The clinical efficacy of salvia officinalis

The clinical efficacy of salvia officinalis An evaluation of the clinical efficacy of Salvia officinalis, Salvia lavandulaefolia and Melissa officinalis for the prophylaxis, management and amelioration of cognitive dysfunction: with particular reference to Alzheimers disease and non-Alzheimer-type senile dementias. 1. Introduction Dementia is a collection of symptoms caused by a chronic, global deterioration of cognitive function. It can occur at any age but is most prevalent in the elderly and increases with age (Beers et al. 2006: 1811). Around 5% of people over 65, 25% over 80 and 45% over 85 have some form of dementia (Knapp et al. 2007: 10; Collins 1997: 185). The population is aging and whereas today there is an estimated 700,000 people in the UK suffering from dementia, this number is set to increase to more than a million by 2025. The huge impact dementia has on society, devastating families and costing around  £17-18 million annually cannot be overstated (Knapp et al. 11). Early identification and safe, effective, intervention is therefore important. Dementia may be classified as Alzheimers or non-Alzheimer-types (Beers et al. 2006: 1811). The most common dementia is Alzheimers disease (AD) (Grossman et al. 2006: 985), affecting around 20 million people worldwide (Akhondzadeh et al. 2003: 53) and accounting for around 62% of dementias (Knapp et al. 2007: 11). Non-Alzheimer-type dementias typically affecting those over 60 include vascular dementia (27%), Lewy body dementia and fronto-temporal dementia (Knapp et al. 29). Cognitive disorders are treated allopathically with drugs that have yet to show real benefits and have a number of side-effects and contraindications. The need for safer, more effective treatments has led to increasing interest in the use of herbs for their management (Akhondzadeh and Abbasi 2006: 117). A variety of herbs, for example Salvia officinalis, Rosmarinus officinalis, Mellissa officinalis, Ginkgo biloba (Heinrich et al 2004: 234), Withania somnifera (Howes et al. 2003: 12), Centella asiatica (Chevallier 1996: 78) and Panax ginseng (Mantle et al. 2000: 207) have long-standing traditional use as memory-enhancing herbs. Consequently a number of clinical studies have been conducted to assess the efficacy of some of these herbs, most notably Ginkgo biloba, Salvia spp. and Mellissa officinalis, in the treatment of cognitive disorders. Of these, only clinical trials of Gingko biloba have been extensively reviewed (Birks and Grimley Evans 2002; Ernst et al. 1999; Oken et al. 1998). This present review aims to fill this gap by providing up-to-date information on whether clinical studies of Salvia spp. and Mellissa officinalis support their traditional use as cognition enhancers. To inform herbal practice it will evaluate clinical studies to assess whether the results have determined safe, effective herbal strategies and prescription for prophylaxis, management and amelioration of cognitive decline. 2. The literature review 2.1. Background: clinical presentation and pathology Although much scientific progress has been made since 1907 when Alois Alzheimer first described a case of dementia with â€Å"peculiar patches† disseminated throughout the cerebral cortex (Collins 1997: 185), there is still much to learn about the aetiology and pathogenesis of Alzheimers disease and other dementias (Knapp et al. 2007: 11). The onset of dementia is insidious, often beginning as mild cognitive impairment (MCI) and progressing to severe dementia over time (Loveman et al. 2006: 4). In the early stages, episodes of mild forgetfulness or misplacing possessions are often attributed to normal aging. Patients commonly suffer from anomic aplasia and agnosia but retain language comprehension (Collins 1997: 186). Dementia becomes more apparent when sufferers are unable to learn new information, to register the content of a conversation, or to recall recent events or the names of family members. Unlike those with benign forgetfulness, dementia patients are unaware of their amnesia. Frequently, there are mood changes, depression and other psychologic disturbances. Language comprehension fails (aphasia) and eventually patients may simply repeat what they hear or be unable to speak at all. Visuospacial deficits usually occur at a late stage (Collins 1997: 186). Those affected have difficulty in copy drawing simple obj ects. Differential diagnosis between MCI subtypes of various and complex aetiologies is challenging (Kidd 1999: 145). As some MCI subtypes are reversible (Levey et al. 2006: 992) prophylaxis for dementia could potentially encompass a range of varied or unknown aetiologies and risk factors. Knowledge of these and an awareness of differing clinical presentations are therefore important (Levey et al: 991). Additionally, an understanding of current orthodox treatment strategies and key neurochemical impairments in dementia can inform herbal practice of the most likely therapeutic actions of herbs. 2.1.1. Alzheimers disease As clinical studies have indicated that mild to moderate Alzheimers disease (AD) responds better to allopathic drugs than severe AD (Levey et al: 2006: 993), to prevent transition of MCI to AD early diagnosis is important. Evidence suggests that MCI associated with memory loss most commonly leads to AD (Levey et al. 991) and results of a clinicopathologic study of 80 subjects with MCI through to autopsy suggest that depression is one of the first features of AD (Galvin et al. 2005: 763). Formation of diffuse neuritic senile plaques in the brain is characteristic of AD but as these can only be determined from biopsy (Collins 1997: 186) probable diagnosis is made by clinical neuropsychological testing (Grossman et al. 2006: 986) such as the Mini Mental state Examination (MMSE) (Alzheimers Society 2002: 436), while magnetic resonance imaging can corroborate diagnosis by identifying areas of temporal neuronal loss (Vandenberghe and Tournay 2004: 347). Progression of AD is unremitting for around 5-10 years until death ensues. In the final stages sufferers may develop apraxia, with difficulty in performing familiar tasks. A common cause of death is pneumonia when patients eventual difficulty with eating results in aspiration pneumonia (Collins 1997: 186). The loss of faculties has been ascribed to both structural and neurochemical abnormalities (Perry et al. 1996: 1063). Senile plaques in the brains of AD patients contain amyloid and tau protein (microtubule associated protein) (Collins 1997: 188). Since isolation of b-amyloid peptide from cerebral vessels in AD patients (Wong et al. 1984: 8729), the accepted hypothesis for the pathogenesis of AD has been the ‘amyloid hypothesis, which proposes that AD is due to excessive formation of extracellular b-amyloid (Ab?) from amyloid precursor protein (APP), a membrane protein in neurons (Grossman et al. 2006: 986). It is thought that Ab molecules initiate a toxic cascade long before plaque forms by causing an inflammatory reaction, disrupting synaptic function and causing neurons to degenerate (Grossman et al. 986) with a loss of cholinergic fibres in the basal forebrain. In vitro results suggest that Ab enters mitochondria and induces free radical damage (Reddy 2006: 9). Intracellular neurofibrillary tangles are believed to be formed by abnormal phosphorylation of tau proteins (Tanzi and Bertram 200 5: 545), particularly in the hippocampus and neocortex, areas of the brain involved in memory (Mantle et al. 2000: 202). To date, thirteen genes have been implicated in AD (Bertram et al. 2007: 17). Of sporadic late onset Alzheimers up to 40% of cases may be due to a faulty gene on chromosome 21, ApoE4, an isoform of the ApoE gene that encodes for apolipoprotein, an astrocytic protein that may play a role in the reparative process in the brain. ApoE4s pathogenetic mechanism may be to enhance amyloid deposits within tissue by accelerating cleavage of b-peptide (Collins 1997: 189). Possession of a gene implicated in AD does not necessarily result in its development, the likelihood of which is further complicated by the potential role of environmental factors such as viruses and toxins in combination with genetic factors (Bird 2005: 864). 2.1.2. Vascular dementia Vascular dementia (VaD) is any type of dementia caused by cerebral blood vessel disease (Micieli 2006: S37). Onset of VaD is usually abrupt. Imaging may reveal areas of multiple infarcts (Collins 1997: 191) but their presence does not necessarily imply dementia (Grossman 2006: 987). According to Looi and Sachdev (1999) it is not possible to differentiate between AD and VaD with neuropsychological testing. Speech and language difficulties associated with vascular dementia may be mild or there may be a more pronounced aphasia as in multi-infarct VaD (Collins 1997: 191). 2.1.3. Frontal lobe dementia Frontal lobe dementia or Picks disease is uncommon and is characterised by neuronal loss and gliosis. Rarely, there are fibrillary inclusion bodies in the neurons. Presentation of frontal lobe dementia differs from AD in that the first symptoms are a change in personality rather than memory loss (Collins 1997: 193). 2.1.4. Lewy body dementias Dementia with Lewy bodies may differ to AD in its presentation in that patients suffer from marked visual hallucinations. Additionally, cognition tends to fluctuate between normality and confusion. Parkinsonian features such as shuffling gait, tremor, bradykinesia and rigidity are prevalent. Sleep behaviour disorder, such as acting out attacking themes, may appear years before other signs of the disease (Grossman et al. 2006: 989). 2.2. Risk factors Factors believed to pose a risk for developing dementia include cardiovascular disease, being female, a family history of dementia, Downs syndrome, older age, head trauma, diabetes and lower educational standards (Collins 1997: 186, 188; Lebson et al. 1997: 301). 2.2.1. Cardiovascular disease: Patients may have more than one type of dementia concurrently (Beers et al. 2006: 1811). This is compounded by results of a number of epidemiological studies suggesting that cardiovascular disease increases the risk of developing AD (Stampfer 2006: 12). Using transcranial Doppler ultrasonography Sun et al. (2007: 152) demonstrated diminished cerebral blood flow velocities in MCI patients who also carried the ApoeE4 allele. Risk factors for VaD are believed to include artherogenic factors such as hypertension, hyperlipidaemia, diabetes, and cigarette smoking (Micieli 2006: S38). Conversely, there are indications from clinical trials that nicotine has a protective effect for AD (Breteler et al. 1992: 71). Results of a randomised, double-blind, multicentred trial in which subjects with hypertension were treated with antihypertensives or placebo suggest that hypertension is a risk factor for developing both AD and VaD. Antihypertensives reduced risk by 55%. The results were significant as subjects had similar characteristics, the sample size was large (3228) and equally divided into placebo and treatment groups. Median follow-up was 3.9 years (Forette et al. 2002: 2047). 2.2.2. Head trauma: A meta-analysis by Fleminger et al. (2003: 858) replicated earlier findings by Mortimer et al. (1991) that head injuries pose a risk for AD but only in males, thought to be due to an early protective effect of oestrogens in females (Fleminger et al. 860). Bias may have been introduced into both studies as informants recalled the injuries. 2.2.3. Diabetes mellitus: Given that diabetes mellitus (DM) is a known risk factor for vascular disease it is not surprising that most studies on the development of vascular dementia in DM patients have shown a positive association (Biessels 2004: 10). Studies on DM as a risk factor for AD, however, have yielded conflicting results, possibly due to study limitations such as small sample sizes and selection bias (Leibson et al. 1997: 301). Large longitudinal studies may be more reliable. A population-based historical cohort study of 1,455 cases followed over 9,981 person years found a statistically significant positive association (Leibson et al. 304). According to results from the Framlingham Study, diabetes may not be an independent risk factor for developing AD but risk is strongly associated with possession of the ApoE4 genotype (Akomlafe et al. 2006: 1551). 2.2.4. Hormones: Women are twice more likely than men to suffer from AD. Although this may be partly due to women having a longer life expectancy (Beers et al. 2006: 1814) there is evidence to suggest that a decline in endogenous oestrogen in later life plays a role in its pathogenesis. Oestrogen is believed to stimulate cholinergic activity, reduce oxidative stress related cell damage, reduce vascular risks, reduce Ab formation and promote synaptic activity (Zandi et al. 2002: 2123; Hoskin et al. 2004: 141). Evidence from studies to determine whether oestrogen-containing hormone replacement therapy (HRT) in women has a protective effect on the brain, however, is conflicting (Colucci et al. 2006: 1376) but this may be due to differences in methodology and confounding factors (Resnick and Henderson 2002: 2171). For example, in one large prospective study that found a positive correlation between HRT use and a significant reduction in AD development, patients with dementia were asked q uestions regarding previous use of HRT (Zandi et al. 2124) yet accurate recall in a dementia sufferer cannot be guaranteed. Results of a retrospective case-control study suggesting the likelihood of women developing AD increases with number of pregnancies (Colucci et al. 2006: 1375) could be of little value. Cases with previous head injuries, low educational standards, both considered risk factors for AD (Collins 1997: 186; Fleminger et al. 2003: 858), and those who had used HRT, were not excluded from the study. There is evidence to suggest testosterone may delay AD onset in men. Men over 32 years of age who were free from AD at baseline (n = 574) were followed for a mean of nineteen years (Moffat et al. 2004: 188). Long-term free testosterone levels were significantly lower in men who developed AD. Due to conflicting results and confounding factors in the research the clinical evidence for risk factors for dementia is inconclusive. However, although more research is needed the results can assist in informing herbal practice. 2.3. Orthodox treatment strategies As cholinergic neurotransmitters are believed to have a role in memory function (Grossman et al. 2006: 985) symptomatic treatment for subtypes of dementia is similar and focuses on acetylcholinesterase (AChE) inhibition with drugs such as donepezil, rivastigmine and galantamine (Loveman et al. 2006: 8). According to Delagarza (2003: 1366) loss of cholinergic neurons causes a decrease in acetylcholine and subsequent drop in AChE with a compensatory rise in butylcholinesterase (BChE). Nicotinic receptors also decrease. Rivastigmine also inhibits BChE; galantamine also acts on nicotinic receptors. Depression in dementia is treated with non-anticholinergic antidepressants as anticholinergic drugs exacerbate symptoms (Beers et al. 2006: 1814). Another drug, memantine, a N-methyl-D-aspartic acid (NMDA) receptor antagonist (Grossman et al. 987), licensed to treat moderate to severe AD, acts by modulating the action of the neurotransmitter glutamate, which is believed to be associated with c holinergic damage and neurodegeneration when secreted in excess (Loveman et al. 2006: 8). Dizziness, diarrhoea, headaches, nausea and vomiting were found by a meta-analysis of dementia drugs to be common adverse events with anti-cholinesterases and memantine (Loveman et al. 2006: 49). Furthermore, their long-term benefits are inconclusive (Loveman et al. 145). Similarly, their use for vascular or Lewy body dementia is controversial as a review of clinical trials data deems there is insufficient evidence for their efficacy. Trials were of generally poor quality and with inconsistent findings (Maggini et al. 2006: 457). Other potential drugs for AD include 70 new compounds formulated to interfere with the toxic amyloid cascade or to target inflammation, oxidation or apoptosis (Grossman et al 2006: 987). As g-aminobutyric acid (GABA) agonists can impair memory GABA antagonists are also being developed (Association of the British Pharmaceutical Industry). 2.4. Potential herbal treatment strategies In view of the hypothesised pathological sequelae, risk factors and current orthodox treatment of dementias, efficacious herbs for these conditions could potentially have one or more of AChE-inhibiting or cholinergic, antidepressant, hypotensive, hypoglycaemic, antioxidant, anti-inflammatory, GABA modulator, nicotinic agonist, testosterogenic and oestrogenic actions. According to Kennedy and Scholey (2006: 4614) orthodox AChE inhibitors are not well tolerated by patients as they are toxic alkaloids and European plants traditionally used for cognitive enhancement may therefore provide non-alkaloid safer alternatives. To this end Salvia officinalis, Salvia lavandulaefolia and Melissa officinalis, members of the Labiatae family (Lamiaceae), have been extensively investigated in vitro. 2.4.1. Salvia spp. Salvia is the largest genus in the Labiatae family with over 700 species. The most common European species are Salvia officinalis L (garden or common sage) (Figure 1) and Salvia lavandulaefolia Vahl (Spanish sage), both of which originate on the shores of the Mediterranean (Kennedy and Scholey 2006: 4614). S. officinalis is an aromatic, evergreen shrub up to 75 cm in height with greyish-green oblong to lanceolate opposite leaves covered in a fine down. It has bluish-violet, two-lipped flowers arranged in whorls (Wildwood 1998: 202). S. lavandulaefolia has narrower leaves and a lower spreading habit (Sergei Savelevs Database). Sage was used in medieval Europe as a tisane for prolonging life and is a traditional spring tonic for strengthening weak constitutions (Lipp 1996: 63). According to Culpepper (1826: 147) ‘Sage is of excellent use to help the memory, warming and quickening the senses and an old country remedy, which indicates its efficacy for inflammation: ‘A sunburnt face is eased by washing with sage tea (Page 1978: 41). Other traditional uses are for headaches and migraine (Page: 34). The major active constituents of the leaves of both species are believed to be the volatile oils (1.0-2.8%), containing monoterpenes such as a-pinene, b-pinene, 1-8-cineole, camphor, geraniol and thujone (Kennedy and Scholey 2006: 4615). S. officinalis contains around 50% a- and b- thujone whereas only traces have been found in S. lavandulaefolia. As thujone, a terpenoid ketone, is potentially neurotoxic, S. lavandulaefolia may provide a safer alternative than S. officinalis to orthodox dementia drugs (Perry et al. 1999: 530). However, S. officinalis is toxic only at doses of over 15 g (Grainger-Bissett and Wichtl 2001: 441) but the oil should not be ingested. Both species contain polyphenolic compounds including rosmarinic acid, methyl carnosate, luteolin, luteolin-7-0-glucoside and caffeic acid (Kennedy and Scholey 4615), triterpenes eg oleanic acid and the flavonoids 5-Methoxysalvagenin (Barnes et al. 2002: 408) and hispidulin (Johnston and Beart 2004: 809). 2.4.2. Melissa officinalis M. officinalis L (balm, lemon balm) (Figure 2) originates from the eastern Mediterranean region and western Asia and is now widely cultivated in the west (Grainger Bissett and Wichtl 2001: 329). It is a bushy perennial, about 60 cm high with bright green, lemon-scented leaves in opposite pairs. Small labiate flowers grow in whorls and change colour from pale yellow to white or pale blue. Fresh leaves should be collected when young (Wildwood 1998: 175). It has been in medicinal use as a nervous system restorative for over 2000 years (Kennedy and Scholey 2006: 4617). The London Dispensary (1696 cited in Grieve 1931) states: ‘An essence of Balm, given in Canary wine every morning will renew youth, strengthen the brain John Evelyn wrote: ‘Balm is sovereign for the brain, strengthening the memory and powerfully chasing away melancholy (cited in Grieve 1931). There are no known contraindications or adverse effects (Barnes et al. 2002: 339). M. officinalis contains 0.2-0.3% essential oil (EO) consisting of over 70 components including around 60% monoterpenoid aldehydes and over 35% sesquiterpenes. The principle monoterpenes include citronellol, neral, geranial, methyl citronellate, ocimene; major sesquiterpenes include b-caryophylene and germacrene D. The herb also contains flavonoids, caffeic and chlorogenic glycosides, polyphenolic acids such as rosmarinic acid, and triterpenes (Granger Bissett and Wichtl 2001: 330). 2.5. Possible mode of action of phytochemical constituents in dementia 2.5.1. Antioxidant properties Numerous studies have been conducted on Salvia officinalis in a search for natural antioxidants to use in the food industry. Consequently, results of chemical tests on purified extracts of the herb have suggested that phenolic compounds rosmarinic acid, carnosic acid, carnosol, carnosoic acid, rosmadiol, rosmanol, epirosmanol, isorosmanol, galdosol methyl carnosate, 9-erythrosmanol and luteolin-7-0-glucopyranoside have significant antioxidant activity (Bertelsen et al 1995: 1272; Cuvelier et al. 1994: 665; Pizzale et al. 2002: 1651; Miura et al. 2002: 1848; Wang et al. 1998: 4869). S. lavandulaefolia dried leaf extracts in ethanol, chloroform and water, and various EO monoterpenes were assayed for antioxidant properties in phospholipid microsomes. The extracts and monoterpenes a-pinene, b-pinene, 1-8-cineole, camphor and geraniol and thujone all showed significant antioxidant activity (Perry et al. 2001: 1351). The extracts showed greater antioxidant activity than any individual monoterpenes, which suggested a synergistic effect (Perry et al. 1352). Ferreira et al. (2006: 35) measured the antioxidant properties of EOs, decoctions and ethanolic extracts of M. officinalis and S. officinalis relative to b-carotene. The EO and decoctions of both herbs showed significant antioxidant activity. Lima et al (2007) found methanolic and aqueous extracts of S. officinalis prevented lipid peroxidation in hepatoma cells. As there were more phenolics in the methanol extract it was thought there were other antioxidant compounds in the aqueous extract. Ethanolic EO extract from dried M. officinalis investigated for its ability to inhibit lipid peroxidation in vitro showed a dose-dependent (10-20 mg) 80-90% protection of linoleic acid from peroxyl radical attack. As no rosmarinic acid was detected in the EO the antioxidant action was attributed to squalene (Marongiu et al. 2004: 790). Considering there are potentially 70 constituents in the EO it is unlikely that this would have been the only active phytochemical but composition of the oil varies according to harvesting, origin and climate (Grainger-Bissett and Wichtl 2001: 329). Interestingly, M. officinalis prepared as a tea demonstrated significant antioxidant capacity, which corresponded to high phenolic content, when assayed with the ABTS (2,2/-azinobis 3-ethylbenzothiazoline-6-sulfonic acid) radical decolourisation assay (Ivanova et al. 2005: 147). 2.5.2. Anti-inflammatory activity Chloroform, aqueous and ethanol extracts and monoterpenes of S. lavandulaefolia, were tested for their ability to inhibit formation of pro-inflammatory eicosanoids thromboxane B2 (TXB2) and leukotriene B4 (LTB4) in leucocytes (Perry et al. 2001: 1348). The chloroform and ethanol extracts showed significant inhibition of LTB4. Alpha-pinene and geraniol showed weak selectivity for LTB4 and TXB2 respectively (Perry et al. 1351). The results support the traditional use of S. lavandulaefolia as an anti-inflammatory herb but indicate that it is the sum of the whole plant phytochemicals acting in synergy that are likely to contribute to this action. A standardised ethanolic extract containing 9.9% rosmarinic acid (RA) from the leaves of S. officinalis reduced Ab-induced neuronal cell death, Ab-induced lipid peroxidation, reactive oxygen species formation, DNA fragmentation and tau protein hyperphosphorylation in vitro (Iuvone et al. 2006: 1143). Kimura et al (1987) found rosmarinic acid (RA) had the ability to inhibit pro-inflammatory cytokines in human polymorphonuclear leucocytes (PMNs) in vitro. As both species contain RA these results suggest antioxidant, anti-inflammatory and neuroprotective properties of M. officinalis and the Salvia spp. against Ab-induced neurotoxicity. 2.5.3. Oestrogenic activity A range of concentrations of EO, ethanolic, chloroform and aqueous extracts and isolated monoterpenes of S. lavandulaefolia were assayed in yeast culture for oestrogen-binding properties. The EO showed weak oestrogenic activity at low concentrations. The aqueous and ethanolic fractions and geraniol showed significant oestrogenic activity (Perry et al. 2001: 1352). The results of this experiment support S. lavandulaefolias use as an oestrogenic herb. The effects of S. officinalis in combination with Medicago sativa were assessed on menopausal symptoms related to oestrogen deprivation. Hot flushes and night sweats were completely eliminated in 20 out of 30 women (De Leo et al. 1998: 207). These effects were attributed to dopaminergic actions but it is not clear for which herb. S. officinalis does, however, contain geraniol found to be oestrogenic in vitro (Perry et al. 2001: 1352). 2.5.4. Acetylcholinesterase inhibitory activity M. officinalis EO demonstrated strong AChE inhibition in homogenised human brain tissue but ethanolic extract of the dried leaf had no effect. Ethanolic fresh leaf extract showed a weak effect (Perry et al. 1996: 1064). Conversely, when EOs and ethanolic extracts of M. officinalis were assayed in solution with AChE negligible results were obtained for its inhibition by EO and significant results for its ethanolic extract (Ferreira et al. 2006: 34). Dried, reconstituted ethanolic, ethyl acetate or aqueous extracts of M. officinalis, yielding 10mg/ml, demonstrated weak AChE inhibitory activity when assayed in a chemical system using thin layer chromatography (Salah and Jà ¤ger 2005: 146). The herbs were purchased from local suppliers in the Lebanon so their quality is unknown. S. officinalis EO and ethanolic extract assayed in solution with AChE showed moderate AChE inhibitory activity (Ferreira et al. 2006: 34). Moderate (dose-dependent) AChE and weak BChE inhibition was demonstrated by ethanolic extracts of fresh and dried S. officinalis and S. lavandulaefolia in human brain homogenates. The EOs had significant effects but not the individual constituents (camphor, thujone, cineole, caffeic acid and borneol) (Perry et al. 1996: 1066). The findings suggest a major synergistic effect of the constituents (Perry et al. 2000: 895), which was later confirmed by Savelev et al. (2003: 667). The results for camphor conflict with another experiment in which S. lavandulaefolia EO and isolated monoterpenes a-pinene, 1-8-cineole and camphor demonstrated AChE inhibitory activity in human erythrocytes. Ethanolic extracts of dried S. officinalis, S. lavandulaefolia and M. officinalis were assayed for acetylcholine (ACh) receptor activity in human brain homogenate. All plants demonstrated ACh receptor activity and M. officinalis had the highest nicotinic displacement value (Wake et al. 2000: 108). 2.5.5. GABA modulation Methanol extract from S officinalis leaves revealed the flavonoids apigenin, hispidulin and cirsimaritin functioning as benzodiazepine receptor-active components (Kavvadias et al. 2003: 113), suggesting a potential calming effect for the herb, which may be relevant to AD. 2.6. Evaluation of in vitro studies According to the results all three herbs may have AChE inhibitory, anti-inflammatory and antioxidant properties, and S. lavandulaefolia and S. officinalis may have and oestrogenic properties (Appendix I, Table 1, page 36) and a sedative effect for S. officinalis. Although these results are interesting in vitro systems cannot be extrapolated to humans and clinical evidence is necessary to support findings. For example, they cannot determine effective human dosage or mode of administration. They largely do not account for potential synergistic effects of the herbs nor do they provide an indication of in vivo physiological, pathological and genetic, or environmental, influences. Furthermore, the extent to which phytochemicals in herbs are effective in dementia may depend upon their bioavailability in the brain (Anekonda and Reddy 2005: 371). It is worth noting, however, that as terpenoids tend to be lipophilic they are able to cross the blood brain barrier (Houghton and Howes 2005: 12). Some results are conflicting but they may depend on methodological quality and design. The experiments cited above vary widely in their approach with regard to extraction methods and assay methods. Savelev (2003: 667) has demonstrated how two different methods used for exploring interactions between the same agents may give different results when applied to the same set of data. Consistency of results may also be affected by differences in harvesting times and quality of herbs. Results for M. officinalis are particularly inconsistent but, according to Perry et al. (1996: 1068) most commercial sources of the EO are adulterated. Additionally, variation in media composition is known to affect the outcome of in vitro tests (Maurer and Kuschinsky 2006: 73). Consequently, in vitro experiments can only provide an indication of the clinical efficacy of therapeutic interventions. However, despite the inherent difficulties of in vitro research with herbs, there is considerable consistency with their potential value in dementia prophylaxis and management (Appendix I, Table I, page 36). Promising results in vitro of constituents of plants traditionally used to enhance memory, and subsequent interest in their potential actions in the brains of human patients, has generated clinical trials of M. officinalis and Salvia spp. for dementia. These will be reviewed. 3. Method A computerised literature search was conducted on the Allied and Complementary Medicine Database (AMED) including CINAHL Database, EMBASE, Pascal Biomed, Biological Abstracts, RCN Journals Database and IPA (International Pharmaceutical Abstracts); PubMed, the Cochrane Collaboration, Bandolier, the NHS Centre for Reviews, The National Research Register, ADEAR (Alzheimers Disease Education and Referral Centre database), PLoS (Public Library of Science), Herbalgram and Alt HealthWatch as well as hand-searching in books and journals. Literature searches dated back to 1985 and the final search was in April 2007. Key words in medical subject headings (MeSH) for an initial search in various Boolean combinations were: memory, cognitive dysfunction, dementia, Alzheimers, herbal, botanicals, phytotherapy, complementary and alternative. Also, in a second search these MeSh terms were entered with key herbs: Salvia, sage, Melissa and lemon balm. Inclusion criteria Controlled clinical trials, observational studies and case reports. Herbs for which there are at least two clinical studies in relation to cognitive enhancement. Exclusion criteria Due to the limitations and ethical considerations of animal experiments the review is restricted to human trials. Trials with combined preparations are excluded. Due to time constraints and a restriction to papers in the English language a complete systematic review is not viable at this time. To eliminate

A.V Lundstedt- Scandinavian Realist

Brief Historical Background of A V Lundstedt Lundstedt (1882-1955) was a Swedish jurist and a proponent of Scandinavian Legal Realism. He was also a professor of Law at the University of Uppsala in Sweden, from 1914 to 1952. Similarly to Haegerstrom, Ross and Olivercrona, he resisted the exposition of rights as metaphysical entities- contending that realistic legal analysis should dispense with such ideology. Beyond being a prominent tort law scholar, Lundstedt was also a social democratic member of the Swedish Parliament from 1929 to 1948.The body of his work can be viewed as an attempt to revolutionise the field of jurisprudence by transforming the law into a catalyst for political and social reform. Legal Knowledge and Legal Science Lundstedt is regarded by some as the most extreme and buoyant of the Scandinavian realists. Lundstedt advocated that legal science should be conceived of as a real science, and to that end he rejected traditional legal science. His main objection to tr aditional legal science was that it employed metaphysical concepts; inter alia, â€Å"right†, â€Å"duty†, â€Å"wrong –doing† and â€Å"guilt†.The focal point of his theoretical work was his sustained attacks towards what he termed the method of justice. The method of justice is the turn of phrase used by Lundstedt to denote traditional legal science, (derived from the traditional method of natural law), which holds that human beings are persons endowed with legal rights and duties. He was of the view that the term â€Å"right† and other metaphysical concepts employed by traditional legal science, were all illusory concepts ; that they were naught else but an intellectual play with expressions of feeling – as if something real were designated thereby.Such concepts could not be used because they did not refer to any natural facts – therefore the terms were devoid of any conceptual meaning. To cement the sphere of legal knowledg e as a bonafide, real science – legal science must be an empirical science, which deals with social facts: â€Å"As a science jurisprudence [legal science] must be founded on experience, observation of facts and actual connections, and consequently be a natural science. † He perceived that terms such as â€Å"legal order† and legal rules† are not concepts but merely empty words that ought to be replaced with the term â€Å"legal machinery†.Legal machinery in this vain, is used to denote the psychological factors that determine human behaviour in relation to the use of legal vocabulary. He postulated that legal concepts such as â€Å"right† and â€Å"duty† are also bereft of any conceptual meaning and should be abandoned. Therefore, the legal vocabulary of traditional legal science is to be understood as a matter of using words and noises to cause the appropriate behaviour; these words and noises are not concepts which could be said to be the reasons for human conduct.However Lundstedt conceded in his writings that, there are some realities that correspond to the concept of â€Å"rights†- namely, a position of advantage and safety, which is a result of the regular enforcement of certain legal rules and the psychological effects this had on the minds of people. In short, because the courts come to one’s aid when a person alleges an infringement of a â€Å"right†, a layman is left with the psychological impression that his/her right is real because the courts have sought to address the â€Å"wrong† they were done.As discussed earlier, the term â€Å"right† does not designate anything observable, tangible nor anything capable of sensory perception. One cannot show you their right- and thus Lundstedt argued that a â€Å"right† is a fictitious entity. It must be borne in mind that Lundstedt’s line of reasoning is not what is understood by the term â€Å"rights† wh en referenced in legal science nor in the public mind, and therefore he argued that it would be better still, to do away with the concept altogether.This stringent scientific attitude of Lundstedt’s , was committed to replacing the magical/metaphysical terms associated with traditional legal science scholarship, with scientific concepts having a basis in reality. In Lundstedt’s view, the scientific concepts were essentially empirical laws, stating the causal relations between the legal words and their effects upon human behaviour. The Method of Social Welfare Lundstedt was of the view that there was no objective means to define the requirements of justice, and that invocations of justice cloaked purely subjective preferences – i. e. he divergences of opinion concerning whether the death penalty is just. Alternatively he argued that such invocations of justice were representations of unacceptable metaphysical claims – i. e. in ancient Rome it was believed that the Emperor was the chosen emissary of God. For this reason, Lundstedt endeavoured to replace the method of justice with the method of social welfare, in solving legal problems. The method of social welfare is premised on social aims- that the aim of all legal activities such as judicial decision making, and the promulgation of legislation should be geared toward benefiting mankind.He emphasised that his notion of social welfare was not a moral or philosophical principle, but that the term should be understood in a descriptive sense; representing the actual valuations of people in society. He ardently denied that his method of social welfare was in anyway way related to the ethical theories of Jeremy Bentham or John Stuart Mill, as his theory was criticised as just another version of utilitarianism. For example, Lundstedt stated the purpose of punishment is not for revenge, but to maintain a system that is for the benefit of all i. . a system in which a thief is held liable for his damages. Were the purpose of the law to be â€Å"justice†, he opined that it could be argued that theft should be condoned if the thief is considerably worse off than the person(s) from whom he stole. (An illustration of why he rejected the concept of justice) Lundstedt argued that the method of social welfare is a scientific approach, as it is premised upon the reality of human needs and wants; and that the aforenamed are facts to be known by science.Lundstedt believed that his method should inform and shape legislation; as it was centred on the objective study of social conditions, and on the practical effects and capabilities of the law in improving society for all its members. In furthering his views that the law should be used as a vehicle for social reform, Lundstedt used this method as a line of argument against a proposed prohibition law in the 1920s. He was of the view that such a ban would harm the public respect for the law.In the 1930s he once again used his method to advocate for the decriminalization of homosexuality, which was quite a radical stance to take, taking into account the times in which he lived. Lundstedt’s arguments have been criticised as being not altogether convincing, as he failed to prove that people generally and truly supported the values he advocated. Moreover, he did not provide a measure for those situations in which the valuations of people differed greatly. ——————————————– [ 1 ].J Bjarup, The Philosophy of Scandinavian Legal Realism (2005) [ 2 ]. J-O Sundell, Vilhelm Lundstedt- A Biographical Sketch , (2010) [ 3 ]. Supra [ 4 ]. J Strang, Two Generations of Scandinavian Legal Realists,(2009) [ 5 ]. T Spaak, Naturalism in Scandinavian and American Realism: Similarities and Differences, [ 6 ]. Supra [ 7 ]. J Bjarup, The Philosophy of Scandinavian Legal Realism (2005) [ 8 ]. M Freeman & P Mindus, The Leg acy of John Austin’s Jurisprudence [ 9 ]. A. V. Lundstedt, Legal Thinking Revised, (1956) 10 ]. M Freeman & P Mindus, The Legacy of John Austin’s Jurisprudence, [ 11 ]. Supra [ 12 ]. M Freeman & P Mindus, The Legacy of John Austin’s Jurisprudence [ 13 ]. J Strang, Two Generations of Scandinavian Realists,(2009) [ 14 ]. Supra [ 15 ]. J Bjarup, The Philosophy of Scandinavian Legal Realism, (2005) [ 16 ]. Supra [ 17 ]. Some believe that it is the retribution of society that justifies the death penalty, whilst others aver that it is not for mortals to deprive the ‘killer’ of life.Whichever side of the coin you fall, your perception as to what is just and moreover whether the death penalty is or is not an injustice depends heavily upon your feelings and values concerning human life. [ 18 ]. J Bjarup, The Philosophy of Scandinavian Legal Realism, (2005) [ 19 ]. Supra [ 20 ]. J Strang, Two Generations of Scandinavian Realists,(2009) [ 21 ]. Supra [ 22 ]. J -O Sundell, Vilhelm Lundstedt- A Biographical Sketch , (2010) [ 23 ]. J Bjarup, The Philosophy of Scandinavian Legal Realism, (2005)

The Sad Theme of the Hunchback of Notre Dame - 806 Words

Is always a happy ending? The Hunchback of Notre Dame is a book by Victor Hugo written in 1831. Victor Hugo was born in Besancon, France on February 26, 1802. The Hunchback of Notre Dame is a French Romantic/Gothic genre book. Hunchback of Notre Dame involves around Quasimodo a hunchback. The Hunchback of Notre Dame has many different themes. I believe one of the biggest theme is you shouldnt judge based on appearances. The Hunchback of Notre Dame is a very sad book, but with it being sad there are many great themes such as judgment, and topics like characters, setting, and plot. Judgment based on appearance is a big theme in The Hunchback of Notre Dame. Quasimodo is very kind hearted, but others otherwise because his appearance. Quasimodo is described by having â€Å"a huge head, bristling with red hair; between his shoulders an enormous hump, a counterpart perceptible in front; a system of the thighs and legs so strangely astray that they could touch each other only at the knees , and, viewed from the front, resembled the crescents of two scythes joined by the handles; large feet, monstrous hands† (33). Because of his appearance people treat him like a monster a terrible, ugly human being, But this isnt true at all Quasimodo is shown to have a sweet personality. Then we have Claude Frollo the antagonist. Claude is a priest, so you’d think hes a good person, but you are very wrong. Claude is the reason Quasimodo commits violent acts as Quasimodo does what his fatherShow MoreRelatedEdward Scissorhands Essay2682 Words   |  11 Pagesfinance Thompsons screenplay while giving Burton complete creative control. At the time, the budget was projected to be around $8–9 million. When writing the storyline, Burton and Thompson were influenced by Universal Horror films, such as The Hunchback of Notre Dame, The Phantom of the Opera, Frankenstein, Creature from the Black Lagoon, as well as King Kong and various fairy tales. Burton originally wanted to make Scissorhands as a musical, feeling it seemed big and operatic to me but later droppedRead MoreRise of the English Novel5132 Words   |  21 Pageseasier for people to learn to read and helped to facilitate the rise of the English novel. As the novel became a more established form of literature, a large number of them began to be published every year. These novels often followed different themes and writing styles, and as the amount of novels published increased one genre was no longer sufficient. The original novel genre was based on the use of realism but as the novel evolved several sub genres developed. These were more specifically, the

Civil Rights and Civil Liberties Essay - 1301 Words

l CIVIL RIGHTS AND CIVIL LIBERTIES AXIA COLLEGE OF UNIVERSITY OF PHOENIX POS / 110 Civil Liberties: The Right to Privacy Civil Liberties 2 Sub Category: Controversy over Abortion In this assignment I will examine civil liberties, main focus on the abortion Controversy. In today’s societies, civil rights and civil liberties are not as common and some are even at risk. Abortion rights are a very special, touchy subject and I believe there will be never a†¦show more content†¦Some women think that the only way off protection than maybe it should be re-considered if sex-education should be a bigger part in todays lessons plan. Also should be parents aware, that not talking to your children make the situation worse. The U.S.A. are number two, behind Russia in statistics with over 1,2 Million abortions a year. Teen pregnancies are sky high, the U.S.A. ranks on number one among the industrial countries; almost 500 000 compare to Canada less than 20 000. What is quite scary, that such an educated country falls so far back. A lot States also ban now, that insurance can cover abortions but on the other hand make birth control not available for the once they needed. So in my view, there should be a new thinking process, what does the country want? It is not just that pregnancies occur but also STD’s and even worse HIV. Where the U.S.A. ranks number 1 in an industrial country as well. So there is another debate, that funding’s from insurances and government funding’s are used for birth control and abortion. But does not a live time treatment for HIV, raising a child through welfare, Medicare and such things put a bigger hole into the countries pocket? 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In the achievement of social liberties and freedoms, laws and statutory arrangements have mustRead MoreCivil Liberties Vs Civil Rights1134 Words   |  5 Pages2017 SLO 1 Civil Liberties vs Civil Rights Democracy in simple sense is understood as rule of people. As said by Abraham Lincoln,† democracy is government of the people, by the people, for the people†. In democracy all the power is seized by the people but, still we find many cases in different parts of the world that the political leaders and government officials and their families having more rights and power as compared to regular people. The violation of civil liberty and civil rights by the governmentRead MoreCivil Liberties And Civil Rights1149 Words   |  5 PagesWhat Role Does Our Civil Liberty and Rights Play In Our Government System? Have you ever put some thought into how our Civil Liberties and Civil Rights work in our system or even attempt to figure out what they are? 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Without certain civil rights being granted by the government, these important rights of expression and suffrage would not exist. There is a difference between civil liberties and civil rights in relation to the government. Civil liberties refer to an individual’s unalienable freedoms that cannot be taken away by political intervention. On the other hand, civil rights are provided by the government in order to promote equality. This ideology

The Battle Of The Civil War - 1390 Words

Challenging the process Lincoln’s most challenging action was when he decided to fight to preserve the Union. In the end the decision to fight the Civil War resulted in the USA remaining one nation rather than splitting into two separate countries. Although Lincoln was criticized for stepping over the traditional bounds of executive power, he was faced with the greatest threat to federal authority in the history of the country (Thomas P., 2008, p. 1-17). There was immense pressure that Lincoln endured during the civil war. Lincoln felt that it was his job to protect the Union from disintegrating. His contribution in the area of freedom for the slaves was extremely challenging. Abraham Lincoln has been honored by the people for his actions†¦show more content†¦1-32). Lincoln’s celebrity spanned the globe by the early twentieth century. A big part of the reason is to rise the United States internationally after 1865. Lincoln came to personify not only principles, but also for American p ower. The global reception of Lincoln thus entailed not only understanding certain political principles but for coming to terms, co-opting with or even opposing an increasingly powerful and active United States. Enabling others to act Lincoln in his speeches, letters, and writings first-person plural sets the tone and adds immeasurably to the impact of intended meaning. The repetition of ‘‘we’’ in the now-canonical opening lines, we are engaged in a great civil war, we are met on a great battlefield of that war. We have come to dedicate a portion of that field, which performs a critical rhetorical function in establishing common ground between speaker and listener in what Aristotle first labeled enthymeme (Field S., 2011, p. 1-17). Education according to Lincoln seemed to be the most important question people would consider, for every man should have sufficient education to enable him to read the history of his own and of other countries, â€Å"By which he may duly appreciate the value of our free institutions to say nothing of the advantages and satisfaction to be derived from all being able to read the scriptures and other works, both of a religious and

The Enemy Within Free Essays

Juan Conde Professor Muniz 19 November 2012 English 67 The Enemy Within Throughout life everyone is forced to face their own worst enemy and will have a lot of trouble confronting and dealing with them that worst enemy will always be themselves. This enemy brings many problems and inner conflicts that are difficult to solve. Everyone has their own way of coping with these problems, some more critical than others. We will write a custom essay sample on The Enemy Within or any similar topic only for you Order Now In the book Drugstore Cowboy, by James Fogle, the main character Bob deals with this dichotomy in different was throughout the book and his two sides are very easily differentiated. Throughout the book Bob is faced with difficult decisions and has the choice of either being that humane and caring man or the cruel and manipulative man that he can be. As he is making these decisions Bob has to not only think of the situation but also make sure that his crew is safe or if he needs to use them. Bob is a very complex individual with two conflicting sides to him, one that is used to show his humane and caring nature and the other is used to intimidate or manipulate people. Deep down, Bob is a caring and humane man. He protects his crew with his life; he puts himself on the line for his crew and for the people he cares about like his mother and Diane. This side of Bob is made very clear when he visits his mother and shows her nothing but respect and he even shows some humility when speaking to her. When Bob’s mom exclaims that Bob is a thief he replies, â€Å"Jesus, Mama, when have I ever stole anything from your house? Name me one thing I ever took from you without telling you? Just name me one thing? † (Fogle58). The way he replies and speaks to his mother shows that he has the outmost respect for her, his way of talking to his mother shows humility. When speaking with his mother he always calls her mama or mom; he never called her by her first name or by anything else. Bob also shows a lot of submissiveness when he is with his mom, it seems like he still feels like a little kid when he talks or confronts her. Bob would do anything for his wife, Diane. Bob loved Diane; when he first met her he felt like she wasn’t like other woman. Bob took Diane cross-roading but had the intentions of stealing her car, instead he fell for her. Fogle comes to explain how Bob felt about Diane, â€Å"Bob loved Diane body and soul by then. Even narcotics had never brought him the pleasure and satisfaction that Diane did back then â€Å"(166). It seems like Bob is truly a caring and humane person because of how he felt and still feels about Diane. Bob seems to put Diane before himself subconsciously he might not want people to see how much he really cares about her but deep down she means everything to him, he will defend her as much as he can. It also seems that Bob only wants to keep Diane happy but he thinks that the only way he can do that is with narcotics. Bob seems to always try to hide how he feels about the people close to him because he is scared that something might happen to them and he just wants them to be safe and out of harm’s way; he is truly a caring and protective individual. On the other hand Bob can also be a very maniacal and manipulative, he can even seem inhuman and cruel; he uses any means necessary to obtain what he is after, he finds a way to manipulate and control people to make his plans go how he wants. Bob will use people to control a situation to go in his favor without any resentment about what happens to the other people. Bob show his manipulative side when he told his crew: â€Å"I just wrote the narcos and anonymously told them that the reason they could never catch Bob Hughes for possession of narcotics was that he had an arrangement with the guy that lived on the north side of him†(Fogle 82). Bob doesn’t seem to have any problem using people to get what he wants he doesn’t seem to have a conscience. Most of Bob’s actions show how he is a manipulative man, he uses people in order achieve what he wants. Bob would go through any means necessary in order to get whatever he wants. Through Bob’s actions it seems that he is nothing but a selfish man that only cares about what he will receive from the situation. It seems that Bob only wants to do only what he will benefit from; he doesn’t seem to care about anything or anyone else. Bob is also cruel and inhumane towards his own crew. When Bob walks into the room after an attempt to get drugs he sees Nadine’s dead body and a hat on the bed; he then pays more attention and is more worried about having a hat on the bed than Nadine being dead. After seeing Rick balling and crying over her â€Å"Bob shook his head in disgust. ’She beat you, man. Your own woman beat you out of part of your own cut on a score. She got what she deserves’† (Fogle 134). This shows how Bob not only doesn’t care about what happened to her, but also he has been desensitized to death, he only cares about the fact that she wasted the drugs and left them with the burden of having to get rid of a dead body. Bob only sees that because he feels like she cheated them out of the drugs and they can’t do anything about it. Bob also seems to react this way because of how Nadine has acted in the past, she would complain a lot and always wanted more than she could handle. Throughout the book Bob shows that he can and will use and manipulate people into doing what he wants so that he gets what he wants and whatever it is he has been working for. In both scenes Bob shows how he can get into people’s heads and make sure that they do whatever he wants them to do to achieve whatever he wants. Life is full of nothing but conflicts and difficult situations and everyone has their own way of dealing with them. Throughout the book, Drugstore Cowboy, Bob is put through various difficult situations which he handles in one of two ways: being a humane and caring man or being a manipulative and maniacal man. Bob is depicted as both a caring and maniacal man in the sense that he cares a lot about his crew but also if the situation calls for it he will not care at all for them. Bob will manipulate anyone who gets in his way of obtaining what he wants, but he cares for those close to him but will sometimes even use them in order to get what he wants. Bob has a very complex way of living and thinking and it is showed in various ways throughout the book. Work Cited Fogle, James. Drugstore Cowboy. New York: Dell Publishing, 1990. Print. How to cite The Enemy Within, Essay examples

System Analysis and Design

Question: Discuss about implementing an automated management system for the medical system. Answer: Introduction The report presented here discuss about the business process operations that has been manually conducted in the medical center. The current operation process in the medical center is totally manual such as payment system, record keeping and schedule and other bookings. This kind of manual functionality do cause slower operations in the medical center and can lead to misplacing data or critical information and takes lot of time for a single procedure (Nielsen et al. 2012). The main objective of the medical center is to implement an automated management system or process to ease the process of management in the medical center. There are some lists of functionalities that Dr. Slate wants to have in their operation management system. The automated system which will be implementing shall maintain the records, have a proper accounting details and providing automatic generated receipt and other such activities to east the management processes (Madathil et al. 2013). The main objective of th is report is to present an overall idea of implementing an automated management process in a medical center. Overview of System and Problem Description Keeping the tracks of the all the records and the activities on paper is always a clumsy and difficult task. It is also important for any medical center to keep track of its daily records and activities of their customers, nurses, doctors and other office staff individuals that keeps the medical center function smoothly and successfully (Padovani et al. 2014). The main objective of the new system is to have the ability of different functionality and it will be a solution to all the business process issues. The system will have a complete and flexible architecture that will support the business process. The paper works are very inefficient and consuming lot of time (ker and zyapici 2013). It has been observed that due to daily increase of visitors and people in the center it has been hard to maintain so many paper works for each individual and recording detail in the record books. It is so inefficient and slow process that consumes lot of time and there are lots of chances of making m istakes. Moreover it is not technical feasible and it is not economical as well to maintain these records on the book (Wagner et al. 2014). Therefore, the main goal is to implement an automated management system in the medical center to improve the process operation in the center. The main goal of the system is to decrease the paper work as low as possible by providing a reliable and cost effective automation system (Tang and Zhang 2013). This system other objective is to provide a better security to the system and the information at each stage of customer system interaction and gives a trustable and robust and backing up functionalities. Key Objectives of the System The objective of having an automated management system is to maintain the daily activities such as maintaining the list of doctors, generating report, admitted and discharged patients and etc. (Van Gigch 2013). The key objectives are listed below: The appointment of the patients with doctors should be properly schedule to ensure convenient for both doctor and patient. To make things digital as far as the details of hospital and patients are concern. It should maintain and control the generated reports of the patients and other official work in the labs of the medical center. For the medical store it should automatically decrease the considiton of the stock in medical section and have to list which medical was issued to which patient. The automatic up-gradation of equipments should be done whenever a transmission is done. All the data should be maintain in individual account of the patients and the staff and it has to be kept in a database for future references. The service scheduling of guest doctors and in emergency cases should be properly done by utilizing the automated management system. Methods of Data Collections Primary Data collection The primary data needs to be collected from the source. The primary data or raw data are not manipulated or processed; it is used as a source input. The primary data is collected from the source through survey of different hospital management systems. The data provided in the assignment consists of the new data collected from the research performed by the team. The raw data are collected directly from the market source and the respondents (Aggelidis and Chatzoglou 2012). The information is regarding the problem that is identified in managing the hospital system. All the inquiries that was asked during the survey was absolutely impartial and defined so that the others could comprehend it. Secondary Data collection For collecting the secondary data the organizational records, census and other internet sources are analyzed, on the other hand the primary data are collected by the researcher. Different multispecialty hospitals are surveyed and their services that they are providing are also analyzed from the internet sources (Vasquez et al. 2013). The collection of secondary data saves time and the database we get from the secondary data collection has high-quality however it may be useless for the company as sometimes the data collected from the different sources are outdated. System Requirements Introduction The system requirement is an entire behavior description of the system which will be created and involve a group of used cases which explains communication the users will have the application. It contains both technical and non-technical needs of the system (Ward and Peppard 2016). The system requirements are critical and need to be met to properly function in the implemented organization. Scope and purpose The key purpose of the system requirement to present in a correct manner all the abilities that will be given by the applied application i.e. Automated HMS (Hospital management system). It is also mentions different restrictions which the system will acknowledge for. The presented document will give us a clear idea about the software requirements, capabilities and specifications (Davenport 2013). The proposed system is HMS. The proposed system will be utilized in pathology labs, medical section, hospital and etc. Functional and Non-Functional System Requirements Let us check some of the functional and non-functional system requirements in the below table. Functional Requirements Description Information or Data management The medical center staff can easily update the relevant data or information in the provided system (Haux et al. 2013). Keeping Records It will allow the management team and other office staff to maintain and control the records. Tracking day to day activities Allow the hospital management to track the daily activities. Table 1: System Functional Requirements (Source: Hatley and Pirbhai 2013) Non-Functional Requirements Description Performance The system can handle multiple operations and can handle a large bandwidth. Reliability The system has to allow data division into other data server. Usability The system has to be easy to use and convenient to operate. Security The system has to be well protected and secured in every stage of user operation Table 2: System Non-Functional Requirements (Source: Iannone et al. 2013) Discussion on the proposed system Product point of view The product would run on windows platform without any third party application programs. User Interface: The software designed for the hospital management system would have a menu based interface design, interactive and graphically user friendly design. The portal would display the category of the user in the first page i.e. the admin and the normal user. The admin could access all the service but the normal users would be restricted to access all the services (Laguna and Marklund 2013). The normal users can search the doctors specialization; number of beds available, charge of the doctor etc. while the admin can search the details of an existing patient from the database and add new patient records. The admin also manages the bills and the appointments for the patients and generate reports according to it. Hardware Requirement Processor: Dual core processor and motherboard RAM: 2GB HDD: 500GB Input Device: Mouse, Keyboard Output Device: Monitor, Printer Software Requirement O.S: Windows 7, 8.1, etc. Front End: Microsoft Visual Basic Back End: Microsoft Access Workings: The software that is implemented for the hospital management system does not automatically records the database. The database administrator handles the client side manually. The DBA also handle the data recovery and backup of the database, the old non required data are deleted by the DBA manually from the database (Lian et al. 2014). System Functionalities Login Module This will record the customers password and customers details. Patient Module It will keep a proper track of entire information about both in-patient and out-patient along with patient details such as name, address, contact number, doctor name and allotted room number which will be stored for future reference. In Out Patient Module It will contain patient in and out details such s request form for admission before the patient is admitted in the hospital along with their health details and prior health history. Secondly the other aspect is that the patient detail will be update in case of patient getting discharge from the hospital and its present health situation. Billing Module This module will produce bill for in and out patient who comes and leaves the hospital and other billing aspect such as medical purchasing bills from the hospital stores. Pathology Module This will generate reports from the pathology labs of the hospital. Advantages of Hospital management system The hospital management needs a lot of decision making which is highly critical if the management system is not so effective then it will create lots of issues in getting the right data and implementing in every stage (Westbrook et al. 2015). A proper system can transform an hospital into super functionality or specialty hospital. Reach better quality ratings The hospital management system will play a critical role when it comes to top-preferred and high rated hospitals. Many hospitals rely on such systems upto a major extent. Better Revenue Management Any hospital with better management system will like to give equal important to serve humanity as well as to make profits as well because its a business. Better revenue management is a key element because it needs fortune to run the hospital (Dey et al. 2013). The automated HMS which is customize as per the medical center needs can solve it effectively. Enhance clinical decision-making The major aspects of having a good management system is to make sure that the clinical decision making and operation process is efficient, accurate and fast (Grefen et al. 2012). Enhance data security It is critical important that every company or business has to have a protected management system to protect their confidential data and it has to be safe to make sure that no unauthorized access is made. Use case diagram Pharmacy Manager Scenario Figure 1: Pharmacy Manager Scenario (Source: Created by author) Management and Staff Scenario Figure 2: Management and Staff Scenario (Source: Created by author) Data Flow Diagram for Medical Center The below table describes the DF diagram for the medical center. Name Symbols Description External Entity The external entities supply data from outside or use the system output. Data flow It is used to represent the flow of the information from the source to the destination. Process The process is used to manipulate and transform the data flow within the system. Database The database is used to store the records and entries. Table 4: Entity Relationship Diagram (Source: Created by author) Context diagram Figure 3: Context Level DFD (Source: Created by author) DFD Level-0 Figure 4: DFD Level-0 (Source: Created by author) DFD Level-1 Figure 5: DFD Level-1 (Source: Created by author) Entity Relationship Diagram for Medical Center The below table describes the ER diagram for the medical center. Name Symbol Description Attribute It describes the characteristics or property of the entity Entity It is a place, person, object or anything Relationship It describes the relationship between the entities Table 4: Entity Relationship Diagram (Source: Created by author) Figure 6: Entity Relationship Diagram (Source: Created by author) Conclusion The report presented here discuss about implementing an automated management system for the medical system. The report provides a clear discussion of what is the system design is all about and how it will serve the medical center functionalities that was mentioned by Dr. Robert Slate. In this report a clear explanation has been provided about how they can be benefited by the upgrading from manual business operation to automated business operation. The Data flow diagrams have been provided with a clear scenario about how the system will perform with respect automated management system. The implementation criteria have also been mentioned in this report. The overall conclusion of this report explains that there are multiple benefits if the automated management system has been implemented in the medical center. References Aggelidis, V.P. and Chatzoglou, P.D., 2012. Hospital information systems: Measuring end user computing satisfaction (EUCS).Journal of biomedical informatics,45(3), pp.566-579. Davenport, T.H., 2013.Process innovation: reengineering work through information technology. 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