Mental Health and Care in the Community

Mental Health and Care in the Community The issue of the mental health of the patient is complex and value-laden. Paternalism and autonomy interests confront difficulties of definition, diagnosis and the impact of labelling. Paternalism dictates intervention, and that the human right of autonomy be minimalist. (Davies, M., Medical Law, Blackstone Press Limited, 1996, p.182). Discuss critically. Within mental health issues there has always been a large degree of paternalism. Healthcare professionals and governments appear to view those with mental health problems as incapable of being able to make decisions for themselves and are often viewed as a potential danger[1] to themselves and others. Over the years various pieces of legislation have been enacted to deal with people with mental health issues starting with the Lunatics Act 1845, the Lunacy Act 1890, Mental Treatment Act 1930, Mental Health Act 1959 and the Mental Health Act 1983. In 1995 the Mental Health (Patients in the Community) Act was introduced. This gave the relevant authorities the power of supervised[2] discharge of mental health patients back into the community. Recent events where mental health patients were placed back into society has caused concern as there have been quite a few highlighted incidents where such patients have proven to be a danger to themselves and others[3]. The governments response to the public outrage when these patients have attacked or killed members of the public is to step back to a more paternalistic approach towards the treatment of mental health patients by introducing the Mental Capacity Act 2005[4]. The new Act allows the professionals to make value judgments over the patients and requires those dealing with such patients to make an assessment of the individual’s capacity[5] to make decisions for themselves. Section 2 (1) of the 2005 Act states (1) For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. Subsection 2 goes on to say that (2) It does not matter whether the impairment or disturbance is permanent or temporary. The very wording of the Act is open to abuse as the scope of what might be deemed as mental incapacity is too broad. In essence anyone who is suffering from a temporary mental breakdown either through circumstances within their own life or as the result of any prescribed medication they might be taken could be viewed as lacking the capacity to make decisions about their selves and could be institutionalised and forced to have treatment. A further problem with the new Act is that the decision on the individual’s capacity is based on the balance of probabilities. (4) In proceedings under this Act or any other enactment, any question whether a person lacks capacity within the meaning of this Act must be decided on the balance of probabilities. In criminal proceedings the court has to prove beyond reasonable doubt that the person charged with the offence has committed the offence. With this new piece of legislation the level of proof required is equivalent to that required within the civil courts and therefore is open to greater abuse and it is likely that a higher proportion of people may find themselves being detained in a mental health institute and subjected to compulsory treatment[6]. Section 3 of the Act goes further to describe how it can be decided that a person is unable to make a decision for himself. It lists 4 areas that should be considered in deciding whether the person lacks the capability to make their own decisions. (1) For the purposes of section 2, a person is unable to make a decision for himself if he is unable- (a) to understand the information relevant to the decision, (b) to retain that information, (c) to use or weigh that information as part of the process of making the decision, or (d) to communicate his decision (whether by talking, using sign language or any other means). Subsection 2 does go on to say (2) A person is not to be regarded as unable to understand the information relevant to a decision if he is able to understand an explanation of it given to him in a way that is appropriate to his circumstances (using simple language, visual aids or any other means). In essence the above is an attempt to limit those who can be regarded as incapable of making decisions due to any physical disability such as deafness or blindness, however, some individuals may be so severely handicapped through conditions such as autism or mongolism that even things explained in simple language may not be understood by them. These people may not be a danger to themselves or others and are usually being cared for by members of their own families[7]. Some families find the strain of a severely handicapped person in the household hard to cope with and for those people this new Act may help them to get the handicapped person institutionalised. Using the above Act they could argue that the person lacks the mental capacity to make decisions for themselves and is a potential danger[8] to themselves so for their own protection they should be removed from society. If the person assessing the individual is satisfied that that individual does not have the capacity to make their own decisions then any treatment they consider to be in the best interests[9] of the individual can be ordered. The person ordering the treatment must take into account whether the patient may at some future time be able to make their own decisions again and if they decide that this is likely they must take all appropriate steps to ensure the patient receives all the assistance they need to recover to a position where they can make their own decisions. Effectively though the legislation allows the person treating the patient with the mental health problem to remove all autonomy from the patient and force treatment on them that they might ordinarily object to if they had the capacity to do so. The legislation does state that the person making the decision on behalf of the patient should take into account the patients past and present wishes and feelings and make judgments based on what they perceive the patient would want if they were able to decide for themselves. The new Act is designed to operate alongside the Mental Health Act 1983 and the Mental Health (Patients in the Community) Act 1995, as was introduced with the aim of simplifying the way in which a person can be adjudged to be in need of treatment in respect of a mental health issue[10]. Under the 1983 Act compulsory admission to mental institutions is determined with reference to section 1 of the Act and refers to mental disorder but also covers any other disorder or disability of the mind. The Act attempts to specify the persons who they deem in need of admission for treatment and covers four broad areas namely mental illness, severe mental impairment, psychopathic disorder or mental impairment. The first 2 conditions trigger automatic admission regardless of whether the treatment is likely to be effective or not. With the last 2 conditions psychopathic disorder and mental impairment, admission can only be ordered if the patients are likely to benefit from the treatment. Under the new Act the definition has been extended to cover a far wider audience and it is likely under the provisions of the 2005 Act that those with a psychopathic disorder can be detained regardless of whether treatment will assist their condition. The 1983 Act does not specifically define mental illness and can be problematic as it does not cover conditions where a person may undertake activities that are potentially life threatening due to a compulsion for risk taking. It is possible that the 2005 At might encompass this area as section 3 (4) states that when deciding whether someone is capable of making their own decisions account should be taken as to whether the person has the capability of being able to reasonably foresee the consequences of the decisions they are making. Whilst it could be argued that this is a positive move[11] there is room for abuse of this inclusion in the legislation and could theoretically be used to cover sado masochistic activities between consenting adults or the participation of dangerous sports. To be effective the 2005 Act should incorporate examples where there is a clear demonstration that the patient lacks the capacity for being able to foresee the consequences of their actions. This would assist the person making the decision about the patients mental capacity as they could compare the actions of their patient with actions previously seen to be harmful. There are a few dangers surrounding the 2005 Act in that mental capacity is judged according to the individual’s capacity to make their own decisions. The 1983 Act defines psychopathic behaviour as a persistent disorder or disability of mind (whether or not including impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned. Research into psycopathy has shown that whilst the psychopath may not always conform to rules they do have the ability to do so. Following the guidance in the 2005 Act regarding mental capacity this could mean that dangerous psychopaths could slip through the net as they may well be able to show that they do not lack the necessary capacity to make decisions on their own. By establishing this they will be able to refuse treatment as autonomy is only forfeited where the patient lacks the capacity to make their own decisions. The new Act is inherently flawed in that temporary mental incapacity can lead to compulsory admission to an institute[12]. This could have a dramatic effect on people such as women suffering post natal depression after childbirth. In the past doctors have prescribed tranquilisers and anti depressants to attempt to cure the patient. Under the 2005 Act the partner of the patient suffering post natal depression could request that their partner be assessed for mental capacity. If the person doing the assessment is of the opinion that the mother is incapable of making their own decisions the mother might find herself placed in a mental institute and forced to receive treatment she might otherwise object to. The 2005 Act also contains a section authorising power of attorney[13] to family and other persons connected to the person who has been assessed as lacking in mental capacity. This is open to widespread abuse as greedy relatives may use a temporary mental impairment of their family member to gain power of attorney over their monetary assets and squander any of their savings away. It has also been proven by past examples that once a person has been admitted to a mental institution it is difficult for the patient to convince the doctors and medical staff that they have now recovered from their mental illness and no longer need to be institutionalised[14]. In the UK paternalistic intervention[15] has been used even when the patient having the treatment poses no threat to others or himself. In the case of W v Egdell [1990] ch 359 a psychiatrist was asked to examine a patient at the request of the patient’s solicitor to assess the suitability of transferring the patient from a secure hospital back into the community. The psychiatrist submitted his report to the Home Office in order to prevent what he perceived could be a danger if the patient was prematurely released. As a result of this report the patient was forced to remain within the secure hospital despite the fact that at no time had the patient committed any acts of violence. This kind of paternalistic intervention offends against the principle of autonomy[16] and should only really be justified when the person for whom the decision has been made is unable to make an informed choice for himself. The approach to deciding whether paternalism should be allowed when assessing a person with a mental illness should be to ask whether the patient would consent[17] to the proposed treatment if they were able to make a rational choice. In America they used what is known as the substituted judgment test which is autonomy based in the sense that the intervention is directed towards the goal of restoring the patients autonomy. Another way in which the mental health professionals have sought to circumvent claims of enforced treatment is by the use of implied consent[18]. The notion behind this is that although the person by reason of incapacity cannot give their consent at that point in time they may be able to endorse the treatment at a later date, which would then amount to a form of retrospective consent[19]. Obviously there are difficulties with this approach as there is no way of predicting that subsequent consent will be given when the person is in a position to give that consent. Frequently those who resent involuntary treatment will continue to do so after recovery. Due to the obvious problems associated with interference with the autonomy of the patient most mental health professionals adopt the paternalistic best interests[20] test as outlined in the Mental Health Act and uses the Act to order compulsory treatment of the patient. The 1983 Act provides 3 ways in which a patient can be compulsorily admitted to hospital for treatment[21]. Section 2 of the Act gives the patient’s nearest relative or any person authorised to act on their behalf the right to apply for the admission of the patient into hospital. In order to qualify for the right to make such an application the applicant must have seen the patient within the 14 days prior to the application. The application must be supported by 2 registered practitioners one of whom must be qualified in psychiatry. Grounds[22] for admission under section 2 are that a patient is suffering from a mental disorder of a degree which warrants detention in a hospital at least for a limited period of time and should be to prevent harm to himself or others. Under this kind of admission the maximum time the patient can be detained is 28 days and admissions cannot be renewed thereafter. The second way in which patients can be admitted is under section 4 of the Act which covers emergency admissions and can be applied for on the recommendation of one doctor only but is only valid for 72 hours. The doctor does not need to be a specialist in the treatment of mental health but if possible must have known the patient beforehand. The applicant must have seen the patient within the last 24 hours. Such emergency admissions can be converted to treatment for 28 days by seeking a second opinion from a mental health specialist. The third way in which compulsory admission can occur is under s3 of the Act and application is similar as those under section 2 of the Act. Under this section of the Act the patient can be detained for up to 6 months and can be renewed thereafter, initially for an extra 6 months and then yearly for periods of a year at a time. Detention under this section can last indefinitely. Those who do recover from their mental disorder may be released from the secure units[23] but held under supervision[24] orders using section 117 of the Mental Health Act, and although they can no longer be forced to receive treatment they will be expected to attend at a treatment centre. Unfortunately there is no system in place to ensure that such patients do attend the treatment centres and no sanctions available to the authorities to enforce their attendance. It has been suggested that those patients who have been discharged and do not comply with the supervision orders should be readmitted to hospital under a compulsory admission so as treatment can be enforced without the patient’s consent. In order to prevent claims being made by those who have been compulsorily admitted to hospital and forced to undergo treatment section 139 of the Mental Health Act was added which states that ‘no person shall be liable†¦to any civil or criminal proceedings†¦in respect of any act purporting to be done in pursuance of this Act†¦unless the act was done in bad faith or without reasonable care.’ This effectively gives the hospitals total paternalism[25] over the treatment of compulsorily admitted patient and negates any patient autonomy or rights to personal autonomy until such a time as the persons treating them are satisfied that the patient is recovered sufficiently to render them capable of making their own decisions. The overall view that is apparent from looking at the 1983 Act and the recent 2005 Act is that paternalism has always been present within the treatment of mental health patients. The 2005 Act broadens the classes of people who may now be classified as in need of compulsory admission and treatment and therefore strengthens the position of paternalism whilst reducing personal autonomy practically into non-existence. The danger in allowing the government to increase the power for compulsory treatment could in the future spread to other areas of medical treatment and could lead to persons with terminal illness who have expressed a wish not to be treated being forced to undergo treatment by being held to be mentally incapable of making rational decisions. There could also be problems where patients refuse treatment on the grounds of religious belief. It might be argued by the person giving the treatment that the patient has been indoctrinated by the religious group they are part of and are therefore incapable of making decisions independent of the doctrines instilled in them by their religious teachings. Allowing paternalism to become acceptable for one classification of person could ultimately lead to problems in all areas of legislation and could result in criminals being locked away indefinitely as it could be viewed as in the best interests of society to keep them locked away. Governments have used the fear that the general public have of people with mental illnesses posing a threat to ordinary members of the public by highlighting those incidents were patients have been released from institutions and then have harmed or killed others[26]. By using this fear they have persuaded the general public that compulsory admission of the mentally ill is the only way to prevent others from being harmed and that it is in the best interests of the patient and society for them to be forced to undergo treatment and remain institutionalised[27]. Bibliography Mason McCall Smith, Law and Medical Ethics, 5th Ed 1999, Butterworths. Darjee R, Crichton J. The MacLean committee: Scotlands answer to the dangerous people with severe personality disorder proposals? Psychiatric Bill 2002;26: 6- Watts J, Priebe S. A phenomenological account of users experiences of assertive community treatment. Bioethics 2002; 16: 439-454 Department of Health and Home Office. Managing dangerous people with severe personality disorder. London: Stationery Office, 1999. Scmukler, G, Homicide Enquiries. What sense do they make?, Psychiatric Bulletin , 24, pages 6-10, 2000 Scottish Executive. Report of the committee on serious violent and sexual offenders. Edinburgh: Scottish Executive, 2000 Steadman, H, Mulvey, E, Monahan, J, Robbins, p, Applebaum, P, Grisso, T, Roth,L, and Silver, E, Violence by people discharged from acute psychiatric inpatient facilities and others in the same neighbourhoods, Archives of General Psychiatry, 55, pages 393-401, 1998. Who Decides; Making Decisions on Behalf of Mentally Handicapped Adults (LCD, 1997) http://www.ethox.org.uk http://www.dh.gov.uk http://www.guardian.co.uk http://bjp.rcpsych.org http://akmhcweb.org Table of Cases R v Bournewood Community and Mental Health NHS Trust ex p L [1998] 3 WLR 107 Re F [1990] 2 AC 1 Re T (adult: refusal of medical treatment) [1992] 4 All ER 649, CA.). Re Y [1996] 35 BMLR 111 S v McC; W v W [1972] AC 24 St Georges Healthcare NHS Trust v S; R v Collins and others, ex parte S [1998] 3 All ER 673, [1998] Fam Law 526, CA W v Egdell [1990] ch 359 Table of Statutes Lunacy Act 1890 Lunatics Act 1845 Mental Capacity Act 2005 Mental Health (Patients in the Community) Act 1995 Mental Health Act 1959 Mental Health Act 1983 Mental Treatment Act 1930 1 Footnotes [1] Scottish Executive. Report of the committee on serious violent and sexual offenders. Edinburgh: Scottish Executive, 2000 [2]http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/MentalHealth/MentalHealthArticle/fs/en?CONTENT_ID=4131958chk=/1k+X3 [3] Steadman, H, Mulvey, E, Monahan, J, Robbins, p, Applebaum, P, Grisso, T, Roth,L, and Silver, E, Violence by people discharged from acute psychiatric inpatient facilities and others in the same neighbourhoods, Archives of General Psychiatry, 55, pages 393-401, 1998. [4]http://www.guardian.co.uk/Archive/Article/0,4273,4448443,00.html;http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/MentalHealth/MentalHealthArticle/fs/en?CONTENT_ID=4089588chk=we/GKL [5] St Georges Healthcare NHS Trust v S; R v Collins and others, ex parte S [1998] 3 All ER 673, [1998] Fam Law 526, CA [6] Mason McCall Smith, Law and Medical Ethics, 5th Ed 1999, Butterworths. P510 -512 [7] R v Bournewood Community and Mental Health NHS Trust ex p L [1998] 3 WLR 107 [8] Darjee R, Crichton J. The MacLean committee: Scotlands answer to the dangerous people with severe personality disorder proposals? Psychiatric Bill 2002;26: 6-8 [9] Re F [1990] 2 AC 1 [10] Department of Health. Reforming the Mental Health Act. London: Stationery Office; 2000. [11]http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/MentalHealth/MentalHealthArticle/fs/en?CONTENT_ID=4089589chk=1fWV90 [12] Mental Capacity Act 2005 s2 (2) [13] Mental Capacity Act 2005 s9 [14] http://akmhcweb.org/News/HungerStrike/LATimesMag10-26-2003.htm [15] Mason McCall Smith, Law and Medical Ethics, 5th Ed 1999, Butterworths p506 [16] http://www.ethox.org.uk/Ethics/econsent.htm#introduction [17] (S v McC; W v W [1972] AC 24; Re T (adult: refusal of medical treatment) [1992] 4 All ER 649, CA.). [18] Mason McCall Smith, Law and Medical Ethics, 5th Ed 1999, Butterworths p507 [19] Watts J, Priebe S. A phenomenological account of users experiences of assertive community treatment. Bioethics 2002; 16: 439-454 [20] Re Y [1996] 35 BMLR 111; http://www.ethox.org.uk/Ethics/econsent.htm#introduction [21] Who Decides; Making Decisions on Behalf of Mentally Handicapped Adults (LCD, 1997). [22] Mason McCall Smith, Law and Medical Ethics, 5th Ed 1999, Butterworths p503 [23] Mental Health (Patients in the Community) Act 1995 [24] Mental Health (Patients in the Community) Act 1995 (c.52) s1 [25]http://bjp.rcpsych.org/cgi/content/full/177/3/196?ijkey=b0b6443d7c871c32507c07da36faadf7633b7b9bkeytype2=tf_ipsecsha [26] Scmukler, G, Homicide Enquiries. What sense do they make?, Psychiatric Bulletin , 24, pages 6-10, 2000 [27] Department of Health and Home Office. Managing dangerous people with severe personality disorder. London: Stationery Office, 1999.

Peripheral Neuropathy among Patients Living with Diabetes

Peripheral Neuropathy among Patients Living with Diabetes Update on Foot Care: Identifying Early signs of Peripheral Neuropathy among  Patients Living with Diabetes Mellitus Bernice S. Samuel DNP  and  Susan J. Appel, PhD, APRN-BC, CCRN, FAHA Introduction Among those individuals living with diabetes, peripheral neuropathy (PNP) is a major contributor in the development of foot ulcers.1 Even though there has been a decline in recent limb amputations due to advanced management of foot ulcers, 7% of those affected with type 2 diabetes (T2D) will still develop foot ulcers.2 Diabetes-related foot ulcers not only cause further physical disability, they also reduce the quality of life and increase the risks of lower extremity amputations. 3 The CDC 4 reports that 65,700 non-traumatic lower-limb amputations were performed among people living with diabetes. While diabetes is a major cause of complications such as vasculopathies and PNP, foot ulcers are the most easily prevented complications. 5 Therefore, practitioners must be fully apprised of tools and methods used to identify early PNP and prevent foot ulcers. Practitioners should also focus on actively educating the patient and family regarding PNP. Most practitioners are familiar with the Semmes-Weinstein Monofilament testing (SWMT) as the gold standard used in primary care to assess for PNP. Mayfield and Sugarman reported the use of the SWMT as a useful tool in the primary care office for practitioners to assess patients for PNP, but indicated it is not without limitations. 6 Further interventions are needed when there is a loss of sensation detected, such as proper footwear and patient education, to prevent trauma and foot ulcers. 6 Research has shown that practitioners can continue to assess patients with diabetes using the monofilament testing as long as PNP is not present. Once PNP is noted, additional assessment and management techniques are warranted. A yearly thorough foot exam by a podiatrist has been recommended by the American Diabetes Association for those living with diabetes. 7 In addition, persons with diabetes and one or more risk factors need frequent assessments of their feet during routine office visits. 5 Patients with known risk factors for foot ulcers (e.g., poor vision, previous foot ulcers or amputation, monofilament insensitivity, and fungal infections of skin or nails) deserve special attention. 8 When practitioners have available clinical information that can help to predict the development of diabetes- related foot ulcers, patients will have better outcomes. 8 These predictors were found to be helpful in accurately targeting clients at high risks of contracting foot ulcers for preventative interventions. The use of proper footwear such as diabetes specialized shoes with proper diabetes foot insoles has been found to be a protective intervention. Pathophysiology of Foot Ulcers Diabetes related foot lesions occur as a result of two or more risk factors: PNP and peripheral arterial disease (PAD). 9 Diabetes-related PNP is a leading contributor to foot lesions. 10 The presence of PAD increases the risk for foot infections and ulcers among people living with diabetes. 11 Foot lesions are less likely to heal due to vascular insufficiency. 12 Research shows that there are three factors that leads to foot ulcers and infections: foot deformities, PNP, and minor trauma. 13 It is important to understand that the longer an individual lives with elevated blood glucose, the more likely he or she will develop PNP. 2 Long term hyperglycemia can affect the skin and delay wound healing if minor cuts or sores occur on the foot. 14 PNP According to Benbow, 14 PNP can be classified as sensory, autonomic or motor. In sensory system PNP, an individual with diabetes has no feeling of sensation on his or her feet, does not feel hot or cold temperature, and does not feel cuts or trauma to his or her feet. 14 When PNP affects the autonomic system an individual will experience a decrease in sweat, resulting in cracked or fissured skin, dilated dorsal veins and an increase in temperature of their feet. 14 When the motor system is affected by PNP, the patient will be at risk for developing foot deformities such as Charcot foot. 14 Commonly, these patients report symptoms of aches and pains with tingling in their feet when PNP is present. 13 Foot Deformities According to Abad Safdar, 13 foot deformities are the second causative factor that leads to foot ulcers among people living with diabetes. People affected by neuropathy have decreased sensation in their feet, and are more prone to foot deformities. 13 These foot deformities affect the muscles and bones of the foot leading to bony protrusions that put the individual at increased risk for ulceration especially when PNP is present. 13 The correlation of PNP and foot deformities was examined by Soyupek, Ceceli, Suslu, Yorgancioglu, 15 utilizing x-rays. Their study showed that the patients with PNP commonly also have foot deformities such as pes planus, pes cavus, tendon calcifications and osteoporosis. 15 Patients living with type 1 diabetes are particularly at risk for developing Charcot neuropathy that causes destruction of the bones of the foot. 16The resultant bone thinning causes the bones to be fragile and leads to foot deformities. 16 Foot Trauma Abad Safar 13 identify foot trauma as the third factor that can lead to foot ulcers. Foot ulceration occurs when there is breaking of the skin, which leads to impaired healing of the lesion. 12 People affected by PNP have sensory loss of their feet and are unable to identify foot pain, trauma, calluses or injury to their feet. 13 Wearing ill-fitting shoes, calluses, onychomycosis, and foot infections that are not treated are all causes of foot trauma leading to ulceration. Once ulceration occurs due to trauma, the wound becomes infected. Testing Tuning Fork and Neurothesiometer A study by Kà ¤stenbauer, Sauseng, Brath, Abrahamian, Irsigler 17 investigated the effectiveness of the Rydel-Seiffer tuning fork in helping with the detection of diabetes-related neuropathy and compared its ability with that of the electronic neurothesiometer. In this study a 128-Hz tuning fork and a neurothesiometer were used at the bedside. 17 The results of the study showed that vibration perception threshold (VPT) was normal in 1917 individuals and abnormal in about 105 individuals when the tuning fork was used. 17 The participants who had abnormal results were older and also had elevated A1c results. The researchers used the neurothesiometer and the results showed that VPT was 2.5 times higher among patients who had an abnormal tuning fork test. 17 The researchers concluded that the tuning fork had a higher sensitivity and a better predictive value in diagnosing PNP at the bedside. 17 The tuning fork is a reliable instrument in helping to detect PNP in the outpatient setting. It is an appropriate clinical tool that practitioners can utilize either at the bedside or in primary care. Neurometer A double-blinded study by Nather and et al. 18 showed that there were other testing methods that were superior in comparison to the SWMT in detecting PNP. One useful tool was neurometer testing. The neurometer measures readings from rapid current perception threshold (R-CPT) which is derived from the lowest strength of stimulus that the patient could perceive. 18 Three different rates of current signals at levels measuring between 0 and 10 mA were applied by the neurometer to the big toe and ankle. 18 Neurometer testing was found to be highly sensitive as compared to the SWMT. Sensory neuropathy was detected with better accuracy when using the neurometer testing at the big toe and ankle sites in comparison to the SWMT. 18 Studies show that the neurometer is an effective tool that practitioners can use to detect PNP. Temperature guided avoidance therapy Research shows that the best intervention in the prevention of foot ulcers was foot temperature guided avoidance therapy (TGAT). 19 A study by Lavery et al. 20 sought to evaluate the effectiveness of infrared temperature monitoring among individuals at a high risk for diabetes related ulceration and amputations. Patients were placed in a usual therapy group or an enhanced therapy group. 20 The enhanced therapy group had additional tasks such as such as the use of a handheld infrared skin thermometer to measure the temperatures on the bottom of their feet twice a day. 20Participants contacted a nurse if they noted a difference in temperature >4 °F between the left and right foot. 20 The results of the study showed that the enhanced therapy group had notably fewer diabetes related foot complications. 20 The TGAT is an effective method in the detection of PNP where practitioners can assist patients in identifying sensory loss so that foot ulcers and complications can be prevented. Scales for Neuropathy Symptoms The Diabetes Neuropathy Symptom (DNS) score is a valuable tool that can be used to screen for and identify PNP. 21 The scoring is based upon symptoms such as ataxic walking, neuropathic pain, paraesthesia, and/or numbness. The DNS criteria are scored with 1 point each and there is a total of 4 points that can be given. 21 Presence of PNP is present with a score of 1, or more. 21 Similarly, the Diabetic Neuropathy Examination (DNE) is another valuable scoring system that helps to identify PNP. This scoring system consists of a total of eight items: two of the items describe the person’s muscle strength; one item addresses reflexes of the tendon and the other five items address sensation. 21 There is a total of 16 points that can be scored with this system. Any score above 3 points is considered to be abnormal and is PNP. 21 Treatment Educating patients Educational interventions are an important tool in reducing foot ulcers. A randomized controlled trial by Gershater and et al. 22 was designed to investigate the effectiveness of patients learning in groups versus learning on their own with information that is provided to them. The authors sought to understand what types of learning would decrease the incidence of foot ulcers. The study results showed that about 42% of the patients got foot ulcers. 22 Some of the reasons for ulcer development were: stress- related plantar ulcer and trauma. 22 The study showed that education in group sessions among patients who are at increased risk for foot ulcers did not have an effect on whether they would develop ulcers of the foot. 22 It was concluded that sessions conducted within a group educational method may be suitable for patients who have a low risk of getting foot ulcers. The authors of the study suggests that it is important to educate practitioners involved in the patient’s medic al care and also their caregivers regarding improved foot care such as footwear and signs of foot problems. Implications for Practice The conclusive results show the best methods to identify PNP and to prevent foot ulcers was the TGAT, the neurothesiometer and the tuning fork. The TGAT method shows that patients can complete this task at home and alert their practitioner about the results. The TGAT is valuable in showing the results of further neuropathy or damage if patients have a prior history of insensitivity to the SWMT. The SWMT is valuable for practitioners to use in the office setting as this is an inexpensive test. The SWMT is not valid once neuropathy is diagnosed. The practitioner should consider the use of the TGAT at this point and teach the patient how to use an infrared sensitive skin thermometer. The patient should be advised to keep a log book and if the temperature on the designated site is >4 °F, he or she will need to reduce the number of steps taken in the following days and contact their practitioner. The tuning fork was also validated as being highly sensitive in diagnosing PNP and is a goo d test for practitioners to use at the bedside. Certain clinical information about the patient is valuable in predicting future foot ulcers. These predictors were high A1c levels, poor vision, prior history of foot ulcer and/or amputation, monofilament insensitivity, tinea pedis and onychomycosis. The practitioner needs to be aware of these predictors and educate the patient about foot care. Practitioners need to increase monitoring of the patient’s foot at every office visit when these predictors are identified. Education is an important criterion in managing PNP. Patients need to be educated about PNP, foot ulcers, proper fitting shoes and the signs of foot infections. This review of the evidence- based literature revealed that basic SWMT is useful in predicting neuropathy but is not useful in preventing ulcers once neuropathy is diagnosed. There is a common misconception among practitioners that SWMT can be used even when neuropathy is diagnosed. The re-education of practitioners is important with the introduction of new testing methods such as TGAT once neuropathy is already diagnosed. This best practice will help to prevent ulcers among persons affected by diabetes and therefore improve the quality of their life. References Meaney, B. (2012). Diabetic foot care: Prevention is better than cure. Journal Of Renal Care, 3890-98. doi:http://dx.doi.org/10.1111/j.1755-6686.2012.00276.x Eddy, J., Price, T. (2009). Diabetic foot care: Tips and tools to streamline your approach. Journal Of Family Practice, 58(12), 646-653 Dorresteijn, J., Kriegsman, D., Valk, D. (2011). Complex interventions for preventing diabetic foot ulceration. The Cochrane Library. Retrieved from http://www.thecochranelibrary.com Centers for Disease Control and Prevention (2012). Diabetes data and trend. Retrieved from: http://www.cdc.gov/diabetes/statistics/prev/national/figraceethsex.htm Broersma, A. (2004). Preventing amputations in patients with Diabetes and Chronic kidney disease. Nephrology Nursing Journal, 31(1), 53-64. Mayfield, J. A., Sugarman, J. R. (2000). The use of the Semmes-Weinstein Monofilament and other threshold tests for preventing foot ulceration and amputation in persons with diabetes. Journal Of Family Practice, 49(11), S17-S29. American Diabetes Association. (2013). Standards of Medical Care in Diabetes. Diabetes care. Retrieved from http://care.diabetesjournals.org/content/36/Supplement_1/S11.full Boyko, E.J., Ahroni , J.H., Cohen, V., Nelson, K.M., Heagerty, P.J. (2006). Prediction of diabetic foot ulcer occurrence using commonly available clinical information: The Seattle Diabetic Foot Study. Diabetes Care, 29(6):1202-7. Retrieved from: http://care.diabetesjournals.org/content/29/6/1202.full.pdf+html Bakker, K., Apelqvist, J., . Schaper, N. C. (2012). Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/metabolism Research and Reviews, 28, 225-231. doi:10.1002/dmrr.2253 Bakker, K., Apelqvist, J., . Schaper, N. C. (2012). Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/metabolism Research and Reviews, 28, 225-231. doi:10.1002/dmrr.2253 Jarrett, L. (2013). Prevention and management of neuropathic diabetic foot ulcers. Nursing Standard, 28(7), 55-65. Nagoba, B., Gandhi, R., Wadher, B., Rao, A., Hartalkar, A., Selkar, S. (2010). A simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades. International Wound Journal, 7(3), 153-158. doi:http://dx.doi.org/10.1111/j.1742- 481X.2010.00666.x Abad, C., . Safdar, N. (2012). From Ulcer to Infection: An Update on Clinical Practice and Adjunctive Treatments of Diabetic Foot Ulcers. Curr Infect Dis Re, 14:540–550. DOI 10.1007/s11908-012-0283-3 Benbow, M. (2012). Diabetic foot ulcers. Journal Of Community Nursing, 26(5), 16 Soyupek, F., Ceceli, E., Suslu, F., Yorgancioglu, R. (2007). Neurologic and radiologic abnormalities of the foot in diabetic patients. Journal Of Back Musculoskeletal Rehabilitation, 20(2/3), 55-60 Holt, P. (2013). Assessment and management of patients with diabetic foot ulcers. Nursing Standard, 27(27), 49-55 Kà ¤stenbauer, T., Sauseng, S., Brath, H., Abrahamian, H., Irsigler, K. (2004). The value of the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a neurothesiometer. Diabetic Medicine, 21(6), 563-567. Nather, A., Keng, W., Aziz, Z., Ong, C., McFeng, B., Lin. C. (2011). Assessment of sensory neuropathy in patients with diabetic foot problems. Diabetic Foot Ankle.2(10). Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/22396819 19. Arad, Y., Fonseca, V., Peters, A., Vinik, A.( 2011). Beyond the monofilament for the insensate diabetic foot: a systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes. Diabetes Care, 34(4):1041-6. doi: 10.2337/dc10-1666. Lavery, L., Higgins, K., Lanctot, D., Constantinides, G., Zamorano, R., Armstrong, D., Kyriacos, A., Agrawal, M. (2004). Home Monitoring of Foot Skin Temperatures to Prevent Ulceration. Diabetes Care, 27 (11):2642-2647. Meijer, J.W., Bosma, E., Lefrandt, J., Links, T., Smit, A., Stewart, R., Van Der Hoeven, J. (2003). Clinical Diagnosis of Diabetic Polyneuropathy With the Diabetic Neuropathy Symptom and Diabetic Neuropathy Examination Scores Diabetes Care, 26(3), 697-701. Retrieved from: http://care.diabetesjournals.org/ Gershater, M., Pilhammar, E., Apelqvist, J., Alm-Roijer, C,. (2011). Patient education for the prevention of diabetic foot ulcers. European Diabetes Nursing, 8(3), 102-107b. Retrieved from: http://dx.doi.org/10.1002/edn.189

Time Travel Paradoxes in A Connecticut Yankee... :: essays research papers fc

Time Travel Paradoxes in Conneticut Yankee   Ã‚  Ã‚  Ã‚  Ã‚  Mark Twain’s Conneticut Yankee in King Arthurs Court is a book about time travel. It was written 1989 which was before science as we now know it, which tells us that time travel is not possible because of paradoxes. This is still a good book that has many good things to say about America versus England, proving that the American way is superior.   Ã‚  Ã‚  Ã‚  Ã‚  America in the day, had just won it’s independence and was trying to establish it’s own identity from England. Mark Twain, whose real name was Samuel Clemens, created the first science fiction novel with Mark Twain’s Conneticut Yankee in King Arthurs Court. In the story a man from the present goes back in time after being hit on the head by a crow bar. He wakes up and is captured by Sir Kay, the Seneschal (Negri, 11). After an eclipse, the man becomes the court’s great magician and blows up Merlin’s castle. He uses modern inventions like the telephone and telegraph and teaches people to read the newspaper he puts out. When a lady comes to the court to get help against the ogres who had captured her and her sister’s, the Boss as the man is now called rides off with her to Britain save them all. After going to Morgan le Fay’s castle and rescuing her prisoners, they find the ogres were swineherds and the princesses wer e really pigs after all. Which is symbolic of the illusion that is society (Negri, 104-105).   Ã‚  Ã‚  Ã‚  Ã‚  One of the problems with the book is that Mark Twain uses modern-day technology in King Arthur’s time. If this was the case that technology would be around more today. At the end of the book the only evidence of that technology was a bullet hole in a suit of armor that the Boss put in him self (Negri, 268).   Ã‚  Ã‚  Ã‚  Ã‚  Even though over a thousand years had past, you would think some of the machines and forges the Boss left behind would still be there and found by scientists. The Boss creates bullets and guns and those would win battles against the swords and spears of the knights of the time. I know I would rather have a gun then a sword and think the knights would also want guns. With this kind of weapons, the English Knights would be invincible every time and conquer the world. Yet they didn’t keep the weapons.

Review of Behind the Arch: The Truth about Drinking at BVU :: College Drinking Essays

Review of Behind the Arch: The Truth about Drinking at BVU Behind the Arch: The Truth About Drinking at BVU, by Chris Allen, Alisa Dixson, Jennifer Durham, Shelley Katzer, Max Kenkel, Teri Kramer, Toby Malavong, and Courtney Weller, is a book about drinking at Buena Vista University. It was written because the University of Illinois did a survey on colleges around the county about their drinking habits. When some BVU students read it, some did not think it was accurate, so, they did their own research and got some of their own statistics. By the opinion of the students, the information they found was more accurate than what the University of Illinois found. This book had many things wrong with it. There were many problems with the writing styles and the research in my opinion. It was too long and too detailed, especially with the insignificant ideas in, which should not have been in it, such as the explanation of our campus, an insignificant detail. There was not a good comparison in the national average, Buena Vista University is a small campus in a small town, not similar to, say, the University of Missouri with a large student population and in the city of Columbia. The research was not well done and was unbalanced. This book was about the drinking at BVU found from the survey, not when some of the professors were attending. The book did have some good points. It did have good statistics and were accurate for out campus. I believe that most of the students on campus do drink, but not to get drunk such as the book stated. The personal experiences were well written also. The book does give a bit of reflection on when drinking was not a large problem on campus, but it is insignificant. This book also did do a good job of what is being done on campus to stop the drinking. We now have midnight basketball, and volleyball, and alternative happy hour so the students have something other to do than drink or go to the bar. Many things could have been changed in the book. It was too long. They went off subject with the September, 11 2001 terrorists attacks, that are not significant and way off topic, and made the book last too long. If they had not strayed off the path of where the book was going it would have been shorter and probably kept my interest more, not making me want to sleep. Review of Behind the Arch: The Truth about Drinking at BVU :: College Drinking Essays Review of Behind the Arch: The Truth about Drinking at BVU Behind the Arch: The Truth About Drinking at BVU, by Chris Allen, Alisa Dixson, Jennifer Durham, Shelley Katzer, Max Kenkel, Teri Kramer, Toby Malavong, and Courtney Weller, is a book about drinking at Buena Vista University. It was written because the University of Illinois did a survey on colleges around the county about their drinking habits. When some BVU students read it, some did not think it was accurate, so, they did their own research and got some of their own statistics. By the opinion of the students, the information they found was more accurate than what the University of Illinois found. This book had many things wrong with it. There were many problems with the writing styles and the research in my opinion. It was too long and too detailed, especially with the insignificant ideas in, which should not have been in it, such as the explanation of our campus, an insignificant detail. There was not a good comparison in the national average, Buena Vista University is a small campus in a small town, not similar to, say, the University of Missouri with a large student population and in the city of Columbia. The research was not well done and was unbalanced. This book was about the drinking at BVU found from the survey, not when some of the professors were attending. The book did have some good points. It did have good statistics and were accurate for out campus. I believe that most of the students on campus do drink, but not to get drunk such as the book stated. The personal experiences were well written also. The book does give a bit of reflection on when drinking was not a large problem on campus, but it is insignificant. This book also did do a good job of what is being done on campus to stop the drinking. We now have midnight basketball, and volleyball, and alternative happy hour so the students have something other to do than drink or go to the bar. Many things could have been changed in the book. It was too long. They went off subject with the September, 11 2001 terrorists attacks, that are not significant and way off topic, and made the book last too long. If they had not strayed off the path of where the book was going it would have been shorter and probably kept my interest more, not making me want to sleep.

Wellness :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  The wellness wheel couldn’t have come at a better time because I’ve recently been trying to change my dieting and exercising habits, as well as the way in which I feel and look at myself. Knowing that my answers to some of these questions could be completely bias, I realize that the wellness wheel is how I look at myself in my perspective. Others could have different opinions about how I score myself.   Ã‚  Ã‚  Ã‚  Ã‚  I found that I did very well on section eight, scoring a perfect twenty. Now, that is just how I felt at the time I took the test. Different answers and scores could appear at different times depending on my mood. Section eight was about wellness with playing and working. I feel I did very well on this particular section because I know how to separate work from play. I know when and how to work hard; and I’m very proud of the things I do and my accomplishments. On the other hand, I know when I’ve been working too much, and personal enjoyment away from work is almost like therapy to me. I think that the way I work is what enabled me to do so well in this section. I usually enjoy work, and I always try to turn work into an enjoyable activity, instead of â€Å"work†. I feel that if you work hard, you should play hard too.   Ã‚  Ã‚  Ã‚  Ã‚  The main areas that I scored low in are the areas surrounding diet and exercise. Throughout my life, up until the past couple of years, I’ve always been extremely athletic and did some form of exercise regularly. However, now that I have more responsibilities; working full-time and going to school full-time, I’ve notice that I have slipped from exercising regularly, to not exercising at all. I’ve become a couch potato, figuring that I put so much time and effort into work, that when I get home I should sit on the sofa and plop my feet on the coffee table, eating junk food till my stomach erupts. I know this isn’t me, and I don’t want to be a couch potato for the rest of my life. However, this horrible habit that I’ve developed is a cycle that spirals downward leading me to unhealthy obesity. I’m only 170 pounds, still in shape, but on the verge of gaining an actual beer belly. I need to break the cycle and set a rou tine exercise plan for myself that will also include a relaxed diet.

A comparison of “Deirdre” and “On Baile’s Strand” by William Butler Yeats Essay

Deirdre and On Baile’s Strand are two plays by William Butler Yeats that incorporate a tragic vision. Both plays deal with a single tragic moment in the life of an important figure. The plays are similar in structure and style. Yeats interweaves supernatural elements in both plays — the Shape Changers in On Baile’s Strand and the circumstances of Deirdre’s birth and the question of her parentage in Deirdre. The endings of the plays are similar, however, the process of coming to a conclusion in the plays is different. In both of these plays, Yeats gives readers the back ground, information about the characters, and sets the scene at the beginning. In On Baile’s Strand Yeats uses two characters, the Fool and the Blind Man, whose purpose in the play was to describe the situation and the characters involved. In Deirdre Yeats uses a group of three female musicians to set the scenes and give information about the characters. Even with this similarity, however, there is a difference. In On Baile’s Strand the Fool and the Blind man are not directly involved in the action of the play. The exception is at the end of the play when through them, Cuchulain learns that he has killed his only son. The Fool and the Blind Man speak prose while the musicians in Deirdre sing. The three female musicians in Deirdre, however, are spoken to and answer the main characters in the play. In both instances, the Fool and the Blind Man, and the three female musicians have knowledge that the other characters do not. The settings of the plays reflect the main characters. In Deirdre, a tragedy with a female main character, the setting is feminine and action takes place in a guest-house in sereneness of the woods. On Baile’s Strand, a tragedy with a male main character, the setting is masculine and the action takes place in an assembly- house near a harsh sea. No only is On Baile’s Strand masculine in the sense that it takes place near a harsh sea, it is also without fully human women. The one fully human woman, Aoife, that is mentioned in the play, is seen as an evil influence. Conchubar tells Cuchulain: That very woman — For I know well that your are praising Aoife — Now hates you and will leave no subtlety Unknotted that might run into a noose About your throat †¦ (28) However, Cuchulain remembers her as being of â€Å"stone-pale cheek and red-brown hair† and stated that None other had all beauty, queen or lover, Or was so fitted to give birth to kings. (28) With Cuchulain’s vivid descriptions of her, Aoife, although she is not seen in the play, is able to be seen as clearly as the other characters. In both of the plays, the most dramatic part revolves around two things: death and the unknown. In Deirdre, Deirdre pleads with Conchubar to spare her and Naoise’s lives. She is unaware that Naoise is already dead. She did not see Conchubar motion to the â€Å"dark-faced men† who gag Naoise and pull him out of view. Deirdre  pleads with Conchubar, telling him that he will need Naoise some day, but Conchubar only laughs. Deirdre tells him: You will cry out for him someday and say, â€Å"If Naoise were but living† — [she misses Naoise]. Where is he? Where have you sent him? Where is the son of Usna? Where is he, O where is he? (69) This is the most tragic part of the play. Even more tragic than the deaths of Deirdre and Naoise because everyone except Deirdre knows that her pleading is futile. The most dramatic scene in On Baile’s Stand comes after Cuchulain kills the Young Man, not knowing that he is his son. The Blind Man tells Cuchulain that he knows the Young Man’s mother: BLIND MAN: I knew him and his mother there. CUCHULAIN: He was about to speak of her when he died. BLIND MAN: He was a queens son. CUCHULAIN: What queen? what queen? [Seizes Blind Man who  is now sitting upon the bench] Was it Scathach? There were many queens. All the rulers there were  queens. And further into the conversation the Fool tells Cuchulain that the Blind Man said â€Å"the young man was Aoife’s son† and that he had also heard Aoife say that she has had only one lover, and he was the  only one who had defeated her in battle. The Blind Man is the one to say â€Å"it is his own son he has slain.† Another important element found in the play is the idea of treachery or betrayal of trust. In both Deirdre and On Baile’s Strand, treachery results in death. In Deirdre Fergus trusts Conchubar and is betrayed by him; and he betrays others in the play by not divulging knowledge he has. Naoise trusts Fergus, and to some extent Conchubar, and is betrayed. Deirdre trusts Naoise and becomes a victim with him after he is killed. Deirdre betrays Conchubar twice. First when she runs away with Naoise and hides for seven years, and again before taking her own life. Conchubar betrays both Deirdre and Naoise in order the win Deirdre and punish Naoise for stealing her from him and, in turn, this is when he is betrayed by Deirdre and Naoise. Early in the play, after Naoise realized that Conchubar has not sent a messenger to meet with them, Fergus tells Deirdre and Naoise that Conchubar will arrive in person. Naoise responds that â€Å"he cannot break his faith† and â€Å"I have his word and I must take that word.† After seeing a chess-board and remembering the tale of Lugaidh Redstripe and his wife, who both died after being betrayed Naoise speaks: If I had not King Conchubar’s word I’d think That chess-board ominous. (53) Fergus recalls the tall of Lugaidh Redstripe as â€Å"the tale of treachery, A broken promise† that is best forgotten. In On Baile’s Strand, Cuchulain is betrayed by the oath he made to Conchubar when Conchubar calls him on it after the Young Man’s arrival. When Cuchulain refuses to fight the Young Man, Conchubar tells him that â€Å"witchcraft has maddened you.† Cuchulain realizes he had been betrayed after he kills his son. He runs out  to the sea to fight the harsh waves, which he sees as an image of Conchubar. Deirdre and On Baile’s Strand are two plays whose outcome is based on the tragedy upholding honor. Cuchulain’s honor of Conchubar in On Baile’s Strand, and Deirdre’s honor of Naoise and Naoise’s honor of Conchubar in Deirdre. The possession of knowledge the reader has about the events of the play heighten the tragic effects found in both Deirdre and On Baile’s Strand.

Development of the Renaissance Centralized Church Plan Essay

Analyze the development of the centralized church plan in Renaissance architecture (15th and 16th centuries). In your examples, include an analysis of meaning and symbolism. During the Renaissance period, new centralized church plans developed as a result of a more scientific approach to nature. The idea of precise proportions and measurement emerged through Vitruvius’ theory regarding human anatomy. Vitruvius described how human body, with extended arms and legs, fits perfectly into the most basic geometrical shapes: circle and square. This concept triggered the minds of artists during the Renaissance to take on a new approach for church plans (Honour and Fleming 444-445). However, it is not until the fifteenth century that the centralized plan was regarded as a divine expression when Alberti discussed scientific method of maintaining God’s image through mathematical approach in De Re Aedificatoria, a treatise containing the first full program of the ideal Renaissance church (Tavernor 30). From Alberti’s perspective, a centralized plan should reveal God’s symbol while keeping pure forms of absolute mathematics in the structure, therefore the Greek-Cross figure is favored (Heydenreich 36). His theory influenced many others to realize the importance of the Greek-Cross planning method, and this is reflected in works such as S. Sebastiano, Maria Della Carceri and St. Peter’s. Thus, the Greek-Cross centralized church plan was developed, that became the divine figure for Renaissance architecture. The development of Greek-Cross plan is derived from Alberti’s theoretical demands based on Vitruvius’ basic principles of accuracy and proportions. In the early sixteenth century, Vitruvius began answering questions regarding how a buildings proportion is constructed through human anatomy (Wittkower 22). Such question is further raised through Vitruvian figures drawn within a square and circle became a symbol of the mathematical relationship between man and god through geometry (Wittkower 25). Alberti, who suggested that to obtain architectural perfection, one must follow the basic laws of symmetry and proportions, expanded on these early ideas. In his treatise, he had defined the laws of symmetry and proportion through the physical characteristics of the human body (Tavernor 40). There, he combined a square and circle to generate the image of the geometrical shapes in relation to human anatomy, identical to Leonard Da Vinci’s drawing of a man with outstretched limbs located within a circle and square (figure 1). Alberti’s intention was to clarify the ideal architectural beauty for others during the time, through accuracy and precision (Tavernor 40). The Greek Cross central plan is developed through three transformations from the square, square plus one-half, square plus one third, and the square doubled (Murray 58). If these square ratios are applied to architectural plans, more complex figures can be produced; subsequently the centralized Greek Cross plan was developed and was a visible expression of the Divine Proportion. (Smith) Alberti’s obsession over geometrical perfection involved applying his theory within the interior structure as well. For example, the height of the wall up to the vaulting in round churches should be one-half, two thirds of three quarters of the diameter of the plan. These proportions of one to two, two to three, and three to four conform to Alberti’s law of harmony, written in his treatise (Murray 58 58). It was Alberti who expressed the theory of beauty in his writing, which became so influential for the High Renaissance. He defined beauty, â€Å"harmony and concord of all the parts, so that nothing could be added or subtracted except for the worse† (Smith). From Alberti’s explanation, the symbolism of the Greek Cross is regarded as a beautiful and natural figure, representing every aspect of God due to the precise measurements on all sides of the shape. Therefore, Alberti argued â€Å"Beauty will result from the beautiful form and from the correspondence of the whole to the parts, of the parts amongst themselves, and of these again to the whole; so that the structures may appear an entire and complete body† (WIttkower 31). He believed to thoroughly appreciate Renaissance architecture, one should understand architecture is not based on theories of function but rather view it as mathematical theory of proportion (Smith). Another significance from the Greek Cross central plan is signifying the development of Renaissance architecture. For Alberti and architects of the Renaissance, the emphasis on classicism is ideal, which challenges a different approach from the previous. Pursuing mathematical order and simplicity of pure whites have replaced the Roman gothic style churches (Heydenreich 27). Also, the prominence of classical features is more suited for Alberti’s theory of proportion so that all sizes and shapes are defined. A clear example of Renaissance classicism is S. Sebastiano, where Alberti used Greek-Cross plan that shows almost all of his own theoretical requirements as well as several classical elements in the architectural design (figure 4) (Murray 59). Alberti’s argument for incorporating classicism, a high flight of steps and pilasters at the temple front is best supported by architect Palladio’s correspondence with Alberti’s ideas: â€Å"buildings in which the supreme Being is invokved and adored should stand in the most noble part of the city, raised above the rest of the city†¦they ought to be built so that nothing more beautiful could be imagined and those who enter should be transported into a kind of ecstacy in admiring their grace and beauty. Buildings dedicated to the omnipotent God should be strong and everlasting†¦Ã¢â‚¬  (Wittkower 31) This idea of rising above is coherent to Leonardo Da Vinci’s principle, which he adhered to in all his designs (Wittkower 26). S. Sebastiano exemplifies the meticulous image of Renaissance beauty, and developing architectural style beyond the Roman gothic style (Smith). Another example of a building resembling absolute proportion is St. Maria Della Carceri, designed by architect Giuliano Da Sangallo. After Alberti’s treatise on architecture was published in 1485, the centrally planned church became popular. Many architects during the Renaissance conformed to his law of harmony. Within the same year, the church of St. Maria Delle Carceri was the first Greek-Cross structure built. The entire interior and exterior description of Giuliano da Sangallo’s church complies with Alberti’s theoretical demands, demonstrating the impact Alberti made through his publication (Wittkower 31). The plan for St. Maria Delle Carceri is based on the two elementary figures of square and circle, where the depth of the arms is half their length and the four end walls of the cross are as long as they are high, therefore forming a perfect square (figure 2). The structure contains desirable symbolic feature by integrating a dome in the center. It appeals more to Christianity to represents closure towards heaven or God’s presence. The grand church is viewed as â€Å"†¦a majestic simplicity, the undisturbed impact of its geometry, the purity of its whiteness are designed to evoke in the congregation a consciousness of the presence of God – of a God who has ordered the universe according to immutable mathematical laws, who has created a uniform and beautifully proportioned world, the consonance and harmony of which is mirrored in His temple below.† (Wittkower 31) Donato Bramante was another architect who responded to historian’s theory concerning centralized plan. His designs are similar to Leonardo Da Vinci’s drawings on centralized plan, where he sketched numerous centrally planned forms and illustrates complex geometrical forms from the first simple shape (figure 5). Da Vinci’s intentions were interpreting Vitruvius’ explanation more accurately through visual art (figure 1) (Wittkower 25). The importance of these drawings reflects Da Vinci’s conscious theoretical speculations for which a new technique of representation is produced (Wittkower 25). Although Da Vinci did not build anything, through his illustrations, Bramente was profoundly influenced that affected the sixteenth century approach. It is likely that those drawings allowed Bramante to comprehended the versatile of geometrical shapes, influencing architecture (figure 4) (Honour and Fleming 444-445). There is even evidence to believe that Bramante’s early design for St. Peter’s was much influenced by Leonardo’s drawings of centrally planned structures. (Honour and Fleming 444-445) When Bramante was appointed to redesign the Saint Peter’s at the beginning of the sixteenth century, he envisioned the new it as a grander version of his previous architectural design: a central, Greek cross plan building. The design must continue the ancient Roman tradition of domed temples, therefore St. Peter’s is crowned by an enormous dome. Bramante, like others before him, combined the symbol of the Greek cross with the symbolic values of centralized geometry. (Wittkower 34). Bramante submitted his Greek cross design on a large scale, which reflects Alberti’s humanist-Christian idea in pure form. In Renaissance thinking, Bramante’s St. Peter’s central plan and dome also symbolized the perfection of God (Honour and Fleming 444-445). Certainly, so overwhelming was Bramante’s design that none of his successors could divert his influence (Honour and Fleming 444-445). The impact of the Greek cross was enormous for the development of Renaissance centralized plan. The geometrical figure is a result of Alberti’s in depth mathematical approach of viewing nature (Tavonor 42). Many Renaissance architects utilized the Greek Cross plan due to Alberti and other historians theory regarding obtaining architectural beauty. For them, comparing building structures to human anatomy proportion was essential in defining what is ideal. More importantly, the Greek cross symbolizes divinity. Vitruvius also discussed the relationship between the human body and geometry, which is crucial for the creation of the Greek cross (Wittkower 25). Such explanation expanded by Alberti influenced the formation in several significant churches, such as the Maria Della Carceri, St. Peter’s design and S. Sebastiano. Architects who designed these churches corresponded with Alberti’s argument, therefore demonstrating the wide acceptance of the Greek Cross. MLA Citations Heydenreich, L. Architecture in Italy, 1400-1500. rev. ed., New Haven, 1996. Honour and Fleming, The Visual Arts: a History, 4th ed, 1995, 444-445. http://www.phs.poteau.k12.ok.us/williame/APAH/readings/Bramante’s%20Tempietto,%20St%20Peters,%20Michelangelo.pdf Murray, P. The Architecture of the Italian Renaissance. London, 1963. Smith, Bernard. â€Å"University of Melbourne.† University of Melbourne. Print. http://shaps.unimelb.edu.au/public-resources/database-resources/bernardsmith/lectures/BSmith-HighRenaissance.pdf. Tavernor, R. On Alberti and the Art of Building. New Haven, 1998. Wittkower, R. Architectural Principles in the Age of Humanism. 3rd ed., London, 1962. Figures Figure 1: Da Vinci’s human anatomy drawing http://www.centopietrevenice.typepad.com/ca_centopietre_bed_and_br/2009/11/leonardothe-vitruvian-man-between-art-and-science-accademia-galleries.html Figure 2: S. Maria Della Carceri centralized plan by Giuliano Da Sanglio Figure 3: S. Sebastiano front view http://architecturetraveljournal.blogspot.ca/2008/02/san-sebastiano-mantua.html Figure 4: S. Sebastiano centralized plan http://www.studyblue.com/notes/note/n/14-italian-renaissance-ii-/deck/2633566 Figure 5: Leonardo Da Vinci’s drawing on centralized plan http://www.art.com/products/p12016104-sa-i1452778/leonardo-da-vinci-sketch-of-a-square-church-with-central-dome-and-minaret.htm Figure 6: Bramante’s St. Peter’s design http://mexichino-jr.blogspot.ca/2011/06/bramantes-st-peters-rome.html