Reducing the Risk of Transmission of Nosocomial Infections

Reducing the Risk of Transmission of Nosocomial Infections CHAPTER 1 INTRODUCTION The standard precautions (SP), proposed by the United States Centers for Disease Control and Prevention (CDC) in 1996, are guidelines for reducing the risk of transmission of nosocomial infections in hospitals. It proposes that body fluid, patient blood, secretions, and excrement are infectious, hence preventive measures are necessary to protect both patients and medical personnel. These preventive measures include avoidance of direct contact with patients and air-borne particles, and require hand washing and sterilization, the use of personal protective equipment (PPE), the safe disposal of sharp instruments and waste management (Luo, He, Zhou Luo, 2010). 1.1  Background of the Study Standard precautions are specifically designed to reduce the risk of acquiring occupational nosocomial infections from both known and unknown sources in the healthcare setting. Awareness and compliance with these recommendations is crucial for the prevention of occupational nosocomial infections in healthcare personnel and patients (Abdulraheem, Amodu, Saka, Bolarinwa Uthman, 2012). Standard precautions include hand washing; use of personal protective equipment (gloves, gown, cap and mask); care with devices, equipment and clothing used during care; environmental control (surface processing protocols and health service waste handling); adequate discarding of sharp instruments; and patient’s accommodation in accordance to requirement levels as an infection transmission source. Hand hygiene is most important measures among the standard precautions advocated (Abdulraheem et al., 2012). Stringent observations of these measures protect the personnel against blood-borne viruses and to decrease transmission of cross infections among patients (Atif et al., 2013). Nurses are the group of health care providers with the most direct contact with patients while providing care. Therefore, nurses’ adherence to infection prevention precautions would have a profound effect on reducing nosocomial infection rates (Al-Hussami Darawad, 2013). The causal agents that bring infections are transmitted mainly by hands, after failure to comply with hygiene procedures. Hand washing is considered the most important measure in preventing infections. However, according to Jusot et al. (2004), in their study in the southeast of France, compliance of healthcare workers (HCWs) with SP was variable and often poor. In terms of knowledge, Chan et al. (2002) reported that in Hong Kong, nurses’ knowledge on SP was inadequate, in terms of applying precautions inappropriately and inadequately. In addition, Abdulraheem et al. (2012) in their study that conducted at North Eastern Nigeria also found that only a very small proportion of HCWs had a good knowledge o n SP. Different epidemiological characteristics of nosocomial infection in children results from the specificities of anatomy, physiology, medical conditions, therapeutic and surgical conditions and type of pathogens in pediatric populations. Besides that, the pediatric-hospitalized population is very heterogeneous, varying in age, diagnosis, and underlying illness, ranging from infants with congenital anomalies to adolescents with multiple traumas. Consequently, even patients admitted to the same ward pose a different risk for hospital-acquired infections (Lopes et al., 2006). Pediatric cancer patients have an increased risk of potentially life-threatening infectious complications due to their underlying illnesses and intensive anticancer treatment (Simon et al., 2008). Thus, SP are very crucial in preventing these nosocomial infections. It is clear that SP reduces the extent to which HCWs exposed to the blood of others, and, presumably, this in turn reduces their risk of occupational infections with blood borne pathogens. Although it has been routinely practiced in high-income countries for a long time, it is hard to achieve full compliance. Noncompliance has been associated with a range of factors, which include lack of knowledge, interference with work skills, risk perception, not wanting to offend patients, lack of equipment and time, uncomfortable PPE, inconvenience, work stress, and perceiving a weak organizational commitment to safety climate (Kermode et al., 2005). 1.2  Problem Statement The reality of adopting SP within the hospital setting is far from what is recommended and had proved to be somewhat problematic (Gammon Gould, 2005). Efstathoiu, Papastavrou, Raftopoulos and Merkouris (2011) also reported that adherence with SP among nurses in Cyprus in order to avoid exposure to microorganisms was low. More specifically, compliance was found insufficient regarding hand hygiene guidelines, use of gloves when exposure to body fluids was anticipated, eye protection, mouth and nose protection (mask use), wearing a gown when required, avoid recapping the needle after it was used for a patient, and provision of care considering all patients as potentially infectious. According to Gammon, Samuel and Gould (2008), in United Kingdom, staff compliance to SP was generally deficient, and practice interventions to improve adherence were generally limited in their effect. Hospital acquired infections (HAI) or nosocomial infections (NI), which pose a serious problem, threatening the health and safety of patients and medical personnel worldwide due to poor compliance towards SP. Nosocomial infections, defined as those occurring within 48 hours of hospital admission, three days of discharge or 30 days of an operation, affect one in every ten patients admitted to hospital. These infections affect the quality of medical care and increase medical care costs (Inweregbu, Dave Pittard, 2005). According to the World Health Organization (WHO) (2009), hundreds of millions of patients develop HAI around the globe every year and as many as 1.4 million cases occur in hospitals alone each day. In pediatric setting, HCWs always assumed that children are low-risk patients. Although it was acknowledged that the children can also carry contagious diseases, but they often do not implement SP (Efstathoiu et al., 2011). Nosocomial infections are a crucial clinical complication in adult and children patients at the different hospital wards worldwide. Nosocomial infections bring considerable morbidity and mortality associated with prolonged hospital stay and increased health care costs (Nagliate, Nogueira, Godoy Mendes, 2013). Kinnula et al. (2012) in their study at Finland and Switzerland found that 8.4% of children in a ward for pediatric infectious diseases acquired a viral HAI during their hospitalization, although only 13% of the HAIs manifested themselves during hospitalization, the majority, 87%, occurring after discharge. So, from here can be proved that, SP are very important to be implemented in the clinical settings. Without these measures, NI will occur. For Hospital USM, pediatric oncology ward, 6 Utara (6U) showed the highest rate of NI if compared to others pediatric ward (Unit Kawalan Jangkitan Epidemiologi Hospital, 2013). This may be due to the low immune system of those children. Pediatric cancer patients are at an increased risk for specific HAI. These adverse events can result not only in significant morbidity and mortality, but also in an increased expenditure of limited financial and personnel resources (Simon et al., 2008). According to Unit Kawalan Jangkitan Epidemiologi Hospital (2013), the average NI occurred per month from August 2012 to August 2013 was 3 cases, which contributed to 4.62% of total admission of the patient. This was quite a high number. Thus, interventions should be taken to investigate the compliance level of the pediatric nurses towards SP and thus to reduce the infection rates. Table 1.2.1 Total nosocomial infection occurred per month at 6Ufrom August 2012 to August 2013 (Source: Unit Kawalan Jangkitan Epidemiologi Hospital, 2013) Date Total NI Total no. of admission Total % of admission in ward August 2012 4 58 6.89 September 2012 3 47 6.38 October 2012 2 82 2.45 November 2012 0 50 0 December 2012 1 74 1.35 January 2013 2 65 3.0 February 2013 5 60 8.33 March 2013 3 62 4.84 April 2013 2 65 3.06 May 2013 4 71 5.6 June 2013 3 67 4.4 July 2013 1 76 1.31 August 2013 4 67 5.97 AVERAGE 3 65 4.62 Guidelines or policies that guide an individual’s behavior exist in a variety of settings (including health care settings), but people do not always comply with them. In order to explain and understand the factors that influence an individual’s adherence with certain guidelines, which consequently may bring to the adoption of certain behavior, a number of conceptual models or theories had been developed (Efstathiou et al., 2011). Conceptual framework that used in this study in explaining the knowledge and compliance towards SP among pediatric nurses at Hospital USM was adapted from the Theory of Planned Behavior (TPB) by Ajzen (1991). The TPB provides a model that has potential benefits for predicting the intention to perform a behavior based on an individual’s attitudinal, normative beliefs and perceived behavioral control. As for this study, the knowledge on SP, self-efficacy (attitude), awareness on the importance of standard operating procedures (SOPs), and some individual factors of nurses will influence their practice towards SP in healthcare setting. 1.3  Research Objectives 1.3.1  General Objective The general aim of this study is to identify the knowledge and compliance towards standard precautions among pediatric nurses at Hospital Universiti Sains Malaysia (Hospital USM). 1.3.2  Specific Objectives To identify the level of knowledge regarding standard precautions among pediatric nurses at Hospital USM. To identify the level of compliance with standard precautions among pediatric nurses at Hospital USM. To determine the association between selected socio-demographic data (working ward, clinical working experience in years and highest nursing educational level) and level of compliance with standard precautions among pediatric nurses at Hospital USM. To determine the association between levels of knowledge regarding standard precautions and level of compliance among pediatric nurses at Hospital USM. To determine the association between self-efficacy and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.4  Research Questions What is the level of knowledge regarding standard precautions among pediatric nurses at Hospital USM? What is the compliance level among pediatric nurses towards the application of standard precautions in the pediatric ward at Hospital USM? Is there any association between working ward and level of compliance with standard precautions among pediatric nurses at Hospital USM? Is there any association between clinical working experience in years and level of compliance with standard precautions among pediatric nurses at Hospital USM? Is there any association between highest nursing educational level and level of compliance towards standard precautions among pediatric nurses at Hospital USM? Is there any association between level of knowledge regarding standard precautions and level of compliance among pediatric nurses at Hospital USM? Is there any association between self-efficacy and level of compliance with standard precautions among pediatric nurses at Hospital USM? Research Hypothesis 1.5.1 Hypothesis 1 HO: There is no significant association between working ward and level of compliance with standard precautions among pediatric nurses at Hospital USM. HA: There is a significant association between working ward and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.5.2 Hypothesis 2 HO: There is no significant association between clinical working experiences in years and level of compliance with standard precautions among pediatric nurses at Hospital USM. HA: There is a significant association between clinical working experiences in years and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.5.3 Hypothesis 3 HO: There is no significant association between highest nursing educational level and level of compliance with standard precautions among pediatric nurses at Hospital USM. HA: There is a significant association between highest nursing educational level and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.5.4 Hypothesis 4 HO: There is no significant association between level of knowledge and level of compliance with standard precautions among pediatric nurses at Hospital USM. HA: There is a significant association between level of knowledge and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.5.5 Hypothesis 5 HO: There is no significant association between self-efficacy and level of compliance with standard precautions among pediatric nurses at Hospital USM. HA: There is a significant association between self-efficacy and level of compliance with standard precautions among pediatric nurses at Hospital USM. 1.6  Definition of Operational Terms Knowledge Knowledge is defined as the level or degree of information acquired in a particular field. It is a basic requirement so that the positive changes in behavior can be developed. Knowledge can further bring into awareness and in turn leads to action. To develop nursing knowledge, it comes from both theoretical and practice perspectives. By gaining knowledge, it raises awareness of personal and professional accountability and the dilemmas of practice (Ndikom Onibokun, 2007). In this research, it was referred to the knowledge regarding SP and its application. Compliance Compliance is defined as the extent to which certain behavior (for example, following physician’s orders or implementing healthier lifestyles) is in accordance with the physicians’ instructions or health care advice. It can be influenced or controlled by a variety of factors such as culture, economic and social factors, self-efficacy, and lack of knowledge or means (Efstathiou et al., 2011). In this research, it was referred to compliance or adherence towards SP to prevent NI. Standard precautions The standard precautions are defined as guidelines to reduce the risk of transmission of blood-borne and other pathogens in hospitals. It proposes that body fluid, patient blood, secretions, and excrement are infectious. Hence these measures are necessary to protect both patients and HCWs (Luo et al., 2010). Standard precautions include hand washing; use of personal protective equipment (e.g., gloves, gown, cap, mask); care with devices, equipment and clothing used dur ­ing care; environmental control (e.g., sur ­face processing protocols, health service waste handling); and adequate discarding of sharp instruments including needles (Vaz et al., 2010). In this research, SP referred to those policies that protect patient and HCWs such as hand washing, use of PPE, safe sharp disposal and waste management. Nosocomial Infections Nosocomial infections are defined as infections that occur within 48 hours of hospital admission, three days of discharge or 30 days of an operation (Inweregbu, Dave Pittard, 2005). In my research, it was referred to the infections that acquired within the period of hospitalization. Self-efficacy Self-efficacy is defined as the confidence to control and guide one’s own activities. General self-efficacy is a general confidence when the individual deals with changeable environments and faces new experiences (Luo et al., 2010). In this research, it was referred to the self confidence in implementing SP to prevent NI. 1.7  Significance of the Study Nosocomial infections control requires a combination of interventions, including knowledge about the use of SP, rational use of antimicrobials, hand washing and compliance with SP and manuals for prevention and controlling microorganisms. Health professionals’ low compliance with and difficulties to use SP had been demonstrated in some research though (Efstathiou et al., 2011; Luo et al., 2010). Hence, in view of application and even compliance failures that compromised patient and professional safety (Sax, Uckay, Richet, Allegranzi Pittet, 2007), it is necessary to assess nurses’ knowledge and compliance about SP (Nagliate et al., 2013). By assessing the knowledge and compliance level toward SP among the nurses, interventions could be taken to improve the quality of health care services as well as provide a holistic nursing care to reduce the morbidity and mortality worldwide. In order to reduce HAI and protect the health of patients and HCWs, the relevant authorities and hospital infection control departments should pay more attention to nurse compliance towards SP, strengthen SP training, and provide sufficient practical PPE. Through learning, the attainment of knowledge and skills, and the formation of health beliefs and attitudes, health activity habits can be formed. Only when individuals are familiar with the content and meanings of the SP, with strengthening of the individual’s health concepts, can individual practice change so as to improve compliance with SP. For nurses, the study on adherence towards SP and factors impacting compliancy should be strengthened in order to improve concepts of health and self-efficacy, to increase compliance with the SP and hence reduce the chances of NI (Luo et al., 2010). The reason that the researcher wished to conduct this research was because from the researcher’s observation during clinical posting, it was observed that, the nurses often neglected the importance of SP. For example, they did not apply the proper ways in implementing SP, some even did not adhere to it at all due to time saving and other reasons. On the other hand, the reason that this study been conducted at pediatric ward was because children is having low immunity if compared to adults, they are at high risk of acquiring NI, so the implementation of SP is very important to ensure a quality health care. In addition, no research on the knowledge and compliance towards SP had been done at Hospital USM before this. Thus, this study is crucial to assess the knowledge and compliance level towards SP among pediatric nurses at Hospital USM to provide a preliminary data that is crucial for the hospital. This study can provide a better insight into the magnitude of the problem of infection control in this hospital. By knowing all these, interventions can be taken if the knowledge and compliance level are disappointing to increase the knowledge and compliance towards SP among the pediatric nurses to reduce the morbidity and mortality rate.

The Da Vinci Code Chapter 87-92

CHAPTER 87 The fireplace in Chateau Villette's drawing room was cold, but Collet paced before it nonetheless as he read the faxes from Interpol. Not at all what he expected. Andre Vernet, according to official records, was a model citizen. No police record – not even a parking ticket. Educated at prep school and the Sorbonne, he had a cum laude degree in international finance. Interpol said Vernet's name appeared in the newspapers from time to time, but always in a positive light. Apparently the man had helped design the security parameters that kept the Depository Bank of Zurich a leader in the ultramodern world of electronic security. Vernet's credit card records showed a penchant for art books, expensive wine, and classical CD's – mostly Brahms – which he apparently enjoyed on an exceptionally high-end stereo system he had purchased several years ago. Zero, Collet sighed. The only red flag tonight from Interpol had been a set of fingerprints that apparently belonged to Teabing's servant. The chief PTS examiner was reading the report in a comfortable chair across the room. Collet looked over. â€Å"Anything?† The examiner shrugged. â€Å"Prints belong to Remy Legaludec. Wanted for petty crime. Nothing serious. Looks like he got kicked out of university for rewiring phone jacks to get free service†¦ later did some petty theft. Breaking and entering. Skipped out on a hospital bill once for an emergency tracheotomy.† He glanced up, chuckling. â€Å"Peanut allergy.† Collet nodded, recalling a police investigation into a restaurant that had failed to notate on its menu that the chili recipe contained peanut oil. An unsuspecting patron had died of anaphylactic shock at the table after a single bite. â€Å"Legaludec is probably a live-in here to avoid getting picked up.† The examiner looked amused. â€Å"His lucky night.† Collet sighed. â€Å"All right, you better forward this info to Captain Fache.† The examiner headed off just as another PTS agent burst into the living room. â€Å"Lieutenant! We found something in the barn.† From the anxious look on the agent's face, Collet could only guess. â€Å"A body.† â€Å"No, sir. Something more†¦Ã¢â‚¬  He hesitated. â€Å"Unexpected.† Rubbing his eyes, Collet followed the agent out to the barn. As they entered the musty, cavernous space, the agent motioned toward the center of the room, where a wooden ladder now ascended high into the rafters, propped against the ledge of a hayloft suspended high above them. â€Å"That ladder wasn't there earlier,† Collet said.† No, sir. I set that up. We were dusting for prints near the Rolls when I saw the ladder lying on the floor. I wouldn't have given it a second thought except the rungs were worn and muddy. This ladder gets regular use. The height of the hayloft matched the ladder, so I raised it and climbed up to have a look.† Collet's eyes climbed the ladder's steep incline to the soaring hayloft. Someone goes up thereregularly? From down here, the loft appeared to be a deserted platform, and yet admittedly most of it was invisible from this line of sight. A senior PTS agent appeared at the top of the ladder, looking down. â€Å"You'll definitely want to see this, Lieutenant,† he said, waving Collet up with a latex-gloved hand. Nodding tiredly, Collet walked over to the base of the old ladder and grasped the bottom rungs. The ladder was an antique tapered design and narrowed as Collet ascended. As he neared the top, Collet almost lost his footing on a thin rung. The barn below him spun. Alert now, he moved on, finally reaching the top. The agent above him reached out, offering his wrist. Collet grabbed it and made the awkward transition onto the platform. â€Å"It's over there,† the PTS agent said, pointing deep into the immaculately clean loft. â€Å"Only one set of prints up here. We'll have an ID shortly.† Collet squinted through the dim light toward the far wall. What the hell? Nestled against the far wall sat an elaborate computer workstation – two tower CPUs, a flat-screen video monitor with speakers, an array of hard drives, and a multichannel audio console that appeared to have its own filtered power supply. Why in the world would anyone work all the way up here? Collet moved toward the gear. â€Å"Have you examined the system?† â€Å"It's a listening post.† Collet spun. â€Å"Surveillance?† The agent nodded. â€Å"Very advanced surveillance.† He motioned to a long project table strewn with electronic parts, manuals, tools, wires, soldering irons, and other electronic components. â€Å"Someone clearly knows what he's doing. A lot of this gear is as sophisticated as our own equipment. Miniature microphones, photoelectric recharging cells, high-capacity RAM chips. He's even got some of those new nano drives.† Collet was impressed. â€Å"Here's a complete system,† the agent said, handing Collet an assembly not much larger than a pocket calculator. Dangling off the contraption was a foot-long wire with a stamp-sized piece of wafer-thin foil stuck on the end. â€Å"The base is a high-capacity hard disk audio recording system with rechargeable battery. That strip of foil at the end of the wire is a combination microphone and photoelectric recharging cell.† Collet knew them well. These foil-like, photocell microphones had been an enormous breakthrough a few years back. Now, a hard disk recorder could be affixed behind a lamp, for example, with its foil microphone molded into the contour of the base and dyed to match. As long as the microphone was positioned such that it received a few hours of sunlight per day, the photo cells would keep recharging the system. Bugs like this one could listen indefinitely. â€Å"Reception method?† Collet asked. The agent signaled to an insulated wire that ran out of the back of the computer, up the wall, through a hole in the barn roof. â€Å"Simple radio wave. Small antenna on the roof.† Collet knew these recording systems were generally placed in offices, were voice-activated to save hard disk space, and recorded snippets of conversation during the day, transmitting compressed audio files at night to avoid detection. After transmitting, the hard drive erased itself and prepared to do it all over again the next day. Collet's gaze moved now to a shelf on which were stacked several hundred audio cassettes, all labeled with dates and numbers. Someone has been very busy.He turned back to the agent. â€Å"Doyou have any idea what target is being bugged?† â€Å"Well, Lieutenant,† the agent said, walking to the computer and launching a piece of software. â€Å"It's the strangest thing†¦Ã¢â‚¬  CHAPTER 88 Langdon felt utterly spent as he and Sophie hurdled a turnstile at the Temple tube station and dashed deep into the grimy labyrinth of tunnels and platforms. The guilt ripped through him. I involved Leigh, and now he's in enormous danger. Remy's involvement had been a shock, and yet it made sense. Whoever was pursuing the Grail had recruited someone on the inside. They went to Teabing's for the same reason I did.Throughout history, those who held knowledge of the Grail had always been magnets for thieves and scholars alike. The fact that Teabing had been a target all along should have made Langdon feel less guilty about involving him. It did not. We need to find Leigh and help him.Immediately. Langdon followed Sophie to the westbound District and Circle Line platform, where she hurried to a pay phone to call the police, despite Remy's warning to the contrary. Langdon sat on a grungy bench nearby, feeling remorseful. â€Å"The best way to help Leigh,† Sophie reiterated as she dialed,† is to involve the London authorities immediately. Trust me.† Langdon had not initially agreed with this idea, but as they had hatched their plan, Sophie's logic began to make sense. Teabing was safe at the moment. Even if Remy and the others knew where the knight's tomb was located, they still might need Teabing's help deciphering the orb reference. What worried Langdon was what would happen after the Grail map had been found. Leigh willbecome a huge liability. If Langdon were to have any chance of helping Leigh, or of ever seeing the keystone again, it was essential that he find the tomb first. Unfortunately, Remy has a big head start. Slowing Remy down had become Sophie's task. Finding the right tomb had become Langdon's. Sophie would make Remy and Silas fugitives of the London police, forcing them into hiding or, better yet, catching them. Langdon's plan was less certain – to take the tube to nearby King's College, which was renowned for its electronic theological database. The ultimate research tool, Langdon had heard. Instant answers to any religious historical question.He wondered what the database would have to say about† a knight a Pope interred.† He stood up and paced, wishing the train would hurry. At the pay phone, Sophie's call finally connected to the London police. â€Å"Snow Hill Division,† the dispatcher said. â€Å"How may I direct your call?† â€Å"I'm reporting a kidnapping.† Sophie knew to be concise.† Name please?† Sophie paused. â€Å"Agent Sophie Neveu with the French Judicial Police.† The title had the desired effect. â€Å"Right away, ma'am. Let me get a detective on the line for you.† As the call went through, Sophie began wondering if the police would even believe her description of Teabing's captors. A man in a tuxedo.How much easier to identify could a suspect be? Even if Remy changed clothes, he was partnered with an albino monk. Impossible to miss.Moreover, they had a hostage and could not take public transportation. She wondered how many Jaguar stretch limos there could be in London. Sophie's connection to the detective seemed to be taking forever. Come on! She could hear the line clicking and buzzing, as if she was being transferred. Fifteen seconds passed. Finally a man came on the line. â€Å"Agent Neveu?† Stunned, Sophie registered the gruff tone immediately. â€Å"Agent Neveu,† Bezu Fache demanded. â€Å"Where the hell are you?† Sophie was speechless. Captain Fache had apparently requested the London police dispatcher alert him if Sophie called in. â€Å"Listen,† Fache said, speaking to her in terse French. â€Å"I made a terrible mistake tonight. Robert Langdon is innocent. All charges against him have been dropped. Even so, both of you are in danger. You need to come in.† Sophie's jaw fell slack. She had no idea how to respond. Fache was not a man who apologized for anything. â€Å"You did not tell me,† Fache continued,† that Jacques Sauniere was your grandfather. I fully intend to overlook your insubordination last night on account of the emotional stress you must be under. At the moment, however, you and Langdon need to go to the nearest London police headquarters for refuge.† He knows I'm in London? What else does Fache know? Sophie heard what sounded like drilling or machinery in the background. She also heard an odd clicking on the line. â€Å"Are you tracing this call, Captain?† Fache's voice was firm now. â€Å"You and I need to cooperate, Agent Neveu. We both have a lot to lose here. This is damage control. I made errors in judgment last night, and if those errors result in the deaths of an American professor and a DCPJ cryptologist, my career will be over. I've been trying to pull you back into safety for the last several hours.† A warm wind was now pushing through the station as a train approached with a low rumble. Sophie had every intention of being on it. Langdon apparently had the same idea; he was gathering himself together and moving toward her now. â€Å"The man you want is Remy Legaludec,† Sophie said. â€Å"He is Teabing's servant. He just kidnapped Teabing inside the Temple Church and – â€Å" â€Å"Agent Neveu!† Fache bellowed as the train thundered into the station. â€Å"This is not something to discuss on an open line. You and Langdon will come in now. For your own well-being! That is a direct order!† Sophie hung up and dashed with Langdon onto the train. CHAPTER 89 The immaculate cabin of Teabing's Hawker was now covered with steel shavings and smelled of compressed air and propane. Bezu Fache had sent everyone away and sat alone with his drink and the heavy wooden box found in Teabing's safe. Running his finger across the inlaid Rose, he lifted the ornate lid. Inside he found a stone cylinder with lettered dials. The five dials were arranged to spell SOFIA. Fache stared at the word a long moment and then lifted the cylinder from its padded resting place and examined every inch. Then, pulling slowly on the ends, Fache slid off one of the end caps. The cylinder was empty. Fache set it back in the box and gazed absently out the jet's window at the hangar, pondering his brief conversation with Sophie, as well as the information he'd received from PTS in Chateau Villette. The sound of his phone shook him from his daydream. It was the DCPJ switchboard. The dispatcher was apologetic. The president of the Depository Bank of Zurich had been calling repeatedly, and although he had been told several times that the captain was in London on business, he just kept calling. Begrudgingly Fache told the operator to forward the call. â€Å"Monsieur Vernet,† Fache said, before the man could even speak,† I am sorry I did not call you earlier. I have been busy. As promised, the name of your bank has not appeared in the media. So what precisely is your concern?† Vernet's voice was anxious as he told Fache how Langdon and Sophie had extracted a small wooden box from the bank and then persuaded Vernet to help them escape. â€Å"Then when I heard on the radio that they were criminals,† Vernet said, â€Å"I pulled over and demanded the box back, but they attacked me and stole the truck.† â€Å"You are concerned for a wooden box,† Fache said, eyeing the Rose inlay on the cover and again gently opening the lid to reveal the white cylinder. â€Å"Can you tell me what was in the box?† â€Å"The contents are immaterial,† Vernet fired back. â€Å"I am concerned with the reputation of my bank. We have never had a robbery. Ever.It will ruin us if I cannot recover this property on behalf of my client.† â€Å"You said Agent Neveu and Robert Langdon had a password and a key. What makes you say they stole the box?† â€Å"They murdered people tonight. Including Sophie Neveu's grandfather. The key and password were obviously ill-gotten.† â€Å"Mr. Vernet, my men have done some checking into your background and your interests. You are obviously a man of great culture and refinement. I would imagine you are a man of honor, as well. As am I. That said, I give you my word as commanding officer of the Police Judiciaire that your box, along with your bank's reputation, are in the safest of hands.† CHAPTER 90 High in the hayloft at Chateau Villette, Collet stared at the computer monitor in amazement. â€Å"This system is eavesdropping on all these locations?† â€Å"Yes,† the agent said. â€Å"It looks like data has been collected for over a year now.† Collet read the list again, speechless. COLBERT SOSTAQUE – Chairman of the Conseil Constitutionnel JEAN CHAFFeE – Curator, Musee du Jeu de Paume EDOUARD DESROCHERS – Senior Archivist, Mitterrand Library JACQUES SAUNIeRE – Curator, Musee du Louvre MICHEL BRETON – Head of DAS (French Intelligence) The agent pointed to the screen. â€Å"Number four is of obvious concern.† Collet nodded blankly. He had noticed it immediately. Jacques Sauniere was being bugged.He looked at the rest of the list again. How could anyone possibly manage to bug these prominent people?† Have you heard any of the audio files?† â€Å"A few. Here's one of the most recent.† The agent clicked a few computer keys. The speakers crackled to life. â€Å"Capitaine, un agent du Departement de Cryptographie est arrive.† Collet could not believe his ears. â€Å"That's me! That's my voice!† He recalled sitting at Sauniere's desk and radioing Fache in the Grand Gallery to alert him of Sophie Neveu's arrival. The agent nodded. â€Å"A lot of our Louvre investigation tonight would have been audible if someone had been interested.† â€Å"Have you sent anyone in to sweep for the bug?† â€Å"No need. I know exactly where it is.† The agent went to a pile of old notes and blueprints on the worktable. He selected a page and handed it to Collet. â€Å"Look familiar?† Collet was amazed. He was holding a photocopy of an ancient schematic diagram, which depicted a rudimentary machine. He was unable to read the handwritten Italian labels, and yet he knew what he was looking at. A model for a fully articulated medieval French knight. The knight sitting on Sauniere's desk! Collet's eyes moved to the margins, where someone had scribbled notes on the photocopy in red felt-tipped marker. The notes were in French and appeared to be ideas outlining how best to insert a listening device into the knight. CHAPTER 91 Silas sat in the passenger seat of the parked Jaguar limousine near the Temple Church. His hands felt damp on the keystone as he waited for Remy to finish tying and gagging Teabing in back with the rope they had found in the trunk. Finally, Remy climbed out of the rear of the limo, walked around, and slid into the driver's seat beside Silas. â€Å"Secure?† Silas asked. Remy chuckled, shaking off the rain and glancing over his shoulder through the open partition at the crumpled form of Leigh Teabing, who was barely visible in the shadows in the rear. â€Å"He's not going anywhere.† Silas could hear Teabing's muffled cries and realized Remy had used some of the old duct tape to gag him. â€Å"Ferme ta gueule!† Remy shouted over his shoulder at Teabing. Reaching to a control panel on the elaborate dash, Remy pressed a button. An opaque partition raised behind them, sealing off the back. Teabing disappeared, and his voice was silenced. Remy glanced at Silas. â€Å"I've been listening to his miserable whimpering long enough.† Minutes later, as the Jaguar stretch limo powered through the streets, Silas's cell phone rang. TheTeacher.He answered excitedly. â€Å"Hello?† â€Å"Silas,† the Teacher's familiar French accent said, â€Å"I am relieved to hear your voice. This means you are safe.† Silas was equally comforted to hear the Teacher. It had been hours, and the operation had veered wildly off course. Now, at last, it seemed to be back on track. â€Å"I have the keystone.† â€Å"This is superb news,† the Teacher told him. â€Å"Is Remy with you?† Silas was surprised to hear the Teacher use Remy's name. â€Å"Yes. Remy freed me.† â€Å"As I ordered him to do. I am only sorry you had to endure captivity for so long.† â€Å"Physical discomfort has no meaning. The important thing is that the keystone is ours.† â€Å"Yes. I need it delivered to me at once. Time is of the essence.† Silas was eager to meet the Teacher face-to-face at last. â€Å"Yes, sir, I would be honored.† â€Å"Silas, I would like Remy to bring it to me.† Remy? Silas was crestfallen. After everything Silas had done for the Teacher, he had believed hewould be the one to hand over the prize. The Teacher favors Remy? â€Å"I sense your disappointment,† the Teacher said,† which tells me you do not understand my meaning.† He lowered his voice to a whisper. â€Å"You must believe that I would much prefer to receive the keystone from you – a man of God rather than a criminal – but Remy must be dealt with. He disobeyed my orders and made a grave mistake that has put our entire mission at risk.† Silas felt a chill and glanced over at Remy. Kidnapping Teabing had not been part of the plan, and deciding what to do with him posed a new problem. â€Å"You and I are men of God,† the Teacher whispered. â€Å"We cannot be deterred from our goal.† There was an ominous pause on the line. â€Å"For this reason alone, I will ask Remy to bring me the keystone. Do you understand?† Silas sensed anger in the Teacher's voice and was surprised the man was not more understanding. Showing his face could not be avoided, Silas thought. Remy did what he had to do.He saved the keystone. â€Å"I understand,† Silas managed. â€Å"Good. For your own safety, you need to get off the street immediately. The police will be looking for the limousine soon, and I do not want you caught. Opus Dei has a residence in London, no?† â€Å"Of course.† â€Å"And you are welcome there?† â€Å"As a brother.† â€Å"Then go there and stay out of sight. I will call you the moment I am in possession of the keystone and have attended to my current problem.† â€Å"You are in London?† â€Å"Do as I say, and everything will be fine.† â€Å"Yes, sir.† The Teacher heaved a sigh, as if what he now had to do was profoundly regrettable. â€Å"It's time I speak to Remy.† Silas handed Remy the phone, sensing it might be the last call Remy Legaludec ever took. As Remy took the phone, he knew this poor, twisted monk had no idea what fate awaited him now that he had served his purpose. The Teacher used you, Silas.And your bishop is a pawn. Remy still marveled at the Teacher's powers of persuasion. Bishop Aringarosa had trusted everything. He had been blinded by his own desperation. Aringarosa was far too eager to believe. Although Remy did not particularly like the Teacher, he felt pride at having gained the man's trust and helped him so substantially. I have earned my payday. â€Å"Listen carefully,† the Teacher said. â€Å"Take Silas to the Opus Dei residence hall and drop him off a few streets away. Then drive to St. James's Park. It is adjacent to Parliament and Big Ben. You can park the limousine on Horse Guards Parade. We'll talk there.† With that, the connection went dead. CHAPTER 92 King's College, established by King George IV in 1829, houses its Department of Theology and Religious Studies adjacent to Parliament on property granted by the Crown. King's College Religion Department boasts not only 150 years' experience in teaching and research, but the 1982 establishment of the Research Institute in Systematic Theology, which possesses one of the most complete and electronically advanced religious research libraries in the world. Langdon still felt shaky as he and Sophie came in from the rain and entered the library. The primary research room was as Teabing had described it – a dramatic octagonal chamber dominated by an enormous round table around which King Arthur and his knights might have been comfortable were it not for the presence of twelve flat-screen computer workstations. On the far side of the room, a reference librarian was just pouring a pot of tea and settling in for her day of work. â€Å"Lovely morning,† she said in a cheerful British accent, leaving the tea and walking over. â€Å"May I help you?† â€Å"Thank you, yes,† Langdon replied. â€Å"My name is – Robert Langdon.† She gave a pleasant smile. â€Å"I know who you are.† For an instant, he feared Fache had put him on English television as well, but the librarian's smile suggested otherwise. Langdon still had not gotten used to these moments of unexpected celebrity. Then again, if anyone on earth were going to recognize his face, it would be a librarian in a Religious Studies reference facility. â€Å"Pamela Gettum,† the librarian said, offering her hand. She had a genial, erudite face and a pleasingly fluid voice. The horn-rimmed glasses hanging around her neck were thick. â€Å"A pleasure,† Langdon said. â€Å"This is my friend Sophie Neveu.† The two women greeted one another, and Gettum turned immediately back to Langdon. â€Å"I didn't know you were coming.† â€Å"Neither did we. If it's not too much trouble, we could really use your help finding some information.† Gettum shifted, looking uncertain. â€Å"Normally our services are by petition and appointment only, unless of course you're the guest of someone at the college?† Langdon shook his head. â€Å"I'm afraid we've come unannounced. A friend of mine speaks very highly of you. Sir Leigh Teabing?† Langdon felt a pang of gloom as he said the name. â€Å"The British Royal Historian.† Gettum brightened now, laughing. â€Å"Heavens, yes. What a character. Fanatical! Every time he comes in, it's always the same search strings. Grail. Grail. Grail. I swear that man will die before he gives up on that quest.† She winked. â€Å"Time and money afford one such lovely luxuries, wouldn't you say? A regular Don Quixote, that one.† â€Å"Is there any chance you can help us?† Sophie asked. â€Å"It's quite important.† Gettum glanced around the deserted library and then winked at them both. â€Å"Well, I can't very well claim I'm too busy, now can I? As long as you sign in, I can't imagine anyone being too upset. What did you have in mind?† â€Å"We're trying to find a tomb in London.† Gettum looked dubious. â€Å"We've got about twenty thousand of them. Can you be a little more specific?† â€Å"It's the tomb of a knight.We don't have a name.† â€Å"A knight. That tightens the net substantially. Much less common.† â€Å"We don't have much information about the knight we're looking for,† Sophie said,† but this is what we know.† She produced a slip of paper on which she had written only the first two lines of the poem. Hesitant to show the entire poem to an outsider, Langdon and Sophie had decided to share just the first two lines, those that identified the knight. Compartmentalized cryptography, Sophie had called it. When an intelligence agency intercepted a code containing sensitive data, cryptographers each worked on a discrete section of the code. This way, when they broke it, no single cryptographer possessed the entire deciphered message. In this case, the precaution was probably excessive; even if this librarian saw the entire poem, identified the knight's tomb, and knew what orb was missing, the information was useless without the cryptex. Gettum sensed an urgency in the eyes of this famed American scholar, almost as if his finding this tomb quickly were a matter of critical importance. The green-eyed woman accompanying him also seemed anxious. Puzzled, Gettum put on her glasses and examined the paper they had just handed her. In London lies a knight a Pope interred. His labor's fruit a Holy wrath incurred. She glanced at her guests. â€Å"What is this? Some kind of Harvard scavenger hunt?† Langdon's laugh sounded forced. â€Å"Yeah, something like that.† Gettum paused, feeling she was not getting the whole story. Nonetheless, she felt intrigued and found herself pondering the verse carefully. â€Å"According to this rhyme, a knight did something that incurred displeasure with God, and yet a Pope was kind enough to bury him in London.† Langdon nodded. â€Å"Does it ring any bells?† Gettum moved toward one of the workstations. â€Å"Not offhand, but let's see what we can pull up in the database.† Over the past two decades, King's College Research Institute in Systematic Theology had used optical character recognition software in unison with linguistic translation devices to digitize and catalog an enormous collection of texts – encyclopedias of religion, religious biographies, sacred scriptures in dozens of languages, histories, Vatican letters, diaries of clerics, anything at all that qualified as writings on human spirituality. Because the massive collection was now in the form of bits and bytes rather than physical pages, the data was infinitely more accessible. Settling into one of the workstations, Gettum eyed the slip of paper and began typing. â€Å"To begin, we'll run a straight Boolean with a few obvious keywords and see what happens.† â€Å"Thank you.† Gettum typed in a few words: LONDON, KNIGHT, POPE As she clicked the SEARCH button, she could feel the hum of the massive mainframe downstairs scanning data at a rate of 500 MB/sec. â€Å"I'm asking the system to show us any documents whose complete text contains all three of these keywords. We'll get more hits than we want, but it's a good place to start.† The screen was already showing the first of the hits now. Painting the Pope. The Collected Portraits of Sir Joshua Reynolds. London University Press. Gettum shook her head. â€Å"Obviously not what you're looking for.† She scrolled to the next hit. The London Writings of Alexander Pope by G. Wilson Knight. Again she shook her head. As the system churned on, the hits came up more quickly than usual. Dozens of texts appeared, many of them referencing the eighteenth-century British writer Alexander Pope, whose counter religious, mock-epic poetry apparently contained plenty of references to knights and London. Gettum shot a quick glance to the numeric field at the bottom of the screen. This computer, by calculating the current number of hits and multiplying by the percentage of the database left to search, provided a rough guess of how much information would be found. This particular search looked like it was going to return an obscenely large amount of data. Estimated number of total hits: 2, 692 â€Å"We need to refine the parameters further,† Gettum said, stopping the search. â€Å"Is this all the information you have regarding the tomb? There's nothing else to go on?† Langdon glanced at Sophie Neveu, looking uncertain. This is no scavenger hunt, Gettum sensed. She had heard the whisperings of Robert Langdon's experience in Rome last year. This American had been granted access to the most secure library on earth – the Vatican Secret Archives. She wondered what kinds of secrets Langdon might have learned inside and if his current desperate hunt for a mysterious London tomb might relate to information he had gained within the Vatican. Gettum had been a librarian long enough to know the most common reason people came to London to look for knights. The Grail. Gettum smiled and adjusted her glasses. â€Å"You are friends with Leigh Teabing, you are in England, and you are looking for a knight.† She folded her hands. â€Å"I can only assume you are on a Grail quest.† Langdon and Sophie exchanged startled looks. Gettum laughed. â€Å"My friends, this library is a base camp for Grail seekers. Leigh Teabing among them. I wish I had a shilling for every time I'd run searches for the Rose, Mary Magdalene, Sangreal, Merovingian, Priory of Sion, et cetera, et cetera. Everyone loves a conspiracy.† She took off her glasses and eyed them. â€Å"I need more information.† In the silence, Gettum sensed her guests' desire for discretion was quickly being outweighed by their eagerness for a fast result. â€Å"Here,† Sophie Neveu blurted. â€Å"This is everything we know.† Borrowing a pen from Langdon, she wrote two more lines on the slip of paper and handed it to Gettum. You seek the orb that ought be on his tomb. It speaks of Rosy flesh and seeded womb. Gettum gave an inward smile. The Grail indeed, she thought, noting the references to the Rose and her seeded womb. â€Å"I can help you,† she said, looking up from the slip of paper. â€Å"Might I ask where this verse came from? And why you are seeking an orb?† â€Å"You might ask,† Langdon said, with a friendly smile,† but it's a long story and we have very little time.† â€Å"Sounds like a polite way of saying â€Å"mind your own business.†Ã¢â‚¬  â€Å"We would be forever in your debt, Pamela,† Langdon said, â€Å"if you could find out who this knight is and where he is buried.† â€Å"Very well,† Gettum said, typing again. â€Å"I'll play along. If this is a Grail-related issue, we should cross-reference against Grail keywords. I'll add a proximity parameter and remove the title weighting. That will limit our hits only to those instances of textual keywords that occur near aGrail-related word.† Search for: KNIGHT, LONDON, POPE, TOMB Within 100 word proximity of: GRAIL, ROSE, SANGREAL, CHALICE â€Å"How long will this take?† Sophie asked. â€Å"A few hundred terabytes with multiple cross-referencing fields?† Gettum's eyes glimmered as she clicked the SEARCH key. â€Å"A mere fifteen minutes.† Langdon and Sophie said nothing, but Gettum sensed this sounded like an eternity to them. â€Å"Tea?† Gettum asked, standing and walking toward the pot she had made earlier. â€Å"Leigh always loves my tea.†

Gambling Pros and Cons and Stages

Gambling is one of the many things that people do. A lot of people see no problem in gambling and others may see different. Gambling has many different cause and effects on certain people and different phases of getting there. Some people may get the better effects, and some may get the not so good effects from it. Gambling doesn’t always just affect the person doing it, but may affect the people around them. There are many pros but more cons to gambling. People may just go gamble just for a night out, others do it on a regular basis.The ones that may do it on regular basis, build their own life around it. Getting into gambling may be caused from stress, greed, and mental health problems. Depression is a big one. When depressed gambling can lift up someone’s mood, especially if he or she is winning all the time. When winning all the time a person becomes greedier with their money than before. Some just don’t know when to stop. Some people waste their winnings on trying to win more when they should’ve just walked away. Other people use gambling when he or she is stressed out about money.They think they win one time there going to win many more, and money problems will disappear. From many stories shared around most likely that won’t be the case more problems just start to occur. The effects from gambling can be something little to something big. There are many harmful effects such as, debt, family issues, pathway to other crimes, endangering ones job, and most likely a high increase in alcohol and drug use. In a study conducted by the United States, 2. 5 million adults suffer from gambling addiction, where 15 million people are under the risk of getting this addiction.Many people who have this addiction go out and gamble their life savings, risking that they might lose it all. Bill money gets spent, and that when one starts to get in debt. Gambling also increase the issues in a household. Increase of child abuse, and neglect of ten occur. He or she might lose a 5,000 dollar bet and take the anger out on the children at home. Many gamblers stop caring about everyone around them, and only think about themselves. There are different stages to having the gambling addiction. The beginning s ones â€Å"winning† stage. One occasionally gambles, gets a big win, and then starts making higher bets. Next the â€Å"losing† phase hits. Some may lose time from work, start borrowing money from others, and start becoming in debt, because of that winning streak. Next the â€Å"desperation† phase. When one is in a panic from all the money lost, and the beginning of doing illegal crimes to get money will begin. Finally, the â€Å"hopelessness† phase hits. Now there is nothing left and suicidal thoughts run threw some people head.The debt is too much to handle and they feel nothing they can do will get them in a stable environment. This is also when in a marriage a divorce might happen, and everyon e that was once there, may not be there anymore. Gambling is a horrible addiction. This addiction may be treatable, as long as the person wants to be treated. Gambling effects a lot more than just one person. It affects everyone around. A winning streak may just be a fluke, taking way too far and ruin one’s life and many more. There can be many pros and cons to gambling, but in the end the cons takes over.

The Soloist Is A Film Based Upon The True Story Of...

The Soloist is a film based upon the true story of Nathaniel Ayers, a Juilliard musical prodigy who has schizophrenia, and Steve Lopez a journalist for the Los Angeles Times, who befriended the (then) homeless Ayers when he was living on the streets of LA. Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves; those who suffer from schizophrenia may seem like they have lost touch with reality. The symptoms of schizophrenia fall into two categories: positive and negative. People with â€Å"positive† symptoms may â€Å"lose touch† with some aspects of reality, and those with â€Å"negative† symptoms are associated with disruptions to normal emotions and behaviors. The movie presents a realistic portrait of schizophrenia and the associated problems of homelessness. It also uses a significant number of the mentally ill homeless population of Los Angeles as extras, which seems to give the film a greater authenticity . Most of Ayer’s schizophrenic symptoms were actually quite typical for this disorder. Ayer’s experiences auditory hallucinations, disorganized speech, a blunted affect and negative symptoms such as social withdrawal and anhedonia, all of which are clearly present for greater than six months. In Nathaniel s introductory scene there is already some evidence his schizophrenia. When asked by Steve if he likes Stevie Wonder (which is written on his visor and shirt), Nathaniel begins to express tangential thoughts with rapid speechShow MoreRelatedEssay on Film Analysis: Beautiful Mind1418 Words   |  6 Pagesadequate contribution of the family members (A beautiful Mind). The Soloist on its part is a film that is based upon the true story of Nathaniel Ayers, a musician who suffers from schizophrenia and Steve Lopez, journalist for the Los Angeles Times, who befriended Ayers amid concerns of the severe and debilitating signs and symptoms associated with the mental condition (The Soloist). With its concept based in real life story, this film provides a remarkable opportunity to review the significant issues