Gender Roles And Inequality The Brief Wondrous Life Of...

Gender Roles and Inequality As a young girl, Malala Yousafzai faced the brutality of gender inequality that the Taliban enforced. Ever since she was a young child, Yousafzai had been an advocate for girls’ education and always eager to learn. On the devastating day of October 9th, 2012, Yousafzai was shot while returning home from school. To this day, nothing has stopped Yousafzai from continuing to speak out about the importance of girls’ education, despite the inequality that she and many other women and girls still must endure. The Brief Wondrous Life of Oscar Wao written by Junot Diaz is an exemplary text that supports reader s understanding of gender roles that are faced daily in Middle Eastern countries. Diaz’s portrayal of gender inequality and gender roles helps inform one’s understanding of the Taliban’s attack on Malala Yousafzai because Maritza, Ana, and Yousafzai are disempowered due to their gender. Yousafzai is a typical girl in Pakis tan, yearning for educational and women’s rights. In Mingora, Pakistan on July 12th, 1997, she was welcomed into the world. Her hometown used to be full of tourists, but the area changed once the Taliban attempted to take control. As a young girl, Yousafzai formed her beliefs in gender equality and began her initial activism. Yousafzai attended her father’s school and was always supporting girls’ rights to education. Once the Taliban’s rules started to be enforced, Yousafzai knew it was time to speak up. The Taliban decided to

Collabrative Working in Health and Social Care free essay sample

Using a model of reflection, reflect how you may effectively contribute to working with others and why this is important in health and social care This essay will describe the key policy drivers for collaborative working in health and social care and the importance of effective collaborative working. It will also relate to and discuss my personal experience of collaborative working. Also, it will outline the roles of different members within health and social care teams. Finally, how my own reflection on personal ability in collaborative working identifies the need for development. According to nursetogether. com (2007), collaboration implies working together for the greater good, but it actually encompasses far more. Community care. co. uk (2003) argues that, collaboration and multidisciplinary working are key drivers of the government’s health and social care policies. The department of Health (1992) has also highlighted the need for collaborative working to be incorporated into a National health strategy. This white paper places collaborative working in the centre reform. It defines collaborative working as a partnership of individuals and organisations formed to enable people to increase their influence over the factors that affect their health and wellbeing. The framework identified key areas for priorities targeted under the recognised health service. The collaborative ventures had to target certain high vulnerability groups in the community, such as women, certain socio- economic groups and ethnic minority groups, Targeting practice (Department of health 1993) identified aspects of good practice to be promoted within community health practice. This includes building health alliances within and beyond the health sector and providing quality service, good communication, good working relationships as well as shared aims and values, mutual respect between professional groups and shared learning. Policies such as the NHS PLAN (2000) have identified the need for collaborative working by looking at drivers and frameworks such as the National Service for children, young people and maternity services. The NHS plan mentions that frameworks and drivers have ‘expressed the need for joint working between health and social services to ensure a joined up or collaborative approach to patient care. The NHS PLAN (2000) has aimed to create a service designed around patient needs by encouraging health professionals to work together in collaboration to meet the needs of patients. The NHS plan (2000) mentions how it is important to involve inter education within the healthcare system. The need for this is mentioned in the plan that it promotes a more collective approach towards patient needs, by sharing of knowledge and information by healthcare professionals so that better decisions can be made regarding patient care. Turner and Palastanga (2005), state how different personalities can cause conflicts in collaborative working and how strategies to understand one’s own behaviour and to deal with difficult people is an important aspect of collaborative working as this enables effective service delivery. There are apparent barriers in communication and working patterns that can affect team work. This has been recognised within the media where health and social care organisations have lacked effectiveness in collaborative working. When a serious incident occurred due to the lack of effective collaborative working, Community Care (2010) reports how the social workers of Haringey council in 2007 failed to notice Baby Peters serious abuse and neglect inflicted from family members which lead to his death. There were missed opportunities by the social workers to save him from his abuse. The judge’s verdict was also delayed when OFSTED announced thousands of pages of undisclosed evidence which should have been passed on to other members of the team involved in Baby Peters case. The report says how there was poor communication between different NHS departments that lead to the failure of Baby Peters care. And how the Police and social workers involved in reviewing the case and practice in the health and social care organisations was poorly monitored. This clearly shows evidence of poor collaborative working by Haringey Council. The National Council for Volunteers (2012), an organisation that is a giving voice and Support to a Civil Society, Argue that in order for collaborative working to be successful, it is essential to discuss how you will work together, defining roles and responsibilities, contractual or other legal obligations. People working in collaboration also recognise the importance of values, such as trust in their relationships. Also to build on preparation planning and a written agreement can help avoid misunderstanding. Atkinson et al (2009, identified essential factors to successful collaborative working, such as, commitment from those involved at all levels, having common joint aims and objectives, a clear focus for the work and also good leadership. Collaborative working is a topic of interest in health and social care as it is vital that each team member understands and fulfils their role. Rafferty et al (2001) states teamwork is regarded by many stakeholders as key to the delivery of effective care. Leathard (2003) applies, individuals in a team are equally important to address issues and demands together. According to Turner and Palastang(2005) individuals in a team should have a flexible approach to working and clear communication channels as well as the importance of each individual in the team to make sense of themselves and the concepts within their own context. For the purpose of this essay partially being based upon my own reflective experiences, I will now talk in the first person. I showed effective collaborative working on a given task within a group of four people. The task was called â€Å"the egg drop task†. We were given a few pieces of material to create satisfactory protection for the egg, so that when it dropped from a certain height the egg would not crack. Reflecting on the task, According to Gibbs Model of reflection (1988) as part of a team member I performed well although initially I had mixed feelings as I took leadership, I later involved everybody in conducting the task and asked for each person’s overall opinion. We showed effective collaborative working as in the end we had a positive outcome because when the egg was dropped, covered in protection that we created as a team, the egg did not crack. According to Belbin team roles (2012) it is important to build mutual trust and understanding and also members of a team seek out roles that are most effective and natural to them. I believe my team trusted me to take leadership within the group, according to Belbin (2012) I am naturally a person who likes to take control. All of members in my group co-operated with each other and got along well. I felt as though all members of my team effectively contributed towards the task and gave their opinions accordingly. However, I did feel at times as though I took overall control of the group and was giving the instructions. According to Belbin (2012) test for assessing team roles, I have â€Å"Shaper â€Å"characteristics, which means I am highly motivated with a lot of nervous energy and have a great need for achievement. I am a sort of person who likes a challenge and to push others into action. I felt as though I had many weaknesses as a member of the team, as I felt I was too controlling and felt that my ways were correct most of the time and other group members methods were not. At times I became quite irritated when I was not being listened to or ignored; I would then instead talk over others and lose my patience. In conclusion, I learnt the importance of collaborative working within health and social care and from personal experiences. It is important for each member of the team to understand and fulfil their role and responsibility, also communicate effectively for a positive outcome. As poor communication, trust and co operation within the team overall contributes to poor collaborative working. Working within the health and social care sector, it is very important to have effective collaborative working as it has been demonstrated that without good collaborative working between different departments, communication and information can be misplaced and mistakes can be made as mentioned.

The Princess I Am Essay Research Paper free essay sample

The Princess I Am Essay, Research Paper The Princess I am As a well-respected adult female of my clip, I would neer in my twenty-four hours talk up to my superior, but this clip things had gone excessively far and I had had plenty. I was tired of watching myself and other fellow adult females being treated like a piece of meat by the work forces that dominated our lives, and I decided that, with the aid of many others I would set an terminal to it. It all started the twenty-four hours I heard the Grand King Oric, ask for my manus in matrimony. It was a great award I thought to be a Queen, being pampered, waited on manus and pes and non holding to make a thing. However, to be married to an absolute King with all power and wealth was even a finer glorification. As I planned my epicurean nuptials with the aid of my maidens, I dreamed of what a all right life I would hold, but I shortly realized how incorrect I was. We will write a custom essay sample on The Princess I Am Essay Research Paper or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page As the nuptials twenty-four hours shortly advanced, I still had non seen my suer. Of coarse I heard of him, but neer had I seen the adult male up near. I grew instead funny, and shortly my enticements got to the best of me. One dark when the sky was black as coal and the lone visible radiation I had was from the Moon, I ventured out, disguised as one of my servant misss, to seek to catch a glance of my boyfriend. I slinked along the twist river and shortly approached the King? s palace. It was tremendous, I did non believe I could happen him such a wide topographic point. Nevertheless I walked in, and began my hunt. There were many all right diggingss so in the palace, yet the 1 that caught my attending by far was the angry, austere voices coming out of what looked like to be a storage room. I drew nigher and the voices softened, so all at one time a big corpulent adult male scampered out, protesting how he demanded to see his bride, with his hireling behind him. I thought to myself, could this be my groom? I did non cognize for certain, so I took it upon myself to happen out. As I closely followed the two work forces, I overheard the plump King state his servile, that he needed a immature kept woman to raise and convey about his kids, since his last married woman was an old beldam, and was now beheaded for being so. Equally shortly as I heard this, I instantly thought to myself, make I hold to be with a adult male that will merely love me for bearing his kids? I did non believe so. I dashed out of the palace, and went back to my expecting bed. The following forenoon I awoke with a different position on work forces. Most work forces I realized at this clip were non at all the gentlemen we thought them to be. I decided to obtain many of the other adult females in the small town and mass meeting to set a halt to work forces like King Oric. However after a few months many of the adult females stopped beat uping and decided they liked the old government better. After I resolved that adult male were non all that wicked. I so married, despite the fact he was non of baronial blood and of no great worth, nevertheless, he did handle me like the princess I was. As I look back on how small I did for adult females sort, I did open up the thought, that adult females should be treated every bit every bit good as work forces.

Science Breakthroughs (2002-2013) Essays

Science Breakthroughs (2002-2013) Essays Science Breakthroughs (2002-2013) Essay Science Breakthroughs (2002-2013) Essay Nueva EciJa University of Science and Technology Laboratory High School Gen. Tinio St. , Cabanatuan City Science Breakthroughs (2002-2013) Submitted to: Maam Arlene Gonzales Submitted by: Euna Rastyne T. Mejia Ill-Argon In 2002, U. S. scientists at the State University of New York at Stony Brook have created the first synthetic virus. Using directions downloaded from the Internet and chemicals obtained from a mail-order company, they built an apparently identical copy of the poliovirus. When injected into lab mice, the synthetic virus caused paralysis and then death. The scientists, who published their findings in the online journal Science Express in July 2002, said that they undertook the experiment to prove the alarming fact that a functional pathogenic virus could be constructed without access to a natural virus. Is this small step for biochemistry a great leap for bioterrorism? Scientists say that few people now have the skill to build a synthetic virus, much less one that could be an efficient bioweapon. The genome of the highly contagious smallpox virus is about 25 times as long as that of the poliovirus and has a more complex process of replication. But its synthesis may one day be possible. This being so, the experiment raises questions about the wisdom of ceasing vaccination when a natural virus has been eradicated. In 2003, the Hubble telescope has detected the oldest known planet†and it appears to have been formed billions of years earlier than astronomers thought possible. Nicknamed Methuselah after the aged biblical patriarch, the planet is an astonishing 12. 7 billion years old. In contrast, all other known planets (including our own) were created about 8 billion years later, roughly 4. 5 billion years ago. Methuselahs age is causing stronomers to reevaluate the prevalent theory of planet formation, which argues that the early universe did not contain sufficient heavy elements (e. g. , carbon, silicon, and oxygen) to allow for planets to form. But Methuselah defies this theory, having debuted when the primordial universe had only one-thirtieth of the heavy elements existing when our own solar system was born. In 2004, celebrated physicist black holes. Whats more, his error cost him a long-standing bet, obliging him to present a baseball encyclopedia to John Preskill of the California Institute of Technology. On the bright side, Hawkings black hole recantation had a rather exciting side-effect: l think, he ventured, l have solved a major problem in theoretical physics. Formed from a collapsed star, a black hole is a cosmic vacuum cleaner, whose gravitational pull is so strong that it sucks up everything in its way. In 1976, Hawking theorized that black holes emit random radiation (later named Hawking radiation) and lose mass until they eventually evaporate without a trace. All the matter sucked into a black hole, and all information about it (its quantum mechanical properties), would then be lost forever. But Hawkings theory contradicts an essential principle of quantum physics: no information can ever be truly destroyed. Black holes, if Hawking was right, defy the laws of the universe as we know it. This radical theory, according to Preskill, precipitated a genuine crisis in fundamental physics. Preskill resisted accepting what became known as the black hole information paradox, and in 1997 Hawking (along with another colleague) bet him that information swallowed by a black hole is forever hidden from the outside universe and can never be revealed, even as the black hole evaporates and ompletely disappears. Seven years later, Hawking claims to have solved the very paradox he created. According to his revised theory, black holes eventually open up, revealing information about what went into them†the information remains firmly in our universe, Hawking asserted. Preskill was pleased enough at having won the bet, but acknowledged, Ill be honest, I didnt understand the talk. Neith er did most others in the audience of the 17th International Conference on General Relativity and Gravitation in Dublin, leaving a stunned group of 800 scientists not sure what had hit hem. Hawkings published proof of his revolutionary findings will follow, but in the meantime, he has paid off his bet to Preskill. The bettors had agreed upon an encyclopedia, which, unlike a black hole, is something from which information can be recovered at will. In 2005, paleontologists discovered the existence of soft tissue in a 68-million-year-old Tyrannosaurus Rex fossil. An unprecedented find in a prehistoric creature†scientists had assumed no such tissue could survive more than 100,000 years†the soft tissue included cells and blood vessels. The discovery was a erendipitous one. Because this T. rex fossil was located in a remote part of Montana (the Hell Creek formation, where about two dozen species of dinosaurs have been found) the fossil had to be removed by helicopter. According to paleontologist Jack Horner, who participated in the excavation, we actually had to split the thighbone into two pieces to get it into the helicopter. When his colleague Mary Schweitzer later examined the hollow cavity of the broken bone in her North Carolina State University lab, she discovered the pliable tissue. Scientists predict the soft tissue will rovide a gold mine of information about the physiology of dinosaurs. Examination of the soft tissue has already yielded several exciting revelations. The tissue included medullary bone, a calcium-enriched substance temporarily present when birds are ready to produce eggshells and lay eggs. Not only does the presence of medullary bone reveal that this particular T. rex was female (paleontologists have never before determined the sex of a dinosaur), but the existence of medullary tissue also According to Schweitzer, it links the reproductive physiology of dinosaurs to birds very closely. It indicates that dinosaurs produced and shelled their eggs much more like modern birds than like modern crocodiles. Horner commented that this is another piece to the puzzle and there are a lot of them. Anyone who would argue that birds and dinosaurs are not related†frankly, Id put them in the Flat Earth Society group. In 2006, paleontologists revealed the discovery of a 375-million-year-old transitional species whose anatomical traits bridge the gap between fish and tetrapod (four-legged vertebrate). Nicknamed the fishapod, its formal name is Tiktaalik roseae, from the Inuit name for a large shallow-water fish. Tiktaalik Joins several other significant transitional fossils†the most famous of which is Archaeopteryx, the part-bird, part-reptile considered the missing link between birds and dinosaurs, which was discovered in 1860, Just two years after Darwin published The Origin of Species. The transformation of aquatic creatures into land animals took place during the Devonian period, about 410 to 356 million years ago. But before the discovery of the 375-million-year-old Tiktaalik fossils, there had been no actual fossil evidence to illustrate this crucial evolutionary moment. According to paleontologist Neil Shubin of the University of Chicago, We are capturing a very significant transition at a key moment of time. What is significant about the animal is that it is a fossil that blurs the distinction between two forms of life†between an animal that lives in water and an animal that lives on land. Tiktaalik resembles a huge scaly fish with a flat, crocodile snout. What amazed scientists was its pectoral fins, which contain bones forming the beginnings of a shoulder, elbow, wrist, hand, and even nascent fingers. Shubin describes the fin as basically a scale-covered arm, asserting hat heres a creature that has a fin that can do push-ups. Tiktaalik could pull its own weight, dragging itself along in shallow water and onto dry land, much like a seal. Tiktaalik also distinguishes itself from a fish by the existence of a primitive neck and ribs. As Harvard University paleontologist Farish A. Jenkins explains, Out of water, these fish encountered gravitational forces very different from the relative buoyancy they enjoyed in an aquatic setting. Restructuring of the body to withstand these forces is evident in the ribs, which are plate-like and overlap like shingles, orming a rigid supporting mechanism for the trunk. And while a fish has no need of a neck†in water, its entire torso easily falls into place behind its head when changing directions†Tiktaaliks developed neck allowed it to move its head while its body, constrained by the stronger pull of gravity on land, remained stationary. According to Edward Daeschler of the Academy of Natural Sciences, the combination of these radically new anatomical features with classic fishlike traits demonstrates that evolution proceeds slowly in a mosaic pattern with some elements changing hile others stay the same. In 2007, scientists reported that they could use human skin cells to create embryonic stem cells. Stem cells have the remarkable ability to grow indefinitely, serving as a sort of repair system for the body. They can potentially divide without limit into any one of the 220 types of cells in the body to without embryonic destruction, which would eliminate the ethical controversy and limited funds for research. With ethical problems out of the way, more resources will become available for stem cell research. Generating stem cells could lead to new isease treatments by taking skin cells from a person with an illness and generating more stem cells that could be observed from the earliest stages of development. By watching a disease as it develops, scientists could potentially design drugs to not only treat it but also prevent it. With stem cells produced from a patients own skin cells, it is possible to create tissue that would not be rejected by their immune system†the same result would require cloning with embryonic stem cells. In 2008, California became the first U. S. state to ban the use of trans fats by restaurants nd food retailers. Trans fats, or hydrogenated oils, are used in processed foods to increase their shelf life. Trans fats are also linked to coronary heart disease. California has 88,000 restaurants that will be affected when this law goes into effect by 2010. California Governor Arnold Schwarzenegger said the new law was a strong step toward creating a healthier future. Any restaurant violating the new law will incur fines from $25 to $1,000. In 2009, the Human Epigenome was decoded. The decoding of the human genome nearly a decade ago fueled expectations that an nderstanding of all human hereditary influences was within sight. But the connections between genes and, say, disease turned out to be far more complicated than imagined. What has since emerged is a new frontier in the study of genetic signaling known as epigenetics, which holds that the behavior of genes can be modified by environmental influences and that those changes can be passed down through generations. So people who smoke cigarettes in their youth, for example, sustain certain epigenetic changes, which may then increase the risk that their childrens children will reach puberty early. In October, a team led by Joseph Ecker at the Salk Institute in La Jolla, Calif. studied human skin and stem cells to produce the first detailed map of the human epigenome. By comparing this with the epigenomes of diseased cells, scientists will be able to work out how glitches in the epigenome may lead to cancers and other diseases. The study, which was published in the journal Nature, is a giant leap in geneticists quest to better understand the strange witches brew of nature and nurture that makes us who we are. In 2010, researchers from the J. Craig Venter Ins titute reported the successful construction of first self-replicating, synthetic bacterial cell. They copied and modified an entire genome of a small bacterial cell, inserted it into a living cell of another species, and by doing so created a new, synthetic life. This is the first self-replicating species that weve had on the planet whose parent is a computer, U. S. scientist Craig Venter who led the team said. It also is the first species to have its own website encoded in its genetic code. This is the first self-replicating species that weve had on the planet whose parent is a computer, U. S. scientist Craig Venter who led the team said. It lso is the first species to have its own website encoded in its genetic code. Scientists hope to patent the organism, called Mycoplasma laboratorium and engineer it to manufacture cheap biofuels, medicines and other useful compounds. In 2011, NASAs Kepler Mission scientists, who are charged with discovering Earth-like planets in the so-called habitable zone of stars in the Milky Way, announced the Tatooine); located the first two known Ea rth-sized exoplanets; quadrupled the number of worlds known to exist beyond our solar system; and spied Kepler-22b † the most Earth-like planet weve encountered yet. And heres the really exciting bit: Kepler is Just getting warmed up. In 2012, for the first time in history, researchers at Kyoto University created a mouse by using eggs derived from stem cells alone. The achievement once again shows the remarkable possibilities presented by regenerative technologies like stem cells, while raising pressing ethical questions about the potential for human births in which parents might not be required. In 2013, the idea of taking someone elses poop and giving it a new home in your own colon may sound repulsive, but the treatment has proven emarkably effective in curing infections of C. ifficile†a nasty bacteria that kills 15,000 people each year. Take heart: The digested food waste in feces isnt itself the cure. Youre simply gaining some of the helpful bacteria living in the donors gut†like a farmer choosing the hardiest crops to seed next years fields. The bacteria produce proteins that are involved in a lot more diseases than we realized, says Roizen. Still grossed out? Researchers in Canada have developed a method to deliver Just the bacteria†no feces†via an oral pill, skipping the need for a poo enema.

Religous Profile Report Research Paper Example | Topics and Well Written Essays - 1000 words

Religous Profile Report - Research Paper Example All the next Gurus worked on the teaching of Guru Nanak and developed the faith and trust of Sikhism over next four centuries and made the religious history of approximately 400 years. Fifth Guru, who was named guru Arjan complied the first holy book of Sikhism (BBC Religion). He also established the first estate â€Å"Amritser† for Sikh Community. All ten gurus devoted their lives for the establishment of the Sikh Religion due to their efforts. Sikhism is one of the fastest growing religion in the world. Belief about GOD: The concept of GOD in Sikhism is very clear. Sikh Community believes that there is only one GOD. He is the only creator of the entire Universe. Sikh community believes that GOD has not any specific gender. In addition, they believe that GOD can be accessed by everyone (BBC Religion). Equality: Equality is one the major beliefs of Sikhism. Teachers of Sikhism state that all the human beings are equal. All people have the same rights. None has any priority over other (kwintessential.co.uk). Other Beliefs: Sikhism aims to make the environment peaceful. Sikhism states that the truth is the key of all virtues. The religion encourages that truth and justice is a key for a peaceful life. The Sikhism also state that if a person wants to feel the pure feelings to GOD, then he must switch his attention from all other material things to only one GOD. That is the only way in which human achieves the maximum level of liberation. In addition, the teachings of the Guru Nanak also state that GOD does not have a gender and cannot be understood by everyone easily. Love and worship is the only way to know the real means of GOD. Sikhs believe that their own souls and hearts are the best tools to find the GOD. Sikhs believe that they can feel the real pleasure and travel on the way of liberation by avoiding certain things such as lust, anger, pride and attachment to the things in this world. The

Building a Foundation for the Persuasive Speech Essay

Building a Foundation for the Persuasive Speech - Essay Example A speech that is accompanied by evidence drawn from credible sources helps to improve its credibility. In this case, I will utilize credible sources that can also be easily accessed by the targeted audiences to that they can prove or refute my claims on their own. Essentially, I will strive to use the best sources in order to convince the speakers about the subject presented. A successful speech is capable of keeping the audience thinking and learning about the topic presented. I will achieve this through appealing to the emotions of the people so that they can use their intellect to think deeply about the topic. I will present current evidence drawn from the media in order to comprehend my argument. This will help the targeted audiences to keep on thinking and learning about the topic presented. The third aspect I will take into consideration when building my speech is to ensure creativity. I will carefully develop my speech in a creative way such that it would appeal to the interests of the targeted people instead of presenting it as a plain speech. I will add some humour in the speech in order to avoid monotony. I am convinced that the speaker should avoid boring the listeners since they would easily lose interest in the speech. The fourth step I will take into consideration is to demonstrate that this topic is relevant to the audiences’ needs and interests. The portrayal of women in different media has a significant impact on their behaviour and these images cannot be ignored. I need to demonstrate to the targeted audiences that the media is a powerful tool and it can significantly influence the behaviour of the people in many ways. This topic is relevant to the targeted people since they often find themselves developing negative perceptions about their own appearances. The main reason is that their attitude has been changed by the media but the truth is that these people only need to be self confident. The fifth step I will take into

Secondary Sjögren’s Syndrome and Rheumatoid Arthritis

Secondary Sjà ¶gren’s Syndrome and Rheumatoid Arthritis Secondary Sjà ¶gren’s Syndrome and Rheumatoid Arthritis Activity – a case of severe dry eyes Authors: Dina Christina Janse van Rensburg, MD1, 2 Catharina Cornelia Grant, PhD1, 2 Audrey Jansen van Rensburg, MSc1,2 Pieter Roelof Cronjà ¨, FC Ophth, MBChB3 Thelani Catharina Grant, BSc Agric (Hons)1, 2 Abstract Patients with Sjà ¶gren’s syndrome present with a wide range of clinical manifestations that carries a high rate of morbidity and mortality with increased risk of lymphoma development. Sjà ¶gren’s syndrome is either a primary disorder, or secondary to other autoimmune disorders e.g. rheumatoid arthritis (RA). Due to the multiple aspects of the disease and the similarity of the symptoms to other diseases, diagnosis and management of Sjà ¶gren’s syndrome is challenging. Among the symptoms, Sjà ¶gren syndrome typically presents with dry eyes that may result in severe ocular surface disorders such as persistent epithelial defects, and conventional dry eye therapy is often unsuccessful in controlling ocular signs and symptoms. We highlight the rare case of a 50 year old woman whom despite well controlled RA disease activity still manifested with severe secondary Sjà ¶grens syndrome. It was only after autologous serum was applied as a last resort that her ocular s ymptoms improved. Keywords: Rheumatoid arthritis, dry eyes, Sjà ¶gren’s syndrome, autologous serum, inflammation Introduction Sjà ¶gren’s syndrome (SS) is a systemic autoimmune disease affecting the exocrine glands. A lymphocytic infiltration in the salivary and lacrymal glands results in reduced secretion, leading to continual dryness of the mouth and eyes.1-3 SS may manifest as a primary disease presenting as a single entity, or secondary in combination with other autoimmune disorders.4 The prevalence of secondary SS relates predominantly to RA5 and associates with increased disease acivity.6 It may present with a systemic component, including painful joints, dry and itchy sunlight sensitive skin, irritable bowel, liver problems and extreme tiredness. Because of the many possible clinical pictures of SS it is a challenging diagnosis to make and may therefore go undiagnosed for many years after the onset of symptoms.3,7-9 Dryness symptoms are amplified in patients with RA, it increases with age and are associated with the severity of illness, relating to worse outcomes measures of the disease. Appr oximately 25% RA patients presents with keratoconjunctivitis sicca as the most prevailing and frequent ocular complication.5,10 Several therapies have been identified that inhibit inflammatory mediators and mechanisms in dry eye disease, however the treatment of persistent epithelial defects and severe ocular dryness by means of topical tear replacement often proofs inadequate.11 In this case study we report a RA patient who regardless of well controlled treatment with a tumor necrosis factor (TNF) inhibitor, still developed severe secondary SS. Autologous serum drops offered significant improvement of her extreme ocular surface inflammation and symptoms, when all other treatment modalities failed. Case Report A 50 year old Caucasian woman was diagnosed with RA. During the course of the illness she was treated with methotrexate, folic acid, meloxicam, prednisone, sulfasalazine and leflunomide. Seven years post RA diagnosis and despite well controlled disease on adalimumab, methotrexate and folic acid, her eyes became extremely dry and highly sensitive to light. This dryness caused severe, constant discomfort and visual blurring, rendering her partially incapacitated, even though her corrected vision was still normal at 6/6. She had to wear sunglasses indoors and could not drive independently. On examination of her corneas the various findings confirmed the severity of her dry eyes. These included a tear breakup time of 5 seconds bilaterally, mucus filaments, punctuate corneal straining and an almost non-existing tear meniscus indicating very little tear secretion. Evidence of previous (healed) peripheral ulcerative keratitis could be seen on the medial aspect of both corneas. These symptoms lead to the diagnosis of Sjà ¶gren’s syndrome. She was treated with all possible modalities including punctum plugs and multitudes of topical medication including Cyclosporine A, with no apparent improvement. A decision was made to attempt an eye drop prepared from autologous serum. Her condition improved remarkably in the year since she started the serum. Discussion Sjà ¶gren’s syndrome was first described by the eye specialist Hendrik Sjà ¶gren in 1933. It presents with a variety of symptoms, including fatigue, arthralgia, myalgia, keratoconjunctivitis sicca(dry eyes, in part known as Sicca syndrome), xerostomia (dry mouth), skin lesions, lymphoproliferative disorders, neurologic involvement, leukocytoclastic vasculitis, rhinitis, pharyngitis and laryngitis.3,9,12 In view of the wide range of severe systemic manifestations of the disease patients are often characterised with higher morbidity and mortality, which are mainly related to an enhanced probability to develop lymphoma.3,13 Most patients with SS are middle-aged women, and symptoms mostly occur with the accompaniment of, but not exclusively to, RA.3,12 Recently literature differentiates between two main types of the disease: The glandular (exocrine gland-localised) form that affects mainly the quality of life of the patient, and the systemic syndrome type which display extraglandular manifestations that may lead to lymphoma.3 The glandular phenomenon includes ocular symptoms (dry eyes, xerophthalmia) and oral involvement (dry mouth, xerostomia, caries and candidiasis).3 Extraglandular manifestations consist of musculoskeletal indications, Raynaud’s phenomenon, renal, liver and neurological involvement, vasculitis and haematologic manifestations.3,13 Diagnosis Sjà ¶gren’s syndrome is difficult to diagnose due to the multiple aspects of the syndrome, and similarity to the symptoms caused by other diseases.3,7,8 SS is a slow progressing disorder, and on average may take approximately 5 years from the onset of symptoms before the correct diagnosis is reached.8 Sjà ¶gren’s syndrome is strongly suggested in patients who present with both signs and symptoms of oral and ocular dryness and who test positive to the diagnostic criteria. From clinical experience it was found that if a patient does not suffer from both dry eyes and dry mouth, it is necessary to exclude further causes of the dry eyes by means of differential diagnoses.13 A series of tests in the diagnosis of Sjà ¶gren’s syndrome are outlined in Table 1. These criteria consider dryness symptoms, changes in salivary and lacrimal gland function, and systemic findings.8 Table 1. Tests and criteria used to diagnose Sjà ¶gren’s Syndrome8 Treatment The aim of treatment for dry eyes is mainly to provide relief of symptoms and to prevent corneal epitheliopathy. Management of the disease currently includes artificial tears, topical secretagogues, local immunomodulatory drops, lachrymal duct occlusion and hypotonic hyaluronic acid drops in the treatment of dry eyes.3 Different methods of treatment that may be used independently or in combination with tear supplements include systemic immunoactive drugs and calcineurin inhibitors, topical corticosteroids and topical non-steroidal anti-inflammatory drugs.3 Patients with dry eyes normally respond well to these treatments that focus on optimising the ocular surface environment. Some patients, however, present with more serious ocular surface disorders, that do not react to conventional treatment, which may lead to severe visual impairment.14,15 Fujita et al.10 drew attention to the exceptionally high incidence of dry eyes in patients with RA. Their conclusions are that although RA patients with SS present with systemic effects on dry eyes, there seems to be other local factors independently of the systemic process, that disturbs the ocular surface and control the severity of dry eyes in RA patients.5,16 Due to the many local elements active in dry eyes it calls for improved new therapeutic agents for managing dry eyes without making use of systemic agents.5 The various factors that contribute to a healthy ocular surface include an adequate blink reflex, normal tear production and healthy adnexae.14 Typically tears contain epitheliotrophic factors including growth factors, vitamins and fibronectin that are of vital importance to the ocular epithelial health.15 These factors support the viability, proliferation and migration of ocular surface epithelial cells.15 They are not found in pharmaceutical tear substitutes, but do however occur in blood serum. Clinical cohort studies have reported the successful useof epitheliotrophic factors in autologous serum drops to improve severe cases of dry eyes where other conventional treatments fall short.14,15 Autologous serum drops was first described in 1984 as a substitute constituent free of potentially harmful substances17 applied as unpreserved artificial tears.15 It is believed that the epitheliotrophic factors in the serum are the rationale behind its success in the treatment of extremely dry eyes.15 The use of autologous serum eye drops may in many cases be a last resort of treatment for SS patients who have not responded well to conventional tear replacement therapy. Even though the preparation thereof is costly and complex, it proofs a clinically effective treatment in ocular surface diseases.3,11 Being non-allergenic with biochemical properties akin to normal tears,3,18 it benefits the conjunctival epithelium supplementing essential vitamins, fibronectin, anti-proteases and growth factors. This may stimulate its proliferation and repair,11 and play an important role in the integrity of the cornea and conjunctiva.3,11 Autologous serum appears to be more effective in resistant cases. It may also play an essential role adjunct to therapy in other ophthalmological conditions as seen in chemical injuries of the ocular surface. Conclusion Sjà ¶gren’s syndrome may cause marked disability in patients suffering from the disease, especially when secondary to RA. In this case study, despite optimal control with a TNF inhibitor the patient still presented with SS and suffered from severe xerophthalmia. All treatment modalities had failed and as a last alternative autologous eye serum was instituted. This significantly improved the severe dry eyes and persistent epithelial defects and enabled her to live a normal life. Consent Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review. References 1.Shiel W. What is rheumatoid arthritis?. 4/24/2014; Available at: http://www.medicinenet.com/rheumatoid_arthritis/article.htm. Accessed June 26, 2014. 2.Antero DC, Parra AGM, Miyazaki FH, Gehlen M, Skare TL. Secondary Sjà ¶grens syndrome and disease activity of rheumatoid arthritis. Rev.Assoc.Med.Bras. 2011 05/20;57(3):319-322. 3.Vitali C, Palombi G, Cataleta P. Treating Sjà ¶grens Syndrome: Insights for the Clinician. Ther Adv Musculoskelet Dis 2010 06;2(3):155-166. 4.Patel R, Shahane A. The epidemiology of Sjà ¶grens syndrome. Clin Epidemiol 2014 07/30;6:247-255. 5.Lemp MA. Dry eye (Keratoconjunctivitis Sicca), rheumatoid arthritis, and Sjà ¶grens syndrome. Am.J.Ophthalmol. 2005 11;140(5):898-899. 6.Fox RI. Sjà ¶grens syndrome. Lancet 2005 07/23;366(9482):321-331. 7.Mayo Clinic. Diseases and Conditions: Sjogrens syndrome tests and diagnosis. Jul. 08, 2014; Available at: http://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/basics/tests-diagnosis/con-20020275. Accessed June 25, 2014. 8.Sjà ¶gren’s Syndrome Foundation. Diagnosis about Sjà ¶grens Syndrome. 2014; Available at: http://www.sjogrens.org/home/ about-sjogrens-syndrome/diagnosis. Accessed June 26, 2014. 9.Kruszka P, OBrian R,J. Diagnosis and management of Sjà ¶gren syndrome. Am.Fam.Physician 2009 03/15;79(6):465-470. 10.Fujita M, Igarashi T, Kurai T, Sakane M, Yoshino S, Takahashi H. Correlation between dry eye and rheumatoid arthritis activity. Am.J.Ophthalmol. 2005 11;140(5):808-813. 11.Cho YK, Huang W, Kim GY, Lim BS. Comparison of autologous serum eye drops with different diluents. 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