Treatment of Rituximab in Pemphigus Vulgaris Patients

Treatment of Rituximab in Pemphigus Vulgaris Patients Part 3: Clinical Research 2 INTRODUCTION Pemphigus is the name of a group of life-threatening blistering diseases of the skin and mucous membranes. The base of treatment for this disease is corticosteroids; however, recently, new drugs, such as rituximab, have been verified for more severe forms of it. In the authors previously unpublished study, the effect of rituximab on variation in the laboratory indices of pemphigus vulgaris patients is addressed. After investigation of the files of pemphigus patients who received rituximab in Razi Hospital, Tehran, Iran from 2008 to 2013, 39 patients were entered into the study. All patients had lab sheets containing CR (creatinine), urea, ALT (alanine aminotransferase), AST (aspartate aminotransferase), Plt (platelet), Hgb (hemoglobin), and WBC (white blood cell) before and after receiving rituximab. The patients received rituximab 4 times at a dosage of 500 mg in 4 successive weeks. The lab results before receiving the first dose of rituximab were compared to the results after receiving treatment. The effect of rituximab on the variation in lab indices with the adjustment effect of age, gender, disease duration, sites of involvement, received adjoins, and the background disease were also investigated. In the initial analysis, rituximab only had a significant effect on urea reduction. In the CellCept ® (mycophenolate mofetil) receiving subgroup, the mixed consumption of rituximab led to a significant reduction in WBC. In the subgroup having background disease, rituximab had a statistically significant impact on platelet reduction. In the subgroup having no background disease, rituximab had a statistically significant effect on urea reduction. The lab indices were shown to have no significant relationship with age and disease duration. Thus, it can be predicted that disease duration and age would have no effect in the relationship between rituximab and lab indices variations. Although in stratified single-variable analysis for adjusting the effect of other variables (involvement sites and received adjoins) on the relation of rituximab and lab indices, some of these variables showed interacting effects with rituximab on the variations of lab indices. However, due to the low volume of sample and non-normal distribution of most of these variables, it was impossible to do multivariable analysis for investigation of their independent and interactive effects on variations of lab indices in an integrated manner, therefore, we can not make certain comments about their relationships. Chapter 1 Pemphigus is the name of a group of life-threatening blistering diseases that have characteristic acantholysis leading to formation of intraepithelial blisters in mucus and skin [1]. The acantholysis process is induced via attachments of flowing autoantibodies to adhesion molecules in the cells [2]. Patients with pemphigus have mucosal erosions, blisters, papules, and cutaneous erosions. The different types of pemphigus are pemphigus vulgaris, pemphigus foliaceus, immunoglobulin A (IgA) pemphigus, and paraneoplastic pemphigus. Different types of pemphigus are differentiated by clinical symptoms, related autoantigens, and histological methods. Pemphigus vulgaris has mucosal and mucocutaneous involvement. The blisters are acantholytic and suprabasal. The autoantibodies responsible for the disease are against desmoglein (DSG) 1 or both desmoglein 3 and 1. Pemphigus foliaceus only involves the skin. The blisters are acantholytic and subcorneal. The responsible autoantibodies are against desmoglein 1. IgA pemphigus has the form of grouped erythematous crusts, papules, and vesicle plucks. Blisters can be subcorneal or intraepithelial and acantholytic. The responsible autoantibodies are against desmocollin (DSC) 1 [3]. Paraneoplastic pemphigus involves vast and resistant stomatite along with different cutaneous findings. The responsible autoantibodies are against desmoplakin (DSP) or other desmosomal antigens. Pemphigus vulgaris is the most common type of pemphigus, but is still very rare. The chance of its occurrence is between 0.1 to 0.5 per 100,000 people [4]. Pemphigus often happens among adults and the average age of onset is 40 to 60 years old. It is very rare among children [5,6]. Its prevalence is almost the same in the 2 sexes [7]. Almost all the pemphigus vulgaris patients have mucosal involvement. The mouth is the most common site of involvement and is often the first site of involvement. Other mucosal membranes such as conjunctivae, nose, esophagus, vulva, vagina, cervix and anus are rarely involved [8]. As mucosal blisters are fragile and burst easily, in clinical examination it is difficult to find intact blisters, and instead the examiner tends to find mucosal erosions. Buccal and pa latal mucosa are the most common sites of blister involvement in the mouth cavity [9]. Mucosal involvement can be very painful. This pain often increases by chewing and swallowing, which can result in improper alimentation and weight reduction. Most of the patients also have cutaneous involvement appearing in the form of soft blisters in healthy skin or erythematosus. The blisters easily break, resulting in painful erosions. Pemphigus vulgaris rarely causes pruritis. Almost any part of body skin can be involved, but the palmar aspects of the foot and hands are rarely involved. The Nikolsky sign is often observed among these patients (mechanical pressure on the healthy skin results in blistering). Pemphigus is diagnosed based on the clinical, histological, immuno-pathological symptoms and laboratory findings. Even in cases where the clinical symptoms are intensively supporting pemphigus, laboratory investigation is still needed to confirm the diagnosis, as other diseases may have the same symptoms. The first line of treatment of pemphigus is systemic corticosteroids, an d addition of adjuvants may also be needed. Patients who do not respond to the first line of treatment might need additional interventions. In such patients, cyclophosphamides, rituximab, intravenous immunoglobulin (IVIG) or plasmapheresis may be helpful. Initial treatment of pemphigus vulgaris is systemic glucocorticoid, which is often applied in combination with other non-steroidal immunosuppressants such as azathioprine and mycophenolate mofetil. Pemphigus resistant to treatment is a type of pemphigus that does not respond to the aforementioned treatments. Pemphigus is a chronic disease that needs long-term treatment. A retrospective study was conducted during 1982-1993 on 40 patients [8]. On average, these patients achieved complete remission after 7.7 years; 25% had remission after 2 years; 50% after 5 years; and 75% after 10 years [8]. Most pemphigus vulgaris patients respond to initial treatments [9]. The first step, in the patients who do not respond to initial treatment, is increasing the dosage of systemic corticosteroids (1.5-2 mg/kg of prednisolone per day) or adjuvant drug. The adjuvant drug can also be changed (changing azathioprine to mycophenolate mofetil). In resistant cases, cyclophosphamides, rituximab, IVIG, and plasmapheresis could also be used. As pemphigus is an auto-immune disease caused by autoantibodies, treatments that reduce B cells are investigated [10-13]. Rituximab is a monoclonal antibody that targets CD20, located on B-lymphocytes, as its antigen. This drug has been shown to have profound effects on pemphigus treatments [13,14]. In a multicenter study conducted on 14 pemphigus vulgaris patients and 7 pemphigus foliaceus patients, both groups were resistant to systemic glucocorticoids and experienced several relapses during glucocorticoid tapering. They were then put on 1 cycle of rituximab with a weekly dosage of 275 mg/m2 for 4 weeks, and this addition proved advantageous [15]. Although, severe infections were reported in the patients under rituximab treatment, its effect on risk of infection is not clear, as other immunosuppressants were also concurrently used. Reactions during injection are among the most common side effects of rituximab. Deep vein thrombosis (DVT), pulmonary embolism, long-term hypogammaglobu linemia, and neutropenia were also common among the patients under rituximab treatment. Regarding the excellent impact of this drug on treatment of resistant pemphigus, and also on other diseases such as idiopathic thrombocytopenic purpura (ITP), vasculitis, lymphocytic leukemia, systemic lupus erythematosus (SLE), we decided to evaluate the effects of this drug on the variation of lab parameters such as white blood cell (WBC), Hemoglobin (Hg), platelet (Plt), aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine (CR). So far, no study has been conducted on investigation of these variations due to receiving rituximab. OBJECTIVES AND HYPOTHESES Major Objective Investigation of laboratory variations after injection of rituximab in pemphigus vulgaris patients. Minor objectives of the project: Determination of rituximab impact on laboratory indices Determination of rituximab impact on laboratory indices by adjusting for the effect of age Determination of rituximab impact on laboratory indices by adjusting for the effect of gender Determination of rituximab impact on laboratory indices by adjusting for the effect of other treatment methods Determination of rituximab impact on laboratory indices by adjusting for the effect of disease duration Determination of rituximab impact on laboratory indices by adjusting for the effect of disease involved sites Determination of rituximab impact on laboratory indices by adjusting for the effect of Underlying disease Application objectives: Enhancement of health level among pemphigus vulgaris patients and paying attention to laboratory effect of patients after rituximab consumption. Research questions or hypotheses: Rituximab affects the laboratory indices Rituximab affects the laboratory indices with age effect adjustment Rituximab affects the laboratory indices with gender effect adjustment Rituximab affects the laboratory indices with disease duration effect adjustment Rituximab affects the laboratory indices with previous treatment effect adjustment Rituximab affects the laboratory indices with other disease effect adjustment Rituximab affects the laboratory indices with involved sites effect adjustment Chapter 2 Literature Review In 1997, rituximab was approved by the US Food and Drug Administration (FDA) as a treatment for non-Hodgkins lymphoma of B-cell that was resistant to chemotherapy. After that, it was applied for treatment for other diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegeners granulomatosis, idiopathic thrombocytopenic purpura (ITP), and Sjà ¶grens syndrome. Ten years later, its impact on the treatment of blister diseases such as pemphigus was shown [16]. In a 2006 study by Larrar et al, 2 children with autoimmune hemolytic anemia who were treated with rituximab experienced acute thrombocytopenia and neutropenia [17]. They resolved in several days, which showed that these hematologic effects are directly dependent on the toxicity of rituximab. In a study by Chairwatanatorn et al in 2003, neutropenia following application of rituximab was tested in 53 patients [18]. All patients except one were under Hodgkins lymphoma treatment. Eight cases of grade 4 neutropenia were observed after 1 to 5 months of rituximab treatment (5 patients only received rituximab and 3 patients were also under additional chemotherapy); 3 patients advanced toward sepsis. Neutropenia was not related to other diseases or treatments, and was related with reduction of neutrophil precursors, except for one of the patients whose bone marrow had hypoplasia. All cases of neutropenia occurred among the patients whose polymorphonuclear neutrophils (PMN) were normally or weakly reduced [18]. In a study by Tesfa et al in 2008, neutropenia occurred 4 or more weeks after rituximab treatment in lymphoma patients [19]. However, the mechanism of how rituximab causes neutropenia is still unknown. In a retrospective study of 113 lymphoma patients under rituximab treatment (alone or along with chemotherapy), 8 patients (7%) had neutropenia. The average onset was 88 days after receiving their last dosage of rituximab. The average time interval of neutropenia was 54 days. Four of the 8 patients underwent stem cell transplantation, 3 patients had neutropenia with fever and 2 of them needed granulocyte-colony stimulating factor (G-CSF) treatment. In the patients who had neutropenia, a cessation in maturation was observed in the promyelocytes category (the same as congenital neutropenia or Kostmann disease) [19]. A study by Otrock in 2005 addressed 2 patients who had acute thrombocytopenia after receiving rituximab [20]. One of the patients had hairy cell leukemia and the other one suffered from mantle cell lymphoma. In these patients, thrombocytopenia improved without the need of any treatment after several days. The reason for this is unknown. A study by Leo et al was conducted in 2004 for investigating the safety of rituximab [21]. In this study, the mixture of fludarabine, rituximab and cyclophosphamide was applied for treatment of follicular lymphoma. Surprisingly, severe thrombocytopenia with World Health Organization (WHO) grades 3 and 4 were observed in the patients, which resulted in the end of trial. Cytological and serological analysis was based on direct toxicity of rituximab. Chapter 3 Investigation Method 39 Therapy resistant pemphigus patients in Razi Hospital in Tehran, who had received rituximab from 2008 to 2012 were considered for inclusion in this retrospective cohort study. Data was collected before and after rituximab treatment. The variables included WBC, Hg, Plt, AST, ALT, Urea, and Cr and age, gender, involved sites, previous therapies, underlying disease, and disease duration. Test sheets associated to before and after rituximab application, containing WBC, Hg, Plt, AST, ALT, Urea and Cr were compared. Type of Study This study is a retrospective cohort study conducted on the pemphigus patients resistant to therapies who had received rituximab in 2008-2012. Studied Population Therapy-resistant pemphigus patients who were treated with rituximab in Razi Hospital, Tehran, Iran in 2008-2012. Inclusion Criteria Pemphigus patients who did not respond to the initial therapies (therapy-resistant pemphigus), and then were treated with rituximab. Exclusion Criteria Patients with no required tests before application of rituximab in their file Patients with no follow-up after receiving rituximab Patients whose first follow-up, after the last dosage of rituximab, is greater than 1 month. Sampling Method According to the available files, files of all the patients who had received rituximab from 2008 to 2012 were considered for inclusion. Data Collection The data collection tool included a checklist divided into 2 parts: one for the data before and one for the data collection after rituximab treatment. The variables included WBC, Hg, Plt, AST, ALT, Urea, and Cr and age, gender, involved sites, previous therapies, underlying disease, and disease duration. Project Implementation After studying the files of therapy-resistant pemphigus patients, the patients who had required data in their files were entered into the research. Rituximab treatment was defined as receiving 4 doses of 500 mg for 4 weeks, along with normal saline. Test sheets associated to before and after rituximab application, containing WBC, Hg, Plt, AST, ALT, Urea and Cr were compared. (The maximum time interval between the second test sheet and the last dosage of rituximab could be 1 month.) Data Analysis Finally, the finalized cases that had the inclusion criteria, were analyzed in Stata statistical software (StataCorp, Texas, USA) in terms of variations in WBC, Hg, Plt, AST, ALT, Urea and Cr after application of rituximab as the major variable and investigation of minor variables. Problems and Limitations As the base of this research was on filed files of hospital, inadequacy of data either before or after rituximab application excluded a bunch of samples from the study in a way that among 105 available files, only 39 files had the required data. Variables Major variables: quantitative measurement of white blood cells (WBC), Hemoglobin (Hgb), platelets (Plt), aspartate aminotransferase (AST), ALT, urea, and creatinine (Cr) before and after application of rituximab Minor variables: Gender Age Involved sites Previous therapies Underlying disease Disease duration The data of variables were collected according to the positive findings in the patients files (Table 1). Table 1 Patient variables. Title Variable Type Quantitative Qualitative Scientific Practical Definition Measurement Method Scale Independent Dependent Continuous Discrete Nominal Ranking WBC Number of WBC per ÃŽ ¼(mu)L of blood File reading Cell/mCl Hgb Amount of hemoglobin File reading Gr/dl Plt Number of plackets in patient blood File reading Cell/mcl AST * Amount of AST File reading IU/L ALT Amount of ALT File reading IU/L Urea Microgram of urea per deciliter of blood File reading Mg/dl Cr * Keratin amount File reading Mg/dl age * Years from birth File reading year gender * According to patient phenotype File reading Male/female Underlying disease * Existence of systemic disease File reading Having/not having Previous therapies * Received adjoin before rituximab File reading Azathioprine, IVIG Cyclophosphamide, CellCept ®, methotrexate Involved sites * Involved sites before starting rituximab File reading Upper body, lower body, face. Genitalia, sculp, mucus Disease Duration Months passed from onset to receiving rituximab File reading Month WBC white blood cell, Hgb hemoglobin, Plt platelet, AST aspartate aminotransferase, ALT alanine aminotransferase, CR creatinine, IVIG intravenous immunoglobulin Chapter 4 Results Among 105 therapy-resistant pemphigus patients who received rituximab treatment in Razi Hospital, Tehran, Iran from 2008 to 2012, only 39 patients managed to enter the study. The others were excluded due to inadequate data. Also in the included patient group, the maximum time interval between the last dosage of rituximab and follow-up was 1 month. The data of the remaining 39 patients were analyzed by Stata statistical software (StataCorp, Texas, USA) and the following results were obtained: The age of the patients ranged from 16 to 67 with a mean of 36.46 years. Their disease duration from the beginning of the disease until receiving rituximab ranged from 5 to 84 months with a mean of 39.30 months. Of the patients, 25 (64%) were men and 14 (36%) were women. It does not seem that the sex difference is related to therapy-resistant pemphigus, it is rather associated with the data collection method and exclusion of patients with incomplete files. Investigation of the involved sites showed that 25 patients (64%) had mucosal involvement, 20 patients (51.3%) had upper body involvement, 18 patients (46.2%) had lower body involvement, 19 people (48.7%) had genitalia involvement, 23 people had facial involvement, 36 people (92%) had body involvement, and in 22 patients (56.4%) the scalp was involved. The lab result variations of the mentioned patients were investigated in terms of the involved sites. The patients, before application of rituximab, were simultaneously under treatment with prednisolone and other adjoins. To summarize the unsuccessful treatments, 5 patients had cyclophosphamide, 18 of them received CellCept ® (mycophenolate mofetil), 7 people (17.9%) had intravenous immunoglobulin (IVIG), 5 patients were treated with methotrexate, and 22 patients had azathioprine. All these patients did not respond to corticosteroid and had active disease. In terms of variation in lab test results after receiving rituximab, the patients were investigated in terms of the previous adjuvants as well. Among 9 patients, 12 of them (30.8%) had systemic underlying diseases such as hypertension (HTN), diabetes mellitus (DM), Ischemic Heart Disease (IHD) and many more. The major variables were WBC, Hgb, Plt, AST, ALT, Urea and Cr before and after application of rituximab. Before Receiving Rituximab: The WBC range was 4,000-14,800 with average of 10,092. The Hgb range was 9.1-16.8 with average of 13.8. The Plt range was 100,000-683,000 with an average of 243,384. The AST range was 6-64 with average of 24.56. The ALT range was 10-143 with average of 43.92. The Urea range was 12-145 with average of 37.25. The Cr range was 0.5-1.2 with average of 0.87. After Receiving Rituximab: The WBC range was 5,400-19,000 with average of 9,964. The Hgb range was 7.4-16.7 with average of 13.42. The Plt range was 110,000-440,000 with average of 232,512. The AST range was 10-121 with average of 25.43. The ALT range was 12-144 with average of 48.46. The Urea range was 15-54 with average of 29.12. The Cr range was 0.6-1.2 with average of 0.85. The WBC had no statistically significant variations. The Hgb had no statistically significant variations. The Plt had no statistically significant variations. The AST had no statistically significant variations. The ALT had no statistically significant variations. The Urea had statistically significant variations. The Cr had no statistically significant variations. After receiving rituximab and adjusting for the effect of gender: The WBC had no statistically significant variations. The Hgb had no statistically significant variations. The Plt had no statistically significant variations. The AST had no statistically significant variations. The ALT had no statistically significant variations. The Cr had no statistically significant variations. In the case of Urea, we concluded that it depends on gender, as in men the variation was significant while in women the variations were not statistically significant. When investigating the results with adjustment of the involved sites, the following results were obtained: In patients with lower body involvement, rituximab had no significant effect on WBC, Plt, AST, ALT, Urea and Cr, but it had significant impact on Hgb reduction. In patients whose lower body was not involved, Urea significantly increased after receiving rituximab. In patients whose lower body was involved, rituximab caused a significant reduction in Cr, Urea, and Hgb. In patients whose upper body was not involved, rituximab had no significant effect on the variables. In the patients with or without facial involvement, rituximab had no significant impact on any of the variables. In patients whose genitalia region was involved, rituximab has no significant impact on any of the major variables. In patients with no genitalia involvement, rituximab resulted in significant reduction of urea. In patients with body involvement, rituximab resulted in significant reduction of urea. In patients with scalp involvement, rituximab resulted in significant reduction of urea. The adjustment of previous therapies was also addressed. As all the patients received prednisolone, the effect of adjoins (azathioprine, CellCept ®, cyclophosphamide, IVIG and methotrexate) was addressed: In patients who had received cyclophosphamide, rituximab has no statistically significant impact on the major variables. In patients who had not received cyclophosphamide, rituximab led to statistically significant reduction of urea. In patients who had received CellCept (mycophenolate mofetil), rituximab has statistically significant impact on reduction of urea and WBC. In patients who did not use IVIG adjoin, rituximab had a significant impact on reduction of urea. In patients who did not use methotrexate adjoin, rituximab had significant impact on reduction of urea. In patients who used azathioprine adjoin, rituximab had significant impact on reduction of urea. The adjustment impact of systemic underlying diseases (such as HTN, DM, IHD) was also addressed. In patients with systemic underlying disease, rituximab had significant impact on platelet reduction. In patients with no systemic underlying disease, rituximab had significant impact on urea reduction. There was no statistically significant relationship between the lab test result variations and disease duration and age (Table 1 through Table 8). TABLES Table 1 Age distribution in the studied patients Min Max Standard Deviation Average Age 16 67 13.48 36.48 Table 2 Disease duration distribution in the studies patients Min Max Standard Deviation Average Disease duration 5 84 20.28 29.30 Table 3 Absolute and relative frequency distribution of patients based on their gender Number % Men 25 64.1 Women 14 35.9 Total 39 100 Table 4 Absolute and relative frequency of involved sites at the time of rituximab injection. Frequency % Upper body 20 51.3 Lower body 18 46.2 Face 23 59 Genitalia 19 48.7 Body 36 92.3 Mucus 25 64.1 Scalp 22 56.4 Table 5 Absolute and relative frequency of received adjoins before application of rituximab Frequency % cyclophosphamide 5 12.8 CellCept ® 18 46.2 IVIG 7 17.9 methotrexate 5 12.8 azathioprine 22 56.4 IVIG intravenous immunoglobulin Table 6 Absolute and relative frequency of the patients based on having or not having underlying disease. Frequency

Big vs Small Colleges

Big vs. Small colleges For the prospective student, size can be a major factor in choosing the precise college. The size of a college not only suggests a greater student population, it can also affect the learning style and environment of the college. In picking a college, one must consider the kind of environment each college size offers, and if that type of setting is right for him or her. Your own personality and academic goals play a crucial role in choosing a college.Small and big colleges are diverse in that each has its own benefits and drawbacks with their expenses, facilities, and campus life. Smaller universities, such as community colleges for the most part are cost effective for the financially struggling college students; on the other hand, small private universities are much more expensive. Financial aid usually covers the majority of expenses at the community college level, leaving the student more time to focus on their studies and less time worrying about tuition.How ever in most cases these campuses may not offer on-campus housing. Paying rent, food and car expenses may be more costly than paying for room and board at a large college level, leaving the student to fend for themselves or forcing them to choose a college close to home. Smaller colleges offer fewer courses and academic programs, whereas large universities have multiple degree programs. Community colleges offer two-year associates degree programs, but not much beyond that. Smaller colleges have fewer and smaller libraries, professors, school staff, and class sizes.Bigger college campuses have larger classes, which many times employ famous professors who have written books, or become celebrated in academic circles, unfortunately they lecture to hundreds of students at a time, so the one-on-one relationship with the student and professor does not develop like they do at smaller campuses. Smaller classes are designed for more student- teacher interaction, which benefits the student, th us creating more opportunity for the student to expand their knowledge.Another plus for attending a small college is the advisors know the students very well. It is almost impossible to make an appointment for your advisor at a major university. They see a hundreds of students a day and it would be impossible to remember all of their students, much less who may be in one of their classes. Also, there is a greater sense of community at a smaller school. The student is not just a number on an ID card; here the student is a person with a face and a name. The larger the campus is, the more student culture there is.More parties, more university events, and more athletic choices are available. Small schools may not have the funding available for extracurricular activities for students, leaving a large part of the college experience missed for these students. One of the major advantages of going to a large university is their athletic programs. If you are a sports fan, or an athlete, then attending larger school might factor into your decision. Televised games, pep rallies, homecoming parades, and rivalries are all part of the student culture at large university.Both college programs have their own benefits and drawbacks, each ensuring a unique college experience to the student. The major factors the student must take into consideration are their expenses, the college facilities, and campus life when selecting a college. The student ultimately must weigh their goals while making this decision. In the end the student really cannot make an incorrect decision regardless of which college he or she chooses as long as they are choosing to further their education to further their life goals.

Competency Goal II Essay

I try to teach the children to stay healthy by getting the proper exercise that is needed for them. I take the children outside everyday if it’s not too hot, or too cold. I practice forms of yoga in the morning and the evenings with the children. This is to stretch their muscles, and to get their blood flowing. Exercising helps the children in the morning if they are still tired. Also, I’ve learned that the children have a better day when they are not tired and sleepy. Functional Area 5: Cognitive As a head start teacher I try to plan activities to develop strong thinking skills. I try to plan activities for cognitive development that make children think. I ask open-ended questions; play verbal guessing games, memory games, and other sensory motor activities. When I ask questions I use current events and experiences that the children can relate to. For an example, I’ve asked the children what happened to Goldilocks once she ran into the woods. Then, I wait for thinking gestures from the children. Their responses were the following: â€Å"She ran as fast as she can away from the Three Bears, she went home and told her mom, and she went home and called the police.† I also, play verbal guessing games such as, â€Å"Guess Who† â€Å"What is white, looks like a horse, and has black stripes?† The children guessed a zebra. I would do an activity like this after checking for prior knowledge (a story about zoo animals or a field trip to the zoo). In addition to open-ended questions and guessing games, I play the â€Å"Memory game.† First we look at all the pictures (starting with about twenty cards or ten mates). Then we place the cards face down and I model by picking up a card and turning it over. Then I turn over another and then the first child follows what I modeled. The children really enjoy this game. Their memory starts kicking in once I turn over quite a few cards. Lastly, but not limited to, I play a guessing game that uses the sense of touch. I use two paper bags, and each one has different contents. I put play dough in one and sand in another. I blind fold each child, allow them to feel the content  inside the bag, and chart their guesses from what they feel. They also describe it to the best of their knowledge. This game really gets them thinking. As a head start teacher cognitive development is very important as well as the other objectives for preschoolers. I try to plan activities to develop a strong thinking skills foundation for children. I try to plan activities for cognitive development that make children think, wonder, and explore. I believe that sensory motor games and memory games are great choices for developmentally appropriate actives to strengthen cognitive skills. Functional Area 6: Communication In order to know if a child is learning, I often ask questions. I give each child an opportunity to build their communication skills. Children really like when I interact and acknowledge what they have to say. In the morning meetings, I make sure that all the children have a chance to tell the class how they are doing and what they look forward to doing throughout the school day. While interacting with the children I remind each child to use their words in order to express themselves. Not only do I read to my children daily but I also play music with different vocabulary words in order for the children to learn new words daily. Functional Area 7: Creativity As a head start teacher, I once believed that creativity was a challenging task. When I start planning activities around the children’s interest, it became much easier. One day the children and I were discussing woodlands. The children where all excited to know that I planned a camp fire. I ask the children what could be used for a pretend fire. The children decided that a paper towel roll could be used as a log. Then I asked how can a fire be started? One child began to rub his two pointing fingers together. I said â€Å"Good idea!† Then I asked what could be used as sticks to rub together to start our pretend fire. Another child suggested that to use two yellow pencils. So we all took turns rubbing the sticks together. After the material was gathered together, I asked what color construction paper could be used to make our camp fire look like fire. Several of children decided on using the following colors: red, orange, blue, and even purple. The children and I placed the logs crisscross. The children and I  pushed the construction paper strips into a slip in the paper towel rolls. Then we used balls of white paper as marsh mellows, attached it to a pencil, and pretended to roast marsh mellows. One child said, â€Å"We need brown paper for gram crackers.† So the children and I cut squares of brown construction paper to make pretend gram crackers. This is how the camp fire was created. This was a creative activity that I planned around the children’s interest. I found it to be easier to plan activities for creativity by consulting the children first. I listen to their conversations from previous discussions and came up with the pretend camp fire activity. I have planned other creative activities using the same strategy to get the children involved.

The Moral Ethics Of Ending An Unborn Child s Life

Rhetorical Analysis Essay: All around the world, there are many controversies that people argue for and fight against. One of these controversies is; abortion which is the deliberate termination of a pregnancy before a fetus is capable of independent life. This is a very controversial topic because people are worried about the moral ethics of ending an unborn child’s life. There are two different sides to this debate that include; people who are pro-life and people who are pro-choice. People who are pro-life believe in anti-abortion because they believe that it is wrong and killing a fetus is taking away a human life. On the other side of the controversy, people who are pro-choice believe that women should have the right to choose to have an abortion in order to get rid of an unwanted pregnancy. Many people have different views on this controversy and the article â€Å"Women Seek Abortions for a Variety of Different Reasons† talks about a study that asked women why they have abortions and compared the different reasons with each other. This article was about a study that was made with researchers; Antonia Biggs a senior researcher of Advancing New Standards in Reproductive Health (ANSIRH), Heather Gould a research coordinator for the study and Diana Greene Foster an interim director of ANSIRH. For the study that they conducted, they used American women who had abortions and asked them open ended questions on why they chose abortion. During the study, they found out there areShow MoreRelatedLegislative Process And Healthcare Lobbying1681 Words   |  7 Pageswere taken to receive this data show initiative on the lobbyer’s part as well as shows their dedication to the issue at hand. Analysis of Political Issues The ethical issue of abortion makes one question many morals and dig deeper to examine their thoughts on whether a fetus is a considered a life (Aiken, T. D., Catalano, J. T., 1994). There are two types of abortions; medical and surgical. In a medical abortion it proves to be a noninvasive procedure that uses the help of pharmaceuticals to beginRead MoreSocial Criticism Of Abortion1438 Words   |  6 Pagesuncounted deaths and several violent confrontations between the supporters of the two separate parties. Pro-life supporters advocate that everyone has the right to life, even â€Å"Fetus,† and Pro-choice supporters argue that the right to abortion is absolute. In â€Å"Abortion, No more Apologies,† Katha Pollitt states abortion as a normal part of a woman’s reproductive life, one that should be accepted as a moral right and a fundamental choice with positive social implications. In this article, Pollitt takes onRead MoreThe Ethical Decision Making Process1253 Words   |  6 Pagesdecision making process is based on moral rules and unchanging principles that are derived from reason and can be applied universally. These universal rules and principles must be considered separate from the consequences or the facts of a particular situation. (McWay, 2014). Health care workers face ethical issues and have to use the ethical decision making process to determine what is best for their patients. The first ethical issue will be right to life and abortion. Abortion remains controversialRead MoreEthical Issues Of The Nursing1944 Words   |  8 Pagesamongst women. It is happening at high rates. â€Å"In 2013, 664,435 legal induced abortions were reported to CDC from 49 reporting areas† (Centers for Disease Control Prevention, 2017). There are those who identify as pro-choice and those who are pro-life. This debate is centered on human rights: the right of the fetus to live, and the woman’s right to control her own body (Butts Rich, 2016). Individuals who are pro-choice recognize that a fetus is also a human and view abortion as murder. AbortionRead MoreEthics: Nursing and Abortion1645 Words   |  7 PagesDupin, Jenifer June 8, 2013 Ethics/ Research Proposal The Ethics for Nurses in Abortion Procedures Working in the field of abortion isn’t an easy task furthermore participating in the abortion procedures. But the field of nursing you have to follow a code of ethics, a set of rules and regulation. Nurses have their personal opinions about abortion, but because they are health professionals and their opinions are sought as such, they are obligated to understand why they hold certain views. NursesRead MoreAbortion Is The Medical Process Of Ending A Pregnancy3690 Words   |  15 Pagesprocess of ending a pregnancy so it does not result in the birth of a baby. It is also sometimes known as a â€Å"termination† or a â€Å"termination of pregnancy†. Depending on how many weeks you have been pregnant, the pregnancy is ended either by taking medication or by having a surgical procedure. An abortion is not the same as a miscarriage, where the pregnancy ends without medical intervention. â€Å"All human life form the moment of conception and through all subsequent stag es is sacred, because human life is createdRead MoreAbortion, Pro And Pro Choice2135 Words   |  9 PagesThere Are Three Sides to the Abortion Issue: Pro-Life, Pro-Choice, Pro- Somewhere in the Middle Abortion divides many Americans, it is one of the many controversial issue in today’s society. There are two major viewpoints that receive the most attention. One point of view is pro-life which is the belief women should not abort a human life. On the other side, is pro-choice which is the belief women may decide whether to carry a baby to full term or abort it. Abortion is known as the act of removingRead More Pro-Choice vs. Pro-Life: No Correct Answer Essay1707 Words   |  7 PagesAbortion is the ending of a pregnancy before birth; it causes the termination of the embryo or fetus inside the women. There are two different types of abortion, a spontaneous abortion, which is also known as a miscarriage, and an induced abortion, where the embryo or fetus is purposely removed from the women’s body. The topic of induced abortion has been widely debated for hundreds of years. The issue of abortion was argued way back in the time of the ancient Hebrews. In the United States itRead MoreAbortion Is Safe And Legal1781 Words   |  8 PagesSince when did you get so prolife?† â€Å"I’m not pro-life! I just happen to not like the whole idea of abortion.† â€Å"Wake up. It’s the twenty-first century and abortion is safe and legal† (Schwarz 3). And that is exactly it. These two ladies fretting over whether or not their pregnant friend should choose to abort or not is a perfect example of one of the most controversial issues today. Similar to one of the friends, most US citizens are not sided pro-life or pro-choice on this topic. Some pro-lifers agreeRead MoreEssay on Evaluating the Current Law on Abortion3636 Words   |  15 PagesEvaluating the Current Law on Abortion An abortion is the ending of a pregnancy before the foetus is developed enough to survive outside of the womb (viability). Abortion can be accidental (miscarriage) or deliberate (termination). The legal definition of ‘Abortion’ is the intentional destruction of the foetus in the womb, or any untimely delivery brought about with intent to cause the death of the foetus (William, textbook, 252) Medical definition is the removal