Intrathecal Chemical Neurolysis With Phenol

Intrathecal Chemical Neurolysis With Phenol CANCER PAIN Intrathecal neurolysis with 6% phenol for intractable and opiate resistant perineal pain secondary to terminal bladder cancer . Name : Dr R Srivastava Department: Heart of England NHS Trust, Solihull. E-mail: [emailprotected] Abstract Background: Intrathecal chemical neurolysis with Phenol is a neurodestructive technique to provide saddle anaesthesia for perineal pain, in patients unresponsive to pharmacological therapy or not ameneable to surgical treatment. Its use has been advocated in patients with terminal illness with a short life expentancy of less than a year. Phenol’s neurodestructive mechanism relies on precipitation of proteins in the nerves with myelin sheath separation and axonal oedema, resulting in fibrosis. Neurolysis can be induced with chemicals like phenol or alcohol or by physical methods of radiofrquency or cryoablation Neurolytic saddl block is a high risk procedure leading to almost irreversible neuro-destruction with significant risks including failure, paralysis and incontinence.Careful patient selection and psychological evaluation is mandatory and comprehensive risks and benefits assessment should be carried out before embarking on this technique. Communication with patient is vital due to the resultant side effects of the block. Results: Patient was extensively evaluated for the procedure with all co-morbidities and life expectancy considered and underwent subarachnoid chemical neurolysis with hyperbaric 5% phenol leading to drastic pain relief and significant reduction in opiate consumption. Case Report: Mr JJ ,a 73 year old gentleman was referred form a hospice with complaints of severe abdominal and anal pain due to a surgically inoperable bladder tumor with extensive pelvic involvement and distant metastases . He was referred to our clinic from hospice with severe opiate resistant pain. Mr JJ was diagnosed with the Transitional Cell Carcinoma: T2a N0 MX(Pulmonary nodules) G3,TCC Bladder, eight months ago when he initially presented with back and pelvic pain. He had pulmonary metastases and bladder biopsy and cystoscopy revealed a large tumor on the back wall of the bladder. Mr JJ underwent a radical course of radiotherapy. Subsequently he was admitted to the hospital with rectal pain . Examination under anaesthetic revealed a large mass extending from the bladder in to the prostrate. MRI scan confirmed the tumor with invasion of seminal vesicles and of the prostrate.He underwent ureteric stenting for his right hydronephrosis and hydroureter. His background included history of chronic obstructive airway disease, hypertension, diabetes, Ischaemic heart disease(Coronary stenting 5 years ago) and hypothyroidism. His pain at the time remained unsettled with associated symptoms of tenesmus, nausea and vomiting and profound weakness. Mr JJ lived alone and was unable to cope on his own and was referred to hospice for further palliative care. He was initially treated with Zomorph 30mg twice a day and with Oromorph as a PRN dose for breakthrough pain. Pain worsened over a period of six weeks when it was decided to start him on a syringe driver of diamorphine 30 mgs and metoclopramide30 mgs. Inspite of some relief, he remained extremely confused and constipated. His syringe driver was changed to alfentanil 5mgs and haloperidol 3 mgs to reduce the confusion and drowsiness. Subsequent increment of alfentanil dose via the syringe driver did not resolve his rectal pain. In view of his worsening symptoms and prognosis ,saddle block with phenol for rectal pain remained the only viable option. After a careful assessment and explanation of the risks ( double incontinence and possible paralysis) and benefits of the procedure explained, patient was transferred to our centre as a day case and underwent intrathecal neurolysis with phenol. 1 ml of 5% phenol in glycerol was injected intrathecally and flushed with 0.2 mls of 0.5% hyperbaric bupivacaine. Patient was sat up for 30 minutes to achieve a saddle block. In recovery he seemed to be pain free with no loss of motor power. Mr JJ was transferred back to the hospice the same day. During follow up it was noted that within a few days Mr JJ’s alfentanil infusion was stopped and he was more awake and was managing on small doses of oral morphine of up to 40 mgs a day. His tenesmus completely disappeared but he still complained of some dull aching and deep visceral pain. Case discussion: There are more than 5000 deaths/year related to bladder cancer in the UK and it is the seventh commonest cause of cancer related deaths. Our patient had an extensive spread of his bladder tumor resulting in a combination of background visceral pain involving the rectum causing intractable tenesmus Prevalence of cancer pain in patients with incurable or advanced disease ranges from 43 -63%. More than one third of the patients complain of significant pain during the terminal stages of the disease.[1] Pathophysiological Mechanisms: The mechanisms involving cancer pain are complex and can not be solely attributed to either nociceptive ,musculoskeletal , visceral or neuropathic pain . Pain presents itself as a combination of various mechanisms, which would be dependent on the characteristics of disease progression. Visceral pain as was the case with our patient has both spinal and vagal innervation with feature of dull and diffuse pain with poor localization. Cancer cells in combination with the stromal cells will result in release of inflammatory markers like endothelin, bradykinin , tyrosine kinase and proteases which would lead to sensitization of the nerve fibres. Tyrosine kinase seems to play an important role in the sensitization of the afferent nociceptors.[2] Growth of the tumor may cause direct compression of the nerve fibres resulting in ischemia related neuropathic pain. Cancer induced bone pain is a result of proliferating osteoclasts which lead to bone resorption. This also leads to stimulation of TRPV1 and acid sensing channels expressed on the nerve fibres resulting in cancer associated bone pain. Periosteal sensitization of afferent fibres in an acidic melieu contributes to the persistence of cancer pain.[3] Assessment of cancer pain remains complex and is influenced by patient population, variability in assessment tool ,scoring systems and under reporting of severity of pain by patients.[4] Assessment of patients with cancer requires a multidimensional approach in order to evaluate the physiological, psychological and social impact on life. A careful assessment of history, symptoms, signs and disease progression is crucial. Patient’s expectations with regards to treatment should be discussed and the impact of pain on patients functional activity should be assessed. Patients with cancer complain of background pain and exacerbation of pain (Breakthrough Pain), which might be related to movement or due to progression of tumor resulting in compression of underling tissues and organs . Metastases to the bone can be the primary cause of pain in up to 75% of the patients. Assessment of localization, severity, duration, exacerbating and relieving factors is a must. Cancer pain patients are often on high dose of opiates for their pain control, which may have a detrimental effect on their daily living due to side effects of tolerance to opiates, opioid induced hyperalgesia, leading to inadequate pain control. Management of cancer pain: Cancer pain management in a palliative patient is challenging and requires consideration of all aspects of pain in the terminally ill. Optimum control can only be achieved if pharmacological and bio-psycho-social element of treatment are carefully reviewed. Most patients understandably are depressed and more than 75% suffer from moderate to severe pain. Surgical management is rarely appropriate in patients with distant metastases but may be indicated in some circumstances like internal fixation for pathological long bone fracture. Chest drainage may be required for patients with mesothelioma for recurrent pleural effusion. Radiotherapy which can be localized or wide field and may be useful in patients with metastatic bone disease with proven efficacy of up to 60%. and 25% respectively. Radioisotopes like strontium are also used to treat metastatic bone disease but may not be cost effective in all healthcare systems. Chemotherapy may be helpful in some types of cancer,provided that the tumor remains chemo-sensitive. Assessing the benefits of chemotherapy with regards to prognosis and life expectancy is crucial as the side effects of chemotherapy may be more detrimental to the patient than the pain itself. Hormonal therapy has been useful in prostrate and breast cancer with anti-androgen and anti-oestrogens as both types of cancer are hormone sensitive. Pelvic pain may result from the tumor invasion to organs and The World Health Organisation (WHO) 3 step analgesic ladder of 1986 recommends a staged approach from non-opiods like paracetamol and non-steroidal anti-inflammatory drugs to weak opioids and if necessary ,strong opioids for moderate to severe pain. However, the role of adjuvants like tricyclic anti-depressants, selective serotonin reuptake inhibitors and anticonvulsants like gabapentin and pregabalin should be considered and individualized depending on the symptomatology of the patient. NMDA antagonist like ketamine may help reduce central sensitization[6] Heavy reliance on strong opioids can lead to troublesome side –effects which should be appropriately managed with laxatives and anti-emetics. Opioid rotation should be considered for opioid induced hyperalgesia as in the case of Mr JJ where diamorphine was substituted for alfentanil infusion. Evaluation of psychological factor of perception of pain and the behavioural responses has a significant impact on patient’s lifestyle. Cognitive behavioral therapy may help elicit these perception and help individuals with chronic pain ,forming coping strategies. Pain management programme is helpful for the patient in identifying all aspects of pain and are aimed at improving the quality of life. Physical therapy for pain is aimed at improving functionality and reducing the physiological deconditioning. Lifestyle adjustment in terms of daily routines ,tasks and adapting to new envoirement should be planned for facilitating any coping strategies. Intervention techniques are aimed at targeting the source of pain involving destructive and non-destructive techniques which could involve local anesthetics and steroids for nerve blocks .Continuous infusions of local anaesthetics and opioids via a catheter placed intrathecally, can be used for spinal cord modulation and pain control. Catheter is connected to a programmable pump to administer the desired dose. Nerve destructive techniques should be only considered in a multidisciplinary framework . Patient selection and progonostication of the illness is paramount. It is important that the patient has a full understanding of the procedure and the benefits at the expense of the undesired consequences of such a block like incontinence or motor paralysis. Trial of local anaesthetic is desirable in most cases to predict efficacy of further neurolysis. Neurolytic blocks necessiate the need for close monitoring and evaluation of patient’s pain scores in order to titrate the strong opioids accordingly. Indications and contraindications to Intrathecal neurolysis: Although there has been a decreasing trend in the use of intrathecal neurolysis following advancement in the techniques of spinal blocks with infusions of local anaesthetics and opioids; intrathecal neurolysis has its place in a select subset of patients in whom the pain remains refractory inspite of conventional therapies and treatment with strong opioids . The distinct advantage with neurolysis is of reduction in the opiate consumption and the associated side effects. Complications of subarachanoid block include bladder and bowel dysfuction along with motor weakness .[5]. Pain relief associated with neurolytic blocks is short lived(less than 6 months), and disease progression may lead to refractory pain .In view of our patient’s limited life expectancy of less than two months with pre- exsisting bowel and bladder dysfunction ,intrathecal neurolysis was the quickest and the most cost effective way to provide pain relief. Neurodestructive techniques used in clinical practice range from cryoablation, radiofrequency lesioning to chemical neurolysis with Alcohol (50-100%),Phenol (7-12%) , Hypertonic saline and glycerol. Intrathecal neurolysis: It involves the destruction of nociceptive afferent fibres ,both myelinated and unmyelinated leading to almost instant pain relief. It is effective in well localized pain. The effect of neurolysis is short lived but it involves a short period of hospitalization in comparision to neurosurgical procedures like cordotomy. Phenol(7-12%) causes nerve destruction by coagulating protein in both small and large fibres which leads to degeneration of the nerves within the nerve roots involving more of the posterior than anterior columns. Nerves tend to regenerate faster with phenol than alcohol . Phenol is hyperbaric and when mixed with glycerol, it tends to diffuse more slowly out of the solution causing a more targeted destruction compared to alcohol. It can be mixed with water but the nerve destruction will be more extensive. Phenol compared to alcohol is not painful on injection and for this reason alcohol injections are administered with a local anaesthetic. In concentrations of lower than 5%, phenol tends to exert local anaesthetic action rather than neurodestructive. Phenol when mixed with glycerol or radiopaque dye can provide a higher concentration of up to 15%. Neurolysis with phenol in comparision to alcohol is milder and short lived. Due to the hyberbaric nature of phenol in comparision with alcohol, the patient is positioned with the affected side down to target the dorsal roots. Phenol being highly viscous requires a wider bore spinal needle for injection. Phenol can cause skin and tissue necrosis along with neuritis if the nerve destruction is incomplete. For patients undergoing neurolysis with alcohol the targeted side is positioned up due to the hypobaric nature of the solution. Patients are initially in the lateral position followed by proning to 45 degrees to target the dorsal roots. Alcohol may cause mild burning on injection. Hypertonic saline(10-15%) for intrathecal neurolysis can provide a significant relief of more than 50% but has significant side effects. Conclusion: Management of cancer pain is very complex and challenging and requires considerable expertise in providing appropriate care to terminally ill patients. Significant reliance on strong opioids is not without it’s side effects and a multifaceted approach towards pain control is warranted. Our patient was treated with chemical neurolysis as a last resort since all other measures had failed. Although it helped in reduction of opiate requirement and drowsiness, it still remains difficult to judge the correct dosage and concentration of phenol and balance it against the duration of pain free interval with minimum side effects for the patient before leading to death. Intrathecal neurolysis is not a routine procedure and outcomes of this type of intervention are variable. The extreme complications of this procedure and availability of other techniques makes clinicians reluctant to use in their regular clinical practice. However, cancer pain treatment needs to be tailored in accordance with the patients condition and chemical neurolysis may perhaps be the only option to relieve pain in specific patients. References: [1]M. H. J. van den Beuken-van Everdingen, J. M. de Rijke, A. G. Kessels, H. C. Schouten, M. van Kleef, and J. Patijn, â€Å"Prevalence of pain in patients with cancer: a systematic review of the past 40 years,† Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. ESMO, vol. 18, no. 9, pp. 1437–1449, Sep. 2007. [2]S. Pezet and S. B. McMahon, â€Å"NEUROTROPHINS: Mediators and Modulators of Pain,† Annu. Rev. Neurosci., vol. 29, no. 1, pp. 507–538, 2006. [3]â€Å"Review of Cellular Mechanisms of Tumor Osteolysis.à ¢Ã¢â€š ¬Ã‚ ¯: Clinical Orthopaedics and Related Research,† LWW. [Online]. Available: http://journals.lww.com/corr/Fulltext/2000/04000/Review_of_Cellular_Mechanisms_of_Tumor_Osteolysis_.13.aspx. [Accessed: 23-Nov-2014]. [4]C. Shute, â€Å"The Challenges of Cancer Pain Assessment and Management,† Ulster Med. J., vol. 82, no. 1, pp. 40–42, Jan. 2013. [5]A. Watanabe and M. Yamakage, â€Å"Intrathecal neurolytic block in a patient with refractory cancer pain,† J. Anesth., vol. 25, no. 4, pp. 603–605, Aug. 2011. [6]Cancer Pain Management. The British Pain Society 2010

The Reluctant Fundamentalist

How does Hamid employ symbolism throughout the novel? Is his use of symbolism effective? What is lost and gained through the use of symbolism? The Reluctant Fundamentalist is a novel in which an American immigrant Changez is living a dream with a great job, money, and the â€Å"regal† Erica by his side. However after the 9/11 attacks Changez’s perception on America shifted, he was forced to question where his allegence lies and this developed into contempt for America.If you read The Reluctant Fundamentalist by Mohsin Hamid, and fail to dig below to the surface of the text then the novel will hold an entirely different meaning to you. Hamid used heavy sybolism to convey meanings and themes that are better not said outright, and overall altered the impression the novel leaft. While reading The Reluctant Fundamentalist it became apperant that Changez’s love interest Erica symbolized America. Besides the obvious that Erica is the last five letters of America, there were multiple parallels in the story Hamid built for Erica and the way he portrayed America.When Changez first met Erica he says, â€Å"She had a presence †¦a naturalist would likely have compared her to a lioness: strong, sleek, and invariably surrounded by her pride†(22). Changez also comments of the pride America shows with, â€Å"stickers of flags adorned windshields and windows; large flags fluttered from buildings. They all seemed to proclaim: We are America†¦the mightiest civilization the world has ever known. †(79). Akin to America after 9/11, Erica seemed to be, â€Å"utterly detached, lost in a world of her own†¦ she was struggling against a current that pulled her within herself†(86).Similarly after 9/11 Changez felt that America, â€Å"retreated into myths of your own difference, assumptions of your own superiority†(168). The grief that Erica felt over the loss of Chris was representative of the grief America felt after 9/11 and how that prevented both Erica and America from moving on and accepting Changez. When Changez goes to see Erica at her clinic he is told by a nurse that, â€Å"It did not matter that the person Erica was in love with was deceased; for Erica he was alive enough, and that was the problem. †(133) America, too, was increasingly giving itself over to a dangerous nostalgia,† he claimed that he, â€Å"had always thought of America as a nation that looked forward; for the first time I was stuck by its determination to look back. †(115) The grief that Erica felt over the loss of Chris was representative of the grief America felt after 9/11 and how that prevented both Erica and America from moving on and accepting Changez. When Changez goes to see Erica at her clinic he is told by a nurse that, â€Å"It did not matter that the person Erica was in love with was deceased; for Erica he was alive enough, and that was the problem. (133) If Erica represents America and their in ability to move on from their grief, then Chris is a symbol for 9/11. When Changez goes to visit Erica in the clinic,the nurse he meets when he first enters tells him that, â€Å"It did not matter that the person Erica was in love with was This was included to show Cahngez’s changing relationship with America and an alternative way to show how America is broken and how because of America’s tendency to look back, and hold on to the past prevented America fro building relationships with outher countriesIf you did not connect that Erica was America you might hink that this was about a Pakistany that came to American and wound up hating and criticisming it until he left. In reality it was about a man, or boy rather, that had big dreams of his life in America, ones that seemed to be coming true. But just as Erica could not let go of the past, America couldn’t let go of the hatred and fear they held for those who seemed un-American.

The Social Organization of Singapore

My research will be based on Political, Economic, and Social Organization of Singapore—an industrialist city-state. Even though Singapore's history dates from the 11th century, the island was little known to the West until the 19th century. Singapore is one of the World's largest ports, because the city of Singapore has become a major port, with trade exceeding that of Malaya's, Malacca and Penang combined. The opening of the Suez Canal in 1869 and the advent of steamships launched an era of prosperity for Singapore as transit trade expanded throughout Southeast Asia (Bureau of East Asian and Pacific Affairs, 2010). Singapore is a very multicultural country, but education through social studies has brought the country into a social cohesive unit (Ho, 2009). Singapore is a Republic—a one-house Parliament makes the county’s laws. A prime minister leads a Cabinet, which carries out the operations of the Government. The ruling political party in Singapore, reelected continuously since 1959, is the People's Action Party (PAP), headed by Prime Minister Lee Hsien Loong† (Bureau of East Asian and Pacific Affairs, 2010). The president (chief of state) previously exercised only ceremonial duties. As a result of 1991 constitutional changes, the president is now elected and exercises expanded powers over legislative appointments, government budgetary affairs, and internal security matters. The PAP believes that rationalism and expertise is the proper approach to social and economic problems that may arise (Bellows, 1985). The PAP has held the overwhelming majority of seats in Parliament since 1966, when the opposition Barisan Sosialis Party (Socialist Front), a left-wing group that split off from the PAP in 1961, resigned from Parliament, leaving the PAP as the sole representative party† (Bureau of East Asian and Pacific Affairs, 2010). â€Å"Singapore became independent in August 1965, and has had compulsory voting since the late 1950s (every Singaporean 21 years of age or older must vote). Between 1968 and October 1981, in four national parliamentary elections and innumerable by-elections, the PAP won every seat† (Bellows, 1985). The maximum term in Parliament is five years. The president appoints nominated members of Parliament from nominations by a special select committee. Nominated members of Parliament (NMPs) enjoy the same privileges as members of Parliament, but cannot vote on constitutional matters or expenditure of funds (Bureau of East Asian and Pacific Affairs, 2010). Members of Parliament serve only two-and-a-half-year terms. As stated above, the opening of the Suez Canal in 1869 and the advent of steamships launched an era of prosperity for Singapore as transit trade expanded throughout Southeast Asia (Bureau of East Asian and Pacific Affairs, 2010). Also, in the 20th century, the Automobile industry’s need for rubber and the packaging industry’s need for tin assisted Singapore in becoming one of the World’s major ports. Singapore’s location among major sea lanes, and its industrious population, is what gives this small country its economic importance (Bureau of East Asian and Pacific Affairs, 2010). â€Å"Upon independence in 1965, Singapore was faced with a lack of physical resources and a small domestic market. In response, the Singapore Government adopted a pro-business, pro-foreign investment, export-oriented economic policy framework, combined with state-directed investments in strategic government-owned corporations. Singapore's economic strategy proved a success, producing real growth that averaged 7. 8% from 1965 to 2009† (Bureau of East Asian and Pacific Affairs, 2010). In addition to this economic strategy, the end of the cold war brought about less tension between Asian counties, which brought the region into a more globalizing production process (Heng, 2006, pg. 2). In the 1980’s, Singapore entered into a growth triangle (GT) with Indonesia and Malaysia, also written as IMS-GT. This triangle would prove to be a good move for the three countries, but with free trade agreements (FTAs) and close economic partnerships (CEPs) coming onto the scene, the growth triangles introduced in the 80’s looked as if they may have competition in the economic realm, but GTs continue to be at the tip of the spear due to the cooperation between the three are still very productive for them all. With all three countries being relatively close together, costs are minimal. Not to mention, this export-oriented cooperation is still attractive to foreign trading (Heng, 2006, pg. 1). The pioneering GT in Southeast Asia is that of the IMS-GT, and its evolution is very much tied to the economic development of the Singapore economy (Toh & Low, 1993, Kakazu, 1997). There are five GT’s in existence and GT’s are highly regarded by the Association of Southeast Asian Nations (ASEAN). There were two major happenings that temporarily effected Singapore’s economy between 2001 and 2003—the worldwide electronics slump and the outbreak of Severe Acute Respiratory Syndrome (SARS). Both times, growth bounced back, by world demand for electronics, pharmaceuticals, other manufactured goods, and financial services. The return was mostly contributed to by the economies of its major trading partners—the United States, the European Union, Japan, and China, as well as expanding emerging markets such as India (Bureau of East Asian and Pacific Affairs, 2010). The next economic hit that Singapore would have to endure would not take place until 2008-2009. The hit was due to global financial crisis. Singapore had their worst two quarters in late 2008 and early 2009, but would bounce back quickly (Bureau of East Asian and Pacific Affairs, 2010). Manufacturing and services are the backbone of Singapore’s economy, producing 26% and 69. 3% of Singapore’s gross domestic product in 2009. Singapore’s manufacturing of electronics accounts for 31. 5%, while chemicals account for 27% of the country’s manufacturing output. The government also approved the development of two casinos in Singapore, in May 2005, to facilitate new life in tourism. The investment produced more than $5 billion U.  S. dollars. Las Vegas Sands’ Marina Bay Sands and Resort opened in April 2010 and Genting International’s Resort World Sentosa opened in February 2010 (Bureau of East Asian and Pacific Affairs, 2010). Lee Kuan Yew once said, â€Å"A casino in the city state was possible, only over my dead body. † Now, with the extra income to the economy, he seemed to have warmed up to the casinos. April 27, 2010, the opening of the Las Vegas Sands’ was published in USA Today and quoted as saying, â€Å"Singapore’s second casino-resort opened Tuesday, a massive $5. billion project by Las Vegas Sands Corp. that aims to makeover the city-state as a Southeast Asian gambling and tourism magnet† Singapore is continuing to grow economically as stated by the Bureau of East Asian and Pacific Affairs, â€Å"The government is actively negotiating eight free trade agreements (FTAs) with emerging economic partners and has already concluded 18 FTAs with many of its key trade partner s, including one with the United States that came into force January 1, 2004. As a member of the Association f Southeast Asian Nations (ASEAN), Singapore is part of the ASEAN Free Trade Area (AFTA), and is signatory to ASEAN FTAs with China, Korea, Japan, India, and a joint agreement with New Zealand and Australia. Singapore is also a party to the Transpacific Strategic Economic Partnership Agreement, which includes Brunei, Chile, and New Zealand† (Bureau of East Asian and Pacific Affairs, 2010). Singapore was a small society open to influence from the west through the English language and subject to homogenizing effects of modernization and industrialization. Ethnicity was not assured as a fundamental element (Unknown, n. d. ). Singapore, as stated by the Bureau of East Asian and Pacific Affairs, is one of the most densely populated countries in the world. The annual population growth rate for 2009 was 3. 1%, including resident foreigners. Singapore has a diversity of linguistic, cultural, and religious backgrounds. Malay being the national language, but Chinese, English, and Tamil are also recognized as official languages. English is utilized in administration, professions, business, and schools (Bureau of East Asian and Pacific Affairs, 2010). English is mandated as the primary language by the Singapore Government to be used at all levels in schools. The government is said to provide at least ten years of education in English for every child (Bureau of East Asian and Pacific Affairs, 2010). I have personally experienced this to be quite true. I have been to Singapore on three different occasions during my Naval career, and there is a surprisingly amount of people in Singapore that speak very good English. Ordering food at a restaurant in Singapore proved to be much easier than expected. Another surprising fact is that the literacy rate in Singapore is 96. 3% (Bureau of East Asian and Pacific Affairs, 2010). A touchy subject in Singapore is the terms race and ethnicity. While 77% of the country’s population is Chinese, all Singaporeans are assigned a â€Å"race† at birth (determined by the father’s race), and this is indicated on an official identification card (Ho, 2009). The Singapore Department of statistics assigns the same meaning to both race and ethnicity and states the term ethnic group refers to a person’s race (Ho, 2009). The Singapore constitution also contains provisions that prohibit discrimination and guarantee protection to minorities, including articles 12, 16, and 152 (Tan, 2004). Singapore has diversity in ethnicity when it comes to religion. Singapore allows freedom of religion for the most part, but religion is subject to government view. Thus, some religions have been banned or restricted. â€Å"Almost all Malays are Muslim; other Singaporeans are Taoists, Buddhists, Confucianists, Christians, Hindus, or Sikhs† (Bureau of East Asian and Pacific Affairs, 2010). The Buddhism is prominently displayed through Buddhist temples throughout Singapore. I actually saw many of these temples in my travels to Singapore. Some of these temples are very extravagant works of art. You may also see the diversity among Singaporeans if you are visiting during National Holidays. The people of Singapore will display their different cultures through dance and cultural clothing all across the country. The Singapore government experienced a loss of cohesiveness due to this multicultural social organization. The Government introduced Social Studies into the educational system in order to bring cohesiveness back into the country. The social studies curriculum was introduced, in 2001, to secondary educational levels—students from fifteen to seventeen years old. It is designed to allow students to grasp an understanding of Singapore’s geopolitical situation, including its strengths and vulnerabilities (Ho, 2009). This curriculum brings to light the differences in this culturally diverse country. This in turn brings the different people of Singapore together, thus encouraging social cohesiveness. Singapore has risen to every challenge that has come her way. Singapore has grown politically, economically, and socially with minimal negative results. Politically, the PAP remains the leader in the government. Realizing the need for economic growth, the PAP has always stood by industrialization. The building of casinos in the city-state has shown a remarkable ability to tap into tourism. Singapore remains at the head of the spear in terms of global trade. The social organization will continue to strengthen with education of youth. This fact has been recognized—education of the next generation will lead to political, economic and social success. â€Å"Economic, social, and political development requires autonomy and creativity as well as an effective, interventionist government staffed by a highly qualified and dedicated civil service. Singapore has come closer to achieving this mix than most other third World countries. There is much that other developing countries could adopt from the Singapore experience† (Bellows, 1985).

Essay On Web Development Trends - 724 Words

12 Web Development Trends You Must Know About in 2016 Arpatech Sep 05, 2016 12Web-Development-Trends_You_Must_Know_About_in_2016 The world of Web development is a rapidly changing domain. 2016 brought some of the hottest trends which you should be aware of if you are part of the web development community. You should follow these trends while designing and developing your website to maintain your position in the web market throughout this year. With new frameworks, evolving technologies and new layouts everything plays a critical role in attracting customers to your web page. Let’s look at some of the hottest trends... 1) IOT (Internet of Things) Much of the development in the app world is the result of IOT and it continued to grow†¦show more content†¦The increased use of this trend is observed as it enables users to jump to full-screen resolutions in an auxiliary natural way. 6) Adds blockers on the sites A huge amount of money the website owners are losing due to advertisement blocking plugins. Many techniques have been developed which enable websites owners to avoid these growing effects. These new techniques happen to reduce the effects of advertisement blocking. 7) Containers Usage To run, create and test an app swiftly Docker, a container service is used by the developers. A lot of advanced changes are making containers go huge this year. Docker is believed to evolve and gain more features and security. 8) Ultimate Browser Power Throughout the past few years, some major developments have been observed in the trend of things which the user can do with the browser. JavaScript is acknowledged as the browser’s de-facto language, making the browser more powerful than ever before. It stands out as the most powerful language for the year 2016. 9) IDEs These days more people are turning towards cloud-based versions of IDEs instead of using the traditional development environment. The key factors of IDE include fast accessibility and flexibility which is provided full-time even if you are not using it. 10) Enhanced Security As users add different apps to their mobile devices the higher the risk becomes of the device getting prone to security breaches. The increase in the efforts to makeShow MoreRelatedEssay On Web Development Trends1626 Words   |  7 PagesHow web development trends will change by 2020? 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