Treating Long Head of Biceps (LHB) Pathology

Treating Long Head of Biceps (LHB) Pathology Abstract Background Clinical examination of the shoulder joint has gained attention in recent years as clinicians aim to practice with an evidence-based and accurate clinical examination of the biceps tendon. There is an increased desire for proper diagnosis while simultaneously minimizing costly imaging procedures and unnecessary procedures. Thus, the purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing and subsequently treating long head of biceps (LHB) pathology. Methods A literature review of level one and two diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of Pubmed, Medline, Ovid and Cochrane Review databases. Tests were combined in series and parallel to determine final sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pre-test probability. The gold-standard for diagnosis in all studies included was arthroscopy or arthrotomy. Results Seven studies regarding LHB clinical diagnostic testing met inclusion criteria. The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test; adding a third test decreases accuracy. Conclusion Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting. Level of Evidence: II Systematic Review and Meta-Analysis Key Words: biceps tendon; long head; physical examination; pathology; diagnosis; shoulder examination Introduction The physical examination is a requisite and inexpensive component to medical diagnosis. The shoulder examination, in particular, encompasses a myriad of special provocative maneuvers, displaying a wide range of sensitivities and specificities pertaining to diagnostic accuracy. Accurate understanding from the correct sequence of maneuvers or tests increases diagnostic yield. In the modern era, clinical diagnosis heavily relies on imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), arthrography, and arthroscopy to diagnose shoulder pathology21,33. Current gold standard diagnostic testing options have limitations. MRI has poor statistical characteristics for diagnostic accuracy as it very reader and technician dependent, adds both direct and indirect costs, and may be less accurate than the physical exam37. Diagnostic arthroscopy is successful in diagnosing intra-articular pathology, but is limited in visualization for extra-articular pathology, is costly, and increases patient risk37. Increased use of diagnostic imaging contributes to rising health care costs14,30,32,38. According to the Centers for Medicare and Medicaid Services (CMS), diagnostic imaging costs are significant, accounting for up to 40% of overall healthcare expenditure increases over the past 10 years25. Advanced imaging techniques res ult in not only higher direct costs, but may increase indirect costs and jeopardize outcomes36,39. As the healthcare landscape transitions to cost minimization and value-based healthcare delivery, the development of an efficient, cost-effective, shoulder examination is desired. Shoulder examinations have poor sensitivity and/or specificity that makes diagnosing certain pathologies difficult4,28,30,33. Thus, evaluating the long head of the biceps brachii tendon (LHB) pathology with high-yield examination maneuvers can aid physicians through increasing the accuracy of shoulder diagnoses and aid in surgical decision making. Previously published studies focused on the following questions: whether physical examination special tests correlate with surgical findings; whether imaging correlates with surgical findings; and whether physical exam tests are accurate enough to diagnose pathology effectively5,9,10,26,28,29,33. Currently, there is a need to develop new algorithms to provide shoulder practitioners with a practical but comprehensive evidence-based approach to diagnose LHB pathology during an office visit and to further reduce the need for diagnostic imaging20,22,34. The purpose of this study was to perform a systematic review and a secondary sensitivity analysis based on pre-formed likelihood scenarios based on the history of present illness (HPI) past medical history (PMH), and epidemiology to provide clinicians a practical, evidence-based clinical (P.E.C) physical examination algorithm to accurately diagnose patients with LHB pathology. Specific objectives were to: compile the peak performing physical exam tests extracted from level I and II studies within the English literature; synthesizing the most accurate test combination; develop a clinical algorithm to provide quantify LHB diagnostic accuracy; and create a diagnostic accuracy reference guide. Materials and Methods A systematic literature review with the terms proximal, biceps, clinical and examination in the Medline database through the Pubmed, Medline, Ovid and Cochrane Review databases was completed in May 2015. The searches included the use of Boolean operators such as AND and OR. The databases were scrutinized independently by three authors. Inclusion criteria included studies that were focused on physical examination tests and compared to the diagnostic gold standard from Level I and II studies published in scientific journals. Exclusion criteria were: non-English, non-full text, level III of evidence or lower, related to superior labrum anterior to posterior (SLAP) lesions, investigated rheumatoid arthritis patients, or did not compare tests to a validated gold standard. The validated gold standard utilized for all studies and systematic reviews included were diagnostic arthroscopy or arthrotomy to confirm anatomical findings. Relevant studies were independently assessed, and conflicting studies were included only if there were consensus amongst the authors. References of included studies were additionally evaluated to identify additional articles for inclusion. Applicable data was extracted by reverse calculation where the information desired was not directly stated. Using PRISMA guidelines for systematic reviews (Fig. 1), our original search retrieved 2,086 studies from Pubmed, Medline, Ovid and Cochrane Review databases. Twenty-eight additional records were included through a review of references from each article included in the systematic review. After duplicates were removed, the initial search yielded 2,112 studies. Subsequently, 1,689 studies were removed for irrelevant titles or abstracts, and an additional 362 were excluded because they were not in English. Lastly, the remaining 63 articles were assessed for eligibility; 14 were excluded for non-full text, 22 were excluded for not being level I or II study, and 18 were excluded for non-relevant data. The data extracted was summarized and analyzed according to the statistical methods described by Eusebi et al. focusing on test specificity, sensitivity, positive predictive value and negative predictive value12. Next, clinical tests were combined to assess improved diagnostic accuracy. The clinical tests were applied both in parallel and in series. The first approach in parallel analysis, consists of two special tests performed in theory at approximately the same time. The parallel analysis can interpret the findings in an and or or technique. When a parallel analysis is performed in an or technique, the overall sensitivity of the two tests is greater than the sensitivity of either special test alone. This parallel analysis allows for two opportunities to observe the potential pathology. If both tests are negative then it is considered a negative finding in the algorithm and rule out the pathology, but if just one of the two special tests is positive then it is not considered a negative result in parallel analysis. The second approach in series analysis, consists of two special tests performed; however, the overall negative or positive finding depends on the outcomes of both special tests. By utilizing two special tests in an and technique in series, the specificity for both tests is higher than for either test alone. If both special tests are positive, then it is considered a positive result. If either special test is negative, then the in series analysis cannot be considered a positive result. In order to calculate the post-test diagnostic probability of LHB diagnosis, we performed calculations for each test with four pre-test probability options. Pre-test probability is defined as the probability of a patient having the target disorder before a diagnostic test result is known. Therefore, pre-test probability is based on patient history, subjective complaints, epidemiologic probability and the medical opinion of the provider ordering the test. The ordinal scale created has four different probabilities: very unlikely 0.2 (20%); unlikely 0.4 (40%); likely 0.6 (60%); and very likely 0.8 (80%). The physical exam test combination with the optimal test performance was identified (named the PEC exam). A decision tree analysis was developed to determine the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A table was created as a simple reference guide to use in the clinical setting. Results The initial electronic database search retrieved 2,112 unique articles, with 28 obtained from a manual search of reference lists. Of these, 2051 studies were found unrelated to the topic of interest based titles and abstract review, resulting in 63 full-text articles evaluated according to selection criteria. Fifty-four articles were excluded for the following: full-text unavailable (N=14), not a Level I/II study (N=22), and irrelevant data after full-text review (N=18). Seven relevant (N = 7) articles were identified through the systematic review and scrutinized (Supplementary Table S1). From the reviewed articles, special tests and modalities evaluated included Speeds, Yergasons, bicipital groove tenderness, uppercut, bear hug, belly press, OBriens, and anesthetic injection. Statistical characteristics for each test are documented in (Supplementary Table S2). The bear hug and uppercut special tests demonstrated the highest sensitivity for the physical examination special maneuvers (79%, 73% respectively), whereas the belly press and Yergasons tests demonstrated the lower spectrum of sensitivity (31%, 41% respectively). The belly press and OBriens special tests demonstrated the highest special test specificities (85%, 84% respectively), whereas the bear hug and bicipital groove tenderness tests showed the lowest specificities (60%, 72% respectively). Diagnostic ultrasound, used as a reference and also included to study as a potential application for in-office point of service testing, demonstrated the highest sensitivity and specificity of all statistical characteris tics revealed through the review (Sensitivity 88%, Specificity 98%). In series and in parallel assessments determined two physical exam tests improved test performance over any single test. Performing more than two physical examination tests decreased diagnostic accuracy. The uppercut test combined with the tenderness to palpation of the LHB test provided the highest physical examination accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3%. We characterize this as the PEC exam. Additional combinations, including diagnostic ultrasound, are reported in (Supplementary Table S3). The uppercut test and diagnostic ultrasound in parallel revealed the highest sensitivity (97%). Each of the Speeds, Yergasons and upper cut tests paired with diagnostic ultrasound all achieved the highest specificity (100%). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability (Fig. 2). A quick reference guide is provided to use in the clinical setting (Fig. 3). Discussion LHB pathology is an increasingly recognized generator of shoulder pain and functional impairment in symptomatic patients. Physicians are faced with diagnostic challenges due to non-specific clinical presentations and lack of direction based on physical exam findings. As such, the purpose of this study was to perform a decision-tree analysis to create a clinical algorithm to diagnose biceps pathology with increased accuracy compared to previously reported diagnostic examinations 8,11,15-17,19,22,24. This was achieved by conducting a systematic literature review including only level I and II studies. Special test sensitivities and specificities were combined in series and parallel. Analysis showed that the uppercut test combined with tenderness to palpation of the LHB within the bicipital groove provided the highest accuracy physical exam tests for diagnosing pathology at the proximal biceps. Application of this PEC exam, coupled with pre-test probability assignments can now provide cl inicians diagnostic confidence in the office. In equivocal cases, point of care ultrasound examination can further improve diagnostic accuracy2,31. Applying the PEC algorithm provides a simple, efficient and reproducible physical examination protocol for shoulder clinicians yielding an accurate diagnosis in the clinic. Now, with the calculated accuracy reference guide available, a clinician may rely on the office-based diagnosis with improved certainty and may consider forgoing advanced imaging, thereby avoiding additional cost, treatment delays and possible patient risk. In order to cover an array of clinical scenarios, we used a pretest probability range of 20-80% at 20% increments according to the likelihood of pathology. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. If the pre-test probability was above 90% or below 10%, we then assume there is no need to perform additional testing with acceptance of a 10% error rate. Combination of physical examination techniques demonstrated that the uppercut test combined with tenderness to palpation of the LHB provided the highest accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3% (Supplementary Table S3). The values of the test used in series and in parallel were definitive and overpowered the value of the pre-test probability assessment in many clinical scenarios. This adds credibility to a reproducible, simplified two-step P.E.C. examination without the need for additional maneuvers to be performed. Furthermore, we feel that the application of the PEC test is generalizable to non-shoulder specialists, facilitating both increased utilization and diagnostic accuracy of LHB disease. Many studies have explored the accuracy of physical examination and special test maneuvers in diagnosing LHB pathology with limited conclusions regarding its efficiency18,22,23,37. However, our study is unique in that it additionally produces a diagnostic tool, both enabling accurate point of care diagnosis of LHB injury and minimizing the need for advanced imaging. The value of the P.E.C. examination corroborates with current clinical recommendations. In 2009, Churgay et al. stated that bicipital groove point tenderness is the most common isolated finding during physical examination of patients with biceps tendinitis, and that ultrasonography is the best modality for evaluating isolated biceps tendinopathy extra-articularly3,6. With regards to diagnostic accuracy and fluidity of exam, our study revealed that the best maneuver combination for diagnosing biceps pathology are the uppercut test and tenderness to palpation. Incidentally, our study has also concluded that use of ultrasound after equivocal physical examination findings improves the sensitivity and specificity of all evaluated test combinations. Unlike past studies, we incorporated a diagnostic algorithm to aid efficient shoulder examination and to increase physician confidence in biceps tendon diagnosis. In addition to enhancing diagnostic accuracy, development of a value-based clinical decision pathway may play a small, but essential role in the improvement of the current state of the healthcare system. High-yield, algorithm-derived examination like our proposed sequence further alleviate the number of follow-up visits needed until diagnosis, which often delay expedient care delivery35,39. Moreover, simplified diagnostic algorithms may also result in cost reduction and decreased iatrogenic injury associated with unnecessary advanced imaging studies. A shoulder examination that provides accurate diagnosis provides multiple advantages that benefits both physicians and the healthcare system with the ultimate goal of improving patient outcomes. However, it is important to note that clinical decisions should be tailored to patient clinical presentation, and that MRI may be a more appropriate diagnostic modality for surgical candidates or patients with inconclusive preliminary workup. These findings provide evidence towards the current trend in orthopedic surgery education as more national conferences and residency programs are increasing musculoskeletal ultrasound (US) courses incorporated into their curriculums. Accordingly, the American Medical Association for Sports Medicine has endorsed increased integration of sports US into sports medicine fellowship curriculums13. Studies have proposed that proficient level diagnostic skills may be quickly obtained by the inexperienced orthopedist with an established examination protocol1. Murphy et al. conducted a study investigating diagnostic improvement in four orthopedic surgeons who attended a formal training course to identify and size tears on the rotator cuff through US. In the later training period, results showed positive predictive value improving by 16%27. An additional study by Roy and colleagues also demonstrated improved diagnostic accuracy of US irrespective of whether a trained radiologist, sonographer or orthopedic surgeon operated the device32. US requires further studies to evaluate its cost effectiveness compared to advanced imaging techniques like MRI or arthroscopy, but an algorithm(Fig. 3) may provide a simple evidence-based decision analysis for physicians to rely on when considering LHB as the major source of pain. This study, however, also has its limitations. Foremost, a majority of the studies included in our data collection did not solely focus on LHB pathology. True positives may have included superior labrum, anterior to posterior (SLAP) lesions within the diagnosis of biceps pathology. Studies may have also incorporated biceps pathology into other diagnostic categories (e.g. impingement). Therefore, it was difficult to find studies which solely focused on diagnostic accuracy of LHB pathology. Additionally, only level I or II studies were considered for diagnosis, which routinely compare diagnostic testing algorithm (DTA) to the gold standard of diagnosis. Unfortunately, there is no clearly defined arthroscopic findings for diagnosis of LHB pathology. To aid in any study misinterpretations due to inaccurate language translations, only articles originally written in English were evaluated, and only published articles were included. This may have introduced both publication and/or selection bias. A method to eliminate some of these potential biases would be to perform a truly systematic review and meta-analysis combining results from multiple studies; however, even this can be hindered by bias with the lack of currently published methods for meta-analyses evaluating diagnostic testing. Another future direction for this study may be to further evaluate the accuracy of new special tests described to evaluate long head of the biceps pathology, specifically the uppercut test. Currently the uppercut test has only been described and analyzed in a single level I or II study that we utilized for our algorithm24. Further validation testing for this specific test may be warranted. Conclusion Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting. References 1. Amoo-Achampong K, Nwachukwu BU, McCormick F. An orthopedists guide to shoulder ultrasound: a systematic review of examination protocols. Phys Sportsmed. 2016 Aug 22;1-10. doi: 10.1080/00913847.2016.1222224 2. Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR. 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Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. Physical examination for partial tears of the biceps tendon. Am J Sports Med. 2007 Aug;35(8):1334-40. doi:10.1177/0363546507300058 17. Gilmer BB, DeMers AM, Guerrero D, Reid JB, Lubowitz JH, Guttmann D. Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy. 2015 Jan;31(1):29-34. doi:10.1016/j.arthro.2014.07.025 18. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD007427. doi: 10.1002/14651858.CD007427.pub2 19. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011 Oct;20(7):1069-73. doi:10.1016/j.jse.2011.04.004 20. Hegedus EJ. 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Am J Sports Med. 2012 May;40(5):1144-7. doi:10.1177/0363546512436944 Figure and Table Legends Figure 1: PRISMA Systemic Review Flow Diagram: This figure displays the process and rationale behind why studies were omitted from the systemic review. Figure 2: (A) Diagnostic Combination to Rule in Pathology: These findings demonstrate that the combination of tests that best help rule out pathology are the TTP + Uppercut test when performed in series. If both tests are negative in a scenario with a low pre-test probability (i.e. prevalence), then there is a very small chance of pathology being present. TTP = Tenderness to palpation (of the long head of the biceps within the bicipital groove); Diamond = TTP + Uppercut in series, square = TTP + Speeds in Series, triangle = TTP + Yergasons in Series (B) Diagnostic Combination to Rule Out Pathology: These findings demonstrate that the combination of TTP + upper

Adult Assumptions On Teenagers :: essays research papers

Adults Assumptions On Tennagers Everyone knows that throughout life, assumptions and stereotypes are made. Whether they concern age, gender, race, class and so on, it does not matter. Stereotypes are always made in some form or another, some can be referring to positive aspects, while others can be bad. Whether good or bad, stereotypes should not be made, if a person has not met someone, they shouldn’t presume to know them or their ‘type’. No two people are identical and so they should not be treated as though they are. Many people have similar interests and characteristics, but not identical. A common group that receives a lot of stereotyping is the youth of today. Not everyone, but a lot of people follow the assumption that the youth of today’s society are nothing but bludgers. Youth usually have plenty of negative assumptions placed upon them such as being known as ‘Know alls’, ‘Trouble makers’, ‘Druggies’ and irresponsible. This names just a few of the negative assumptions that youth have placed upon them nearly, if not, everyday. There are also some positive assumptions made in regard to the youth of today, these are statements like they (the youth) are beginning to understand the importance of education in order to have a chance at a secure future. Youth are very out going and don’t have a concern for tomorrow as they prefer to live for today. Youth have a creative imagination, not just towards art and work, but towards life in general and are willing to learn new skills in order to forward their knowledge, and are being thought of as the future generation. I believe that all of these as sumptions have an element of truth, but in the way of being stereotypes. To certain individuals, these assumptions may be true, but not every youth is a trouble maker or a drug addict and so on. As I said before, everyone is an individual and so should be treated as one, and not just as ‘one of them’. The reason I think this is because I know that I wouldn’t like it if someone treated me the same as other people who are nothing like me. I know that I’m not a ‘Druggie’ or a ‘Know all’ and so I do not want to be treated the way people treat these sort of youths. I know that this is sounding as though I am stereotyping but I am not, I am saying that people do put these groups under headings such as ‘Druggies’ and they then treat them different.

Federal Civil Procedure

I. Personal Jurisdiction – in what state can the P sue the D? a. Two step-analysis i. Satisfy a statute AND ii. Satisfy the constitution (due process) b. In Personam Jurisdiction – jurisdiction over person, not property, b/c of some contact b/t D and forum state i. Statutory Analysis 1. Every state has statutes allowing jurisdiction based on domicile, presence instate when served w/ process, and consent (implied or actual). 2. Long-arm statute ( allows jurisdiction over non-residents ii. Constitutional Analysis (International Shoe) 1. Test ( Does D have â€Å"such minimum contacts w/ the forum so that exercise of jurisdiction does not offend traditional notions of fair play and substantial justice† 2. Factors a. Contact – some tie b/t D and forum i. Purposeful Availment – D’s voluntary act 1. i. e. D ships goods into forum state or D uses roads or causes effects in forum state ii. Foreseeability – D would get sued in this forum b. Fairness i. Relatedness – b/t contact and the claim 1. not always necessary to have relatedness if have substantial ties w/ the forum a. i. e. D domiciled there, business there, served w/ process there can be sued in that state under general jurisdiction ii. Convenience – forum ok unless puts D at a severe disadvantage in the litigation iii. State’s interest – provide forum for its citizens TIP: My parents frequently forgot to read childrens’ stories M – minimum contacts P – purposeful availment F – foreseeability F – fairness R – relatedness C – convenience S – state’s interest II. Subject Matter Jurisdiction – in what court? Federal courts only hear two types of cases: diversity of citizenship and federal question a. Diversity of Citizenship Cases i. Citizens of different states 1. Complete diversity rule ( no diversity if ANY P is a citizen of the same state as any D, at the time the case is filed 2. Citizenship a. Human – can only have one place of citizenship i. Domicile – 1. presence instate AND 2. subjective intent to make permanent home b. Corporation – can have more than one place of citizenship i. State where incorporated AND ii. One state principal place of business 1. Only one PPB a. Headquarters OR i. Most use this to designate unless all activity is in one state b. Most production or service activity c. Un-incorporated associations i. Use citizenship of ALL ITS MEMBERS d. Decedents, minors, incompetents i. Look to their citizenship NOT the representative’s citizenship ii. Amount in controversy – good faith allegation the claim in the complaint exceeds $75,000. 00, exclusive of interest and costs 1. Aggregation – adding together two or more claims to meet amount in controversy requirement a. Need one P and one D b. Joint tortfeasors – use total value of claim, irrelevant of the # of parties 2. Equitable Relief – if either test met, then it’s OK a. P’s viewpoint: does injunction cover loss of value by more than $75k? OR b. D’s viewpoint: would it cost D more than $75k to comply w/ the injunction b. Federal Question – claim â€Å"arises under† federal law c. Supplemental Jurisdiction – no federal jurisdiction b/c no diversity or FQ, BUT may still be able to get into federal court i. Test 1. common nucleus of operative fact – arise out of same transaction or occurrence as underlying claim ii. Limitation 1. can not use to overcome lack of diversity in a diversity of citizenship case BUT 2. Can use to overcome lack of diversity in a FQ case 3. Can use to overcome amount in controversy in diversity cases d. Removal – allows D’s to have case filed in state court â€Å"removed† to federal court i. What cases? – if case could be heard in federal court ii. Where? – ONLY to the federal district court embracing the state court iii. When? – no later than 30 days after service of the first removable document e. Erie Doctrine III. Venue IV. Service of Process V. Pleadings VI. Joinder of Parties VII. Discovery VIII. Pretrial Adjudication IX. Conferences and Meetings X. Trial, Judgment and Post-trial Motions XI. Appeal XII. Claim and Issue Preclusion

The Slope of a Horizontal Line is Zero

The Slope of a Horizontal Line is Zero In The Slope of a Line, you learned that the slope, or m, of a line describes how rapidly or slowly change is occurring. Linear Functions have 4 types of slopes: positive, negative slope, zero slope, and undefined slope. Real World Example of Negative Slope Refer to the graph, Horizontal Line, m 0.   The x-axis represents time, in hours, and the y-axis represents distance, in miles, from Downtown Houston, Texas. Hurricane Prince, a Category 5 storm, threatens to flood (among other things) the Bayou City in 24 hours. You have the bright idea- along with 2 million other Houstonians- to leave Houston now. You’re on Interstate 45 North, the road that snakes northward to flee anything blowing in from the Gulf of Mexico. Notice how time is moving. One hour passes, two hours pass, but you’re still one mile away from downtown. Remember, slope is a rate of change. For every two hours that pass, you move zero miles. Because of this, your slope is 0. Calculating Zero Slope Refer to the PDF, Calculate_Zero_Slope to learn how to  use a graph and  the slope formula to  calculate a zero slope.  To download free software to view the PDF, visit https://get.adobe.com/reader/.

ROLE OF ELECTION COMMISSION IN ENSURING FREE AND FAIR ELECTION AND DET

ROLE OF ELECTION COMMISSION IN ENSURING FREE AND FAIR ELECTION AND DET Research Dissertation On ROLE OF ELECTION COMMISSION IN ENSURING FREE AND FAIR ELECTION AND DETERRENCE OF DISCRIMINATION ON THE BASIS OF CASTE AND RELIGION Submitted to: Amity Institute of Advanced Legal Studies (AIALS), Amity University Uttar Pradesh IN PART FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF LAWS (LLM) Submitted by: 2014-2015 TABLE OF CONTENTS Contents Page No. 1. Chapter-1 Introduction Outline of role of election commission in ensuring free and fair election Theory of State Theory of Democracy Government and Politics in India 2. Chapter-2 Framework of Election Commission of India Electoral system Constitutional status of ECI Reservation in legislative bodies 3. Chapter-3 Legislative Framework Relating to Election Election Process Representation of People Act(Amendment and validation) Bill, 2013 President and Vice-President Act 4. Chapter-4 Election Disputes and Issues Free and Fair Elections Registration of Political Parties MCC- Model Code of Conduct Election Expenditure Election Offences: Penal Laws Anti-Defection Laws Election Petition 5. Chapter-5 Political and Religious Influence on Elections- An Analytical Overview Vote Bank Politics Religious impact on Election Discrimination on the basis of caste its aftermaths 6. Chapter-6 Conclusion and Suggestions Table of cases Bibliography. CHAPTER 1 INTRODUCTION 1.1 OUTLINE OF ROLE OF ELECTION COMMISSION IN ENSURING FREE AND FAIR ELECTION The Election Commission of India is an independent and self-governing body, established under federal authority. It is responsible for administering all the electoral processes in India. Under the supervision of the commission, free and fair elections have been held in India at regular intervals as per the principles enshrined in the Constitution. The Election Commission has the power of superintendence, direction and control of all elections to the Parliament of India and the State Legislatures and of elections to the office of the President of India and the Vice-President of India. Elections are conducted according to the constitutional provisions and other laws made to that effect by the Parliament. The major laws in this regard are Representation of the People Act, 1950, which mainly deals with the preparation and revision of electoral rolls; the Representation of the People Act, 1951 which deals with all aspects of conduct of election disputes in detail. These disputes include the post-election disputes. The Supreme Court of India has held that where the enacted laws are silent or make insufficient provisions to deal with a given situation in the conduct of elections, the Election Commission has the residuary powers under the Constitution to act in an appropriate manner. One of the most important features of the democratic polity is elections at regular intervals. Holding intervallic free and fair elections are essentials of democratic system. It is a part of the basic structure of the Constitution. The Election Commission is regarded as the guardian of free and fair elections. In every election, it issues a Model code of Conduct for political parties and candidates to conduct elections in a free and fair manner. The Commission issued the code for the first time in 1971 and revised it from time to time. It laid down guidelines for conduct of political parties and manner of candidature during elections. However, there occur instances of violation of code by the political parties and misuse of official machinery by the candidates. The need for such code is in the interest of free and fair elections. However, the code does not have any specific statutory basis. It has only a persuasive effect. It only contains rules of electoral morality". But this lack of statutory backing does not prevent the Commission from enforcing it. A law regarding the registration process for political parties was enacted in 1989 and many parties got registered with the Commission. It was effective in avoiding the confusion of the administrative machinery and the electorate and ensuring that political parties are brought under the purview of the Election Commission. Also, in order to get rid of the growing corrupt influence of money during elections, the Election Commission has made many suggestions in this regard. The Election Commission has fixed the legal limits on the amount of money which a candidate can spend during election campaigns. These limits have been revised from time to time. The other measures have also been taken by the Election Commission in order to ensure free and fair elections. Modern methods such as introduction of EVMs- Electronic Voting Machines, supervision of electoral candidature, etc. are some of the basic steps taken by the Commission so as to develop the process of election on

Answer the three question separately Assignment Example | Topics and Well Written Essays - 500 words

Answer the three question separately - Assignment Example The people have the ultimate voice in choosing the source of government authority, which drives its right to govern from their consent. The people have their freedom of speech with the government and know their rights. The most important key that the opposition plays is also to push the government to set a balance wage, to all employees within the country. To ensure that the society is democratic, the primary values of constitutional democracy have to mirror human dignity, freedom of individuals, and the worth of every person within the society. To begin with challenging the ideas that the only proper criterion, in which a decision would be judged. Therefore, this right should be complete to life aspects such as employment rights, social rights, health care, the economy, and education. Every, individual including children, young people, and both women and men of older age have their rights. Additionally, democracy creates a further income of sources within the counties to ensure that every resource is protected. This may include cash crops, or any resources that may bring funds in the society, whether in rural or urban areas. However, the most important component of constitutional democracy is its highest purpose in securing freedom, which has the highest value in healthy functioning of a country. This is necessary since every individ ual working late hour while running a business or any companies that operate in the night requires the freedom to operate. Democracy gives good protection of people’s properties to the security of the government. However, constitution laws do not rely on one side of politics or any other political parties. The Constitution allows judges to rule according to the constitution rights of the human. Hence, if the court fails to rule on their complaints with constitutional rights, they would be able to protest

Health information system Essay Example | Topics and Well Written Essays - 1250 words

Health information system - Essay Example Furthermore, distribution and access to to healthcare is determined by income and standards of living. These features form a social pattern in health that tends to shape health dynamics with respect to certain social requirements. It is important to note with complete patient data, avoidable hospital visits are reduced. Some hospitals use other forms of communication such as email and telephone to reach and support patients from home by checking their health records. For instance, physicians use EHR to determine a patients' health concern. An integrated and comprehensive health record transfers the trend of health care to an efficient approach while maintaining the quality of health care. This results in minimal wastage on financial implications to the hospital, patient and government. Importance of aligned financial incentives. Health outcomes for the population are seen as being influenced by the operation of the capitalist economic system at two levels. Within the capitalist socie ties, health matters have progressed with refined technology in drug production. Poor societies are more likely to fall ill compared to richer societies. Poor disease prevention measures, minimal awareness initiatives by stakeholders, poorly funded research and costly treatment procedures are likely to affect access to health by poor clusters of people. These are some of results of inadequate health data (Gruber, Cummings, LeBlanc, & Smith, 2009). For instance, patients in the least developed areas have been subjected to low quality medication and clinical care. As a result, many people die out of preventable diseases due to early detection or lack of treatment fees. With health records on such scenarios, it would be easy for health providers make adequate arrangements for such people. Meadows Ginny (2002) asserts that, â€Å"Utilizing clinical information systems, an informatics nurse can help other nurses explore and understand the informational and cognitive foundations of their profession. The ability to electronically record, integrate, and analyze data and information enables nurses to quickly move to the synthesis of nursing knowledge and the development of nursing wisdom, which they can then apply to affect patient care.† (Meadows, 2002). It is important to note that the rich controls the health organizations, health research institutions and drug distribution, thus making it difficult for the poor people to make any significant decision or policy on health matters. This has been achieved in some areas through creating enforcement departments within institutions to monitor progress and recommend necessary changes. EHS is important in generating information on how to tackle socioeconomic differences in health care and health policies in any nation are important for equal access to health facilities (Kaufman, Roberts, Merrill, Lai, & Bakken, 2006). This should address areas such as health information technology to shape a coordinated and focused n ational policy in support of patient care. A socially supportive atmosphere prompts the adoption of healthy behaviors. This can be realized when all people have equal and unlimited access to health facilities irrespective of class. Electronic health record (EHS) helps in adopting a patient-centerdness approach that involves shared decisions, outcome