analysis of klinefelters syndrome

analysis of klinefelters syndrome Many chromosomal abnormalities occur early in development and involve the sex chromosomes. Klinefelters Syndrome falls directly into this category. Klinefelters Syndrome is a genetic condition affecting the male population. The following information observes who discovered Klinefelters Syndrome and when it was first diagnosed. The etiology or genetic and environmental factors of the condition are discussed as well as complete description of the disability and the clear diagnostic criteria. The affects of Klinefelters Syndrome are more recognized in adulthood, when it is typically diagnosed. Many Klinefelters patients live out their entire lives without ever knowing they have the condition. Upon conclusion, there should be an adequate amount of information that will give you, the reader, valuable knowledge into the diagnosis and treatment of Klinefelters Syndrome. History Klinefelters Syndrome was first diagnosed in 1942 at the Massachusetts General Hospital in Boston Massachusetts (Schoenstadt, 2006). Dr. Harry Klinefelter was completing his fellowship at the Massachusetts General Hospital when he was assigned to work with Dr. Fuller Albright, also known as the father of endocrinology (Bock, 1993; Klinefelter Syndrome, 2006). Dr. Klinefelter came to examine nine adult men that had a common set of symptoms during the course of his fellowship (Klinefelter Syndrome, 2006). Dr. Klinefelter organized a case study that involved these nine men and their similarities and was encouraged by Dr. Albright to lead the study (Klinefelter Synrome, 2006). The Journal of Clinical Endocrinology was published in November of 1942 with the completed case study of these nine mens similar qualities, which Dr. Klinefelter identified as Klinefelters Syndrome (Klinefelter Syndrome, 2006). The report written by Dr. Klinefelter on these men described them as having testicular dysgenesis, elevated urinary gonadotropins, eunuchoidism, azoospermia, and gynecomastia, all of which have an effect on the underdeveloped size of the testes, the lack of the amount of testosterone produced by the testes, and infertility (Schoenstadt, 2006; Visootsak Graham, 2006). These adult males also exhibit enlarged breast and sparse facial hair (Schoenstadt, 2006). Two groups found out fourteen years after Dr. Klinefelters original description of the syndrome, that the buccal mucosal cells contained an extra chromatin mass or that the cells were chromatin positive (Klinefelter, 1966). Although the patients were described as having a positive female sex chromatin, Dr. Klinefelter states that the patients are phenotypic males and should never be considered otherwise (Klinefelter, 1996). Fourteen years after Dr. Klinefelter first diagnosed Klinefelters Syndrome, another case study was performed to further understand the characteristics that define the condition (Klinefelter Syndrome, 2006). In 1956, Dr. Joe Hin Tjio and Dr. Albert Lavan took the research further to determine the factors that made those men with Klinefelters Syndrome dissimilar from normal adult males through genetic research (Klinefelter Syndrome, 2006; Schoenstadt, 2006). With the advanced experimental methodology available, Dr. Joe Hin Tjio and Dr. Albert Lavan found that humans had 23 pairs of chromosomes, confirming 46 chromosomes, which prior to this time there was thought to be 48 chromosomes (Bock, 1993; Klinefelter Syndrome, 2006). This clarification by Dr. Tjio and Dr. Lavan is the basic foundation for modern cytogenetics, the study of chromosomes and diseases originating from numerical or structural abnormalities in chromosomes (Klinefelter Syndrome, 2006). Dr. Tjio and Dr. Lavan discovered that men with symptoms of Klinefelters Syndrome had an extra sex chromosome that created the chromosomal arrangement of XXY, which is distinct to the normal male chromosomal arrangement of XY (Klinefelter Syndrome, 2006; Schoenstadt, 2006,). Klinefelter Syndrome was still believed to be an endocrine disorder of unknown etiology at this time (Visootsak Graham, 2006). In 1959, just three years after Dr. Tjio and Dr. Lavan made their historical discoveries, an English researcher by the name of Dr. Patricia Jacobs and her associate Dr. J. A. Strong published a study supplementing earlier studies (Klinefelter Syndrome, 2006; Noble, 2003). Dr. Jacobs and Dr. Strong found the link between the endocrinal disease and the extra X sex chromosome (Noble, 2003). Dr. Jacobs linked forty-seven chromosomes in Klinefelters Syndrome males and determined it to be the X chromosome, which she considered an aneuploidy defined as an unusual number of chromosomes and labeled 47, XXY (Bock, 1993; Klinefelter Syndrome, 2006; Schoenstadt, 2006). The 1970s brought forth a larger examination of males born with Klinefelters Syndrome (Bock, 1993). During this time doctors began screening newborn male babies for the extra chromosome (Bock, 1993; Visootsak Graham, 2006). The most significant of the studies done at this time was sponsored by the National Institute of Child Health and Human Development (NICHD) whom examined over forty thousand infants for this extra chromosome (Bock, 1993; Visootsak Graham, 2006). This study was important for the reason that most studies done prior to the 1970s were biased and primarily done on adult males in mental institutions and the penal system (Visootsak Graham, 2006). At this time is when the prevalence of Klinefelters Syndrome was noticed as frequently as one in five hundred to one in one thousand male newborns (Bock, 1993; Visootsak Graham, 2006). Also observed in this study was the reduction in speech and language abilities as well as decreased reading and spelling achievement (Bock, 1993; Visootsak Graham, 2006). Along with these disabilities, Klinefelters patients are characterized by an increased tendency towards fertility, endocrinal, and psychiatric disorders (Noble, 2003). This study demonstrated that most but not all of these males born with the extra chromosome will have these characteristics, and many demonstrate varying degrees of the characteristics (Bock, 1993; Visootsak Graham, 2006). Based on this research it has been found that the extra X chromosome that causes Klinefelters Syndrome is very common, however, the symptoms and characteristics that are most recognizable are quit uncommon (B ock, 1993). Most males are not diagnosed as having Klinefelters Syndrome until they reach adulthood, and many that have the syndrome are never diagnosed as having this chromosomal defect at all (Bock, 1993). One pediatrician at the University of Colorado Medical School in Denver and the director of the National Institute of Child Health and Human Development (NICHD) during the major screening research referred to these newborn males as not having Klinefelters Syndrome because of the possibility that the characteristics may not develop into a syndrome (Bock, 1993; Visootsak Graham, 2006). Etiology and Genetic Factors Every normal human cell has 46 chromosomes that are made up of 23 pairs (Stewart, 2007). Of these 23 pairs, there are 22 that are exactly the same in both males and females called autosomes (U.S. National Library of Medicine, 2010). The 23rd pair of sex chromosomes is what makes males and females different in that the male will have only one X and Y chromosome whereas the female will have two copies of the X chromosome (Stewart, 2007; U.S. National Library of Medicine, 2010). During the formation of the egg and the sperm, or gametes, the chromosomes are halved through a process called meiosis (Stewart, 2007; The Dorsey, 2009). Cells that carry a single chromosome such as the X or Y chromosome are called haploid cells (The Dorsey, 2009). When the egg and sperm join carrying 23 chromosomes each they create the fertile egg, or zygote, which has two haploid sets of chromosomes (The Dorsey, 2009). Therefore, the baby receives two copies of each chromosome, 46 total chromosomes, just like the parents (Stewart, 2007). The extra X in Klinefelter Syndrome is caused from either nondisjunction or anaphase lag. Nondisjunction occurs when the chromosome pairs do not separate as they are intended in the meiosis I or meiosis II stage (Pineyard Zipf, 2003; Stewart, 2007). When this happens there may be a chromosome pair with 24 chromosomes instead of the 23 chromosomes (Stewart, 2007). If this chromosome pair of 24 joins with an egg or sperm with 23 chromosomes then it results in a karotype with 47 chromosomes (Stewart, 2007). In this case there will be three copies of chromosomes rather than the usual two copies of chromosomes (Stewart, 2007). The sperm or egg may donate the extra X chromosome at conception causing a chromosomal abnormality (Mayo Foundation for Medical Education and Research, 2008; Stewart, 2007). This forms the XXY chromosomal formation, which is diagnosed as Klinefelters Syndrome. At least half of 47, XXY conceptions are spontaneously aborted (Pineyard Zipf, 2003). The chromosomal abnormality is random and not known to be caused by any environmental factors (Genetic Science Learning Center, 2010; Mayo Foundation for Medical Education and Research, 2008; National Institute of Health, 2007). This anomaly happens entirely by chance and is unrelated to family history prior to the male childs birth (Mayo Foundation for Medical Education and Research, 2008). This is to say that the male embryos likelihood of being born with Klinefelters Syndrome is not increased or decreased by what the parent does or does not do (Mayo Foundation for Medical Education and Research, 2008). Klinefelters Syndrome is not affected by race (Chen, 2010). This is a completely random occurrence of the sex chromosomes not successfully separating during the formation of the egg or the sperm (Genetic Science Learning Center, 2010). Once this occurs the extra chromosome is then copied into every cell of the embryo (Genetics Science Learning Center, 2008). There are extremely rare cases when there may be three or four extra X chromosomes in all copies of the cells known as 48,XXXY or 49, XXXXY (Stewart, 2007). The 49, XXXXY mosaic is also known as Fraccaros Syndrome and is the most rare form of Klinefelters Syndrome (Duenas et al., 2007). This rare chromosomal abnormality results in more exaggerated features of Klinefelters Syndrome (Stewart, 2007). There are instances where an extra X chromosome is found in only some of the cells (Stewart, 2007). This can be found as two different chromosomal patterns (Stewart, 2007). One pattern occurs when some cells have 46 chromosomes and some have 47 chromosomes (Stewart, 2007). The other pattern is called the mosaic XXY syndrome, or chromosomal mosaicism, and affects approximately six percent of these cases, with the most rare cases being the 48, XXXY or the 49, XXXXY, or other arrangements of X chromosomes (Stewart, 2007). The mosaic XXY syndrome occurs only after conception from a mistake in cell division (Stewart, 2007). Anaphase lag is a result of a gamete lacking a sex chromosome (Klinefelter, 1966). When this chromosome lags it is not incorporated into the new cell during the mitosis stage (Kinefelter, 1996). Anaphase lag is thought to be a reason for the mosaic variations of Klinefelters Syndrome (Klinefelter, 1966). Although the chromosomal abnormality of 49, XXXXY is considered to be a variant form of Klinefelters Syndrome, it appears to have a very independent, distinct phenotype (Duenas et al., 2007). Males that show the 49, XXXXY chromosomal structure have much more severe clinical features than that of a Klinefelters Syndrome male (Duenas et al., 2007). This is the most rare of the Klinefelters Syndrome variants and has been reported in over one hundred cases with the frequency being approximately 1 in 85,000 newborn males (Duenas et al., 2007). There have been reports of an even more extreme variant of Klinefelters Syndrome mosaic in newborn males (Duenas et al., 2007). This variant is a 47, XXY/48, XXXY/49, XXXXY mosaicism and has only been reported in three cases according to a researcher in Mexico (Duenas et al., 2007). This means that the male newborn would have the whole spectrum of XY variations. Another variant that affects only males is the 46, XX chromosomal variation (Bock, 1993). This condition occurs when individuals have two X chromosomes in each cell, but are male in appearance. These individuals have male external geniltalia. These individuals also have small, undescended testes possibly along with an urethra opening on the underside of the penis. A small amount of 46, XX Males have external geniltalia that dont clearly resemble either male or female genitalia. These individuals are typically raised male. Phenotypically, there are three groups of these sex-reversed individuals. The first group includes phenotypically normal XX Males, the second group includes the males with genital ambiguities, and the third group is the true hermaphrodites (Bock, 1993). Description of Characteristics or Traits Klinefelters Syndrome has only one constant physical description and that is the small testicular size (Visootsak Graham, 2003). Boys with Klinefelters Syndrome have variable phenotypic characteristics with no obvious facial dysmorphology (Visootsak Graham, 2003). The presence of gynconemastia, or enlarged breast, and other findings of eunuchoid body habits and sparse body hair vary (Visootsak Graham, 2003). Eunuchoid or eunuchoidism is defined as an abnormal condition in males, characterized by underdeveloped reproductive organs with some female characteristics, such as a higher voice or the lack of facial and body hair that results in the lack of male sex hormones (Eunuchoidism, n.d.). Gonadotropins are produced by glands, such as the pituitary, and can result in sparse body hair when not produced adequately (Gonadotropin, 2010). The medical dictionary states that eunuchoidism is marked by a deficiency of sexual development with the persistence of prepubertal characteristics, and often has the presence of characteristics that are typical of the opposite sex (Eunuchoidism, n.d.). Another likely characteristic is azoospermia (Schoenstadt, 2006; Visootsak Graham, 2006). Azoospermia is defined as having little or no sperm count (Azoospermia, 2010). Testicular dysgenesis, or gonadal dysgenesis, is another characteristic of Klinefelters Syndrome (Schoenstadt, 2006; Visootsak Graham, 2006). Testicular dysgenesis is considered a reproductive system developmental disorder that causes a progressive loss of primordial germ cells, or cells that create gametes, in the developing gonads of an embryo (Gonadal dysgenesis, 2010). This gonadal dysgenesis can lead to the extremely hypoplastic, or underdeveloped, and disfunctioning gonads mainly composed of fibrous tissues (Gonadal dysgenesis, 2010). Most infants and children with the 47, XXXY chromosomal abnormalities go through normal growth stages. It is not until puberty that the Klinefelters Syndrome characteristics or traits become more prevalent and noticeable (Visootsak Graham, 2003). There is a significant increase in height between the ages of five and eight (Visootsak Graham, 2003). Another characteristic of Klinefelters Syndrome is the elongated length of arms and legs (Klinefelter, 1966). There is a decrease in androgen production that causes the secondary sexual characteristics to not fully develop (Visootsak Graham, 2003). An androgen is any substance such as androsterone or testosterone that supports male characteristics (Androgen, n.d.). Typically Klinefelters males are infertile (Visootsak Graham, 2003). However, there have been cases of impregnation without the assistance of medical technology (Visootsak Graham, 2003). Autoimmune diseases such as juvenile arthritis can also be present in Klinefelters adolescents. Whereas boys with Klinefelters Syndrome are generally tall with long limbs and remain thin until puberty, they tend to suffer from obesity latter in life. Neurocognitive effects of Klinefelters Syndrome may be more subtle than that of the physical stigmata. Klinefelters males have been found to have relative deficits on verbal IQ subtests and have verbal IQ scores around 20 points lower than those of unaffected siblings. There are also deficits in articulation, word finding, phonemic processing, verbal memory, language comprehension, oral expression problems, as well as linguistic processing speed. It seems that the speech/language problems and some motor deficits are most common in Klinefelters males that have an extra X chromosome. Ninety-two percent of individuals with Klinefelters Syndrome confirm difficulty learning to read. Seventy percent had reading achievement discrepancies or absolute reading deficits on standardized testing. A group of boys with mental retardation and suspicion of fragile X were subject to a genetic screening and the results showed that eight of these boys had Klinefelters Syndrome. Most of the more extreme verbal, visuospatial, and motor skills, such as found in mental retardation and fragile X syndrome are typically spa red. However, some boys with Klinefelters Syndrome suffer from poor manual dexterity and are commonly found to be clumsy and below average in sports (Wodrich Tarbox, 2008). There are many different factors that may underlie linguistic and reading problems. One possibility is a dysfunction of the left hemisphere that may be related to diminished gray matter or a lack of hemispheric asymmetry, or both. It is also possible that executive and frontal deficits may be a cause (Wodrich Tarbox). There is evidence that language is a fundamental issue for Klinefelters children and this can result in further scholastic issues. This problem seems to manifest as dyslexia as defined by poor reading in the setting of normal intelligence. Klinefelters males have also been observed to have difficulties with arithmetical functions. The deficits in auditory processing and verbal memory are the two key cognitive processes that underlie these difficulties. These deficits are also true for normal chromosomal children with dyslexia. The findings are supportive of the concept that defects in frontal systems seem to be caused by a language-based, left frontal-systems problem (Geschwind Dykens, 2004). Adult Klinefelters males have reported to have difficulties with mental flexibility (Wodrich Dykens, 2004). Even with these studies, it should be noted that not all adults that have Klinefelters Syndrome show these classic patterns of verbal deficits that are observed in children (Geschwind Dykens, 2004). However, these findings are not appropriate for all Klinefelters males, many of which complete high school and move on to post-secondary education successfully (Wodrich Tarbox, 2008). Two characteristics that has been falsely associated with Klinefelters males in the past, is sociopathy and criminal behavior. There is, contrary to this belief, fewer psychiatric problems reported among these individuals. However, there are commonly traits of introversion, unassertiveness, and a paucity or lack of ambition. There are also possible traits of impulsivity and social inappropriateness (Wodrich Tarbox, 2008). A Reiss Profile of Fundamental Goals measurement was used to assess the degrees of which Klinefelters males were motivated in 15 domains (Geschwind Dykens, 2004). The Reiss Profile generates a profile that is based on the motivational sensitivities across the domains of aversive sensations, citizenship, family, curiosity, honor, independence, food, order, physical exercise, rejection, power, sex, social contact, vengeance, and social prestige. The Reiss Profile is a well-established psychometric measure that is being used more and more to assess people with and without mental retardation (Geschwind Dykes, 2004). The results suggested that the Klinefelters male group was not particularly motivated by the need for social prestige, independence, or the desire to seek vengeance. This group was also not motivated to avoid physical pain. The general motivator for all the Klinefelters males in this group was curiosity. There were no age effects to this study (Geschwind Dykes, 2004). Characteristics in Adulthood There is a persistent deficiency of androgen in adulthood that can result in the loss of libido, decreased muscle bulk and tone, decreased bone density, a propensity for thromboembolism (an obstruction in a vein or artery from a blood clot), and an increased risk of mortality from cardiovascular and diabetic complications. A common characteristic for Klinefelters adults is gynecomastia (Wattendorf Muenke, 2005). Gynecomastia involves the risk of developing breast carcinoma. There is 200 times more of a risk for Klinefelters males to develop breast carcinoma than other karyotypically normal individuals. This may be a result of the estradiol (the prominant sex hormone in females) to testosterone ratio being so much higher that karyotypically normal men. Another possibility is that it is caused by the increase of peripheral conversion of testosterone to estradiol (Visootsak Graham, 2006). There are different views as to whether Klinefelters adult males are more aggressive or have a greater chance of psychological issues depending on the resource. One study describes the differences as relative to individual testosterone levels and the age at which they received the diagnosis (Morris, Jackson, Hancock, 2009). Equally, there is an impact from the way the diagnosis is reacted to by the Klinefelters male, the family, and friends or peers. The seven major themes that emerged from this study were the diagnosis, the testosterone treatments, health care problems, appearance, self-identity, relationships, and school and education. Of the Klinefelters adults studied, 60 % reported clinical levels of anxiety and 34% had clinical levels of depression. The results of this study show that a prolonged lack of testosterone can have far reaching negative effects on the Klinefelters adult (Morris, Jackson, Hancock, 2009). The historical studies show a disturbingly increased risk for psychiatric disturbance, criminality, and mental retardation. However, these results are outdated and extremely questionable given the initial examinations were given to institutionalized populations (Chen, 2010). Differential Diagnosis Classic Klinefelters Syndrome, 47, XXY, cases make up approximately 80-90% of all Klinefelters diagnosis. There are approximately 6-10% of these cases that are mosaics, which are the cells with 46, XY/47, XXY; 46, XY/48, XXXY; and 47, XXXY/48, XXXY (Chen, 2010; Visootsak Graham, 2003; Visootsak Graham, 2006). In 5% of the cases there are two X chromosomes without a Y chromosome or 46, XX (Visootsak Graham, 2006). The other cases were karyotypes 48, XXXY, 48, XXYY, 49, XXXXY, and 49, XXXYY (Visootsak Graham, 2003). Approximately 1% of these cases are due to a structurally abnormal X with a normal X and Y chromosome described as kayotypes 47, X,i(Xq)Y and 47, X,del(X)Y (Chen, 2010). Klinefelters Syndrome variants occur much less frequently than the classic 47, XXY chromosomal abnormality (Bock, 1993; Visootsak Graham, 2006). Klinefelter variant 48, XXXY is characterized by being average or tall stature with ocular hyperterlorism, which are widely spaced or deep set eyes; flat nasal bridge; curving of the fifth finger, or clinodactyly. Other characteristics are small penis and testicles with hypergonadotropic hypogonadism, which is the absence or decrease in function of the male testes. Theses individuals intelligence quotients range from 40-60. Variant 48, XXYY is characterized by having a tall stature, an eunuchoid habitus with long legs, sparse body hair, small testicles and penis, hypergonadotropic hypogonadism and gynecomastia. These individuals intelligence quotients range from 60-80. Males with variant 49, XXXXY are severely affected. They have smaller than average head circumference also known as microcephaly, short stature with ocular hypertelorism, flat nasal bridge, and upslanting palpebral fissures. Cleft palates are present along with small geniltalia and a heart defect known as patent ductus arteriosus. These individuals intelligence quotients range from 20-60. (Visootsak and Graham, 2003). Klinefelters Syndrome 47, XXY, has no major physical signs, which explains why it may go undiagnosed or misdiagnosed throughout an individuals life. Also with no physical signs, it is truly only diagnosed when genetic testing occurs for a variety of unrelated reasons. Klinefelters Syndrome may be diagnosed prenatally or during early childhood, as an adolescent during puberty, or as an adult when there are recognized fertility problems (Bock, 1993). Klinefelters Syndrome can be diagnosed prenatally through amniocentesis or chorionic villus sampling (Bock, 1993). These tests are normally done if the pregnant woman is older than 35, if there is a family history of genetic defects, or when other medical indications exist (Bock, 1993). A pediatrician may suspect a male child as having Klinefelters Syndrome if there are delays in learning to talk or difficulties in reading and writing as well as physical abnormalities during adolescence (Bock, 1993). Treatments and Interventions All hope is not lost when it comes to the treatment and interventions of the undesirable traits and characteristics that males diagnosed with Klinefelters Syndrome may display or develop. It is recommended that Klinefelters males have a comprehensive neurodevelopmental evaluation as soon as they have been diagnosed. A multidisciplinary developmental evaluation can determine the appropriate treatments during infancy and early childhood. These treatments may include physical therapy, infant simulation programs, and speech therapy (Wattendorf, 2005). If the language difficulties are detected in childhood, then there is more of a possibility for intervention. The language barriers that Klinefelters males may have to cope with can not only affect their academics, it can obstruct their building of social relationships and learning social skills necessary for these relationships. Here is where the Klinefelters child could benefit from a social skills training program. In a social skills training program, the Klinefelters child will be able to practice talking and listening, observing childrens making friends processes, sharing of information, attitudes, and beliefs. This will also assist them in proper classroom behavior and playground behavior. Language disabilities and barriers can prevent Klinefelters males from fitting in socially, so this kind of intervention and assistance can benefit the child greatly. Hearing can be an issue if frequent ear infections occur. Hearing test and screens should be done to ensure that a hearing impairment is not a part of the language difficulties. If the Klinefelters child is not communicating effectively with single words by the ages of 18 to 24 months, then consultation with a speech and language pathologist will be very beneficial (Klinefelter Syndrome Information, 2002). Teachers should be informed of the difficulties that a Klinefelters child may be dealing with in the classroom. A teacher may consider the Klinefelters child to be lazy and daydreaming and a teacher may even forget the child is even in the room. This can result in the Klinefelters child falling behind and eventually being held back a grade. Under the Public Law 94-142, the Individuals with Disabilities Education Act, adopted by Congress in 1975, all children with disabilities have a right to a free, and appropriate public education (Klinefelter Syndrome Information, 2002). Once the Klinefelters male reaches puberty there is usually an inability to produce a normal amount of testosterone. This along with hypogonadism can result in impaired bone mineral density and skeletal muscle development. Also associated with testosterone deficiency is a decrease in libido and energy (Wattendorf Muenke, 2005). Androgen therapy or Testosterone Treatment should begin by time the Klinefelters male reaches middle school, approximately 12 to 14 years of age, based on the level of pubertal development (Klinefelter Syndrome Information, 2002; Wattendorf Muenke, 2005). Testosterone Treatment will ultimately increase the muscle size and strength, as well as, promoting the growth of body and facial hair. It must be noted that Testosterone Treatments can also bring on psychological changes. It is important to adequately inform the parent(s) and the child of these changes so that they can make the most informed decision (Klinefelter Syndrome Information, 2002). There are diff erent ways to receive Testosterone Treatment and that is through injections, transdermal (patches, gels, or creams), orally, or implantation. The kind of testosterone injection will depend mainly on the dosage used and the country in which you receive the injections. Some injectable testosterone esters are Testosterone enanthate, Testosterone cypionate, Sustanon, Testosterone propionate, Testosterone phenylpropionate, Omnadren, and Aqueous testosterone suspension. Types of transdermal patches are Androderm and Testosterone TTS. Two different kinds of testosterone gels and creams are Androgel, and Testim. A few oral supplements include Methyltestosterone and Testosterone undecanoate. The last form of Testosterone Treatment is the Subcutaneous testosterone pellet, which is delivered by implanting a pellet of pure, crystalline testosterone under the skin of the buttocks or abdomen (Testosterone Types and Delivery, n.d.). Adult males with Klinefelters Syndrome usually develop gynecomastia which predisposes men to breast cancer. Therefore, it is important that Klinefelters males do monthly breast examinations. If gynecomastia causes psychological or physical problems, then possible treatment would be cosmetic surgery to remove the breast tissue (Wattendorf Muenke, 2005). Swerdlow et. al (2005) stated that men with Klinefelter Syndrome have elevated risks of several cancers. Prostate cancer, along with breast cancer was more prevalent. Men with Klinefelter Syndrome are also at a substantially higher risk for non-Hodgkin lymphoma, and possibly lung cancer. Breast cancer risk is higher in 47, XXY mosaics. Adult males may face possible infertility issues due to the lack of testosterone production, but if diagnosed early on, this can be minimized and they will be able to reproduce without outside assistance. Summary Klinefelter Syndrome is one of the more recently discovered medical syndromes. Klinefelter Syndrome is not one that causes major dysfunctions and is usually only discovered during genetic testing for infertility or during prenatal testing due to maternal age or prior genetic issues within the family. Because Klinefelter Syndrome has not had a lot of research until the last few years, there is no federal funding set aside for this syndrome. Families with sons that are found to be affected by it have no real support system that is knowledgeable of this syndrome and have to research on their own and create resources to fit their situation as none are available in most areas.

Studies Related To Dementia And Caregivers Burden Nursing Essay

Studies Related To Dementia And Caregivers Burden Nursing Essay The literature review was based on extensive survey of books, journals and international nursing studies. A review of literature relevant to the study was undertaken which helped the investigator to develop insight into the problem and gain information on what has been done in the past. An extensive review of literature was done by the investigator to lay a broad foundation for the study and a conceptual framework based on Wiedenbachs Helping Art Clinical Nursing Theory to proceed with the study under the following headings. For the purpose of logical sequence the chapter was divided into the following sections: 2.1 Section A: Studies related to dementia and caregivers burden of clients with dementia. 2.2 Section B: Studies related to psychological interventions on level of burden among caregivers of clients with dementia. SECTION A: STUDIES RELATED TO DEMENTIA AND CAREGIVERS BURDEN Harrison BE (2012) conducted a study to identify the evidence of factors influencing dementia related caregivers burden. 565 caregivers participated who were selected by purposive sampling technique. Caregivers Interview Schedule were given to the caregivers of clients with dementia. The findings of the study revealed that, many factors influence the impact of the caregiving experience such as gender, relationship to the patient, culture and personal characteristics. Hepworth JT (2012) conducted a cross -sectional study on burden experienced by caregivers of clients with dementia in Taiwan. 150 caregivers were participated from outpatient clinics of three hospitals by convenience sampling technique. The Caregiver Burden Inventory and Cost of Care Index Scale were used to assess the caregiver burden. The findings of the study revealed that 62% of caregivers had high level of burden. Rosenheck R (2012) conducted a cross sectional study on caregiver burden in dementia. 421 ambulatory outpatients with a diagnosis of dementia, those caregivers were participated as sample who were selected by convenient sampling technique. Burden Interview, caregiver distress scale, The Beck Depression Inventory Scales were administered. The findings of the study revealed that 80% of caregivers had severe behavioural disturbances, and psychiatric symptoms. Scheltens P (2012) conducted a epidemiological study on identifying a target group depression among caregivers of clients with dementia in Netherland. 725 caregivers participated who were selected by convenient sampling technique. Depression scale was administered to the caregivers. The findings of the study revealed that 72% caregivers had increased risk for depression and psychological distress. Steven H. Zarit (2012) conducted a longitudinal study to assess the subjective burden of husbands and wives in the care of clients with dementia. 1585 caregivers participated and selected by convenient sampling technique. Zarit Burden Assessment Scale was administered to caregivers of clients with dementia. The findings of the study revealed that among spouses, 65% of wives are having more burden than husbands. Christofoletti G (2011) conducted a cross sectional study to assess the neuropsychiatric disturbance of caregivers of clients with dementia and mental burden of their caregivers. 59 caregivers participated .Semi structured Burdren Interview Scale was used to assess the data. The result of the study revealed that 40% of caregivers had neuropsychiatric disturbance and mental burden. Papastavrou E (2011) conducted a descriptive study to investigate the burden experienced by families providing care to a relative with dementia in Cyprus. 172 caregivers are participated in the study. Convenient sampling technique was used. Data collected by using Burden Interview Scale, Behaviour Memory Problem Checklist, Depression Scale and Ways of Coping Questionnaire. The results showed that 68.02% of caregivers were highly burdened and 65% of caregivers exhibited depressive symptoms. Aizcorbeurrozc (2010) conducted a cross sectional study to evaluate the association between caregivers burden and psychological distress and to estimate the prevalence of mental disorder among the caregivers. 40 caregivers participated and assessed by Zarit Burden Scale and GHQ 28 to evaluate psychological distress. Convenient sampling technique was used. The result of the study showed that 80.7% of caregivers had high level of psychological distress. Ebenezer E, Prince MJ (2010) conducted a cross sectional study to examine selected factors of dementia patients and their caregivers that were associated with the burden of family caregivers. 225 caregivers participated in the study. Participants were selected by convenient sampling. Zarit Burden Interview Schedule was used to measure the caregivers burden. The result of the study showed that 78% of caregivers had high level of burdened because of informal support and ethnicity. Rinaldi P (2010) conducted a cross sectional study to investigate the burden perceived by caregivers of clients with dementia in different aspects of caregivers life and caregivers characteristics on its difference dimension in Italy. 419 caregivers participated. Caregivers burden inventory scale was used to quantify burden. The findings revealed that 80% of caregivers experienced that high level of anxiety and depression. Rothkopf M (2010) conducted a descriptive study to assess the distress and burden associated with sleep disturbance in dementia caregiver. 60 female caregivers participated through convenient sampling technique. Actigraphic Sleep Parameter and Burden Interview Schedule was used to measure the sleep and level of burden. The result of the study revealed that 98% of caregivers had depressive symptoms associated with poorer sleep efficiency. Williams C (2010) conducted a descriptive correlational study to identify the factors within marital relationships that increase risk of burden and depression in USA. 5 men and 11 women caregivers of clients with dementia participated. Zarit Burden Interview Schedule was used to measure the caregivers burden. The results showed that 74 % of spouses caregivers were overburdened and had depression. Anderson S (2009) conducted a cross-sectional study to examine association between caregivers burden and perceived health among caregivers of clients with dementia living at home in Netherland. 2238 samples participated. Caregivers Burden Scale was used to collect the data. The findings of the study revealed that the 84% of caregivers experienced moderate burden associated with isolation, disappointment and emotional involvement with perceived health. Elmstnhl S (2008) conducted a cross-sectional study to assess the financial burden and psychological distress among caregivers of clients with dementia in Sweden. 50 caregivers were participated. Burden Interview Schedule was used to assess the economic and social conditions. The study revealed that caregivers experienced total burden, strain and disappointment because of low income that leads to higher degree of burden. SECTION B: STUDIES RELATED TO PSYCHOLOGICAL INTERVENTIONS ON LEVEL OF BURDEN AMONG CAREGIVERS OF CLIENTS WITH DEMENTIA. Hauck WW (2011) conducted a prospective study to assess the Tailored Activity Program to reduce caregivers burden of clients with dementia. 60 caregivers were participated. Tailored Activity Program was given as an intervention for 4 months to reduce the caregivers burden. Zarit Burden Interview Schedule was used to assess the burden level. The findings of the study revealed that Tailored Activity program reduce the depression and anxiety among caregivers of dementia clients. Guetin S (2011) conducted a cross sectional study to assess the impact of music therapy on depression for caregivers of clients with dementia. 286 caregivers were participated. Hamilton Depression and Anxiety Scale, Zarit Burden Scale was used to assess the depression and burden level of caregivers of clients with dementia. 44 session music therapy was given to the caregivers. The findings of the study revealed that music therapy was reduced 80% of caregivers anxiety and depression. Jerimia Heinik (2011) conducted a cross sectional study to assess the effectiveness of recreational activities on level of burden among caregivers of relatives with dementia. 286 caregivers were participated. Zarit Burden Scale, Hamilton Depression and Anxiety Scale was used to assess the level of burden. Recreational activities were given for 5 months. The findings of the study revealed that recreational activities reduced 75% of level of burden among caregivers of clients with dementia. Sinder T (2010) conducted a cross sectional study to identify the effects on deep breathing exercise to reduce the level of burden among caregivers of clients with dementia in Taiwan. 465 caregivers participated. Convenient Sampling Technique was used. Deep breathing exercise was given to the caregivers of clients with dementia for 3 months. The findings of the study revealed that deep breathing exercise reduced the anxiety, anger among caregivers of clients with dementia. Philip D (2009) conducted a cross sectional study to assess the effectiveness of recreational activities on level of burden experienced by caregivers of clients with dementia in Europe. 238 samples participated in this study. Zarit Burden Interview, Burden Assessment Scale was used to identify burden. Painting, drawing was given as recreational activities for 12 weeks. The findings of the study revealed that 84 % of burden level was reduced for caregivers of clients with dementia with the help of recreational activities. Chandragupta and Bhola (2008) conducted a meta analysis studies to find the effectiveness of support groups for caregivers of dementic patients to reduce the burden and psychological well being. 521 caregivers participated. Burden Assessment Scale was used. Purposive sampling technique was used.The result indicated that support group helps to reduce the depression, anxiety and it improves the psychological well being. Graff ST (2008) conducted a longitudinal study to assess the effectiveness of community based occupational therapy on level of burden among caregivers of clients with dementia in France. 10 sessions of occupation therapy was given for 5 weeks. Caregiver burden was assessed with Zarit Burden Interview Schedule. 400 samples participated in this study. The findings of the study revealed that occupational therapy reduced 60 % of level of burden among caregivers of client with dementia. Naresh R, et al., (2007) conducted a longitudinal study on self efficacy for managing dementia and reduce the level of burden and depression among dementia caregivers. 84 caregivers participated. Zarit Burden Interview Schedule was used. Convenient sampling technique was used. The result revealed that self efficacy is used to alleviate the symptoms of burden and depression among caregivers of clients with dementia. Mittelman M (2007) conducted a longitudinal study to assess the effectiveness of family meetings to prevent of anxiety and depressive symptoms among caregivers of clients with dementia. 420 caregivers participated. Caregivers Burden Assessment Scale, Hamilton Anxiety Depression Scale were used to collect the data. The findings of the study showed that family meetings help to reduce the anxiety and depressive symptoms among 75% of caregivers of clients with dementia. Stella et al., (2007) conducted a cross sectional study to assess the effectiveness of physical activity on the level of mental burden among caregivers of clients with dementia. Convenience sampling technique was used. 245 caregivers participated. Burden Assessment Scale was used. The results revealed that the regular practice of physical activity reduce the burden of the caregivers of dementia patients. Gerentol GZ (2006) conducted a longitudinal study to assess the effectiveness of structured teaching program on activities of daily living on care of clients with dementia. 425 caregivers participated. Burden Assessment Scale was used to collect the data. Convenient sampling technique was used. The findings of the study showed that planned activities of daily living for dementia clients reduces the level of burden, depression and anxiety among caregivers of clients with dementia. Cantent C (2005) conducted a cross sectional study to assess the effectiveness of self group on level of burden among caregivers of clients with dementia. 425 caregivers participated. Zarit Burden Assessment Schedule was used to collect the data. Convenient Sampling Techinique was used.The findings of the study revealed tha self group reduces the level of burden among 65% of caregivers of clients with dementia. Pahlavandeh S (2005) conducted a study on effectiveness of family education program on caregiver burden of dementia clients. 560 caregivers participated. Zarit Burden Assessment Scale was used in this study. The findings of the study revealed that family education program reduces the level of burden among 60% of caregivers of clients with dementia. Kuskowski MA and Kirk LN (2005) conducted a exploratory study to examine the personal and relational impact on caregiving wives. Supportive group therapy was applied as a intervention. 115 female spouse caregivers participated. Convenient sampling technique was used. Burden Assessment Scale was used in this study. The findings of the study was revealed that supportive group therapy enhance the caregivers sense of personal mastery and it help to reduce the negative effects of caregivers of dementia clients. Tuokko H (2005) conducted a cross sectional study to assess the effectiveness of educational training program on reducing the level of burden among caregivers of clients with dementia in Lucknow. 526 caregivers participated. Burden Assessment Scale was used in this study. The findings of the study revealed that educational training programme brought awareness among caregivers and it helped to reduce the overburden and depression among 60% of caregivers of clients with dementia.

Autism in Children :: detection, intervention, education

All children deserve to have an equal chance to learn and perform in any number of categories. The only problem is that not every child can function correctly for various reasons. The condition that I am covering is autism. Autism is a difficult symptom to correct because it is a brain disorder that takes time and much work with doctors and teachers. I wanted to learn more on this disorder because I have a family member that have this condition. Autism affects communication skills, social skills, creativity skills, and learning skills. The ways to help correct these symptoms would be early detection, early intervention, and how to educate children with autism. Every parent wants to know what causes autism for their child. The only problem is that no one knows what causes autism. There are many signs and different theories, but no answers to what causes autism. Many different methods have been conducted to see the cause of autism. Methods like brain research, genetics, and neurochemistry have not solved this dilemma. The causes of autism have not been solved, and might never be discovered. Parents want to know if their child can be cured and be able to live a normal life. The answer to that is no and yes. There is no cure for autism, but with the proper treatment and education, a child can grow and live a very normal life. There are many cases of people with autism living a normal based life, even though they still have autism. Autism is a life long condition that can not be cured, but people can still live normal lives. One person in particular (Peter) interested me as he lives a very normal life and is an inspiration to not only autistic people, but to everyone, Today, things are much easier for me. I go to Inver Hills Community College, where I?m working for my associate of arts degree. I am very hopeful about my future. I?ve taken some very difficult classes in geography, but I have passed all of them with a fairly decent grade?This past October, I gave a talk in front of nearly three hundred people up in the Twin Cities about my autism?I talked about what autism felt like for me, and I told some funny stories?On the whole, this talk was a very big success for me. My talk brought tears to the eyes of many.

A Review of Emma :: essays research papers

A Review of Emma I’ve read Sense and Sensibility, Pride and Prejudice, and most recently Emma. All of them are wonderful, and I can never decide which one is my favorite book by Jane Austen. But definitely Emma is, to me, a very engaging one. I have no special feeling about this book at first glance. Because of Jane Austen, I choose it and take some patience to read. And finally, the patience is greatly rewarded. Emma is a timeless story which is both funny and compelling. The characters are all really well developed, especially Emma, a 21-year-old girl, who is portrayed as incredibly human. The story is, briefly, about Emma, who is young, beautiful, rich and witty and lives with her father Mr. Woodhouse. She has vowed herself never to marry, but loves to play a matchmaker. She has just matched her tutor, Miss Taylor, up with Mr. Weston. She is quite proud of her success and finds satisfaction in it. In her arrogance, she believes that she knows what is right for everyone, and determined to appoint herself Cupid for all of her friends. Mr. Knightley, a neighbor and the brother of her older sister’s husband, warns her not to meddle in the other’s affairs, but she doesn’t take it seriously. She takes care of a young girl of unknown parentage named Harriet. Harriet is in love with a farmer named Robert Martin, but Emma thinks that he is beneath her, so she encourages Harriet to set her sights on Mr. Elton, a local vicar, as a future husband. Poor Harriet is completely bowled over by Emma. But unfortunately, everything goes to the opposite side, and fina lly Emma knows the fact that Harriet and Mr. Elton are completely unsuited, and that Harriet and her farmer are made for each other. Through a lot of hilarious scenes, Emma comes to realize that she doesn’t know as much as she thinks, and learns that it’s better to let other people manage their own lives. As the other works of Jane Austen, Emma describes the ordinary person and trivial matters. The plot develops around the activities of choosing spouse for the heroines. It reveals the bad habit that people regarded marriage as the economic insurance to woman at that time. In order to raise the economic position, they emphasized the family status but ignored women’s feelings and rights. The main female characters in Emma all seek the equal communication with man, they demand the equal rights in the social position, and insist on the freedom of observing and choosing spouses.

Repairing the Problem with Americas Transportation System Essay

Repairing the Problem with America's Transportation System   There is a serious problem with our nation's roads and highways.   I find myself repeatedly avoiding trips to the city for this very reason, as I'm sure many others do as well.   This nerve-wracking congestion is even beginning to find its way into the suburbs and surrounding areas of large cities.   It is a  Ã‚   serious problem that affects everyone who owns an automobile, as well as, businesses that are dependent on reliable and convenient transportation.   To top it all off, this problem is getting worse every year.   The population of this nation is growing, which translates to an increase in cars on the road.   More people are moving to cities and the suburbs that surround them, creating gridlocks everywhere.   No matter what any politician in Washington or employee of the Federal Highway Administration may say, there is a serious and immediate problem with our nation's transportation systems.   The Texas Transportation Institute has recently done several studies that have produced some very alarming results.   For example, the average American spends approximately 26 hours a year stuck in traffic.   Let?s think about that.   The ?average? American spends this long cruising at five miles per hour and cursing at other cars around.   By saying average, the study means this figure also takes into account people living in rural areas who spend maybe one hour a year stuck in traffic.   That means for the majority of us, in the Phoenix area and other large cities, we spend 3 or 4 times more wasting our valuable time in traffic.   For people who drive into the city   everyday for work, it might even be worse (Fay 3).   Now that?s a lot of time if you ask me. To make matters worse... ...ve. Works Cited Fay, William D. & Slater, Rodney E.   ?Q: Should gasoline taxes be used exclusively for  Ã‚   highways Insight on the News   May 26, 1997: 24. Henderson, Rick. ?An end to highway robbery Reason August-Sep 1996: 12. Peratta, Ed.   ?Despite bumps in the road, privatization races on.?   American and City and   County Oct 1995: 50. Peters, Eric.   ?Privatization: the Road Ahead   Consumers? Research Magazine   Dec   1995: 10. Roth, Gabriel.   ?How to Solve our Highway Problems.?   Consumers? Research Magazine  Ã‚   June 1997: 10. Samuel, Peter.   ?The case for privatizing America?s highways.?   USA Today Jan 1997:  Ã‚   60. Voinovich, George V. ?Federal highway spending needs to be road less traveled.? Insight  Ã‚   on the News Jan 6, 1997: 29. West, Jim.   ?Different Views of Gasoline Taxes.?   The Oil and Gas Journal   August 14,   1995: 9.   

Benefits of Cost Allocation in an Organization

Introduction: The Need for Cost Accounting and Allocation A product or a service cannot be provided without costs going into its creation. The ability to transform a raw material into the final product, whatever the final product may manifest, is unavoidably connected with a cost. Often costs are incurred in a manner that is not even directly related to the making of the final product but to activities that are necessary for the production process.Activities such as planning and administration come under the support activities that are not directly related to the creation of a product or service but they are necessary for a organization to operate. Often a situation arises when a cost becomes attached to more than one product or department. The question as to whom to ascribe a cost to when more than one party seems responsible for the charge had been a highly problematic issue for accountants for long while. Many schools of thought have sprung up with regard to this dilemma.Some feel that costs can be assigned based on dividing space, or percentages of use. Others were of the view that there is no need to allocate costs at all. â€Å"A third group preferred no allocation at all, because regardless of the method applied, bottom-line would not change† (Doost, 1997). The introduction of Activity Based Costing further pushed cost allocation into the background (Doost, 1997). However, Activity Based Costing had a major shortcoming in that not all cost incursion are clear-cut enough to be charged to the ultimate users.The need to allocate costs in the face of multiple users remained. Cost allocation is also known as cost apportionment and cost distribution. Defining Cost Allocation Cost allocation is the process of accounting developed to deal with a situation in which assigning costs to a particular product or department is difficult. The process involves identifying and linking the costs incurred with the cost objectives. Cost allocation consists of three ma in steps: ? Defining an â€Å"object† to link costing to ?Accruing the costs linked to the object Determining a method to link the object with the accrued cost The cost object can be thought of as an activity or a process, a product or service or even a part of the organization for which a separate measure for costs is required. Definition of the object is based largely on the needs and circumstances of the organization. After costs are incurred, they undergo an appraisal and are assigned to various pools depending upon a criterion that has been determined to link costs to the object. The costs are of two types; direct and indirect (Ijiri, 1975).Direct costs are traceable to the cost object through a highly objective, uncomplicated relationship. Indirect costs are the real purpose of cost allocation and are cost incurred without any traceable source. They must be assigned according to some bridging activity that will form the link between costs and cost object. The Benefits o f Cost Allocation Most literature follows the disadvantages of cost allocation and shows why it should not be used. However, cost allocation continues being used in numerous organizations.Two authors, Horngren and Kaplan have been the exceptions in relating this aspect and Zimmerman builds on their work to show, that in spite of what research, what benefits are derived from cost allocation which makes it popular among the practitioners. Horngren and Kaplan refer to the benefits to managerial behavior. Zimmerman (1978) divides this into the agency problem and using allocation as a proxy. The agency problem arises whenever a relationship is formed between a principal and an agent, such as that between the owners of the company and its managers (Jenson and Meckling, 1976).This situation assumes that the agent will do his or her best to increase the welfare of the principal; however, in reality an agent will sometimes act in ways that reduce the welfare of the principal. This is due to the lack of optimal monitoring systems. The monitoring system can restrict such acts but not completely stop them. The portion that can not be reduced is, thus, a expenditure and is known as agency costs that a principal needs to bear. A similar situation occurs between a superior and a subordinate when costs are allocated. The subordinate has his own interests at heart, including his chances of advancement.Thus, by allocating to the subordinates the superior’s expenditures, motivation is created for subordinate to carefully monitor their superior’s spending and ensure that the superior does not spend unnecessarily or for personal gain on the company’s tab. Thus, the subordinate will monitor the spending by the superior, ensuring less shirking and adequate spending on perquisites (non monetary incentives e. g. air conditioning in the office). Thus, the superior’s welfare is dependent directly on the subordinate’s productivity, subordinate’s compensation and the agency costs related to this relationship.This agency costs include the monitoring costs, bonding costs and residual loss. Excessive consumption of prerequisites by the superior, thus, negatively affects the subordinate's future promotions. To avoid this, the subordinate would either go over the direct superior’s head or attempt to convince the direct superior to reduce spending. Thus, cost allocation itself allows a principal-agency relation to be created in the organization, and using allocated costs, a means of monitoring superiors is created.This monitoring is not so effective if done by a person higher-up than the superior (because of one-to-many relation and lack of incentives), and is one reason that costs allocation are widely used in organizations. Another assumption made is the fact that lump-sum tax can also reduce an agent’s spending on perquisites. Here, costs allocations act as a lump-sum tax as they allow costs to be allocated to dif ferent departments. Thus, if a cost is allocated among five departments, then for each department this is similar to a lump-sum tax, and this is reduce the agent’s spending on perquisites in each of the departments.However, if this tax amount is tied to profits, then theory shows that mathematically the perquisites spending may actually increase. Thus, non-controllable costs are allocated to managers to decrease their perquisite spending and should be based on lump-sum overhead allocation rather than tied to profits. The above discussion also implies that costs allocations are better used when other forms of monitoring costs are high, perhaps due to geographical locations etc. Another benefit of cost allocation is observed with regards to manufacturing overhead costs.Zimmerman (1978) shows that a shared resource inflicts costs on others, for instance, for a shared resource a user will be constantly expanding his utilization. Besides the overuse, this agent is also inflicting a delay costs on other whose work may be affected by the delay they have to endure. After a certain point though, the costs will be more than the benefit derived from the shared resource and it would be more profitable to expand resources. Costs allocation acts a proxies to this expansion costs and allows proper allocation of costs which can be monitored. Thus, the manufacturing overhead issue is as follows.For a manufacturing concern, its main costs are its direct material used, direct labor required and manufacturing overhead, which are not directly traceable to one product but are incurred in manufacturing. When a principal assigns an agent, he also passes on the responsibilities and decision making thus resulting in a decentralized organization. In such a setting, each person will choose that level of inputs which minimizes the overall costs. This will be at a point when minimum variable costs are used by decreasing inputs and using maximum fixed costs, which are indirect costs. This will firstly not operate at optimum level, and secondly this will impose costs on other departments by using more of the manufacturing overhead costs. Hence, a need for centralized decision making arises. By using centralized decision making, a level of inputs is selected which minimizes input costs. . Also, manufacturing overhead is allocated based on requirements rather, than to show minimum costs. Thus, cost allocation allows optimal distribution of indirect costs, and also incorporates other immeasurable costs like delay costs, expansion costs etc.Doost (1997) also shows how cost allocation is useful for determining actual product costs by using all relevant costs, and can be used for control purposes. He demonstrates that the budgeted amount of manufacturing overhead costs allow monitoring of overspending or under spending and is the responsibility of the specific department. Conclusion Cost accounting is a highly useful method of accounting that is very accommodating to c ontrol and coordination measures of various costs. The importance of cost allocation has not diminished over the years.Cost allocation continues to be as important today as it was in the seventies. The basic principle behind cost allocation has remained largely the same; however, new methods of forming the link between costs and cost objects are continuously being formed. It continues to finds its application in cost control and accountability. By no means a cure-all, cost accounting does, however, provide a sound foundation for increasing responsibility, control and accountability by changing the very behavior of managers and creating an environment where cost reduction can be linked to advancement.

An Analysis of Tragic Love between Gatsby and Daisy

Many critics hold the view that Daisy is one of the causes that lead to the disillusion of Gatsby’s dream. They think Daisy is an as? set class miss, who has no thought, no sentiment, flimsiness and bored person. Unlike many critics, I don’t think Daisy is a fickle, shallow, and sardonic woman. I believe she is also a victim of that era. Zhou Jiaqiu has pointed out in the Half is an Angle; the Half is the Devil thatâ€Å"if we only regards Daisy as a material girl, we not on? ly humiliate the sacred love of Gatsby, but also influence the reputa? tion of the author.Because under the description of the writer, the leading lady is depicted as fullness and vivid character, a pathetic scorned wife whose husband leads a double life. She is both realis? tic and romantic, a half angle and a half devil. † Gatsby cheated and occupied Daisy by telling a lie, making Daisy believe he has the ability to take care of her, but actually he does not have. The evening before Daisy got married, she received Gatsby’s letter, and she cried out of heart, almost changed her mind of marrying Tom.But when Daisy really needed him, he couldn’t accompany her. From this point of view, Gatsby should feel sorry for Daisy. I think Daisy is a realistic girl. After she married Tom, al? though she kept her affluent life and social status of upper class, she had to endure her husband’s betray and abandon again and again. In the world of East Egg, alluring appearance serve to cover unattractive realities. The marriage of Tom and Daisy Buchanan seems menaced by a quiet desperation beneath its pleasant surface.Daisy’s tragedy lies in that she has the instinct of love, but she can submit to reality. She knew life is an illusion by control pains? takingly, but she still will live in illusion. Trapped in the contradic? tion, Daisy only made the gesture, so she lost the right to enjoy the real emotion. Faced with the pain of life, Daisy chose to hypnotize herself, just as her hope about her daughter—â€Å"I hope she’ll be a fool—that’s the best thing a girl can be in this world, a beautiful lit?