Exosome as Nanoscale Vesicles | Pancreatic Cancer Research

Exosome as Nanoscale Vesicles | Pancreatic Cancer Research Abstract Exosome are nanoscale vesicles that are released from cancer cells, playing an important role in the microenvironment of cancerous tumour cells.6,8 The exosomal vesicles (EV) contribute to the progression and growth of the tumour, and can be targeted using gold nanoparticles (GNP).1,6,7 The exosomes are isolated from the blood plasma, and with their stability in bodily fluids, they can be targeted and inhibited using GNP.   The GNP will inhibit the cancer cell, and will stop tumour growth and production.   Using proteomic and quantitative methods, the exosome EphA2, showed the highest detection of specificity and sensitivity in pancreatic cancer patients.1,2,4,8 Further tests confirmed that EphA2-EV has potential in early detection for pancreatic cancer, due to the levels specificity and sensitivity being higher in comparison to pancreatitis patients and the control patients.1 Keywords: Biomarkers, Exosome, Pancreatic cancer, Nanoparticle, Proteomics, Vesicles, Plasma, Antibody Introduction Pancreatic cancer, is vastly terminal, with a survival rate of less than 5%.   Pancreatic ductal adenocarcinoma (PDAC), is the most common form of exocrine pancreatic cancer, accounting for around 95% of pancreatic cancer cases.10 PDAC is a silent cancer, and with the lack of testing, the need for novel biomarkers to aid in early detection is imperative.   With no valid early detection methods, and no symptoms of early stage PDAC, the cancer will progress rapidly throughout the body before it is detected.   There is need to find a biomarker, aiding in the early detection PDAC, so that a treatment can be provided to stop the cancer from progressing.   The current tumour biomarker, CA19-9, is not reliable in early detection due to falsely elevated results of diseases other than PDAC.10 Recent studies suggest that exosomes, a nanovesicle, has a high potential as the future biomarker of PDAC, due to the stability and detection sensitivity in human blood plasma.1,2,4,8 Malicious exosomes, are veiled by cancer cells, screening the importance in tumour maturation and progression.7 Studies show how to optimize a method, to isolate exosomes from the blood plasma, to further assist in biomarker discovery.   In regards to analysing exosomes as a potential biomarker, exosomes need to purified and isolated with differential centrifugation paired with ultracentrifugation (UC).   Another technique used, is affinity purification of the exosomal membrane antigens using density gradient (DG) centrifugation, separating the vesicles based on their density.8 A practise needs to be conducted, to purify exosomes, from only a small volume of blood plasma. With studies being conducted on the stability in fluids of circulating exosomes, it can be confirmed that these nanovesicles have the ability of targeting to uptake to hinder or delay tumour development.   With the size of the exosomes ranging from 40 100 nm, they are distinguished for tumour microenvironment.   Exosomes, a potential biomarker, for the early detection of PDAC, are also being studied as potential nanocarriers to target cancer cells and delaying tumour growth.1,7,8 The most common nanocarrier being studied is the gold nanoparticle (GNP), due to its imaging, diagnostics, and therapy abilities.   The GNP can be easily synthesized via the citrate reduction, which is why is has potential in medical theranostics.7 Extracellular vesicles (EV), are secreted into extracellular space, they are involved in tumour initiation, progression as well as metastasis.   EVs can be used as non-invasive biomarkers, but the current studied methods are time consuming in regards to EV isolation.1,7,8 The EV membrane markers which are part of the tetraspanin family, are CD9, CD63, and CD81, respectively, and an assay demonstrates similar features.6 A nanoparticle EV assay, will be captured by an EV-specific antibody with the dual binding of EV, using 2 nanoparticle probes.   The 2 nanoparticle probes, will produce a plasmon, promoting an increase in sensitivity and specificity for the discovery of an exosomal biomarker.   Ephrin type A receptor 2 (EphA2), has recently been identified as a biomarker, of the tumour derived pancreatic cell line, and enriched on EV.1   EphA2, shows overexpression, increases in vitro invasiveness and anoikis resistance in pancreatic cancer cell lines.1 A recent study has been conducted with healthy control patients, pancreatitis patients as well as pancreatic cancer patients, with the use of nanoplasmon-enhanced scattering (nPES) assay a fast, sensitive, and specific method in biomarker detection. Convention Tumour Markers in Pancreatic Cancer Carcinoembryonic Antigen CEA CEA, is a glycoprotein, that is measured in a common blood test used for testing patients with cancer, including pancreatic cancer.   This will measure the amount of the CEA protein that is in the blood of a patient who may have cancer, and the CEA levels can be used to determine whether treatment is working or if the cancer is spreading.   A CEA level of 5 ng/mL, is considered a normal level of this protein, but there are several conditions that can alter the levels of the CEA in your blood, which is why this is not a valid biomarker in the detection of pancreatic cancer.5 CEA testing can be useful in regards to recurrent colon cancer as well seeing if treatment is successful.   Levels of CEA can be elevated due to smoking, as well as in other diseases such as Crohns disease.   Due to the unreliability of CEA levels in cancer, this blood test confirms that CEA is not a consistent biomarker for the early detection of pancreatic cancer. CEA is expected to be paired with other biomarkers, for early detection reasons.   When paired with CA19-9, there is an increase in detection for sensitivity and specificity, showing an improvement in diseases including pancreatitis as well as pancreatic pseudocyst.   Despite the improved results for pancreatic diseases, CEA is still not valid for the detection of pancreatic cancer, even when it is paired with another marker such as CA19-9.5 Carbohydrate Antigen CA19-9 Carbohydrate antigen (CA19-9) was discovered in 1981, and is considered a sialyl lewis a (sLea).9 CA19-9 is found on the surface cancer cell, expressed as a glycolipid and an O linked glycoprotein, and is related to the Lewis blood group antigens.3   Patients with Le (alpha beta +) or Le (alpha + beta -) blood group, express levels of CA19-9 in their blood, whereas approximately 5 10% of patients with Le (alpha beta -) blood group do not express CA19-9, limiting the use as a valid biomarker.9 Due to the low, and uncertain sensitivity of CA19-9, it is a poor interpreter of PDAC, therefore it is not a valued biomarker. CA19-9 is unable to differentiate between benign, precursor lesions and malignant conditions in PDAC patients, and it gives elevated results in many other gastrointestinal cancers.3   This blood test can show elevated CA19-9 levels in patients with other non-cancer diseases including pancreatitis and cirrhosis.3,9 The CA19-9 blood test can be beneficial in regards to knowing if a pancreatic tumour is secreting it, and to judge the efficiency of treatment, and look for pancreatic cancer recurrence.   A healthy patient will have a CA19-9 level of 0 37 U/mL, therefore with increasing levels of CA19-9, this could indicate tumour growth.3 For more accurate results, a PDAC marker needs to be discovered and paired with CA19-9, to increase the sensitivity and specificity in early detection.   With CA19-9 as the only marker, studies show it was only elevated in 50 75% of patients having PDAC, confirming that is not consistent as a biomarker and should not be used in diagnostic testing.3,9 Expressing elevated levels in other diseases such as benign jaundice, pancreatitis, and ovarian cancer, confirms the lack of consistency using the CA19-9 marker and that it cannot be used as an accurate indication of early pancreatic cancer detection.3 Emerging Biomarkers With the absence of reliability using the current PDAC biomarker, C19-9, it is a necessity to discover a biomarker with improved sensitivity as well specificity for the early detection of PDAC.   Recent studies suggest, that exosomes can be detected in body fluid such as blood, and they have potential as disease biomarkers.   Exosomes, found in blood plasma, need to be collected from healthy patients to obtain individual and pooled samples.   The collected blood plasma, will need to be separated, by centrifugation, to isolate the exosomes for further proteomic and quantitative studies.8 Isolation Methods Isolation of exosomes using the UC method, involves normal human plasma, and diluting it with PBS.   The sample will be differentially centrifuged, to eradicate cell debris, which is followed by UC.   The subsequent pellet, is washed in PBS, and filtered, and the filtrate was ultracentrifuged.   The resulting exosomal pellet, used for the study, will be resuspended in PBS.8 Using the EI isolation method, the plasma, is diluted in PBS and centrifuged.   The supernant is filtered, and the filtrate will be incubated using a blocking agent.   A microcolumn was placed in magnetic separators, where the column was rinsed with rinsing solution.   Beads were bound to the exosome, and were applied to the magnetic column.   The column will be washed with rinsing solution, and the immune captured exosomes were recovered by removing them from the column and placing them in a collection tube.   The exosome bound microbeads are washed to elute the exosomes, and centrifuged to obtain the exosomal pellet.   The exosomal pellet will be resuspended in PBS.8 Lastly, isolation using DG method, involved the exosomal pellet that was obtained from UC as well as normal blood plasma that was layered on iodixanol solution and centrifuged.   To the top of the tube, there were 12 fractions, with increasing densities.   The fractions are diluted with PBS and centrifuged, the resulting pellet was washed with PBS, centrifuged and resuspended in PBS.8 Western Blot and Microscopic Analyses The western blot method, shows the enrichment of the exosomal marker proteins.   Gel electrophoresis is used to separate and identify the different proteins.   The thickness of the band, indicates the amount of the protein that is present.   There is a labelled antibody, that is bound to the protein of interest.   AFM is used, to get a 3D image of the exosomal vesicle. Recent studies confirma that the exosomal markers CD9 and CD63 are enriched in exosomes purified using UC and EI methods.8 The study indicates that the UC method, had four exosomal markers whereas the EI method had only two exosomal markers, CD9 and CD63.   Transmission electron microscopy (TEM) and atomic force microscopy (AFM), were used on the isolated exomes, from the three exosomal isolation techniques.   In the DG sample, the TEM reported homogeneous vesicle, with diameter ranging from 40 100 nm, confirming the characteristics of exosomes.   The AFM produced a 3D image of the exosome, and after further analysis it was revealed that the exosomes had round membranous vesicle characteristics. LC-MS/MS Liquid chromatography mass spectrometry (LC-MS/MS), is a quantitative method used for the identification of proteins at the peptide level.   The first quadrupole is for the selection of the precursor and the second quadrupole is highly specific for detection.   In comparison to gas chromatography mass spectrometry (GC-MS), LC-MS/MS is not limited to volatile substances, it is better for the detection of molecules.   LC-MS/MS can produce many quantitative results, and has a high specificity and sensitivity. The study was carried out, using an LTQ Orbitrap Velos with a nanoelectrospray interface coupled to an Ultimate 3000 RSLC nanosystem and the LTQ Orbitrap Velos mass spectrometer operates using a nano -ESI spray.   The LC-MS/MS spectra are searched against the human protein database using MASCOT.   Equal amounts of protein from the three exosomal samples were separated, reduced, alkylated and digested with trypsin.   The DG sample had the highest number of protein identifications, followed by the UC isolation method.   Therefore, the western blotting, microscopy and MS results confirm that the DG isolation method is the most effective, in regards to isolating exosomes from blood plasma.8 Targeting with Gold Nanoparticles Malicious Exosomes The exosomes are formed from endosomal pathways, after they are fused from multivesicular bodies (MVBs) with plasma membrane.   The formation of malicious exosomes, also starts in the endosomal pathway.   The early exosome is formed from the migration from the cell periphery to the nucleus, by the formation of intraluminal vesicles (ILV).   The process interceded by exosomal complexes required for transport (ESCRT) and other proteins.   Late exosomes/ MVB, migrate to the periphery and fuse with the membrane, releasing the ILV, which are called exosomes.   The proteins, Rab GTPases, mediate the endosome migration.7 The malicious exosomes, are released from cancer cells found in the tumour microenvironment.   Exosomes play a role in variation and shaping of that tumour microenvironment.1,2,4,6,8 Malicious exosomes have potential as biomarkers, due to their stability in biological fluids including blood plasma.   There have been increased levels of circulating exosomes seen in several cancers including pancreatic cancer.1,6,7,8 Nanovesicles can be used to carry therapeutics, and have potential to limit cancer progression.1,7 The method consists of inhibiting the malicious exosomes biogenesis. Gold Nanoparticles The GNPs can be easily synthesised, as well they consist of a variety of shapes and sizes.   These nanoparticles exhibit intense light absorption and scattering, and they are deemed to be highly stable.1,7   They have potential in targeting, therapeutics as well as diagnostic capabilities. Regarding rapid tumour growth, a compressed lymphatic vessel will collapse causing lymph drainage, which will then allow for the nanosized molecule to be taken at the tumour site.7 This process will allow for passive targeting with nanosized molecules.   The cellular interest will be dependent upon the size and shape of the GNP.1,7 The tumour cells will overexpress their cell number receptors, which can be used for potential biomarkers.1,2,4,6,7,8 These cell surface receptors, will aid in the direction of the GNP to the tumour cells. Gold Nanoparticle Targeting The GNP will target malicious exosomes, by undertaking the malicious exosomes biogenesis with GNP specific targeting moieties as well as silencing moieties.7   Using antibodies to aim at the exosome for capture and selective retention.   Lateral flow immunoassay, will aid in exosome detection with CD9 and CD81 as antibodies, and CD63 with GNP.1,7 Therefore, GNP are being studied as a potential candidate for cancer therapy as well as for malicious exosome targeting.   The use of nanotheranostics to help quantify and inhibit the malicious exosomes. Sample Collection and Processing This recent study, developed a method for the purification of exosomes in blood plasma, as well as finding the EV concentrations in the plasma samples.   A three-probe EV capture was used, with a capture antibody that recognizes an EV membrane protein (anti-CD81), with antibody conjugated AuS and AuR to serve as two EV probes.   This EV capture was designed to form a plasmon, with the different GNP binding on an EV to improve sensitivity and specificity of EV detection.1   The study examined 59 pancreatic cancer patients, 48 pancreatitis patients, and 48 control patients, to see if early pancreatic cancer stage could be distinguished from pancreatitis patients and the control patients.1 Method The EV isolation consisted of cells grown in culture media, and washed with PBS.   The culture supernatants were collected and centrifuged to pellet cells, and centrifuged again to remove cell debris.   Concentrated with centrifugal filtering units, and centrifuged, the precipitates were collected and resuspended in PBS and centrifuged.   The resulting precipitates were collected and dissolved in PBS.   The ELISA assay, consisted of ninety-six well plates, which were incubated with antibody CD81.   The ELISA assay was analysed for absorbance, and the standard curve plotted the light absorbance versus the log10 EV standard concentration in pg/uL.1 The peptides were separated using Ultimate 3000 nano-LC, with an enrichment column as well as an analytical column.   The peptide fractions were analysed with Velos Dual-Pressure Linear Ion Trap mass spectrometer, and one MS scan, was followed by eight MS/MS scans. The nPES platform was constructed by filling sample wells with plasma sample or cell culture EV samples, followed by incubation and being washed three times with PBST and three times with PBS.   The sample wells were then filled with AuS and AuR PBST solution, and were incubated and washed three times each with PBST and PBS, respectively.   The sample wells were fitted with a cover slip and dark-field microscopy (DFM) was used for imaging.   The DFM images, that had image areas with brightness equal to 225 were selected, and the ratio of the image area to the whole image gave area ratios that were indicative to the nPES EV signal.1 A standard concentration curve was generated with a linear regression of nPES area ratio with log10 concentrations.1 SEM images analysed the images of GNP binding to EV, from EVs that were purified from human plasma.   The purified EVs were hybridized with anti-CD63-AuS and anti-CD9-AuR.   The SEM fields were analysed to calculate the total EVs, as well as the number of GNP-bound EVs per um2 of each assay. Proteomics and the Early Detection of PC An nPES was previously designed, for EV detection using GNP, that can scatter light at different wavelengths indicative to their shape and size.   Using both gold nanospheres (AuS) as well as gold nanorods (AuR), a plasmon is formed, increasing the scattering intensity.   With the plasmon, antibodies against CD9, CD81, and CD63 can capture and detect EV in a sample.1,7   AuS and AuR are detectable using dark field microscopy (DFM), and will form the complexes AuS-EV-AuR, AuS-EV and AuR-EV.   These complexes can be analysed using scanning electronic microscopy (SEM), examining the binding and distribution.   Following the pure preparation of EV samples, EV plasma was added to give the EV plasma standard.   The anti CD81 was incubated with the standard and two antibodies conjugated GNPs, AuS-Anti-CD63 and AuR-Anti-CD9, which exhibited ratios >0.35%.   A comparison was done with nPES and enzyme linked immunosorbent assay (ELISA), of the sensitivity and linearity of thei r EV values.   The nPES assays showed to be highly sensitive, requiring less plasma as well has exhibiting more advantages over ELISA in regards to measuring EV concentrations.1 Since CA19-9 is the only accepted pancreatic cancer marker that is not valid, pancreatic cancer derived EV marker is a more feasible biomarker due to the multiple factors that the pancreatic cancer cells express.   The nPES assay will quantitate tumour derived EV from blood samples, and one of the two EV specific GNP were replaced with one specific for the membrane protein.   LC-MS/MS proteomics, bioinformatics is used to identify trans-membrane proteins on EV PC (PANC-1 and MIAPaCa-2) and PDAC (BxPC-3).1 There were 128 membrane proteins identified, and 26 were expressed on EV.   The EphA2 showed the highest expression and is associated with cancer progression, metastasis, and prognosis.   The EphA2, was also not expressed by EV in HPNE. EphA2 was chosen as the potential marker, and CD81 and CD9 were chosen for EV capture.   The nPES was modified, using one capture antibody (anti-CD81) and two antibody-conjugated GNP probes (anti-EphA2-AuS and anti-CD9-AuR).1 The plasma EphA2-EV levels were higher in pancreatic cancer patients, in comparison to pancreatitis patients and the normal control (NC).   With the strong association between the circulating EphA2-EV and early stage pancreatic cancer, there is potential for EphA2-EV to be used as an early detection marker.1   The CA19-9 levels were increased in the pancreatic cancer patients in comparison to the pancreatitis patients and the NC, but the levels were not increased in the early stages of PC.   The receiver operating characteristic (ROC) curves, showed that the plasma EphA2-EV levels are promising in the classification of pancreatic cancer stages. The current EV analysis methods are tedious and lengthy for the isolation procedures, as will having volume requirements.   The nPES platform that has been studied, assimilates EV capture and detection with the use of the plasmon coupling effect, to have an increase in both detection sensitivity and specificity in small volume samples and fast sensitive biomarker quantification.   This EV nPES platform, can be generalizable for any disease state that has a specific EV marker.1  Ã‚   The nPES EphA2-EV blood assay shows substantial value regarding pancreatic cancer screening tests, due to being a rapid, accurate and non-invasive blood test for the early diagnosis of pancreatic cancer. Conclusions This review article explains the need to find a valid biomarker in the early detection of pancreatic cancer, as well as discussing how exosomes have potential to be that marker in the early detection process.1,2,4,6,7,8   The existing biomarkers for pancreatic cancer, are not valid markers in the early detection due to the lack of sensitivity and specificity that they exhibit when differentiating between benign and malignant stages.   The use of exosomes for the early detection of pancreatic cancer, shows potential as a biomarker, with the use of nPES platform.1 The platform allows for EV capture using plasmon coupling, which increases in detection sensitivity and specificity, which allows for the discovery of an ultrasensitive biomarker.   The nPES EphA2-EV assay could differentiate between pancreatic cancer patients (stage I and II) and pancreatitis and NC patients.1 The role of EphA2-EV, could help to improve early detection rates as well as improving patient outcome, and th is blood test is inexpensive, accurate and non-invasive.   This review involved proteomic and quantitative methods, to find a novel biomarker for the early detection of pancreatic cancer, and non-invasive nPES EphA2-EV analysis can aid in improving early pancreatic cancer detection and treatment. References Liang, K.; Liu, F.; Fan, J.; Sun, D.; Liu, C.; Lyon, C. J.; Bernard, D. W.; Li, Y.; Yokoi, K.; Katz, M. H.; Koay, E. J.; Zhao, Z.; Hu, Y. Nature Biomedical Engineering 2017, 1 (0021). Duxbury, M. S.; Ito, H.; Zinner, M. J.; Ashley, S. W.; Whang, E. E. Biochemical and Biophysical Research Communications 2004, 320 (4), 1096-1102. Jazieh, K. A.; Foote, M. B.; Diaz, L. A. Seminars in Radiation Oncology 2014, 24 (2), 67-76. Ansuini, H.; Meola, A.; Gunes, Z.; Paradisi, V.; Pezzanera, M.; Acali, S.; Santini, C.; Luzzago, A.; Mori, F.; Lazzaro, D.; Ciliberto, G.; Nicosia, A.; Monica, N. L.; Vitelli, A. Journal of Oncology 2009, 2009, 1-10. Ballehaninna, U. K.; Chamberlain, R. S. Tumor Biology 2013, 34 (6), 3279-3292. Melo, S. A.; Luecke, L. B.; Kahlert, C.; Fernandez, A. F.; Gammon, S. T.; Kaye, J.; Lebleu, V. S.; Mittendorf, E. A.; Weitz, J.; Rahbari, N.; Reissfelder, C.; Pilarsky, C.; Fraga, M. F.; Piwnica-Worms, D.; Kalluri, R. Nature 2015, 523 (7559), 177-182. Roma-Rodrigues, C.; Raposo, L.; Cabral, R.; Paradinha, F.; Baptista, P.; Fernandes, A. International Journal of Molecular Sciences 2017, 18 (1), 162. Kalra, H.; Adda, C. G.; Liem, M.; Ang, C.-S.; Mechler, A.; Simpson, R. J.; Hulett, M. D.; Mathivanan, S. Proteomics 2013, 13 (22), 3354-3364. Ballehaninna, U. K.; Chamberlain, R. S. Indian Journal of Surgical Oncology 2011, 2 (2), 88-100. Pancreatic Cancer https://www.cancer.org/cancer/pancreatic-cancer.html (accessed Mar 20, 2017). Eldorado by Edgar Allan Poe | Analysis Eldorado by Edgar Allan Poe | Analysis In the poem Eldorado, poet Edgar Allan Poe delivers a fundamental message that can be understood if carefully evaluated. Poe gives the account of a knight in search of a land called Eldorado, which holds riches and fortune. After much futile searching, the knights enthusiastic quest for treasure ends in death. The foremost theme of this poem is the desire for wealth and treasure. This theme is an influence from Poes life and the relevant Gold Rush of 1849 (Coad 60). The literary devices, symbols, relevancy, and personal experiences offer a deeper meaning to the poem than what lies on the surface. Poes skillful use of these elements helps to stress the ignorant desire humans have for wealth and fortune. The poem delivers a reflective moral issue many readers can, in some way or another, relate to. Poe uses the word shadow in each of the four stanzas of the poem, each stanza consisting of six lines. The third line in each stanza is where the use of the word shadow is introduced. Though the word occurs multiple times, it has a different meaning each time. The first shadow represents a literal shadow, a casting shadow of the sun. It could also be interpreted as happiness and sadness. The second shadow represents the shadow that has overcome the knights heart after much unsuccessful searching. The third shadow represents a live figure, possibly his or maybe an angel. And the fourth shadow figuratively refers to Valley of the Shadow (21). The fact the knight has grown old and weak, and must cross Over the Mountains Of the Moon, Down the Valley of the Shadow is seen as a symbol of the knights death, relating to the Biblical valley of death (19-21). Through Poes use of the word shadow and the period in which the poem was written, readers can understand Poes message. Poe uses the shadow in each stanza to convey his message. As the meaning of the shadow changes, so do readers emotional state. As he begins the first stanza, readers see a happy, gaily, bedighted knight who is enthusiastic about going on his search for gold. This start gives readers a sense of happiness and jolt of energy. His shadow could also be a foreshadowing of future events. However, Poe begins the second stanza with the word But. This contradictory word signals a shift between the first and second stanza and also a shift in emotion. The knight has become old, disheartened, and dismayed as the shadow is used in context to signal the emotional state of the knight. This signal causes readers to suddenly have a change in emotion; readers become sympathetic towards the knight. Poe continues to elaborate on the disappointment of the knight in stanza three. The knight encounters a live or possibly imaginative figure and asks the shadow where is Eldorado, reflecting on his hopeless jo urney in which he wasted his life. This figure could possibly be an angel providing guidance, an angel of death, or even himself. As the shadow replies to the question in stanza 4, readers are left with the idea that he has come to the end of his life and has died. With the closing of the poem, the audience can relate to the pain the knight feels. In all, the repetitive shadow becomes engraved in the readers mind, helping to sway the emotions. The life of the knight also provides a moral for people to learn. Poes moral in Eldorado is not to seek for riches on earth. The only true riches are the riches one receives after death. The knight in the poem seeks for physical riches for many years without any hope, leaving him disheartened and at the end of his life. When asked where Eldorado could be, the knight was told Down the Valley of the Shadow (21). This insinuation emphasizes the main point that true riches are found in Heaven, not earth, and any riches sought on earth leads to despair and death. As suggested by The Meaning of Poes Eldorado by the John Hopkins University Press, it can be argued Poe portrayed himself as the knight (Coad 60). Poe published his poem in 1849, the same year as his death. Like the knight, Poe had sought after an accomplished life, which he failed to do during his life. He was also unstable in the last years of his life. However, the knight most probably was a reference to the many prospectors of the California Gold Rush, which took place during the time the poem was written. The poem may have been Poes warning to the many prospectors that would experience the same hardships of the knight. Poes repetition of shadow and Eldorado and use of other symbols play an important part in his poem. It helps to further stress his main point. Other such devices Poe uses to communicate to his audience is through auditory and imagery senses. Poe uses aabccb rhyme scheme in the first three stanzas and xxabba rhyme scheme in the fourth stanza of his poem . Poes creatively written stressed and unstressed poem is one way Poe remarkably appeals to the readers auditory and imagery senses. The use of this rhyme scheme creates a thumpity, thump sound when read aloud, bringing the clattering of the horses trot to life. The symbols and rhyme scheme helps to immerse the reader into the scene of the poem and drives them to continue reading until the end. Eldorado is a poem by Edgar Allan Poe that has a stressed message to readers. It tells the story of a knight who traveled for a period of his life searching for a city of gold, Eldorado. It provides a message to all readers that true riches and happiness are only acquired through Heaven after death. If one attempts to search for wealth, in hopes happiness will follow, that person will come to the end of their life saddened and in despair. Poes use of symbols, rhyme scheme, and repetition brings life to his poem, which keeps the readers entertained and helps to convey his message. The poem brings light to the life of everyone and anyone searching for happiness and wealth on earth. Thus, Eldorado is Over the Mountains Of the Moon, Down the Valley of the Shadow, Ride, boldly ride . . . If you seek for Eldorado! (19-24).

Architecture Design, the Royal Ontario Museum

The museum is currently undergoing a major renovation and expansion project, dubbed Renaissance ROM, located at the corner of Bloor Street and Avenue Road, north of Queen’s Park and on the east side of Philosopher’s Walk in the University of Toronto. The centrepiece is the recently-opened Michael Lee-Chin Crystal, designed by architect Daniel Libeskind and Bregman + Hamann Architects; installation of exhibits in the addition will continue over a period of months. Existing galleries and buildings are also being modified. Renovated galleries in the historic buildings will reopen in stages, and all work is scheduled to be completed by 2010. The final cost of the project will be $270 million CAD. The Libeskind design, selected from among 50 entrants in an international competition, saw the award winning Terrace Galleries torn down and replaced with a Deconstructivist crystalline-form clad in 25 percent glass and 75 percent aluminium. The building is named after Michael Lee-Chin, who donated $30 million towards its construction. It houses the new main entrance to the museum, a gift shop, a restaurant (C5 Restaurant and Lounge), a cafeteria (Food Studio), seven additional galleries and Canada’s largest temporary exhibition hall in the lower level. The Crystal’s canted walls do not touch the sides of the existing heritage buildings, save for where pedestrian crossing occurs and to close the envelope between the new form and the existing walls. Although designed to conform to existing height restrictions and maintain sight lines along Bloor Street, the Crystal, at certain points, cantilevers over the setback and into the street allowance. The building’s design is similar to some of Libeskind’s other works, notably the Jewish Museum in Berlin, the London Metropolitan University Graduate Centre, and the Fredric C. Hamilton Building at the Denver Art Museum. The steel framework was manufactured and assembled by Walters Inc. of Hamilton, Ontario. The extruded anodized aluminium cladding was fabricated by Josef Gartner in Germany, the only company in the world that can produce the material. The company also provided the titanium cladding for Frank Gehry’s Guggenheim Museum in Bilbao, Spain.

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Essay about The Call of the Wild Versus Into the Wild

Chris McCandless and Buck serve as examples of the archetype of the wild through their experiences of leaving where they feel most comfortable and answering the call of the wild. They show that each experience is inimitable because the wild is unique to every individual. For Buck, the wild is a place outside of civilization and his dependence on man, where the external threats of nature exist and he must prove himself as a true animal with instincts for survival. In McCandless case, the place outside of civilization is actually an escape from his fears because the wild for him is in relationships, where the threat of intimacy exists and he must learn to trust others for happiness. This is because for each of us, the wild is what we†¦show more content†¦The feelings shared between them were often based on inexplicable natural impulses, characteristic of the relationship between man and beast. He went wild with happiness when Thornton touched him or spoke to him....the str ength of Bucks gaze would draw John Thorntons head around, and he would return the gaze, without speech, his heart shining out of his eyes as Bucks heart shone out (London 75). The connection that the two share is very important in Bucks transformation because it is the last thing he must surrender to complete his transformation and answer the call of the wild. John Thornton, who is unafraid of the wild, is the last thing Buck has that protects him from the hostile environment where only the strong survive (London 86). After Thornton nurses Buck back to life from his brush with starvation, Buck slowly realizes that he is ready to face the wild, where he would find his true self, not as a pet or a sled dog, and most importantly as an animal without a master. It becomes apparent that, Faithfulness and devotion, things born of fire and roof, were his; yet he retained his wildness and wiliness. He was a thing of the wild, come in from the wild to sit by John Thorntons fire, rather than a dog of soft Southland stamped with the marks of generations of civilization (London 76). Buck used Thorntons love as an escape from the wild, and depended on the comfort Thornton provided as a safeShow MoreRelatedCreation : God Vs. Nature1191 Words   |  5 Pagesquestion the explanation of God for why humans, plants, and animals exist the way they do. The work of Darwin and Wallace introduced the idea of the evolutionary theory, which changed the boundaries between humans and nature by driving people to call into question one of the fundamental ideas of the divine creation myth as written in the Bible: that humans were created by God separately from animals. Darwin and Wallace s theory of evolution broke down this boundary between human exceptionalismRead MoreWhat Are Capuchin Monkeys Are Well Known For Their Brains1309 Words   |  6 Pagesthe wild. From their unique fur colorization, their fur is white from head to shoulders while from the shoulders down there color is black. The locomotion that they use to maneuver swinging from tree to tree is by using all four li mbs and for a short period of time they can walk on two legs. Capuchin monkeys are uniquely different and surprisingly very knowledgeable at what they do in order to be able to maintain their survival based on learned and experimental behaviors. Tool Use among Wild Capuchins:Read MoreJack London : An Oyster Pirate1204 Words   |  5 Pagesshared include: his life, evolution, brutality of society, socialism, and adjustment of man against elemental ways of life (Jack London Themes and Messages) 2. Many of his works were based off experiences London had in his lifetime, such as â€Å"Call of the Wild.† London was a serious believer of Charles Darwin’s theory of evolution and the theory of survival of the fittest can be found in everything he wrote. London was also a follower of Karl Marx and his beliefs; many of these views can be seen inRead MoreEssay about Personal Narrative - My Mother, the Hippie775 Words   |  4 Pagescontact with nature that occurs (i.e., mucking around and seeing alligators in the wild). As my mother lives in Alaska, she has only been to Miami to visit me once since I moved here, and unfortunately it was within the first few months that I lived here, so I was unable to adequately provid e her with answers to her inquiries of the local plant and animal life. But now, even after only one day of class, I feel the need to call my mom and tell her all about the plants and animals I saw, and which are nativeRead MoreThe Wolf: Homo Homini Lupus811 Words   |  3 Pagesaddresses the idea that Europeans may be the savages. He says,† It is no lie to say that these men are indeed savages- by our standards; for either they must be or we must be: there is an amazing gulf between their souls and ours†(239). Montaigne calls the cannibals savages, implying that their practice and society are not comparable to those that he is acquainted with. This quotation helps to exemplify that the perception of a culture as barbaric or animal-like is dependent on the individual’s perspectiveRead MoreEssay on A Study Of Inheritable Traits In Fruit Flies1554 Words   |  7 Pages We collected the data from the crosses and analyzed them in relation to the expected results. MATERIALS AND METHODS For the monohybrid cross in this experiment, we used an F1 generation, which resulted from the mating of a male homozygous wild-type eyed fly with a female homozygous sepia eyed fly. Males and females are distinguished by differences in body shape and size. Males have a darker and rounder abdomen in comparison to females, which are more pointed. Another difference occursRead MoreA Study of Inheritable Traits in Fruit Flies1698 Words   |  7 Pagesthe next. We collected the data from the crosses and analyzed them in relation to the expected results. MATERIALS AND METHODS For the monohybrid cross in this experiment, we used an F1 generation, which resulted from the mating of a male homozygous wild-type eyed fly with a female homozygous sepia eyed fly. Males and females are distinguished by differences in body shape and size. Males have a darker and rounder abdomen in comparison to females, which are more pointed. Another difference occursRead MoreWhy Humans Develop Their Psychological Attributes Based On Genetics ( Nature ) Or Their Environment1085 Words   |  5 Pagesferal child was raised by wild animals such as Victor, the wild boy of Aveyron it is inevitable for the child s nurture to be superior to that of its nature(The development of children, 7th edition, Lightfoot, and Cole).Feral children are considered a debate between nature and nurture because the child recovered from the wild, mimics the environment and the characteristics of the wild animal that raised the child while applying the wisdom it gained surviving in the wild, lacking social intelligenceRead MoreResearch Paper On Trading Volume1034 Words   |  5 Pagesmore capitalization and better fundamentals overall (but not always!). The majority of the penny stocks do not trade on the big exchanges. Instead, they trade in what I like to call Wild West of the stock market. The Wild West consists of the bulletin boards (OTCBB) and the pink sheets. While the OTCBB is part of the WIld West, it is a tamer portion. Most people dont realize but the OTCBB is actually owned by the NASDEQ and they do have rules and requirements for listing. Where you get the mostRead More Henrik Ibsen Essay2054 Words   |  9 Pages In the plays Ghosts, An Enemy of the People, and Wild ducks by Henrik Ibsen there are many similar themes, which become evident to the reader. A theme, which is consistant though out these plays, is the opposing values of the Ideal and the Real. The views of the idealist versus the realists make for many duels between the two personalities. The theme of idealism versus realism is also dealt with in the play The Wild Duck. Gregers Werle has avoided his father, whom he detests, by spending fifteen

Compare and Contrast Ethics and Virtue Theory - 802 Words

Ethics and virtue have been a very contentious issue facing society for centuries. Many argue over the merits of various theories, each with its own philosophies and assumptions. It is this argument that has given rise to many popular and followed theories of ethics and virtues. The theories discussed primarily in this document include the virtue theory, utilitarianism, and deontological theory. Each is very distinct to the others in regards to its principles and assumptions regarding human behavior. Each however, has merit in regards to question of ethics and virtue, and how it should subsequently be valued. Virtue Theory relies heavily on the character of the person rather than the circumstances in which the individual acts. The virtue theory deemphasizes rules and regulations and instead focuses on the internal character of the act in question. The virtue theory is not concerned with the intentions of the act. Nor is it concerned primarily with the consequences of the act. Instead the virtue theory relies on moral virtues. If the individual is of good character or not is the primary concern with virtue theory. What is difficult to ascertain however, is the question of what constitutes character? How can one appropriate establish the contents of ones character? A persons character traits are the compesition of his character traits. These traits can either be good (virtuous) or bad (vices). In both instances, the virtue theory establishes and emphasized these twoShow MoreRelatedThe Ethics Of Virtue Ethics925 Words   |  4 PagesVirtue ethics is a normative theory whose foundations were laid by Aristotle. This theory approaches normative ethics in substantially different ways than consequentialist and deontological theories. In this essay, I will contrast and compare virtue ethics to utilitarianism, ethical egoism, and Kantianism to demonstrate these differences. There is one fundamental aspect of virtue ethics that sets it apart from the other theories I will discuss. For the sake of brevity and to avoid redundancy, I willRead MoreEthics : Virtue Ethics And Ethics1351 Words   |  6 Pages 1. what is virtue ethics and what does it do that the two major ethical approaches do not? Virtue ethics is one of the three major approaches in ethics. This approach of ethics emphasizes the virtues, or moral character, in contrast to other approaches which emphasizes duties or rules. Virtue ethics has three central concepts; virtue, practical wisdom, and eudemonia, however, these are often misunderstood. The three approaches of ethics are virtue ethics, consequentialist ethics, and deontologyRead More7 Philosophies Essay1449 Words   |  6 Pages| The Seven Moral Philosophies | Compare and Contrast Research Paper | | Terence A. Betts | 3/27/2011 | Instructor: Kimber Cramer Davenport University | The textbook breaks down seven philosophies used in business decisions; they are Teleology, Egoism, Utilitarianism, Deontology, Relativist, Virtue ethics, and Justice. In this paper I will define each of the seven listed and compare and contrast so that it is clear to decipher each one from the other. Also I will provide anRead MoreAldo Leopold’S Essay â€Å"The Land Ethic† Was Published In1122 Words   |  5 PagesAldo Leopold’s essay â€Å"The Land Ethic† was published in A Sand County Almanac. The short paper confronts the imperfections in the most common approaches in preserving the environment. Leopold’s answer is to develop a new branch of environmental ethics to model humanity’s ever-changing relationship with the environment. Leopold observantly describes the history of ethics, the meaning of community with the land and why it’s appropriate to do so. Toward the end of the essay – as the reader is ready forRead MorePsyc hological and Ethical Egoism, Mill vs Kant, and Ethical Relativism904 Words   |  4 PagesTopic 1 Distinguish between psychological and ethical egoism and subject each to critical scrutiny in detail. Compare and contrast ethical egoism with virtue theory. Egoism is a view that states that what a person wants is somewhat relevant to what humans actually do. There is two main types of egoism: psychological and ethical. These two views are very similar; because of this they can easily be interchanged. It is important to be able to recognize the dissimilarity of these two views. PsychologicalRead MoreWhat Makes A Good Person?933 Words   |  4 Pagesperson you think you are and the person you’re aspired to be. This is the main element of virtue ethics. Virtue ethics focuses on specific qualities that make a good person. Also, what thrives and contributed to lead a successful life. Compared to utilitarian, virtue ethics doesn’t need any type of rules or formulas to deciding what qualities are virtues and vices. It states in Ethical Argument, â€Å"†¦virtue ethics tend to play down the importance of principles and stress the nature of the person whoRead MoreMy Personal And Professional Ethics Essay1087 Words   |  5 Pageson biomedical ethics. There are morals that have been engrained into my character. These include what is right or wrong and how I will behave in certain situations. I will compare my personal and professional ethics in order to be ready for my healthcare career. My personal ethics are deeply implemented into my professional ethics. This could make conflicts arise between my professional workplace and personal ethical view because of differing perspectives on issues. My personal ethics govern how IRea d MorePositve Psychology and Aristotles Virtue Ethics Converge Essay1569 Words   |  7 Pageswell as, eudemonic happiness, as key components to optimal mental health. Like many other contemporary theories, positive psychology borrows principles and tenets of philosophies, which preceded its formal conception. The purpose of this paper is to compare and contrast virtue, character strengths, relationships, and happiness as presented by positive psychology with Aristotle’s virtue ethics theory. Positive psychology utilizes five pillars in order to flourish, achieve fulfillment, and satisfactionRead MoreConsequentialism And Consequentialism : Virtue Ethics, Consequentialism, And Deontology1200 Words   |  5 PagesEthics is a study dealing with standards that prescribe rules on what people ought to do based on various criteria such as obligation, human rights, and virtue. More precisely, it is a development and establishment of one’s moral principle. And under the normative ethics, there are three categories of ethical frameworks: virtue ethics, consequentialism, and deontology. In this essay, I will more concentrate on consequentialism, especially utilitarianism, and deontology to make compare and contrastRead MoreParameters of Ethical Decision Making1342 Words   |  6 Pagesdecision making, we are better equipped to make the right choices when the need arises. Joseph Weiss (2009) identifies fundamental ethical principles that guide decision making: utilitarianis m, universalism, rights, justice, and ethical virtue. John Rawls contributes his Theory of Justice as Fairness as another approach for consideration in resolving ethical dilemmas. Utilitarianism The utilitarian view states that an action is considered right or good based on its consequences (2009). The utilitarian

The Prodigal God Younger Brother vs. Older Brother Free Essays

Writing II-1st Younger Brother Sin vs. Older Brother Sin Luke 15:11-32 is one of the most famous parables in the Bible. It is the parable of the prodigal son. We will write a custom essay sample on The Prodigal God: Younger Brother vs. Older Brother or any similar topic only for you Order Now This parable is about a son who runs away with his inheritance, wastes all of it, and then comes back home to his father’s open arms. Tim Keller goes more in depth into this parable with his book The Prodigal God. In this book, Keller compares the two sons’ sins, â€Å"two brothers, each of whom represents a different way to be alienated from God, and a different way to seek acceptance into the Kingdom of heaven† (9). Throughout the book, comparisons can be made between the younger brother’s sin and the older brother’s sin. The younger brother was selfish and wanted his inheritance immediately so that he can go party. The older brother follows all of the rules to get things and doesn’t want his brother to come back. Throughout The Prodigal God, comparison can made between the two brothers’ sin in that both of their intentions are selfish and they both want control. Tim Keller’s book is more than just discussing the parable of the prodigal son. While the tradition seems to focus more on the younger brother and his sins, Keller goes more depth with the older brother and his faults, â€Å"Most readings of this parable have concentrated on the flight and return of the younger brother-the ‘Prodigal Son. ’ That misses the real message of the story, however, because there are two brothers, each of whom represents a different way to be alienated from God, and a different way to seek acceptance into the Kingdom of heaven† (9). The first way that the older brother and the younger brother’s sins are similar is that both of their intentions are selfish. With the younger brother, he wanted his inheritance early so he could go and party. â€Å"The young man humiliates his family and lives a self-indulgent, dissolute life. He is totally out of control. He is alienated from his father. † (39) This behavior showed he wanted freedom for himself and that he was impatient. Keller goes on to say that the younger brother thought of his relationship with his father as unimportant and he only wanted him for his possessions. He says that once he got tired of the relationship, he basically said that he was tired of it and he wanted out. Even though the older brother is different, his sins are still of the same context. He obeys all of his father’s rules so that he appears to be a good son, yet he is only doing these things to take advantage of his father so that he can get what he wants. â€Å"Elder brothers obey God to get things. They don’t obey God to get God himself- in order to resemble him, love him, know him, and delight in him. So religious and moral people can be avoiding Jesus as Savior and Lord as much as younger brothers say they don’t believe in God and define right and wrong for themselves† (49). The second way in which the younger brothers and the older brother’s sins are similar is that they both want control. â€Å"There are two ways to be your own Savior and Lord. One is by breaking all the moral laws and setting your own course, and one is by keeping all the moral laws and being very, very good. † (50) Both brothers sought to control the father. The younger brother wants the inheritance to have control over his own life. â€Å"He wanted to make his own decisions and have unfettered control of his portion of wealth. (41) The younger brother felt he could handle is life without any help, but he needed earthly treasures so that he could feel powerful. The older brother is keeping all of the rules so that he can get his way with his father. â€Å"Elder brothers do good to others, but not out of delight in deeds themselves, or for the love of the people or the pleasure of God† (70). The older brother feels his obedience should keep his father obligated t o him. When his father offers the younger brother forgiveness and a feast, the older brother is angry because he has lost control over his father. The obedience the older brother kept for so many years seems to be futile. â€Å"It is impossible to forgive someone if you feel superior to him or her. †(63) When looked at more closely, the younger brother and older brother show an unexpected similarity in their sins throughout the parable of the prodigal son. Keller states in his book The Prodigal God that the goal of this book is to lay the essentials of the gospel, and to either introduce or reassure the message of both this story and the gospel. This parable is thought of as one of the best readings in the Bible to help someone grasp the understanding of God’s love. How to cite The Prodigal God: Younger Brother vs. Older Brother, Papers

Law and Leadership in Nursing Samples †MyAssignmenthelp.com

Question: Discuss about the Law and Leadership in Nursing. Answer: Introduction In the field ofnursing and care to a patient, several factors affect the decision and judgement of various clinical cases. Such decisions and judgements are very important as they determine the next course of action. The fact that a human life depends on the very decision, calls for great precision and most sound judgement to make the right moves. Professional nurses are trained on how to go about this including various leadership theories that have been established. Even with this, however, nurses are sometimes faced with cases that are new in both magnitude and direction, and their decision needed. In such cases, nurses must be careful and sometimes fast. The factors affecting decision made by Kevin and Daisy, advise to their case and justification for the advice in accordance with the leadership theories are discussed next. Factors Affecting The Decision Made By Kevin And Daisy There are several factors that affect the decision made by Kevin and Daisy. These include: Familiarity This implies how conversant the two are with the work environment. The duo are students and have not been in this environment before and as such its overwhelming for them. They have only learnt in class but have not had an opportunity to practise what theyve learnt. Familiarity may also to imply the case in question. Its true to say that they have not dealt with such a case as Mr. Smiths. this affects their decision making. Uniqueness The uniqueness of the case also affects the decision made by Kevin and Daisy. Every patient presents with their own unique set of signs and symptoms. No two patients are likely to present with exactly similar signs and symptoms. This ultimately influences their decision as they must judge each clinical case as presented. This seems a hard task especially to these novice nurses. It can be concluded that since each case is unique, the decisions made will vary depending on the different situations and cases. Certainty This implies to the extent of the knowledge that Daisy and Kevin have in relation to various clinical cases. Presence of guidelines may influence the amount of information that these two have. If they are well certain about the diagnosis that can be arrived at using such a set of symptoms, then their decision-making process easier and simplified. On the other hand, if they are not certain about such signs and symptoms, then they are likely to have a hard time arriving at the decision. Either way, the information owned by the duo and their certainty influences the decision that they make. Urgency The urgency with which diagnosis and management of the patient is needed also influences the decision made by the nurse. In this case, Kevin and Daisy are the nurses and Mr Smith is the patient. The patient is sitting, and despite saying that he is feeling unwell, the two students, it seems, judges the case as not urgent. The time available may be limited and in such cases, quick decision making and interventions are necessary and vital. In other cases, investigation requires more time and the decision is consequently delayed. The duo, Kevin and Daisy, have also in mind the advice of Mr. Henry that its good to take their tea on time. This inevitably affects the decision they make since they tell the patient that they will take a tea break and be back after 20 minutes. Advise To Kevin And Daisy First, they need to understand that they will meet different cases and that each decision thy make will depend on several factors as discussed above. They will require to have a great wealth of information as pertains to clinical cases. This will assist them exude the necessary confidence during their work. This is important also in reassuring the patient of their wellbeing. Kevin and Daisy also need to understand that their own initiative will be needed in several cases. For instance, though their head would prefer them to have their tea on time, they should be able to judge the best time to do that sometimes depending on the situation and the working environment. Kevin and Daisy should also maintain high professional standards and show understanding of emotional intelligence, moral courage and professional indemnity. These are the guiding blocks that teach them to do what is in their hands and to ask for help in cases where they have challenges. Upholding high levels of honesty and hard work in their practice is also necessary in ensuring that they can effectively perform their obligation. Justification For The Advice About Various Leadership Theories Giltinane, (2013) leadership theories form a framework of decision making. The theories give informed choices about the various ways people should respond to critical and complex situations. Different theories give different perspectives of what people should do when making complex decisions or assuming leadership roles. The great man theory emphasizes the statement that the history of the world is made by the biography of great men. This emphasizes that, people who make good choices in life always form the pattern of how things ought to be carried out. In relation to the case of Daisy and Kevin, they should seek advice from colleagues who are experienced in the work and outstanding personnel in the field to be more productive in the unit. Trait leadership theory according to Carayon, (2016) observes that peoples outstanding personal characteristics may foster a leadership that is directed on the right direction. Leaders should therefore try to put emphasis on developing important traits that help them to lead positively. Borrowing of important traits from others also directs leaders to make informed decisions. This brings about the focus on integrity and honesty in the operations that Daisy and Kevin need to undertake. Situational leadership puts emphasis on the fact that leadership varies from the situation at hand to the level of readiness or the competence of leaders in the task. This really explains why the two should observe professional indemnity despite the shortage of workforce in the unit, the two should only engage in fields they are competent in. Strategies That Daisy And Kevin Can Use To Help Them Improve Their Abilities To Perform Effectively As A Leader During Placement And Their Careers Have a multi-dimensional knowledge base This would go a long way in assisting them become better decision makers and consequently better leaders too. This is because, they would be able to put into consideration all the important factors before deciding or arriving at a judgement. Improving their cognitive capabilities This will assist the two develop vital skills such as recalling what they have learnt, there precision will be greatly improved, and their analysis and diagnosis of different cases and situations is likely to improve by a great deal. Improve their emotional capabilities This implies: Awareness of emotions and when they are impacting on decision making, particularly awareness of self-efficacy. Capability to deal with problematic emotions to make difficult decisions required for patient management. Motivation to learn and improve quality of decision making in the face of potentially conflicting emotions that impact on decision. References Carayon, P. (Ed.). (2016).Handbook of human factors and ergonomics in health care and patient safety. CRC Press. Giltinane, C. L. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39 Kouzes, J., Posner, B. (2011). Leadership begins with an inner journey. Leader to Leader, 2011(60), 22-27.