and miscarriage. Focusing on positive lifestyle changes before and after pregnancy could yield better results by improving the health and intellect of the baby. Thus for safe and healthy pregnancy, it is always better to be planed to avoid all harmful behaviors.    REFERENCES Shahid Athar, â€Å"Effects of Fasting in Pregnant Women during Ramadan†, Journal of Islamic Medical Association, November 1987. Hadith, â€Å"Studies on Fasting during Ramadan†, Islamic Horizon, October 2003. Kevin Grove, â€Å"Overeating and its impact on child†, Oregon Health and Science University, September 2006 Kristen Hurley, Janet DiPietro, Kathleen Costigan and Laura Caulfield, â€Å"Stress and its Impact in Pregnant Women,† Johns Hopkins University Bloomberg School of Public Health, June 2005.    David Martin, Dr. Jennifer Cropley, Catherine Suter, Kenneth Beckman, â€Å"Diet modification during pregnancy affects the child and the offspring†, Children Hospital and Research Centre at Oakland, December 2006. World Health Organization, â€Å"Obesity related to cardiovascular disease in children†, Blackwell Publishing Ltd, May 2005. Frank D. Gilliland, Yu-Fen Li, â€Å"Smoking during Pregnancy affects the Child and Grandchild†, Chest Vol. 128, No. 5, April 2005, Pp 1231-1241. Mozurkewich EL. â€Å"Working Conditions and Adverse Pregnancy Outcome.† Obstetrics and Gynecology 2001. 96:624-636.

Stereotype Threat Is A Phenomenon Psychology Essay

Stereotype Threat Is A Phenomenon Psychology Essay Membership in a stereotyped group is the one condition that must always be present in order for stereotype threat to occur. Everyone is a member of at least one stereotyped group, and is vulnerable to being affected by stereotype threat in different situations. Although greatly contested, women and members of ethnic minorities are not the only groups affected by stereotype threat. Research on stereotype threat has shown that a diverse set of groups can be affected by stereotype threat. Aronson, Lustina, Good, Keough, Steele, and Brown (1999) showed that White males performed worse on a math test when the performance of Asians in mathematics was made salient. In this context, White males are part of the stereotyped group because of the stereotype that White males are worse at math than Asian males. Individuals Who Identify Strongly With Groups Certain individuals are more vulnerable to stereotype threat than others because their memberships are salient to them in many situations. These individuals strongly identify with groups which use gender or ethnicity as inclusive criteria. This strong identification with groups can make stereotypes chronically accessible (what does this mean?). In turn, they will increase stereotype threat more often and in varying situations. Whereas certain individuals need to have their stereotyped group membership made salient, these individuals are always aware of their stereotypes. Marx, Stapel and Muller (2005) found that the performance of women on a math test was inversely proportionate to the degree to which their gender was emphasized. Cole, Matheson and Anisman (2007) found similar results. Higher ethnic identification predicted greater psychological distress and poorer performance for minority students in their first year of college. Stereotype Belief and Knowledge Though stereotype threat can arise in situations where the person is unconsciously aware of the stereotype, it is more easily processed when the person is aware or knowledgeable of the stereotype. Since adults are usually aware of many stereotypes, McKown and Weinstein (2003) conducted a study that examined the knowledge of stereotypes by children and its effects on their performance in domains that produce stereotype threat in adults. The researchers found that children who were aware of stereotypes were more likely to show effects of stereotype threat. Belief of stereotypes is another factor that affects the degree to which a stereotype threat is experienced. In a study by Schmader, Johns, and Barquissau (2004), women who endorsed gender stereotypes about womens math ability did worse on a task in the stereotyped domain when under stereotype threat more so than their counterparts who did not endorse a gender stereotype. Consequences of Stereotype Threat Decreased Performance on Tasks Test performance in academic settings is the context in which most stereotype threat research is conducted. Cole, Matheson and Anisman (2007) found that ethnic minority students at a predominantly White Canadian institution showed increased levels of anxiety and depression compared to the White students, and had lower grades at the end of the school year. Scores on Ravens Advanced Progressive Matrices (APM) task, a task that has been described as being a pure measure of cognitive ability and culture-free, have been shown to be affected by stereotype threat (Brown Day, 2006). Performance on tasks in other domains has also been affected by stereotype threat. Undergraduate female golfers performed more poorly when the stereotype of females being poor golfers was purported either subtly or blatantly (Stone McWhinnie, 2008). The reason for reduced performance when under stereotype threat has been attributed to factors such as anxiety (Max Stropel, 2006), physiological arousal (Blascovic h et al., 2001) and reduced working memory capacity (Schmader and Johns, 2003). Changes in Appraisal of Situations When faced with stereotype threat, individuals use different strategies to account for lapses in their performance. Some individuals attribute internal reasons/causes as to why they failed the task. In a study by Koch, MÃ ¼ller, and Sieverding (2008), participants were asked to find a document on a computer and save it to an external storage device. Participants were told that women perform worse on the task than men (stereotype threat condition for women) or that women perform better on the task than men (stereotype threat condition for men). Women in the stereotype threat condition were more likely to make internal attributions for their failures than men in the same experiment. Self-handicapping is another strategy used by individuals affected by stereotype threat. These individuals erect barriers to performance in order to provide attributions for their failure (Stone, 2002). A specific type of self handicapping is task discounting. Tasks are critiqued in some way in order to ex plain poor performance. A study by Lesko and Corpus (2006) found that women who were taking part in a math task and under stereotype threat were more likely to agree with statements such as this test is not an accurate measurement of my math ability. Reducing Stereotype Threat Reframing the Task Stereotype threat can arise when task descriptions or test instructions make threatened identities and negative stereotypes more accessible. Ergo, stereotype threat can be reduced by reframing a task in such a way that stereotypes are not invoked or made salient. Steele and Aronson (1995) were able to reduce stereotype threat by explicitly stating that a test was not diagnostic in nature. Though this strategy is unrealistic in regular testing situations, other task reframing methods have been shown to be equally effective. Gender stereotypes are common, and affect the performance of women in stereotyped domains (Spencer, Steele Quinn, 1999). However, gender stereotypes and their subsequent effect on test performance can be reduced by reframing the task. For example, Spencer, Steele and Quinn (1999) showed that when both male and female participants completed a mathematics test and were told that there would be gender differences, the males outperformed the females. Contrarily, when the task was reframed and the participants were told that there would be no gender differences, the scores of the male and female participants were equivalent. Another task reframing strategy is addressing the fairness of the task. Good, Aronson and Harder (2008) were able to reduce stereotype threat present on a mathematical ability test by assuring the test takers that this mathematics test has not shown any gender differences in performance or mathematics ability. Even the though the tests outlined in the above studies were diagnostic in nature, reframing the tasks was able to negate potential stereotype threat effects. Task reframing strategies can be employed by testing agencies in order to reduce the potential effects of stereotype threat, which can affect the scores of test takers belonging to certain demographics on standardized tests. De-emphasizing Threatened Identities Stereotype threat can be reduced in situations where the threatened social identities are made less salient. Threatened social identities can consist of gender, ethnicity, socioeconomic status and other domains that are often stereotyped. Stricker and Ward (2004) conducted field studies that examined the effects of asking about ethnicity prior to Advanced Placement (AP) calculus exams. A re-analysis of their data by Danaher and Crandall (2008) found that soliciting identity information at the end of the exam decreased sex differences in test scores by 33% compared to when identity questions were asked at the beginning of the exam. Danaher and Crandall concluded that if the demographic questions were asked at the end of AP calculus exams, 4700 additional female students would receive a credit annually. Stereotype threat can also be reduced if individuals are encouraged to think in ways that reduce the significance of the threatened identity. Ambady, Paik, Steele, Owen-Smith and Mitchell (2004) found that when women were individuated by having aspects of the self made more salient, they performed better on a difficult math test than women who were not individuated. The researchers concluded that individuation allows individuals to distance themselves from the threatened social identity. Emphasizing the similarities between groups has also been shown to reduce stereotype threat. Rosenthal, Crisp and Sue (2007) found that generating similarities between men and women in academic settings led to higher performance expectations and improved performance by women in a stereotyped domain. Rosenthal, Crisp and Sue (2007) selected mathematical ability as the stereotyped domain in which similarities between ingroup and outgroup employment strategies would be tested. Individuals with multiple social identities have a low risk of being affected by stereotype threat. Gresky, Ten Eyck, Lord and McIntyre (2005) examined the role of multiple social identities in undergraduate university students. The participants were instructed to answer questions from what was supposedly a new version of the GRE math exam. Stereotype treat was induced by informing the participants that men usually outperform women on math tests. The participants were then split into three conditions. Before the math test, some subjects were instructed to create a simple self-concept map whereas others were instructed to create a complex self-concept map. Subjects in the control condition did not create a self-concept map. The female participants who did not create a self-concept map or created a simple self-concept map performed poorly on the math test whereas the female participants who were instructed to create a complex self-concept map were unaffected by the stereotype threat ma nipulation. Creating self-concept maps did not have an effect on the scores of the male participants, presumably because they were not affected by the stereotype threat manipulation. Consequently, encouraging stereotype threatened individuals to think of themselves as multifaceted individuals reduces vulnerability to stereotype threat effects. Though all people have multiple identities, some are more vulnerable to stereotype threat than others. This can be explained by the fact that different social identities are highlighted to different degrees in individuals. Having stereotyped social identities that are easily highlighted (not the right word) increases the vulnerability of an individual to stereotype threat. Mcglone and Aronson (2006) demonstrated this effect by instructing participants to complete the Vandenberg Mental Rotation Test (VMRT) in varying conditions of identity salience. This salience was achieved by having participants complete questionnaires that highlighted different social identities. For the male participants, performance on the VMRT was best when gender was made salient and worst when their status as citizens of the Northeast was made salient. The female participants performed the best when their college identity was made salient and performed the worst when their gender was emphasized. Affirming Self-Worth Stereotype threat acts on an individuals fear of confirming negative stereotypes (Steele Aronson, 1995). Self-affirmation can be used as a strategy to protect the self from perceived threats. Self-worth can be increased by encouraging people to think about characteristics, roles and skills that they are proud of or view as important. Schimel, Arndt, Banko and Cook (2004) examined whether self-affirmation and affirming self-worth can protect individuals from stereotype threat. Before completing a math test, female participants were randomly assigned sentence fragments to complete that provided either intrinsic affirmation, extrinsic affirmation or no affirmation. The participants were also placed in either a stereotype threat or control condition. The researchers found that women in the stereotype threat condition who reaffirmed their self worth by completing the sentence fragments that provided intrinsic motivation performed better on the exam in the stereotype threat condition than in the control condition. Conversely, women in the stereotype threat condition who extrinsically self-affirmed performed worse in the stereotype threat condition compared to the control condition. Cohen, Garcia, Apfel and Master (2006) came to similar conclusions when studying seventh grade students in racially diverse middle schools. Students were assigned to self-affirmation conditions and no self-affirmation conditions. The students in the self-affirmation condition were instructed to write an essay that indicated values that were important to them and why they were important to them. Students who did not self-affirm were instructed to write an essay about their least important values and why they were not important. The researchers found that African-American students in the self-affirmation condition performed 0.3 grade points better over the semester compared to African-American students who did not self-affirm. These results are notable because African-American students are the demographic that is usually most affected by stereotype threat in academic settings. As a result, enhancing the individuals internal coping capacity through providing affirmation has shown to improve the performance of individuals that are most susceptible to stereotype threat. Providing Role Models Individuals who focus on outgroup members who perform well on a specific domain have a negative effect on their performance on tasks from that domain. Huguet and RÃ ©gner (2007) showed that the performance of female participants on a math test in a mixed environment was negatively affected by their thoughts about males who performed well in mathematics. This type of stereotype threat effect can be reduced by providing ingroup role models that are proficient in a specific domain. Marx and Roman (2002) examined this effect by providing females with role models who were competent in math. Male and female participants were given a difficult math test to complete. When the experimenter was a male, the female participants performed poorer on the exam than the male participants. However, when the test was administered by a female who embodied subject confidence, the female participants performed equally as well as the male participants. The role models provided do not need to be present in order to reduce stereotype threat. Various studies have shown that stereotype threat can be reduced by providing role models through priming. McIntyre et al. (2005) examined the relation between exposure to positive role models through priming and reduction of stereotype threat effects. Undergraduate students were asked to participate in two studies, and were told that women perform worse than men on math tests. The researchers also manipulated the tasks by having the participants read anywhere from 0-4 essays describing successful women. The researchers found that the performance of the female participants increased as the number of essay read increased, supporting the finding that providing role models decreases stereotype threat effect. Attributing Difficulties to External Factors The effects of stereotype threat can be reduced if difficulties on tasks are attributed to external factors rather than the self. Ben-Zeev, Fein, and Inzlicht (2005) illustrated the effect of attributing difficulties to external factors on stereotype threat. Women who identified highly with mathematics completed a math test in the presence of either 2 males (stereotype threat condition) or 2 females (control condition). Participants were also shown a subliminal noise generator before the test. They were told that the machine would either increase arousal and heart rate or that it would not produce any adverse effects. The female participants in the stereotype threat condition performed worse on the math test only when they were told that the subliminal noise generator would not produce any adverse effects. The participants who were told that the machine would increase arousal attributed their difficulties to the noise generator, and did not experience stereotype threat effects. Provi ding subliminal noise generators are not practical in normal testing situations. However, recent studies have used different techniques to produce the same effect. Johns, Inzlict and Schmader (2008) eliminated stereotype threat effect by telling individuals under stereotype threat conditions that the anxious feelings they were experiencing would not hinder their performance, and might even improve their performance. Attributing difficulties to external factors is a strategy that can be utilized effectively in order to reduce stereotype threat. Conclusion Stereotype threat is highly pervasive and is not restricted to people with certain characteristics or backgrounds. Although it can affect anyone, certain individuals are more susceptible to the effects of stereotype threat than others. The effects of stereotype threat make it a serious problem that needs to be addressed. The literature has revealed that although stereotype threat cannot be completely eliminated, certain cognitive reappraisal strategies can help reduce or attenuate its effects. These strategies include reframing tasks, providing role models, providing external attributions for difficulties and deemphasizing threatened social identities. These strategies have been shown to be effective, and should be considered in situations where stereotype threat is known to be present.

Role of agriculture cooperative societies

Role of agriculture cooperative societies PRIMARY AGRICULTURE COOPERATIVE SOCIETIES An agricultural cooperative society, also known as a farmers co-op, is a cooperative where farmers pool their resources in certain areas of activity. A broad typology of agricultural cooperatives distinguishes between agricultural service cooperatives, which provide various services to their individually farming members, and agricultural production cooperatives, where production resources (land, machinery) are pooled and members farm jointly. Agricultural production cooperatives are relatively rare in the world, and known examples are limited to collective farms in former socialist countries and the kibbutzim in Israel. Worker cooperatives provide an example of production cooperatives outside agriculture. The default meaning of agricultural cooperative in English is usually an agricultural service cooperative, which is the numerically dominant form in the world. There are two primary types of agricultural service cooperatives, supply cooperative and marketing cooperative. Supply cooperatives supply their members with inputs for agricultural production, including seeds, fertilizers, fuel, and machinery services. Marketing cooperatives are established by farmers to undertake transformation, packaging, distribution, and marketing of farm products (both crop and livestock). Farmers also widely rely on credit cooperatives as a source of financing for both working capital and investments. Various development activities in agriculture, small industry marketingand inprocessing, distribution and supplies are now carried on through the co-operative societies. The co-operatives societies have madean all-round progress and their role in, and contribution to agricultural progress has particularly been significant. The schemes regarding the construction of godowns and the conversion of villages into model villages have assumed great importance in the wake of the Green Revolution. INTRODUCTION OF COOPERATIVE MOVEMENT The Co-operative Movement was introduced into India by the Government. It is the only method by which the farmers could overcome their burden of debt and keep them away from the clutches of the money-lenders. The Co-operative Credit Societies Act, 1904 was passed by the Governmentof India and rural credit societies were formed. Through the appointment of registrars and through vigorous propaganda, the Government attempted to popularize the Movement in the rural areas. Within a short period, the Government realized that there are some shortcomings of the 1904 Act and, therefore, passed a more comprehensive Act, known as theCo-operative Societies Act of 1912. This Act recognized non-credit societies also. But the rural credit societies have continued to be predominant till now. MAIN FEATURES: PRIMARY AGRICULTURAL CREDIT SOCIETIES Assessment of credit needs Disbursement of credit to members Recovery of credit Promote the economic interests of the members DISTRICT CENTRAL COOPERATIVE BANKS Serve as balancing centre in the district central financing agencies Organise credit to primaries Carry out banking business Sanction, monitor control implementation of policies STATE COOPERATIVE BANKS Serve as balancing centre in the state Organize provision of credit for credit worthy farmers Carry out banking business Leader of the cooperatives in the state NATIONAL FEDERATION OF STATE COOPERATIVE BANKS Provides a common forum to the member banks Promotes and protects the interests of the member banks Co-ordinates and liaison with government of India, RESERVE BANK OF INDIA , NATIONAL BANK AND OTHERS Provides research and consultancy inputs to the member banks Organizes conferences/seminars/workshops/meetings THE PRIMARY AGRICULTURAL CREDIT/SERVICE SOCIETIES The agricultural co-operative credit structure is broadly divided into two sectors, one dealing with the short-terms andmedium-terms finance and the other with the long-term credit. The short-term and medium-term credit structureis based on a three-tier system, i.e., the Apex Co-operative Bank at the State level, the Central Co-operative Bank at the district/tehsil level and the Primary Agricultural Credit Societies at the village level. The major objectives of the primary agricultural credit service societies are to supply agricultural credit to meet the requirements of funds for agricultural production, the distribution of essential consumer commodities, the provision of storage andmarketing facilitiesand for light agricultural implements and machinery. Owing to an increasing emphasis on the development of land and agriculture, long-term co-operative credit has assumed great importance. There is the Punjab State Land Mortgage Bank at the Apex and the Punjab Mortgage Bank at the district/tehsil level. These Primary Land Mortgage Banks advance loans to the farmers for long term purposes. At the operational level, there exists a primary co-operative to extend credit to the farmer. This unit epitomizes the vitality and service potential of the Co-operative Movement in India. The organization of these societies dates back to 1904, when the first Co-operative Societies Act was passed. These societies were started with the object of providing cheap credit to the agriculturists in order to free them from the clutches of the rapacious money-lenders. The agricultural primary credit society is the foundation-stone on which the whole co-operative edifice is built. Even now these societies dominate the co-operative picture. The first Agricultural Credit Society in the Firozpur District was registered on 4 October 1911, at the Village of Khalchi Kadim in the Firozpur Tehsil. Originally, the movement was confined to the credit societies only and, thus, credit dominated till the partition (1947). After the partition, the Co-operative Movement began to spread to other field, viz labour, construction and farming. AGRICULTURAL NON-CREDIT SOCIETIES While credit is and must remain for some time the chief concern of the Co-operative Movement relatively slow, since 1912, when the non-credit societies were brought officially under the aegis of the Movement. The World War II (1939-45) came as a God send boon with respect to the development of the Co-operative Movement. Prices of agricultural goods began to rise and touched new peaks. The repayment of loans was accelerated and depositsbegan to pour in. The number of societies also rose. Another interesting development in co-operativeduring the War was the extension of the Movement to non-credit activities, viz. Consumers co-operative marketing societies, consolidation societies, etc. Agricultural co-operative Marketing Societies: Marketing has occupied a far smaller place in the co-operative picture in India than in many countries, notably Denmark and the USA, but not other non-credit line of co-operation, with the possible exception of the consolidation of land holdings and joint farming enterprises,seems to holdgreater possibilities of help to the agricultural population of India. The development of co-operative marketing in India is closely bound up with the problem of credit-the claims of the money-lenders commonly inhibiting the cultivators freedom of action in disposing of his crop. The full utilization of loans advanced depends upon the arrangements for the marketing of surplus produce. For this purpose, there the Punjab State Marketing Federation at the State Level, wholesale societies at the district level and marketing societies at the market level. These societies also provide other agricultural facilities and make arrangements for the supply of domestic items in the rural areas. At the State level, the Punjab State co-operative Supply and Marketing Federation (MARKFED) is playing an important role in building up an integrated structure for remunerative marketing and storing of agricultural produce. it has played an important role in hastening the Green Revolution in the State by arranging ready supplies of essential farm inputs needed by the cultivators. Co-operative Farming Societies: The Royal Commission on Agriculture in 1928 observed that it co-operation failed, there would fail the hope of the Indian agriculturist. Co-operative farming is a compromise between collective farming and the peasant proprietorship and gives all merits of large-scale farming without abolishing private property. It implies an organization of the farmers on the basis of common efforts for common interests. Under this system, all landowners in a village form a co-operativesociety for tilling the land. The land is pooled, but each farmer retains the right of property. The produce is distributedby each. They are allowed to withdraw from the co-operative farm whenever they desire. In India, the exceedingly small size of holdings is perhaps the most serious defect in our agriculture. If agriculture has to be improved, the size of the holdings must be enlarged. TYPE OF SOCIETIES Co-operative Weavers society Co-operative Consumers Societies Co-operative Housing Societies Co-operative Womens Societies Co-operative Milk-Societies NAME OF THE SOCIETY ADAWAD Primary Agriculture Co-operative Credit SOCIETY (713/29-1-1914) AKULKHEDE Primary Agriculture Co-operative Credit SOCIETY (7769/7-6-1937) ANWARDE BK. Primary Agriculture Co-operative Credit SOCIETY (7873/16-3-1939) ANWARDE KD. Primary Agriculture Co-operative Credit SOCIETY (5291/30-6-1926) ADGAON Primary Agriculture Co-operative Credit SOCIETY (5497/26-6-1926) AKHATWADE Primary Agriculture Co-operative Credit SOCIETY (3652/18-10-1921) BIDGAON Primary Agriculture Co-operative Credit SOCIETY (9421/18-03-1946) BUDHGAON Primary Agriculture Co-operative Credit SOCIETY (5182/10-03-1926) CHALLENGES BEFORE CO-OPERATIVES The Indian Co-operative Movement has earned distinction of being the largest in the world. This is true in terms of membership and Co-operative network which spread over almost all the villages in the country and the number of Co-operative Societies. In our country: There are about 5.5 lakhs of cooperative Societies with membership of more than 22crores. It covers a wide range of commercial activities and nearly 50% of them are engaged in agriculture and agriculture related matters. Nearly 70% of the Indian population being dependant on agriculture, is thus, connected with agricultural Co-operatives. Co-operatives have covered 100% of villages and 67% of rural households. Co-operative sector contributes 50% of total agricultural credit and distributes 35% of total fertilizer consumption in the Country. They are procuring 60% of total sugar-cane. They are also playing crucial role in the agro-processing sector i.e. processing of sugar-cane, milk, cotton and oil seeds etc. Dairy Co-operatives have excelled in their area of operation and have enabled India to attain top position in milk production in the world. Edible oil marketed through Co-operative channel is estimated at 50% and handloom Co-operatives account for 55% of the total out-put. But in spite of being largest movement in the world and strongest link, it faces number of challenges like lack of internal resources and poor mobilization of external resources, inadequate infrastructure, competitive tier structure, apathy of members towards management, lack of accountability increasing sickness, dormancy, low level professionalism, excessive government control, political interference, dominance of vested interest over the management, lack of human resources development, education and training. Despite all challenges, Co-operatives have to be sustainable over a period of time for which professionalism is a must. Co-operatives have been looking for Governmental help. But they have been paying of it like official domination and interference in their day-to-day working etc. Dr. Kuriyan, an eminent co-operator in the country said recently that the Co-operatives have undergone a crisis of identity being neither government nor private. He further said that Co-operatives need to be more efficient and competitive, but at the same time they cannot sacrifice the basic tenets of co-operation. Inefficient Co-operatives will have to either pull up their socks or down their shutters. Co-operatives have many advantages in tackling problem poverty alleviation, employment generation and food security. They also have the potential to deliver goods and services in areas where both the State and Private sectors have failed. Over the past few years, steps like the enactment of mutually aided Co-operative Societies Act by some States and the Multi-State Co-operative Societies Act have been taken to give the Co-operative sector a boost. But we are aware that the Co-operatives registered under the Mutual Aided Act have certain constraints and deficiencies, which may be Lack of supervision and inspection by Registrar of Co-operative Societies resulting into financial misuse and disproportion institutional development. Government is hesitating to entrust any important government work since it does not have any participation. These Co-operatives are away from the mainstream. The Co-operative Banks and other important institutions are not prepared to admit them as members. NABARD and RBI are not agreeing for conversion of Central and Urban Co-operative Banks. R.B.I. has also objection about the use of word Co-operative since Banking Regulation Act uses the word Co-operative Society. Perhaps we are not prepared or educated or sensitized enough to work without control and supervision. Mischievous persons may take advantage of the situation to cheat the general public. When the Government is exploring the possibility of regulating the Non-governmental organizations having vast experience, it is doubtful as to whether the mutually aided Co-operatives in various fields can give desired result. The circumstances and the situation give rise to the Co-operative Movement in the Country are still prevalent. The market is still not accessible to small and marginal farmers. Supply of agricultural credit is not adequate. About 50% of our rural and tribal household still has no facility for institutional credit. The Co-operatives are today at the cross road at their existence, particularly in view of the fast emerging economic liberalization and globalization. The Co-operatives still continued to function in a traditional way with poor governance and management, poor resource mobilization, outside interference, dependence on Government and lack of professionalization. The Co-operatives are neither member-driven nor functioned professionally in a transparent manner with accountability to members. In spite of all these, no doubt, the Co-operatives have contributed a lot to the agriculture development of the Country. We cannot afford to see that these institutions wither away. It need s reform. It is not-worthy to say that in the National Common Minimum Programme of present UPA Government it has been mentioned to bring constitutional amendment to ensure the democratic autonomous and professional functioning of Co-operatives. The constitutional amendment may limit itself with timely conduct of elections timely conduct of audit, uniform tenure of managing committee conduct of general body meetings right of a member for access to information and The accountability of the management. In this context the strategies may be as follows. Co-operatives need be member-driven; stakeholders should have a command over its affairs and activities. There is need for more transparency, more of interaction and confidence -building measures. Aggressive marketing strategy be adopted for sensitizing members and general public about the service and quality rendered by the Co-operatives. Commitment to best Service and pursuit for excellence should be the hallmark of Co-operative. Every society should adopt their customers or members charter and should meticulously adhere to this charter. Co-operative should compete with other players in prevailing market forces without any protectionist or discriminator approach. In respect of short-term, medium-term, long-term sector and Urban Bank sectors, restrictions have been stipulated by Reserve Bank of India, NABARD in respect of finance. These restrictions need be liberalized which would help Co-operative to optimize its lendable resources and provide finance to members. Strengthening information and database of Co-operatives is of utmost importance. MIS need be adopted by the process of computerization and inter-connectivity to provide best services to members and customers with anytime and anywhere service. Professionalization of management is one of the basic prerequisites of Co-operatives. Both the personnel as well as directors of committee of management should be exposed to regular training, interaction and orientation. Adoption of scientific planning for deployment of human resources on the principle of right man for the right post at right time would help Co-operatives to accelerate the pace of reforms. Human resources need be proactive. Motivation, recognition for good work and leadership be inculcated for augmenting productivity. Basic tenets corporate governance is adopted like fair play, transparency and accountability. The PACS, as the foundation of the Co-operative system are meeting the development needs of the farmers by providing credit, inputs and storage and processing and marketing facilities. The Co-operative federated at the district and State level constitutes the Co-operative system. But it is found that the Apex institutions have grown stronger whereas the primaries and in some cases, Central Co-operatives have gone weaker. The situation has to be changed and the primaries have to grow stronger. The business of the Primary Societies has to be diversified. AGRO-INPUTS DISTRIBUTION IN AGRICULTURAL COOPERATIVES Agricultural Cooperatives in India are very actively and intimately involved in several agriculture related activities. The most important activities are the disbursement of production credit and distribution of fertilizers and other inputs viz seeds, pesticides and agricultural implements. Agricultural Cooperatives are also involved in procurement of farm produce, processing and marketing of oilseeds, Cotton, sugar, milk and milk products, distribution of essential commodities, clothes, kerosene oil and merchandise etc. Coop. movement in India started way back in 1905. Till 1939, Agricultural Cooperatives in India were distributing only the credit to the farmers. Its activities got diversified to consumer articles and also some agricultural inputs in the rural areas over a period of time. Subsequently, based on the suggestions made by different committees and commissions, the cooperatives were given a significant role in distribution of fertilizers. Currently, cooperatives are playing a significant role both in production and marketing of fertilizers. Cooperatives Role in Agricultural Credit Disbursement Cooperatives play a very important role in disbursement of agricultural credit. Credit is needed both by the distribution channel as well as by the farmers. The distribution channel needs it to finance the fertilizer business and farmers need it for meeting various needs for agricultural production including purchasing fertilizers. The credit needed by the farmers for purchase of fertilizers and other inputs is called short term credit or production credit whereas credit needed by the distribution channel is called Distribution Credit. Cooperatives also play a very important role in disbursement of Medium Term and Long Term credit needed by the farmers for purchasing agricultural equipments viz tractors, installation of tube wells and land development works etc. will not be able to adopt the modern agricultural practices unless they are supported by a system which ensures adequate and timely availability of credit on reasonable terms and conditions. Credit in India is made available to the farmers through a multi-agency network consisting of cooperatives, commercial banks and Regional Rural Banks (RRBs). However, cooperatives accounts for a large proportion of the agricultural credit made available to the farmers. National Bank for Agriculture and Rural Development (NABARD) was established in the year 1982 by an Act of Parliament and was entrusted will all matters concerning policy, planning and operation in the field of credit for agriculture and other economic activities in the rural areas. Before that, this job was being done by Reserve Bank of India itself. NABARD works for progressive institutionalization of the rural credit and ensures that the demands for credit from agriculture including the new and upcoming areas like floriculture, tissue culture, bio-fertilizers, sprinkler irrigation, drip irrigation etc. are met. The medium and long term of loans are disbursed to the farmers through Primary Land Development Banks (757) who draw their finances from Central Land Development Banks (20) who in turn draw their finances from NABARD. As for the short term credit, this is disbursed to the farmers through Primary Agricultural Credit Societies (PACS -66,200) who draw their finances from Central Cooperative Banks (363) who in turn draw their finances from the State Cooperative Banks (29). The State Cooperative Banks draw their finances from NABARD. Cooperatives Role in Fertilizer Distribution Agriculture continues to be the mainstay of Indias national economy. Its contribution to Indias Gross Domestic Product (GDP) is about 30 per cent. Nearly two thirds of the population still depends on this sector directly or indirectly. Self-sufficiency in food grains has been the basic objective of Indias policy on agriculture. Food grain reduction has increased from the level of 52 thousand tones in 1951-52 to 199 million tonnes in 1996-97. However, the food grain production declined to 193 million tonnes in 1997-98. The present population of the country is about 960 million and is likely to touch 1000 million by the turn of this century. To feed this level of population, India has to produce 208 million tonnes of food grains from the present level of 193 million tonnes which is; no doubt, a gigantic task The vital role of fertilizers in increasing agricultural production is well recognized. Since, the land man ratio is declining due to increasing population; the additional food gra in production has to come by increasing the productivity of land under cultivation. Adoption of modern agricultural practices is the only way for increasing agricultural productivity. This calls for application of inputs like chemical fertilizers, high yielding seeds and pesticides besides use of mechanical equipments like seed-cum-fertilizer drills, sprayers, pump sets etc. Chemical fertilizers are very costly, particularly the phosphatic and potassic ones which have been decontrolled w.e.f 25th August, 1992. Urea, of course, is relatively low priced due to grant of subsidy by GOI. However, unless balanced trients are applied, the productivity cannot be sustained. Fertilizer Distribution Channels Fertilizers are produced/ imported at about 200 locations in the country and distributed to the farmers scattered through the length and breadth of the country in about 600,000 villages through a network comprising of private and institutional channels. Some quantities are also made available through manufacturers own outlets. Private trade accounts for about 60 per cent of the total fertilizers distributed in the country followed by institutional agencies at 35 per cent and remaining 5 percent through the manufacturers own outlets. Among the institutional agencies, cooperatives are the main agency which alone account for nearly 30% of the total fertilizer business. The total number of fertilizer sale points in the country is 262,000; out of which about 71,000 (27%) are institutional agencies sale points (mainly cooperatives) and the remaining 1, 91,000 (73 %) are controlled by the private trade. Cooperative Channels Cooperatives are the main institutional agency in the country handling fertilizers. Cooperative network, at present, comprises of 29 state level marketing federations, 171 district level marketing societies and about 66,200 village level cooperative societies. These village level cooperative societies are generally called Primary Agricultural Credit Societies (PACS). These societies are the backbone of the cooperative marketing system. These societies are well spread in the entire country covering 97 % of the 0.6 million villages and 95 % of the farming families. The other main institutional agencies engaged in the distribution of fertilizers are State Agro-Industries Development Corporations, Commodity Federations and State Departments of Agriculture etc. They operate both through their own sale depots as well as through the private dealers network. However, their share is only marginal. The cooperative structure differs from state to state and societies at different levels (district/taluka/village) perform different functions in different states. Generally, the cooperative network operates through a 3 tier system. However, in some states such as Haryana, the cooperative marketing system operates on 2 tier basis, while in some others like Gujarat a 4 tier system exists. At the state level, Apex Cooperative Marketing Federations act as wholesalers; marketing societies at district/taluka level as sub-wholesalers while PACS, PAMS (Primary Agricultural Marketing Societies) at grass root level act as retailers. The function of State level Apex Cooperative Marketing Federations differ from state to state. In some states, the Federations are actively involved in fertilizer business like Gujarat, Haryana, West Bengal, Madhya Pradesh etc. and they act as the wholesalers for the entire State. In some States like Uttar Pradesh (U.P.), they are not directly involved in the fertilizer business and do the job of liaison and coordination only for which they are getting service charges from the fertilizer suppliers. In U.P., the State Federation is also doing warehousing as well as transportation job both for IFFCO and KRIBHCO (The only manufacturers in the cooperative sector). In the States where Federation is not involved in fertilizer business, the manufacturers are supplying fertilizers directly to the lower societies at the district/village level and the societies are getting full or near full distribution margin which has improved the financial health of these societies. CURRENT COOPERATIVE FERTILISER DISTRIBUTION STATUS Presently, in Gujarat, Haryana, Madhya Pradesh, West Bengal, Tamil Nadu, J K, H.P. and Assam, in the cooperative sector, fertiliser supplies are made to the Apex Coop. Marketing Federations only and they act as wholesalers. Direct supplies are not there at all. Only small quantities under the special scheme like IFFCO-NCDC scheme in Haryana and IFFCO societies adoption programme in M.P. are supplied directly to the societies. In these states district level societies operate as sub-wholesalers. In the states like Punjab, Karnataka, Maharashtra, Orissa A.P. and Kerala, both the systems i.e. supply through federation as well as direct supply to the societies are prevalent. As a result, some of the societies at the lower levels are getting supplies directly from the manufacturers while others are getting from the Federations. However, in the states of U.P. and Bihar, supplies of fertilisers are made to the village level societies directly by the manufacturers. In states where state level federations act as wholesalers, the manufacturer has to deal with only one agency. Consequently, the job of sales planning, movement and stocks planning, realisation of sales proceeds etc. becomes very easy. In states where manufacturer deals with the lower tier cooperatives directly, the volume of work increases many fold and it becomes much more complex. The material has to be released to individual societies and the sales proceeds realisation has also to be done at that level only. This requires deployment of larger field force. Decentralised release system leads to establishing larger number of warehouses and correspondingly larger inventory. This all increases the operating cost. Manufacturers Own Outlets Some manufacturers viz. IFFCO, KRIBHCO, GSFC, GNFC and NFL have their own retail outlets called Farmers Service Centres or Service Centres or Farm Information Centres etc. In these outlets, agricultural inputs like fertilisers, seeds, agro-chemicals and agricultural implements etc. are made available to the farmers under one roof along with agricultural production technology literature. The main motto of these service centres is not only to provide all quality agro-inputs to the farmers but also educating them on scientific agricultural by providing technical know how in the field of agriculture. This help the farmers in increasing their agricultural productivity and profitability. Promotion activities are also carried out in the villages located around these centres ( within radius of 8-10 kms) which includes demonstrations, farmers meetings, soil test campaigns, crop seminars etc. In addition, social campaigns like tree plantations, medical check-up, veterinary check up etc. are also organised. They also serve the purpose additional/alternative distribution channel for the organisation. POLICY PLANNING OF COOPERATION DEPARTMENT The Department of Cooperation is responsible for promotion and development of Cooperatives, which have been recognised as an instrument of planned economic development and all-round socio-economic transformation, particularly in rural areas of the State. The Department formulates policies in this behalf and prepares plans to execute the policies. The Department has reoriented its policies during the last four years, 1997-2000 to enhance professional competence, encourage adoption of modern methods of management and to introduce required structural, administrative and techno-legal reforms in Cooperatives to meet the challenges of economic liberalization and globalization in the country. Some of the Policies are: Promotion and Development of Cooperatives The Department has so far pursued a policy of providing catalytic assistance, which include financial and technical assistance, to all Cooperatives in the State, irrespective of the fact whether they were involved in execution of policies and programmes of the Government or not. This policy has now been reforme