Nespresso Essay

Nespresso was not in an excellent circumstance. The time had come to change to experiment and they understood consequently that it was important to look through a business person. Someone yearning , solid head , and innovative who had the option to take profoundly choices and start another time of prevail of Nespreso. This individual was Mr Lang. How might we sell Nespresso in general stores ? was the underlying inquiry. Question that was replied with an incredible vital choice which was created by Nespresso so as to enter in another market and be increasingly gainful. â€Å" A little activity in a different organization with isolated product† Lang said. Toward the starting it was no reasonable what he needs to do , and if this technique will be successful yet he doesn’t care about it and he kept building up this gambled methodology. Lang understood that Nespresso prospect in the workplace segment was restricted yet they was potential in the family unit showcase. At the time it didn't exist a major statistical surveying of the family units advertise , so it was a generally excellent open door for them. â€Å"Positioning Nespresso away from the more utilitarian office espresso and focusing on shoppers at the highest point of the family market† was his principle target Land got â€Å"green light† from the Nestle? general administration so as to build up this technique however just in Switzerland to be demonstrated during a timeframe. On the off chance that the business increment the administration concurred and the business could proceed. When something is new there will be consistently a great deal of uncertainties and buts , yet it must to hazard and set out to accomplish something imaginative and unique to got succeed.

Structured query language: Development

Organized inquiry language: Development Theoretical Database innovation and the Structured Query Language (SQL) have developed massively lately. This paper presents aftereffects of the examination on the chronicled viewpoint of the advancement of SQL and its proceeding with improvement. Applications from various spaces have various necessities for utilizing database innovation and SQL. This paper likewise presents a review on meaning of the Standard Query Language, and featured the few advantages and produce writing on dangers of embracing a Standard Query language. Catchphrase SQL, DBMS, XML, Data, Database. Presentation Standard Query Language (SQL) is today the standard language for social and article social databases. Application programs normally incorporate a generally huge number of SQL inquiries and updates, which are sent to the Database Management System (DBMS) for execution. The most by and large utilized database the executives frameworks, for example, Oracle, Access, mySQL, SQLserver, Paradox, Ingres, and others, are totally professed to be social. Unquestionably, they all utilization SQL which itself is regularly mimicked to be a marker of a social database framework. The motivation behind this paper is to talk about the chronicled point of view of the advancement of SQL and its proceeding with improvement. This article likewise featured the advantages and dangers of embracing a standard question language. This paper depends on survey history of the Standard Query Language and writing on advantage and dangers of embracing SQL. Advancement and current circumstance of the SQL Abreu, et.al. (2006) portrayed that the social model came to fruition because of E. Codds investigate at IBM during the sixties. The SQL, initially named SEQUEL (Structured English Query Language), was executed in an IBM model (SEQUEL-XRM), during the mid-seventies. A few years after the fact, a subset of this language was actualized in IBMs System-R. In 1979, ORACLE developed as the principal business DBMS dependent on SQL, trailed by a few different items, for example, SQL/DS, DB2, DG/SQL, SYBASE, INTERBASE, INFORMIX, UNIFY. Indeed, even those which had not initially actualized SQL as their base inquiry language, offered SQL interfaces, for example, INGRES, ADABAS, SUPRA, IDMS/R. Because of this procedure, Standard Query Language turned into an accepted norm. In late 1982, American National Standards Institute (ANSI) H23 starts to normalize SEQUEL which is form of the social information model through the IBM language. In 1986, renamed SQL by H2, fundamental SQL was finished and turn into an American National Standard and soon an ISO standard. In 1989, the principal variant of the SQL standard was updated and an addendum, which remembered principle enhancements for referential respectability issues, was distributed. In the mean time, ANSI drew out a standard for inserted SQL. In the mid nineties, another form, known as SQL2 or SQL-92, was distributed by ISO. Both the semantic capacities of the language and blunder the executives were then extensively improved. That standard was supplemented a couple of years after the fact, with the endorsement of SQL/CLI (Call-Level Interface) and SQL/PSM (Persistent Stored Modules). SQL turned into a total computational language, with highlights, for example, control structures and exemption dealing with. During the last 50% of the nineties, SQL was reached out by the incorporation of article arranged capacities. The subsequent standard was partitioned into a few sections. This adaptation, recently known as SQL3 and afterward at long last called SQL:1999, joined highlights, for example, new essential information types for instance huge articles, client characterized information types, recursive inquiry administrators, delicate cursors, tables speculation and client jobs. As per Abreu, et.al. (2006), The most recent rendition of the standard is the SQL:2003, which is there are significant corrections and expansions to most pieces of the SQL:1999 standard. This form contains SQL/XML which is XML related determinations, new essential information types, for example, bigint, multiset and XML, improvements to SQL-conjured schedules, expansions to the CREATE TABLE articulation, there are new MERGE explanation, construction object which is the arrangement generator and two new sorts of sections for personality and produced. He likewise created the Table 1 as sums up the advancement of SQL. Table 1 Evolution of SQL Year SQL 70s Social model DBMS models (SEQUEL XRM) First social DBMS 80s ANSI SQL-86 norm ISO SQL-87 norm SQL-89 addendum ANSI implanted SQL 90s SQL 92 SQL/CLI SQL/PSM SQL:1999 2003 SQL:2003 Accordingto Wikipedia, thereis another standard delivered at 2006 and 2008, The SQL:2006 by ISO/IEC 9075-14:2006 which characterizes waysfor SQL for combination with XML. It additionally characterizes how to do putting away and bringing in XML information for SQL, controlling the information on database and distributing SQL information and XML in XML structure. What's more, by utilization of Query and XML Query Language, it can incorporate into their SQL code the distributed by World Wide Web Consortium (W3C) so as to simultaneously get to normal SQL-information and XML archives. The most recent standard is SQL:2008, it legitimizes ORDER BY outside cursor definitions. It includes INSTEAD OF triggers and the TRUNCATE explanation. Abreu, et.al. (2006) featured the SQL:2003 standard is made out of nine sections, which are quickly depicted in Table 2. The numeration of parts isn't adjacent because of authentic reasons: a few sections have vanished, for example, SQL:1999s section 5 SQL/Bindings was remembered for section 2 of SQL:2003 and different parts are new. The last came about either from further dividing of past parts, for example, section 11 was recently remembered for SQL:1999 section 2 or from the execution of new prerequisites, for example, parts 13 and 14, managing Java techniques and XML information, separately. Since the SQL:1999, the SQL standard has developed, to help the item social worldview. This worldview proposes a decent trade off among social and article situated databases. The previous have a vigorous information model which is the social one and ground-breaking inquiry streamlining, recuperation, security and simultaneousness instruments. The last consolidate object-situated systems, for example, epitome, speculation, accumulation and polymorphism, and permit speaking to increasingly complex components which are required in a few spaces, for example, CAD, CAM or GIS. Article social databases offer the chance of characterizing classes or conceptual information types, just as tables, essential and remote keys and requirements, as social databases likewise do. Moreover, speculation progressions can be characterized among classes or tables. Table characteristics can be characterized in a basic area for instance CHAR(25) or in a client characterized class, as a mind boggling number or picture. Table 2 Structure and outline of the SQL:2003 standard Part Name Portrayal 1 Structure (SQL/Framework) Overviewof the norm. It portrays terms and documentation utilized in different parts. It likewise characterizes the consequence of handling articulations in that language and the sentence structure of SQL by a SQL-usage that has been outlining in the reasonable system utilized for different parts. 2 Establishment (SQL/Foundation) Thispart portrays the essential procedure on SQL-information and information structures. The utilitarian question, for example, controlling, keeping up, getting to, making, and securing SQL-information. It likewise characterizes the semantics and sentence structure of a database language. It manages the convenientce of information definitions and assemblage units between SQL-usage and the interconnection of SQL-executions. 3 Call-Level Interface (SQL/CLI) Itdescribes methodology to execute SQL explanations inside standard programming language in application composed, such the SQL articulations will be executed utilize autonomous capacities. 4 Tenacious Stored Modules (SQL/PSM) It characterizes how the semantics and punctuation of a database language has been proclaim and keep up steady database language frameworks in SQL-server modules. 9 The board of External Data (SQL/MED) Extensionsto Database Language SQL is definedfor bolster the executives of outside information reason by utilizing information interface types and remote information wrappers 10 Article Language Bindings (SQL/OLB) Itdefines SQLJQ, which is depicts expansions in the Java programming language, for help installing of SQL explanations into programs composed. The punctuation and semanticsof SQLJ portrayed by this part, just as instruments to ensure paired conveyability of coming about SQLJ applications. This part additionally characterizes various Java bundles and their classes. 11 Data and Definition Schema (SQL/Schemata) Thispart characterizes a Definition Schema that describes the SQL object identifier, the uprightness and structure requirements of SQL-information, the approval and security particulars related to SQL-information, the highlights, sub-highlights and the help that each of these has in a SQL execution and furthermore bundles of this norm, and an Information Schema. It likewise incorporates SQL-implementationinformation and estimating things. 13 Schedules and Types Using the Java Programming Language (SQL/JRT) Itdescribes the Java programming language on doing capacity of summoning static strategies as SQL-conjured schedules and SQL organized client characterized types for utilizing classes indicated in the Java programming language. 14 XML-Related Specifications (SQL/XML) Thispart depicts manners by which SQL likewise can be utilized for combination with XML. SQL Overview Gardner and Hagenbuch (1983) expressed that Relational DBMSs are ordinarily gotten to through an information language. So as to permit the DBMS to enhance gets to the database and to manage issues identified with simultaneous access by various clients, the dialects are commonly extremely significant level. The SQL is a case of such a language, that can be utilized for that reason. They likewise said that SQL articulations are non-procedural proclamations of what information to recover, for instance the question explanations to recover representative such a

9 Success Tips for Dating a Single Mom

9 Success Tips for Dating a Single Mom More in Relationships Spouses & Partners Marital Problems LGBTQ Violence and Abuse So youve got your eye on a  ?single mom. Shes smart, strong, and beautiful, but also a bit of a mystery. How can you make this relationship work? And how do you let her know that youre not just playing gamesâ€"without getting overly involved too soon? Before you start dating a single mom or explore taking this relationship to the next level, set the stage for success with these 9  tips. Recognize That Dating a Single Mom Is Different Her time is limited, and much of her energy goes toward taking care of her kids. But she’s also much more clear about what she wants in life, and thats an attractive quality! Accept That Her Top Priority Will Always Be Her Children In other relationships, you may have been able to gauge a woman’s feelings for you by how much time and energy she put into your relationship. When you’re dating a single mom, this isn’t necessarily the case. She may not have the time to see you as often as she’d like, and it’s not always as simple as hiring a sitter to go out. Instead of taking the limits on her time as a slight, learn to look for other expressions of her feelings for you. Let Your Girlfriend Discipline Her Own Children When you’re dating a single mom, let her handle 100% of the kids’ discipline. The only exception to this rule is if she specifically asks for your support or help. If you have concerns about the kids’ behavior, talk with your girlfriend about it privately. Never attempt to handle the issue yourself without discussing it with her first. Stay Clear of Any Drama With Her Ex If there’s tension with her ex, let your girlfriend handle it. Shes been doing a pretty good job up to this point! Of course, you can support her and encourage her, but don’t contact her ex on her behalf or get involved in an ongoing court battle over their custody agreement. Pace Yourself It’s important to give your relationship time to develop. Don’t rush into moving in together or getting engaged. Instead, take it slow and focus on developing trust before you take your relationship to the next level. Offer Emotional Support As a single mom, there is a tremendous amount of pressure on your girlfriend to provide for her children financially and emotionally. Be the kind of boyfriend who can listen to the things she’s going through without trying to “solve” every problem for her. She’s strong, and she will work it out in time. Offering support and encouragement along the way will help you build a stronger bond together. Practicing Active Listening in Your Daily Conversations Be Trustworthy As a single mother, your girlfriend may have experienced situations previously where she depended on someone who was not trustworthy. Set yourself apart by being someone she can trust. Be responsible to her without being responsible for her. Allow Your Relationship With Her Kids to Develop Naturally Don’t try to be too much too soon to either your girlfriend or her children. If you’re not sure about how involved you want to be with the kids, be open and honest about that. Talking about it can ease both of your concerns. At the same time, it’s important for both your girlfriend and her children that you don’t begin to take on a role that you can’t maintain for the long haul. A Word From Verywell You’re the only one who can know whether dating a single mom is right for you. Don’t get caught up in listening to family members or friends who will try to discourage you or suggest that she’s just looking for a father figure. This is rarely the case. Pay attention, instead, to the woman you know and the relationship you’re building together.

Essay on A Closer Look at the Vietnam War - 1774 Words

The Vietnam War The Vietnam war was a very hard and emotional time for many people. From the vietnamese to the u.s., the vietnam war was a tradgedy. People said that the vietnam war had been the longest lasting battle that took place in the cold war. The whole thing started because the vietnamese wasnted to have their independence. They no longer wanted to be under the control of france. France did not want to give up the land that they had ruled for years. France was getting supplies and goods from vietnam so they didnt want to give it up so they fought for it. Ho Chi Minh was vietnams president as you can say he was in control of north vietnam. He wanted vietnam to be a communist country much like the soviet union. After†¦show more content†¦Countries such as the soviet union , the U.S. , China , Vietnam and the French all met in Geneva to negotiate. They wanted a peace agreement which later turned into dividing up vietnam into two regions that would split the north and so uth between a boundary called the DMZ line. Then at that time the north and south was divided between the line. The line was called the Demilitarized Zone where the vietnamese were given total control of all territory of the north and everything to the south was controlled by the country of vietnam and france. (Don Lawson the united stantes in the vietnam., p. 16) . When the DMZ line went in full , the north vietnamese went through the south , which created a food shortage throughout south vietnam. The U.S. supported them and gave them aid for food. Ho Chi Minh and Diem agreement came to a reunification election that would basically depend on vietnam being a communist country or not. In the mean time, the U.S. wanted Diem to take the land that the wealthy land owners had and give it to the peasants for farm land so he had their full support. Gary B. Nash said Diem didnt want anything that would weaken the ruling class (Nash, p. 770). Eisenhower knew that if the elections went on , Ho Chi Minh would win and vietnam would become a communist country. He convinced Diem to cancel the reunification election. with the U.S. support , He cancelled the elections which led toShow MoreRelatedâ€Å"Facing It† by the American black poet Yusef Komunyakaa of Shreveport is written with the use of600 Words   |  3 PagesVietnams Veterans Memorial in Washington DC. This Memorial is a long polished slab of black reflectant granite with the names of all the US soldiers who lost their lives in Vietnam. Yusef says â€Å"my black face fades, hiding inside the black granite†. Here Yusef uses his reflection in the wall to bring the reader back to the war and how he feels standing at the wall now. He makes his feeling ambiguous and give the reader the opportuntity to decide what he is feeling through his use of viual images.Read MoreReflecting The Viewpoints of Time in Art Essay1137 Words   |  5 Pageswell as concepts such as war and violence, have acquired differe nt connotations. During the 19th century, they had a positive connotation. With the occurrence of revolutions war and violence was justified under the ideals of patriotism and heroism. During the 21st century, society began to was in the process of developing a more sophisticated view. The century was even more violent than the 19th century with conflicts such as the world wars and in particular the Vietnam War. Yet they were no longerRead MoreThe Second Indo China War947 Words   |  4 PagesThe Second Indo-China War, which is commonly referred to as the Vietnam War around the world and in the United States (US), pitted two very different nations against each other. This fight represents the modern day version of the biblical story of David versus Goliath. The United States at the time possessed the most technically advanced military in the world utilizing the latest high-tech equipment. The Democratic Republic of Vietnam or North Vietnam (DRV) was only a semi-industrialized nation strugglingRead MoreHistorical Events That Were Captured Within Photos And Paintings1348 Words   |  6 PagesWith these artwork, the artist try to convey the image in the most captivating way that makes people want to look at these images. Many of these images have been famous to this very day for displaying powerful messages that are behind the work of art. When people look at art, they don t realize that there’s more meaning than to what they see through the image. Sometimes you just have to look at it and see how important the piece of artwork is to the time period and to what they artist is trying toRead MoreHow Public Opinion Changed the Course of the Vietnam War950 Words   |  4 PagesThe Vietnam War certainly left a distaste in the lives of many who have been affected by the war; scholars have become increasingly interested in the interaction between war and public opinion. There have been many scholarly works published on the Vietnam War, but the issue that will be analyzed here is how public opinion changed the course of the war. The first article by Scott Gartner and Gary Segura is titled, â€Å"Race, Casualties, and Opinion in the Vietnam War,† it examined how the diverse racesRead MoreCritical Review : Citizen Soldiers : The U.s. Army861 Words   |  4 PagesSoldiers: The U.S. Army from the Normandy Beaches to the Bulge to the Surrender of Germany is a book following Allied soldiers until the end of World War II written by American author Stephen E. Ambrose. All the stories in this book are non-fiction and covers the brutality of war through the eyes of a several different soldiers as the Allied forces move closer to Berlin. The development of the story is in chronological order which is ideal for this type of book. To develop the story further, AmbroseRead MoreFacing It By Yusef Komunyakaa1158 Words   |  5 Pageshimself is the one who is speaking, the poem is about his own life experience at the Vietnam Memorial. The way a person can tell if the own poet of the poem is the speaker is by the use of first person. In this case, the poet uses words like â€Å"I† and â€Å"I’m† that support the fact that he is the speaker. The Vietnam War was a Historical event taken place in Vietnam, Laos, and Cambodia. Which was one of the first War that African Americans were integrated with White people, and the majority of the soldiersRead MoreThe Vietnam War Had A Tremendous Effect On The World1415 Words   |  6 PagesThe Vietnam War had a tremendous effect on the world, especially the United States. Not only did the war affect people in battle, but also left permanent effects on people a ll over the world. Over 57,000 U.S. citizens died and over 140,000 injured in battle. Multiple Americans were impacted by the war, vast amount of people died but more were injured. North Vietnam won the battle against South Vietnam and their allies. The Fall of Saigon in 1975 was the end of a gruesome war. The war had multipleRead More Counterculture Essay1501 Words   |  7 Pagesin many ways. Various things from protests to songs expressed their views and made their point get across to America. This cultural movement had a profound impact on society. It had both beneficial and detrimental effects on the society. As we look back on the sixties, it was one of the most important decades because it accomplished so many important things. The sixties was an era that was filled with so many important events that caused people to become actively involved in challenging theRead MoreA Justifiable War Essay1109 Words   |  5 PagesA Justifiable War Was the booby-trap theirs or ours? And his question was the answer.-Bryan Alec Floyd. Throughout history there has been a countless number of wars. Some in the name of God or some other holy figure, others have been for noble things such as freedom, and some have been for simple things such as money and land, but for which one of these issues is it justifiable to lead men to their deaths for? When talking of just causes of warfare within the last thirty years many

Hybridization Theory of Globalization Essay - 1711 Words

Pieterse states that â€Å"since culture is a battleground, hybridity is a matter of mapping no man’s land.† (Pieterse, 117) While this argument is sound in many ways, I do believe that â€Å"battleground† conveys far more violence than is involved in most cultural mixing. However, Pieterse tempers his argument somewhat as he continues, saying that â€Å"hybridity does not preclude struggle but yields a multifocus view on struggle and by showing multiple identity on both sides, transcends the ‘us versus them’ dualism that prevails in cultural and political arenas.† (Pieterse, 117) Through this explanation, Pieterse backs up his description of â€Å"no man’s land,† which I think is a very apt term for the new territories created by hybridization because the†¦show more content†¦. . trying to create a different kind of globalized world;† a â€Å"globalized† world in which there would be no hybridization or coo peration at all, a world where one culture would dominate and obliterate all who opposed it. (Chanda-Friedman Interview, 3) Whether a battleground or a peace conference, the thoughts and actions of each individual who either accepts or denies globalization as an unstoppable process greatly affect globalization. Both views described above create the no-man’s land of hybridization– either an unknown blend of cultures that has not yet been explored, or a barren waste land where all cultures but one are destroyed and the only hybridization possible is homogenization. Hybridization is a process of re-creation and recombination of culture which can cause a full range of reactions, from peace to violence. It affects many aspects of culture, first and foremost the social relations between individuals, societies, cultures, and nations. International politics have always been erratic because of the vast gulfs of understanding separating many civilizations (showing that there has always been no-man’s land standing between cultures), and have become even more so with the advent of the modern concept of globalization, especially multiculturalism and the questions of identity that accompany it. Multiculturalism gained importance in the overall scheme of international relations, and hasShow MoreRelatedGlobalization and Education1373 Words   |  6 Pages(UNESCO)’s Bureau of Strategic Planning (2004) reported that globalization has not only contributed to the greater exchanges of ideas and awareness of the uniqueness of individual cultu res and societies, but has highlighted the fundamental differences that result from these unique characteristics. There are many advantages for societies and cultures as they become increasingly interconnected (Heimonen, 2012) through the process of globalization. Interconnectedness allows for the sharing of assets andRead MoreHybridity As The Cultural Effect Of Globalization- Introduction1563 Words   |  7 PagesHybridity as the cultural effect of globalization- Introduction According to Avtar Brah and Annie Coombes, the term hybridity originated as a biological term that was used to describe the outcome of a crossing of two or more plants or species. It is now a term that is used for a wide range of social and cultural phenomena involving mixing, and has become a key concept within cultural criticism and post-colonial theory (A. Brah and A.E. Coombes. 2000.). Marwan Kraidy defines the term as theRead MoreThe Melting Pot 1277 Words   |  6 Pagesgrounds for new playing fields globally. This growing interconnectedness known as globalization shows how the world we live in is full of innovations that bring us closer together than ever imagined before. Whether it be economically, politically, culturally, technologically, ecologically or socially, there’s no doubt globalization has become one of the strongest forces behind cultural homogenization. Globalization brings about opportunities such as richer societies through trade, and the sharingRead MoreLast Is Hybridization Which Focuses On Interactions Between1515 Words   |  7 PagesLast is hybridization which focuses on interactions between internal and external flows. With this theory, the world becomes more pluralistic and can break borders while producing unique cultural hybrids which combine their elements. They also have the ability to adapt and innovate as there are more global and local flows. Muslim girl scouts are a strong example of hybridization as girl scouts are a part of American institutions, and they are becoming more accepting with including Muslim girls. HybridizationRead MoreCapitalism, Commodification And The Consumer Citizen884 Words   |  4 Pagestowards articles that gave a more broad view of how capitalism and neo-liberalism has affected world-wide structures. Being from another country, the articles that I felt more drawn to focused on the globali zation of capitalist ideologies and its effect on the rest of the world. Hall touches upon globalization, arguing that it is a direct consequence of neo-liberalism’s favor of industrialization and foreign trade and investment. Interestingly, Hall uses Great Britain’s governments to discuss techniquesRead MoreThe Globalization of Animated Features and the Merging of Cultures1030 Words   |  5 PagesBy using the inherent talents of its people to create digital media forms as anime, Japan has been spreading its culture and philosophy all over the globe, and this can be described as globalization. Up until recently, there were around 60 anime production companies, such as Crunchyroll and Funimation, and these companies â€Å"provided products in 112 countries† that held approximately â€Å"87 percent of the world’s population† (Anonymous). Additionally, in 2010, the anime-related market in North AmericaRead MoreThe widespread image of American cultur e is seen to hold a strong base for globalisation. The1000 Words   |  4 Pageslike â€Å"magic bullet† and â€Å"hypodermic needle theory†. Nevertheless, researches on new media theories have gone down significantly, focusing mainly on the level of impact of transnational media. Yet, other scholars were drawn to the bases of imperial culture theories where an alternate way of viewing different aspects of culture and society is developed without theoretical evidence. The study and notion of global interaction claims that imperialism theory has originated from western developed countriesRead MoreThe Cultural Dynamics Of Globalization1062 Words   |  5 Pagesanthropologists have made it their life’s work to attempt an understanding of the facets surrounding the concept of globalization, especially through a cultural lens. Large scale globalization is something that historians have traced back to the early 19th century, but it has developed increasingly quickly and continually in the 20th century. (Ritzer and Dean, 2015) When studying globalization, it is impractical to view it a question of being simply something new or old, but rather as a process that constantlyRead MoreHow Foreign Cultures and Media Influence Local Cultures, and Whether Local Cultures Are Eroded by Foreign Influences and Media969 Words   |  4 PagesLiterature review An increasing number of studies (Arnett 2002; Morris 2002; The UN 2003) have examined the trend of cultural globalisation and the relationship between foreign influences, media and local cultures. These studies draw on various theories in the fields of cultural globalisation, most notably cultural imperialism. This refers to the promotion of Western culture especially American culture through the export of media products. This flow of commodities and media products is uni-directionalRead MoreEthnography Study of Coffee House2553 Words   |  11 Pagescontinually inventing polychromatic phrases to explain their differing points of view on cultural shifts caused by globalisation. â€Å"Globalization has been associated with a range of cultural consequences. These can be analysed in terms of three major theses, namely, homogenization, polarization, and hybridization,† (Holton 2000). This essay seeks to lend credence to the hybridization thesis, by observing a coffee house locate d in the developing country of Trinidad and Tobago (TT). Focusing on the aesthetics

The Future of Nursing Free Essays

The Affordable Care Act of 2010 (ACA) will have a great effect on nursing. According to this article nursing will have to change it role in the ACA and the three main categories that need to be changed and redeveloped is transforming practice, education and leadership. â€Å"The ACA outlines some new health care arrangements, and with these structures will come new opportunities for new roles. We will write a custom essay sample on The Future of Nursing or any similar topic only for you Order Now Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses. † (IOM, 2010, p. 85) â€Å"The ACA will place many demands on health professionals. The legislation has begun the long process of shifting the focus of the U. S. health care system away from acute and specialty care. † (IOM, 2010, p. 86) â€Å"When the system takes on another additional 32 million people soon to be covered by health insurance under the ACA would receive care in the coming years, it identified as a serious barrier. † (, 2010, p. 96) â€Å"If the United States is to achieve the necessary transformation of its health care system, the evidence points to the importance of relying on nurses in enhanced roles. † (IOM, 2010, pg. 87) This article however complain about number of educational grants and scholarships available and most individuals seek nursing education must finance it themselves. Yes because all college nursing programs are filled every year and cannot support more nursing programs these are filled by the private sector which requires student loans. However there is an abundance of money offered by United States’ government does provide more federal student loans than ever before. â€Å"Student loan debt as of first quarter of 2012 was up to $904 billion which is up $241 Billion form a decade ago and it is said to reach well over trillion dollars by the end of the year. † (American Progress, 2012) â€Å"There is not enough nursing faculty to teach the current  number of nursing students, let alone the number of qualified applicants who wish to pursue nursing. † (Allan Aldebron, 2008, p. 214) â€Å"The ACA and the need for APRNs, nurse faculty, and nurse researchers would have increased dramatically under any scenario. † (L R Cronenwett [RWJF Iniative on the Future of Nursing], 2010, table 1). â€Å"Not only must schools of nursing build their capacity to prepare more students. Nursing need to focus on fundamental improvements in the delivery of nursing care to improve patient safety and quality is key. † (IOM, 2010, p.  208) Those involved in the health care system—nurses, physicians, patients, and others—play increasingly interdependent roles. Leaders who merely give directions and expect them to be followed will not succeed in this environment. What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration (A Pearson, H Laschinger, K Porritt, Z Jordan, D Tucker and L Long [International Journal of Evidence-Based health Care], 2007, p. 224). Looking to the future, nurse leaders will need the skills and knowledge to understand and anticipate population trends.  (IOM, 2010, p. 234) In conclusion The Affordable Care Act of 2010 will place many demands on health care professionals, and it will offer many opportunities to create a system that is more patient centered. The will be much focus on these three initial roles practice, education and leadership. We still must remember the system is getting 34 more million people and a push for changing our current system from acute care to a preventive system and this will not happen overnight. It is 2014 and most of us still do not know what is in this health care law, how it will affect us and what it will cost us? Let alone what it will take to change practice, education and leadership across the whole country. This undertaking may take decades to implement. We could have only wished this law was written by doctors and nursing professional with details about where and how the system would be changing yet it was written by lawyer, lobbyist and our Congress that was more concerned about pushing it through than reading it. Nursing is definitely going to play a huge role in this transformation and yes the practice, education and leadership is going to be part of the key of getting this done. How to cite The Future of Nursing, Papers

Essay On Conformity The Crucible By Arthur Miller Example For Students

Essay On Conformity The Crucible By Arthur Miller The selection, â€Å"The Crucible†, is in the form of a play. The setting takes place in Salem, Massachusetts in the year 1692. The people of Salem led a strict life, whose concerns were mostly concentrated upon the worklife while following the principles and rituals of the Christian religion. Any time off of work meant that they would only concentrate harder on praying. They were a â€Å"God-fearing† community believing that they were under constant surveilance by God and will be damnned for all mortal sins. The story first starts out in Rev. Samuel Parris’s house in the bedroom of his daughter Betty. She is apparently sick and he is praying by her bedside. Many people of the town have gathered to discover some explaination for her sudden sickness. They all have heard rumor of possible previous witch-craft causing her sickness. Rev. Parris does not want his church to corrupt on the fact that his daughter many have made contact with the devil. He is more concerned about the fate of his church than the well being Betty. Betty and other girls of the town have been seen dancing to psalms of witch-craft with the Reverend’s servant Tituba. After the arrival of Rev. John Hale, Betty awakes and tells of her visions of many women the the town with the devil. Those women who were accused were to be tried in court for contact with the devil through witch-craft. As a God-fearing communtiy, any evidence of evil could not be denied. Because they believe that if they deny evil, then at the same time they are denying goodness, which is God. So no defense of accused peoples could be based upon evidence, simply because evil can not be seen. So any accused person must confess to it and be rehabilitated, or will be hung if they are willing to show pride in their innocence. The court in which they base the law states that â€Å"God damns all liars†. Ironically, if they were to confess guilt and yet they were innocent then they will be â€Å"damned by God. † Arthur Miller, through the context of the play, could be telling us that when dealing with our inner conflicts, our desicions should be based on what our conscious thinks is right. The desicions that the characters faced in the story may be the most important desicions they have ever made. And the desicions they made was right with their own hearts.

The Handmaids Tale and On Chesil Beach Essay Example

The Handmaids Tale and On Chesil Beach Paper In both novels, a strong theme of sexual inequality is present. This is produced in different and yet very similar ways. For example, Context (time periods) aids the novels to put across this point. Both authors also at least hint at some form of sexual abuse, which fortifies the idea of sexual degradation throughout both novels. There is also a persistent theme in both books, of rapid reversal, where the female character goes from a status of individuality and freedom, to one of subordination to mens desires. Both authors use narrative techniques to show the characters perspective to the reader. Margaret Atwoods sexual themes in The Handmaids Tale are obviously motivated by the times in which she wrote and published the book (early 80s). To go even further, you could say that Margaret Atwoods approach to a dystopian American future is motivated by the political and theological sexual ethics of pre- 1985. Whilst writing her novel, Margaret Atwood toyed with the idea of adding, in the epigraph, the recent UN quote: women represent fifty percent of the adult world population, [ ] and own less than one percent of the world property. This idea of women [owning] less that one percent of the world property (UN) and men owning the rest, is an apparent oppression against women, present in The Handmaids Tale, in which the extent of this ownership covers the female body. It is obvious that the Gileadean regime has created this scenario so that women cannot live independently, and rely on men, they therefore must accept being inferior. This is shown when Offred speaks about the time when the Gileadeans took over the country, when all women were relieved of their jobs. Its strange, now, to think about having a job. We will write a custom essay sample on The Handmaids Tale and On Chesil Beach specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on The Handmaids Tale and On Chesil Beach specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on The Handmaids Tale and On Chesil Beach specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Job. Its a funny word. Its a job for a man. Do a jobbie, theyd say to children when they were being toilet-trained. Or of dogs: he did a job on the carpet. (182) Offred does many things when she plays with the word job in her head. Firstly she creates a very patronizing tone towards women, Do a jobbie, theyd say to children when they were being toilet-trained, suggests that Offred feels that herself, as well as other women, needed to be looked after. However, by knowing Offreds personality, we know that she does not truly feel this, but feels how the regime wants her too. She then goes on to compare herself to a dog, mans best friend. This shows that she feels like her husband, Luke, owned her, at the time, she did not own herself, and doesnt as we progress through the novel. On Chesil Beach contrasts to Atwoods novel (in this case). McEwans novel was published in 2007, a recent year, in a time period with no noticeable sexual changes going on. However the context of the plot gives more insight into how sexual inequality was used to create pressure on Florence. The novel is set in the early 60s, the cusp of the sexual revolution, nicknamed The swinging-sixties. When people were beginning to experiment with non-marital sex (Free Love), and more importantly, women begin to have more control in the bedroom. At the point which Edward and Florence are in their marital suite Florences sexual opinions are based upon the cusp of this new-era sexual status quo, and the former etiquette in which the man is dominant, this causes room for an unspoken pressure upon Edward and Florence equally, to dominate the scenario. This causes Florences body to be used as the scape goat for Edwards lack of control of his own body Both novels appear to have some hint of sexual abuse present in the lives of the female characters. In The Handmaids Tale Offred and the other Handmaids are made to take part in The Ceremony; the basis of the Gileadian regime. During The Ceremony, the Commander has sexual intercourse with Offred which, according to the laws of the regime is purely for procreative purposes. Throughout the ceremony Offred distracts herself from the present, not by thinking of the past or future directly, but by overthinking the situation, this gives the reader a narration from an onlookers point of view. This distraction shows that although the physical body is all the Regime has interest for, the mind is a much more powerful resource to the individual. Atwood uses Offreds ever blunt language to generate the audiences emotions, Below it the Commander is fucking. What he is fucking is the lower part of my body (105) By using a more crass phrase, Offred explains that The Ceremony is vile act that she has to endure, by saying What he is fucking is the lower part of my body she detaches herself from the act, which shows that she views it, the Commander and herself with contempt for being part of this. She continues I do not say making love, because this is not what hes doing. Copulating too would be inaccurate, because it would imply two people and only one is involved. She tells us that all of this is [his] doing, she again tries to distance herself from any involvement, this is contrasted by Nor does rape cover it: nothing is going on here that I havent signed up for. Offred seems to be partially indoctrinated by the regime here, suggesting that this was her choice, but as we know this is not entirely true, their only other choice was what many would consider a worse fate, going to the Colonies and working in terrible conditions until they died of starvation, radioactive poisoning and other such painful demises. Or, as we find later, she could become a common prostitute, serving the commanders for sexual pleasure rather than procreation. This clearly shows that in the theocracy, women are viewed as resources; procreation, manual labor, or pleasurable sex. d This links closely to On Chesil Beach: McEwan hints throughout the novel that Florences phobia of sex is rooted in her past. Here came the past anyway, the indistinct past McEwan explains the Florence has obviously been trying hard to forget this part of her childhood, therefore telling the audience that whatever she is now unintentionally remembering, is a sincerely troubling one. She was twelve years old, lying still like this, waiting, shivering in the narrow bunk with polished mahogany sides . Florence compares the way she lay on a bunk in a bed on her fathers boat, to how she is lying, feeling vulnerably naked while Edward undresses in preparation for their love making, this suggests that a traumatic sexual experience occurred at this point in her life. Such trauma is shown by the emphasized detail of the wooden interior, it appears that she was trying to concentrate on anything but the present situation, much like she is doing in the hotel room. It was late in the evening, and her father was moving around the cabin, undressing, like Edward now. We are told that her father is taking off his clothes the same way the Edward is. McEwan explains subtly that there are different methods of de-robing, and having explained earlier that Edward undressed hurriedly, we are giving insight into an implied paternal rape of Florence at a young age. A shocking discovery, that McEwan only hints at, further emphasising the fact that it is an instance too terrible to discuss. The fact that Florence is one a boat, crossing the channel means that she cannot escape from her father, she is trapped, physically, where as now she is trapped mentally; she wants to please Edward, but she doesnt want to have to be put in a sexual situation again. Edward is oblivious to this fact, but does not ask either. The reader is presented with the morale knowledge that if Edward were perhaps more sensitive, and did not see Florence as a commodity for sex on their wedding night, he would be able to understand the issue much better, perhaps to an extent that they could save their marriage. Another technique used by both writers to show that the female is nothing but the body, is that of rapid reversal of rights. During one of Offreds flashbacks, she re-lives the day of the Gileadean coup. When she is remembering lying in bed with her husband, having just been told she could no longer work, or own her own possessions, and take care of her accounts, and that they were all controlled, instead, by the man in the relationship, she comes to the conclusion that, We are not each others, any more. Instead, I am his. (192). Offred, uses this simple sentence to some up what happened over the course of a few days, by bringing the time frame from days to a few words, shows how quickly she has lost every freedom that she once had. describes how the equality that she once had in her relationship, has declined, and she is powerless, and Lukes subordinate. Throughout the novel Atwood describes how it is not just the handmaids who succumb to the rapid reversal in the Gileadean society. The novel has a succinct hierarchy, that is, one without any exceptions. If, before the coup took place, a women were infertile, a side effect of the biological weapon; Agent Orange (as we find out in the Historical Notes), and had no husband, and no uses, she would be deemed an unwoman, and be sent to the colonies to work herself to death. If they were infertile but useful (i. e: wife to a upstanding member of society, or had skills and were willing to be part of the Republic of Gilead), they would become a Commanders Wife, a Martha, an Aunt, among other things. Women had very little say in any of these matters. Such an oppression of their rights, reducing them so quickly to common stereotypes, shows how rapid reversal was used to turn the women into cogs in a machine, they all had a part, and it always depending on their physical potential. On Chesil beach shows a different, more subtle, but nonetheless reduction of a womans rights. McEwan shows Edwards obvious lust for Florence, throughout the novel we hear of his misinterpretations of Florences behavior, from examples of her committing perfectly innocent actions, which he deems to be a sign of a similar sexual lust. However in every instance before their marriage that he judged as a time for sexual lust, turned out to be obviously wrong; he could not escape the memories of those times he had misread the signs, most spectacularly in the cinema [ ] when she leaped out of her seat and into the aisle Here we see that Edward is actually hopelessly clueless as to what his intentions should be at that stage in their relationship, and as we progress, we see that Edward schemed to get Florence to marry him, in order to bed her, he seems to justify his urge to have sex with her with marriage vows, showing us that he has managed to turn her into a stereotypical wife of the early 20th century, who pleases her husband. From Florence being what we could deem as a feminist, with her own individual will, and passion, to this shows a strong, again purposeful rapid reversal of rights. Margaret Atwood writes The Handmaids Tale in the first person through Offred. Whilst reading the novel they subconsciously read as if it were written down by Offred, however in the historical notes, we are told that the story is compiled of dictated transcripts found many years after Offreds abrupt escape. Katharina Ochsenfahr writes: She is recording her story on tape afterwards, probably when she is in a safe house. So she is telling it from her memory. Despite this the reader sees her story through her eyes and therefore gets to know the treatment of women in Gilead. By doing this, Atwood forces the reader to think back to especially emotional parts of the narrative and imagine it being spoken. It causes the word plays to make more sense, deepening the personal impact of the story, and making the reader carry on thinking about it long after closing the book. McEwan uses a contrasting narrative, whereas Offreds narration is subject to her understanding of events (although quite an intuitive one), McEwans narrative is described by Jake Seliger (The Storys Story) as: A clever variation of the omniscient viewpoint in a way similar to but different from the way he wrote Atonement, and it conveys the uncertainty of the characters while informing and clarifying for the reader. We are left with a central scene from a life, but not a still life, for the motion of the characters minds and the aftermath of their encounter reverberates through time. He suggests that McEwans hopping between person, time and place bring the characters of Edward and Florence alive from the numb state which they are in on Chesil Beach. This technique is similar to that of modernist writers of the early twentieth century such as Woolf, and Joyce who tunneled massive caverns of history behind their characters which built up their personalities. In this case it causes a clash between Edward and Florence as Edward feels he should be in control, but is not in control of himself, a feeling that is shown through instances in his life such as his mother becoming brain damaged by a freak accident. Florence contrasts this by feeling out of control, and feels like that is her rightful place, this has been induced by her aforementioned experiences of sexual abuse. Both novels have strong links, and equally strong differences. However, both writers have expressed these similarities or differences using the same techniques. Resulting in a clear theme of unequal sexual ethics towards women. They have used role reversal, language, disturbing experiences of abuse, contextual knowledge and narrative technique to conclude with the ideology of The Female [being] Nothing But the body.

Civil Rights And Public Policy Essay Example

Civil Rights And Public Policy Essay Example Civil Rights And Public Policy Paper Civil Rights And Public Policy Paper Essay Topic: Claim of Policy All men are created equal has had little weight In American society and has been the cause of social unrest in America for decades. From blacks to minorities to women, unequal treatment has been the cause of protest and objection. Civil rights and inequality cases and issues are focused on by Congress, the courts, and the bureaucracy. Not only is discrimination an issue against race and gender, other groups have been demanding social and constitutional protection. There are some that have to do with GE and disability, and there are more controversial ones like sexual orientation. Call rights must be demanded and quieted upon. These fights have to take place on philosophical levels, as well as Constitutional interpretations. The Declaration of Independence might have stated equal rights for all, but does it actually mean equal opportunities for all. Even though we might have equal opportunities, does that mean we all have equal chances of succeeding? Do all of these other minorities have the same chance to succeeding as do all other peoples? Are they all getting the same results and reward? This Is the focus of the 21st call liberties fight. Founding fathers did not explicitly mention equal rights for all; however, the interpretations of the constitution and other historical documents do no not limit freedom to any specific government. The constitution is unequal in many terms. The First Amendment didnt explicitly allow freedom of expression which allows people to protest for equality. Equality only appeared in the post-civil War in the Fourteenth Amendment which prevents states from making laws depriving anyone from their rights, In this case, equal protection. Equal protection Is a key tool for determining call rights and equality. Standards of review are used by the higher courts to determine nature of potential discrimination. For example. In Standards of review, there are laws that classify groups based on age and wealth. They have to pass test and get a result of reasonableness. Then there is potential classification by gender and that must passed pass intermeddle scrutiny. The last is classification by race, in which the laws are Inherently suspected. The most important group of people who have fought tirelessly for their rights are the African Americans. For the first 250 years the united States was created, blacks were treated as property with no rights. The 1 857 Dread Scott Scott v. Sanford ruling declared that even slaves escaping to free states had no rights as a citizen and that Congress could not ban slavery in the territories. The Missouri Compromise made Missouri a slave state but with the condition that the northern territories were free. After all of this and decades later, the thirteenth Amendment banned slavery and Involuntary servitude which led to the era of reconstruction and segregation which broke three Amendments at the same time. The 13th, 14th, and the 15th. In the 1896 Please v. Ferguson case: Supreme Court gave Constitutional justification to segregation, ruling that separate but equal was Constitutional. This made segregation even worse because the government was officially supporting it after they had made those three amendments. Equal education was a major issue now. From this issue rose the issue of busing which was extremely popular among all people In ten earlier years. From tens Issue, Trot ten education and from many other issues, the Civil Rights Movement was formed. The Civil Rights Movement, and its nonviolent activists, attempted to end political, social, and economic policies that promoted segregation. By the asses the majority of white Americans supported civil equality. The influence of courts and shifting public stances led to many public policies and laws aimed at promoting racial equality in the asses and asses. Most notably, the Civil Rights Act of 1964: made racial discrimination in public accommodation areas (ex. Restaurants and hotels) illegal. The Voting Rights Act of 1965 would be the most massive attempt to enforce black forage. After the Brown ruling, congress set to end all forms of segregation. After the African American Civil Rights Movement, other minority groups set out to claim their rights. Native Americans, Hispanic Americans, Asian Americans, and Arabs Americans and Muslims. Women also battled public policy. Feminists groups sprung out of nowhere in the past century. For the first time in American history an American Women almost won presidency. Wage discrimination is an issue under the spotlight. Sexual harassment is an issue that been around for a very long time. Womens enlistments in the military has been a huge turning point for women in history. Other groups Active under the Civil Rights Umbrella are the elderly of America. Presidential candidates focus a great deal of their time on this social group. People with disabilities have also been asking for rights and have been facing much discrimination. LIGHT have been gaining massive support nowadays, with their issue being one of the biggest controversial issues Americas has faced. Affirmative Action is a policy designed to give special attention to or compensatory treatment for members of some previously disadvantaged groups.

Solutions of Slow Housekeeping Services In Palomar Hotel Research Paper

Solutions of Slow Housekeeping Services In Palomar Hotel - Research Paper Example   According to the customer comments from the data collection, the time taken for cleaning a room, the delays in response to customer calls, and the delays of delivering extra towels indicate the slow performance of housekeeping service to customer needs. Therefore, Palomar Hotel needs to solve the situation of above slow services problem to avoid major effects on customer satisfaction. There are two effective solutions to improve the slow housekeeping service, which are additional training for the staff that deals with housekeeping services, and the upgrading of the Property Management Systems (PMS). Additional TrainingAdditional training to the staff to provide more refresher information to guide them in responding to customer requests will improve the level of speed with which housekeeping services are conducted. Additional training will enable the employees to learn how to handle customer request and the response to give to ensure the customer feels attended to. In providing th e additional training, the provision of cleaning services for the rooms is enhanced. The staff is educated on the right times to handle cleaning and retain cleaning material nearby to handle any requests for cleaning services.When a customer call is received, the procedure that it follows to ensure a response is provided is vital. Additional training to equip the staff with confidence and the right attitude to work will provide the staff with motivation that will help increase their speed and efficiency.   

Global finance Essay Example | Topics and Well Written Essays - 500 words

Global finance - Essay Example The stock price of Lloyds Banking Group (UK: LLOY) has dropped by as much as ?10 per share over the past 2 months. Ignoring the minor increase in the stock price during the first week of July, this decline has been gradual over this period. The share price has dropped consistently during recent months due to a number of reasons that will be elaborated below. These trends also fall in line with some of the observations made during the beginning of the sample period based on macroeconomic trends in the UK and Europe in general (Desai, 2011). Based on information on other players in the banking sector, Adams (2011) says that most banks have been performing below their book values due to the longstanding negative sentiment in the financial markets over the stability of these banks. At a time when the world is just starting to recover from the 2008 global financial crisis, investors are reluctant to place their money on this sector, especially in favor of the bigger banks (Brown, 2010). T hus, a major factor inhibiting the growth of the share price is the current sentiment over liquidity concerns and debt quality within banks. Thus, the current stock scenario reflects the short term outlook of the investors.

Pain Sensation: Nociceptive receptors and transduction

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