Are attitudes, policies and procedures for dealing with female Essay

Are attitudes, policies and procedures for dealing with female offenders difficult to justify when compared with their male counterparts - Essay Example In line with this, this research will answer the question ‘Are the attitudes, policies and procedures for dealing with female offenders difficult to justify when compared with their male counter parts?’ the methodology employed in order to address this question is documentary research. The study, utilising the documentary research methodology, relied on using secondary data collected from various scholarly literatures written about female offenders, UK Case Laws, crimes, and legislation. In the documentary analysis undertaken, the answer to the primary question is NO. It is not difficult to justify. This answer to the question is supported by the following suppositions: 1. Justice is impartial. The gender and sex of the offender is immaterial in the resolution of the case 2. There is a need to redefine the court system in such a way that it will accommodate female offenders and workers in the justice system 3. There is a need for restructuring of the justice system. 4. Reformation in the justice system 5. Training among the workers on treatment of female offenders. The notion of women committing crimes have been considered as a deviancy from the cultural image and gendered expectations that society has of women.1 Being such, traditional theories pertinent to female delinquency and female offending have been focused on how women are biological destined in committing crimes or by explaining it away via citing pathological explanations that confound the criminal act. Recognizing the importance of these views as necessary in understanding the criminal behaviour of women, does not preclude the fact that women ‘do’ commit crimes and that there are factors and explanations behind their criminal acts and not simply because of their gender or sexuality.2 Although Table 1 shows that compared with men, women commit less crimes but it does not show the fact that there is an increase in the number

Chemistry and Anatomy Essay Example for Free

Chemistry and Anatomy Essay My life began as a simple and talented student in Geneva. My father was Alphonse Frankenstein, who was a wealthy, rich and benevolent man. I was the first son of my father, Alphonse Frankenstein. My mother Caroline visited a beautiful orphan girl, Elizabeth Lavenza, fair-haired girl. She was adopted by my family and was my cousin. I had two brothers who were very lovely and they loved me and Elizabeth a lot. My best friend was Henry Clerval, who was a considerate man. I became a student of Chemistry and Anatomy in the quest to determine what gives life. I was a young man who led a happy and peaceful life, but the events happened after, made a great change to my living. The world according to me was a secret of research, creation and experimenting. I learnt the theories of electricity and galvanization. I also initiated a theory of how to create human life using the principles of electricity. I became devoted to the human creation and the spark of life that I had abandoned earlier. I asked my University for specimens to make my creation. I figured out what gives life.  Ã¢â‚¬Å"I have begged my University for specimens. They say I’ve had all their best material for years, and produced nothing to show for it.† I feel that I have begged my University for some specimens to make my creation, but they refused to afford me the specimens because they say that they have given all the best pieces of specimens to me for creating nothing. Finally, I got the body parts from the graveyard. Then I went out without my meals to buy some chemicals. I took the body parts from the corpses. I stored my chemicals and specimens in the dissecting room so that it would be safe. I constructed a giant man, 8 feet tall, with super human strength and endurance from harvested body parts that I took from the corpses. I worked secretly without rest for almost a year. I can tell you that I was a bit disappointed with my creation. My perfect creation was a frightening disaster. My creation was a result of horror.  Ã¢â‚¬Å"No, this isn’t what I wanted. Oh, dear god, what have I done?†Ã‚  I was not at all happy with my monstrous creation. So, I rejected, abandoned and left him away. I was also scared, frightened and afraid of him. I also avoided my scientific studies because it remained me about the disastrous experiment. I wanted him to help and like mankind. This was not what I expected. I wanted my creation to be helpful rather than being a nuisance. My excitement soon changed when my creature came into life. My lovely, little brother William was murdered by my creation, the monster. Elizabeth cried a lot and I was not able to convince her. She also told me that my five- year-old brother, William and she went for a walk. She also told me that she saw William disappear. She was searching for him all over. I examined what had happened and found out that it was the monster, who was responsible for the murder of my brother. I was very angry with the behaviour of my creation. I created him to help human life and not to destroy them. He came to my room. I was very angry at him and wanted to destroy him. He told me to control my temper and he asked me to listen to him. He told me that the only person to be kind to him was Agathe, a young blind lady. The other villagers chased him away through their dogs. He also told me that his intention towards William was not to kill him. Then he explained to me about what had happened. He told me, â€Å"I put my hands to his mouth to silence him, because I was afraid.†Ã‚  The monster asked William to play with him for a while. But William shouted and refused to play with him. So, he just kept his hands in William’s mouth to silence him and request him to play with him. He also convinced me by telling the truth, but I am very sad that my brother is being murdered by my creation.  I was asked by the monster to make a bride to the monster. I agreed to him because as a creator, I should have to fulfill the wishes of my creation. He said to me that,  Ã¢â‚¬Å"I am alone and miserable; man will not associate with me; but one as deformed and horrible as myself would not deny herself to me. My companion must be of the same species and have the same defects. This being you must create.† He conveyed me his feelings of how it was to be alone without a companion or a comrade. He also gave me two years time to make a complete creation. He also told me that he would not trouble me in the time in between. I repulsed myself to make a bride for the monster. I wanted to finish the bride before marrying Elizabeth. I was also worried that the monster may harm my family. I still found it difficult to make the second monster. I made it because he told me that he wanted to love. I also made it, but this creation was spoilt by the monster, himself. The thing where he went wrong was, giving wrong wire connections to the creation and made it destroy. I explained to him that,  Ã¢â‚¬Å"She’ll never live now! Monster, what have you done?†Ã‚  He thought that he knew to make his own creation. He acted over- smart by giving the wrong wire connections and destroying his bride by himself. I beautifully laid out the bride in white colour clothes, to symbolize that she was going to get married. There is no use for him to commit the murders of Elizabeth and Clerval, by knowing that was his fault. I was really angry when he killed my brother, William. Then, he explained to me about what had happened. He told me that,  Ã¢â‚¬Å"I put my hands to his mouth to silence him, because I was afraid.†Ã‚  It was my fault to create him and abandon him. Since I have created him I lost my Elizabeth, Clerval and my dear brother William. I got the feelings of how it was to face death. If I think of him, my first thoughts were, why did I create him? I found it like a battle of â€Å"Evil vs. Good†.

Risk Factors For Neutropenic Fever Health And Social Care Essay

Risk Factors For Neutropenic Fever Health And Social Care Essay Cancer patients, who receive cytotoxic antineoplastic therapy sufficient to harmfully affect myelopoiesis and the developmental integrity of the gastrointestinal mucosa, are at high risk for invasive infection due to the translocation of colonizing bacteria and/or fungi across intestinal mucosal surfaces. Since the level of the neutrophil-mediated component of the inflammatory response are typically attenuated in neutropenic patients 1, physical findings of exudate, fluctuation, ulceration or fissure, local heat, swelling, and regional adenopathy are all less prevalent in the neutropenic patient1. Thus, fever might be the earliest and only sign of a severe underlying infection 2. With the increasing use of myelo-suppressive agents in the treatment of neoplastic and nonneoplastic diseases, the increased rate of infection in patients with neutropenia has been clearly established 3. Sadly, many of these commonly fatal infections go unrecognized until autopsy 4. Therefore, in order to avoid unfortunate outcomes such as sepsis and possibily death, it is critical to recognize neutropenic fever early and to start empiric systemic antibacterial therapy promptly. It is also crucial to assess the risk of serious complications in patients with febrile neutropenia, since this assessment will dictate the approach to therapy, including the need for inpatient admission, IV antibiotics, and prolonged hospitalization 2. An overview of the concepts related to neutropenic fever, including definitions of fever and neutropenia and categories of risk are reviewed here. The risk assessment and the diagnostic approach to patients presenting with febrile neutropenia are also discussed. This topic also provides a general approach to the management of neutropenic fever syndromes in cancer patients at high and low risk for complications, and the prophylaxis of infections in such patients. DEFINITIONS Fever: The definition of fever as an indicator of infection in patients with neutropenia has varied. Carl Wunderlich proposed in 1868, that the mean normal body temperature was 37 ¿Ã‚ ½C (98.6 ¿Ã‚ ½F) with an upper limit of normal of 38 ¿Ã‚ ½C (100.4 ¿Ã‚ ½F), above this limit, fever was defined 5,6. Although it has been observed that there is a range of normal body temperatures, according to a survey of 270 medical professionals, 75 percent of subjects reported that normal body temperature is 37 ¿Ã‚ ½C (98.6 ¿Ã‚ ½F)5,7. While, a survey of members of the British Society for Hematology concerning their institutional definitions of fever identified ten definitions of fever, ranging from a single temperature >37.5 ¿Ã‚ ½C to either a single temperature >39 ¿Ã‚ ½C or two successive temperatures >38.4 ¿Ã‚ ½C 5,6. Despite these beliefs, the mean oral temperature was reported as 36.8 ¿Ã‚ ½0.4 ¿Ã‚ ½C (98.2 ¿Ã‚ ½0.7 ¿Ã‚ ½F) with a range of 35.6 ¿Ã‚ ½C (96.0 ¿Ã‚ ½F) to 38.2 ¿Ã‚ ½C (100.8 ¿Ã‚ ½F), after observation of 148 healthy adults ages between 18 and 40 years 6. The definition of fever in neutropenic patients, according to The Infectious Diseases Society of America, was proposed as a single oral temperature of >38.3 ¿Ã‚ ½C (101 ¿Ã‚ ½F) or a temperature of >38.0 ¿Ã‚ ½C (100.4 ¿Ã‚ ½F) sustained for >1 hour2. Similar definitions have been provided from South America, Europe, and Asia. It has been approved to use this definition of fever in neutropenic patients9 ¿Ã‚ ½11. Neutropenia: The definition of neutropenia differs from institution to institution, but it is usually defined as an absolute neutrophil count (ANC) The absolute neutrophil count (ANC) is defined as the product of the white blood cell count (WBC) and the percentage of polymorphonuclear cells (PMNs) and bands: ANC = WBC (cells/microL) x percent (PMNs + bands)  ¿Ã‚ ½ 100 Based upon the level of ANC, neutropenia is categorized as mild, moderate or severe. An absolute neutrophil count between 1000 and 1500/microL corresponds to mild neutropenia. While, an ANC between 500 and 1000/microL corresponds to moderate neutropenia. Severe neutropenia is usually defined as an ANC As the neutrophil count drops below 500 cells/microL, the risk of clinically serious infection increases and is higher in those with a prolonged duration of neutropenia (>7 days). However, the risk is also related to the adequacy of the marrow reserve pool of granulocytes. Two terms, leukopenia and granulocytopenia are often used interchangeably with neutropenia, although they are somewhat different:  ¿Ã‚ ½ Leukopenia is defined as a low total white blood cell count that may be due to any cause such as lymphopenia and/or neutropenia; yet, almost all leukopenic patients are neutropenic since the amount of neutrophils is so much higher than the amount of lymphocytes.  ¿Ã‚ ½ Granulocytopenia is defined as a reduced absolute number of all circulating cells of the granulocyte series (neutrophils, eosinophils, and basophils); yet, almost all granulocytopenic patients are neutropenic since the amount of neutrophils is so much higher than the amount of eosinophils and basophils.  ¿Ã‚ ½ Agranulocytosis is defined as the absence of granulocytes, but the term is often inaccurately used to denote severe neutropenia. CATEGORIES OF RISK RISK FACTORS FOR NEUTROPENIC FEVER The risk factors for the development of neutropenic fever can be divided into three sub-categories including patient-related, disease-related and anti-cancer treatment-related predictors. Patient-related predictors include: age = 65 years, female sex, high body surface area, poor performance status based upon preexisting active comorbidities (e.g., cardiovascular, pulmonary, renal, endocrine, etc.) and poor nutritional status12 ¿Ã‚ ½19. Disease-related predictors include: Elevated lactate dehydrogenase (LDH) in patients with lymphoreticular diseases, bone marrow failure due to replacement of hematopoietic tissue by anomalous tissue which is know as myelophthisis19, lymphopenia20,21 and advanced stage of the underlying malignancy 13,16,20 ¿Ã‚ ½22 Treatment-related predictors include: administration of the planned dose-intensity of high-dose chemotherapy regimens15,20 ¿Ã‚ ½23 and failure to administer prophylactic hematopoietic growth factor support to patients receiving high-risk regimens14,21. RISK OF SERIOUS COMPLICATIONS This risk assessment is essential to determine the management of patients, including the need for inpatient admission, IV antibiotics, and prolonged hospitalization. High-risk patients require hospital admission for IV antibiotics, and often a prolonged length of stay. In contrast, low-risk patients may be treated as outpatients with oral antibiotic after a short period of observation or hospitalization. Definitions of low-risk and high-risk patients: The Infectious Diseases Society of America (IDSA) and National Comprehensive Cancer Network (NCCN) use different definitions in their guidelines:  ¿Ã‚ ½ Low-risk patients are those who are expected to have neutropenia (absolute neutrophil count [ANC]  ¿Ã‚ ½ High-risk patients are those expected to have neutropenia (ANC 7 days. While, neutropenic febrile patients with comorbidities or evidence of significant hepatic or renal impairment are considered high risk, regardless of the duration of neutropenia. Some experts have identified patients at high risk as those who are expected to have profound neutropenia (ANC = 100 cells / microliter) for > 7 days on the basis of experience that these patients are more likely to have serious and potentially fatal complications2,24. Nevertheless, formal studies to clearly differentiate between patients with a neutrophil count Some studies combine these groups to define high-risk patients. Deep prolonged neutropenia (ANC = 100 cells / microL expected to last > 7 days) is more likely to occur in the pre-transplant hematopoietic cell transplantation (allogeneic in particular) and in patients undergoing induction chemotherapy for acute leukemia. Risk based on underlying disease Patients who suffer from neutropenia after induction chemotherapy for acute myelogenous leukemia or as part of the conditioning regimen for allogeneic hematopoietic stem cell transplantation (HCT) are at a high-risk for serious infections. Other factors that are considered as high-risk status include gastrointestinal and oral mucositis, uncontrolled cancer, chronic obstructive pulmonary disease, advanced age and poor functional status. Patients receiving consolidation chemotherapy for leukemia or undergoing autologous HCT may also have long periods of neutropenia, but seem to be at somewhat lower risk, especially if they received prophylactic hematopoietic growth factors. In contrast, patients with solid tumors are mostly at low risk for serious infections. Guidelines An assessment of risk (high versus low-risk) for medical complications related to neutropenic fever should be obtained at the initial assessment of neutropenic fever episode. The Infectious Diseases Society of America (IDSA), the European Society for Medical Oncology (ESMO), the National Comprehensive Cancer Network (NCCN) as well as the American Society of Clinical Oncology (ASCO)2,24,25 , has recommended this. The IDSA and ASCO defined high-risk neutropenic patients as those who are expected to have profound neutropenia (ANC = 100 cells / microliter) for > 7 days or those with evidence of current comorbidities or hepatic or renal dysfunction2,24 . The National Comprehensive Cancer Network (NCCN) has used similar criteria for definition, but also includes a category of intermediate risk [21]. Multinational Association of Supportive Care in Cancer (MASCC) risk index that can be used as an alternative to clinical criteria, is a validated tool to assess the risk of medical complications associated with neutropenic fever (calculator 2)26 ¿Ã‚ ½29 . IDSA Risk assessment: The Infectious Diseases Society of America (IDSA) has established the following criteria for the definition of high risk or low risk patients with neutropenic fever 2: High-risk febrile neutropenic patients are defined as having one or more of the following criteria: ? Profound neutropenia (ANC = 100 cells / microliter) expected to last for > 7 days. ? Proof of current comorbidities, such as (but not limited to): ? Hemodynamic instability ? Oral mucositis limiting swallowing or gastrointestinal tract mucositis causing severe diarrhea ? Gastrointestinal symptoms such as abdominal pain, nausea and vomiting or diarrhea ? Changes in neurological status or mental appearance of new onset ? Intravascular catheter infection ? New pulmonary infiltrates or hypoxia ? Underlying chronic lung disease ? Signs of hepatic insufficiency (serum transaminase> 5 times normal) or renal insufficiency (creatinine clearance Low-risk febrile neutropenic patients are expected to have a relatively short duration of neutropenia for 7 days or less, with an absolute neutrophil count (ANC) Patients with evidence of severe sepsis (sepsis syndrome in end organ dysfunction) should be considered at high risk and managed as in-patients with initial intravenous antibacterial empirical treatment. While, patients with signs of septic shock should be managed in an intensive care unit based upon goal-oriented therapy30 . NCCN risk assessment The National Comprehensive Cancer Network (NCCN) has developed certain criteria to classify patients as high risk or low risk, which must be performed during the initial evaluation [21]. High-risk febrile neutropenic patients are those having one or more of the following criteria: [21] ? The patients are hospitalized at the time of the development of fever ? Evidence of significant medical comorbidity or the presence of clinical instability ? Expected profound prolonged neutropenia (ANC = 100 cells / microliter expected to last> 7 days) ? Hepatic insufficiency (serum transaminase> 5 times normal) or renal insufficiency (creatinine clearance ? Any patient with leukemia not in complete remission, or any non-leukemic patient with signs of disease progression after more than two courses of chemotherapy. ? Any complex infection such as pneumonia at clinical presentation ? Alemtuzumab (antineoplastic agent) in the last two months ? Grade 3 or 4 mucositis ? MASCC risk index score Low-risk febrile neutropenic patients are those who do not meet any of the criteria for high-risk described above and meet most of the criteria as follows [21]: ? Ambulatory status at the time of the development of fever ? No acute comorbid illness requiring hospitalization and close monitoring ? Expected short duration of severe neutropenia (ANC = 100 cells / microliter should last for 7 days or less) ? Good performance status (Eastern Cooperative Oncology Group [ECOG] 0-1 (Table 2)) ? No hepatic or renal insufficiency ? MASCC risk index score of = 21 risk index Intermediate risk neutropenic patients are defined as those meeting one or more of following criteria: [21] ? Patients undergoing autologous HCT ? Lymphoma ? Chronic lymphocytic leukemia ? Multiple Myeloma ? Patients receiving purine analogue therapy ? The expected duration of neutropenia is 7 to 10 days For patients at intermediate risk, the NCCN recommends consideration of fluoroquinolone prophylaxis. Multinational Association of Supportive Care in Cancer (MASCC) score As an alternative to the IDSA and NCCN risk assessments described above, the MASCC risk index is validated for assessing the risk of medical complications associated with febrile neutropenia. Using the MASCC risk index, the following features are assessed and given a weighted score2,26 : ? Burden of disease (clinical condition of the patient at the time of presentation with neutropenic fever): ? No symptoms or mild symptoms (5 points) ? Moderate symptoms (3 points) ? Severe symptoms or dying (0 point) ? No hypotension (systolic blood pressure> 90 mmHg) (5 points) ? No chronic obstructive pulmonary disease COPD (4 points) ? Solid tumor or hematologic malignancy without prior history of fungal infections (4 points) ? No dehydration that requires parenteral fluids (3 points) ? Ambulatory status at the time of the onset of neutropenic fever syndrome (3 points) ? Age The highest possible score is 26. Patients with a score = 21 are considered to be at low risk of serious medical complications, and for whom outpatient treatment with oral empirical antimicrobial can be safe and effective29 . While, patients with a score The MASCC risk index has classified 98% of patients as low-risk and 86% as high risk with a sensitivity and specificity of 95%, and positive and negative predictive value of 98, and 86 percent, respectively 28. Patients with complicated infections have been reclassified as high risk for serious medical complications, which further increased the predictive value of the model. Complicated infections include non-necrotizing skin or soft tissue infection (SSTI) of >5 cm diameter, necrotizing SSTI of any size, grade 2 oral mucositis, sepsis syndrome or the presence of a visceral site of infection. [28]. The classification error rate has been 10 to 29 percent. [4] In addition, the MASCC risk index can predict the probability of death as follows:27 ? Score = 15: 29 % ? Score = 15 but ? Score = 21: 2 % The MASCC risk index has been criticized for the lack of a standard definition of this criterion the burden of febrile neutropenia, which could be a source of confusion2, or it could be interpreted differently by different clinicians. I addition, the MASCC risk index does not include the duration of neutropenia as a criterion, though it is considered as an important predictor of risk2. The MASCC risk index has been also criticized because it was developed using heterogeneous patient populations; thus, it might not function optimally in all populations. For example, in a retrospective study of patients with solid tumors who seemed to be clinically stable, the MASCC risk index had a low sensitivity to detect complications (36 percent)31. The low sensitivity was likely to be attributed to the fact that patients were all outpatients, and the rates of hypotension, dehydration and invasive fungal infections were low; hence, only three criteria were present to distinguish prognosis. The serious medical complications are provided by the MASCC risk index as follows 26: ? Hypotension defined as systolic blood pressure ? Respiratory failure defined as arterial oxygen pressure ? The admission to ICU ? Disseminated intravascular coagulation ? Presence of confusion, delirium, or altered mental status ? The development of congestive heart failure documented by chest imaging and requiring treatment ? Bleeding diathesis sufficient to require a blood transfusion ? Electrocardiogram changes or arrhythmias requiring treatment ? Renal failure sufficient to require an investigation and / or treatment with IV fluids, dialysis, or other intervention ? Other complications judged serious and clinically significant by the health care team All patients who were treated with systemic antineoplastic therapy six weeks prior to a systemic inflammatory response syndrome (SIRS) are assumed to have neutropenic sepsis syndrome until proven otherwise. SIRS is defined by the presence of two or more of the following conditions: temperature >38 ¿Ã‚ ½C or 90/minute, respiratory frequency > 20/minute, PaCO2 Patients presenting with altered mental status, hypotension, hypoxia, oliguria or any other sign of new organ impairment must be managed emergently for severe sepsis. RISK OF TREATMENT FAILURE The risk of failure to respond to initial empirical antibacterial therapy is a composite outcome to be considered clinicians. Treatment failure is proposed if one or more of the following events occur within 30 days after the start of treatment 33,34: ? Persistence, progression or recurrence of signs of infection ? Modification of the initial empirical antibacterial treatment ? Readmission to the hospital for outpatients ? Death Patients with documented clinical or microbiological infections are more likely to be at risk for treatment failure, clinical or microbiological than for unexplained neutropenic fever (39 against 18 percent33. High-risk patients are more likely to be at risk for treatment failure than those with low risk. For example, patients with hematologic malignancies have a higher percentage of treatment failure than those with solid tumors (44 against 18 percent) 33. Observations have shown that among all febrile neutropenic patients at low risk of medical complications, adult patients at higher risk for treatment failure than children with 16% against 5% respectively34. PREVENTION In order to prevent neutropenic fever and infectious complications in patients at increased risk, the administration of an antimicrobial drug should be used as a prophylaxis. Antibacterial prophylaxis Pseudomonas aeruginosa and other gram-negative bacilli is the target of the antibacterial prophylaxis, because these pathogens are virulent and may cause life-threatening infections. INDICATIONS The beneficial effect on clinical outcomes has been sought from the administration of prophylactic antibacterial agents. The fluoroquinolones, levofloxacin (500 mg orally once daily) and ciprofloxacin (500 mg orally twice daily) have been the most studied antibacterial agents. Levofloxacin in particular is preferred in patients at increased risk for oral mucositis-related Streptococcus viridans infection 2. Results have been mixed with respect to effectiveness and have incited concern about toxicities and antibacterial resistance35 ¿Ã‚ ½37. A systematic monitoring of the prevalence of fluoroquinolone resistance among gram-negative bacilli should be done, at the intitutions that use fluoroquinolone prophylaxis. Based upon the available data, high-risk neutropenic patients defined by those who are expected to have an absolute neutrophil count Fluoroquinolone should be used with caution in patients at risk of a prolonged QT interval particularly in those who may require other QT prolonging agents, such as voriconazole. In addition, the potential to promote resistance among gram-negative and gram-positive should be considered when deciding whether to give a fluoroquinolone prophylaxis or not37. Concerns about the possibility of increasing the risk of Clostridium difficile infection has also been present, though this has not been proven in neutropenic patients receiving fluoroquinolone prophylaxis37. The use of prophylactic agents in institutions and geographic areas where the levels of resistance to fluoroquinolones are high is less likely to be efficient36,38.The use of antibacterial prophylaxis varies from one center to another with some centers avoiding such practices. For most patients with chemotherapy-induced neutropenia expected to be of short duration particularly patients with solid tumors, the use of antibacterial prophylaxis is not recommended. TIMING The ideal timing for the initiation and cessation antibacterial prophylaxis has not been sufficiently studied2. Many clinicians begin anti-bacterial prophylaxis, the first day of chemotherapy or the day after the administration of the last dose of chemotherapy cycle. Antibacterial prophylaxis is usually withheld when neutropenia resolves, or when empirical antibacterial regimen is initiated for patients who become febrile during neutropenia. Antifungal prophylaxis Among cancer patients and HCT recipients, a high rate of life-threatening invasive fungal infections such as candidemia has been observed since the late 1980s, which incited interest in antifungal prophylaxis for patients receiving chemotherapy. Antiviral prophylaxis INFLUENZA Annual immunization with an inactivated influenza vaccine is recommended for all cancer patients undergoing treatment2. The influenza vaccine is generally administered >2 weeks before the initiation of chemotherapy or, when circumstances dictate, between chemotherapy cycles and at least seven days after the last cycle. However, the best timing for such immunization has not been established2. All family members and other close contacts should get annual immunization too. HSV and VZV Reactivation of herpes simplex virus (HSV-1 and HSV-2) and varicella-zoster virus (VZV) occur commonly in HCT recipients who are not receiving prophylaxis and are important causes of morbidity. However, reactivation of both HSV and VZV infections can be effectively prevented with antiviral prophylaxis. Antiviral prophylaxis with acyclovir (400 mg orally three to four times daily or 800 mg orally twice daily) or valacyclovir (500 mg orally once or twice daily) is recommended in all patients who are seropositive for HSV and who are undergoing allogeneic HCT or induction chemotherapy for acute leukemia39. Antiviral prophylaxis with acyclovir or valacyclovir is also recommended in all HCT recipients who are seropositive for VZV. Based upon randomized trials, benefits of antiviral prophylaxis in these populations have been demonstrated; thus, recommended41. CMV CMV prophylaxis is indicated for HCT recipients because they are at are at significant risk for reactivation. In contrast, prophylaxis is not indicated in patients with chemotherapy-induced neutropenia, because it does not occur commonly. HEPATITIS B Antiviral prophylaxis should be considered for the following categories of patients and should be sustained for at least six months after the completion of chemotherapy40 : ? Patients receiving chemotherapy who have a previous history of hepatitis B virus infection, due to the risk of reactivation and hepatic failure. ? Patients with elevated circulating hepatitis B DNA or detectable levels of circulating hepatitis B surface antigen (HBsAg) ? Patients with a previous history of infection with detectable levels of antibody to HBsAg or to hepatitis B core antigen. This has been demonstrated to be able to reduce the risk of reactivation from 24 to 53 percent to 0 to 5 percent. Colony stimulating factors Granulocyte colony stimulating factors (CSFs) have been widely evaluated for prophylactic use following the administration of intensive cytotoxic chemotherapy when neutropenia is expected (primary prophylaxis). CSFs have been also evaluated for their prophylactic use during retreatment after a previous cycle of chemotherapy that caused neutropenic fever (secondary prophylaxis), and have been shown to minimize the extent and duration of severe chemotherapy-induced neutropenia in afebrile patients (afebrile neutropenia). Their use is not recommended in febrile chemotherapy-induced neutropenia2. However, prophylactic use of granulocyte CSFs has not been shown to have an effect on survival in most clinical situations. PRIMARY PROPHYLAXIS Primary prophylaxis denotes the use of granulocyte CSFs during the first cycle of myelosuppressive chemotherapy in order to prevent neutropenic complications. The goal of primary prophylaxis is to decrease the incidence of neutropenic fever and the need for hospitalization, to maintain dose-dense or dose-intense chemotherapy strategies that have survival benefits. Updated 2010 guidelines from the European Organization for Research and Treatment of Cancer (EORTC), the Infectious Diseases Society of America (IDSA), consensus-based guidelines from the National Comprehensive Cancer Network (NCCN), and The 2006 guidelines from the American Society of Clinical Oncology (ASCO), all recommend primary prophylaxis when the expected incidence of neutropenic fever is over 20 percent, to reduce the need for hospitalization for antibiotic therapy2,22,41. These recommendations are based upon randomized trials that have shown that primary prophylaxis was cost effective when the risk of neutropenic fever with a specific regimen was over 20 percent42,43 . In contrast, guidelines recommend against the routine use of granulocyte CSFs for primary prophylaxis in adult patients receiving chemotherapy regimens with an anticipated low probability ( However, when the anticipated risk of neutropenic fever is between 10 and 20 percent, the decision of primary prophylaxis should be individualized and may be appropriate in a number of clinical settings in which patients are at risk or increased complications22,41 :  ¿Ã‚ ½ Age >65 years  ¿Ã‚ ½ Preexisting neutropenia  ¿Ã‚ ½ More advanced cancer  ¿Ã‚ ½ Poor performance and/or nutritional status  ¿Ã‚ ½ Renal or hepatic impairment  ¿Ã‚ ½ In the case of epithelial ovarian cancer  ¿Ã‚ ½ Extensive prechemotherapy surgery, particularly if it included a bowel resection. In patients receiving concomitant chemoradiotherapy for either head and neck cancer or lung cancer, the use of granulocyte CSFs has been associated with adverse outcomes, therefore, it better be avoided. Despite the lack of comparative data from randomized controlled trials, that could recommend one CSF over the other for prophylaxis of infection during chemotherapy-induced neutropenia, in practice, most institutions use G-CSF. SECONDARY PROPHYLAXIS Secondary prophylaxis denotes to the use of a granulocyte CSF in subsequent chemotherapy cycles after a prior cycle has caused neutropenic fever. Secondary prophylaxis with CSFs reduces the risk of reccurence of neutropenic fever by approximately one-half 44. ASCO and EORTC guidelines recommend that secondary prophylaxis with granulocyte CSFs be limited to patients for whom primary prophylaxis was not given and who experience a neutropenic complication from a prior cycle of chemotherapy if neutropenic fever would prevent the administration of full dose chemotherapy and if reduced dose intensity might affect treatment outcome22,41 . TIMING G-CSF and GM-CSF therapy is usually initiated 24 to 72 hours after cessation of chemotherapy and is frequently continued until the absolute neutrophil count reaches 5000 to 10,000/microL. A reasonable alternative is continuation until clinically adequate neutrophil recovery. MANAGEMENT Initial Assessment Since, fever might be the first and only sign of infection in a neutropenic patient, its occurrence should be considered a medical emergency. Therefore, empiric broad-spectrum antibacterial therapy should be started immediately after blood cultures have been obtained and before any other investigations have been completed. The Infectious Diseases Working Party of the German Society of Hematology and Oncology and the Northern Ireland Cancer Network has recommended this. It has been recommended that empiric broad-spectrum antibacterial therapy should be administered within 60 minutes of presentation for all patients suffering from neutropenic fever at presentation. (algorithm 1) Diagnostic Approach At presentation, a detailed history and physical examination should be done, as well as a complete laboratory, microbiologic and imaging work-up for all febrile neutropenic patients. The table below summarizes the diagnostic approach to patients with febrile neutropenia.

Hackers Essay -- Hacking Computers Technology Security Essays

Hackers It is the weekend you have nothing to do so you decide to play around on your computer . You turn it and than start up , calling people with your modem , conneciting to another world with people. This is all fine but what happens when you start getting into other people’s computer files , then it becomes a crime and who are the criminals. To begin i will start with hacking and hackers. Hacking is the act of breaking into computers and network of other poeple’s with out any permission . Hacking is like drugs or any other substance , its an addiction for the mind and once started it is diffucult to stop . Hacker is a person who enjoy learning details of a programming language or system , who tries to break into computer systems .There is two types of hackers. On is the benign hackers , who likes get into his or her own computer and understand how it works . The malicious hackers is the person who likes getting into other people’s system . Black hat is used to discribe a hacker who break into a computer system or network with malicious intent . Unlike white hat , the black hat takes advantage of the break in perhaps destroying files or stealing data for some future purpose. White hat hackers describes a hacker who identifies a security weakness in a computer system or network but instead of taking malicious advantage of it . They will allow the system‘s owners to fix it before can be taken advantage by others . But U.S law does not see differences between black hat hacker and white hat hacker. Many of the poeple in our society today often think that computer hackers are very smart individuals who have special talents and abilities and enabiling them to crack passwords , send viruses , cancel your cable tv , raid your social security and crash computer systems. Most people in our society do not spend the time to break into computer systems but all studies indicate that hackers are genarlly young and not haave full time jobs or own property kaygusuz2 They have so much time and energy to break into computers. Hackers learn hacking from reading different kind of computer books , they find many available tools on the internet , they spend so much time on the computer to learn the techniques of hacking . Some of the hackers hack for to gain highest pre... ...entality work and their lifestyle and also goverment regulations against these smart indivuduals. à nformation security professions must be more visible in a way that get children before the hackers community gets them . They get together to teach parents and schools and also they must teach children about hacking and hackers before somebody else does. And also goverment takes to find a way to stop hackers. If the goverment does not hurry up they are going to get buried by hackers and when that happens the world will not be a fun places to live in and aslo the cyberspace WORKS CITED Cert Coordination Center Computer Crime in today’s Society Retrieved: November 10, 2000 from the World Wide Web: http:// www.cert.org// Choas Computer Club ( januvary 05 , 1995 ) Hacker Bible The New Hackers Dictionary ( online education ) Retrieved November 10 , 2000 from the Worl Wide Web A non-technical artical from business web zine about Distrbuted Denial Service Attacks: http://www.cert.org/advisories /Ca-99-17-denial-of-service-tools.html Tool from the FBI’s National Infrastructure Protection Center : http://www.nipc.gov/

The Character of Falstaff in Shakespeares Henry IV, Part I Essay

The Character of Falstaff in Henry IV, Part I      Ã‚  Ã‚  Ã‚   Shakespeare's genius in character and plot development is exemplified in two of his most complex history plays, Richard II and Henry IV, Part I. With these sequential plays, Shakespeare vividly develops characters and sets up complicated plots by juxtapositioning people with others. Specifically, he first creates a binary opposition between Richard and Bolingbrook in Richard II, and then, recalls the plot and carries out an almost mirror image character contrast with Hal and Hotspur in Henry IV, Part I. However, in typical Shakespeare fashion, the seemingly mirror-image binaries of Richard/Bolingbrook and Hal/Hotspur break down with Shakespeare's character complexity.    A major reason why these character parallels do not perfectly hold up is because of the marvelous character of Falstaff. Absent from Richard II, Falstaff is introduced in Henry IV to create intricacy and ambiguity regarding likenesses among these characters. Falstaff significantly complicates the Hotspur-is-to-Bolingbrook-as-Hal-is-to-Richard II assumption because Falstaff has so much in common with the King. Therefore, as opposed to Hotspur's becoming the Bolingbrook persona, it is the drunken and disorderly Falstaff who becomes the character most parallel to the King. However, the King associates himself with Hotspur, who, as his name suggests, is a relentless warrior. The King puts forth a sense that Hotspur will act as Bolingbrook did in Richard II, by challenging the Prince's right to the throne; he feels that Bolingbrook's rivalry with Richard is reflected in Hotspur's position as Hal's challenger.    In the first scene of Henry IV, Part I, King Henry immediately ... ...tspur seems unfitting. Adding complexity to characterization through his comical action, Falstaff is a crucial character in Henry IV, Part I, and it is through the character of Falstaff that we see the parallel between Hotspur and Bolingbrook breaks down.    Works Cited and Consulted Coleridge, Samuel Taylor. H.C. Robinson's Memoranda Henry IV, Signet Classic, pp. 236-237. Goldman, Michael. Shakespeare and the Energies of Drama Henry IV, Signet Classic, pp. 260-261. Johnson, Samuel. The Plays of William Shakespeare Henry IV, Signet Classic, pp.234- 235. Kahn, Coppelia. Man's Estate: Masculine Identity in Shakespeare Henry IV, Signet Classic, pp.262-266. Shakespeare, William. Henry IV, Part I, ed. M.A. Shaaber, Penguin Books (NY: 1985). Wilson, John Dover. The Fortunes of Falstaff Henry IV, Signet Classic, pp.238-243.   

The US, the ICC and the future: A suggestion on how to convince the US

The US, the ICC and the future: A suggestion on how to convince the US that signing and ratifying the ICC would be to its benefit Introduction Throughout the 20th century, the world has experienced some of the greatest wars and catastrophes for human life. Simultaneously the world has achieved some of the greatest advances in codifying human rights and enhancing the understanding that we are all citizens of this world and invariably connected. Whatever human crisis occurs in one part of the world will in the short or long term influence the other parts of the world and nobody is immune to this fact. Especially the United States seems to have understood in the 20th century that interaction between states and individuals is vital, and that the rule of law has to be established on a national and international level. Arguable after the civil rights struggle and eventually the end of the Cold War the US was able to take action in order to criticize human rights violations across the globe. The civil rights movement indicated the US slowly growing willingness to accept the equality of all its citizens, while the fall of the Berlin Wall gave the US (and arguably other countries too), the freedom to care and openly criticize human rights violations wherever they happened to occur. However, despite the US strong involvement in codifying human rights and international criminal law through treaties, conventions and institutions, the US has already recently been accused of maintain an isolationist and even hegemonic stance across the globe. The US, through its omnipresent stance in the international media, international political arena, military capacity etc. is able to be unilateralist and not care about hum... ... of the United Nations. The International Criminal Court: The Making of the Rome Statute: Issues, Negotiations, Results [10] 81. Herman von Hebel and Darryl Robinson. The International Criminal Court: The Making of the Rome Statute: Issues, Negotiations, Results [11] Statement by US President Bill Clinton, authorizing the US signing of the Rome Statute of the International Criminal Court, 31 December 2000, Camp David, Maryland, United States [12] UNDER SECRETARY OF STATE FOR ARMS CONTROL AND INTERNATIONAL SECURITY WASHINGTON, John R. Bolton. http://www.newsmax.com/archives/articles/2002/5/6/114156.shtml [13] P. 38. John Bolton. Toward an International Criminal Court? A Council Policy Initiative. [14] 39. John R. Bolton. Toward an International Criminal court? A Council Policy Initiative [15] 43. Ibid. The US, the ICC and the future: A suggestion on how to convince the US The US, the ICC and the future: A suggestion on how to convince the US that signing and ratifying the ICC would be to its benefit Introduction Throughout the 20th century, the world has experienced some of the greatest wars and catastrophes for human life. Simultaneously the world has achieved some of the greatest advances in codifying human rights and enhancing the understanding that we are all citizens of this world and invariably connected. Whatever human crisis occurs in one part of the world will in the short or long term influence the other parts of the world and nobody is immune to this fact. Especially the United States seems to have understood in the 20th century that interaction between states and individuals is vital, and that the rule of law has to be established on a national and international level. Arguable after the civil rights struggle and eventually the end of the Cold War the US was able to take action in order to criticize human rights violations across the globe. The civil rights movement indicated the US slowly growing willingness to accept the equality of all its citizens, while the fall of the Berlin Wall gave the US (and arguably other countries too), the freedom to care and openly criticize human rights violations wherever they happened to occur. However, despite the US strong involvement in codifying human rights and international criminal law through treaties, conventions and institutions, the US has already recently been accused of maintain an isolationist and even hegemonic stance across the globe. The US, through its omnipresent stance in the international media, international political arena, military capacity etc. is able to be unilateralist and not care about hum... ... of the United Nations. The International Criminal Court: The Making of the Rome Statute: Issues, Negotiations, Results [10] 81. Herman von Hebel and Darryl Robinson. The International Criminal Court: The Making of the Rome Statute: Issues, Negotiations, Results [11] Statement by US President Bill Clinton, authorizing the US signing of the Rome Statute of the International Criminal Court, 31 December 2000, Camp David, Maryland, United States [12] UNDER SECRETARY OF STATE FOR ARMS CONTROL AND INTERNATIONAL SECURITY WASHINGTON, John R. Bolton. http://www.newsmax.com/archives/articles/2002/5/6/114156.shtml [13] P. 38. John Bolton. Toward an International Criminal Court? A Council Policy Initiative. [14] 39. John R. Bolton. Toward an International Criminal court? A Council Policy Initiative [15] 43. Ibid.

Angels Demons Chapter 32-35

32 Langdon held his breath as the X-33 spiraled into Rome's Leonardo da Vinci International Airport. Vittoria sat across from him, eyes closed as if trying to will the situation into control. The craft touched down and taxied to a private hangar. â€Å"Sorry for the slow flight,† the pilot apologized, emerging from the cockpit. â€Å"Had to trim her back. Noise regulations over populated areas.† Langdon checked his watch. They had been airborne thirty-seven minutes. The pilot popped the outer door. â€Å"Anybody want to tell me what's going on?† Neither Vittoria nor Langdon responded. â€Å"Fine,† he said, stretching. â€Å"I'll be in the cockpit with the air-conditioning and my music. Just me and Garth.† The late-afternoon sun blazed outside the hangar. Langdon carried his tweed jacket over his shoulder. Vittoria turned her face skyward and inhaled deeply, as if the sun's rays somehow transferred to her some mystical replenishing energy. Mediterraneans, Langdon mused, already sweating. â€Å"Little old for cartoons, aren't you?† Vittoria asked, without opening her eyes. â€Å"I'm sorry?† â€Å"Your wristwatch. I saw it on the plane.† Langdon flushed slightly. He was accustomed to having to defend his timepiece. The collector's edition Mickey Mouse watch had been a childhood gift from his parents. Despite the contorted foolishness of Mickey's outstretched arms designating the hour, it was the only watch Langdon had ever worn. Waterproof and glow-in-the-dark, it was perfect for swimming laps or walking unlit college paths at night. When Langdon's students questioned his fashion sense, he told them he wore Mickey as a daily reminder to stay young at heart. â€Å"It's six o'clock,† he said. Vittoria nodded, eyes still closed. â€Å"I think our ride's here.† Langdon heard the distant whine, looked up, and felt a sinking feeling. Approaching from the north was a helicopter, slicing low across the runway. Langdon had been on a helicopter once in the Andean Palpa Valley looking at the Nazca sand drawings and had not enjoyed it one bit. A flying shoebox. After a morning of space plane rides, Langdon had hoped the Vatican would send a car. Apparently not. The chopper slowed overhead, hovered a moment, and dropped toward the runway in front of them. The craft was white and carried a coat of arms emblazoned on the side – two skeleton keys crossing a shield and papal crown. He knew the symbol well. It was the traditional seal of the Vatican – the sacred symbol of the Holy See or â€Å"holy seat† of government, the seat being literally the ancient throne of St. Peter. The Holy Chopper, Langdon groaned, watching the craft land. He'd forgotten the Vatican owned one of these things, used for transporting the Pope to the airport, to meetings, or to his summer palace in Gandolfo. Langdon definitely would have preferred a car. The pilot jumped from the cockpit and strode toward them across the tarmac. Now it was Vittoria who looked uneasy. â€Å"That's our pilot?† Langdon shared her concern. â€Å"To fly, or not to fly. That is the question.† The pilot looked like he was festooned for a Shakespearean melodrama. His puffy tunic was vertically striped in brilliant blue and gold. He wore matching pantaloons and spats. On his feet were black flats that looked like slippers. On top of it all, he wore a black felt beret. â€Å"Traditional Swiss Guard uniforms,† Langdon explained. â€Å"Designed by Michelangelo himself.† As the man drew closer, Langdon winced. â€Å"I admit, not one of Michelangelo's better efforts.† Despite the man's garish attire, Langdon could tell the pilot meant business. He moved toward them with all the rigidity and dignity of a U.S. Marine. Langdon had read many times about the rigorous requirements for becoming one of the elite Swiss Guard. Recruited from one of Switzerland's four Catholic cantons, applicants had to be Swiss males between nineteen and thirty years old, at least 5 feet 6 inches, trained by the Swiss Army, and unmarried. This imperial corps was envied by world governments as the most allegiant and deadly security force in the world. â€Å"You are from CERN?† the guard asked, arriving before them. His voice was steely. â€Å"Yes, sir,† Langdon replied. â€Å"You made remarkable time,† he said, giving the X-33 a mystified stare. He turned to Vittoria. â€Å"Ma'am, do you have any other clothing?† â€Å"I beg your pardon?† He motioned to her legs. â€Å"Short pants are not permitted inside Vatican City.† Langdon glanced down at Vittoria's legs and frowned. He had forgotten. Vatican City had a strict ban on visible legs above the knee – both male and female. The regulation was a way of showing respect for the sanctity of God's city. â€Å"This is all I have,† she said. â€Å"We came in a hurry.† The guard nodded, clearly displeased. He turned next to Langdon. â€Å"Are you carrying any weapons?† Weapons? Langdon thought. I'm not even carrying a change of underwear! He shook his head. The officer crouched at Langdon's feet and began patting him down, starting at his socks. Trusting guy, Langdon thought. The guard's strong hands moved up Langdon's legs, coming uncomfortably close to his groin. Finally they moved up to his chest and shoulders. Apparently content Langdon was clean, the guard turned to Vittoria. He ran his eyes up her legs and torso. Vittoria glared. â€Å"Don't even think about it.† The guard fixed Vittoria with a gaze clearly intended to intimidate. Vittoria did not flinch. â€Å"What's that?† the guard said, pointing to a faint square bulge in the front pocket of her shorts. Vittoria removed an ultrathin cell phone. The guard took it, clicked it on, waited for a dial tone, and then, apparently satisfied that it was indeed nothing more than a phone, returned it to her. Vittoria slid it back into her pocket. â€Å"Turn around, please,† the guard said. Vittoria obliged, holding her arms out and rotating a full 360 degrees. The guard carefully studied her. Langdon had already decided that Vittoria's form-fitting shorts and blouse were not bulging anywhere they shouldn't have been. Apparently the guard came to the same conclusion. â€Å"Thank you. This way please.† The Swiss Guard chopper churned in neutral as Langdon and Vittoria approached. Vittoria boarded first, like a seasoned pro, barely even stooping as she passed beneath the whirling rotors. Langdon held back a moment. â€Å"No chance of a car?† he yelled, half-joking to the Swiss Guard, who was climbing in the pilot's seat. The man did not answer. Langdon knew that with Rome's maniacal drivers, flying was probably safer anyway. He took a deep breath and boarded, stooping cautiously as he passed beneath the spinning rotors. As the guard fired up the engines, Vittoria called out, â€Å"Have you located the canister?† The guard glanced over his shoulder, looking confused. â€Å"The what?† â€Å"The canister. You called CERN about a canister?† The man shrugged. â€Å"No idea what you're talking about. We've been very busy today. My commander told me to pick you up. That's all I know.† Vittoria gave Langdon an unsettled look. â€Å"Buckle up, please,† the pilot said as the engine revved. Langdon reached for his seat belt and strapped himself in. The tiny fuselage seemed to shrink around him. Then with a roar, the craft shot up and banked sharply north toward Rome. Rome†¦ the caput mundi, where Caesar once ruled, where St. Peter was crucified. The cradle of modern civilization. And at its core†¦ a ticking bomb. 33 Rome from the air is a labyrinth – an indecipherable maze of ancient roadways winding around buildings, fountains, and crumbling ruins. The Vatican chopper stayed low in the sky as it sliced northwest through the permanent smog layer coughed up by the congestion below. Langdon gazed down at the mopeds, sight-seeing buses, and armies of miniature Fiat sedans buzzing around rotaries in all directions. Koyaanisqatsi, he thought, recalling the Hopi term for â€Å"life out of balance.† Vittoria sat in silent determination in the seat beside him. The chopper banked hard. His stomach dropping, Langdon gazed farther into the distance. His eyes found the crumbling ruins of the Roman Coliseum. The Coliseum, Langdon had always thought, was one of history's greatest ironies. Now a dignified symbol for the rise of human culture and civilization, the stadium had been built to host centuries of barbaric events – hungry lions shredding prisoners, armies of slaves battling to the death, gang rapes of exotic women captured from far-off lands, as well as public beheadings and castrations. It was ironic, Langdon thought, or perhaps fitting, that the Coliseum had served as the architectural blueprint for Harvard's Soldier Field – the football stadium where the ancient traditions of savagery were reenacted every fall†¦ crazed fans screaming for bloodshed as Harvard battled Yale. As the chopper headed north, Langdon spied the Roman Forum – the heart of pre-Christian Rome. The decaying columns looked like toppled gravestones in a cemetery that had somehow avoided being swallowed by the metropolis surrounding it. To the west the wide basin of the Tiber River wound enormous arcs across the city. Even from the air Langdon could tell the water was deep. The churning currents were brown, filled with silt and foam from heavy rains. â€Å"Straight ahead,† the pilot said, climbing higher. Langdon and Vittoria looked out and saw it. Like a mountain parting the morning fog, the colossal dome rose out of the haze before them: St. Peter's Basilica. â€Å"Now that,† Langdon said to Vittoria, â€Å"is something Michelangelo got right.† Langdon had never seen St. Peter's from the air. The marble faà §ade blazed like fire in the afternoon sun. Adorned with 140 statues of saints, martyrs, and angels, the Herculean edifice stretched two football fields wide and a staggering six long. The cavernous interior of the basilica had room for over 60,000 worshipers†¦ over one hundred times the population of Vatican City, the smallest country in the world. Incredibly, though, not even a citadel of this magnitude could dwarf the piazza before it. A sprawling expanse of granite, St. Peter's Square was a staggering open space in the congestion of Rome, like a classical Central Park. In front of the basilica, bordering the vast oval common, 284 columns swept outward in four concentric arcs of diminishing size†¦ an architectural trompe de l'oiel used to heighten the piazza's sense of grandeur. As he stared at the magnificent shrine before him, Langdon wondered what St. Peter would think if he were here now. The Saint had died a gruesome death, crucified upside down on this very spot. Now he rested in the most sacred of tombs, buried five stories down, directly beneath the central cupola of the basilica. â€Å"Vatican City,† the pilot said, sounding anything but welcoming. Langdon looked out at the towering stone bastions that loomed ahead – impenetrable fortifications surrounding the complex†¦ a strangely earthly defense for a spiritual world of secrets, power, and mystery. â€Å"Look!† Vittoria said suddenly, grabbing Langdon's arm. She motioned frantically downward toward St. Peter's Square directly beneath them. Langdon put his face to the window and looked. â€Å"Over there,† she said, pointing. Langdon looked. The rear of the piazza looked like a parking lot crowded with a dozen or so trailer trucks. Huge satellite dishes pointed skyward from the roof of every truck. The dishes were emblazoned with familiar names: Televisor Europea Video Italia BBC United Press International Langdon felt suddenly confused, wondering if the news of the antimatter had already leaked out. Vittoria seemed suddenly tense. â€Å"Why is the press here? What's going on?† The pilot turned and gave her an odd look over his shoulder. â€Å"What's going on? You don't know?† â€Å"No,† she fired back, her accent husky and strong. â€Å"Il Conclavo,† he said. â€Å"It is to be sealed in about an hour. The whole world is watching.† Il Conclavo. The word rang a long moment in Langdon's ears before dropping like a brick to the pit of his stomach. Il Conclavo. The Vatican Conclave. How could he have forgotten? It had been in the news recently. Fifteen days ago, the Pope, after a tremendously popular twelve-year reign, had passed away. Every paper in the world had carried the story about the Pope's fatal stroke while sleeping – a sudden and unexpected death many whispered was suspicious. But now, in keeping with the sacred tradition, fifteen days after the death of a Pope, the Vatican was holding Il Conclavo – the sacred ceremony in which the 165 cardinals of the world – the most powerful men in Christendom – gathered in Vatican City to elect the new Pope. Every cardinal on the planet is here today, Langdon thought as the chopper passed over St. Peter's Basilica. The expansive inner world of Vatican City spread out beneath him. The entire power structure of the Roman Catholic Church is sitting on a time bomb. 34 Cardinal Mortati gazed up at the lavish ceiling of the Sistine Chapel and tried to find a moment of quiet reflection. The frescoed walls echoed with the voices of cardinals from nations around the globe. The men jostled in the candlelit tabernacle, whispering excitedly and consulting with one another in numerous languages, the universal tongues being English, Italian, and Spanish. The light in the chapel was usually sublime – long rays of tinted sun slicing through the darkness like rays from heaven – but not today. As was the custom, all of the chapel's windows had been covered in black velvet in the name of secrecy. This ensured that no one on the inside could send signals or communicate in any way with the outside world. The result was a profound darkness lit only by candles†¦ a shimmering radiance that seemed to purify everyone it touched, making them all ghostly†¦ like saints. What privilege, Mortati thought, that I am to oversee this sanctified event. Cardinals over eighty years of age were too old to be eligible for election and did not attend conclave, but at seventy-nine years old, Mortati was the most senior cardinal here and had been appointed to oversee the proceedings. Following tradition, the cardinals gathered here two hours before conclave to catch up with friends and engage in last-minute discussion. At 7 P.M., the late Pope's chamberlain would arrive, give opening prayer, and then leave. Then the Swiss Guard would seal the doors and lock all the cardinals inside. It was then that the oldest and most secretive political ritual in the world would begin. The cardinals would not be released until they decided who among them would be the next Pope. Conclave. Even the name was secretive. â€Å"Con clave† literally meant â€Å"locked with a key.† The cardinals were permitted no contact whatsoever with the outside world. No phone calls. No messages. No whispers through doorways. Conclave was a vacuum, not to be influenced by anything in the outside world. This would ensure that the cardinals kept Solum Dum prae oculis†¦ only God before their eyes. Outside the walls of the chapel, of course, the media watched and waited, speculating as to which of the cardinals would become the ruler of one billion Catholics worldwide. Conclaves created an intense, politically charged atmosphere, and over the centuries they had turned deadly: poisonings, fist fights, and even murder had erupted within the sacred walls. Ancient history, Mortati thought. Tonight's conclave will be unified, blissful, and above all†¦ brief. Or at least that had been his speculation. Now, however, an unexpected development had emerged. Mystifyingly, four cardinals were absent from the chapel. Mortati knew that all the exits to Vatican City were guarded, and the missing cardinals could not have gone far, but still, with less than an hour before opening prayer, he was feeling disconcerted. After all, the four missing men were no ordinary cardinals. They were the cardinals. The chosen four. As overseer of the conclave, Mortati had already sent word through the proper channels to the Swiss Guard alerting them to the cardinals' absence. He had yet to hear back. Other cardinals had now noticed the puzzling absence. The anxious whispers had begun. Of all cardinals, these four should be on time! Cardinal Mortati was starting to fear it might be a long evening after all. He had no idea. 35 The Vatican's helipad, for reasons of safety and noise control, is located in the northwest tip of Vatican City, as far from St. Peter's Basilica as possible. â€Å"Terra firma,† the pilot announced as they touched down. He exited and opened the sliding door for Langdon and Vittoria. Langdon descended from the craft and turned to help Vittoria, but she had already dropped effortlessly to the ground. Every muscle in her body seemed tuned to one objective – finding the antimatter before it left a horrific legacy. After stretching a reflective sun tarp across the cockpit window, the pilot ushered them to an oversized electric golf cart waiting near the helipad. The cart whisked them silently alongside the country's western border – a fifty-foot-tall cement bulwark thick enough to ward off attacks even by tanks. Lining the interior of the wall, posted at fifty-meter intervals, Swiss Guards stood at attention, surveying the interior of the grounds. The cart turned sharply right onto Via della Osservatorio. Signs pointed in all directions: Palazzio Governatorio Collegio Ethiopiana Basilica San Pietro Capella Sistina They accelerated up the manicured road past a squat building marked Radio Vaticana. This, Langdon realized to his amazement, was the hub of the world's most listened-to radio programming – Radio Vaticana – spreading the word of God to millions of listeners around the globe. â€Å"Attenzione,† the pilot said, turning sharply into a rotary. As the cart wound round, Langdon could barely believe the sight now coming into view. Giardini Vaticani, he thought. The heart of Vatican City. Directly ahead rose the rear of St. Peter's Basilica, a view, Langdon realized, most people never saw. To the right loomed the Palace of the Tribunal, the lush papal residence rivaled only by Versailles in its baroque embellishment. The severe-looking Governatorato building was now behind them, housing Vatican City's administration. And up ahead on the left, the massive rectangular edifice of the Vatican Museum. Langdon knew there would be no time for a museum visit this trip. â€Å"Where is everyone?† Vittoria asked, surveying the deserted lawns and walkways. The guard checked his black, military-style chronograph – an odd anachronism beneath his puffy sleeve. â€Å"The cardinals are convened in the Sistine Chapel. Conclave begins in a little under an hour.† Langdon nodded, vaguely recalling that before conclave the cardinals spent two hours inside the Sistine Chapel in quiet reflection and visitations with their fellow cardinals from around the globe. The time was meant to renew old friendships among the cardinals and facilitate a less heated election process. â€Å"And the rest of the residents and staff?† â€Å"Banned from the city for secrecy and security until the conclave concludes.† â€Å"And when does it conclude?† The guard shrugged. â€Å"God only knows.† The words sounded oddly literal. After parking the cart on the wide lawn directly behind St. Peter's Basilica, the guard escorted Langdon and Vittoria up a stone escarpment to a marble plaza off the back of the basilica. Crossing the plaza, they approached the rear wall of the basilica and followed it through a triangular courtyard, across Via Belvedere, and into a series of buildings closely huddled together. Langdon's art history had taught him enough Italian to pick out signs for the Vatican Printing Office, the Tapestry Restoration Lab, Post Office Management, and the Church of St. Ann. They crossed another small square and arrived at their destination. The Office of the Swiss Guard is housed adjacent to Il Corpo di Vigilanza, directly northeast of St. Peter's Basilica. The office is a squat, stone building. On either side of the entrance, like two stone statues, stood a pair of guards. Langdon had to admit, these guards did not look quite so comical. Although they also wore the blue and gold uniform, each wielded the traditional â€Å"Vatican long sword† – an eight-foot spear with a razor-sharp scythe – rumored to have decapitated countless Muslims while defending the Christian crusaders in the fifteenth century. As Langdon and Vittoria approached, the two guards stepped forward, crossing their long swords, blocking the entrance. One looked up at the pilot in confusion. â€Å"I pantaloni,† he said, motioning to Vittoria's shorts. The pilot waved them off. â€Å"Il comandante vuole vederli subito.† The guards frowned. Reluctantly they stepped aside. Inside, the air was cool. It looked nothing like the administrative security offices Langdon would have imagined. Ornate and impeccably furnished, the hallways contained paintings Langdon was certain any museum worldwide would gladly have featured in its main gallery. The pilot pointed down a steep set of stairs. â€Å"Down, please.† Langdon and Vittoria followed the white marble treads as they descended between a gauntlet of nude male sculptures. Each statue wore a fig leaf that was lighter in color than the rest of the body. The Great Castration, Langdon thought. It was one of the most horrific tragedies in Renaissance art. In 1857, Pope Pius IX decided that the accurate representation of the male form might incite lust inside the Vatican. So he got a chisel and mallet and hacked off the genitalia of every single male statue inside Vatican City. He defaced works by Michelangelo, Bramante, and Bernini. Plaster fig leaves were used to patch the damage. Hundreds of sculptures had been emasculated. Langdon had often wondered if there was a huge crate of stone penises someplace. â€Å"Here,† the guard announced. They reached the bottom of the stairs and dead-ended at a heavy, steel door. The guard typed an entry code, and the door slid open. Langdon and Vittoria entered. Beyond the threshold was absolute mayhem.