Advanced Accounting by Guerrero Essay

Chapter 1 Multiple choice answers and solutions 1-1: a Jose’s capital should be credited for the market value of the computer contributed by him. 1-2: b(40,000 + 80,000) ï‚ ¸ 2/3 = 180,000 x 1/3 = 60,000. 1-2: c 1-3: a CashP100,000 Land300,000 Mortgage payable( 50,000) Net assets (Julio, capital)P350,000 1-4: b Total Capital (P300,000/60%)P500,000 Perla’s interest ______40% Perla’s capitalP200,000 Less:Non-cash asset contributed at market value LandP 70,000 Building90,000 Mortgage Payable( 40,000)_120,000 Cash contributionP 80,000 1-5: d- Zero, because under the bonus method, a transfer of capital is only required. 1-6: b ReyesSantos CashP200,000P300,000 Inventory–150,000 Building–400,000 Equipment150,000 Mortgage payable________( 100,000) Net asset (capital)P350,000P750,000 1-7: c AABBCC CashP 50,000 Property at Market ValueP 80,000 Mortgage payable( 35,000) Equipment at Market Value______________P55,000 CapitalP 50,000P 45,000P55,000 2Chapter 1 1-8: a PPRRSS CashP 50,000P 80,000P 25,000 Computer at Market Value__25,000_______ ­Ã‚ ­__60,000 CapitalP 75,000P 80,000P 85,000 1-9: c MariaNora CashP 30,000 Merchandise inventoryP 90,000 Computer equipment160,000 Liability( 60,000) Furniture and Fixtures 200,000________ Total contributionP230,000P190,000 Total agreed capital (P230,000/40%)P575,000 Nora’s interest______60% Nora’s agreed capitalP345,000 Less: investment190,000 Cash to be investedP155,000 1-10: d Roy Sam Tim CashP140,000–– Office Equipment–P220,000– Note payable_________( 60,000) ______ Net asset investedP140,000P160,000 P – Agreed capitals, equally (P300,000/3) =P100,000 1-11: a LaraMitra CashP130,000P200,000 Computer equipment–50,000 Note payable________ ­_( 10,000) Net asset investedP130,000P240,000 Goodwill (P240,000 – P130,000) =P110,000 1-12: a PerezReyes CashP 50,000P 70,000 Office Equipment30,000– Merchandise–110,000 Furniture100,000 Notes payable_______( 50,000) Net asset investedP 80,000P230,000 Partnership – Basic Considerations and Formation3 Bonus Method: Total capital (net asset invested)P310,000 Goodwill Method: Net assets investedP310,000 Add: Goodwill (P230,000-P80,000)_150,000 Net capitalP460,000 1-13: b Required capital of each partner (P300,000/2)P150,000 Contributed capital of Ruiz: Total assetsP105,000 Less Liabilities__15,000__90,000 Cash to be contributed by RuizP 60,000 1-14: d Total assets: CashP 70,000 Machinery75,000 Building_225,000P370,000 Less: Liabilities (Mortgage payable)__90,000 Net assets (equal to Ferrer’s capital account)P280,000 Divide by Ferrer’s P & L share percentage____70% Total partnership capitalP400,000 Required capital of Cruz (P400,000 X 30%)P120,000 Less Assets already contributed: CashP 30,000 Machinery and equipment25,000 Furniture and fixtures__10,000__65,000 Cash to be invested by CruzP 55,000 1-15: d Adjusted assets of C Borja CashP 2,500 Accounts Receivable (P10,000-P500)9,500 Merchandise inventory (P15,000-P3,000)12,000 Fixtures__20,000P 44,000 Asset contributed by D. Arce: CashP 20,000 Merchandise__10,000__30,000 Total assets of the partnershipP 74,000 4 Chapter 1 1-16: a Cash to be invested by Mendez: Adjusted capital of Lopez (2/3) Unadjusted capitalP158,400 Adjustments: Prepaid expenses17,500 Accrued expenses( 5,000) Allowance for bad debts (5% X P100,000)_( 5,000) Adjusted capitalP165,900 Total partnership capital (P165,900/2/3)P248,850 Multiply by Mendez’s interest â…“ Mendez’s capitalP 82,950 Less Merchandise contributed ­Ã‚ ­Ã‚ ­__50,000 Cash to be invested by MendezP 32,950 Total Capital: Adjusted capital of LopezP165,900 Contributed capital of Mendez__82,950 Total capitalP248,850 1-17: d Moran, capital (40%) CashP 15,000 Furniture and Fixtures_100,000P115,000 Divide by Moran’s P & L share percentage______40% Total partnership capitalP287,500 Multiply by Nakar’s P & L share percentage______60% Required capital of credit of Nakar:P172,500 Contributed capital of Nakar: Merchandise inventoryP 45,000 Land15,000 Building__65,000 Total assetsP125,000 Less Liabilities__30,000P 95,000 Required cash investment by NakarP 77,500 1-18: c Garcia’s adjusted capital (see schedule 1)P40,500 Divide by Garcia’s P & L share percentage ­Ã‚ ­Ã‚ ­______40% Total partnership capitalP101,250 Flores’ P & L share percentage______60% Flores’ capital creditP 60,750 Flores’ contributed capital (see schedule 2)__43,500 Additional cash to be invested by FloresP 17,250 Partnership – Basic Considerations and Formation 5 Schedule 1: Garcia, capital: Unadjusted balanceP 49,500 Adjustments: Accumulated depreciation( 4,500) Allowance for doubtful account( 4,500) Adjusted balanceP 40,500 Schedule 2: Flores capital: Unadjusted balanceP 57,000 Adjustments: Accumulated depreciation ( 1,500) Allowance for doubtful accounts( 12,000) Adjusted balanceP 43,500 1-19: d OrtizPonceTotal ( 60%)( 40%) Unadjusted capital balancesP133,000P108,000P241,000 Adjustments: Allowance for bad debts( 2,700)( 1,800)( 4,500) Inventories3,0002,0005,000 Accrued expenses_( 2,400)( 1,600)( 4,000) Adjusted capital balancesP130,900 P106,000 P237,500 Total capital before the formation of the new partnership (see above)P237,500 Divide by the total percentage share of Ortiz and Ponce (50% + 30%)______80% Total capital of the partnership before the admission of RoxasP296,875 Multiply by Roxas’ interest______20% Cash to be invested by RoxasP 59,375 1-20: d Merchandise to be invested by Gomez: Total partnership capital (P180,000/60%)P300,000 Gomez’s capital (P300,000 X 40%)P120,000 Less Cash investment__30,000 Merchandise to be invested by GomezP 90,000 Cash to be invested by Jocson: Adjusted capital of Jocson: Total assets (at agreed valuations)P180,000 Less Accounts payable__48,000P132,000 Required capital of Jocson_180,000 Cash to be invested by JocsonP 48,000 6Chapter 1 1-21: b Unadjusted Ell, capital (P75,000 – P5,000)P 70,000 Allowance for doubtful accounts( 1,000) Accounts payable( 4,000) Adjusted Ell, capitalP 65,000 1-22: c Total partnership capital (P113,640/1/3)P340,920 Less David’s capital_113,640 Cortez’s capital after adjustmentsP227,280 Adjustments made: Allowance for doubtful account (2% X P96,000)1,920 Merchandise inventory( 16,000) Prepaid expenses( 5,200) Accrued expenses___3,200 Cortez’s capital before adjustmentsP211,200 1-23: a Total assets at fair value P4,625,000 Liabilities (1,125,000) Capital balance of FlorP3,500,000 1-24: c Total capital of the partnership (P3,500,000 à · 70%)P5,000,000 Eden agreed profit & loss ratio30% Eden agreed capital 1,500,000 Eden contributed capital at fair value 812,000 Allocated cash to be invested by EdenP 688,000 1-25: c __Rey __Sam_ __Tim __Total_ Contributed capital (assets-liabilities)P471,000 P291,000 P195,000 P957,000Agreed capital (profit and loss ratio) 382,800 382,800 191,400 957,000 Capital transfer (Bonus)P 88,200 P(91,800) P 3,600 – 1-26: d Total agreed capital (P90,000 à · 40%)P225,000 Contributed capital of Candy (P126,000+P36,000-P12,000) 150,000 Total agreed capital (P90,000 à · 40%) 225,000 Candy, agreed capital interest 60% Agreed capital of Candy 135,000 Contributed capital of Candy 150,000 WithdrawalP 15,000 Partnership – Basic Considerations and Formation 7 1-27: a Total agreed capital (210,000 à · 70%) P300,000 Nora’s interest 30% Agreed capital of NoraP 90,000 Cash invested 42,000 Cash to be invested by NoraP 48,000 1-28: a Contributed capital of May (P194,000 – P56,000)P138,000 Agreed capital of May (P300,000 x 70%) 210,000 Cash to be invested by May P 72,000 1-29: c __Alex__Carlos___Total__ Contributed capitalP100,000P84,000P184,000 Agreed capital 92,000 92,000 184,000 Capital investedP( 8,000)P 8,000 – 8Chapter 1 SOLUTIONS TO PROBLEMS Problem 1 – 1 1.a.Books of Pedro Castro will be retained by the partnership To adjust the assets and liabilities of Pedro Castro. 1.Pedro Castro, Capital600 Merchandise Inventory600 2.Pedro Castro, Capital200 Allowance for Bad Debts200 3.Accrued Interest Receivable35 Pedro Castro, Capital35 Computation: P1,000 x 6% x 3/12=P15 P2,000 x 6% x 2/12=_20 TotalP35 4.Pedro Castro, Capital100 Accrued Interest Payable100 (P4,000 x 5% x 6/12 = P100) 5.Pedro Castro, Capital800 Accumulated Depreciation – Furniture and Fixtures800 6.Office Supplies400 Pedro Castro, Capital400 To record the investment of Jose Bunag. Cash15,067.50 Jose Bunag, Capital15,067.50 Computation: Pedro Castro, Capital (1)P600P31,400 (2)20035(3) (4)100400(6) (5)___800 P1,700P31,835 P30,135 Jose Bunag, Capital:1/2 x P30,135 = P15,067.50 Partnership – Basic Considerations and Formation 9 b.A new set of books will be used Books of Pedro Castro To adjust the assets and liabilities. See Requirement (a). To close the books. Notes Payable4,000 Accounts Payable10,000 Accrued Interest Payable100 Allowance for Bad Debts1,200 Accumulated Depreciation – Furniture and Fixtures1,400 Pedro Castro, Capital30,135 Cash6,000 Notes Receivable3,000 Accounts Receivable24,000 Accrued Interest Receivable35 Merchandise Inventory7,400 Office Supplies400 Furniture and Fixtures6,000 New Partnership Books To record the investment of Pedro Castro. Cash6,000 Notes Receivable3,000 Accounts Receivable24,000 Accrued Interest Receivable35 Merchandise Inventory7,400 Office Supplies400 Furniture and Fixtures6,000 Notes Payable4,000 Accounts Payable10,000 Accrued Interest Payable100 Allowance for Bad Debts1,200 Accumulated Depreciation – Furniture and Fixtures1,400 Pedro Castro, Capital30,135 To record the investment of Jose Bunag. Cash15,067.50 Jose Bunag, Capital15,067.50 10Chapter 1 2. Castro and Bunag Partnership Balance Sheet October 1, 2008 A s s e t s CashP21,067.50 Notes receivable3,000.00 Accounts receivableP 24,000 Less Allowance for bad debts___1,20022,800.00 Accrued interest receivable35.00 Merchandise inventory7,400.00 Office supplies400.00 Furniture and fixtures6,000 Less Accumulated depreciation___1,400__4,600.00 Total AssetsP59,302.50 Liabilities and Capital Notes payableP 4,000.00 Accounts payable10,000.00 Accrued interest payable100.00 Pedro Castro, Capital30,135.00 Jose Bunag, Capital_15,067.50 Total Liabilities and CapitalP59,302.50 Problem 1 – 2 Contributed Capitals: Jose:Capital before adjustmentP 85,000 Notes Payable62,000 Undervaluation of inventory13,000 Underdepreciation( 25,000)P 135,000 Pedro:Cash28,000 Pablo:Cash11,000 Marketable securities_57,500 ­___68,500 Total contributed capitalP 231,500 Agreed Capitals: Bonus Method: Jose (P231,500 x 50%)P115,750 Pedro (P231,500 x 25%)57,875 Pablo (P231,500 x 25%)__57,875 TotalP231,500 Partnership – Basic Considerations and Formation 11 Goodwill Method. To have a goodwill, the only possible base is the capital of Pablo. The computation is: ContributedAgreed CapitalCapitalGoodwill JoseP135,000P137,000 (50%)2,000 Pedro28,00068,500 (25%)40,500 Pablo__68,500__68,500 (25%)_____– TotalP231,500274,00042,500 Total agreed capital (P68,500 ï‚ ¸ 25%) = 274,000 Jose, Pedro and Pablo Partnership Balance Sheet June 30, 2008 Bonus MethodGoodwill Method Assets: CashP 49,000P 49,000 Accounts receivable (net)48,00048,000 Marketable securities57,50057,500 Inventory85,00085,000 Equipment (net)45,00045,000 Goodwill______–__42,500 TotalP284,500P327,000 Liabilities and Capital: Accounts payableP 53,000P 53,000 Jose, capital (50%)115,750137,000 Pedro, capital (25%)57,87568,500 Pablo, capital (25%)__57,875__68,500 TotalP284,500P327,000 Problem 1 – 3 1.Books of Pepe Basco To adjust the assets. a.Pepe Basco, Capital3,200 Estimated Uncollectible Account3,200 b.Pepe Basco, Capital500 Accumulated Depreciation – Furniture and Fixtures500 12Chapter 1 To close the books. Estimated Uncollectible Account4,800 Accumulated Depreciation – Furniture and Fixtures1,500 Accounts Payable3,600 Pepe Basco, Capital31,500 Cash400 Accounts Receivable16,000 Merchandise Inventory20,000 Furniture and Fixtures5,000 2.Books of the Partnership To record the investment of Pepe Basco. Cash400 Accounts Receivable16,000 Merchandise Inventory20,000 Furniture and Fixtures5,000 Estimated Uncollectible account4,800 Accumulated Depreciation – Furniture and Fixtures1,500 Accounts Payable3,600 Pepe Basco, Capital31,500 To record the investment of Carlo Torre. Cash47,250 Carlo Torre, Capital47,250 Computation: Pepe Basco, capital (Base)P31,500 Divide by Pepe Basco’s P & L ratio___40% Total agreed capitalP78,750 Multiply by Carlo Torre’s P & L ratio___60% Cash to be invested by Carlo TorreP47,250 Problem 1 – 4 a.Roces’ books will be used by the partnership Books of Sales 1.Adjusting Entries (a)Sales, Capital3,200 Accumulated Depreciation – Fixtures3,200 (b)Goodwill32,000 Sales, Capital32,000 Partnership – Basic Considerations and Formation 13 2.Closing Entry Allowance for Bad Debts12,800 Accumulated Depreciation – Delivery Equipment8,000 Accumulated Depreciation – Fixtures91,200 Accounts Payable64,000 Notes Payable40,000 Accrued Taxes8,000 Sales, Capital224,000 Cash4,800 Accounts Inventory72,000 Merchandise Inventory192,000 Prepaid Insurance3,200 Delivery Equipment48,000 Fixtures96,000 Goodwill32,000 Books of Roces (Books of the Partnership) 1.Adjusting Entries (a)Roces, Capital1,600 Allowance for Bad Debts1,600 (b)Accumulated Depreciation – Fixtures16,000 Roces, Capital16,000 (c)Merchandise Inventory8,000 Roces, Capital8,000 (d)Goodwill40,000 Roces, Capital40,000 2.To record the investment of Sales. Cash4,800 Accounts Receivable72,000 Merchandise Inventory192,000 Prepaid Insurance3,200 Delivery Equipment48,000 Fixtures96,000 Goodwill32,000 Allowance for Bad Debts12,800 Accumulated Depreciation – Delivery Equipment8,000 Accumulated Depreciation – Fixtures91,200 Accounts Payable64,000 Notes Payable40,000 Accrued Taxes8,000 Sales, Capital224,000 14Chapter 1 b.Sales’ books will be used by the partnership Books of Roces 1.Adjusting Entries See Requirement (a). 2.Closing Entry Allowance for Bad Debts1,600 Accumulated Depreciation – Delivery Equipment12,800 Accumulated Depreciation – Fixtures64,000 Accounts Payable104,000 Accrued Taxes6,400 Roces, Capital224,000 Cash14,400 Accounts Receivable57,600 Merchandise Inventory132,800 Prepaid Insurance4,800 Delivery Equipment19,200 Fixtures144,000 Goodwill40,000 Books of Sales (Books of the Partnership) 1.Adjusting Entries See Requirement (a). 2.To record the investment of Roces. Cash14,400 Accounts Receivable57,600 Merchandise Inventory132,800 Prepaid Insurance4,800 Delivery Equipment19,200 Fixtures144,000 Goodwill40,000 Allowance for Bad Debts1,600 Accumulated Depreciation – Delivery Equipment12,800 Accumulated Depreciation – Fixtures64,000 Accounts Payable104,000 Accrued Taxes6,400 Roces, Capital224,000 Partnership – Basic Considerations and Formation 15 c.A new set of books will be opened by the partnership Books of Roces 1.Adjusting Entries See Requirement (a). 2.Closing Entry See Requirement (b). Books of Sales 1.Adjusting Entries See Requirement (a). 2.Closing Entry See Requirement (a). New Partnership Books To record the investment of Roces and Sales. Cash19,200 Accounts Receivable129,600 Merchandise Inventory324,800 Prepaid Insurance8,000 Delivery Equipment (net)46,400 Fixtures (net)84,800 Goodwill72,000 Allowance for Bad Debts14,400 Accounts Payable168,000 Notes Payable40,000 Accrued Taxes14,000 Roces, Capital224,000 Sales, Capital224,000 16Chapter 1 Problem 1 – 5 1.To close Magno’s books. Allowance for Bad Debts1,000 Accounts Payable6,000 Notes Payable10,000 Accrued Interest Payable300 R. Magno, Capital24,700 Cash5,000 Accounts Receivable13,000 Merchandise Inventory12,000 Equipment3,000 Other Assets9,000 2.To adjust the books of Lagman. Goodwill8,000 Allowance for Bad Debts210 J. Lagman, Capital7,790 3.To record the investment of Magno. Cash5,000 Accounts Receivable13,000 Merchandise Inventory12,000 Equipment3,000 Other Assets9,000 Allowance for Bad Debts1,000 Accounts Payable6,000 Notes Payable10,000 Accrued Interest Payable300 R. Magno, Capital24,700 To adjust the investments of the partners. Cash10,300 R. Magno, Capital10,300 (P35,000 – P24,700 = P10,300) J. Lagman, Capital35,790 Cash23,300 Accounts Payable to J. Lagman12,490 (P63,000 + P7,790 = P70,790 – P35,000 = P35,790) Partnership – Basic Considerations and Formation 17 4. Lagman and Magno Balance Sheet December 31, 2008 A s s e t s CashP – Accounts receivableP34,000 Less Allowance for bad debts1,21032,790 Merchandise inventory21,000 Equipment8,000 Other assets46,000 Goodwill___8,000 Total AssetsP115,790 Liabilities and Capital Accounts payableP 18,000 Notes payable15,000 Accrued interest payable300 Accounts payable to J. Lagman12,490 J. Lagman, capital35,000 R. Magno, capital__35,000 Total Liabilities and CapitalP115,790 Problem 1 – 6 1.Books of Toledo Toledo, Capital4,800 Allowance for Bad Debts (15% x P32,000)4,800 Books of Ureta Ureta, Capital2,400 Allowance for Bad Debts (10% x P24,000)2,400 Cash (90% x P12,000)10,800 Loss from Sale of Office Equipment1,200 Office Equipment12,000 Toledo, Capital (1/4 x P1,200)300 Ureta, Capital900 Loss from Sale of Office Equipment1,200 18Chapter 1 2.New Partnership Books Cash3,200 Accounts Receivable32,000 Merchandise40,000 Office Equipment10,000 Allowance for Bad Debts4,800 Accounts Payable10,000 Notes Payable2,000 Toledo, Capital68,400 To record the investment of Toledo. Cash22,800 Accounts Receivable24,000 Merchandise36,000 Toledo, Capital300 Allowable for Bad Debts2,400 Accounts Payable16,000 Ureta, Capital64,700 To record the investment of Ureta. 3.Cash3,400 Ureta, Capital3,400 To record Ureta’s cash contribution. Computation: Toledo, capital (P68,400 – P300)P 68,100 Divide by Toledo’s profit share percentage____50% Total agreed capital of the partnershipP136,200 Multiply by Ureta’s profit share percentage____50% Agreed capital of UretaP 68,100 Ureta, capital__64,700 Cash contribution of UretaP 3,400 or Toledo, capital (P68,400 – P300)P 68,100 Less Ureta, capital__64,700 Cash contribution of UretaP 3,400 Partnership – Basic Considerations and Formation 19 4. Toledo and Ureta Partnership Balance Sheet July 1, 2008 A s s e t s CashP 29,400 Accounts receivableP56,000 Less Allowance for bad debts__7,20048,800 Merchandise76,000 Office equipment__10,000 Total AssetsP164,200 Liabilities and Capital Accounts payableP 26,000 Notes payable2,000 Toledo, capital68,100 Ureta, capital__68,100 Total Liabilities and CapitalP164,200

Emerging Disease Trends Essay

People use health care services for many reasons: to cure illnesses and health conditions, to mend breaks and tears, to prevent or delay future health care problems, to reduce pain and increase quality of life, and sometimes merely to obtain information about their health status and prognosis. Health care utilization can be appropriate or inappropriate, of high or low quality, expensive or Inexpensive. The study of trends in health care utilization provides important information on these phenomena and may spotlight areas that may warrant future in-depth studies because of potential disparities in access to, or quality of, care. Trends in utilization may also be used as the basis for projecting future health care needs, to forecast future health care expenditures, or as the basis for projecting increased personnel training or supply initiatives. The health care delivery system of today has undergone tremendous change, even over the relatively short period of the past decade. New and emerging technologies, including drugs, devices, procedures, tests, and imaging machinery, have changed patterns of care and sites where care is provided. The growth in ambulatory surgery has been influenced by improvements in anesthesia and analgesia and by the development of noninvasive or minimally invasive techniques. Procedures that formerly required a few weeks of convalescence now require only a few days. New drugs can cure or lengthen the course of disease, although often at increased cost or increased utilization of medical practitioners needed to prescribe and monitor the effects of the medications. Over the past decade, both public and private organizations have made great strides in identifying causes of disease and disability, discovering treatments and cures, and working with practitioners to educate the public about how to reduce the incidence and prevalence of major diseases and the functional limitations and discomfort they may cause. Clinical practice guidelines have been created and disseminated to influence providers to follow recommended practices. Public education campaigns urge consumers to comply with behavioral recommendations (e. g. , exercise and lose weight) and treatment regimens (e. g. , take your medications) that may help to prevent or control diseases and their consequences. Health care utilization also has evolved as the population’s need for care has changed over time. Some factors that influence need include aging, sociodemographic population shifts, and changes in the prevalence and incidence of different diseases. As the prevalence of chronic conditions increases, for example, residential and community-based health-related services have emerged that are designed to minimize loss of function and to keep people out of institutional settings. Aging The median age of the world’s population is increasing because of a decline in fertility and a 20-year increase in the average life span during the second half of the 20th century. These factors, combined with elevated fertility in many countries during the 2 decades after World War II (i. e. , the â€Å"Baby Boom†), will result in increased numbers of persons aged ;65 years during 2010–2030. Worldwide, the average life span is expected to extend another 10 years by 2050. The growing number of older adults increases demands on the public health system and on medical and social services. Chronic diseases, which affect older adults disproportionately, contribute to disability, diminish quality of life, and increased health- and long-term–care costs. Increased life expectancy reflects, in part, the success of public health interventions, but public health programs must now respond to the challenges created by this achievement, including the growing burden of chronic illnesses, injuries, and disabilities and increasing concerns about future caregiving and health-care costs. This report presents data from the U. S. Bureau of the Census, the World Health Organization, and the United Nations on U. S. and global trends in aging, including demographic and epidemiologic transitions, increasing medical and social costs related to aging, and the implications for public health. In the United States, the proportion of the population aged ;65 years is projected to increase from 12. 4% in 2000 to 19. 6% in 2030. The number of persons aged ;65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons aged ;80 years is expected to increase from 9. 3 million in 2000 to 19. 5 million in 2030. In 1995, the most populous states had the largest number of older persons; nine states (California, Florida, Illinois, Michigan, New Jersey, New York, Ohio, Pennsylvania, and Texas) each had more than one million persons aged ;65 years. In 1995, four states had ;15% of their population aged ;65 years; Florida had the largest proportion (19%). By 2025, the proportion of Florida’s population aged >65 years is projected to be 26% and >15% in 48 states (all but Alaska and California). The sex distribution of older U. S. residents is expected to change only moderately. Women represented 59% of persons aged >65 years in 2000 compared with an estimated 56% in 2030. However, larger changes in the racial/ethnic composition of persons aged >65 years are expected. From 2000 to 2030, the proportion of persons aged >65 years who are members of racial minority groups (i. e. , black, American Indian/Alaska Native, Asian/Pacific Islander) is expected to increase from 11. 3% to 16. 5%; the proportion of Hispanics is expected to increase from 5. 6% to 10. 9%. The world has experienced a gradual demographic transition from patterns of high fertility and high mortality rates to low fertility and delayed mortality (2). The transition begins with declining infant and childhood mortality, in part because of effective public health measures (2). Lower childhood mortality contributes initially to a longer life expectancy and a younger population. Declines in fertility rates generally follow, and improvements in adult health lead to an older population. As a result of demographic transitions, the shape of the global age distribution is changing. By 1990, the age distribution in developed countries represented similar proportions of younger and older persons. For developing countries, age distribution is projected to have similar proportions by 2030. People are living longer because of both lifestyle changes and advances in health care. For example fewer people smoke today than in the past. In the 1950’s more than half of men and a third of women smoked cigarettes. By 2005, those numbers were down to 23 percent of men and 19 percent of women. Thanks to major advances in medicine, fewer people die at an early age from heart disease and cancer. For example the five year cancer rate improved from 50 percent in the mid 70’s (1975-1977) to 66 percent at the turn of the 21 century (1996-2002). With increased longevity , Boomers will reach retirement age, have more years to enjoy it and , in turn , more years in need of health care services. Diabetes The number of Americans with diabetes is expected to rise from 30 million today to 46 million by 2030, when one of every four Boomers -14 million-will be living with the chronic disease. These diabetic Boomers will require continuous medical management in both inpatient and outpatient settings. Arthritis The number of Americans with arthritis is expected to rise from 46 million today to 67 million by 2030. At that point, nearly one out of every Boomers-over 26 million-will be living with the condition. While health risk of arthritis are not as great as other chronic illnesses, the decrease mobility arthritis can trigger will cause many Boomers to seek new alternative therapies, pain control treatments, exercise regimens and joint replacements. Obesity If America’s obesity trend continues at its current pace, all 50 states could have obesity rates above 44 percent by 2030 according to a new report from Trust for Americans’ Health and the Robert Wood Johnson Foundation. With current U. S. obesity rates holding steady around 35 percent — that’s one-third of Americans — the 9-plus percent gain within two decades would be a significant increase; however, not as large of an increase as the nation has seen in the past two decades. While the health hazards are apparent — the report projects double the number of new cases of obesity-related ailments like diabetes, heart disease hypertension by 2030 — the increase in American obesity would also take a toll on the healthcare system itself. Current estimates put the medical costs of obesity at more than $147 billion. With increasing rates, the costs of preventative healthcare relating to obesity would rise by $48 billion to $66 billion in the next two decades. Many Americans aren’t very physically active. One reason for this is that many people spend hours in front of TVs and computers doing work, schoolwork, and leisure activities. In fact, more than 2 hours a day of regular TV viewing time has been linked to overweight and obesity. Other reasons for not being active include: relying on cars instead of walking, fewer physical demands at work or at home because of modern technology and conveniences, and lack of physical education classes in schools. People who are inactive are more likely to gain weight because they don’t burn the calories that they take in from food and drinks. An inactive lifestyle also raises your risk for coronary heart disease, high blood pressure, diabetes, colon cancer, and other health problems. Our environment doesn’t support healthy lifestyle habits; in fact, it encourages obesity. Some reasons include: (1) Lack of neighborhood sidewalks and safe places for recreation. Not having area parks, trails, sidewalks, and affordable gyms makes it hard for people to be physically active. (2) Work schedules. People often say that they don’t have time to be physically active because of long work hours and time spent commuting. (3) Oversized food portions. Americans are exposed to huge food portions in restaurants, fast food places, gas stations, movie theaters, supermarkets, and even at home. Some of these meals and snacks can feed two or more people. Eating large portions means too much energy IN. Over time, this will cause weight gain if it isn’t balanced with physical activity. (4) Lack of access to healthy foods. Some people don’t live in neighborhoods that have supermarkets that sell healthy foods, such as fresh fruits and vegetables. Or, for some people, these healthy foods are too costly. (5) Food advertising. Americans are surrounded by ads from food companies. Often children are the targets of advertising for high-calorie, high-fat snacks and sugary drinks. The goal of these ads is to sway people to buy these high-calorie foods, and often they do. Part of the reason for the rise in the obesity rate is the changing demographics of the U. S. population. The baby boomer generation is aging. With aging comes a decrease in activity. If you are less active, the calories you take in can mean the difference between being lean and being obese. It is all about a balance between diet and fitness. Biology also works against you. With the loss of muscle mass, you burn fewer calories. Menopause also sets up a scenario where women in this age bracket put on a few pounds. However, according to Mayo Clinic, you don’t have to follow the path of age-related weight gain. You have control over your activity. If you stay active, you can maintain the balance between the fuel your muscles use and your caloric intake. Unfortunately, the media teaches people that being overweight is not something for which to be ashamed. However, being fat is not okay. It is unhealthy and not something that can be dealt with by trendy fashions or slimming panels. The only solution is to lose weight. Otherwise, you will likely fall prey to the health risks of those added pounds. They can take months or years off your life. Losing weight is not an option; it is a necessity. Health  » With the rise in heart disease and diabetes, the medical field has been forced to consider the main causes of obesity in America in order to halt the alarming trends of this health epidemic. If you are overweight or obese, it behooves you to find ways to get your weight under control in order to avoid the consequence of excessive weight. Part of the reason for the rise in the obesity rate is the changing demographics of the U. S. population. The baby boomer generation is aging. With aging comes a decrease in activity. If you are less active, the calories you take in can mean the difference between being lean and being obese. It is all about a balance between diet and fitness. Biology also works against you. With the loss of muscle mass, you burn fewer calories. Menopause also sets up a scenario where women in this age bracket put on a few pounds. However, according to Mayo Clinic, you don’t have to follow the path of age-related weight gain. You have control over your activity. If you stay active, you can maintain the balance between the fuel your muscles use and your caloric intake. Unfortunately, the media teaches people that being overweight is not something for which to be ashamed. However, being fat is not okay. It is unhealthy and not something that can be dealt with by trendy fashions or slimming panels. The only solution is to lose weight. Otherwise, you will likely fall prey to the health risks of those added pounds. They can take months or years off your life. Losing weight is not an option; it is a necessity. The fact remains that fat tastes good. It gives you a satisfying feeling. It is the epitome of comfort food. If you want to lose weight, it is up to you to break the fat addiction, which is one of the main causes of obesity in America. At the simplest level, added weight makes your heart work harder. You may huff and puff going up the stairs or even walking across the room, if you lug around an extra 30 to 40 pounds. If you have tried to lift a heavy suitcase or other load that size, you know how difficult toting the added weight can be. Imagine carrying around that excess baggage 24/7. Obesity feeds upon itself. As you gain weight, it becomes more difficult to move around. Your muscles ache. You become easily fatigued. Your inactivity causes you to increase weight. This vicious cycle is one of the main causes of obesity in America. In order to overcome it, you must break this cycle of inactivity. Being obese increases your risk of several chronic health conditions including heart disease, high blood pressure and diabetes The good news is that losing a small amount of weight can reduce your chances of developing heart disease or a stroke. If you are overweight, reducing your weight by 5%-10% is proven to decrease your chance of developing heart disease. Fortunately, even a modest weight loss of 10 to 20 pounds can bring significant health improvements, such as lowering one’s blood pressure and cholesterol levels You can reduce your risk of developing type 2 diabetes by losing weight, eating a balanced diet, getting adequate sleep, and exercising more. If you have type 2 diabetes, losing weight and becoming more physically active can help control your blood sugar levels. Increasing your physical activity may also allow you to reduce the amount of diabetes medication you need. Future There will be some very disruptive and some transformational changes in the way health care is delivered, not as a result of reform, but as a result of the drivers of change described in a previous post on KevinMD. com. They included an aging population, an obese society, shortages of doctors, and emerging consumerism, among others. There will be many more patients needing substantial levels of medical care. These won’t be just any patients but two specific groups that are growing rapidly. Americans are aging. â€Å"Old parts wear out† and there are certain diseases that become more prevalent with age like Alzheimer’s and osteoarthritis. And of course our society has many adverse lifestyles such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and 20% still smoke. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will many more individuals with chronic illnesses. The especially sad thing is that many of these individuals will be moderately young as a result of obesity since one third are overweight and another one third are frankly obese. This increase in chronic diseases and diseases of aging will have huge impacts on care delivery. Health care delivery will help obesity related issues by educating obese clients the proper diet and food intake and how important exercise to lose weight. The health team can discuss patients on the effect to the body . the serious disease that they can get being obesed. they can guide them in their food intake and control and help them lose weight. As for age related health issues- health teaching is the best way to inform patients to diseases that is related to age. The team can help them be aware and give them preventive measures for the age related diseases.

Changes

Historians and cultural critics trace the post-modernist hip hop movement which pioneered sampling and graffiti art to the sasss, New York, a movement rooted in the black nationalism of the black panthers post civil rights movement (Price, 2006). Hip Hop has become a dominant global youth culture with music, art, fashion, films and Outpace an Icon within this culture a Black Elvis. Hip Hop has many different sub genres such as conscious, gangs, party rap and with emcees in the different genres according to their subject matter.The paper will explore Changes a conscious rap Eng that was recorded by Outpace in 1 992, at a time when African Americans were affected by the beating of Rodney King by Police Officers, which led to the Los Angels Riots of 1992 (Johnson, 2009). The environment was politically charged and conducive for a song chronicling that moment in history. What is interesting is that the song was posthumously released in 1998 on Tubas Greatest Hits album, two years after Outpace died of gunshots wounds on the 13th of September 1996 (Scott, 1997). Outpace Shakers music Is characterized by hard hitting hip hop beats sampled room different music genres and lyrics that criticize, the capitalist system that divides America into the haves and have-nots. The collective identity in Tubas music is identified In the struggle of the lower classes to find political, economic, social discourse In a capitalist society by chronicling from the perspective of a young black male growing up in post civil rights America.His work vocalizes the thoughts of the masses trapped within a modern slavery system (poverty and discrimination). The writers credited on the album sleeve are Shaker, T. , Evans, D. , Horns, B. ; Changes ample the beat and part of the chorus from Bruce Harmonys The way It is(1986) and appropriated It Into a Hip Hop political anthem. This part of the paper will delve into the psyche of the artist and explore the lyrics of Changes. ANALYZING OUTPACE When did I ever say I was a gangs rapper? Is Frank Sinatra a gangs singer?Is Steve Seal a gangs actor? What is that? Thats such a limited term. Maroon Brandon is not a gangs actor, hes an actor. Axle Rose and them are not gangs rock and rollers, thieve rock and rollers. So Im a rapper, this is what I do. Im an artist. And I AP about the oppressed taking back their place. I rap about fighting back. To me, my lyrics and my verses are about struggling and overcoming, you know (Shaker, 2003) Left: OPAC. 1996. All Eyes On Me (outpace. Com) Right: OPAC. 1995. Me against the World (outpace. Mom) Outpace Shakers controversial image drowned his work; the media at the time concentrated on what he did off record and forget that he was a brilliant rapper, lyricist and actor. He did cultivate the gangster image with Thug Life tattered across his abdomen and his persona as seen on the album cover of All eyes on me (1996) Is that of a gangs, The persona Is evident on him with the words Outlaw tattered on his lower arm, a panthers head on his upper arm with a miscreant intensity and 1 OFF on music videos, further reiterates that he is a gangs rapper.However on the cover of an earlier album Me against the world(1995) another side of the rapper is seen, with his back against a wall, he stares at the camera like a deer caught between two headlights. In interviews and talk shows when he takes off his mask, an intelligent, misunderstood, creative young man who wants to change the world with his music merges. Tyson (2002) in his explanation of Tubas dua l persona mentioned something very interesting that Tubas mother Affine was impregnated by one of two possible candidates, a revolutionary black panther by the name of Billy Garland and Legs a drug dealer.On the song Dear Mama he writes They say Im wrong and Im heartless, but all along I was looking for a father he was gone (1995) these lyrics give the assumption that he might have looked for a father within himself and thus created twin personae founded on the character of the two people he thought could e his father. Outpace created binary oppositions as creative mechanisms, the socially constructive poet vs.. The destructive street thug and he could write as well as speak from both alter egos.His conscious rapper ego tackled social issues such as racism, violence, drug abuse whilst his gangster rapper ego talked about selling drugs, perpetrating violence and called women derogatory names. To understand Just a little part of Tubas complex character, the following quotation by Carl Jung would give some insight. Such a man knows that whatever is wrong in the world is in myself, and if he only learns to deal with his own Shadow he has done something real for the world.He has succeeded in shouldering at least an infinitesimal part of the gigantic, unsolved social problems of our day. These problems are mostly so difficult because they are poisoned by mutual projections. How can anyone see straight when he does not even see himself and the darkness he unconsciously carries with him into all dealings? Nouns, 1938). The two images of Outpace show that instead of hiding his other self (the shadow) he consciously projected it and White toes (1997) that a misguided Outpace drew his masculine principles from Legs his father figure.Outpace Shaker was born on the 16th of June 1971; a month after his mother Affine Shaker was released from prison for her suspected part in the alleged Black Panther plot to bomb banks and department stores (White, 1997). In several songs and interviews Outpace has mentioned his birth and childhood as a miracle. l was born not to make it, but I did (Still I Rise, 1999) and on the last verse of Mama Just a Little Girl (Better Days, 2002) he philosophies You see you wouldnt ask why the rose hat grew from the concrete had damaged petals, on th e contrary, we would all celebrate its tenacity.We would all love its will to reach the sun. Well we are the roses, this is the concrete and these are my damaged petals He uses symbolic words to compare himself and his peers to that of beauty natured in an unnatural environment. This verse is a self reflective analysis of his impoverished childhood in socially depraved ghettos of America and by noting We are the roses he feels that any child that grows up in that environment and makes it however damaged they are should be celebrated.According to Goals (2007) in 1985 Outpace was enrolled at the prestigious Baltimore Schools of the Arts, where he learned how to act and he spent Outpace went through moral Juggling as a teenager, selling Drugs whilst writing poetry. His childhood experiences gave him the canon to be able to articulate social and political commentary easily identifiable with his audience. Tyson emphasis (2003) that Outpace believed in keeping it real a slang term defined on (revolutionary. Com) as try to benefit the environment and society that surrounds you a nd eventually serving humanity for the greater good.Outpace has achieved musical immortality with eight albums produced posthumously, an art center (task. Org) producing the next generation of thespians, dancers and poets and a Biopic on his life is currently in Production, written by Oscar nominated screenwriters Stephen J Revile and Chris Wilkinson (All, Nixon). In a recent Manage. Com article Revile had this to say about Outpace He was a really sensitive, very romantic talented young poet who also could sing, dance and act, but the realities [of the hip-hop record business] were that he had to create this persona of the gangster.He saw the contradiction between the musical persona of Thug Life and his essential nature as a gentle, sensitive person. And that was partly responsible for his murder. He was not a gangster, but the people around him were, and they saw he was going to leave, that they were going to lose him, and so I think they decided to kill him(Borders-Manner, 2011) CHANGES Changes portrays America from a critical non violent point of view, the view of a young black male living in the projects (Ghetto) committing crime as a survival necessity, whilst been abused by the system.Changes (Shaker, Evans Hornsby, 998) uses basic slang, repetition, melodic rhythm, the artist does not use profanity, the word Niger is used to make a racial statement not intimidate. Analysis of this song elicits reaction in the listener, a desire to become the Change that Outpace requires of his audience. Tubas ability to elicit this type of reaction can be attributed to the authority yet passionate sensitivity of his voice and the flow of his rap.The chorus uses the same melody as The Way it is with a slight change of chorus whereas the or iginal says, Some things will never change, Changes is changed to say, Things will never be the same. Elaborating that inequality will always be rooted in American society; the chorus is repeated to drum the message. The opening line to Changes l see no changes seems to be a modern reply to the original The way it is Bob Dylan The times they are changing(1964), which is considered the civil rights movement theme song.He then continues to show his frustration with his situation, which has not been changed by the I have a dream speech by DRP King Wake up in the morning and ask myself is life worth living should I blast myself, I am tired of en poor and even worse Im black, my stomach hurts so I am looking for purse to snatch, hes telling his audience that he is poor, black, hungry and faced with two choices either to kill himself or alleviate his economical situation by stealing. Cops give a damn about a negro, pull the trigger kill a Amiga hes a hero He uses the N words to emphasize how racist the police are and the reward for killing a black person. Give the crack to the kids who the hell cares, one less hungry mouth on watch me kill each other He paints an image of a big brother conspiracy of shipping rugs and guns into the Ghetto and then watching the fabric of black America dismantle with kids on crack, drug dealers killing each other, a genocidal way of easing the welfare system. Its time to fight back thats what Hue Said, 2 shots in the dark now Hues dead By mentioning Hue Newton founder of the Black Panthers, he acknowledges that Black militant mantra of fighting back the system with guns is wrong because you will be slain by a gun. Outpace then finds a socialist solution in how to beat the system and unify We can never go nowhere unless we share with each there, We goat start making changes, learn to see me as a brother instead of 2 distant strangers, thats how it is supposed to be.How can the Devil take a brother if hes close to me, Id love to go back to when we played as kids, but things changed, and thats the way it is He wants to go back to the innocents of childhood, not complicated by what Freud regards as the ID, however Outpace is resigned to the fact that even if he goes back to that moment, he cannot change Today because change will never happen. L see no changes all I see is racist faces, misplaced hate makes grace to races, We under, I wonder what it takes to make this one better place, lets erase the wasted Outpace is not talking about or to a specific race but to the people of America that racial hatred should not be tolerated but erased from society. Both Black and White is smoking crack tonight Drugs are not Just a black problem It anti a secret and dont conceal the fact the penitentiarys packed and its filled with blacks His observation is backed by Discard, Mouth and Andrews Of the 789,700 male inmates in 1992, 51 percent, or 401,700 were black and that is still a fact today.Although it seems heaven sent we anti ready, to see a black president, uh This line is prophetic in the sense that even though America now has a black President, but some quarters of society are still not ready to accept a Black President Some things will never change. Try to show another way, but you staying in the dope game. Now tells me whats a mother to do. Been real dont appeal to the brother in you.You goat operate the easy way In these lyrics hes now using Frauds structural model of the psyche, the mother is the Super Ego telling the impulsive child (the ID) hat look at another way to survive but morals do not appeal to the ID for it wants everything now and then when it gets satisfaction it shows off l made a G Today the super ego critics but you made it in a sleazy way, selling crack to the kids Finally the ego goes into defense mechanism Well hey, thats Just the way it is The third verse begins with Outpace talking instead of rapping so that everybody understands the clear message he conveys We goat make a change, Its time for us as a people to start making some changes. Lets change the way we eat, Lets change the way we live and lets change the way we treat each other. You see the old ways wasnt working so its on us to do what we goat do, to survive he is speaking to his generation, that the only way to change is complete transformation from the racial philosophies of old for the survival of the human race. Its war on the streets and war in the middle east, Instead of war on poverty they got war on drugs so the police can bother me, And I anti never did a crime I anti have to do. Outpace observes that whilst America concentrates on foreign wars in the Middle East, domestic street wars rage on. He problem poverty.

Assignment 3 - individual written format business report an

3 - individual written format business report an organization i would like to work for - Assignment Example BCG has been consistently maintained a top five positions over the years as the best organization. Recently they were ranked third by the fortunes magazine’s 2014 list of â€Å"top 100 companies to work for† (12). There is a lot that goes on before one gets hired at BCG since the expectations are always high, but the experience is just phenomenal. The organization may be small in size, but it casts a relatively large shadow amongst its competitors, mainly McKinsey. This has in turn attracted many admirers in the business world who tend to compare themselves to BCG even though it is a consulting firm. The competition is intense at the organization; an insider says that the organization hires approximately one candidate in over 200 applicants for an associate position. The main secret to the rampant success at BCG has been mainly gaining good strategy projects that require planning and hard work as compared to implementation only. New ideas are highly appreciated in the company. This gives the organization varied approaches to tackle business hurdles. The organization had its downfall in business; in 2001, the global revenue hit a downfall as technological explosion ventured in the business. The event resulted to layoffs, and the organization had to reduce its support staff as well as consulting by 12 percent (WetFeet 38). The strategies employed by BCG may be seen as small, but they have long term solutions to business problems. This has enabled the organization to stay top of its competitors like McKinsey and Bain, even if BCG has less staff compared to the two. Intellectualism has always stood up as the best culture for the organization over the decades. An insider describes the company’s growth as just incredible. At one point, he says he used to know almost everyone in the offices but now there are very many people that he can hardly identify with (WetFeet 36). Despite having all the success and growth, the

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The Marginal Productivity Theory of Distribution Term Paper

The Marginal Productivity Theory of Distribution - Term Paper Example As such, each factor of production can be paid based on what it contributes to the production of the output. This paper argues that the marginal productivity theory of distribution is valid, and, on certain highly limited assumptions, bears relevance to micro-economic problems such decisions of individual firms with regard to employment of factors of production. Marginal productivity theory of distribution presented a unified inter linkage between the pricing of commodities and the â€Å"pricing of persons† by indicating that the returns to all factors of production, are grounded in a single, marginal productivity principle. However, from the start, it was apparent that the marginal productivity theory could not stand by itself and only represented a derivative section of the theory of value. Three core properties of marginal productivity theory make this apparent: (1) the theory is essentially a theory of the demand for factors rather than their supply; (2) it adopts prices o f products as derived in the determination of demand for factors; (3) the theory cannot be applied to the determination of values within an exchange economy (Rima, 2001). ... the previous political economy with a novel science of economics or a discipline that employed rigorous methods mimicking those of the physical sciences (Fetter & Rothbard, 2007). Since its inception in the early 19th century, the marginal productivity theory of distribution (MPTD) has been cited by some economists as the solution to the ethical problem of distributive justice (as a means of determining fairness in wages, interest, profits, and rent). Other economists have rebuffed this ethical claim but have perceived the MPTD as a valid demand-side criterion, which forms the basis of determining equilibrium and efficiency (Blaug, 1996). Some of the pioneers of the theory such as John Bates and Philip Henry Wicksteed argued that a business enterprise would be prepared to remunerate a productive agent only that which it adds to the firm’s utility. Clark sought to establish that each unit of labour and capital can be settled based on the value that it adds to the total product or its marginal productivity (Wicksteed & Robbins, 1935). Clark maintained that, although, all tasks within an enterprise vary in significance the remaining work can be reassigned to ensure that all essential tasks would be undertaken; hence, no single unit of labour can be considered to be more critical than the other (Stigler, 1994). Clark’s marginal productivity theory can be considered to be a rebuttal to Marx’s assertion that competitive capitalism methodically robs workers their labour since the workers contributes more to the total product relative to the wages that they receive. According to Clark, the payment to capital can be established based on its marginal productivity, and that there cannot be a â€Å"surplus value† expropriated from the labour as Marx had claimed (Blaug, 1996).

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Business Ethics in IT Management - Essay Example When the organization collect data related to employees they are supposed handle it with secrecy and confidentiality. My organization is highly strict on safeguarding the details of the employees and other information related to the human resource department. Information related to pay scale of employees, social security numbers and other account details are allowed to be handled only by authorized personnel. Even the organization is not supposed to conduct any activity which can harm the environmental balance of nature. The nature of business is not supposed to be conducted against the social interest of the community and nation. The managers are not allowed to manipulate and misuse the key strategies and policies of the organization. My organization also have the right to monitor our activities to assess whether we follow the ethical code and principles of the business. In my organization employees are evaluated by the ethical standard they follow, as it is the core value of the or ganization. A person with no moral or ethical value can never be a good employee and can spoil the goodwill and reputation of a firm. My company tests my ethical behavior while I work in the organization in order to make sure that I am productive and harmless to the organization working process. My company does not allow using the company telephones to make long distant calls as this show that as an employee I want to misuse the company services. Manipulating the software’s of the company and using company products when not in offices are against my organizational ethical standard. My organization feels that if the employee cannot adhere to the ethical code of the firm then he is not worth to work in the organization. An employee can only be trusted and relied upon if he can follow the moral and ethical value of the organization.  

Kenneth Burke’s Dramatism Essay Example for Free

Kenneth Burke’s Dramatism Essay Life is drama; playing roles in relation to other people. Interest in the interaction of language and action. Symbolic Interactionist—Language is symbolic action. â€Å"Verbal symbols are meaningful acts from which motives can be derived (Griffin, p. 329).† â€Å"Human beings†¦are a symbol-creating, symbol-using, and symbol misusing animal (Littlejohn, 1978, p. 69).† A theory of Motives—why do people act (particularly rhetorically) the way they do? Assess motives. Texts/Speeches created by people to â€Å"DO SOMETHING.† Can be analyzed to determine what it is they are trying to do. Distinguishes human â€Å"Action† from Animal â€Å"Motion† Action Motion Done on purpose;Behaviors that are non- voluntary behavior purposeful/non-meaningful e.g. DramatismïÆ' ª ïÆ' ªAll animals and objects Peoplehave motion ïÆ' ªÃ¯Æ' ª Forms of ThoughtThe study of motion is ïÆ' ªmechanism Understood through motives ïÆ' ª Pentad (tool for understanding motives) Motive: Linguistic Product of Rhetorical Action Created a Grammar of Motives (â€Å"grammar† meaning rules, principles, elements, structure and/or book) Motives are viewed by Burke in terms of internal sources of action; but rather in terms of how language and terms are used to make actions understandable. Guilt as Motive: guilt is an â€Å"all-purpose word for any feeling of tension within a person—anxiety, embarrassment, self-hatred, disgust, etc. (Littlejohn, 1978, p. 70).† We communicate to purge ourselves of guilt. Guilt arises out of language. Three sources of guilt: 1. The Negative: Language allows for rules, morals, etc. that surround us and we can’t escape violating. 2. The Principle of Perfection: Language allows us to â€Å"imagine† the ideal (should). 3. The Principle of Heirarchy: Structure society with competing class and group distinctions We seek redemption (reduce or eliminate guilt) through communication/rhetoric/dramatism 1. Mortification: self-blame 2. Victimage: external enemy is the source 3. Scapegoating: blame other(s) Substance: general nature of a thing Consubstantiation: (shared substance, commonality) Identification: (same as consub) degrees of; conscious or unconscious; 1) material identification—goods, possessions, things 2) idealistic identification—values, ideas, feelings, attitudes 3) formal identification—form or arrangement of act/conventions; roles, customs, etc. Division—differences with others (source of guilt) PENTAD Tool for understanding motives Act SceneAgent Agency Purpose (Hexad: Attitude: delayed or incipient action) Statement of motives will answer: What was done (act), when or where it was done (scene), who did it (agent), how it was done (agency), and why it was done (purpose).

Patient`s Laws Essay Example for Free

Patient`s Laws Essay Patients should feel at ease when giving personal information to their physician or nurse (Burkle Cascino, 2011). Patients may resist offering pertinent information if they feel their confidence may be betrayed. Confidentiality can only be broken when it involves a gunshot wound, injuries resulting from child abuse or an infectious disease, which would put the community at risk. Such is the case presented in Nathanson’s article titled: â€Å"Betraying trust or providing good care? When is it okay to break confidentiality?† (2000). The article addresses an ethical dilemma presented in an episode of NBC’s ER. Nurse Carol Hathaway promises two reluctant teenage patients who are seeking care, that anything they tell her will remain confidential, even from their parents and anyone else. Agreeable to this, the girls divulge they have been sexually active with multiple partners and suspect they have been exposed to a sexually transmitted disease (STD). Tests were performed on the teenager for STD’s and receive Pap tests to detect any cervical abnormalities. The test results confirm, Andrea, is positive for the human papillomavirus (HPV) and cervical cancer. Promising Andrea confidentiality, Nurse Hathaway knows she must break the promise or potentially endanger herself and the community. Nurse Hathaway is faced with ethical consequences if she breaks confidentiality with her patient. Of these consequences are reluctance to disclose pertinent information, feelings of betrayal, enraged parents, disrespect of staff members, job termination, demeaned hospital reputation, poor school reputation, and a non supportive bureaucratic and legal system (Burkhardt Nathaniel, 2008). Nurses are fearful of these ethical implications, which keep them from disclosing important information, which can have disastrous results (Griffith, 2008). Deontology best describes Nurse Hathaway’s ethical framework when she finds it necessary to break Andrea’s confidentiality. The deontology theory is based on the concept that a person adheres to what is right and wrong in their actions and thoughts rather than the consequences (Purtilo Doherty, 2011). Since this has become a public issue she is compelled to fulfill her duty by courageously choosing to bring the situation out in the open. Her reasoning for informing Andrea’s parents and school would ensure the appropriate course of treatment and avoiding further injury for the teen and society. Even though Nathanson says  there is no advantage in notifying the school of Andrea’s sexual involvement with multiple partners, Nurse Hathaway chose to do so. By doing this, Andrea attempts to take her life when she finds out the school is aware of her situation. There are several ethical decision-making models to choose from but the best would be Uustal’s model to handle this particular situation. Uustal proposes a nine-step method to direct one toward making an ethical decision. This model follows the nursing process and also includes and explanation of values when using and ethical decision-making model. Step 1) those implicated in the dilemma are the teenage girls, their parents, the students at the school and Nurse Hathaway. Whether or not to inform the school of the sexual behavior of the girls and of Andrea’s diagnosis is the ethical dilemma at hand. Step 2) without giving specific information about the girls, the school needs to be aware of the student’s sexual conduct with multiple partners. Step 3) the spread of HPV and the concern for the protection of the community from STD’s related to promiscuous sex are the issues related to the situation. A resolution to the dilemma would to inform the school of the concern for the sexual behavior of the students. Step 5) with good intentions, Nurse Hathaway notifies the school of the girl’s activities but should not kept their identities anonymous and only discussed her concern for the students in general about their participation in multiple sex partners. Step 5) implementing education in the school regarding the risks, treatments and prevention of STD’s would follow. Step 6) the main priority should have been informing the school of the promiscuity among the students rather than of the two teens in question and Andrea’s new found diagnosis. Step 7) Nurse Hathaway should have only discussed her concern for sex with multiple partners between the students. Step 8 and 9) if Nurse Hathaway had followed th is model, education could have occurred, the school would have been protected and Andrea’s privacy would have been respected. This particular model allows for the analysis of various options to sensitive, ethical dilemmas. An ethics committee consists of of representatives from different fields in and outside of health care as well as professionals, lawyer, clergyman, etc., from the community. With different perspectives, experiences, and educational backgrounds the committee can have a well-rounded discussion and provide suggestions proposed to advocate for the rights of patients and foster mutual decision  making in the event of an ethical dilemma. When conflicting moral claims are presented, the ethics committee can suggest an unbiased approach to solving the ethical dilemma (Burkhardt Nathaniel, 2008). Consulting with an ethics committee would have been in Nurse Hathaway’s best interest before deciding to break confidentiality. Had she not divulged pertinent information about Andrea to her school, Andrea most likely would not have attempted suicide. In conclusion, as nurses we are confronted with ethical dilemmas pertaining to upholding confidentiality in our day-to-day practice. Ethical decisions should not be taken lightly and treated exclusively with sensitivity for our patients and the public. Making the wrong decision could cost us the trust we build with out patients and community and our job. Burkhardt, M. A., Nathaniel, A. K. (2008). Ethics issues in contemporary nursing (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Burkle, C. M., Cascino, G. D. (2011, December). Medicine and the media: Balancing the public’s right to know with the privacy of the patient. Mayo Clinic Proceedings, 86(12), 1192-1196. Ethical decision-making lecture [Module 3 lecture]. Retrieved from Grand Canyon University: http://my.gcu.edu. Griffith, R. (2008). Patient confidentiality: rights and duties of nurse prescribers. Nurse Prescribing, 6(2), 116-120. Purtilo, R. B., Doherty, R. B. (2011). Ethical dimensions in the health professions (5th ed.). St. Louis, MO: Elsevier.

Diagnosis of Middle Ear Disorders Using Wideband Energy

Diagnosis of Middle Ear Disorders Using Wideband Energy CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERSÂ  USING WIDEBAND ENERGY REFLECTANCE A Doctoral Thesis Presented to The Graduate College of Missouri State University In Partial Fulfillment Of the Requirements for the Degree Copyright 2008 by [Alaaeldin Elsayed] CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCE Communication Sciences and Disorders ABSTRACT Accurate diagnosis of middle ear disorders in adults and children is a challenging task because of the complexity of disorders. Wideband energy reflectance (WBER) technique provides simplicity and accuracy in diagnosing middle ear disorders across wide frequency range. This research is expanding the studies of WBER to investigate the middle ear function in normal and pathological conditions of the middle ear in adults and children. Findings showed that WBER not only can distinguish abnormal from normal middle ear function but also can characterize different middle ear disorders in adults and children. Several specific WBER patterns were established in a variety of middle ear disorders among adults and children that will help in early diagnosis of such pathologies. The ER pattern was including significant higher ER in the children control group than the adult control group at 0.5 kHz and 1 kHz, abnormally high or shallower in otosclerotic ears, abnormally low in ears with TM perforati on and abnormally low ER with deep notch in ears with hypermobile TM. In presence of negative middle-ear pressure, elevated ER at ambient pressure is also expected. Results also showed that standard tympanometry was less sensitive in diagnosing middle ear disorders when compared to WBER especially in otosclerotic cases. Further studies are still required to validate the clinical use of ER in larger number of individuals with confirmed middle ear disorders. KEYWORDS: wideband energy reflectance, otosclerosis, otitis media with effusion, eustachian tube dysfunction, tympanometry. This abstract is approved as to form and content Wafaa Kaf, MD, MS, PhD Chairperson, Advisory Committee Missouri State Universit CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCETITLE OF THESIS By Alaaeldin Elsayed A Doctoral Thesis Submitted to the Graduate College Of Missouri State University In Partial Fulfillment of the Requirements For the Degree of Doctorate, Audiology ACKNOWLEDGEMENTS I would like to thank so many who encouraged me along this dissertation. First and foremost, I am thankful to God for all his blessings. I am very grateful to Dr. Neil DiSarno for all his support and kind caring throughout my graduate school education. Further, I am indeed grateful to Dr. Wafaa Kaf, my doctoral advisor, for her guidance, encouragement, and support throughout this work. In addition, I would like to show appreciation to my committee members for their helpful comments and direction for this dissertation. Special thanks also to the faculty and secretarial staff of the Department of Communication Science and Disorders. Thanks to Dr. Walid Albohy, and Dr. Ahmad Alhag for their help in collecting data for this study. Special thanks and appreciation for my wife Enass and my children Mohamed and Nada, your love and delightful spirits has kept me going forward. DEDICATION This work is dedicated To My dear parents, My beloved Enass, Mohamed, and Nada, Who made all of this possible, for their endless encouragement and patience. REVIEW OF THE LITERATURE Hearing mechanism and the middle ear Sound transmission. The hearing process includes the transmission of sound energy through the auditory canal to the tympanic membrane (TM). This sound energy results in vibration of the TM with an equal atmospheric pressure on both sides of the TM. The mechanical vibrations are, then, transmitted from the TM to the air-filled middle ear space and ossicles (malleus, incus and stapes), which further amplify the sound energy and transmit it, via oval window, to the fluid-filled inner ear. At the inner ear, the mechanical vibration is converted into electric waves and transmitted as nerve signals that are interpreted by the brain as sounds. Mechanical properties of middle ear. The middle ear is an air-filled cavity that connects the outer ear canal to the labyrinth of the inner ear. This connection is established through the middle ear ossicels-malleus, incus and stapes. The malleus is attached to the TM by its handle; the incus bone lies in the middle between the malleus and the stapes while the footplate of the stapes is attached to the oval window of the inner ear. The middle ear cavity is also connected to the nasopharyngeal cavity through the Eustachian tube (Musiek and Baran, 2007). The Eustachian tube is important in maintaining an equal pressure on both sides of the TM and ventilation of the middle ear cavity. The tube also drain the middle ear into the nasopharynx (Channell, 2008). Figure 1 demonstrates schematic representation of the anatomy of the ear. When the sound pressure moves the TM the mallus and incus consequently move together as one unit around a pivotal point. In doing so, both bones act as a lever; the lever arm formed by the manubrium of the malleus is slightly longer than that of the incus (about 1:1.3 ratio). In turn, the rotation of the long process of the incus around its pivotal point leads to the back and forth (piston-like) movement of the stapes footplate in the oval window of the inner ear. The movement of the stapes footplate is directly proportional to the frequency and amplitude of the sound waves. This route of sound transmission is called the ossicular route. Acoustic route is another way of transmitting sound waves directly from the TM and the oval window to the cochlea. The direct acoustic stimulation of the oval and round windows, by passing the ossicles (acoustic route), plays a part in sound transmission In normal ears both routs are functioning but the upper hand is for the ossicular route (Voss, Ro sowski, Merchant, and Peake, 2007). From the above information, it appears that the middle ear plays important role in the hearing process. The middle ear mainly helps to correct the impedance mismatching between the air-filled middle ear and the fluid-filled cochlea and to transform the acoustic energy at the TM into mechanical energy that will eventually be transferred to the inner ear. The Impedance matching function of the middle ear is carried out by three mechanisms: the lever action of the ossicles of the middle ear, the area difference between the TM and the area of the stapes footplate, and the buckling of the curved TM. An outcome of these mechanisms is that the vibration obtained from the large area of the TM is focused to the much smaller oval window of the inner ear (21:1 area ratio), resulting in a differential pressure between the oval window connected to scala vestibuli and the round window connected to the scala tympani. This pressure differential is critical in maximizing the flow of sound energy and activation of the cochlear structures (Cummings, 2004). Accordingly, middle ear disorders are expected to affect the normal transmission of sound, resulting in conductive hearing loss (discussed below). An illustration of the anatomical structure of External, Middle and Inner ear. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. In addition to correcting the impedance mismatch between the air-filled middle ear and the fluid-filled cochlea, the middle ear also protects the inner ear from loud sound via the acoustic reflex. This mainly occurs as a result of reflex contraction of the two middle ear muscles, the tensor tympani and the stapedius, in response to loud sound leading to increased stiffness of the oscicular chain, and hence diminished sound transmission (Allen, Jeng, and Levitt, 2005). Given that the acoustic reflex mainly decreases the transmission of low frequency sounds thus, it improves speech discrimination in loud, low-frequency noisy environments. Unfortunately, the reflex does not protect the ear against impulsive sounds as gun shots due to prolonged latency in muscle contraction (Lynch, Peake, and Rosowski, 1994). Pathophysiology of middle ear disorders To further understand the pathology of middle ear disorders, it is important to consider the middle ear system as a vibrating mechanical system. Such a system is composed of three elements: mass, stiffness, and friction. When the mass and stiffness components are equal, so-called resonant frequency of the middle ear, it is expected that the amplitude of vibration of the middle ear is at maximum. On the other hand, when there is an increase in the mass without change in stiffness or friction the resonant frequency is lowered and the amplitude of vibration is lowered at frequencies above the resonant frequency. In contrast, when there is an increase in the stiffness component of the middle ear the resonant frequency increases and the magnitude of vibration reduces for frequencies below the resonant frequency (Roeser, Valente, and Hosford-Dunn, 2000). Middle Ear Disorders are a variable group of pathological conditions that includes, for example, middle ear infection (Otitis Media with Effusion: OME), chronic otitis media with perforation of the TM, Eustachian Tube Dysfunction (ETD), ossicular disruption or dislocation and or/ otosclerosis. Such middle ear disorders may lead to conductive hearing loss due to their effects on mass, stiffness, and/or friction elements of the normal middle ear. Perforated TM is induced by chronic otitis media or trauma to the ear. As a result, the normal structure and the function of the TM are altered. The degree of hearing loss is directly related to the size of the perforation (Voss et al., 2000) The perforation leads to equalization of pressure on both sides of the membrane which consequently leads to disturbance of the ossicular route and hearing loss (Voss et al., 2000). Normally the inward movement of the stapes is followed by an outward movement at the round window (push and pull mechanism). In the presence of TM perforation, this push and pull mechanism of the ossicles is disturbed and the sound waves energy reaching the oval window is reduced. Ossicular dislocation usually follows a violent trauma to head or as a consequence of chronic otitis media and/or cholesteatoma. Disarticulation of the incudostapedial joint due to traffic accident was the most common pathlogy of ossicular disruption(Yetiser s, 2008). With the exception disruption due to chronic otitis media, the dislocation of the ossicles may or may not be accompanied by TM rupture. The injury results in loss of the impedance matching mechanism of the middle ear and a conductive hearing loss of about 40-60 dB (Merchant, Ravicz, and Rosowski, 1997). Otosclerosis is a progressive disease of bone resorption and reformation that affects bones derived from the otic capsule. The etiology of the disease is not fully understood. The disease leads to osteodystrophy and fixation of the stapes in the oval window. Among the most accepted eatiological factors is genetic factors and viral infection. Otosclerosis is characterized clinically by progressive hearing loss, tinnitus and vertigo (Menger and Tange, 2003). Both conductive and sensory neural hearing loss has been reported in otosclerotic patients (Ramsay and Linthicum, 1994). Otosclerosis may affect the cochlea and other parts of the labyrinth as well (Menger and Tange, 2003). The resulting fixation of the footplate of the stapes leads to increased stiffness of the ossicular chain early in the disease. Increased stiffness of the middle ear affects the transmission of low frequency sounds. At later stages of the disease, the bone starts to grow adding a mass effect. This increase in ma ss of the middle ear affects the transmission of high frequency sounds as well (Shahnaz and Polka, 1997). More disorders include inflammatory conditions of the middle ear such as otitis media (OM) and media with effusion (OME), chronic otitis media, and cholesteatoma. OM usually results from upper respiratory infections or allergies that lead to obstruction of the Eustachian tube (Channell, 2008). As a consequence, negative pressure develops in the middle ear resulting in otalgia due to stretching of the TM and mild hearing loss due to the increased stiffness of middle ear transmitting mechanism. If the negative pressure inside the middle ear is not relieved, a transudate accumulates inside the middle ear. The condition is then called OME. The hearing is further affected by the mass- friction effect. The degree of hearing loss depends on the type and the amount of the transudate. The combination of fluid and pressure in the middle ear was found to reduce TM movement at the umbo by 17 dB over the auditory frequency range (Dai, Wood, and Gan, 2008). Middle ear function measures Tuning fork testing. The tuning fork testing is one of the traditionally used qualitative hearing tests. They are used to examine the conductive component of hearing loss (external or middle ear pathology). Several tests have been descried including: Rinne, Schwabach, Bing, and Weber tests. For Rinne test, the vibrating tuning fork is held against the skull, usually on the mastoid process bone behind the ear to cause vibrations through the bones of the skull and inner ear. To cause vibrations in the air next to the ear, the vibrating fork is then held next to, but not touching, the ear. In the test the patient is asked to determine if the sound heard through the bone is louder or that heard through the air. The results of the test are categorized as positive, negative, or equivocal. A negative Rinne test is indicated when the sound is heard louder by bone conduction than by air conduction which suggests a conductive component of the hearing loss. Although Rinne test was found to be highly specific in one study; the same author has suggested that it should be carried out only as a pack up test for pure tone audiometry in audiological evaluation of hearing loss (Browning and Swan, 1988; Thijs and Leffers, 1989). The Schwabach tuning fork test compares patients bone conduc tion to the normal examiner. Bing tuning fork tests determines the presence or absence of the occlusion effect. Weber tunning fork test determines the type of a unilateral hearing loss. While Rinne test compares air conduction to bone conduction in the same patient. Although the tuning fork testing is easy and reliable; it is still a subjective test that depends on the response of the patient and the degree of hearing loss. Additional drawbacks are that tuning fork testing is a qualitative and not a quantitative test, and does not diagnose the etiology of the conductive hearing loss. Pure-tone Audiometry. Pure-tone Audiometry is a behavioral test that measures hearing threshold. The test has been used to diagnose type and degree of hearing loss for more than one hundred years. During test setting, the patient is subjected to different tones to test the hearing mechanisms via air-conduction and bone conduction. Typically, the normal level of pure tone audiogram air and bone conduction will lie between 0-15 dB HL for children and 0-25 dB HL for adults. According to Northern and Downs (1991), the degree of hearing loss can be classified in adults as (0-25 dB HL) within normal limits, Mild (26-40 dB HL), Moderate (41- 55 dB HL), Moderate-Severe (56-70), Severe (71-90 dB HL) or Profound (91 + dB HL) hearing loss. In children it is classified as normal (0-15 dB HL), Slight (15-25 dB HL), Mild (25-30 dB HL), Moderate (30-50 dB HL), Severe (50-70 dB HL), Profound (70 + dB HL) hearing loss. This classification is applied to PTA of 500, 1000, and 2000 Hz (Roeser et al, 2000). Different types of hearing loss are interpreted by comparing air conduction thresholds to bone conduction thresholds. When the air conduction threshold elevated to a maximum around 60-70 dB HL in the presence of normal bone conduction threshold, this type of hearing loss is called conductive hearing loss. In sensorineural hearing loss the pure tone audiogram shows both air and bone conduction thresholds are elevated and with a 10 dB HL or less in between. Mixed hearing loss displays elevation in both air and bone conduction thresholds, but with the bone conduction threshold at better intensities than the air conduction by 10 dB HL or more. In both conductive and mixed hearing loss, the difference in air and bone conduction thresholds is called air-bone gap; and it represents the amount of conductive hearing loss present (Roeser et al, 2000). The use of pure-tone audiometry provides quantitative information regarding the degree and type of hearing loss. However, it does not diagnose the cause of hearing loss and cannot be used in infants, young children, and difficult-to-test subject. Mannina (1997) reported that the diagnosis of middle ear disorders in school-aged children is less efficient when using pure-tone audiometry alone. To improve the diagnosis of middle ear disorder, Yockel (2001) demonstrated that the addition of tympanometry to audiometry does improve the diagnosis of OME than using audiometry alone. Assessing Middle ear function is a very important step in early diagnosis and treatment of conductive hearing loss. Since the usually used subjective tests, the tuning-fork and pure tone audiometry, cannot identify the etiology of underlying middle ear disease, other objective measures such as acoustic immittance are needed for differential diagnosis and accurate diagnosis of specific middle ear disorders. Acoustic Immittance. Several objective measurements of middle ear function have been developed over the last four decades. Various anatomical structures of the middle ear represent complex network system that affects the sound presented to the ear. Not all the sound represented to the middle ear is delivered to the cochlea, but some of the power is absorbed by the bony structure of the middle ear (Zwislocki, 1982). Acoustic Immittance using tympanometry assess the middle ear status by measuring the transmitted sound energy to the middle ear. Acoustic Immittance provides objective information about the mechanical transfer function in the outer and middle ear. Acoustic Immittance is defined, as the velocity with which an objects moves in proportional to an applied force, while Acoustic Impedance (Za) is the opposition offered by middle ear and the TM to the flow of energy. Mathematically acoustic admittance (Ya) of a system is the reciprocal of impedance. Acoustic Immittance refers collectively to acoustic admittance, acoustic impedance or both (Tympanometry. ASHA Working Group on Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation, 1988). Investigators have found that abnormalities in the middle ear transmission might be reflected in the acoustic condition of the TM (Allen et al, 2005). Acoustic Immittance can be measured to single probe-tone frequency (single frequency tympanometry) or to series of multiple probe frequencies (multifrequency tympanometry). Single frequency tympanometry. Tympanometry is one of the earliest objective methods used to evaluate middle ear function. Tympanometry measures the acoustic immittance of the middle ear as a function of changing the air pressure in the ear canal. A single probe tone tympanometry is the conventional measure of middle ear function in response to low frequency probe tone, 226 Hz, under varying static air pressure. Evaluation of the acoustic immittance of normal and different middle ear disorders was done by Otto Metz, 1946, and confirmed later by Feldman, 1963 (Katz, 2009) In 1970, James Jerger began to incorporate immittance measurement into the routine audiological evaluation. Jerger classified tympanograms as type A, B, or C depending on the shape of the tympanogram (with or without peak) and location of the peak when present. Type A is the normal tympanogram with the peak at or near the atmospheric pressure (+25 to -100 daPa). Type A is further divided into subtypes Ad and As for high and low peaked type A tympanograms respectively (Feldman, 1976). Type B tympanogram has no peak and relates to middle ear effusion, infection with normal ear canal volume, or due to large TM perforation with large ear canal volume. Type C is a negatively shifted tympanogram that reflects Eustachian tube dysfunction, a precursor of serous OM, mostly evolved from type B (Katz, 2009). Since 1970, single frequency Tympanometry is the conventional clinical middle ear measure because it is a non-invasive, objective, and cheap indicator of many middle ear pathologies in children and adults. Unfortunately, low frequency probe tone tympanometry has high false negatives in infants younger than seven months (Holte, Margolis, and Cavanaugh, 1991). This is explained by the movement of the infants ear canal wall with pressure changes in the external ear canal due to immaturity of the bony part of the external auditory canal. In addition, tympanometry was found to be relatively insensitive to many lesions that affect the ossicular chain of the middle ear (Lilly, 1984). Furthermore, Keefe and Levi (1996) reported false positive tympanometry results compared to energy reflectance, a recent middle ear function measure. They found normal middle ear energy reflectance at higher frequencies in infants with flat low probe tone tympanometry. Multifrequency tympanometry. Multifrequency Tympanometry (MFT), which was first introduced by Colletti in 1976, measures middle ear impedance using multiple frequency probe tones ranging from 226-Hz to 500 Hz and up to 2000 Hz (Colletti,1976) . Similar to previous discussion about the three elements of the mechanical system of the middle ear, admittance of the middle ear has three components: stiffness (compliant susceptance), mass susceptance and conductance (resistance). A tympanometric pattern was developed by Vanhuyse and colleagues in 1975 that helped in interpreting the underlying middle ear pathology using MFT. The Vanhuyse tympanometric pattern is based on the assumption of the shapes and locations of reactance (X) and resistance (R) tympanograms. Using a conversion equation the model can predict the shapes of susceptance (B) and conductance (G) tympanograms. Vanhuyse et al proposed four normal patterns: 1B1G, 3B1G, 3B3G, and 5B3G as shown in Figure 2. 1B1G pattern is the normal tympanogram with a one susceptance (B) and one conductance (G) peak. It occurs when reactance (X) is negative and its absolute value is greater than resistance (R) at all pressure used (the ear stiffness is controlled). As the probe frequency increases the curve becomes more complex and notched. 3BIG model has three peaks of susceptance (B) and one conductance (G) peak. It represent negative reactance (X) with an absolute value greater than resistance (R) at low pressur e and smaller than resistance (R) at high pressure. The third model (3B3G) appears when the ear is mass-controlled. In 3B3G model the reactance is positive and less than resistance (X R) at low pressure and becoming negative at high pressure (Margolis, Saly, and Keefe, 1999). Figure 2. A graphic presentation of the model presented by Vanhuyse, Creten and Van Camp (1975). The resistance (R) , negative resistance (-R) and the reactance (X) tympanograms is shown in the upper left corner of each panel. Negative R is shown to compare the magnitude of the reactance X. The corresponding admittance (Y), (lower left corner), susceptance (B), (upper right corner) and conductance (G), (lower right corner) are also shown in each panel. Four patterns are presented and classified according to the number of extrema in the susceptance B and conductance G tympanograms. The pattern (1B1G) in panel one shows both susceptance and conductance have single extrema and reactance is negative. The pattern (3B1G) in panel two shows conductance G is single peaked with three extrema in susceptance B, reactance X is still negative but its absolute value is greater than resistance at high pressure. The pattern (3B3G) in panel three shows three extrema in susceptance B, conductance G, and admitta nce Y tympanograms, reactance Y is positive but less than resistance R . The pattern (5B3G) in panel four shows five extrema in susceptance B tympanogram and three extrema in conductance G, and admittance Y tympanograms, reactance Y is positive and greater than resistance R at low pressure. Because of the use of measuring middle ear function to several probe tone frequency, MFT is considered superior to single frequency tympanometry in detecting high impedance pathological conditions of the middle ear such as middle ear effusion, otosclerosis, and cholesteatoma. Such pathological conditions were not detected by conventional tympanometry (Colletti, 1976, Keefe and Levi, 1996, Shahnaz et al 2009). Several studies have shown that MFT has higher sensitivity and specificity in detecting middle ear pathologies such as TM mass or adhesions (Margolis, Schachern, and Fulton, 1998). Also, MFT is more sensitive than single frequency tympanometry in identifying normal and abnormal middle ear condition in neonates (Shahnaz, Miranda, and Polka, 2008). However, MFT is of limited clinical use for several reasons: long testing time, limited frequency range, and unreliable data above 1000 Hz (Allen et al, 2005). The use of wideband energy reflectance is shown to address the above limitat ions of MFT. Wideband energy reflectance. The wideband energy reflectance (WBER) is a new technique that has been introduced recently to evaluate middle ear dysfunction (Keefe, Ling, and Bulen, 1992). Simply the idea of WBER is that incident sound to the ear is transmitted through the ear canal and TM, some of this sound energy is absorbed through the middle ear and cochlea and part of it is reflected back (Figure 3). The energy reflectance (ER) is defined as the square magnitude of pressure reflectance ÂÂ ¦R(f) ÂÂ ¦2, which represents the ratio of the sound energy reflected from the TM to the incident sound energy at frequency (f). ER ratio ranges from one to zero (1.0 = all incident sound energy is reflected, and 0.0 = all sound energy is absorbed) (Allen et al, 2005). ER is an indicator of the middle ear power to transfer sound (Feeney, Grant, and Marryott, 2003). Energy reflectance (ER) measurers middle ear function over a wide band of frequencies (0.2- 8 kHz). ER is the ratio of the reflected energy (red arrow) to the incident energy (yellow arrow). When all incident sound energy is reflected back ER ratio equals one. When all incident sound energy is absorbed ER equals zero. Red arrow represents reflected sound energy; yellow arrow represents incident sound energy; green arrow represent absorbed sound energy. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. WBER measures middle ear function using a chirp stimulus at 65 dB SPL over a wide frequency range, typically 0.2 to 8 kHz and at fixed ambient pressure (Feeney et al, 2003) . Normative data has shown that most incident acoustic power is reflected back to the ear canal (ER ratio closes to 1) at frequency range below 1 kHz or above 10 kHz that also show poor hearing threshold or at frequencies below 1 kHz and above 4 kHz (less efficient middle ear function) (Keefe, Bulen, Arehart, and Burns, 1993). More specifically, 50% of the acoustic power is transmitted to the middle ear between 1-5 kHz frequency range, indicating that the most effective middle ear transfer function (ER is at its lowest values, closer to one) occurs around 1-5 kHz (Allen et al, 2005; Keefe et al, 1993; Schairer, Ellison, Fitzpatrick, and Keefe, 2007). WBER has been used in measuring normal middle ear function and middle ear disorders using ambient pressure (Allen et al, 2005; Feeney et al, 2003; Shahnaz et al., 2009). In other studies the researchers used pressure to measure the acoustic stapedial reflex (Feeney and Sanford, 2005; Schairer et al, 2007). Development of the middle ear in infants was also investigated using WBER (Keefe and Abdala, 2007; Keefe e al, 1993; Keefe and Levi, 1996). Wideband energy reflectance in neonatal screening Keefe et al. (1993) and Keefe and Levi (1996) reported that the acoustic response properties of the external and middle ear varies significantly over the first 2 years of life. These changes, mostly physical changes, are responsible for the mass-dominant infants middle ear system with lower resonant frequency. The main components of this mass-dominant effect is the pars flaccida of the TM, ossicles, and perilymph in the cochlea (Van Camp, Margolis, Wilson, Creten, and Shanks, 1986). The mesenchyme in infants middle ear may add to the mass effect (Meyer, Jardine, and Deverson, 1997). This is completely in contrast to adults middle ear, which is a stiffness-dominant system at low frequency (Holte et al, 1991; Keefe and Levi, 1996). The TM, tendons and ligaments, the space between the mastoid and the middle ear cavity, and the viscosity of the perilymph and the mucous lining of the middle ear cavity constitute the stiffness component of the middle ear (Van Camp, Margolis, Wilson, Creten , and Shanks, 1986). Recently, Shahnaz (2008) have compared MFT and WBER findings between normal adults and normal-hearing neonates in the neonatal intensive care units (NICU), who passed the neonatal hearing screening test. The researcher found maximum absorption of the incident energy at narrower range of frequencies (1.2 2.7 kHz) in normal babies compared to adults (2.8 4.8 kHz) (Shahnaz, 2008; Shahnaz et al, 2008). This preliminary normative data from 49 neonatal ears reflects the potential diagnostic benefits of the WBER test in detecting middle ear effusion in neonates. Wideband energy reflectance in otosclerosis Although the main definitive diagnosis of Otosclerosis is during surgery, an accurate preoperative audiological diagnosis is very important indication for surgery. Still, pure-tone audiometry has its own limitations that prevent accurate diagnosis of otosclerosis. Also, standard 226 Hz tympanometry is usually within normal type A tympanogram in most otosclerotic patients (Jerger, Anthony, Jerger, and Mauldin, 1974). While multiple frequency tempanometry may be helpful in diagnosing otosclerosis, it adds little information to the diagnosis (Probst, 2007). On the other hand, the WBER responses in three ears of otosclerosis fell outside the 5th to 95th percentile of the normative data and presented a distinctive pattern for the disease (Feeney et al, 2003); which suggests that WEBR is a sensitive middle ear measure. In a recent study WBER was found to be helpful in distinguishing 28 otosclerotic ears from normal and/or other causes of conductive hearing loss. A significantly higher ER w as found in otosclerotic ears at frequency range of 0.4- 1 kHz as compared to normal ears. In the same study WBER was found to be more sensitive in diagnosing otosclerosis than the conventional 226 Hz tympanometry and the MFT (Shahnaz et al., 2009). Wideband energy reflectance in other middle ear pathology Hunter and colleagues (2008) found higher sensitivity of WBER in detecting otitis media in infants and children with cleft palate (Hunter, Bagger-Sjoback, and Lundberg, 2008). Feeney and colleagues in 2003 studied WBER at ambient pressure in 13 ears with different middle ear disorders and comparative normal. Different middle ear disorders were involved in this study included: four ears with OME, one ear with ossicular discontinuity, two ears with otosclerosis, two ears with hypermobile TM, two ears with perforated TM, and one participant with bilateral sensorineural hearing loss. The results suggested a distinctive WBE