Research into the history of klinefelters syndrome

Research into the history of klinefelters syndrome Many chromosomal abnormalities occur early in development and involve the sex chromosomes. Klinefelters Syndrome falls directly into this category. Klinefelters Syndrome is a genetic condition affecting the male population. The following information observes who discovered Klinefelters Syndrome and when it was first diagnosed. The etiology or genetic and environmental factors of the condition are discussed as well as complete description of the disability and the clear diagnostic criteria. The affects of Klinefelters Syndrome are more recognized in adulthood, when it is typically diagnosed. Many Klinefelters patients live out their entire lives without ever knowing they have the condition. Upon conclusion, there should be an adequate amount of information that will give you, the reader, valuable knowledge into the diagnosis and treatment of Klinefelters Syndrome. History Klinefelters Syndrome was first diagnosed in 1942 at the Massachusetts General Hospital in Boston Massachusetts (Schoenstadt, 2006). Dr. Harry Klinefelter was completing his fellowship at the Massachusetts General Hospital when he was assigned to work with Dr. Fuller Albright, also known as the father of endocrinology (Bock, 1993; Klinefelter Syndrome, 2006). Dr. Klinefelter came to examine nine adult men that had a common set of symptoms during the course of his fellowship (Klinefelter Syndrome, 2006). Dr. Klinefelter organized a case study that involved these nine men and their similarities and was encouraged by Dr. Albright to lead the study (Klinefelter Synrome, 2006). The Journal of Clinical Endocrinology was published in November of 1942 with the completed case study of these nine mens similar qualities, which Dr. Klinefelter identified as Klinefelters Syndrome (Klinefelter Syndrome, 2006). The report written by Dr. Klinefelter on these men described them as having testicular dysgenesis, elevated urinary gonadotropins, eunuchoidism, azoospermia, and gynecomastia, all of which have an effect on the underdeveloped size of the testes, the lack of the amount of testosterone produced by the testes, and infertility (Schoenstadt, 2006; Visootsak Graham, 2006). These adult males also exhibit enlarged breast and sparse facial hair (Schoenstadt, 2006). Two groups found out fourteen years after Dr. Klinefelters original description of the syndrome, that the buccal mucosal cells contained an extra chromatin mass or that the cells were chromatin positive (Klinefelter, 1966). Although the patients were described as having a positive female sex chromatin, Dr. Klinefelter states that the patients are phenotypic males and should never be considered otherwise (Klinefelter, 1996). Fourteen years after Dr. Klinefelter first diagnosed Klinefelters Syndrome, another case study was performed to further understand the characteristics that define the condition (Klinefelter Syndrome, 2006). In 1956, Dr. Joe Hin Tjio and Dr. Albert Lavan took the research further to determine the factors that made those men with Klinefelters Syndrome dissimilar from normal adult males through genetic research (Klinefelter Syndrome, 2006; Schoenstadt, 2006). With the advanced experimental methodology available, Dr. Joe Hin Tjio and Dr. Albert Lavan found that humans had 23 pairs of chromosomes, confirming 46 chromosomes, which prior to this time there was thought to be 48 chromosomes (Bock, 1993; Klinefelter Syndrome, 2006). This clarification by Dr. Tjio and Dr. Lavan is the basic foundation for modern cytogenetics, the study of chromosomes and diseases originating from numerical or structural abnormalities in chromosomes (Klinefelter Syndrome, 2006). Dr. Tjio and Dr. Lavan discovered that men with symptoms of Klinefelters Syndrome had an extra sex chromosome that created the chromosomal arrangement of XXY, which is distinct to the normal male chromosomal arrangement of XY (Klinefelter Syndrome, 2006; Schoenstadt, 2006,). Klinefelter Syndrome was still believed to be an endocrine disorder of unknown etiology at this time (Visootsak Graham, 2006). In 1959, just three years after Dr. Tjio and Dr. Lavan made their historical discoveries, an English researcher by the name of Dr. Patricia Jacobs and her associate Dr. J. A. Strong published a study supplementing earlier studies (Klinefelter Syndrome, 2006; Noble, 2003). Dr. Jacobs and Dr. Strong found the link between the endocrinal disease and the extra X sex chromosome (Noble, 2003). Dr. Jacobs linked forty-seven chromosomes in Klinefelters Syndrome males and determined it to be the X chromosome, which she considered an aneuploidy defined as an unusual number of chromosomes and labeled 47, XXY (Bock, 1993; Klinefelter Syndrome, 2006; Schoenstadt, 2006). The 1970s brought forth a larger examination of males born with Klinefelters Syndrome (Bock, 1993). During this time doctors began screening newborn male babies for the extra chromosome (Bock, 1993; Visootsak Graham, 2006). The most significant of the studies done at this time was sponsored by the National Institute of Child Health and Human Development (NICHD) whom examined over forty thousand infants for this extra chromosome (Bock, 1993; Visootsak Graham, 2006). This study was important for the reason that most studies done prior to the 1970s were biased and primarily done on adult males in mental institutions and the penal system (Visootsak Graham, 2006). At this time is when the prevalence of Klinefelters Syndrome was noticed as frequently as one in five hundred to one in one thousand male newborns (Bock, 1993; Visootsak Graham, 2006). Also observed in this study was the reduction in speech and language abilities as well as decreased reading and spelling achievement (Bock, 1993; Visootsak Graham, 2006). Along with these disabilities, Klinefelters patients are characterized by an increased tendency towards fertility, endocrinal, and psychiatric disorders (Noble, 2003). This study demonstrated that most but not all of these males born with the extra chromosome will have these characteristics, and many demonstrate varying degrees of the characteristics (Bock, 1993; Visootsak Graham, 2006). Based on this research it has been found that the extra X chromosome that causes Klinefelters Syndrome is very common, however, the symptoms and characteristics that are most recognizable are quit uncommon (B ock, 1993). Most males are not diagnosed as having Klinefelters Syndrome until they reach adulthood, and many that have the syndrome are never diagnosed as having this chromosomal defect at all (Bock, 1993). One pediatrician at the University of Colorado Medical School in Denver and the director of the National Institute of Child Health and Human Development (NICHD) during the major screening research referred to these newborn males as not having Klinefelters Syndrome because of the possibility that the characteristics may not develop into a syndrome (Bock, 1993; Visootsak Graham, 2006). Etiology and Genetic Factors Every normal human cell has 46 chromosomes that are made up of 23 pairs (Stewart, 2007). Of these 23 pairs, there are 22 that are exactly the same in both males and females called autosomes (U.S. National Library of Medicine, 2010). The 23rd pair of sex chromosomes is what makes males and females different in that the male will have only one X and Y chromosome whereas the female will have two copies of the X chromosome (Stewart, 2007; U.S. National Library of Medicine, 2010). During the formation of the egg and the sperm, or gametes, the chromosomes are halved through a process called meiosis (Stewart, 2007; The Dorsey, 2009). Cells that carry a single chromosome such as the X or Y chromosome are called haploid cells (The Dorsey, 2009). When the egg and sperm join carrying 23 chromosomes each they create the fertile egg, or zygote, which has two haploid sets of chromosomes (The Dorsey, 2009). Therefore, the baby receives two copies of each chromosome, 46 total chromosomes, just like the parents (Stewart, 2007). The extra X in Klinefelter Syndrome is caused from either nondisjunction or anaphase lag. Nondisjunction occurs when the chromosome pairs do not separate as they are intended in the meiosis I or meiosis II stage (Pineyard Zipf, 2003; Stewart, 2007). When this happens there may be a chromosome pair with 24 chromosomes instead of the 23 chromosomes (Stewart, 2007). If this chromosome pair of 24 joins with an egg or sperm with 23 chromosomes then it results in a karotype with 47 chromosomes (Stewart, 2007). In this case there will be three copies of chromosomes rather than the usual two copies of chromosomes (Stewart, 2007). The sperm or egg may donate the extra X chromosome at conception causing a chromosomal abnormality (Mayo Foundation for Medical Education and Research, 2008; Stewart, 2007). This forms the XXY chromosomal formation, which is diagnosed as Klinefelters Syndrome. At least half of 47, XXY conceptions are spontaneously aborted (Pineyard Zipf, 2003). The chromosomal abnormality is random and not known to be caused by any environmental factors (Genetic Science Learning Center, 2010; Mayo Foundation for Medical Education and Research, 2008; National Institute of Health, 2007). This anomaly happens entirely by chance and is unrelated to family history prior to the male childs birth (Mayo Foundation for Medical Education and Research, 2008). This is to say that the male embryos likelihood of being born with Klinefelters Syndrome is not increased or decreased by what the parent does or does not do (Mayo Foundation for Medical Education and Research, 2008). Klinefelters Syndrome is not affected by race (Chen, 2010). This is a completely random occurrence of the sex chromosomes not successfully separating during the formation of the egg or the sperm (Genetic Science Learning Center, 2010). Once this occurs the extra chromosome is then copied into every cell of the embryo (Genetics Science Learning Center, 2008). There are extremely rare cases when there may be three or four extra X chromosomes in all copies of the cells known as 48,XXXY or 49, XXXXY (Stewart, 2007). The 49, XXXXY mosaic is also known as Fraccaros Syndrome and is the most rare form of Klinefelters Syndrome (Duenas et al., 2007). This rare chromosomal abnormality results in more exaggerated features of Klinefelters Syndrome (Stewart, 2007). There are instances where an extra X chromosome is found in only some of the cells (Stewart, 2007). This can be found as two different chromosomal patterns (Stewart, 2007). One pattern occurs when some cells have 46 chromosomes and some have 47 chromosomes (Stewart, 2007). The other pattern is called the mosaic XXY syndrome, or chromosomal mosaicism, and affects approximately six percent of these cases, with the most rare cases being the 48, XXXY or the 49, XXXXY, or other arrangements of X chromosomes (Stewart, 2007). The mosaic XXY syndrome occurs only after conception from a mistake in cell division (Stewart, 2007). Anaphase lag is a result of a gamete lacking a sex chromosome (Klinefelter, 1966). When this chromosome lags it is not incorporated into the new cell during the mitosis stage (Kinefelter, 1996). Anaphase lag is thought to be a reason for the mosaic variations of Klinefelters Syndrome (Klinefelter, 1966). Although the chromosomal abnormality of 49, XXXXY is considered to be a variant form of Klinefelters Syndrome, it appears to have a very independent, distinct phenotype (Duenas et al., 2007). Males that show the 49, XXXXY chromosomal structure have much more severe clinical features than that of a Klinefelters Syndrome male (Duenas et al., 2007). This is the most rare of the Klinefelters Syndrome variants and has been reported in over one hundred cases with the frequency being approximately 1 in 85,000 newborn males (Duenas et al., 2007). There have been reports of an even more extreme variant of Klinefelters Syndrome mosaic in newborn males (Duenas et al., 2007). This variant is a 47, XXY/48, XXXY/49, XXXXY mosaicism and has only been reported in three cases according to a researcher in Mexico (Duenas et al., 2007). This means that the male newborn would have the whole spectrum of XY variations. Another variant that affects only males is the 46, XX chromosomal variation (Bock, 1993). This condition occurs when individuals have two X chromosomes in each cell, but are male in appearance. These individuals have male external geniltalia. These individuals also have small, undescended testes possibly along with an urethra opening on the underside of the penis. A small amount of 46, XX Males have external geniltalia that dont clearly resemble either male or female genitalia. These individuals are typically raised male. Phenotypically, there are three groups of these sex-reversed individuals. The first group includes phenotypically normal XX Males, the second group includes the males with genital ambiguities, and the third group is the true hermaphrodites (Bock, 1993). Description of Characteristics or Traits Klinefelters Syndrome has only one constant physical description and that is the small testicular size (Visootsak Graham, 2003). Boys with Klinefelters Syndrome have variable phenotypic characteristics with no obvious facial dysmorphology (Visootsak Graham, 2003). The presence of gynconemastia, or enlarged breast, and other findings of eunuchoid body habits and sparse body hair vary (Visootsak Graham, 2003). Eunuchoid or eunuchoidism is defined as an abnormal condition in males, characterized by underdeveloped reproductive organs with some female characteristics, such as a higher voice or the lack of facial and body hair that results in the lack of male sex hormones (Eunuchoidism, n.d.). Gonadotropins are produced by glands, such as the pituitary, and can result in sparse body hair when not produced adequately (Gonadotropin, 2010). The medical dictionary states that eunuchoidism is marked by a deficiency of sexual development with the persistence of prepubertal characteristics, and often has the presence of characteristics that are typical of the opposite sex (Eunuchoidism, n.d.). Another likely characteristic is azoospermia (Schoenstadt, 2006; Visootsak Graham, 2006). Azoospermia is defined as having little or no sperm count (Azoospermia, 2010). Testicular dysgenesis, or gonadal dysgenesis, is another characteristic of Klinefelters Syndrome (Schoenstadt, 2006; Visootsak Graham, 2006). Testicular dysgenesis is considered a reproductive system developmental disorder that causes a progressive loss of primordial germ cells, or cells that create gametes, in the developing gonads of an embryo (Gonadal dysgenesis, 2010). This gonadal dysgenesis can lead to the extremely hypoplastic, or underdeveloped, and disfunctioning gonads mainly composed of fibrous tissues (Gonadal dysgenesis, 2010). Most infants and children with the 47, XXXY chromosomal abnormalities go through normal growth stages. It is not until puberty that the Klinefelters Syndrome characteristics or traits become more prevalent and noticeable (Visootsak Graham, 2003). There is a significant increase in height between the ages of five and eight (Visootsak Graham, 2003). Another characteristic of Klinefelters Syndrome is the elongated length of arms and legs (Klinefelter, 1966). There is a decrease in androgen production that causes the secondary sexual characteristics to not fully develop (Visootsak Graham, 2003). An androgen is any substance such as androsterone or testosterone that supports male characteristics (Androgen, n.d.). Typically Klinefelters males are infertile (Visootsak Graham, 2003). However, there have been cases of impregnation without the assistance of medical technology (Visootsak Graham, 2003). Autoimmune diseases such as juvenile arthritis can also be present in Klinefelters adolescents. Whereas boys with Klinefelters Syndrome are generally tall with long limbs and remain thin until puberty, they tend to suffer from obesity latter in life. Neurocognitive effects of Klinefelters Syndrome may be more subtle than that of the physical stigmata. Klinefelters males have been found to have relative deficits on verbal IQ subtests and have verbal IQ scores around 20 points lower than those of unaffected siblings. There are also deficits in articulation, word finding, phonemic processing, verbal memory, language comprehension, oral expression problems, as well as linguistic processing speed. It seems that the speech/language problems and some motor deficits are most common in Klinefelters males that have an extra X chromosome. Ninety-two percent of individuals with Klinefelters Syndrome confirm difficulty learning to read. Seventy percent had reading achievement discrepancies or absolute reading deficits on standardized testing. A group of boys with mental retardation and suspicion of fragile X were subject to a genetic screening and the results showed that eight of these boys had Klinefelters Syndrome. Most of the more extreme verbal, visuospatial, and motor skills, such as found in mental retardation and fragile X syndrome are typically spa red. However, some boys with Klinefelters Syndrome suffer from poor manual dexterity and are commonly found to be clumsy and below average in sports (Wodrich Tarbox, 2008). There are many different factors that may underlie linguistic and reading problems. One possibility is a dysfunction of the left hemisphere that may be related to diminished gray matter or a lack of hemispheric asymmetry, or both. It is also possible that executive and frontal deficits may be a cause (Wodrich Tarbox). There is evidence that language is a fundamental issue for Klinefelters children and this can result in further scholastic issues. This problem seems to manifest as dyslexia as defined by poor reading in the setting of normal intelligence. Klinefelters males have also been observed to have difficulties with arithmetical functions. The deficits in auditory processing and verbal memory are the two key cognitive processes that underlie these difficulties. These deficits are also true for normal chromosomal children with dyslexia. The findings are supportive of the concept that defects in frontal systems seem to be caused by a language-based, left frontal-systems problem (Geschwind Dykens, 2004). Adult Klinefelters males have reported to have difficulties with mental flexibility (Wodrich Dykens, 2004). Even with these studies, it should be noted that not all adults that have Klinefelters Syndrome show these classic patterns of verbal deficits that are observed in children (Geschwind Dykens, 2004). However, these findings are not appropriate for all Klinefelters males, many of which complete high school and move on to post-secondary education successfully (Wodrich Tarbox, 2008). Two characteristics that has been falsely associated with Klinefelters males in the past, is sociopathy and criminal behavior. There is, contrary to this belief, fewer psychiatric problems reported among these individuals. However, there are commonly traits of introversion, unassertiveness, and a paucity or lack of ambition. There are also possible traits of impulsivity and social inappropriateness (Wodrich Tarbox, 2008). A Reiss Profile of Fundamental Goals measurement was used to assess the degrees of which Klinefelters males were motivated in 15 domains (Geschwind Dykens, 2004). The Reiss Profile generates a profile that is based on the motivational sensitivities across the domains of aversive sensations, citizenship, family, curiosity, honor, independence, food, order, physical exercise, rejection, power, sex, social contact, vengeance, and social prestige. The Reiss Profile is a well-established psychometric measure that is being used more and more to assess people with and without mental retardation (Geschwind Dykes, 2004). The results suggested that the Klinefelters male group was not particularly motivated by the need for social prestige, independence, or the desire to seek vengeance. This group was also not motivated to avoid physical pain. The general motivator for all the Klinefelters males in this group was curiosity. There were no age effects to this study (Geschwind Dykes, 2004). Characteristics in Adulthood There is a persistent deficiency of androgen in adulthood that can result in the loss of libido, decreased muscle bulk and tone, decreased bone density, a propensity for thromboembolism (an obstruction in a vein or artery from a blood clot), and an increased risk of mortality from cardiovascular and diabetic complications. A common characteristic for Klinefelters adults is gynecomastia (Wattendorf Muenke, 2005). Gynecomastia involves the risk of developing breast carcinoma. There is 200 times more of a risk for Klinefelters males to develop breast carcinoma than other karyotypically normal individuals. This may be a result of the estradiol (the prominant sex hormone in females) to testosterone ratio being so much higher that karyotypically normal men. Another possibility is that it is caused by the increase of peripheral conversion of testosterone to estradiol (Visootsak Graham, 2006). There are different views as to whether Klinefelters adult males are more aggressive or have a greater chance of psychological issues depending on the resource. One study describes the differences as relative to individual testosterone levels and the age at which they received the diagnosis (Morris, Jackson, Hancock, 2009). Equally, there is an impact from the way the diagnosis is reacted to by the Klinefelters male, the family, and friends or peers. The seven major themes that emerged from this study were the diagnosis, the testosterone treatments, health care problems, appearance, self-identity, relationships, and school and education. Of the Klinefelters adults studied, 60 % reported clinical levels of anxiety and 34% had clinical levels of depression. The results of this study show that a prolonged lack of testosterone can have far reaching negative effects on the Klinefelters adult (Morris, Jackson, Hancock, 2009). The historical studies show a disturbingly increased risk for psychiatric disturbance, criminality, and mental retardation. However, these results are outdated and extremely questionable given the initial examinations were given to institutionalized populations (Chen, 2010). Differential Diagnosis Classic Klinefelters Syndrome, 47, XXY, cases make up approximately 80-90% of all Klinefelters diagnosis. There are approximately 6-10% of these cases that are mosaics, which are the cells with 46, XY/47, XXY; 46, XY/48, XXXY; and 47, XXXY/48, XXXY (Chen, 2010; Visootsak Graham, 2003; Visootsak Graham, 2006). In 5% of the cases there are two X chromosomes without a Y chromosome or 46, XX (Visootsak Graham, 2006). The other cases were karyotypes 48, XXXY, 48, XXYY, 49, XXXXY, and 49, XXXYY (Visootsak Graham, 2003). Approximately 1% of these cases are due to a structurally abnormal X with a normal X and Y chromosome described as kayotypes 47, X,i(Xq)Y and 47, X,del(X)Y (Chen, 2010). Klinefelters Syndrome variants occur much less frequently than the classic 47, XXY chromosomal abnormality (Bock, 1993; Visootsak Graham, 2006). Klinefelter variant 48, XXXY is characterized by being average or tall stature with ocular hyperterlorism, which are widely spaced or deep set eyes; flat nasal bridge; curving of the fifth finger, or clinodactyly. Other characteristics are small penis and testicles with hypergonadotropic hypogonadism, which is the absence or decrease in function of the male testes. Theses individuals intelligence quotients range from 40-60. Variant 48, XXYY is characterized by having a tall stature, an eunuchoid habitus with long legs, sparse body hair, small testicles and penis, hypergonadotropic hypogonadism and gynecomastia. These individuals intelligence quotients range from 60-80. Males with variant 49, XXXXY are severely affected. They have smaller than average head circumference also known as microcephaly, short stature with ocular hypertelorism, flat nasal bridge, and upslanting palpebral fissures. Cleft palates are present along with small geniltalia and a heart defect known as patent ductus arteriosus. These individuals intelligence quotients range from 20-60. (Visootsak and Graham, 2003). Klinefelters Syndrome 47, XXY, has no major physical signs, which explains why it may go undiagnosed or misdiagnosed throughout an individuals life. Also with no physical signs, it is truly only diagnosed when genetic testing occurs for a variety of unrelated reasons. Klinefelters Syndrome may be diagnosed prenatally or during early childhood, as an adolescent during puberty, or as an adult when there are recognized fertility problems (Bock, 1993). Klinefelters Syndrome can be diagnosed prenatally through amniocentesis or chorionic villus sampling (Bock, 1993). These tests are normally done if the pregnant woman is older than 35, if there is a family history of genetic defects, or when other medical indications exist (Bock, 1993). A pediatrician may suspect a male child as having Klinefelters Syndrome if there are delays in learning to talk or difficulties in reading and writing as well as physical abnormalities during adolescence (Bock, 1993). Treatments and Interventions All hope is not lost when it comes to the treatment and interventions of the undesirable traits and characteristics that males diagnosed with Klinefelters Syndrome may display or develop. It is recommended that Klinefelters males have a comprehensive neurodevelopmental evaluation as soon as they have been diagnosed. A multidisciplinary developmental evaluation can determine the appropriate treatments during infancy and early childhood. These treatments may include physical therapy, infant simulation programs, and speech therapy (Wattendorf, 2005). If the language difficulties are detected in childhood, then there is more of a possibility for intervention. The language barriers that Klinefelters males may have to cope with can not only affect their academics, it can obstruct their building of social relationships and learning social skills necessary for these relationships. Here is where the Klinefelters child could benefit from a social skills training program. In a social skills training program, the Klinefelters child will be able to practice talking and listening, observing childrens making friends processes, sharing of information, attitudes, and beliefs. This will also assist them in proper classroom behavior and playground behavior. Language disabilities and barriers can prevent Klinefelters males from fitting in socially, so this kind of intervention and assistance can benefit the child greatly. Hearing can be an issue if frequent ear infections occur. Hearing test and screens should be done to ensure that a hearing impairment is not a part of the language difficulties. If the Klinefelters child is not communicating effectively with single words by the ages of 18 to 24 months, then consultation with a speech and language pathologist will be very beneficial (Klinefelter Syndrome Information, 2002). Teachers should be informed of the difficulties that a Klinefelters child may be dealing with in the classroom. A teacher may consider the Klinefelters child to be lazy and daydreaming and a teacher may even forget the child is even in the room. This can result in the Klinefelters child falling behind and eventually being held back a grade. Under the Public Law 94-142, the Individuals with Disabilities Education Act, adopted by Congress in 1975, all children with disabilities have a right to a free, and appropriate public education (Klinefelter Syndrome Information, 2002). Once the Klinefelters male reaches puberty there is usually an inability to produce a normal amount of testosterone. This along with hypogonadism can result in impaired bone mineral density and skeletal muscle development. Also associated with testosterone deficiency is a decrease in libido and energy (Wattendorf Muenke, 2005). Androgen therapy or Testosterone Treatment should begin by time the Klinefelters male reaches middle school, approximately 12 to 14 years of age, based on the level of pubertal development (Klinefelter Syndrome Information, 2002; Wattendorf Muenke, 2005). Testosterone Treatment will ultimately increase the muscle size and strength, as well as, promoting the growth of body and facial hair. It must be noted that Testosterone Treatments can also bring on psychological changes. It is important to adequately inform the parent(s) and the child of these changes so that they can make the most informed decision (Klinefelter Syndrome Information, 2002). There are diff erent ways to receive Testosterone Treatment and that is through injections, transdermal (patches, gels, or creams), orally, or implantation. The kind of testosterone injection will depend mainly on the dosage used and the country in which you receive the injections. Some injectable testosterone esters are Testosterone enanthate, Testosterone cypionate, Sustanon, Testosterone propionate, Testosterone phenylpropionate, Omnadren, and Aqueous testosterone suspension. Types of transdermal patches are Androderm and Testosterone TTS. Two different kinds of testosterone gels and creams are Androgel, and Testim. A few oral supplements include Methyltestosterone and Testosterone undecanoate. The last form of Testosterone Treatment is the Subcutaneous testosterone pellet, which is delivered by implanting a pellet of pure, crystalline testosterone under the skin of the buttocks or abdomen (Testosterone Types and Delivery, n.d.). Adult males with Klinefelters Syndrome usually develop gynecomastia which predisposes men to breast cancer. Therefore, it is important that Klinefelters males do monthly breast examinations. If gynecomastia causes psychological or physical problems, then possible treatment would be cosmetic surgery to remove the breast tissue (Wattendorf Muenke, 2005). Swerdlow et. al (2005) stated that men with Klinefelter Syndrome have elevated risks of several cancers. Prostate cancer, along with breast cancer was more prevalent. Men with Klinefelter Syndrome are also at a substantially higher risk for non-Hodgkin lymphoma, and possibly lung cancer. Breast cancer risk is higher in 47, XXY mosaics. Adult males may face possible infertility issues due to the lack of testosterone production, but if diagnosed early on, this can be minimized and they will be able to reproduce without outside assistance. Summary Klinefelter Syndrome is one of the more recently discovered medical syndromes. Klinefelter Syndrome is not one that causes major dysfunctions and is usually only discovered during genetic testing for infertility or during prenatal testing due to maternal age or prior genetic issues within the family. Because Klinefelter Syndrome has not had a lot of research until the last few years, there is no federal funding set aside for this syndrome. Families with sons that are found to be affected by it have no real support system that is knowledgeable of this syndrome and have to research on their own and create resources to fit their situation as none are available in most areas.

Old Man And The Sea Summary Essay -- essays research papers

The Old Man and the Sea by Ernest Hemingway (1899 - 1961) Type of Work: Symbolic drama Setting North Coast of Cuba; early twentieth century Principal Characters Santiago, an old, weathered fisherman Manolin , a boy, Santiago's young fishing companion The Marlin, a gigantic fish Story Overveiw Eighty-four days had passed since Santiago, the old fisherman, had caught a fish, and he was forced to suffer not only the ridicule of younger fishermen, but near-starvation as well. Moreover, Santiago had lost his young companion, a boy named Manolin, whose father had ordered him to leave Santiago in order to work with more successful seamen. But the devoted child still loved Santiago, and each day brought food and bait to his shack, where they indulged in their favorite pastime: talking about the American baseball leagues. The old man's hero was the New York Yankees' Joe DiMaggio. Santiago identified with the ballplayer's skill and discipline, and declared he would like to take the great DiMaggio fishing some time. After visiting one particular afternoon, the boy left Santiago, who fell asleep. Lions immediately filled his dreams. As a boy he had sailed to Africa and had seen lions on the beaches. Now, as an old man, he constantly dreamed of the great and noble beasts. He no longer dreamed of storms, nor of women, nor of Great occurrences, nor of great fish, nor fights nor contests of strength, nor of his wife. He only dreamed of places now and of the lions on the beach ... He loved them as he loved the boy. Before dawn of the next day, the fisherman, as usual, hauled his salt-encrusted skiff onto the beach and set out by himself. But today, in hopes of breaking his unlucky streak, he was determined to sail into deep waters, out much farther than the other anglers would go. He followed the sea birds and flying fish; they would tell him b y their movements where the fish congregated. He watched the turtles swimming near his boat. He loved the turtles, "with their elegance and speed... " Most people are Heartless about turtles because a turtle's heart will beat for hours after he has been cut tip and butchered. The old man thought, I have such a heart too ... Early on, Santiago managed to land a tenpound tuna. Thinking this a good omen, he used the fresh meat to bait one of his lines. By n... ...ng manly courage, endurance, and noble suffering. In fact, the novel would be little more than an adventure story were it not for Santiago's dialogues with himself - his repetitive and symbolic musings, daydreams and plottings. Unlike other fishermen, who see the ocean merely in terms of economic gain, Santiago looks on the sea and its inhabitants with love and respect. Notably, he prefers to call the sea "la mar," its feminine form, rather than the harsher, masculine "el mar." Some readers may see Christian symbolism in the story: Santiago means St. James in Spanish; the battle with the fish lasts three days; Santiago, arriving at the shore, carries his mast, like a cross, on his shoulders, and, like the biblical Christ, stumbles under its load. Later, the fisherman lies down exhausted on the floor of his hut with his arms stretched out stiffly and the palms of his hands up. But the giant fish - representing the hopes and dreams of mankind - and the old man's relationship with it, is what creates the extraordinary pathos of the novel. And, in the end, even Santiago's (humankind's) modest expectations are snatched from his grasp.

Does the Current Electoral Process Result in the best Candidate for President?

History informs us about the first method the parties developed in order to pick their presidential candidates. This method was the congressional caucus. The framer’s method in 1787 was that each elector would cast two electoral votes, each for a different person for president. The person who received the majority of the electoral votes would win the presidential election and the person who received the second most amount of electoral votes won the vice presidential election. However, the rise of political parties and the election of 1800 made a great change to the system.During this time the electors cast their two votes for two different persons. The 12th Amendment established the separation of the presidential and vice presidential election. With the election of Thomas Jefferson, each of the 73 Democratic- Republican Party voted for Thomas Jefferosn and Aaron Burr which caused a tie. To resolve this there was 36 separate votes in the House of Representatives to select the P resident and Vice President. In 1832, both major parties turned to the national convention as their presidential nomination device and still continues to serve them.Whether the current electoral process results in the best candidates for president is debatable. We must further look into the steps taken in order to become a president. Electing a president consists of five steps. These steps include primaries/caucuses, nomination at national convention, campaigning, election, and electoral college. Presidential primaries help to ensure that a party gets strong candidates for president. They do this by democratizing the delegate selection process and force would-be nominees to test their candidacies in actual political combat.This is how most states select the Democratic Republican candidate who will run against each other. A caucus is a nominating device where a group of people with similar views meet to select delegates to the national convention. Not just anyone is nominated. To be nominate one must be more than just an older white male. Though, it is usually male. One must have experience and have served in elective offices. They sometimes are protestant or incumbent with a pleasant appearance and developed speakings skills.Once all the primaries and  caucuses have been held and delegates are selected, the two major parties hold their nation conventions. The three main goals of the national convention are promoting party unity, adopting the party’s platform, and naming the party’s candidates. During this time each Presidential candidate chooses a running-mate for Vice-President. Once a candidate has won their party's nomination, he or she begins mapping campaign strategy . Campaigning is very important in order to win the votes of the American people. Through campaigning the cadidate states his or her position on various current issues.He or she steps up efforts to raise money and recruit volunteer workers. Fans of the candidates most likely w ill begin holding up signs encouraging to vote for their choice of candidate. Swing voters are important to campaigns since these are the 1/3 of the electorate who has not made up their minds at the start of the campaign. They are more open to persuasion for either campaigns. They also focus on battle-ground states since either candidate could win in those states. Finally on the first tuesday of November, the people vote for one candidate. This happens every four years.When a person casts a vote in the general election, they are not voting directly for an individual Presidential candidate. Instead, voters in each state actually cast their vote for a group of people, known as electors. These electors are part of the Electoral College and are supposed to vote for their state’s preferred candidate. In the Electoral College system, each state gets a certain number of electors, based on each state's total number of representation in Congress. Each elector gets one electoral vote. For example, a large state like California gets 54 electoral votes, while Rhode Island gets only four.All together, there are 538 Electoral votes. In December after the election, the electors cast their votes. When the votes are counted on January 6th, the Presidential candidate that gets more than half, 270, wins the election. The President-elect and Vice President-elect then take the oath of office and are inaugurated two weeks later, on January 20th. Returning to the main question, I don’t believe the electoral process results in the best candidates for President. I believe the choice should not be left for the electoral college but for each person’s vote to count.One alternative is the popular vote where everyone’s vote would count for one vote. I don't think it is fair to try to convince people that they have a voice and encourage them to vote, when the Electoral College has the final say. The Electoral College leads to things like there being massive amoun ts of campaigning being down in â€Å"battleground states† like Ohio and Florida while people in solidly â€Å"red† or solidly â€Å"blue† states have their issues basically ignored because it's almost certain which way the state is going to go.History informs us about the first method the parties developed in order to pick their presidential candidates. This method was the congressional caucus. The framer’s method in 1787 was that each elector would cast two electoral votes, each for a different person for president. The person who received the majority of the electoral votes would win the presidential election and the person who received the second most amount of electoral votes won the vice presidential election. However, the rise of political parties and the election of 1800 made a great change to the system.During this time the electors cast their two votes for two different persons. The 12th Amendment established the separation of the presidential a nd vice presidential election. With the election of Thomas Jefferson, each of the 73 Democratic- Republican Party voted for Thomas Jefferosn and Aaron Burr which caused a tie. To resolve this there was 36 separate votes in the House of Representatives to select the President and Vice President. In 1832, both major parties turned to the national convention as their presidential nomination device and still continues to serve them.Whether the current electoral process results in the best candidates for president is debatable. We must further look into the steps taken in order to become a president. Electing a president consists of five steps. These steps include primaries/caucuses, nomination at national convention, campaigning, election, and electoral college. Presidential primaries help to ensure that a party gets strong candidates for president. They do this by democratizing the delegate selection process and force would-be nominees to test their candidacies in actual political comb at.This is how most states select the Democratic Republican candidate who will run against each other. A caucus is a nominating device where a group of people with similar views meet to select delegates to the national convention. Not just anyone is nominated. To be nominate one must be more than just an older white male. Though, it is usually male. One must have experience and have served in elective offices. They sometimes are protestant or incumbent with a pleasant appearance and developed speakings skills.Once all the primaries and caucuses have been held and delegates are selected, the two major parties hold their nation conventions. The three main goals of the national convention are promoting party unity, adopting the party’s platform, and naming the party’s candidates. During this time each Presidential candidate chooses a running-mate for Vice-President. Once a candidate has won their party's nomination, he or she begins mapping campaign strategy . Campaigning is very important in order to win the votes of the American people. Through campaigning the cadidate states his or her position on various current issues.He or she steps up efforts to raise money and recruit volunteer workers. Fans of the candidates most likely will begin holding up signs encouraging to vote for their choice of candidate. Swing voters are important to campaigns since these are the 1/3 of the electorate who has not made up their minds at the start of the campaign. They are more open to persuasion for either campaigns. They also focus on battle-ground states since either candidate could win in those states. Finally on the first tuesday of November, the people vote for one candidate. This happens every four years.When a person casts a vote in the general election, they are not voting directly for an individual Presidential candidate. Instead, voters in each state actually cast their vote for a group of people, known as electors. These electors are part of the Electora l College and are supposed to vote for their state’s preferred candidate. In the Electoral College system, each state gets a certain number of electors, based on each state's total number of representation in Congress. Each elector gets one electoral vote. For example, a large state like California gets 54 electoral votes, while Rhode Island gets only four.All together, there are 538 Electoral votes. In December after the election, the electors cast their votes. When the votes are counted on January 6th, the Presidential candidate that gets more than half, 270, wins the election. The President-elect and Vice President-elect then take the oath of office and are inaugurated two weeks later, on January 20th. Returning to the main question, I don’t believe the electoral process results in the best candidates for President. I believe the choice should not be left for the electoral college but for each person’s vote to count.One alternative is the popular vote where e veryone’s vote would count for one vote. I don't think it is fair to try to convince people that they have a voice and encourage them to vote, when the Electoral College has the final say. The Electoral College leads to things like there being massive amounts of campaigning being down in â€Å"battleground states† like Ohio and Florida while people in solidly â€Å"red† or solidly â€Å"blue† states have their issues basically ignored because it's almost certain which way the state is going to go.

The Role of Religion in Manifest Destiny - Free Essay Example

Sample details Pages: 3 Words: 828 Downloads: 1 Date added: 2019/06/17 Category Religion Essay Level High school Topics: Manifest Destiny Essay Did you like this example? In the 1770s the North American expansion was on the rise and was causing controversy among the people of the United States. The most controversial topic of the time was Manifest Destiny. Manifest Destiny was the long process of American territorial expansion that was both facilitated and justified by the mid-nineteenth-century ideology (or natural vision). Manifest Destiny was viewed from many different standpoints such as religious, political, ethnic, and economic. The most influential standpoint was the religious standpoint because its effects were seen in every aspect of lifestyle and decision making in every societal group of that time. Manifest Destiny was a general idea rather than a specific policy with a set of principles. Many Americans believed in the integrity and value of expansion. The nation felt a sense self-identity and the need to spread its beliefs and freedom to others. John L. OSullivan spoke of a divine destiny that focused on the moral salvation of man. In his magazine The Democratic Review, OSullivans Manifest Destiny was a perfect expression of the current enthusiastic belief in American democracy and in the mission of the United States to carry it throughout the North American continent . OSullivan urged the United States to annex the Republic of Texas because it was their Manifest Destiny. Even though the Whigs were against expansion Texas was annexed in 1845. OSullivan believed the United States had been given a mission to spread republican democracy by God. With this belief in mind he felt that as Americans immigrated to the new places, they would set up a democratic government and ask for ad mission to the United States. America was given a Divine Providence to manifest to mankind the excellence of divine principles through expansion . Don’t waste time! Our writers will create an original "The Role of Religion in Manifest Destiny" essay for you Create order The blessing of the American way of life could easily be extended. (p.6) George Washington subdued the Indians with military force. In 1794, the Indians had to give two-thirds of Ohio and a part Indiana to the United States. Thomas Jefferson bought the trans-Mississippi region from France in 1803. The democrats supported expansionism, but some opposed it saying expansion would cause the nation to fail (p.6). The Louisiana Purchase doubled the size of America (p.7). John Quincy Adams thought America would be safe with expansion to other territories. Spain was forced to surrender Florida and Oregon to the United States (p.8). The United States was a rural and religious nation. Because of the growing population and the desire to own land, families moved west, believing in their divine destiny to expand. If a person could not afford to buy the land, they squatted on it. The federal government allowed for and even encouraged the systematic displacement of native people so that settlers could acquire their land. (p.10) The Indian people had first claims to the land they lived on; however, with the belief of Manifest Destiny, Americans took the Indians lands. State and territories encouraged squatters to push further west. White people believed in the alleged superiority of white civilization (p.14). The Cherokee adopted the social, political, economic, and cultural norms of their white neighbors. (p.14) However, the Indian Removal Act of 1840 forced them to leave. This act set a precedent for expansionism in the 1840s (p.14). White people believed that their religion must be expanded west across the North American Continent. They felt the white civilization had been given a divine providence to expand. After the war of 1812, the British Hudsons Bay Company declared that everyone at the forts should attend Sunday services. The Indians were fascinated with Christianity as well as farming. Religious obligations were enforced at the forts. Christian baptisms were offered only on the condition of learning agriculture (p.227). American whites wanted to civilize Indians through making them more dependent on whites. The HBC made European civilization a package deal of trade, religion, and medicine (p.227). The HBC doctors were able to manipulate the Indians through vaccinations like smallpox (p.228). American men migrating to the west intermarried with Native American women. Catholic and Protestant missionaries arrived in the areas. These missionaries were bringing religion but felt as though the Indians were inferior to them (p.238). We have come to elevate them and not to suffer ourselves to sink down to their standard (p.238). The westward expansion of American from 1812 to 1860 is referred to as the age of manifest destiny. Religion influenced the westward movement. Many Americans wanted to carry their religious beliefs across the continent through expansion. Manifest Destiny lasted from the end of the War of 1812 to the beginning of the Civil War. John Quincy Adams was one of the leaders who believed that the United States would eventually include all of North America. He wrote that all of North America was destined by Divine Providence to be governed by one nation, the United States. Adams believed that this nation would speak one language and follow one system of religious and political practices. Promoting Americas religious beliefs was an important factor in Manifest Destiny and the desire to move westward.