Physics paper Essay Example | Topics and Well Written Essays - 1000 words - 1

Physics paper - Essay Example Another area of research will be determining the different between resistance and current. The distinct properties of resistance and current will be considered in order to identify various types of resistance in conductors of electricity. Resistivity and conductivity are also studied in this research; the factors which influence the conductivity for instances temperatures are also studied.in addition to exploring various types of applications which has high resistance and current consumption the knowledge of electric generation will be featured (S. Knight). For further understanding of resistance and current, an experiment is performed in the laboratory in order to analyze the effects of resistance and current in electricity transmission. The following apparatus and materials required while carrying out the experiment (S. Knight). In the above set up, while the electrons are passing through thin metal filament of the lamp, the electrons face more opposition because the filament is thinner when compared to the wire used in the experiment. The opposition to electric current depends on the type of material, cross-sectional area and its temperatures (Jeong). Basically it can be said the conductors have low resistance while insulators have low resistance. The resistance reduces amount of current through the circuit and the bulb will glow depending on the amount of electrons passing through the wire. When electrons are moving against the same direction it causes friction, this is manifested in form of heat.at the same time the readings of ammeter changes. The concentration of heat in filament will force the bulb to glow. In the cases of short circuit, the bulb will stop glowing because there is no complete flow of electrons. There will be any resistance because the circuit is incomplete. When we use batteries in the above set up, the battery will run short of the charge because the

Contributing factors toward SWB of the Institutionalized Elderly Essay Example for Free

Contributing factors toward SWB of the Institutionalized Elderly Essay Apart from delineating the cognitive and affective indicators of SWB, this study also attempted to identify the possible factors which contribute to SWB. A host of factors were identified in the largely western literature. These are presented in the succeeding pages. Physical Health: Health is one of the most important variables in predicting whether people are happy (Campbell et al. , 1976). The World Health Organization defines health as, the optimal functioning of the human organism to meet biological, psychological, ethical and spiritual needs (Emeth Greenhut, 1991). In this study the elderly were said to have ‘optimal functioning’ when he or she had basic competence, which was necessary for maintenance of independent living (Martin, 2001). In the case of the elderly in the study it was denoted by their ability for personal care on their own. It also pertained to mental health, which was a state where the elderly were not prone to depression, or other mental illness, and did not have any major cognitive impairments. Autonomy: Autonomy could be equated to having the capacity for selfdetermination, independence, internal locus of control, and internal regulation of behavior (Ryff, 1989). Having a sense of being in control (autonomy) means that one’s thoughts and actions are one’s own and not determined by others. It is related to physical health too as it gives a sense of mastery over situations. It is important for all and particularly for the elderly to maintain that sense of control or autonomy because a sense of losing control of one’s life or one’s power is to in some ways lose one’s worth, which can have detrimental effect on one’s physical as well as psychological health. Money/Income: Income or money is importantly related to a sense of well-being in old age (Diener, 1984) and the elderly in the study may or may not enjoy financial security Money is important probably because of the sense of security that they experience when they have enough money which could implicitly affect their sense of autonomy and self-worth. Family Relationships: Family is a natural institution constant across time and space which is a very close and intimate group and one’s sense of well-being is sustained by membership in this primary group, as it provides a sense of security, connectedness, and belongingness to the aged. There are no substitutes for the close relationship in the experience of well-being in the case of the aged. In the case of the elderly in the study, family relationship is limited to this intimate group consisting of the spouse, children and grandchildren as the extended family is almost nonexistent in the given context. Friendship: Friendship or close relationship with members of the same age group often sharing personal characteristics, life styles, values and experiences is a source of enjoyment, socializing, and reminiscing the past; promote a higher satisfaction among the older adults (Sorensen Pinquart, 2000). In the given situation it could be long standing friends from the past, and or the friendship developed among the co-residents of the home. Social Support and Social Interest: To experience a sense of well-being persons should have deep feeling of sympathy, and affection for human beings (social interest/altruism). That is, their ability to go beyond the personal to interpersonal establishing deep, profound interpersonal relationships and social support, to transpersonal, which is relating to the Divine in the social context of one’s life. These play a significant role in maintaining their psychological, social, and physical integrity over time (Witmer Sweeny, 1992) and consequently the sense well-being. Attitude toward Death: Death can be understood as a natural process of transition from one stage of life to another. Depending on the meaning people attach to death, they fear death or embrace it as a natural transition with a sense of acceptance and surrender (Atchley, 1997). Accepting old age and death meaningfully makes life happier. Fear or acceptance of death is closely related to general satisfaction. According to (Moberg, 2001), when life is lived to the full, death becomes a fulfillment, a completion. Religion and Spirituality: Subjective aspects of religion and spirituality include religious identification, religious attitudes, values, beliefs, knowledge, and mystical/religious experiences. Religious experience provides a sense of meaning and purpose in daily life (Polner, 1989). Spirituality usually refers to a unique, personally meaningful experience of a transcendent dimension that is associated with wholeness and wellness (Westgate, 1996). Spiritual wellness is the dimension that permits the integration of one’s spirituality with the other dimensions of life, thus maximizing the potential for growth and self-actualization (Westgate, 1996). At this point of SWB research, there is already an idea of the variables which correlate with SWB. However, a better understanding of parameters that influences the relationships, the directions of influences between variables, and the different influences interact are still needed (Diener, 1984). Given the assumption that these features are deep cross-cultural, universally applicable, core characteristic features of well being sought by the aged, the researcher believed that the institutionalized care for the aged and their subjective sense of well-being is also context specific. An understanding of psychological well-being necessarily rely upon the moral visions that are culturally embedded and frequently culture specific (Christopher, 1999). In this context, one might ask how the institutionalized aged of Gladys Spellman experience the transition from mathru-pithru devobhava (mother and father are like gods) to institutionalized care, what their experience of the subjective well-being consisted in, and what might be the specific factors that would contribute to their sense of well being. It is possible that the western culture-specific factors of subjective well-being outlined above may not have the same relevance for the population under investigation. This study was expected to help understand the contextspecific aspects of well-being of the institutionalized aged.

Gitlow vs New York Essay -- communism, freedom of speech, criminal anar

In the twenty century, the U.S society was in the period of tending to be a human base society. The laws in America were introduced to create a fair and regulated society for its citizens. The First and Fourteenth Amendment of Constitution granted that the U.S citizens have the freedom of speech. And the New York State had its law of Criminal Anarchy Act since 1902 for â€Å"organized government should be overthrown by force or violence, or by assassination of the executive head or of any of the executive officials of government, or by any unlawful means (n.p).† The citizen in the any state of the U.S should always both obey the state law and follow the national constitution. Otherwise, the citizen would get corresponding punishment for jail, community service or even death for most states. However, the case of Gitlow vs New York happened in 1925 that majorly argued about the U.S citizens’ guaranteed freedom of speech in the First Amendment of Constitution and the New Y ork State’s Criminal Anarchy Act. Gitlow vs. New York is a case that influences the integrity of U.S legislative system importantly. In the 1925s, Benjamin Gitlow, a left wing socialist, published speeches of anti-government to advocate a new better communist government. His action caused the charge as unpopular and dangerous speech for the whole society from the New York state government, and his behavior became a court case. According to the website thefreedictionary.com, that â€Å"The opinions expressed in† â€Å"The Revolutionary Age† and â€Å"The Left Wing Manifesto† â€Å"formed the bases for the defendant's convictions under Sections 160 and 161 of the penal law of New York, which were the criminal anarchy statutes† (n.p). â€Å"The Revolutionary Age† and â€Å"The Left Wing Manifesto† ar... ... his action could actually be really harmful for the society. Gitlow defended him as not guilty merely depends on the part of the context of the First Amendment of Constitution about U.S citizens’ freedom of speech. It is actually make a deliberate misinterpretation out of the context. Gitlow’s claims that he is innocent might because of his less awareness and misunderstanding of the laws. Or, he might believe that the faults of the Constitution would help him escape from the punishment. However, in my point of view, Gitlow fail to consider the primarily goal of the U.S Constitution that is to protect the best profit of its majority. Bibliography http://legal-dictionary.thefreedictionary.com/Gitlow+v.+New+York http://principlesofafreesociety.com/freedom-of-speech/ http://www.aynrand.org/site/PageServer?pagename=objectivism_nonfiction_the_ayn_rand_column

Book Review: When Genius Failed Essay

Lowenstein’s ability to come up with a concise, coherent story and his experience in financial journalism is strongly evident in this book. Not only can Lowenstein weave together and tell a great story (this author felt he was being led through the history of the fund and its characters by one of its inner partners while reading through this book), he also pays attention to details whenever it is needed – and he succeeds greatly by catching many important subtleties (such as in the beginning of Chapter one when he used one of those â€Å"subtleties† in Meriwether’s early areer to explain the basis of LTCM’s core business model and the subtle, but gradual â€Å"style drift† that brought down the hedge fund afterwards) as well as making many interesting observations along the way (such as the fatal flaw LTCM committed when it started engaging in stocks arbitrage as opposed to sticking to bond arbitrage). 7. Concept: Unsystematic Risk. A specifi c risk is a risk that affects a very small number of assets. This is sometimes referred to as â€Å"unsystematic risk†. In a balanced portfolio of assets there would be a spread between general market risk and risks specific to individual components of that portfolio. Unlike systematic and market risk, specific risk can be diversified away. A diversified portfolio is the realisation of the proverb â€Å"don’t put all your eggs in one basket†. As Irish investors become more sophisticated in their strategies, they look beyond the risks of stock-picking to managing risk through diversified, balanced investment portfolios. Mr. Fitzgerald, portfolio manager for Hibernian Investment Managers said that often the first step in reducing risk is investing in pooled investments like mutual funds, unit trusts and unit-linked funds. It’s a toe-in-the-water position, they begin with cautiously-managed funds, and then as they grow in wealth or experience they may choose a managed fund with higher equity content† Source: Margaret E. Ward, The Irish Times, 2nd July 1999. 10. Concept: The Capital Asset Pricing Model (CAPM). William Sharpe the Capital Asset Pricing Model in 1964. Parallel work was also performed by Jack Treynor, John Lintn er and Jan Mossin. CAPM is used in finance to determine a theoretically appropriate required rate of return of an asset. It considers a simplified world where there are no taxes and transaction costs, all investors have identical investment horizons and identical opinions about expected returns, volatilities and correlations of available investments. This model states that the expected return on a specific asset equals the risk-free rate plus a premium that depends on the asset’s beta and the expected risk premium on the market portfolio. CAPM extended Harry Markowitz’s modern portfolio theory and of diversification to introduce the notions of systematic and specified risk. Source: www. google. com 11. Concept: Capital Budgeting. Capital Budgeting or Investment Appraisals are the planning processes used to determine a firm’s long term investments such as new machinery, replacement machinery, new plants, new products and research and development projects. This is the process of identifying which long-lived investment projects a firm should undertake. US entertainment giant Warner Brothers investigated a possible high-tech back office studio development in Belfast. Executives from the group conducted an appraisal of possible investment opportunities on the site. The group planned a high-tech quarter in Belfast, which it hoped would attract multimedia, informatics and telecoms firms to set up in Northern Ireland. Source: Francess McDonnell, The Irish Times, 7th August 2001. 18. Concept: Financial Management. This is managing a firms internal cash flows and its mix of debt and equity financing, both to maximise the value of the debt and equity claims on firms’ and to ensure that companies can pay off their obligations when they come due. This is illustrated through financial reporting; the dream of consistent and uniform systems of financial reporting around the world is a seductive one. It is also elusive. The problem is that, however great the attempts at providing a universally acceptable standard, the differing goals of the world’s reporting regimes get in the way. Europe and about a 100 other countries go for the International Financial Reporting Standards (IRFS) whereas, the US stand alone and stick to their US generally accepted accounting (GAAP) yet seek reconciliation from the IRFS. It is the electronic tagging and analysis system XBRL that will enable the elements of a company’s financial reports to be accessed by users and reconfigured to provide whatever information the user wants. Mr. Cox, the Securities and Exchange Commission chairman said he was â€Å"looking forward to a future in which XBRL, US GAAP and IFRS would be interconnected and hence the problem of global comparability would be solved†. Source: Robert Bruce, Financial Times, 4th January 2007.

Life of Quaid E Azam

ACCF/AHA Pocket Guideline Adapted from the 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy November 2011 Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons  © 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc.The following material was adapted from the 2011 ACCF/AHA Guidelines for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (J Am Coll Cardiol 2011;XX:XX–XX). This pocket guideline is available on the World Wide Web sites of the American College of Cardiology (www. cardiosource. org) and the American Heart Association (my. americanheart. org). For copies of this document, please contact Elsevier Inc. Reprint Department, e-mail: [ema il  protected] com; phone: 212-633-3813; fax: 212-633-3820.Permissions: Multiple copies, modification, alteration, enhancement, and/ ordistribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at [email  protected] com. Contents 1. Introduction †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 2. Clinical Definition †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦ 6 3. Genetic Testing Strategies/Family Screening †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 4. Genotype-Positive/Phenotype-Negative Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 5. Echocardiography †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 10 6. Stress Testing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 14 7. Cardiac Magnetic Resonance †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 15 8. Detection of Concomitant Coronary Disease †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 9. Asymptomatic Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 19 10.Pharmacologic Management†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 21 11. Invasive Therapies †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 26 12. Pacing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 29 13. Sudden Cardiac Death Risk Stratification †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 30 14. Selection of Patients for Implantable Cardioverter-Defibrillators †¦ 32 15. Participation in Competitive or Recreational Sports and Physical Activity †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 16. Management of Atrial Fibrillation †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 38 17. Pregnancy/Delivery †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 41 2 1. Introduction The impetus for the guidelines is based on an appreciation of the frequency of this clinical entity and a realization that many aspects of clinical management, including the use of diagnostic modalities, genetic testing, utilization of implantable cardioverter-defibrillators (ICDs), and therapies for refractory symptoms lack consensus.The discussion and recommendations about the various diagnostic modalities apply to patients with established HCM and to a variable extent to patients with a high index of suspicion of the disease. Classification of Recommendations The ACCF/AHA classifications of recommendations and levels of evidence are utilized, and described in more detail in Table 1. 3 Applying Classification of Recommendations and LevelRecommendations and Level of Evidence Table 1. Applying Classification of of Evidence Table 1. Applying Classification of Recommendations and Level of Evidence S i z e Class I Benefit >>> Risk f T r e a T m eSni T ee f ffe c T e a T z o Tr Class IIb Class IIa Benefit >>> Risk Benefit Risk Additional studies with broad Additional studies with objectives objectives needed focused needed; additional registryreasonable to perIt Is data would be helpful Class IIa Class I Benefit >> RiskRisk Benefit >>> Additional studies with Procedure/Treatment focused objectives needed should be performed/ Procedure/Treatment should be performed/ administered It administered Is reasonable to perform procedure/administer treatment n Recommendation favor n Recommendation in thatProcedure/Treatment form procedure/administer may be ConsIdered treatment n n Rec ommendation Recommendation’s eSTimaTe of cerTainTy (PreciSion) of TreaTmenT effecT a populations d* ived from multiple zed clinical trials analyses Recommendation that level a procedure or treatment Multiple populations is useful/effective evaluated* n Sufficient evidence from Data randomized multiple multiplederived from trials randomized clinical trials or meta-analyses or meta-analyses n of procedure or procedure treatment treatment is useful/effective being useful/effective n Sufficient evidence from n Some conflicting evidence n favor usefulness/efficacy less of treatment or procedure well established being useful/effective conflicting evidence evidence from multiple from multiple randomized randomized trials or trials or meta-analyses meta-analyses in favor of treatment or procedure usefulness/efficacy less being useful/effective well established conflicting evidence from single evidence from single randomized trial randomized trial oror nonrandomized studies nonrandomi zed studies in favor usefulness/efficacy less of treatment or procedure well established being useful/effective opinion, case studies, or opinion, case studies, standard of care care or standard of may/might be considered is reasonable may/might be reasonable can be useful/effective/beneficial usefulness/effectiveness is is probably recommended unknown/unclear/uncertain or indicated or not well established n n Some Greater multiple randomized trials from multiple randomized or or meta-analyses trialsmeta-analyses b populations d* ived from a ndomized trial ndomized studiesRecommendation that level b procedure or treatment Limited populations is useful/effective evaluated* n Evidence from single Data derived or randomized trialfrom a single randomized trial nonrandomized studies or nonrandomized studies n n Recommendation in that n Recommendation favor n n Recommendation Recommendation’s of procedure or procedure treatment treatment being useful/effective is useful/effective n Some conflicting single n Evidence from n n Some Greater evidence from trial or randomized single randomized trial or nonrandomized studies nonrandomized studies n Recommendation favor n Recommendation in that C ited populations d* sensus opinion ts, case studies, ard of careRecommendation that level C procedure or treatment is Very limited populations useful/effective evaluated* n Only expert opinion, case Only consensus opinion studies, or standard of care of experts, case studies, or standard of care n n n Recommendation Recommendation’s of procedure or procedure is treatment treatment useful/effective being useful/effective n Only expert expert n Only divergingopinion, case studies, or studies, opinion, casestandard of care or standard of care is reasonable should can be useful/effective/beneficial is recommended is probably recommended is indicated oris useful/effective/beneficial indicated n n Only diverging expert Only diverging expert d phrases for commendations shou ld Suggested phrases for writing recommendations is recommended is ndicated is useful/effective/beneficial s treatment/strategy A is Comparative recommended/indicated in effectiveness phrases†  preference to treatment B treatment/strategy A is probably treatment/strategy A is recommended/indicated in in recommended/indicated preference to to treatment B preference treatment B it is reasonableshould be chosen treatment A to choose treatment A over treatment B over treatment B treatment/strategy A is probably recommended/indicated in preference to treatment B it is reasonable to choose treatment A over treatment B ive ess phrases†  4 treatment A should be chosen over treatment B e T menT e ffe c T A recommendation with Level of Evidence B or CClass IIIIIb Benefit Class No orBenefit > Risk Class III Harm Procedure/ Additional studies with broad test treatment objectives needed; additional Cor III: Not No Proven be helpful noregistry data would Benefit benefit Helpful Class II I No Benefit or Class III Harm Procedure/ test Cor III: Not no benefit Helpful Cor III: harm treatment No Proven Benefit does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. Procedure/Treatment Cor III: Excess Cost Harmful harm be w/o Benefit to Patients may ConsIdered or Harmful n n Recommendation’s Recommendation that Excess Cost Harmful w/o Benefit to Patients or Harmful Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †  For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. n procedure or treatment is usefulness/efficacy less not useful/effective and may well established be harmful conflicting n Greater n evidence from multiple Sufficient evidence fromRecommendation that procedure or treatment is not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses Recommendation that procedure or treatment is not useful/effective and may be harmful Evidence from single randomized trial or nonrandomized studies Recommendation that procedure or treatment is not useful/effective and may be harmful Only expert opinion, case studies, or standard of care COR III: Harm potentially harmful causes harm associated with excess morbidity/mortality should not be performed/ be done administered/ other n multiple randomizedor randomized trials trials or meta-analyses meta-analyses n n Recommendation’s Recommendatio n that n sefulness/efficacy less procedure or treatment is well established not useful/effective and may be harmful conflicting n Greater n evidence from single Evidence from single randomized trial randomized trial oror nonrandomized studies nonrandomized studies n Recommendation’s Recommendation that usefulness/efficacy less procedure or treatment is well established not useful/effective and may n Only diverging expert be harmful opinion, case studies, or n Only expert opinion, case standard of care studies, or standard of care n n n n COR III: COR III: may/might be considered Nomay/might be reasonable Benefit Harm usefulness/effectiveness is is not potentially unknown/unclear/uncertain recommended harmful or indicated not well established harm is not causes associated with excess morbidity/mortality should not be done COR III: No Benefit is not recommended is not indicated should not be performed/ be done administered/ is not useful/ other beneficial/ is not useful/ effect ive bene? cial/ effective should not be done s not useful/ beneficial/ effective 5 2. Clinical Definition The generally accepted definition of hypertrophic cardiomyopathy (HCM), is a disease state characterized by unexplained left ventricular (LV) hypertrophy associated with nondilated ventricular chambers in the absence of another cardiac or systemic disease that itself would be capable of producing the magnitude of hypertrophy evident in a given patient. Clinically, HCM is usually recognized by maximal LV wall thickness ? 15 mm, with wall thickness of 13 to 14 mm considered borderline, particularly in the presence of other compelling information (e. g. , family history of HCM), based on echocardiography.In terms of LV wall-thickness measurements, the literature has been largely focused on echocardiography, although cardiovascular magnetic resonance (CMR) is now used with increasing frequency in HCM. In the case of children, increased LV wall thickness is defined as wall thickness ? 2 standard deviations above the mean (z score ? 2) for age, sex, or body size. However, it should be underscored that in principle, any degree of wall thickness is compatible with the presence of the HCM genetic substrate and that an emerging subgroup within the broad clinical spectrum is composed of family members with disease-causing sarcomere mutations but without evidence of the disease phenotype (i. e. , LV hypertrophy). 6 3. Genetic Testing Strategies/Family Screening Class I 1.Evaluation of familial inheritance and genetic counseling is recommended as part of the assessment of patients with HCM. (Level of Evidence: B) 2. Patients who undergo genetic testing should also undergo counseling by someone knowledgeable in the genetics of cardiovascular disease so that results and their clinical significance can be appropriately reviewed with the patient. (Level of Evidence: B) 3. Screening (clinical, with or without genetic testing) is recommended in first-degree relatives of pati ents with HCM. (Level of Evidence: B) 4. Genetic testing for HCM and other genetic causes of unexplained cardiac hypertrophy is recommended in patients with an typical clinical presentation of HCM or when another genetic condition is suspected to be the cause. (Level of Evidence: B) 7 Class IIa 1. Genetic testing is reasonable in the index patient to facilitate the identification of first-degree family members at risk for developing HCM. (Level of Evidence: B) Class IIb 1. The usefulness of genetic testing in the assessment of risk of sudden cardiac death (SCD) in HCM is uncertain. (Level of Evidence: B) Class III: 1. Genetic testing is not indicated in relatives when pathogenic mutation. (Level of Evidence: B) 2. Ongoing clinical screening is not indicated in genotype-negative relatives in families with HCM. Level of Evidence: B) No Benefit the index patient does not have a definitive 8 4. Genotype-Positive/Phenotype-Negative Patients Class I 1. In individuals with pathogenic mutat ions who do not express the HCM phenotype, it is recommended to perform serial electrocardiogram, transthoracic echocardiogram (TTE), and clinical assessment at periodic intervals (12 to 18 months in children and adolescents and about every 5 years in adults), based on the patient’s age and change in clinical status. (Level of Evidence: B) 9 5. Echocardiography Class I 1. A TTE is recommended in the initial evaluation of all patients with suspected HCM. (Level of Evidence: B) 2.A TTE is recommended as a component of the screening algorithm for family members of patients with HCM unless the family member is genotype negative in a family with known definitive mutations. (Level of Evidence: B) 3. Periodic (12 to 18 months) TTE screening is recommended for children of patients with HCM, starting by age 12 or earlier if a growth spurt or signs of puberty are evident and/or when there are plans for engaging in intense competitive sports or there is a family history of SCD. (Level o f Evidence: C) 4. Repeat TTE is recommended for the evaluation of patients with HCM with a change in clinical status or new cardiovascular event. (Level of Evidence: B) 5. A transesophageal echocardiogram (TEE) is recommended for the intraoperative guidance of surgical myectomy. (Level of Evidence: B) 10 6.TTE or TEE with intracoronary contrast injection of the candidate’s septal perforator(s) is recommended for the intraprocedural guidance of alcohol septal ablation. (Level of Evidence: B) 7. TTE should be used to evaluate the effects of surgical myectomy or alcohol septal ablation for obstructive HCM. (Level of Evidence: C) Class IIa 1. TTE studies performed every 1 to 2 years can be useful in the serial evaluation of symptomatically stable patients with HCM to assess the degree of myocardial hypertrophy, dynamic obstruction, and myocardial function. (Level of Evidence: C) 2. Exercise TTE can be useful in the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting outflow tract obstruction in patients with HCM. (Level of Evidence: B) 11 3.TEE can be useful if TTE is inconclusive for clinical decision making about medical therapy and in situations such as planning for myectomy, exclusion of subaortic membrane or mitral regurgitation secondary to structural abnormalities of the mitral valve apparatus, or in assessment for the feasibility of alcohol septal ablation. (Level of Evidence: C) 4. TTE combined with the injection of an intravenous contrast agent is reasonable if the diagnosis of apical HCM or apical infarction or severity of hypertrophy is in doubt, particularly when other imaging modalities such as CMR are not readily available, not diagnostic, or contraindicated. (Level of Evidence: C) 5.Serial TTE studies are reasonable for clinically unaffected patients who have a first-degree relative with HCM when genetic status is unknown. Such follow-up may be considered every 12 to 18 months f or children or adolescents from high-risk families and every 5 years for adult family members. (Level of Evidence: C) 12 Class III: 1. TTE studies should not be performed more HCM when it is unlikely that any changes have occurred that would have an impact on clinical decision making. (Level of Evidence: C) 2. Routine TEE and/or contrast echocardiography is not recommended when TTE images are diagnostic of HCM and/or there is no suspicion of fixed obstruction or intrinsic mitral valve pathology. (Level of Evidence: C)No Benefit frequently than every 12 months in patients with 13 6. Stress Testing Class IIa 1. Treadmill exercise testing is reasonable to determine functional capacity and response to therapy in patients with HCM. (Level of Evidence: C) 2. Treadmill testing with monitoring of an electrocardiogram and blood pressure is reasonable for SCD risk stratification in patients with HCM. (Level of Evidence: B) 3. In patients with HCM who do not have a resting peak instantaneous g radient of greater than or equal to 50 mm Hg, exercise echocardiography is reasonable for the detection and quantification of exercise-induced dynamic LVOT obstruction. (Level of Evidence: B) 14 7. Cardiac Magnetic Resonance Class I 1.CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis. (Level of Evidence: B) 2. CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography. (Level of Evidence: B) Class IIa 1. CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive. (Level of Evidence: B) 15 Class IIb 1.In selected patients with known HCM, when SCD risk stratification is inconclusive after docume ntation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement may be considered in resolving clinical decision making. (Level of Evidence: C) 2. CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy. (Level of Evidence: C) 16 8. Detection of Concomitant Coronary Disease Class I 1. Coronary arteriography (invasive or computed tomographic imaging) is indicated in patients with HCM with chest discomfort who have an intermediate to high likelihood of coronary artery disease (CAD) when the identification of concomitant CAD will change management strategies. (Level of Evidence: C) Class IIa 1.Assessment of coronary anatomy with computed tomographic angiography is reasonable for patients with HCM with chest discomfort and a low likelihood of CAD to assess for possible concomitant CAD. (Level of E vidence: C) 2. Assessment of ischemia or perfusion abnormalities suggestive of CAD with single-photon emission computed tomography or positron emission tomography myocardial perfusion imaging (because of excellent negative predictive value) is reasonable in patients with HCM with chest discomfort and a low likelihood of CAD to rule out possible concomitant CAD. (Level of Evidence: C) 17 Class III: 1. Routine single-photon emission computed echocardiography is not indicated for detection of â€Å"silent† CAD-related ischemia in patients with HCM who are asymptomatic. (Level of Evidence: C) 2.Assessment for the presence of blunted flow reserve (microvascular ischemia) using quantitative myocardial blood flow measurements by positron emission tomography is not indicated for the assessment of prognosis in patients with HCM. (Level of Evidence: C) No Benefit tomography myocardial perfussion imaging or stress 18 9. Asymptomatic Patients Class I 1. For patients with HCM, it is recom mended that comorbidities that may contribute to cardiovascular disease (e. g. , hypertension, diabetes, hyperlipidemia, obesity) be treated in compliance with relevant existing guidelines. (Level of Evidence: C) Class IIa 1. Low-intensity aerobic exercise is reasonable as part of a healthy lifestyle for patients with HCM. (Level of Evidence: C) Class IIb 1.The usefulness of beta blockade and calcium channel blockers to alter clinical outcome is not well established for the management of asymptomatic patients with HCM with or without obstruction. (Level of Evidence: C) Class III: Harm 1. Septal reduction therapy should not be performed for asymptomatic adult and pediatric patients with HCM with normal effort tolerance regardless of the severity of obstruction. (Level of Evidence: C) 2. In patients with HCM with resting or provocable outflow tract obstruction, regardless of symptom status, pure vasodilators and high-dose diuretics are potentially harmful. (Level of Evidence: C) 19 Fi gure 1. Treatment Algorithm HCM PatientsACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; DM, diabetes mellitus; EF, ejection fraction; GL, guidelines; HCM, hypertrophic cardiomyopathy; HTN, hypertension; and LV, left ventricular. Treat comorbidities according to GL [HTN, Lipids, DM] Obstructive Physiology No Heart Failure Symptoms or Angina No Yes Yes Avoid vasodilator therapy and highdose diuretics Systolic Function Annual clinical evaluation No Heart Failure Symptoms or Angina LV EF 50 mm Hg) for whom standard medical therapy has failed. (Level of Evidence: C) 4.When surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation, when performed in experienced centers, can be beneficial in eligible adult patients with HCM with LVOT obstruction and severe drug-refractory symptoms (usually New York Heart Association functional classes III or IV). (Level of Evidence: B) 26 Class IIb 1. Alcohol septal ablation, when performed in experienced centers, may be considered as an alternative to surgical myectomy for eligible adult patients with HCM with severe drug-refractory symptoms and LVOT obstruction when, after a balanced and thorough discussion, the patient expresses a preference for septal ablation. (Level of Evidence: B) 2. The effectiveness of alcohol septal ablation is uncertain in patients with HCM with marked (i. e. , >30 mm) septal hypertrophy, and therefore the procedure is generally discouraged in such patients. (Level of Evidence: C) Class III: Harm 1.Septal reduction therapy should not be done for adult patients with HCM who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on optimal medical therapy. (Level of Evidence: C) 2. Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with HCM. (Level of Evidence : C) 27 3. Mitral valve replacement for relief of LVOT obstruction should not be performed in patients with HCM in whom septal reduction therapy is an option. (Level of Evidence: C) 4. Alcohol septal ablation should not be done in patients with HCM with concomitant disease that independently warrants surgical correction (e. g. coronary artery bypass grafting for CAD, mitral valve repair for ruptured chordae) in whom surgical myectomy can be performed as part of the operation. (Level of Evidence: C) 5. Alcohol septal ablation should not be done in patients with HCM who are less than 21 years of age and is discouraged in adults less than 40 years of age if myectomy is a viable option. (Level of Evidence: C) 28 12. Pacing Class IIa 1. In patients with HCM who have had a dualchamber device implanted for non-HCM indications, it is reasonable to consider a trial of dual-chamber atrial-ventricular pacing (from the right ventricular apex) for the relief of symptoms attributable to LVOT obst ruction. (Level of Evidence: B) Class IIb 1.Permanent pacing may be considered in medically refractory symptomatic patients with obstructive HCM who are suboptimal candidates for septal reduction therapy. (Level of Evidence: B) Class III: 1. Permanent pacemaker implantation for the performed in patients with HCM who are asymptomatic or whose symptoms are medically controlled. (Level of Evidence: C) 2. Permanent pacemaker implantation should not be performed as a first-line therapy to relieve symptoms in medically refractory symptomatic patients with HCM and LVOT obstruction in patients who are candidates for septal reduction. (Level of Evidence: B) No Benefit purpose of reducing gradient should not be 29 13. Sudden Cardiac Death Risk Stratification Class I 1.All patients with HCM should undergo comprehensive SCD risk stratification at initial evaluation to determine the presence of: (Level of Evidence: B) a. A personal history for ventricular fibrillation, sustained ventricular tach ycardia, or SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * b. A family history for SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * c. Unexplained syncope. d. Documented nonsustained ventricular tachycardia (NSVT) defined as 3 or more beats at greater than or equal to120 bpm on ambulatory (Holter) electrocardiogram. e. Maximal LV wall thickness greater than or equal to 30 mm. Appropriate ICD discharge is defined as ICD therapy triggered by VT or ventricular fibrillation, documented by stored intracardiac electrogram or cycle-length data, in conjunction with the patient’s symptoms immediately before and after device discharge. 30 Class IIa 1. It is reasonable to assess blood pressure response during exercise as part of SCD risk stratification in patients with HCM. (Level of Evidence: B) 2. SCD risk stratification is reasonable on a periodic basis (every 12 to 24 months) for patients with HCM who have not under gone ICD implantation but would otherwise be eligible in the event that risk factors are identified (12 to 24 months). (Level of Evidence: C)Class IIb 1. The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: a. CMR imaging with late gadolinium enhacement. (Level of Evidence: C) b. Double and compound mutations (i. e. , >1). (Level of Evidence: C) c. Marked LVOT obstruction. (Level of Evidence: B) Class III: Harm 1. Invasive electrophysiologic testing as routine SCD risk stratification in patients with HCM should not be performed. (Level of Evidence: C) 31 14. Selection of Patients for Implantable Cardioverter-Defibrillators Class I 1.The decision to place an ICD in patients with HCM should include application of individual clinical judgment, as well as a thorough discussion of the strength of evidence, benefits, and risks to allow the informed patient’s active participation in decision making. (Level of Evidence: C) 2. ICD placement is recommended for patients with HCM with prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. (Level of Evidence: B) Class IIa 1. It is reasonable to recommend an ICD for patients with HCM with: a. Sudden death presumably caused by HCM in 1 or more first-degree relatives. (Level of Evidence: C) b. A maximum LV wall thickness greater than or equal to 30 mm. (Level of Evidence: C) c. One or more recent, unexplained syncopal episodes. (Level of Evidence: C) 2.An ICD can be useful in select patients with NSVT (particularly those 30 mm or Recent unexplained syncope No Yes ICD reasonable Nonsustained VT or Abnormal BP response Yes Other SCD Risk Modifiers* Present? Yes No ICD can be useful Legend Class I Class IIa No ICD not recommended Class IIb Class III Role of ICD uncertainRegardless of the level of recommendatio n put forth in these guidelines, the decision for placement of an ICD must involve prudent application of individual clinical judgment, thorough discussions of the strength of evidence, the benefits, and the risks (including but not limited to inappropriate discharges, lead and procedural complications) to allow active participation of the fully informed patient in ultimate decision making. BP indicates blood pressure; ICD, implantable cardioverter-defibrillator; LV, left ventricular; SCD, sudden cardiac death; SD, sudden death; and VT, ventricular tachycardia. 35 15. Participation in Competitive or Recreational Sports and Physical ActivityClass IIa 1. It is reasonable for patients with HCM to participate in low-intensity competitive sports (e. g. , golf and bowling). (Level of Evidence: C) 2. It is reasonable for patients with HCM to participate in a range of recreational sporting activities as outlined in Table 2. (Level of Evidence: C) Class III: Harm 1. Patients with HCM should not participate in intense competitive sports regardless of age, sex, race, presence or absence of LVOT obstruction, prior septal reduction therapy, or implantation of a cardioverterdefibrillator for high-risk status. (Level of Evidence: C) 36 Table 2. Recommendations for the Acceptability of Recreational Noncompetitive) Sports Activities and Exercise in Patients With HCM* Intensity Level High Basketball (full court) Basketball (half court) Body building†¡ Gymnastics Ice hockey†¡ Racquetball/squash Rock climbing†¡ Running (sprinting) Skiing Soccer Tennis (singles) Touch (flag) football Windsurfing § Moderate Baseball/softball Biking Modest hiking Motorcycling†¡ Jogging Sailing § Surfing § Swimming (laps) § Tennis (doubles) Treadmill/stationary bicycle Weightlifting (free weights)†¡|| Hiking 2 4 4 3 3 3 2 5 4 5 1 3 (downhill)†¡ Skiing (cross-country) 0 0 1 2 0 0 1 0 2 2 0 0 1 1 Eligibility Scale for HCM†  Intensity Level Low Bowling Golf Hor seback riding†¡ Scuba diving § Skating ¶ Snorkeling § Weights (nonfree weights) Brisk walking 5 5 3 0 5 5 4 5 Eligibility Scale for HCM†  *Recreational sports are categorized according to high, moderate, and low levels of exercise and graded on a relative scale (from 0 to 5) for eligibility, with 0 to 1 indicating generally not advised or strongly discouraged; 4 to 5, probably permitted; and 2 to 3, intermediate and to be assessed clinically on an individual basis. The designations of high, moderate, and low levels of exercise are equivalent to an estimated >6, 4 to 6, and

Fitzgerald Research Paper Essays

Fitzgerald Research Paper Essays Fitzgerald Research Paper Paper Fitzgerald Research Paper Paper Essay Topic: Short Stories of F Scott Fitzgerald F. Scott Fitzgerald F. Scott Fitzgerald lived during the time of the Great Depression, where money was low In almost every household. This pushed Fitzgerald favorite topic of a poor boy becoming rich Into the American public. Dexter, the mall character In Winter Dreams went from being an average boy that was living a good life to a rich man because of the love he had for a wealthy girl named Judy Jones. Through, Winter Dreams Fitzgerald explained the major events of his own life. Although many critics believed that Fitzgerald had a great talent in writing and he lived a great life, some live that he wasted the talent that was given to him by drinking and shortening his life every day. Many believe that he was responsible for his own death. Fitzgerald did not come from a wealthy family; however the family was considered upper- middle class. Fitzgerald was born to Edward and Mollie Fitzgerald on September 24th 1896 In Saint Paul Minnesota. Since his parents were strong Catholics, they sent him to two different private schools. The first one was the Holy Angel in New York, and later after having some money problems they moved back to Minnesota and he tended SST Paul Academy. The most well known school that Fitzgerald went was Princeton. While he was there he wrote for the Nassau magazine as well as the Princeton Tiger school newspaper. He attended Princeton for a few years until World War One began. At the time of the war the country was flooding with nationalism and many young fit boys were enlisting to play their role for their country. And of course Fitzgerald Joins with his fellow classmates. : After Fitzgerald came home from the war, he started his writing career with his first novel, This Side of Paradise. This novel spooned greatly and was an instant, famous American novel at the time. After a few short stories for magazines such as Winter Dreams, he published his second novel, The Great Gatsby. This novel was also a great success and the American public loved his work. Fitzgerald wrote his best work when he was the most popular (Bryant and Pits 5). However, after The Great Gatsby, his career In writing started to go downhill E was dead as an author before he was dead (Chain. E. Charles 77). This was because he and his lovely wife were partying every day, and they had become heavy drinkers. By the near end of Fitzgerald life, everything was completely broken. His wife was in a hospital because she was having Psychotic episodes, and he had a really bad habit of abusing alcohol. He passed away by the age of forty four. Winter Dreams portrays an average American kid growin g up to living the American dream, or at least trying to do so. The story takes place in a few different states throughout the United States. Winter Dreams passes by summer, fall winter and spring quickly showing us how fast time is passing by in the story. Dexter, the main character starts if the story In the state of Minnesota. HIS part time Job was to be a caddie, and he was pretty good at his Job, Dexter falls In love with a beautiful, stunning girl named Judy Jones. However, the fantasies that Dexter has for Judy cannot play out because of the class difference between Judy and Dexter. Judos family is considered wealthy Judy Dexter decides to get rich and become part of the wealthy life. After college Dexter invests in a laundry business at a town near his home town in Minnesota. This brings Dexter a great deal of money and now he is considered rich. Due to the money e now has he tried his best to fit with the wealthy people in the town. However, he will never be like them because of the fact that he is new money while the others are old money. His plan of getting rich and then getting Judy somewhat plays out right; he gets invited to dinner with the Jones family by Judy. When Dexter is in Judy room he knows that she has had many lovers before but he does not seem to care. Time passes by and one day Dexter realizes that Judy does not actually love him, and he realizes how crazy he was being. To get away from his mistakes he marries a girl named Irene and attempts to forget everything he can about Judy. A few years after his marriage Dexter ends up having an affair with Judy, having realized once again how stupid he was being he moved to east New York with his wife. While he was there he decided to Join the army and take part in WWW. When he returns from the war he learns that Judy Jones is now married, and not only that she has lost the stunning beauty Dexter once loved her for. That is when Dexter knows that his Winter Dreams of being with Judy and all of her money is not gone and he cant ever get it back. Winter Dreams and Fitzgerald life have a direct connection to each other. Dexter lives in a Minnesota for most of the short story and then moved to East New York. These were also the two places that Fitzgerald lived during his life time, he was schooled in New York when he was a boy and later moved to Minnesota due to money troubles. The two main characters in the short story, Dexter and Judy, represent Fitzgerald own love life that he has with Zelda. In the short story Dexter proposes to Judy, and gets rejected. This also happened to Fitzgerald when he first reposed to Zelda. Winter Dreams also shows a direct connection to Fitzgerald personal life as well. Fitzgerald took part in World War One and Dexter also Joins the war in the story. Many critics viewed Winter Dreams as the start of Fitzgerald writing career. This was the story that made him popular with the American reading public. And some people believed that Fitzgerald wrote his best works when he was at his highest level of being an author (Bryant 6). The American public responded well to the Winter Dreams which inspired Fitzgerald to make it into a novel. This wows how Fitzgerald liked to use his short stories as experiments to see how the topic or theme is responded to by the readers. Although Fitzgerald wrote many great short stories and novels, some critics believed that, towards the end of his life his works were nothing compared to his earlier works (Bryant 60). Also many people believe that he was responsible for his own death, because of his drinking problems he was shortening his own life. It was considered wasting his great talent of writing stories and novels ( Chain 77). Fitzgerald was one of the greatest American writers to ever lived, he was brought up in an average family and turned out to be wealthy because he chased and earned the American dream. A few stories like, Winter Dreams represents the American dream and his own life. Although he had a tough adulthood with his wife being a in a hospital and him drinking more than ever, he still tried to keep his dream alive.

Free Essays on Ludwig Van Beetoven

Beethoven was born in Bonn. His father’s harsh discipline and alcoholism made his childhood and adolescence difficult. At the age of 18, after his mother’s death, Beethoven placed himself at the head of the family, taking responsibility for his two younger brothers, both of whom followed him when he later moved to Vienna, Austria. Beethoven’s music is generally divided into three main creative periods. The first, or early, period extends to about 1802, when the composer made reference to a â€Å"new manner† or â€Å"new way† in connection with his art. The second, or middle, period extends to about 1812, after the completion of his Seventh and Eighth symphonies. The third, or late, period emerged gradually; Beethoven composed its pivotal work, the Hammerklavier Sonata, in 1818. Beethoven’s late style is especially innovative, and his last five quartets, written between 1824 and 1826, can be regarded as marking the onset of a fourth creative period. The celebrated Symphony No. 5 in C minor op. 67 from 1808 is the most thematically concentrated of Beethoven’s works. Variants of the four-note motif that begins this symphony drive all four movements. The dramatic turning point in the symphony-where a sense of foreboding, struggle, or mystery yields to a triumphant breakthrough-comes at the transition to the final movement, where the entrance of the trombones reinforces the music. Beethoven uses here a large-scale polarity between the darker sound of C minor and the brighter, more radiant effect of C major, which is held largely in reserve until the finale. The series of gigantic masterpieces of Beethoven’s third period include the technically demanding Hammerklavier Sonata, completed in 1818, about which he correctly predicted on account of its challenges that â€Å"it will be played fifty years hence,† and the Diabelli Variations. The latter work for piano transforms a trivial waltz by Viennese publ isher Anton Diabelli into an ... Free Essays on Ludwig Van Beetoven Free Essays on Ludwig Van Beetoven Beethoven was born in Bonn. His father’s harsh discipline and alcoholism made his childhood and adolescence difficult. At the age of 18, after his mother’s death, Beethoven placed himself at the head of the family, taking responsibility for his two younger brothers, both of whom followed him when he later moved to Vienna, Austria. Beethoven’s music is generally divided into three main creative periods. The first, or early, period extends to about 1802, when the composer made reference to a â€Å"new manner† or â€Å"new way† in connection with his art. The second, or middle, period extends to about 1812, after the completion of his Seventh and Eighth symphonies. The third, or late, period emerged gradually; Beethoven composed its pivotal work, the Hammerklavier Sonata, in 1818. Beethoven’s late style is especially innovative, and his last five quartets, written between 1824 and 1826, can be regarded as marking the onset of a fourth creative period. The celebrated Symphony No. 5 in C minor op. 67 from 1808 is the most thematically concentrated of Beethoven’s works. Variants of the four-note motif that begins this symphony drive all four movements. The dramatic turning point in the symphony-where a sense of foreboding, struggle, or mystery yields to a triumphant breakthrough-comes at the transition to the final movement, where the entrance of the trombones reinforces the music. Beethoven uses here a large-scale polarity between the darker sound of C minor and the brighter, more radiant effect of C major, which is held largely in reserve until the finale. The series of gigantic masterpieces of Beethoven’s third period include the technically demanding Hammerklavier Sonata, completed in 1818, about which he correctly predicted on account of its challenges that â€Å"it will be played fifty years hence,† and the Diabelli Variations. The latter work for piano transforms a trivial waltz by Viennese publ isher Anton Diabelli into an ...