Apex Investment Essay

AccessLine’s initial financing came in the form of strategic alliances. In 1989, McCaw Cellular Communication invested in AccessLine, providing a considerable amount of their intial capital. This funding secured the strategic partnership between AccessLine and McCaw Cellular. This launched further alliances between AccessLine and other phone company carriers, in which AccessLine granted them an exclusive franchise in the market for a set fee. The carriers were permitted to market AccessLine’s service under their own company name. AccessLine also developed partnerships with equipment manufacturers such as Stratus Computer and Motorola, also providing them with a franchise in exchange for funding. However AccessLine’s growth prompted the need for larger investments. Thus, in 1994, AccessLine diversified their financing to professional equity investors. Providing funding worth $15. 5 million, AccessLine’s CFO Bill Stuart, and Morgan Stanley’s Bill Brady executed the transaction, involving the private placement from five investors. Such a strategy was chosen due to AccessLine’s lack of capital in the initial stages of AccessLine’s establishment. AccessLine was not lacking in management or technology and thus was not in need of a venture capitalist in its early stages to control the company or provide the company with expertise or administration. Private investors, such as McCaw Cellular Communications, were more appropriate for AccessLine in that they provided the necessary funding without coercing AccessLine to forsake control of the company. McCaw also provided both clientele and investments. AccessLine’s lack of experience from mergers and acquisitions forced them to eventually turn to venture capitalists in 1994, a time when their strategy had changed. The venture capitalists could help in evaluating a target company through their experience in purchasing and selling businesses. The funds from Apex Investment Partners would serve beneficially for AccessLine because of their vast knowledge and experience in the industry. George Middlemas and Rick Bolander, both of whom had joined Apex in the early 90’s, had had previous experiences working in the telecommunications industry and racked up an extensive list of contacts in the industry. Thus, Apex would eventually prove to be a profitable investment for AccessLine.

Dalit Empowerment in India Essay

Dalits movement for empowerment started way back during second half of the nineteenth century with reformatory efforts to uplift the backward groups of Indian society, especially ‘Dalits’. Later on, it turned into seeking state intervention and generating the idea of paying special attention to Dalits/untouchables. Dalits/Untouchables have been described as â€Å"The oppressed of the oppressed and lowest of the low†, who have not been benefited from the opening up of modern economic, social, political and cultural opportunities. It is said say that at present, millions of people, belonging to Dalit community have been the victims of discrimination, violence, exploitation, untouchability, poverty, illiteracy, ignorance, other hate crimes and consequential disabilities for a very long time. They are treated as lesser human beings. Dalit’s movement for empowerment was initiated by non-Brahmins of South India. It had economic and social thrusts. It demanded education and land for backwards and freedom from caste rigidities. Some economically strong but educationally backward non-Brahmins groups resisted the hold of Brahmins on land, wealth, jobs in government and education. Access of modern education to all and spree of Reform Movements of early 19th century led anti Brahmin currents to gain momentum. By the end of the 19th century, it turned into a political movement. Non-Brahmin leaders, supported by other backward communities – Muslims, Indian Christians, untouchables and tribals, desired to secure a place for themselves in modern callings, to obtain legal rights and position of power through govt.’s intervention. They succeeded in fixing up quotas for them in the state Government jobs. During 1874 and 1885, Mysore state reserved 20% of middle and lower level jobs in the police department for Brahmins and 80% for Muslims, Non-Brahmins Hindus and Indian Christians. From Government jobs, it spread to educational field too, in order to prepare non-Brahmins for Government jobs. Around 1909, for the first time, the lowest strata of non-Brahmin Community or the service class, earlier known as Shudras, was conceptualized politically under the name of untouchables, when the Census Commissioner suggested excluding untouchables (comprising of about 24% of the Hindu Population and 16% of the total population at that time) from Hindu fold for forthcoming 1911 Census. The proposal had divided non-Brahmin Community into two Backwards and untouchables. Also, it had immediately increased the importance of untouchables in political circle, in social circle, and in their own eyes too. It had also made numbers important in taking political decisions. The suggestion to exclude untouchables from Hindu population was not acceptable to prominent National Hindu leaders at any cost, for whom continuous decline of the number of Hindu population had already been a matter of concern. Granting special electorate to Muslims had already weakened the National movement of Independence. They were concerned that such a proposal was made intentionally to divide Indians. That was a crucial point. Since then, the assertion of Dalit leaders has travelled a long distance and has passed through various stages. The whole of 20th century, especially the first and last two decades have been especially important for political empowerment of Untouchables/Dalits. Different terms have been used for Dalits at different points of time. Each one assumed importance, as Dalit movement has passed through various stages – ‘Shudras’, ‘Outcasts’ and ‘Panchamas’: Till the beginning of 20th Century, the lowest strata of Hindu Community were known as Shudras, Panchamas or outcastes. Existence of Shudras (at present referred as untouchables/Dalits) was recognized, as early as, Pre Mauryan Period (6th century BC to 3rd century BC). Though given a lower status, they were always an integral part of Hindu society. In ancient India, Shudras performed essential social and economic tasks as well as in agricultural sector. Segregation of lower castes in Hindu Society was not based on economic status or their incapability to do any intellectual work, but on cultural grounds – unclean habits, in-disciplined life style, speaking foul and abusive language etc. Conquered groups or individuals, groups engaged in menial or unclean occupations, groups clinging to the practices, which were not considered respectable, persons born illegitimately or the groups engaged in anti-social activities were treated as Shudras and were given lowest status in the society. Breaking the caste rules meant loss of caste, meaning complete ostracism or having no place in the society. Permanent loss of caste – out-caste- was considered to be the greatest catastrophe for an individual, short of death penalty. By the beginning of Christian era, the out-castes themselves developed caste hierarchy and had their own out-castes. In Western and Southern parts of India, they were kept outside the four Varnas. In the Northern and Eastern parts of India, they were very much belonged to fourth Varna â€Å"Shudra†, which was divided into two parts pure or non-excluded and excluded or untouchables. In ancient India all the social groups were placed more or less as a series of vertical parallels. All of the people living in a local area, whether high or low were bound together by economic and social ties and had a strong bond of mutual dependence. They cared and supported each other in fulfilling different kind of their needs. Socially, Shudras were supposed to do all sorts of menial work and serving the upper castes of the three Varnas. Respect to a person or group was never given on the basis of material success or control of power. There was hardly any room for any section of society to consider itself, as being placed in greater or lesser disadvantageous position with reference to another. Concept of forwards or backwards or feeling of exploitation of lower strata by upper castes was almost non-existent at that time. Many studies have shown that Hindu system always kept masses reconciled, if not contended in the past. Hindu Dharma taught the people that instead of holding others responsible, for all their sufferings, exploitation and miseries it was their own â€Å"Adharma† (immoral behaviour), â€Å"Alasya† (laziness) and Agyan (ignorance) which were to be blamed. It never prevented Shudras or others to rise in the scale of society or to earn respect of the society. In many parts of the country, people belonging to lower strata held position of power/superior status or earned respect of Hindu society. Many warrior kings of Shudra and tribal origin sought Brahmins’ help to acquire Kshatriyas status for themselves. Many Shudras were accepted and revered as philosophers or spiritual teachers. All troubles of lower strata of society started after the downfall of Hindu Raj and old Hindus values. Continuous invasions by Turks, Afghans and Mughals who earlier drained out the wealth of the nation to foreign lands and afterwards made India their homeland and ruled the country for centuries. Feudalistic attitude, extravagance and luxurious life style of rulers and those at the helm of authority, increased the disparity between the rulers and the ruled. Therefore, it can be said that it was not out of malice, but the circumstances, which has pushed Shudras away from the mainstream. The low status and sufferings of Shudras or their exclusion from the mainstream for centuries has gradually stopped growth of their personality and made them completely dependent on others for their livelihood. Centuries old enslavement, ignorance, suppression and ostracism shook their confidence, deteriorated severely their condition and made them to suffer inhuman treatment by other sections of the society. Depressed Class: During the nineteenth Century, in official circles lower castes were addressed as ‘Depressed classes or ‘Exterior classes. British government in India regarded these people as ‘Oppressed of the oppressed and lowest of the low’. Missionaries were trying to convert this section of society into Christianity. British rulers passed many Legislative regulations and administrative orders and declared denial of access to untouchables to schools, well, roads and public places as illegal. Till now, untouchable activities were combined with the intermediate castes’ non- Brahmin movement. But now all these developments inspired them to enter into the political arena under the name of â€Å"depressed class† and desired to a share in political power separately in India. Harijans: The attempt of British rulers in 1911 to exclude untouchables from Hindu population and continuous decline of number of Hindus cautioned the national leaders. In order to retain their Hindu identity, Gandhiji and his followers called them Harijans meaning the â€Å"people belonging to god†. On one hand, Gandhiji tried to create compassion in the hearts of forward communities for Harijans and on the other he appealed to Harijans to observe cleaner habits, so that they could mix up freely with other sections of society. Dalit leaders did not like the word Harijan as it symbolized a meek and helpless person, at the mercy and benevolence of others, and not the proud and independent human being that they were. During this period, the attention of humanitarians and reformers was also drawn towards the pathetic condition of untouchables. They took the path of Sankritisation to elevate them. In order to prevent alienation of untouchables from Hindu community, they drew the attention of forward communities towards inhuman condition of lower strata of society and tried to create compassion in their hearts for downtrodden. They gave top most priority to the abolition of untouchability. They tried to clarify that Untouchability was neither an integral part of Hinduism nor an outcome of Varna/caste system, nor have any religious sanctity, but an external impurity and sinful blot on Hinduism. They laid emphasis on education, moral regeneration and philanthropic uplift. They also appealed to untouchables to observe cleaner habits, so that they could mix up with other sections freely and become proud and independent human beings, which they were. Untouchables By 1909, the lowest strata of Indian society came to be known as untouchables. Emergence of Dr.Ambedkar on the political scene provided the leadership and stimulus to untouchable movement. He insisted to address untouchables just as untouchables. He regarded the terms ‘Depressed classes’, ‘Dalits’, ‘Harijans’ either confusing or degrading and contemptuous. Dr.Ambedkar made it abundantly clear, ‘It was through political power that untouchables were to find their solution, not through acceptance by Hindus’. He gave untouchable movement a national character and a distinct identity during late twenties and early thirties. Other prominent Dalit leaders like Mahatma Phule, Ambedkar or Gopal Ganesh vehemently criticized Hindu hierarchical structure and regarded untouchability as an inevitable concomitant of Varna/caste system. They taught the lower castes to get united and make eradication of caste system their major plank as it engaged them to forced labour or unsavory jobs, imposed many restrictions on them and prevented them from joining the mainstream of the society. According to them, Hindus treated lower castes as lesser human beings, meek and helpless persons, who should always remain at the mercy and benevolence of upper castes. They tried to find the solution of their problems through political power, not through acceptance by Hindus. By 1920’s, numerous caste organizations, especially in the South and West, organized themselves into larger collectiveness by keeping contacts and alliances with their counterparts at other places; formed associations and federations at local and regional levels and emerged as a powerful political force. Together, they demanded special legal protection and share in politics and administration on the basis of caste. In 1928, Simon Commission established their separate identity at national level, independent of intermediate castes as untouchables. It readily accepted their demands through Communal Award of 1932. Gandhiji along with other National leaders regarded it as the â€Å"Unkindest cut of all†, which would create a permanent split in Hindu Society, perpetuate casteism and make impossible the assimilation of untouchables in mainstream. Dr.Rajendra Prasad said, â€Å"The principle of dividing population into communal groups, which had been adopted in the Minto Morely Reforms, had been considerably extended, even beyond what had been done by Montagu Chelmsford Reforms†¦.The electorate in 1919 was broken up into ten parts, now it is fragmented into seventeen unequal bits†¦ Giving separate representations to Schedule Castes further weakened Hindu community†¦ Th e British introduced every possible cross-division†. Untouchables in Independent India: After Second World War emergence of the concept of ‘welfare state’ swept the whole world. Independent India, as a civilized democratic society, considered it its humanitarian obligation to uplift and empower the submerged sections of society. The overwhelming poverty of millions belonging to lower strata of society and their near absence in echelons of power at the time of Independence has led the government to of India to intervene. The Constitution of India has directed the Government to promote social justice and educational, economic and other interests of the weaker sections with special care. It instructed the Government to remove the poverty and reduce inequalities of income and wealth and provide adequate representation to the downtrodden in power echelons through Affirmative Action Program/Reservation Policy. Public facilities, which were denied to untouchables so far, should be made accessible to them. The successive governments both at national as well as provincial levels initiated various Welfare Plans and Policies for employment generation and their social, economic and political growth from time to time. Dalits: Dalit, a Marathi word means suppressed. The term was chosen and used proudly by Ambedkar’s followers under the banner of various factions of Republican Party of India (Formed in 1956). The Mahars of Bombay (8%), Jatavs of UP (Half of the SC Population in UP) and Nadars and Thevars of Southern TN being numerically significant, played a decisive role in taking forward Dalit movement. Maharashtra Dalit movement has a longest and richest experience. In 1972, a distinct political party, in the name of Dalit Panther was formed in Maharashtra. It organized the lower castes under the banner of ‘Dalit’ throughout India. One of the founders of Dalit Panther, Mr.Namdeo Dhasal widened the scope of Dalit by including SC, tribes, neo-Buddhists, landless labour and economically exploited people. Its orientation was primarily militant and rebellious. Dalit Sahitya Movement legitimized and reinforced the use of the term Dalit. Since then, this term is very popular amongst the unto uchables. Earlier, a few leaders of untouchables had at least some regard for the cultural tradition of India. They did not reject Vedic literature or the foundations of Hinduism, out-rightly. Dr.Ambedkar accepted that all parts of Manusmiriti were not condemnable. Gopal Baba Walangkar had said that Vedas did not support untouchability. Kisan Fagoi, another Mahar leader of pre-Ambedkar era had joined Prarthna Samaj. But present Dalit leaders are vehemently against cultural traditions of India, which according to them, are based on inequality and exploitation. There is always a fear of upper caste or intermediate caste backlash. In mid sixties, an aggressive Dalit movement started under the banner of Shoshit Samaj Dal in Central Bihar, which has, presently, become a major center of Naxalite movement. Dal was founded by Jagdeo Mahto, who began to mobilize the lower castes against economic repression and exploitation of women by upper caste feudal elements. The new phase of Dalit assertion is most prominent in the most populous state of UP, where the upper caste domination has been challenged by BSP (Bahujan Samaj Party) formed in 1984 under the leadership of Kanshi Ram and Mayavati. They redefined Dalit politics especially in north India. Their approach to Dalit issues was more socio-political rather than economic. BSP has started pursuing power with militancy since 1990. Of late, BSP has made significant inroads in UP, Punjab and Madhya Pradesh. BSP has borrowed all their phraseology from Dalit Panthers. Most of their utterances are arrogant, revengeful and opportunistic. Political and economic vested interests of its leaders have aroused militancy among discontented youths of different castes and communities all over the nation. They care only for rights and pay scant attention to their duties. There started a cutthroat competition for scarce positions of power and prestige. Once again, the tendency of ‘divide and rule’, as was there during British domination, has emerged in national scenario. The growing desire of Dalits to rule has made them very sure of their friends and foes. Dalit leaders, even after so many years of Independence has identified Upper Castes as their enemy and intermediate castes sometimes as their friends and sometimes as their enemies. Kanshi Ram, a BSP leader initiated a formula of DS4, meaning Dalit Shoshit Samaj Sangarsh Samiti, taking into its fold untouchables, STs, Muslims and OBCs. OBC leaders also know that Dalit parties now control a large vote bank. Therefore, from time to time, they try to please Dalits leaders in order to increase their own political strength. But Dalits are in no mood to play a second fiddle to other national political parties. They are aware of their growing influence and crucial role as a kink-maker in today’s highly competitive and unstable political atmosphere. All the three major national political formations – Congress’s UPA BJP’s NDA and National Front – are wooing frantically Dalit leaders and competing with each other to have a pre or post poll alliance with them. Instead of demanding a share in power structure, equity or social justice, Dalits now want to reverse the power equation and to transform the society by capturing all political power. Their aim is to get hold over the posts of PM-CM (Political Power) through electoral politics and control over administrative authority – the bureaucracy – through Reservations/Affirmative Action Program. There is an elite section amongst Dalits, which protects its turf under the banner of Dalits at the cost of poorest of Dalits. It does not care much to bring Dalit masses into the mainstream. For some, presence and miseries of large number of Dalits is a recipe for Dalit vote-bank, for others enjoying all the benefits of affirmative action programs initiated and implemented by the Government of India and other concessions given to them. Whatever might be the condition of Dalit masses, but the political power and arrogance of Dalit leaders and intellectuals are at rise. And here lies the crux of Dalit politics. Dalits at International platform Dalits are not satisfied even after having growing influence in ballot-box politics and attaining enough places in the government jobs. Since 2001, these activists have been pushing the cause internationally arguing that Indian Dalits are like blacks in US till 1950. They faced problems in workplace, at school and in temples. In 2005, some Dalit leaders belonging to All India Confederation have sought intervention USA, UN and the British and EU Parliaments on the issues of ‘untouchability’. UN recognizes religion, race, language and gender as main causes of inequality in the world. Dalit activists want caste to be included too in this category. They desire to have Global alliance, global involvement and intervention of the international community to put pressure on the government of India to address the problem Dalit marginalization. They feel that globalization and privatization has made it difficult for Dalits, tribals and OBC’s to compete on equal footing or fi nd enough space in the job market within the country or abroad. At the behest of the Republican Congressman from New Jersey, Chris Smith, the US Congress had held a hearing on 6.10. 05 on the subject. A resolution on the issue – â€Å" India’s unfinished Agenda: Equality and Justice for 200 million victims of the caste system† was prepared by the house committee on International Relations and US Human Rights to be tabled in the US Congress. â€Å"Despite the Indian government’s extensive affirmative action policies, which aim to open government service and education to Dalits and tribes, most have been left behind by India’s increasing prosperity†¦. Much much more remains to be done.† The resolution says, â€Å"It is in the interest of US to address the problem of the treatment of groups outside the caste system†¦ in the republic of India in order to better meet our mutual economic and security goals†¦.† So far, intensive lobbying by Dalit groups including followers of Ravidass sect succeeded in getting passed the Equity Bill on March 24, 2010 in the House of Lords. It empowered the government to include ‘caste’ within the definition of ‘race’. In 2001, India was able in keeping caste out of the resolution adopted at 2001 Durban Conference. Along with it, staunch supporters of Human Rights, some Scandinavian countries, Church organisations around the world and Lutheran World Federation have shown interest and expressed their solidarity with Dalits. Recently the comment of UN Commissioner for human rights, Navipillay asking India that â€Å"time has come to eradicate the shameful concept of caste† and proposals of UN Human Rights Council’s or US based Human Rights Watch (HRW) to recognise caste as a form of discrimination ‘based on descent and birth’ appear not to be based on rational understanding of caste system. Their opinion about untouchability is greatly influenced by the lobbying of powerful/influential Dalit leaders and Dalit intelligentsia. No one knows where the Dalit assertion will lead the nation to? It is not the paternalistic policies, (which have failed to yield so far the desired results) that are required for the upliftment and empowerment of submerged sections of society, but there is need to educate, make them aware of their rights and duties, provide enough employment opportunities and other civic facilities like health etc at the grass root level for the sustainable growth of backward communities.

Ideas for Fun Dates for College Students

Being in college doesnt mean youre limited with ideas for fun dates. Even though finding the money, getting off campus, and being alone can seem complicated, these fun date ideas are easy to plan -- and enjoy. Mix up the dinner-and-a-movie tradition. Sure, dinner and a movie can be fun -- but it can also be expensive. Consider mixing it up by doing breakfast, brunch, or lunch and a movie. Youll save money on lunch vs. dinner and a matinee vs. a late night show. Additionally, you can still enjoy the rest of the day ... with each other, too, if things go well. Head to a museum with an interesting exhibit. Youre both in college, meaning you both like to learn new things. Head to a museum with a new and interesting exhibit. Youll have time to talk and hang out while also doing something fun and relaxing. Think small and head to a concert. Tickets for your girlfriends/boyfriends favorite band are perhaps out of your budget. Instead, find a local band playing somewhere nearby. Youll have a more intimate experience, get to hear some great music, and still have a fun night out. Go for a classic at a not-so-classic place. Heading out for a nice dinner is a timeless date idea, but paying for a supe r nice meal often isnt in a college students budget. Instead, mix it up by heading to a hole-in-the-wall place or even to a place that serves cuisine that is new for both of you. Youll have fun while exploring something new together. Do something your date is really into. Is your date really into dancing, for example? Consider heading to a dance troupe performance or even doing a one-time lesson of a kind of dance he or she has never done. Do something youre really into. Conversely, you might be really into something youre date has never experienced. If, for example, youre really into astronomy, consider taking your date out to a planetarium or even somewhere where you can show him or her your knowledge of the constellations once the stars come out. Do something new to both of you. Never taken a cooking class? A kayaking class? Sign up for a local (and usually cheap!) class that offers a one-time session for an hour or two. Youll have fun, learn something new, and definitely have so mething to laugh about later. Head to a farmers market. Farmers markets are nearly everywhere these days. Even if you dont have anything specific to buy (or a kitchen to store a ton of veggies in), the trip to the market, the time you spend walking around, and the conversation you can have about all the different foods, arts and crafts, etc., are all perfect ingredients for a fun date. Go see a musical, play, performance, etc., off campus. Even if youre at a huge public university, chances are youll see someone one or both of you knows. Head off campus for some kind of show to make sure your date, well, really feels like a date. Do something physical if you both like being active. If both of you enjoy being active, dont be afraid to incorporate that into a date. You can go for a hike, volunteer somewhere, or otherwise do something fun and engaging outdoors.

Confidentiality in Nursing Practice - 826 Words

The Importance of Confidentiality in Nursing Practice This essay will discuss why confidentiality is important within nursing practice and the reasons why a registered nurse and student nurse are accountable and to whom they are accountable to in relation to patient care. It will further discuss patient’s rights in relation to law. Definition of Confidentiality, Bailliere’s Dictionary (2005) â€Å"Spoken, written or given in confidence† With this in mind the Nursing Midwifery Council states: â€Å"As a registered Nurse, Midwife or Health†¦show more content†¦Consent can be quite tricky, a legal minefield for healthcare teams, this is due to the patients who will give or refuse to give private information about themselves who is legally competent butShow MoreRelatedThe Role Of The Nmc And The Code Of Practice919 Words   |  4 Pagesthe role Nursing and Midwifery Council plays in safeguarding the public and maintaining standard care within the UK. 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Within these elements there are three standards nursesRead MoreThe Importance of Acting Lawfully as a Nurse Essay1335 Words   |  6 PagesStudent number: 17038485 When working within the nursing profession, it is of great importance for a nurse to act lawfully within their roles and responsibilities. It is imperative for nurses to comprehend legal aspects such as negligence, duty of care, documentation and confidentiality. As such acting lawfully will protect and reduce the risk of becoming deregistered and provide a high standard of care for the patients. I choose to study nursing for various reasons. My family suggested becoming

The Problem Of Induction And Its Metaphysical Implications

The problem of induction and its metaphysical implications. The pursuit of knowledge and the desire to understand our world in terms of what is and what it is like has been the endeavor of mankind for centuries. One of the main methods used in order understand the reality presented to us is inductive inference. While humanity has no doubt advanced by employing inductive inference, the problem of induction, recognized by David Hume (1711-1776) forces us to question if induction is a justifiable method and in turn what that means concerning the knowledge acquired by its application. The result of the problem of induction is that we cannot rely on past experience to help us understand the past, our current situation or make future†¦show more content†¦Relations of ideas are a priori and are logically true statements, they are epistemologically prior to experience and the denial of such a proposition implies a contradiction. For example, a square has four equal sides and imagini ng a square with five sides, or unequal sides leads to contradiction as the definition of a square is, ‘a shape with four equal sides’ and as a result nothing will be a square unless it has four equal sides. Conversely, matters of fact are a posteriori and therefore grounded in experience, this means that they can be denied without any contradiction as an alternate statement can be just as plausible. As an example, if the statement is made that, ‘it is raining outside’ it is no less plausible to think that it is not raining outside and so until it has been experienced one cannot say that either of these situations is more likely than the other. In the world we live in and especially in science, it is not always possible to experience every instance of a phenomena in question and that is why we look to other methods to advance our knowledge. We are only able to increase our knowledge by moving from the particular to the general, which is how the process of i nduction works. However, the question that arises is, ‘when is it justifiable to make a general claim

Discussion on MERS-Free-Samples for Students-Myassignementhelp

Question: Critical review of the literature on one Emerging or Re-Emerging Communicable Disease Threat. Answer: Introduction Middle East Respiratory Syndrome (MERS) is a respiratory syndrome that can be traced back to Saudi Arabia in 2012. It was initially restricted to persons who were traveling within the Middle East and/or their contacts, but later had a spill-over effect into other countries as demonstrated by outbreaks in countries out of the Middle East block such as the Republic of Korea (RoK), Austria, the Philippines, Thailand, France, Tunisia, Germany, Malaysia, Greece and the United Kingdom (World Health Organization (WHO), 2017; NSW Government, 2017). MERS is caused by Middle Eastern respiratory syndrome coronavirus (MERS-CoV). MERS is not a national notifiable in Australia, but it is at least classified as a notifiable condition in some parts of Australia, precisely South and Western Australia (Government of South Australia - SA Health, n.d.) and the US (Centers for Disease Control and Prevention (CDC), 2015). This paper is a discussion on MERS with focus on the role of agent, host and environmental factors in the development and spread of the condition and the corresponding potential policy responses to the same. This is achieved through discussions on three main sections. The first section discusses the epidemiology, transmission routes, risk factors and clinical features, while the second part is a discussion on the interaction between the causative agent, host and environmental factors in the production of the illness in individuals, and the last part discusses various responses towards the control of the spread of the virus. Discussion Epidemiology, Transmission Routes, Risk Factors and Clinical Features The MERS coronavirus belongs to the large and diverse family of coronaviruses which are known to cause ill health to both humans and animals. Four strains of coronaviruses that affect humans {human coronaviruses (hCoV)} are known to cause respiratory infections in human, with severity ranging from mild to moderate. These hCoVs include the alpha-coronaviruses hCoV-NL63 and hCoV-229E and betacoronaviruses hCoV-HKU and hCoV-OC43 (The Department of Health, 2014). In the class of beta-coronaviruses also lies the viruses causing MERS-CoV and severe acute respiratory syndrome coronavirus (SARS-CoV). However, according to The Australian Department of Health, these two viruses are genetically distinct from each other (The Department of Health, 2014). The MERS coronavirus was only identified in 2012 as a new variant of the coronavirus family that could lead to a rapid onset of severe respiratory illness in humans (Zaki, van Boheemen, Bestebroer, Osterhaus, Fouchier, 2012). Most of MERS cases have been found to develop in persons presenting with other underlying conditions which predispose them to respiratory infections. While MERS-CoV is distinct from the SARS-CoV in humans, the MERS-CoV has some similarity to coronaviruses found in bats (The Department of Health, 2014). Up to date, all cases of MERS in humans have been in persons who have been residents in or travellers to the countries in the Middle East or have had a close contact with persons presenting with the infection in the same region. The disease has been predominantly reported in in travellers or residents in the United Arab Emirates (UAE), Jordan, Qatar and the Kingdom of Saudi Arabia (Who Mers-Cov Research Group., 2013). But as demonstrated in later years, the infection is not just restricted to the Middle East as evidenced by the reported cases in countries, not in the Middle East. This includes countries in Europe such as Italy, Germany, the United Kingdom, France, Tunisia, Malaysia, South Korea, the Philippines, Thailand and Greece (NSW Government, 2017). South Korea reported the largest outbreak in 2015, which was a multi-centre hospital outbreak which was traced to a traveller from the Middle East (WHO, 2015; CDC, 2015). Notably, Australia has so far reported zero MERS-CoV cases. ( NSW Government, 2017). A MERS situation update by WHO for the months of January and February 2017 states that as of the beginning of March 2017, a total of 1,916 laboratory confirmed cases of MERS have been reported to WHO and a total of 702 persons have died, translating to a case-fatality rate of 36.6% (WHO, 2017). According to the same update, a total of 27 countries worldwide have reported MERS cases. Transmission routes The epidemiologic aspects of the MERS-CoV have not been adequately defined, but the most recognized means of transmission is the human-to-human transmission of the virus, in healthcare settings. However, just like other coronaviruses, the spread of the virus is thought to occur through contact with an infected individuals secretions. The exposure in healthcare facilities could be justified by the 2015 outbreak in South Korea and Saudi Arabia, whose point of introduction is always a single introduction of MERS, probably zoonotic (Al-Abdallat, et al., 2014). According to the WHO, MERS-CoV is a zoonotic virus which enters the sphere of humans through contact with infected dromedary camels in the Middle East (WHO, 2016). The restriction that it is dromedary camels in the Arabian Peninsula can be supported by negative findings of the virus in tested camels from other parts of the world (Chan, et al., 2015). Studies have demonstrated strong indicators of both direct and indirect exposure to camels to causing the infections. This hypothesis is supported by at least one group in which the camels also tested seropositive (WHO, 2017). Outstandingly, a review of literature also indicates cases where the infections resulted even in the absence of a history of prior exposure to other animals. This perspective rather suggests the likelihood of the virus being introduced through multiple channels as opposed to a single zoonotic case. The primary hypothesis in the transmission and resulting outbreaks of MERS has been a hypothesised link to some animals serving as either the reservoir or intermediate host(s), with dromedary camels as the primary suspects. They are known to produce a significant amount of MERS-CoV RNA in their lungs and the urinary tract (Khalafalla, et al., 2015). The droplet transmission route is claimed to play a significant role in the transmission of the virus. The exact source from which people acquire the virus from camels has not been clearly defined but it is postulated that there is an intricate interplay of both animal and human behaviours as demonstrated in the figure below. Source: (Mackay Arden, 2015) Figure 1: Speculated transmission routes of MERS-CoV and how humans and camels contribute to epidemics. Human-to-human transmission of the virus has also been observed especially in healthcare settings, among family workers, and among co-workers. The usually suspected transmission mechanisms in human-to-human transmission have been suspected to be either respiratory (sneezing, coughing) or direct physical contact with the affected individual or contamination of the environment by the infected individuals, but this is yet to be fully demonstrated. The only definitive comment made by the WHO is that the virus is not easily transmitted from an individual to another unless there is close contact between the two, as demonstrated in the provision of unprotected care to an infected patient (WHO, 2017). Cases of human-to-human transmission have only been documented in the health care environment and nowhere else. Notably, the origins of MERS-CoV virus are yet to be fully understood, but analysis of the virus genomes have demonstrated that the virus could have originated in bats and was transmitted to dromedary camels during early ages. Risk factors The distribution of the disease among the already reported cases is demonstrated to be skewed heavily to middle-aged persons and the elderly. The risk is heightened in persons who are elderly, are immunocompromised, or present with other comorbidities (WHO, 2017). For MERS associated with the health care environment, the risk for infection among healthcare workers is magnified among those who have close contact with patients infected with the virus, especially radiology technicians and nurses (Alraddadi, et al., 2016). In addition, according to the same authors, health care workers with a history of smoking had 3 times increased risk for the infection compared to non-smokers. This association further arouses the curiosity of the role that smoking plays in the risk profile, unluckily, there is no literature addressing the same. This requires further research. Males aged above 60 years are also claimed to be at increased risk of contracting the virus. The risk is further heightened if they suffer from underlying conditions such as renal failure, hypertension, and diabetes (WHO, 2017). A twist to this association could rather suggest that instead of a sex-specific difference in biologic susceptibility, males have exhibit social and behavioural factors which increase their exposure to the virus compared to females. This can be supported by an observation by Mackay and Arden, (2015) in which males infected by MERS-CoV present with a more severe disease compared to females of the same class. Clinical picture The mean incubation period for MERS-CoV has been determined to be 5 to 6 days, ranging from 2 to 16 days, with 13-14 days between when one person develops the diseases and spreads it to another (Assiri, et al., 2013; Memish, Zumla, Al-Hakeem, Al-Rabeeah, Stephens, 2013). For cases with progressive illness, the median death is 11-13 days (Assiri, et al., 2013; Ki, 2015). Early symptoms of the illness include fever, myalgia, chills and gastrointestinal symptoms, which subsequently decline, only be substituted with more severe systemic and respiratory syndrome, severe pneumonia with acute respiratory distress syndrome and multi-organ failure (Kraaij-Dirkzwager, et al., 2014; Mailles, et al., 2013). The Interaction Between The MERS-CoV, Host and Environmental Factors to Produce MERS Majority of camels in the Arabian Peninsula are dromedary camels and their contact with humans ranges between little to close. This contact serves as the gateway to the transmission and the corresponding outbreaks; hence it is significant to illustrate the interplay of the agent, the reservoir and the environmental factors that predispose the host to the virus and consequential development of the syndrome. The human-camel contact is commonplace in the Arabian Peninsula and may result from various ways (as illustrated in the figure above). Most of the countries in the Middle East (with special reference to Saudi Arabia due the fact that it has so far recorded the highest number of cases), has several large well-attended festivals, parades, sales and races which feature dromedary camels and also, these camels are bred and reared close to populated areas (Al-Mukhtar Estimo, 2014; Hemida, et al., 2015)127-128. In addition, inhabitants of these countries have the tendency to consume milk and meat from camels after the Hajj pilgrimage (Mackay Arden, 2015). Notably, however, reports of infections of MERS-CoV are much lower compared to the frequent habits of preparing, drinking, eating products from dromedary camels. It is also established that some tribes in Saudi Arabia consume fresh unpasteurised milk from dromedary camels, alongside their urine which is claimed to be having some health b enefits. It is however interesting to note that butchers make up a larger proportion of the local occupations, and neither them nor any of the associated risk groups have ever been identified among MERS cases (Mackay Arden, 2015). A logical explanation to explain the same is that there is a heightened likelihood to be a reporting issue and not just an unexplainable absence of the illness. This association can be corroborated by evidence from a 2015 case-control study that concluded that the onset of MERS is as a result of direct contact with dromedary camels and not the ingestion of products from these animals (Alraddadi, et al., 2014). Some researchers hold a different hypothesis that there is the likelihood of humans infecting dromedary camels, contrary to the already established hypothesis. This divergent proposition has been instigated by laboratory finding in which whenever cases of MERS have been reported, the camel population is also found to have nasal colonisation of the v irus alike. This hypothesis is however yet to be studied and proven. Camels often calve during the winter months that run between late October and late February and this season may be characterised by an increased risk of spill-over of the virus to humans because new infections are often likely to occur within the camel populations (Hemida, et al., 2015). The role played by maternal camel antibody in delaying infection in the calves is yet to be established (Memish, et al., 2013; Hemida, et al., 2015). Young camels have been found to host active infection more often compared to their parents, and as a result of the inclination to choose camels aged 5 years or older for sacrificial slaughter, and this is accompanied with an insignificant risk of exposure to the virus. This conclusion draws reference back to the fact that slaughterhouse workers stand out as a high-risk occupational group. The survivability of MERS-CoV in the environment is also important towards understanding the association between the various parameters leading to the development of the illness. Laboratory experiments have demonstrated that adding the virus to milk from either a camel, goat or cow, and storing it at low temperatures (4 degrees Celsius), the virus could still be recovered at least seventy-two hours later, and if stored at 22 degrees Celsius (almost room temperature), the virus could still survive up to 48 hours (van Doremalen, Bushmaker, Munster, 2013). On the survivability of the virus in the environment in the absence of a milk medium, a study by van Doremalen, Bushmaker, and Munster, (2013) was able to demonstrate that even at high ambient temperatures (about 30 degrees Celsius) and low relative humidity (30%), the virus still remains viable for up to 24 hours. This demonstrates quite a significant survivability rate compared to other well-known and efficiently transmitted respiratory virus such as influenza A virus which cannot be recovered even after four hours under the same conditions to those survived by MERS-CoV (van Doremalen, Bushmaker, Munster, 2013). However, the survival of MERS-CoV is still said to be inferior compared to that of SARS-CoV (Chan, et al., 2011). MERS outbreaks have been so far experienced in health care settings as opposed to community settings. It is therefore hypothesized that the hospital environmental facilitates environments that promote super-spreading of MERS-CoV. The above-demonstrated survivab ility characterised therefore plays a significant role in the development of these outbreaks. For purposes of understanding how they contribute to this, it is an established fact that pathogenic bacteria can remain viable and airborne for three-quarters of an hour in a coughed aerosol and can spread for four metres (Mackay Arden, 2015). The ability of MERS-CoV to remain viable for extended times gives it the capacity of thoroughly infecting surfaces of rooms occupied by either infected or symptomatic patients (Knibbs, et al., 2014). It is however unknown whether the virus can remain truly airborne. These findings help paint a clear picture of the possibilities of aerosols to transmit the virus in various settings such as hospital waiting rooms, treatment rooms, private patient rooms, emergency departments and open intensive care facilities. It is thus of significance to consider the variable or air exchange, circulation and filtration as variable in measuring and reducing the risk of MERS-CoV spread, and the use of negative pressure rooms in the containment of known cases. Human-to-human transmission is attributed to droplet spread as demonstrated in both outbreaks in Saudi Arabia and South Korea (Assiri, et al., 2013; Assiri A. , et al., 2013; Al-Tawfiq Memish, 2014; Zumla Memish, 2014). As a result, environmental control in terms of risk measurement and reduction efforts directed at curbing the spread should be targeted at aerosols-generating events that involve camels (urination, defecation, and preparation and consumption of camel products), and the formulation of personal protective equipment worn by healthcare workers working with infectious cases. Policy Responses To MERS-CoV The response to MERS can be categorized to either individual countries or as a cumulative response by the World Health Organisation. Notably, however, no specific policies have been designed to control the virus, but rather various guidelines are available for the control of the same. For instance, the Saudi Arabian Ministry of health has responded with both outbreak control policies touching on notification of suspected cases, risk assessment, investigation procedures and treatment protocols. WHO has likewise taken various steps and also projected steps to be undertaken later on. WHO works with various countries, and has notably worked with CDC to develop policies aimed at improving the efficiency of surveillance (Banerjee, Rawat, Subudhi, 2015), and the Saudi Arabian Ministry of Health (MoH) to develop specific guideline for the control and prevention of infections by the virus for both health care workers, patients and their family members contained under the Scientific Advisory Boards Infection Prevention and Control Guidelines for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection (Saudi Arabia Ministry of Health, 2014; Scientific Advisory Board, 2015). Neither CDC nor Saudi Arabia MoH has prescribed specific guidelines for the control of the agent, but have rather made recommendations for quarantine measures for infected individuals and have also prescribed guidelines to be followed before the infected person resumes regular activities following recovery. Both the CDC, Saudi Arabian MoH and various agencies from most countries (Australia included) have also prescribed guidelines for airport staff on the management of suspected MERS cases, and likewise developed advisories and precautionary statements for travellers into and out of the countries. The WHO Director-General convened the International Health Regulations (IHR) Emergency Committee on MERS which is chaired by Australias Chief Medical Officer (The Department of Health, 2016). In the case of Australia, the countrys Communicable Diseases Network Australia has also developed a national guideline for the public health management of MERS, and these guidelines have also been endorsed by the Australian Health Protection Principal Committee (AHPPC). In addition, as from 2015, information is provided on the disease to both the public, clinicians, laboratory and public health personnel and general practitioners. State and territorial AHPPC and its standing committees work in tandem with the Australian department with regard to this. Among these recommendations, it is stipulated by the Public Health Laboratory Network that the ideal diagnosis of the infections should be done using PCR-based tests. In addition, the government through the Department of Foreign Affairs and Trade ( DFAT) has issued a Smartraveller bulletin on MERS alongside country-specific advice for travelling to the affected countries. As the coordinating body, the WHO strives for the development and application of universal standard infection control precautions and transmission-based precautions when dealing with MERS (The Department of Health, 2016). Conclusion MERS-CoV stands as one of the emerging infectious agents responsible for a significant amount of respiratory illness across three continents. MERS was originally restricted to countries in the Arabian Peninsula but as a result of human dynamics, it has successfully caused outbreaks outside of the Middle East with the most notable one being a healthcare-associated in South Korea in which 186 persons were infected and a total of 36 died. The main transmission routes for MERS-CoV are camel-to-human and human-to-human. Dromedary camels remain as the primary reservoir of the virus which is claimed to have been sourced from paths. Several epidemiologic aspects of MERS are however yet to be known. Hospital environments are characterised to be bearing ideal conditions for the spread of the virus, hence liable to the health care outbreaks so far. Regardless of the infection having been reported across 27 countries, neither individual countries nor the WHO have developed any specific policies aimed at controlling the virus, but rather various guidelines have been provided. References Al-Abdallat, M., Payne, D., Alqasrawi, S., B, R., Tohme, R., Abedi, G., . . . Haddadin, A. (2014). Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description. Clin Infect Dis. , 1225-33. Al-Mukhtar, R., Estimo, R. (2014). Link between MERS virus and camels worries breeders. Alraddadi, B. M., Al-Salmi, H. S., Jacobs-Slifka, K., Slayton, R. B., Estivariz, C. F., Geller, A. I., . . . Haynes, L. (2016). Risk Factors for Middle East Respiratory Syndrome Coronavirus Infection among Healthcare Personnel. Emerg Infect Dis, 1915-1920. Alraddadi, B., Watson, J., Almarashi, G., Turkistani, A., Sadran, M., Housa, A. (2014). Risk Factors for Primary Middle East Respiratory Syndrome Coronavirus Illness in Humans, Saudi Arabia. Emerg Infect Dis. Al-Tawfiq, J., Memish, Z. (2014). Middle East respiratory syndrome coronavirus: transmission and phylogenetic evolution. Trends Microbiol., 573-9. Assiri, A., Al-Tawfiq, J., Al-Rabeeah, A., Al-Rabiah, F., Al-Hajjar, S., Al-Barrak, A., . . . M. Z. (2013). Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis., 752-61. Assiri, A., McGeer, A., Perl, T. M., Price, C. S., Rabeeah, A. A., Cummings, D. A., . . . Mad, H. (2013). Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus. NEJM, 407-416. Assiri, A., McGeer, A., Perl, T., Price, C., Al Rabeeah, A., Cummings, D. (2013). Hospital outbreak of Middle East respiratory syndrome coronavirus. 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Use of Acupuncture for Treatment of Lateral Epicondylitis free essay sample

Lateral epiconylitis is a commonly encountered condition resulting from minor injury to the extensor muscles of the forearm, which originate from lateral epicondyle of humerus. This condition is characterized by pain and tenderness over the lateral epicondyle of humerus. Pain is typically present upon the resisted dorsiflexion of the wrist, middle finger or both (Buchbinder, Green Struijs, 2007). Lateral epiconylitis is known by many analogous terms like tennis elbow (TE), rowing elbow, tendonitis of the common extensor origin, peritendonitis of the elbow etc. In the United Kingdom, the incidence of tennis elbow in general practice has been estimated to be about four to seven per 1,000 persons a year (Buchbinder et al). Though TE is a self-resolving condition its symptoms can persist for as long as 18-24 months. Pain of tennis elbow can interfere with normal day to day functioning like carrying objects, lifting and gripping things etc. Though pain of TE can be initially cured with various conservative treatment modalities and rest, it can frequently recur after resumption of activity. We will write a custom essay sample on Use of Acupuncture for Treatment of Lateral Epicondylitis or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Thus TE can cause significant amount of chronic pain and disability, which can lead to considerable morbidity and financial cost (Buchinder et al, 2007). Thus there is a need for an efficient treatment modality for TE. Till date, physicians and physiotherapists are uncertain about the exact etiology and best management option for patients with TE. There are several conventional therapies which are being used for treatment of TE. These therapies are believed to relieve pain, promote tissue healing and improve joint mechanics. These conventional therapies include anti-inflammatory medicines [NSAIDS (non-steroidal anti-inflammatory drugs) and corticosteroids], physiotherapy interventions (such as stretching and strengthening exercises), cast immobilization, ultrasound therapy, using ice packs, neural stretches, deep friction massages, surgery etc (Trinh, Philips, Ho Damsma, 2004). Various non conventional therapeutic modalities like acupuncture, pulsed electromagnetic field therapy, transcutaneous electric nerve stimulation etc have also been used for treatment of TE. In 1992, Labelle et al attempted to perform a quantitative meta-analysis in order to evaluate the therapeutic effectiveness of above mentioned treatment modalities (both conventional and non-conventional) for patients suffering from TE. They considered the results of 18 clinical trials conducted in the period from 1966 to 1990. From their analysis they concluded that the various randomized and controlled trials, which they had analyzed, were of poor quality and did not provide sufficient scientific evidence to support or oppose the therapeutic benefit of any of these conventional or non-conventional treatment modalities. Labelle et al (1992) did find some weak evidence supporting the beneficial effect of ultrasound therapy in comparison to that of placebo therapy in treatment of patients with TE. More recently, a systematic review of the literature, comprising of randomized controlled trials evaluating the effectiveness of various treatment options for TE was carried out by Assendelft, Green, Buchbinder, Struijs, Smidt, (2003). They have suggested significant beneficial effect of NSAIDS (both topical and oral) in comparison to placebo in the providing short term relief from pain in patients with TE. However they found little evidence regarding the beneficial effect of NSAIDS (both topical and oral) in providing long term pain relief. While the use of topical NSAIDS was not found to be associated with significant side effects, use of oral NSAIDS, typically aspirin was associated with significant side effects like gastro-intestinal bleeding etc. This review found limited evidence regarding the beneficial effects of steroid injections in comparison to placebo, local anaesthetic agents, elbow strapping or physiotherapy. Assendelft et al also found insufficient evidence to support long term or short term beneficial effect of treatment modalities like acupuncture, physiotherapy exercises, orthoses (elbow strapping), extra corporeal shock wave therapy and surgery. They have recommended long term use of oral and topical NSAIDS and physical therapies (elbow strapping, physiotherapy, etc and avoidance of provoking activities as the first line of treatment, especially in the early stages of the disease.   They have also suggested the use of corticosteroid injections as second line therapy for providing relief from pain. However the pain relief provided by corticosteroids is usually temporary in nature with the pain recurring again after a few months. Thus they have suggested that the patients receiving such therapy should be counselled about not subjecting the extensor muscles to increased activity during the pain-free period resulting from use of corticosteroid injections. On the other hand, Bisset, Paungmali, Vicenzino, Beller,   Herbert, (2005) from their systematic review of literature, comprising of studies evaluating   the effectiveness of   various physical interventions (non pharmaceutical or   non-surgical therapeutic modalities) for treatment of TE have shown short term benefit   with the use of physical interventions like ultrasound therapy, ionisation, and acupuncture. However no evidence of long term benefit due to these therapeutic modalities was observed in this review; benefit due to these interventions was usually seen to last between two to eight weeks. Bisset et al observed insufficient evidence regarding the beneficial effect of manual therapy (involving manipulation of elbow or cervical spine), use of elbow strapping and physiotherapy exercises in the management of TE. They also observed the presence of sufficient evidence that disapproved the beneficial effect of extracorporeal shockwave therapy and laser therapy in the treatment of TE (both in short term and long term). However they have indicated the requirement of larger studies in future in order to confirm this finding. Since no clinical study till date has been able to demonstrate definite clinical efficacy of any conventional therapeutic modality in treatment of TE, there has been increasing trend towards the use of non-pharmacological treatment modalities, especially acupuncture, since last two decades, for alleviation of chronic pain due to TE. One major advantage of using acupuncture for treating   pain of TE over the conventional anti-inflammatory drugs like NSAIDS (oral or topical), corticosteroids etc is that it is free from the numerous deleterious   side effects commonly associated with the use of these drugs. Also the evidence supporting the use of these conventional pharmacological interventions is no better than that supporting acupuncture [National Institute of Health (NIH), 1998]. Despite the growing popularity of acupuncture in treatment of pain related to lateral epicondylitis, presently, there is little evidence which confirms the efficacy of acupuncture in treatment of tennis elbow. The studies conducted until now have produced conflicting results. Bisset et al (2005), in their systematic review of literature considered four studies evaluating the therapeutic effect of acupuncture in treatment of TE. Three studies out of these four compared acupuncture with placebo whereas one study compared acupuncture with ultrasound. The overall evidence considered in this review supports short term beneficial therapeutic effect of acupuncture over placebo in patients with TE. Two studies, (Fink, Wolkenstein, Karst, Gehrke, 2002; Molsberger Hille, 1994) which compared acupuncture with placebo are described below in details. Fink et al (2002) conducted a study to evaluate the clinical efficacy of acupuncture in   treatment of TE. They also tried to compare the therapeutic effects produced by stimulating selected acupuncture points (as defined by traditional Chinese acupuncture) in contrast to those achieved through stimulation at non-specific points (these puncture points were at least 5 cm away from the traditional Chinese acupuncture points). The results of this study indicated that use of acupuncture with correct location and stimulation, in accordance to the recommendations of tradition Chinese acupuncture helped in significantly alleviating the pain, reducing disability of arms, shoulders and hands (measured through DASH questionnaire) and improving the strength of the extensor muscles in the patients suffering from TE. However these therapeutic effects (pain relief and muscle strength) of acupuncture were less evident in long term. In this study, at the time of follow-up after two months, though the overall functioning of the arm was observed to be better in the treatment group as compared to the control group, the differences in pain intensity and muscle strength were no longer found to be significant. The main aim of the study by Molsberger Hille (1994) was to find out whether acupuncture showed an intrinsic analgesic effect even after only one treatment session in comparison to that of placebo treatment for TE pain. In one single session of acupuncture treatment, patients in the treatment group were treated at a non-segmental distal point on the fibulo-tibial joint of the homolateral leg. The painful area of the elbow itself was not needled. The depth of insertion was 2 cm and during the procedure of needling, the patient was asked to move the painful arm. Patients were treated for a total of 5 min. Overall reduction in the pain score was 55.8% in the treatment group and 15% in the placebo group. After one treatment session, 79.2% (19 patients out of 24) patients in the treatment group reported pain relief of at least 50%, whereas in the placebo group only 25% patients (6 patients out of 24) reported pain relief. The average duration of analgesia after one treatment was 20.2 h in the treatment group whereas that after placebo was 1.4 h. All these results show that acupuncture has a statistically significant intrinsic analgesic effect in the clinical treatment of TE pain, which exceeds that of placebo treatment.   Since this study dealt with short term analgesic effects of acupuncture, further studies need to be carried out in future in order to evaluate the long-term therapeutic value of acupuncture for treatment chronic tennis elbow. Davidson et al (2001, cited in Bisset et al, 2005) conducted a study to compare the   therapeutic effect of acupuncture with that of ultrasound treatment in patients suffering from TE. Though significant improvement in two outcome measures i.e. pain reduction and disability prevention were observed in both the groups, no statistically significant differences in terms of these outcome measures were observed between the two groups. Thus this study indicates that there is no difference in therapeutic benefit between ultrasound and acupuncture in patients with TE. However it is difficult to reach to any definite conclusion from the results of a single study. More studies are required in future in order to arrive at a definite conclusion. In a publication by the NIH in 1998, it was determined that the results of various studies conducted till date has been promising enough to support the use of acupuncture as an adjunct treatment or an alternative to classical conventional therapeutic modalities for patients with TE. Trinh, et al (2004) conducted a systematic review of literature regarding use of acupuncture in treatment of TE, using the best evidence synthesis approach (BESA), which aimed at qualitative analysis of clinically homogeneous studies. The results of this review strongly suggested that acupuncture was an effective therapeutic modality for attaining short-term pain relief in patients with TE. Though there was a great deal of clinical heterogeneity between various studies considered in this review, five studies out of six studies considered in this review indicated that acupuncture treatment was more effective compared to placebo treatment. The studies conducted till date have failed to provide us with definite results. This can   be attributed to a variety of factors like: flaws in study design, heterogeneous treatment protocols, small sample size, inherent difficulty in the use of appropriate controls etc (NIH publication, 1998). Selection of method for performing the procedure in control group for these studies poses to be a difficult problem. Method of performing the   procedure in control group is important because the insertion of placebo needles itself results in inherent analgesic effect due to release of local ÃŽ ²-endorphins (opioid like substances), which can influence the outcome of the study too (NIH publication, 1998). Future research is recommended to resolve the issues discussed above. Thus there is a need for large scale, well-designed, multicentric, randomized control trials in future that will use standardized treatment protocol and appropriate methods for performing the procedure in controls. It is evident from the above discussion that various studies which aimed at assessing the   efficacy of acupuncture in treatment of TE had employed different processes for performing acupuncture, in terms of location of puncture points, depth of insertion of needles, the number of needles used, duration of treatment etc. In order to arrive at a definite conclusion regarding the efficacy of acupuncture in treatment of patients with TE and in order to maximize the chances for a successful treatment with acupuncture, there is a need for a uniform, accurate and complete description of the most effective method to be used for performing acupuncture in patients with TE. With this in mind, Webster-Harrison, White Rae (2002) conducted a study in order to develop a standardized treatment protocol for acupuncture therapy in patients with TE. They adopted a modified Delphi’s consensus technique to combine the opinions of fourteen British acupuncture experts into a standardized treatment protocol. This protocol contained eight items pertaining to the treatment of TE using acupuncture and has been described in table 1. The various items considered in this protocol were: selection of acupuncture points; length and diameter of needles used; depth of insertion; duration of treatment; interval between successive treatments; whether the needle should be stimulated or not; the type of response to be achieved upon stimulation and number of treatment cycles needed. Use of this protocol in randomized multicentric trials conducted in future is likely to give accurate results (Webster-Harrison et al). Conclusion From the discussion in this paper it becomes apparent that till date no study in published   literature has been able to demonstrate long term beneficial effects of any pharmacological, surgical or physical therapy in comparison to that of a placebo therapy for treatment of patients with TE. Among various non-pharmacological therapeutic options, acupuncture presents an effective and safe adjunct treatment or an alternative to classical conventional therapeutic modalities, especially in cases where these conventional therapeutic modalities had previously failed (NIH, 1998). Presently, the optimal treatment option for patients with tennis elbow in clinical care largely remains unclear. Acupuncture appears to be a lucrative treatment option for both clinicians and patients. However, the therapeutic benefits provided by use of acupuncture are not supported by sufficient evidence, at present. There is a need for well designed, high quality research studies, especially randomized control trials in future, in order to help in establishing the appropriate place for acupuncture in treatment of patients with TE in modern medical practice. References Assendelft, W., Green, S., Buchbinder, R., Struijs, P., Smidt, N. (2003). Extracts from concise   clinical evidence: Tennis elbow. British Medical Journal, 327, 329-340. Bisset, L., Paungmali, A., Vicenzino, B., Belle, E., Herbert, R.D. (2005). A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine, 39(7), 411 422. Buchinder, R., Green, S., Struijs, P. (2007). Tennis elbow. American Family Physician, 75 (5),   701-702. Retrieved on 30 June 2007 from http://www.aafp.org/afp/20070301/bmj.html Fink, M., Wolkenstein, E., Karst, M., Gehrke, A. (2002). Acupuncture in chronic   epicondylitis: A randomized controlled trial. 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