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Johnson and scholes cultural web …
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Johnson and scholes cultural web …
Sialorrhea and Aspiration Pneumonia: A Case Study. This case study compares two different clinical outcomes for a patient with a long-standing psychotic disorder prescribed clozapine on two occasions. During the first trial, clozapine was used at a higher dose for johnson cultural web essay, this patient (350-450mg/day) and included clinically significant sialorrhea, pneumonia, and pneumonia-like illnesses requiring immediate medical intervention including hospitalization. There were also patient complaints of fatigue, cough, choking, and constipation leading to poor adherence. Clozapine was discontinued when the patient withdrew his consent due to essay poetry and ambition side effects, despite his awareness of its benefits, including reduction of command hallucinations and irritability. The second clozapine trial was associated with lower daily doses and therapeutic serum blood levels. The patient was actively participating in and adhering to the medication plan. A very narrow window of clozapine dose was exceeded for two days and the patient complained of hypersalivation, cough, and lethargy. He was subsequently hospitalized for a two week period to treat aspiration pneumonia. This hospitalization helped establish the ideal daily dose of cultural clozapine for this patient and cover also brought the johnson relationship between aspiration pneumonia and clozapine to the attention of the psychiatrist and medical specialist. Once the appropriate dosage for this patient was established, his psychotic and affective symptoms were controlled, he was not hampered by adverse side effects, and he started to actively participate in social and recreational activities and plans that culminated in discharge from a state psychiatric facility to a supportive community residence.
It is our hope that the cool designs lessons we have learned from our shared experience with this patient will be of benefit to other clinicians and patients. This case study compares two different clinical outcomes for a patient with a long-standing psychotic disorder prescribed clozapine on two occasions, from 2005 to cultural 2009 and again from 2010 to gcse pe pep coursework 2012. During the first trial, clozapine was used at a higher dose for web essay, this patient (350-450mg/day). This trial included clinically significant sialorrhea, pneumonia, and pneumonia-like illnesses requiring immediate medical intervention including hospitalization. Essay Benefits Wireless. There were also patient complaints of and scholes cultural web essay fatigue, cough, choking, and pe pep coursework mark scheme constipation leading to poor adherence. Clozapine was discontinued when the patient withdrew his consent, due to side effects, despite his awareness of johnson cultural its benefits, which included a reduction of benefits wireless command hallucinations and irritability. The second clozapine trial was associated with lower daily doses and therapeutic serum blood levels. The patient was actively participating in and adhering to the medication plan. Clozapine was slowly increased and in two months the daily dose was 200mg. When the daily dose was increased to and scholes 225 mg for two days and 250mg for an additional two days the patient complained of designs hypersalivation, cough, and lethargy.
He was subsequently hospitalized for a two-week period to treat aspiration pneumonia. This hospitalization helped establish the ideal daily dose of clozapine for this patient and also brought the relationship between aspiration pneumonia and clozapine to the attention of the psychiatrist and medical specialist. Clozapine was then augmented with quetiapine resulting in the significant clinical improvement of psychotic symptoms (relative to johnson cultural web essay baseline). Lithium was also added to cool cover letter designs the medication regimen to control affective disorder symptoms. With his psychotic and and scholes web essay affective symptoms controlled he started to actively participate in social and recreational activities and plans that culminated in discharge from a state psychiatric facility to a supportive community residence. It is our hope that the lessons we have learned from our shared experience with this patient will be of benefit to other clinicians and cool designs patients. This 56-year-old, single, never-married Native-American man had a long history of a psychotic disorder complicated by and scholes web essay substance abuse, borderline intellectual functioning, antisocial and borderline personality disorders, and cool designs criminal behaviors. And Scholes Web Essay. He had multiple admissions to civil and forensic psychiatric facilities since 1967 for the evaluation and treatment of depression, suicidal thoughts and/or self-mutilation, selfisolation, and impulsivity. He also experienced severe, disabling paranoia and auditory hallucinations. Pe Pep Mark. In the past he made deep cuts (requiring stitches) to his wrists and and scholes web essay arms in response to command hallucinations, as well as several suicide attempts including at least one overdose with over-the-counter medications. Just prior to this patient#x02019;s transfer to our state psychiatric center, he had served 15 years in prison for rape and assault with a weapon (knife).
He was due to donald hall be paroled, but he admitted to and scholes cultural correctional officers that he felt more comfortable in prison and that if he were released he had anxiety and trepidation that he would rape again and/or kill someone. Cool Designs. He was admitted to a forensic psychiatric facility to johnson cultural evaluate his statements and then transferred to our state psychiatric facility, on parole, for continued evaluation, treatment and discharge planning. During admissions to forensic psychiatric facilities, his primary psychiatric diagnosis was borderline personality disorder, though in one instance, after cutting his forearm in response to command hallucinations, his primary psychiatric diagnosis was mood disorder, organic, mixed. Unfortunately, other than the diagnosis, no rationale for this diagnosis is provided. Donald Essay Poetry. Upon admission to our psychiatric center he was diagnosed with major depression recurrent with psychotic features; polysubstance dependence by johnson cultural history; antisocial personality disorder; and borderline personality disorder. Thesis Order Table Of Contents. When admitted to our state psychiatric center the admission conference established a diagnosis of schizophrenic reaction, paranoid type, rule out psychopathic personality. The patient had been offered multiple trials of antipsychotic medication, including perphenazine, thiothixene, risperidone, ziprasidone, and quetiapine. He was prescribed primarily valproic acid as a mood stabilizer but recently valproic acid was discontinued in favor of lithium. His antidepressant medication included doxepin, nortriptyline, bupropion, sertraline, and escitalopram. Johnson Cultural Web Essay. At the time of discharge from our psychiatric center he was not prescribed an antidepressant.
Reportedly he experienced serious side effects with chlorpromazine and thioridazine in the past, and essay he is considered #x0201c;allergic#x0201d; to cultural these medications, although his medical records do not list these medications as having been prescribed. The patient had the following health issues: positive purified protein derivative (PPD) test (a skin test used to diagnose tuberculosis) since 1991 (treated with isoniazid [INH]), edentulous with no hard fruits or vegetables (annual choking/aspiration screens performed over letter designs, the past seven years show that the edentulous patient increased the risk for choking and/or aspiration), status post-surgery (S/P) for cataracts in 2004, and S/P prostatectomy in 2008. A computed tomography (CT) scan in 2010 indicated #x0201c;normal pressure hydrocephalus (NPH) versus mild obstructive hydrocephalus.#x0201d; Consultation with neurosurgery did not recommend surgery. The absence of ataxia and dementia ruled out the diagnosis of NPH. He had a 20-year history of smoking one pack of cigarettes per day until our facility became smoke-free in January of 2007. A pulmonary CT scan done in 2008 provided evidence of chronic airway disease. First clozapine trial, 2005 to 2009.
In 2005, this patient was admitted to our state psychiatric center, given medical clearance, and, with the patient#x02019;s consent, started on clozapine. Clozapine was titrated over the next two months to johnson web essay 450mg daily. The most immediate side effect, and most notable, was sialorrhea. The patient also reported significant lethargy and constipation. Pe Pep Scheme. One month after starting clozapine, there were multiple nursing reports that the and scholes web essay patient was throwing some doses away. Two months after starting clozapine, the patient was taken to an emergency room at a local hospital after being found unconscious and suspected of having a cerebrovascular accident (CVA).
Examination proved mostly negative, but he was admitted for additional testing lasting seven days. With no other viable alternative explanations, it was determined that the patient had not been taking his clozapine and then resumed use of the 450mg/day prescribed dose. The syncope that had resulted can occur when clozapine is titrated up too quickly. 1 Clozapine was discontinued by the attending physician at essay the local hospital and the patient was returned to the state psychiatric center. Shortly after the patient#x02019;s return, clozapine was reordered and titrated to 300mg daily. In 2006, there were mostly complaints from the patient about his medication, such as episodic sore throat, hypersalivation, lethargy, and constipation. For the most part, he was able to manage these side effects with throat lozenges, additional rest, and and scholes web essay laxatives. His clozapine blood levels were exceptionally low for mark scheme, his prescribed daily dose. Additionally, we know he used tobacco products at this time, which may be, at least in part, responsible for the lower blood levels.
2 In January of 2006, he complained of a severe sore throat, cough, and fever. Johnson And Scholes Cultural. Rales were noted bilaterally, and the possibility of wireless technology pneumonia was raised. Given that sputum and chest x-rays were negative, the patient was not treated and the symptoms cleared in a few days. In May of 2006, he complained of a severe cough, and the chest x-ray was essentially negative. Again, his cough cleared in a few days. There was no attempt to johnson control his sialorrhea with medication at any time during this first trial. In 2007, additional references to hypersalivation, cough, lethargy, and constipation were noted in his record on daily doses of 350 to 400mg. Donald Hall Essay. The facility became a tobacco-free zone during 2007, although most patients were able to obtain tobacco for johnson and scholes web essay, the remainder of 2007. Clozapine blood levels remained lower than expected but higher than in 2005 and 2006 ( Figure 1 ). In May, the pe pep coursework mark scheme patient was admitted for two days to a local hospital with chest pain. Scattered rales were noted bilaterally. And Scholes Cultural Web Essay. Hypersalivation, cough, and lethargy were patient complaints.
Pneumonia was considered but x-rays were negative. He was hospitalized again in September with similar complaints and symptoms. In addition to sialorrhea, cough, and lethargy, he had a fever. Order Table Of Contents. A chest x-ray demonstrated either atelectasis or a left basal infiltrate. In 2008, daily doses of 350 to 400mg were prescribed for johnson, this patient.
He continued to pe pep coursework have sialorrhea, cough, and johnson and scholes cultural lethargy. There were also two hospitalizations for pneumonia in 2008. The hospital smoking ban was in full effect by wharton essay this time, and his serum blood levels continued to move up slowly ( Figure 1 ). Johnson Cultural Web Essay. In January of 2008, the patient was transferred to a local hospital complaining of shortness of breath, cough, fever, and malaise. The CT scan showed #x0201c;infiltrate within the right lower lobe.#x0201d; He was diagnosed with right lower-lobe pneumonia. He was treated and returned to the state psychiatric center. Gcse Scheme. In September of 2008, the and scholes cultural web essay patient was again transferred to coursework mark a local hospital for nine days to treat right lower-lobe pneumonia.
He had a productive cough, fever, and chills. The initial chest x-ray demonstrated right lower pneumonia, a repeat chest x-ray showed only minimal fluid in the minor fissure. Additionally, the patient complained of abdominal pain when he presented at the emergency room. Johnson. A CT scan suggested a significant fecal impaction. The patient often complained of constipation secondary to clozapine. In April of 2009, despite a partial therapeutic response, clozapine was discontinued because staff reported difficulty obtaining weekly blood samples. You Admire. He was started on johnson cultural web essay, a low dose of haloperidol, which was gradually increased in an effort to control his psychotic symptoms. Donald Hall Essay Poetry. Haloperidol was augmented with olanzapine, valproic acid, and johnson cultural web essay quetiapine over the following year. Coursework Scheme. On these combinations of medications, he reported severe command auditory hallucinations criticizing him and telling him to harm himself or others. He made no attempt to hurt himself or others during this time; however, it was apparent that his response to clozapine was more effective in controlling his psychosis.
Literature review. Kane and Correll 3 demonstrate two central points: that an effective approach considers current symptoms, past therapeutic response, adverse effects, patient choice and and scholes web essay expectations, and that clozapine is the only evidence-based treatment for refractory patients. Farka and Azorin 4 add that clozapine is the treatment of hall essay and ambition choice for patients with schizophrenia who are refractory to treatment, display violent behaviors, or at high risk for suicide. There are serious and sometimes fatal adverse effects associated with the use of clozapine. Agranulocytosis, seizure activity, myocarditis, cardiomyopathy, metabolic syndrome, diabetes mellitus, fever, and neuroleptic malignant syndrome (with clozapine alone or when used in combination with lithium or other central nervous system [CNS] drugs) are the more well-known and severe adverse effects. And Scholes Cultural. Orthostatic hypotension, sialorrhea, constipation, and somnolence are also considered common but less serious. 5 , 6 Additional events observed possibly related to order clozapine are coughing, pneumonia, pneumonia-like symptoms, aspiration, pleural effusion and pneumonia, and lower respiratory tract infection, which may be fatal. 6. The adverse effects of sialorrhea, aspiration pneumonia, and pneumonia-like illnesses are central to our discussion. Pathophysiology and management of clozapine-induced sialorrhea are reviewed by and scholes web essay Praharaj, Arora, and Gandotra and Hussaini.
7 , 8 Sheriff et al 9 note that there is still room for you admire, additional research on clozapine-induced hypersalivation. Johnson Cultural. Aspiration pneumonia and pneumonia-like illnesses and their association to clozapine are increasingly being addressed in the literature. 10 - 13. Hypersalivation is the most prominent side effect associated with the use of clozapine. Approximately 30 to 50 percent of patients prescribed clozapine will report sialorrhea. The question is cool, why, especially given the strong anticholinergic properties of clozapine. And Scholes Cultural Web Essay. 1 , 5 Early studies did not find a significant difference between the saliva flow rate between healthy controls and those prescribed clozapine.
14 , 15. More recently, the evidence seems to suggest that clozapine does in fact increase the wharton essay saliva flow rate; however, there was no correlation between salivary flow rate and mean clozapine dose. And Scholes Cultural. 16 Ekstrom, Godoy and Riva#x02019;s animal study found the overall actions of clozapine suggested salivation increased during sleep and at rest, but decreased during meals. 17 Clozapine also caused secretion by direct action on muscarinic (M1) receptors of acinar cells, a response independent of mark central nervous mechanisms, presynaptic intraglandular events, and circulating catecholamines. It appeared likely that the net effect is an increase in cultural web essay, saliva production with clozapine, which may increase the risk for aspiration pneumonia, especially for those who also experience swallowing difficulties, a side effect also often associated with clozapine. When Rabinowitz et al 15 found that clozapine did not increase saliva flow rate, they hypothesized that drooling, choking, and someone you admire aspiration may result from interference disrupting signals to the brain that the oral cavity needs to johnson be cleared in order to swallow. Pearlman 18 reported that a patient with significant nighttime drooling and episodes of awakening with sensations of choking on benefits wireless, his saliva had reduced pharyngeal peristalsis demonstrated by cultural a barium swallow study. Essay. However, he noted that instruction in johnson and scholes cultural web essay, swallowing two or three times without inhaling alleviated the choking sensation without affecting the sialorrhea, leading him to suggest that the risk of choking would be better handled by patient education regarding swallowing than by treating sialorrhea.
Hinkes et al 19 reported that a patient developed severe hypersalivation and moderate sedation secondary to clozapine with subsequent pneumonia. They speculated that the sedation and hypersalivation, in combination with pharyngeal/esophageal peristalsis, may have led to the aspiration of the oral contents. They suggest that a reduction in clozapine dose when patients develop sialorrhea and sedation secondary to clozapine could reduce the risk of life-threatening aspiration pneumonia. McCarthy and Terkelson 20 report two cases in which esophageal dysfunction developed when clozapine was the only treatment agent. One case was complicated by hypersalivation; one was not. Importantly, both individuals responded well to reduced daily doses of clozapine. Swallowing was greatly improved with no significant subjective complaints voiced by the patients. Kuo#x02019;s group 10 looked at the association between second-generation antipsychotics and wharton essay the risk of pneumonia requiring hospitalization in web essay, non-geriatric patients with schizophrenia. Current use of clozapine was found to be associated with a dose-dependent increased risk of pneumonia. Quetiapine, olanzapine, and cool cover designs risperidone were also found to be associated with increased risk of johnson and scholes pneumonia with no clear dose-dependent relationship.
There was also an increased risk of essay someone pneumonia if clozapine was used in johnson, combination with quetiapine, olanzapine, or risperidone. They noted that while the affinity of clozapine for the M1 receptors is remarkably high, olanzapine and quetiapine showed moderate affinity and risperidone had minimal affinity for the M1 receptor. Essay Someone. The adjusted odds ratio (risk of pneumonia) for the medications followed the affinity profile for the M1 receptors. Johnson And Scholes Web Essay. They also note that clozapine, olanzapine, and quetiapine had high affinity for benefits technology, the histaminergic-1 (H1) receptor and risk ratios for pneumonia, while risperidone had a low affinity for the H1 receptor and a low risk ratio for pneumonia. The findings, according to Kuo et al 10 provide some association between pneumonia and H1 receptors, and they concluded that affinities for cultural, H1 and M1 are the most plausible explanation for the association between a given antipsychotic medication and the risk of pneumonia. Kuo#x02019;s perspective significantly adds to cool letter the understanding of the association of atypical antipsychotic medication and the risk of pneumonia. 10 If the Ekstrom, Godoy, and Riva 17 animal model is applicable to human physiology and clozapine actually causes secretion by the direct action on M1 receptors of the acinar cells, instead of dry mouth we would have increased salivation.
We are not alone in concluding that sialorrhea combined with esophageal hypomotility and sedation could, in certain individuals, lead to cultural web essay aspiration pneumonia. 19 This mechanism is likely responsible for the pneumonia and pneumonia-like symptoms experienced by our patient. Second clozapine trial 2010 to 2012. Due to clear therapeutic effects of clozapine for this patient, especially reduction of auditory hallucinations and absence of lethal command hallucinations, in October of 2010, the patient was approached with the thesis order idea of a low-dose clozapine trial. The patient voiced his concerns about the side effects he had experienced with clozapine and johnson cultural the difficulty in obtaining blood samples from him but acknowledged the gcse pe pep coursework mark positive effects of the medication. He agreed to a trial of clozapine at and scholes doses around 200mg/day. As the clozapine was initiated and titrated he was observed closely.
Adherence to taking clozapine was excellent. One month after restarting clozapine at a daily dose of 200mg, the patient was not complaining of lethargy, sialorrhea, or constipation. Order. The dose was titrated to 225mg for johnson and scholes, two days and then to 250mg for two days. Donald And Ambition. After four days at a daily dose over and scholes cultural, 200mg the patient complained of gcse pe pep coursework scheme a sore throat, increased saliva production, and johnson and scholes cultural cough. The next day he was hospitalized for donald essay and ambition, the treatment of aspiration pneumonia.
A videofluoroscopy swallowing study was performed during this hospitalization. It demonstrated residual matter in the patient#x02019;s oropharynx, prolonged pooling of the bolus, and a delay in johnson cultural web essay, the swallowing reflex. Gcse. Recommendations to prevent repeated aspiration pneumonia for this patient included a percutaneous endoscopic gastrostomy (PEG) tube (no oral feedings) or use of a pureed diet. The client objected to both options, though finally agreed to johnson and scholes cultural web essay the pureed diet. The patient was returned to the psychiatric center still on a daily dose of 250mg of clozapine. Pe Pep Mark Scheme. Immediately the dose was lowered to 75mg daily and gradually increased to 200mg daily. Johnson Cultural Web Essay. At 200mg daily the patient, as earlier in the second trial, did not complain of lethargy, sialorrhea, or constipation.
However, a year later at benefits wireless technology a time when he was experiencing increased auditory hallucinations and irritability, the dose was increased once again to 250mg for two days. And Scholes Cultural Web Essay. By the essay you admire second day, the patient reported cough and johnson cultural lethargy. His temperature was 101.1#x000b0; F. Wharton Essay. He was not hospitalized but his daily dose of clozapine was reduced to 200mg and within a few days his cough and cultural web essay other symptoms resolved. With a daily dose of clozapine at 200mg for the following year until present, the patient has not experienced lethargy, constipation, sialorrhea, and/or aspiration pneumonia. A follow-up videofluoroscopy swallowing study was essentially normal as well. Clozapine was then augmented by quetiapine in the second trial resulting in the significant clinical improvement. Lithium was also added to control symptoms of his affective disorder, specifically irritability. Cool Cover Designs. With his psychotic and affective symptoms controlled, he started to actively participate in social and recreational activities as an inpatient.
He was discharged to a supportive community residence on web essay, clozapine 200mg/day, quetiapine 100mg/day, and lithium 600mg HS. He had been on this combination for at least the past year. Use of a lower clozapine dose. As noted above, the side effects in someone, the second trial were primarily addressed with lower doses of clozapine. Reducing the dose of clozapine to reduce associated side effects is currently supported in the literature and has been for many years. 1 , 5 , 19 , 21 , 22. While there was significant improvement in the client#x02019;s symptoms of psychosis, he still reported occasional hallucinations. Cultural Web Essay. Therefore, with the patient#x02019;s consent, the dose was increased over wharton essay, four days to cultural web essay 250mg PO daily. Almost immediately, hypersalivation and essay you admire cough were noted and the patient was hospitalized for the treatment of aspiration pneumonia.
Hinkes 19 reported a case of aspiration pneumonia in a patient taking 250mg of cultural clozapine daily as well. Cool Cover. Substantial symptom reduction in this case occurred with the and scholes web essay lower dose of clozapine and without the untoward effect of aspiration. Therapeutic drug monitoring of clozapine serum levels. Although studies indicate a linear relationship between dosage and serum clozapine up to 1000ug/L with low intra-patient variability in individual patients, there can be a 45-fold difference in serum clozapine levels on the same dose between patients (e.g., a 300mg dose of clozapine can result in serum levels between 200ng/mL and 600ng/mL. Cool Designs. 23 - 25 Previous studies mostly agree with Nielsen et al 21 that in johnson, case of partial response or non-response, the use of therapeutic drug monitoring of clozapine is recommended. A minimal plasma level above the therapeutic threshold of essay 350 to 420ng/mL is necessary to determine nonresponse to clozapine.
21 , 26 , 27 These studies also found no added value in exceeding the upper therapeutic level as it would not improve the clinical response but would increase the potential for adverse effects. A more recent article is also in johnson and scholes cultural, agreement with the 350ng/mL serum lower level; however, it states that the upper level that corresponds to toxicity remains unclear. Cover Designs. 28 They suggest that levels between 350 to 1000ng/mL achieved through slow titration are likely to and scholes cultural be effective and less likely to cause toxicity. However, they note that levels above 600ng/mL or rapid titration are associated with seizures. They recommend ongoing monitoring when a patient is prescribed higher doses of clozapine (i.e., #x0003e;600mg daily), there has been a change in the patient#x02019;s concomitant medication or cigarette use, and when there is suboptimal response. During the first three years (2005-2007) the patient#x02019;s serum levels were low considering the prescribed dose. The patient#x02019;s partial adherence and use of cigarettes are probable explanations. Wharton Essay. In 2008, the clozapine levels are elevated, though still in the therapeutic range, at doses similar to what was prescribed in 2007. As noted above, the hospital-wide smoking ban was in effect at this time and the higher levels are likely to be a reflection of his smoking cessation.
2 , 29 , 30 It was in 2008 that he developed serious respiratory issues including pneumonia and aspiration pneumonia requiring hospitalization. There was never a period during the first trial where he did not have some degree of hypersalivation while using clozapine. It is likely that the upper level that is and scholes cultural web essay, tolerable before serious side effects for this individual is well below the quasi-established upper limit of wharton essay 1000ng/mL. The second trial began with adherence and with the patient remaining a nonsmoker. Mostly the patient was prescribed 200mg daily and the serum blood levels were in the 330 to johnson and scholes cultural 350ng/mL range. As noted previously, he was a partial responder at this level but side effects, even sialorrhea, were nonexistent.
Two attempts to essay wireless technology increase his clozapine to johnson 250mg daily did not significantly improve his clinical presentation, but did cause develop serious side effects including one instance of cover letter designs aspiration pneumonia requiring hospitalization. Unfortunately, a blood level is not available around the time he was hospitalized. But, around the second time he developed significant respiratory problems with a dose of 250mg daily, his blood level 523ng/mL. It appears from this level that moving beyond a blood level of 400 to 450ng/mL predicts serious side effects for this individual. Maintaining serum levels that are in johnson web essay, the lower acceptable limits, even though only cool letter designs, partially therapeutic, limits the side effect burden for him. Augmentation with another antipsychotic medication. Goff and johnson cultural Dixon 31 state when patients fail to respond to an adequate dose of an antipsychotic, clozapine is the only option with established efficiency. The problem is that there are a substantial number of order table of contents patients, estimated to be around 30 to 50 percent, refractory to antipsychotics who will also be refractory or only johnson cultural web essay, partial responders to clozapine. 21 , 32 , 33 In this case, how does one proceed? It is important to note that there is still a question a full 23 years since the FDA approved clozapine whether or not clozapine is the answer for a substantial number of treatment-resistant people with schizophrenia. Goff and Dixon 31 suggest that in these situations clinical judgment combined with patient preference must take over when treatment algorithms fall short.
Clinical experience holds that when clozapine is ineffective or not an option for a patient, the art of psychopharmacology comes into poetry play. Given that clozapine is typically used in treatment-resistant schizophrenia, combinations of medications that include clozapine are often tried if clozapine monotherapy is unsuccessful. The addition of another agent can help to lower the dose of clozapine and johnson cultural potentially help with lowering the side effect burden. Augmenting clozapine with other antipsychotics if a patient is a partial responder to clozapine is, though reluctantly, supported by the current literature. 21 , 22 , 34 - 36. After discussing the rationale for augmentation with our patient, he agreed to a low dose of quetiapine in the second clozapine trial. There is order, some support for the use of quetiapine in combination with clozapine for johnson cultural, treatment-resistant patients.
35 The choice of essay wireless technology quetiapine, however, is web essay, strictly the prerogative of the prescriber. Letter. For this patient, the combination was quite helpful in controlling his positive symptoms of psychosis. Lithium was also added to the medication plan primarily to address the affective component of our patient#x02019;s psychiatric illness and not necessarily to augment the johnson and scholes clozapine. There is support in of contents, the literature for using lithium in web essay, combination with clozapine. Buckley 21 cited evidence from uncontrolled trials that lithium enhanced the antipsychotic effect when added to a stable dose of clozapine. This was particularly beneficial for patients with a major affective component to hall poetry their illness. There were also some additional concerns relative to this combination of medications (e.g., seizures and neurotoxicity even with lithium levels #x0003c;0.5mEq/L). This added to the importance that this patient continue to receive very close monitoring for potential side effects. This case suggests a relationship between clozapine dose and johnson cultural vulnerability to essay wireless technology aspiration pneumonia. Individual responses to medications have an impact on clinical efficacy and and scholes the presence and severity of associated side effects. Further research is needed to clarify this association.
Monitoring aspiration and dose while on clozapine may be of importance for cool letter designs, many patients. As a result of our clinical experience with this patient we have ascertained that using tightly controlled pharmacological monitoring and prescribing a finely tuned titration of clozapine dose can result in controlling sialorrhea, and johnson and scholes cultural web essay that an effort to rechallenge a patient on someone, clozapine is feasible even when severe sialorrhea and complications arising from it have occurred previously. FUNDING: There was no funding for the interviews, development, and writing of this article. FINANCIAL DISCLOSURES: The authors do not have conflicts of interest relevant to the content of this article.
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Robert Bly Bly, Robert (Vol. Johnson Cultural Web Essay. 10) - Essay. Bly is an American poet, translator, essayist, and editor who through his rebellion against rhetoric and his development of the deep image has greatly influenced contemporary poetry. Often characterized as mystical or visionary, his is a poetry of the inner world, filled with images of nature and solitude. Bly was a founder of American Writers against the Vietnam War. A 1968 recipient of the wharton essay, National Book Award, he donated the prize money to aid young Americans in defying the johnson, draft. (See also CLC , Vols. 1, 2, 5, and Contemporary Authors , Vols. Coursework Scheme. 5-8, rev. ed.) Access our Robert Bly Study Guide for Free. [There] was a radical shift between [Robert Bly's] first and cultural second books, Silence in the Snowy Fields and The Light Around the wharton essay, Body . Since then, however, Bly has not put aside one style or mode to take up another, as some other poets have tended to do.
Rather, he has taken the discoveries made in the first two books and used them to write different sorts of poems simultaneously, and has mingled the ways of and scholes writing explored there in new ways. The result has been a fascinating body of work, a voice as distinctive as any we now have in our poetry. (p. 2) A quietly revolutionary book, [ Silence in essay wireless, the Snowy Fields ] has had an important influence in American poetry in the years since [it appeared]. The snow, fields, barns, lakes, and johnson and scholes trees, presented so plainly and precisely, yet seeming to resonate, to glow, with some deep, moving mystery; the wharton essay, quiet declaratory tone; the open expressions of pleasure (there must have been a refreshing, freeing feeling then in writing lines like: There is a privacy I love in this snowy night and I love to see old boards lying on the ground in and scholes, early spring); the unexpected leaps of metaphor; the silence, the sense of solitude, the poetry in the blank spaces between the stanzas; the rich subjectivity of it all;—all went to make a book that was strikingly original, and that tapped resources that had long been turned away from, for the most part, in American poetry: silence, subjectivity, association, the unconscious, a limpid style. Bly was not alone in his interest in this kind of poetry, but Silence in the Snowy Fields was one of the crucial examples of its reemergence. More important, it was and is a beautiful and moving book of poems. Someone You Admire. I think it still stands as Bly's best single collection.
The critic who reviewed it in 1963 and said that the poems were less effective read grouped together was dead wrong; the repetition of and scholes cultural web essay images, phrasings, and someone you admire feelings enriches the book—artful repetition being one of the oldest keys to poetry—and in a way holds it together as if it were a single long poem. As an expression of a deep marriage between the inner and outer worlds in one man's life and place it is in the line of Walden . Web Essay. I imagine that it will stand, in spite and because of its limitations, as a small (i.e., 60 pages) classic in American poetry. (pp. 2-3) While there is of course some continuity between [this and The Light Around the Body ] (most notably interest in what is wharton essay now well-known as the web essay, deep image), the change from Silence to The Light was a jarring one. The Light doesn't have the clarity, the purity, of pe pep Silence; instead it is cultural web essay woolly with surrealism and wild associative leaps. Cool. The remarkable evocations of the motions of the soul in peaceful solitude are replaced—nearly obliterated—by political and social rage and despair: the Vietnam War, The Great Society, America's Hatred of Men With Black Hair. It is an angry, uneven, powerful book, and clearly with it Bly made a major contribution to the growth of an American poetry which is truly political and truly poetry. After The Light , the question was: what sort of poetry would Bly write now? Inward pastorals, or barrages of wild imagery and political passion? As I've said, the answer has been to abandon neither, to open himself to the energies, and risks, of cultural web essay both. So in Bly's most recent book, Sleepers Joining Hands , we find together his most ambitious political poem, The Teeth-Mother Naked at Last, a surrealistic, wildly associative poem like Hair, and the quiet, brief, haunting meditations of essay someone you admire Six Winter Privacy Poems.
The single most important word with regard to Sleepers is johnson association; it is the dominant principle throughout the book. Bly has written a good deal about association in his essays; an entire issue of his magazine The Seventies (#1) was devoted to it. While it doesn't detract from the self-sufficiency of the poetry or the value of his stimulating essays, it is obvious that with Bly, as with Poe (and probably every other writer who has written both poetry and critical essays), a knowledge of the criticism is an important aid in getting a fuller understanding of the donald hall essay and ambition, poetry. When he speaks of johnson and scholes web essay association Bly seems to wharton essay have three things in mind. First, association is a structural principle…. Second, association has to do with speed, the speed with which a poet is cultural able to move from one image, feeling or idea to another, from the known part of the mind to the unknown part and back to the known.… Third, association means being able to travel a long way from an initial, literal subject into subjectivity and the unconscious, and still be talking about the wharton essay, original subject….
Taken together, the result of these three ideas—the absence of connectives or natural order, rapid leaping, and moving the and scholes web essay, poem far. (The entire section is cover letter designs 2012 words.) Get Free Access to this Robert Bly Study Guide. Start your 48-hour free trial to unlock this resource and thousands more. Get Better Grades.
Our 30,000+ summaries will help you comprehend your required reading to ace every test, quiz, and essay. We've broken down the chapters, themes, and characters so you can understand them on your first read-through. Access Everything From Anywhere. We have everything you need in johnson and scholes web essay, one place, even if you're on the go. Download our handy iOS app for free. Robert Bly's poetry owes its appeal in part to mark vivid descriptions of the region around Madison, Minnesota, where he has spent much of his life. The chief concern of his verse, however, is not the objective portrayal of external nature but, rather, the presentation of various states of mind. Johnson Cultural Web Essay. Natural surroundings assume importance for him either as influences contributing to thoughts or emotions or as media of symbolic expression. Wharton Essay. Along with James Wright, James Dickey, Robert Kelley and others, Bly has argued for the writing of poetry of increased subjectivity, with emphasis upon johnson cultural, the poet's personal vision…. Wireless. He shares significant ground with the johnson cultural web essay, surrealist Andre Breton, particularly in his fondness for images generated by powerful feelings in the poet's unconscious and wharton essay designed to appeal to the unconscious of the reader. Although he lacks Breton's Freudian faith in cultural, the omnipotence of the dream, dreams and dream-images do appear in his verse.
Similarly, while his art is much more consciously constructed than the automatic writing or pure psychic automatism prized by the surrealists, it does contain such notable imagistic departures from objectivity as moles with golden wings and someone you admire Arabic numerals dressed as bankers and sportsmen, images which are solidly in the surrealist tradition. In accordance with his attraction to subjectivity, Bly's typical authorial stance is emotional, as reflected in titles like Three Kinds of Pleasures, Unrest, Depression, Melancholia, and Written in cultural web essay, Dejection near Rome. Despite the predominant gloominess of these titles, the emotion most often expressed in the poems is cool cover letter designs not sadness but delight. Joy or happiness frequently overtakes the author while he is alone in the out-of-doors. And Scholes Cultural. He is cool letter designs both comforted and inspired by solitude, not only because it facilitates the reflective and meditative moments which are vital to his well-being but also because is frees him to develop a mental intensity out of which poetry may issue. Bly refers to and scholes the artist's psychic potential as desire-energy and explains that during periods of solitude this desire-energy accumulates until it overflows into expression…. (pp. 231-32) Since Bly's verse depends heavily upon dominant images, it is essential that the most important images be carefully examined.
Among his most frequently repeated images is darkness. One third of the poems in Silence in the Snowy Fields are set in darkness, the poet delighting especially in late night walks across the fields. No doubt darkness attracts him partially because it is conducive to solitude. Furthermore, it serves as a convenient emblem of the unconscious, an important realm to coursework mark scheme this poet who, like the surrealists, wishes to open new corridors into the psyche by association.… For Bly, as for generations of johnson and scholes cultural web essay other poets, darkness also represents death. Such observations as: the darkness of death, The farmer looks up at someone the paling dome reminding him of death, and We are falling,/ Falling into the open mouths of darkness, combined with the and scholes cultural, juxtaposition of darkness and death in table, poems such as Night and Riderless Horses provide conclusive evidence of cultural Bly's intentions. Frequently linked with darkness (as in the quotation above from Return to Solitude) is the image of water, occasionally described by of contents Bly as itself dark.… Having an easily penetrable surface and variable depth, water is and scholes cultural uniquely appropriate as an image attached to the related conditions of sleep and death, both of which Bly associates with a fertile strangeness and pe pep mark scheme inwardness.
Somewhat as a sleeper falls away from surface consciousness into the depth of the unconscious, so the newly dead literally descend beneath the earth's surface and figuratively break through the surface of and scholes cultural conscious existence and into a mysterious, unfamiliar realm. The imagistic usefulness of water in such contexts is self-evident. Bly's aspiration to escape the tyranny of rational consciousness, experiencing instead the inward state and its richness, is essay expressed through a water-image in After Drinking All Night With a Friend …. The poet acknowledges that his experiences have been essentially conscious, that his have been the same interests which, as he says elsewhere, have caused American poetry to cling at cultural unprofitable length to the surface of life. Like the boat in essay benefits wireless technology, which he is seated, he has simply drifted above the depths, but he yearns to go underwater…. (pp. 232-34) Like darkness and web essay water, snow is a favorite Bly image associated with sleep and death. As with darkness, he is employing a traditional, even archetypal, image because of gcse pe pep coursework its proven suggestive power. In his preference for and scholes cultural web essay, snow he joins a symbolic tradition among whose modern representatives are James Joyce's The Dead and Robert Frost's Stopping by wireless Woods on johnson and scholes cultural web essay, a Snowy Evening. Like Joyce and Frost, Bly prefers to link snow and darkness, thereby intensifying if not actually doubling the evocative powers of the images. Hall Essay And Ambition. (pp. 234-35) Frequently associated with snow, water, or darkness in Bly's poems is moonlight.
To fully understand its place in johnson and scholes web essay, his imagistic realm, it is first necessary to review his relation to the German mystical theologian Jacob Boehme (1575–1624), whose writings have furnished epigraphs for both Silence in the Snowy Fields and The Light around the Body . The poet's choice of epigraphs, such as, We are all asleep in the. (The entire section is 2230 words.) Get Free Access to this Robert Bly Study Guide. Start your 48-hour free trial to unlock this resource and thousands more. In Sleepers Joining Hands , Robert Bly offers his readers a various weave of the personal and the public, the psychological and the political modes of experience. Wharton Essay. Each mode illuminates the other, though … the collection is most fundamentally and formally psychological. The layout of the book is pleasantly indirect: two dozen pages of poems, ranging from haiku-like meditation moments to and scholes cultural longer poems of protest.
Then there is the pe pep, essay, a short course in the Great Mother, an analysis of the disturbing but finally nourishing configuration of feminine archetypes in the collective unconscious. And finally we have the oneiric title sequence: four poems and a coda, written at and scholes different times and published in. (The entire section is 3377 words.) The experience of reading Sleepers Joining Hands … is a bit like slogging your way through a violent storm. The book begins in deceptive calm, with Six Winter Privacy Poems.… Bly's central theme, beautifully rendered: the donald essay poetry, duality of inner and outer worlds, the deep duality of a consciousness often conflicted but existing here in a momentary state of peaceful coexistence. It's the American haiku, fully and quietly accomplished…. [However,] the final, frenetic Whitmanesque catalogue of wildly various identifications [in An Extra Joyful Chorus for Those Who Have Read This Far] should give you some idea of the bumpy ground Bly travels in Sleepers Joining Hands . (The entire section is 806 words.) Robert Bly's prose poems have a parallel hallucinatory quality [to the drawings by Gendron Jensen that illustrate This Body Is Made of Camphor and johnson cultural web essay Gopherwood]…. My beloved is to me as a cluster of essay someone camphor, we read in the Song of Solomon (1:14); and the Ark, God told Noah (Genesis 6:14), was to johnson cultural be made of gopherwood.
The Ark was by some accounts an allegory for the body, and that's all the explanation you're going to get in these pages about what it's like to be alive in a body; in it, yet through it mysteriously part of everything else material…. Bly is attempting to essay write down what it's like to be alive, a state in which, he implies, not all readers find themselves all. (The entire section is 168 words.) Nowadays, everything Bly touches becomes a holy cause and reason for another book. Johnson Web Essay. [In This Body is wharton essay Made of Camphor and Gopherwood ] he consecrates the often neglected[?] medium of the johnson and scholes web essay, prose poem. Like the snail in the book's twenty-one drawings by Gendron Jensen, Bly has crept into the shell of his own meditations and wharton essay remains absorbed in Sufi poetry, Rilke, protozoa, animals, woods, and fog. The pilgrim's mecca is a small black stone, mysterious and impenetrable. One may admire such pure isolation, but the poet does not help us to share it. The result is not mysticism but solipsism, and johnson and scholes cultural web essay we are left out in wharton essay, the cold by passages like this one from The Pail; So for two days I gathered ecstasies from and scholes cultural my own. (The entire section is 302 words.) Robert Bly Homework Help Questions.
[eNotes editors are only permitted to answer one question per coursework mark posting. If you have additional questions, please post them separately.] In Robert Bly's poem, Prayer for My Father, I believe that. The master mentioned in the final line of the and scholes cultural web essay, Robert Bly's poem Waking from Sleep is benefits wireless actually sleep itself. Bly personifies sleep by making it our master as if sleep controls and demands rest. This is short but powerful poem about the relationship between the and scholes web essay, speaker and his father. The father is near death, but the son is reassuring him that he will be OK after the father's passing. In order to answer the question you have to consider your various association with hawks.
What immediately should come to wharton essay mind is their independent nature. They are usually seen in solitary. Ask a question.
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0195052471 - Essays the Schomburg Library of Nineteenth-century Black Women Writers by Ann Plato. Johnson And Scholes Cultural Web Essay. First Edition (3) Seller-Supplied Images (1) Not Printed On Demand. Free US Shipping (8) star star star star star (13) Essays (The Schomburg Library of Nineteenth-Century Black Women Writers) Oxford University Press, 1988. Book Condition: Good. A+ Customer service! Satisfaction Guaranteed!
Book is in Used-Good condition. Pages and cover are clean and intact. Wharton Essay. Used items may not include supplementary materials such as CDs or access codes. May show signs of minor shelf wear and contain limited notes and johnson and scholes cultural highlighting. Essay Poetry. Essays (The Schomburg Library of Nineteenth-Century Black Women Writers) Oxford University Press. Hardcover. And Scholes. Book Condition: GOOD. Good clean copy with no missing pages might be an ex library copy; Possibly may have minor marginal notes and or highlighting. Essays; Including Biographies and Miscellaneous Pieces, in Prose and gcse mark scheme Poetry.
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Oxford University Press, USA. And Scholes Web Essay. Hardcover. Book Condition: New. Hardcover. 178 pages. Dimensions: 6.8in. x 4.9in. x 0.7in.Ann Plato was the first black to publish a collection of essays, in essay someone 1841. --Newsweek This item ships from multiple locations. Your book may arrive from Roseburg,OR, La Vergne,TN. Hardcover. Essays (Schomburg Library Of Nineteenth-Century Black Women Writers) Book Condition: New.
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These writings, which first appeared in 1841, tell us much about the johnson web essay, writer herself and the city in which she lived: Hartford, Connecticut. Essay Technology. A cultural centre of the new nation, the city s Congregationalism, its free black society, and local literary tradition, are all reflected in Ann Plato s work. The topics that dominate are her ardent Christianity, her belief in education as a means of web essay, advancement, and her romantic preoccupation with death and, occasionally, racial issues. Essays: Including Biographies and Miscellaneous Pieces in Prose and Poetry (Hardback). Oxford University Press Inc, United States, 1988. You Admire. Hardback. Book Condition: New. Language: English . Brand New Book ***** Print on Demand *****.These writings, which first appeared in web essay 1841, tell us much about the writer herself and the city in cover designs which she lived: Hartford, Connecticut. A cultural centre of the johnson cultural web essay, new nation, the city s Congregationalism, its free black society, and local literary tradition, are all reflected in Ann Plato s work.
The topics that dominate are her ardent Christianity, her belief in cool cover designs education as a means of advancement, and her romantic preoccupation with death and, occasionally, racial issues. Essays (Schomburg Library of Nineteenth-Century Black Women Writers) Oxford University Press, USA, 1988. Hardcover. Book Condition: Used: Good. Essays (The Schomburg Library of Nineteenth-Century Black Women Writers) Oxford University Press, 1988. Johnson Cultural. Hardcover. Book Condition: New. Gcse Pe Pep Coursework Mark. book. Essays (The Schomburg Library of Nineteenth-Century Black Women Writers) Oxford University Press.
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Johnson and scholes cultural web …
Discursive Essay Sample Essays and Research Papers. Definition: discursive essay writing explores an cultural, issue using reasoned argument and then comes to a fitting conclusion based on wharton essay, . Johnson And Scholes Cultural! looking at both sides of the cool cover, argument. Johnson Cultural! If you like, the first part of the essay will explore the “pro”- argument and gcse mark the second part explores the counter-argument. The conclusion will summarise both arguments and then with reflection you can give your own definitive opinion on the subject. This type of writing requires skill. The essay is a process you undertake and you. Argument , Bariatric surgery , Childhood obesity 764 Words | 3 Pages. Discursive Essay It is argued nowadays on whether teenagers, who go to school, should be wearing a uniform.
There are many . advantages but also some disadvantages, such as : All the students wearing the same uniform , which can take the stress off looking better than other students as they are wearing similar attire, and also having a uniform can make a person look smart and respectable, but on the other hand, students can feel that their uniforms are too boring and doesn't show their personailty. Clothing , Dress code , Education 1000 Words | 3 Pages. ? Discursive Essay Structure: I. Introduction? nowadays in ancient times in johnson cultural analysing it we can draw out positive and negative + . Pe Pep Coursework Mark Scheme! thesis (economic, politic, social) II. Body Paragraphs? economically, politically, environmentally speaking/connection/on (ecology) in addition, similarly, moreover, therefore however, conversely III. Conclusion? in finalizing, we can see considering; taking into consideration Extraordinary Essay should: 1) Content and Structure Be consistently well developed, logical stages. Tourism 1949 Words | 6 Pages.
argument related to it. Organising a discursive essay There are three basic structures (ways of organising) for the . discursive essay - * you argue strongly for a given discussion topic * you argue strongly against a given discussion topic * you argue about a given discussion topic in a balanced way. Ideally, you should read these over (and complete any accompanying tasks)before you attempt the test bite. Good luck! Finding information for a discursive essay In the and scholes cultural, same way as you would look. Animal testing , Argument , Arguments 1703 Words | 5 Pages. Sample essay Topic: Test anxiety causes university students to underperform in their examinations. Discuss. NOTE: The . essay is in the left column.
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Crime , Criminology , Developmental psychology 1600 Words | 5 Pages. What do I need to know about . Discursive Writing? ?What's the point? Discursive wirting discusses the johnson and scholes web essay, situation at hand. It . presents an argument in cover designs a more balanced way than argumentative and persuasive writing and can appreciate the arguments both for and against a given position. Discursive writing does not argue for or against a point throughout the cultural, essay . Cool Cover! After having assessed and evaluated all arguments, the writer generally states his/her opinion at the end. ?What are the johnson and scholes, conventions? . Animal testing , Argument , Essay 1291 Words | 5 Pages. Discursive Essay: The Dark Sides of letter designs Cartoons. ? Academic Reading and Writing I Discursive Essay “The Dark Sides of Cartoons” In the early 21st . century children become more and more abused by cartoons. Cultural! Even parents themselves encourage their offspring to watch animated films. Commonly, we consider cartoons as sources of entertainment for our children to relax and benefits wireless technology have fun.
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Progress ESSAY Theodore Roosevelt once said, “A great democracy must be progressive or it will soon cease to coursework scheme, be a great democracy.” This . quote illustrates his belief that a great country can be advanced through challenge and pursuit of the innovative. Society’s development is based on and scholes cultural web essay, adopting pioneering values, rather than maintaining conventional ways. The benefits of progress and innovation are exemplified by the New Deal policies implemented by Franklin D. Roosevelt. As a response to. Democratic Party , Eleanor Roosevelt , Franklin D. Roosevelt 1017 Words | 4 Pages. “’I thought you inherited your money’” (95). To reply, Gatsby states, “’I did, Old Sport, but I lost most of it in the big panic – the panic of the designs, war’” . Winston Patterson 5/17/10 9:38 PM Comment: Single quote inside a double quote to and scholes, indicate a quote in the passage was quoted in the essay . (95). After giving an inappropriate reply to Nick’s later question concerning Gatsby’s business, he clarifies that he “was in the drug business and then . Essay Benefits! . . in the oil business” (95).
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Independence is on their agenda. Sooner or . later there will be a referendum. But why exactly should we be independent? Would our tiny, economically challenged country really be able to stand on its own two feet against the big players in the global market? For over 300 years we have been part of Great Britain’s success but now in a time of economic hardship, people have a growing desire for.
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Consanguinity , Cousin , Dannii Minogue 972 Words | 3 Pages. ? Structuring a Discursive Essay Your task is to help structure a discursive . essay about the advantages and disadvantages of car use. You will be given the various arguments both in favour of and against car use. Order Table Of Contents! Your first task will be to organise these arguments. Johnson And Scholes Cultural! Task 1 Read the following notes. Identify all the points in gcse pe pep scheme favour of car use and mark them with a tick. Johnson And Scholes Cultural Web Essay! Identify all the points against car use and mark them with a cross. …………………………………………………………………………. Air pollution , Article , Automobile 1406 Words | 6 Pages. ?Are Social Networks a Good Thing? When I think of social networks, I personally feel that they are a waste of time and there really is essay someone you admire, very little need . for them; I can concede that they are helpful and give a lot of freedom and communication to virtually anybody but I feel that the johnson cultural, more and more they evolve, the wharton essay, more engrossed in web essay them people soon become.
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Essay Writing, Sample Essay Topic: Philosophy Essay in and scholes web essay German - 1220 Words. Essay writing, sample essay topic: Philosophy Essay In German - 1220 words Formulierung des . Problems (Zusammengefasst): Man nehme an, dass es einen Hgel gibt auf dem eine Straenbahn fhrt und am Ende des Hgels eine Strae verluft. Nehmen wir an auf der Strae genau auf den Straenbahnschienen steht ein Schulbus voll mit kleinen Kindern und pltzlich versagen die bremsen der Straenbahn und sie rast auf den Schulbus zu. Es ist klar das alle Kinder sterben, wenn die Straenbahn den Schulbus trifft. Zwischen.
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