A Summary Of The US Monetary Policy Peering Into 2018

US Monetary Policy: Peering Into 2018 The fast approaching US Christmas shopping season is always a convenient juncture to review the baseline outlook for the economy and, therefore, monetary policy over the next year. Meanwhile, Congress appears to be busy formulating tax reform proposals that will ultimately be resolved by a Conference Compromise Agreement. President Trump appears keen to get tax reform passed by the end of 2017. Consequently, incoming Fed Chairman Powell may be forced to forge an appropriate monetary offset in 2018. US economic activity accelerated during 2017, partly due to a recovery in oil prices that helped to spur higher capital spending. Crucially, faster underlying growth has pushed the economy into above-trend†¦show more content†¦Should the economy fail to decelerate as supply constraints continue to mount, then ensuing rate rises will become front-end loaded than currently expected in financial markets. Fed Policy: Limited Recent Experience of Life at Full Employment Arguably, we are entering an environment where most policymakers and commentators have limited experience of an economy operating at full employment for a protracted period. Despite its critics, the Phillips Curve remains an integral part of the Fed’s econometric model of the US model. The decline in inflation, notably since 1995, has contributed to an increased incidence of flattening in the curve. Moreover, the compressing of the curve has persuaded some commentators to claim that the Phillips Curve has effectively been rendered useless as a policy guide. Their contention is that supply constraints in the labour market, as testified by low unemployment, no longer need to be heeded. The last time the US economy endured a protracted period of growth whilst at full employment was during the late-1960s. Unemployment dipped below 4% in February 1966 and remained in this territory for four years. Although the economy continued to expand, inflation accelerated from 1.9% to 6.2% at the end of 1969. Thus, the combination of full employment and continued economic growth eventually produced higher inflation, something which the FOMC was slow to respond to with

Essay On Phoenix Jackson - 821 Words

Phoenix Jackson The story â€Å"A Worn Path,† by Eudora Welty tells the story of a woman named Phoenix Jackson, who lives in Natchez Mississippi. Phoenix has a grandson that she cares for that has swallowed a chemical called lye, that was used in many households back when this story was written. Lye poisoning was common in a lot of rural areas. Welty is writing about this problem the hardship Phoenix Jackson had to go through to get medical treatment at that time. Without the name Phoenix Jackson and the characteristics, she possesses there is no way she could have overcome the obstacles that stood in her way. With the first name of Phoenix, Ms. Welty is showing the symbol of a Greek mythological bird that could live to be one hundred to one†¦show more content†¦The young white hunter assisted her out of a ditch only to belittle her and put a gun in her face (Welty). This shows great courage to endure this encounter that must have been something Phoenix had endured and witnessed her entire life. Hard work was a way of life, much like Dr. Jackson that worked tirelessly to find a cure to save the young children who had swallowed lye, it made her strong enough to face this encounter (Stang). In addition, it was hard work and agility to walk along a log to cross a creek with her eyes closed, the wisdom to shimmy under barbed wire fences without getting hung up, the endurance to go up and down hills and through hollers, and the devotion to make the trip to the Doctors office and back (Welty). Although, in her nineties Phoenix was strong and very capable to walk that worn path and do it with the dignity of a grandmother that cares about her grandson. The story tells that Phoenix was a selfless, devoted, and caring person. In addition, Dr. Jackson cared for his patients, many times using his own money for research and charity cases (Stang 17. By taking advantage, making yearly trips to the Doctor’s office, because the doctor said, if she comes and gets the medicine she can have it, shows her wisdom and devotion. She takes the time to tell the nurse how cute her grandson is and that he will survive, showing her optimism. Even after enduring belittling wise cracks from the attendantShow MoreRelatedPhoenix Jackson in A Worn Path Essay499 Words   |  2 PagesPhoenix Jackson in A Worn Path â€Å"’Out of my way, all you foxes, owls, beetles, jack rabbits, coons and wild animals!†¦ Keep the big wild hogs out of my path. Don’t let none of those come running my direction. I got a long way’† (116). Through the character of Phoenix Jackson in â€Å"A Worn Path† Welty produces a picture of an aging African-American woman in the Jim Crow South. In â€Å"A Worn Path† we learn of the hardships Jackson faces on her weekly journey for medicine to sooth the pain ofRead MoreCharacter Analysis: Phoenix Jackson Essay examples942 Words   |  4 Pagesthe most considerable, being the legend of the phoenix. There are numerous symbols and allusions brought about in the story relating to the legend of the phoenix. The phoenix is a bird that comes from Egyptian mythology. The best analogy of the phoenix is a magnificent bird. The phoenix has astonishing powers. It has the knack to materialize and vanish in the blink of an eye. The myth states the phoenix travels to the sun. The sun gives the phoenix it powers. The heat incinerates the bird. The birdRead MoreA Worn Path: Phoenix Jackson a Very Old Woman Essay701 Words   |  3 Pagescan be parents and grandparents. It all depend s on what the person does to be considered a hero, such as a grandparent that would walk about 50 miles to get medicine for their sick grandson. That is what Phoenix Jackson did for her grandson in the short story, A Worn Path. Phoenix Jackson is a very old woman who lives out in the backcountry of Mississippi with her sick grandson. She takes care of him because she is his only family left and he has some kind of a problem with his throat, heRead MoreDecoding The Symbolism Used in A Worn Path by Eudora Welty1276 Words   |  6 Pagestalking about the different literary references used throughout Eudora Welty’s â€Å"A Worn Path†. I will explain and decode different techniques used by the author throughout her story. The story is of an old southern African American woman, named Phoenix Jackson, making her way into to town to pick up her grandsons medication from the doctor’s office. But this is no normal old woman. She cannot see and is picking her way with a cane to make her way across a barrage of obstacles. Throughout her journeyRead MorePhoenix Jackson in A Worn Path by Eudora Welty: Courageous or Crazy?793 Words   |  3 PagesCrazy or Courageous? The power and determination of women to go to every end of the earth for kids is put into a different perspective in this essay. Women from almost any time period would go and do anything for kids, even if the kids were disrespectful and unloving in return. A perfect example of this is Phoenix Jackson, an old woman making a journey for her grandson in the short story â€Å"A Worn Path† by Eudora Welty. She runs into many obstacles along the way, but is it enough to take care ofRead MoreThe Quests Of Araby And A Worn Path984 Words   |  4 PagesThe Quests in â€Å"Araby† and â€Å"A Worn Path† Both â€Å"Araby† (1914) by James Joyce, and â€Å"A Worn Path† by Eudora Welty (1941) pursue life through a journey. The protagonists, Phoenix Jackson in â€Å"A Worn Path† and Joyce’s narrator in â€Å"Araby,† embark on an errand out of love. In â€Å"Araby,† Joyce’s narrator develops an infatuation for Mangan’s sister. He laments, â€Å"I had never spoken to her, except for a few casual words, and yet her name was like a summons to all my foolish blood† (Joyce 200). He volunteers toRead More Realism in Eudora Weltys A Worn Path Essay1229 Words   |  5 Pagesnatural symbolism of the surroundings. The main character in the story, Phoenix Jackson, is an old black woman who seeks out to find medicine for her sick nephew. This story contains a motif, which is the continuous walking of Phoenix Jackson throughout her journey. She lives in the pinewoods and faces the challenging experience of walking through the snowy, frozen earth to get to the hospital in the city of Natchez. Phoenix Jackson is a very caring person, and is in love with life. Although she isRead MoreA Worn Path Research Paper959 Words   |  4 PagesHeroic Efforts Of Phoenix Jackson In â€Å"A Worn Path† In Eudora Welty’s â€Å"A Worn Path,† the character Phoenix Jackson is introduced. Phoenix Jackson is an uneducated, African-American woman without any family besides her sick grandson. Phoenix is the hero of this story and fits the role well by delivering much-needed medicine to her grandson. Phoenix shows many distinct traits that reveal her to be a hero to her grandson. The heroic feats she accomplishes pave a path that leads to her satisfaction asRead MoreThe Character Of Phoenix Jackson, A Worn Path939 Words   |  4 PagesAdrianna Ratliff English 1123-UTAB Critical Analysis Essay Hampton 29 October 2014 The Character of Phoenix Jackson,† A Worn Path† Eudora Welty’s â€Å"A Worn Path,† is a story about an elderly woman name Phoenix Jackson walking on a path to Natchez to get some medicine for her ill grandson that swallowed some lye that affected him severely. The story portrayed a vivid idea of her personalities and the readers realize how unique Phoenix Jackson is. Phoenix faced many trials and tribulations while on herRead MoreSymbolism in A Worn Path By Eudora Welty1096 Words   |  5 Pageswoman named Phoenix Jackson who takes a journey along a path with manifold of dangerous objects. Phoenix Jackson takes the journey thru the path because her grandson drank liquid named lye and got sick from his throat. Phoenix Jackson makes her journey thru the path to go to the doctor’s office to get some medicine. As Phoenix Jackson walks thru the path she encounters a lot of animals like foxes, owls, beetles, jack-rabbits, coons, little bob-whites and big wild hogs. Phoenix Jackson also encounters

Considered As A Technologically Advanced †Myassignmethelp.Com

Question: Discuss About The Considered As A Technologically Advanced? Answer: Introduction Today Japan is considered as a technologically advanced country. Its sound technology base help the nation to develop rapidly. In the past seventy years the country has made remarkable progress in growth and development perspective. The country possesses a strong manufacturing and service sector. These two sectors are two main pillars of the economy. External sector in Japan is also string enough to support the growth path of the nation. Present paper has made a brief analysis on how the economy in Japan has performed in the last few years. Evaluation has been made on overall production performance of the economy. In addition inflation and unemployment trend over the past several years has been taken for consideration. Production Output Performance Analysis GDP Gross domestic product or GDP is an aggregate measure of countrys overall production or output. It is the monetary values of all goods and services produced in the economy in a particular economy. To calculate the values of goods and service in monetary terms either current market prices or base year price are used. The former is called nominal GDP while the latter is known as real GDP (Tachibanaki, 2016). Figure 1: Yearly GDP values Japan (Source: tradingeconomics.com) Gross domestic product in Japan recorded as 4939.38 billion USD in the year 2016. GDP records its highest value in 2012. Total values of domestic goods and services in that year was 6203.2 billion. Japan accounts almost 7.97% of world GDP. The average national income in the last 40 years in Japan is 2656.84 billion USD. The lowest value recorded in 1960. From then GDP is more or less increasing in Japan as shown by the statistics. GDP growth rate Growth in GDP measures the output growth in the economy. Growth output expresses the change in GDP between two consecutive years as a percentage of the first year. Is is also considered as economys growth rate as it measures the growth of output and hence income in the economy overtime. Figure 2: GDP growth rate in Japan (Source: tradingeconomics.com) Japan economy is considered as fourth largest world economy. It is a diversified economy with making remarkable progress in advanced technology. Being a developed country the the contribution of service sector is highest in GDP composition. The share of service sector in GDP is nearly 62%. Thus, maximum growth contribution in the economy is coming from service sector. Within the service sector retail and wholesale trade is considered as most important. The next important sector in Japan in manufacturing with making a 22% contribution in GDP (Angelini et al, 2015). Construction is also an important sector in the economy GDP per Capita analysis Per capita GDP is a measure of average income of the nation. Per capita GDP is obtained when GDP of an accounting year is divided by the population of that year. Since GDP is used as a measure of countrys output performance, Per capita GDP also used as a measure of average productivity of the nation. Higher the average income or productivity, higher is the living standard in the economy. Figure 3: per capita GDP in Japan (Source: tradingeconomic.com) Per capita GDP in Japan has more or less increased overtime. In 2007 per capita GDP was 46687.3 billion. This became 47606.7 billion in 2016. In 2009 per capita GDP fell to record its lowest amount. The figure of per capita GDP stood at 42724.5 billion. The downturn in the economys average income is explained by the global financial crisis in 2008. Government measure to achieve output performance Government uses monetary and fiscal policy tool to achieve targeted economic growth. The direct tools of fiscal policy include direct and indirect taxes, government expenditure in different sectors of the economy and government debt. The instruments of monetary policy are government regulation, availability of credit in the economy and its cost. In Japan ministry of finance takes major initiatives to achieve economic growth in the postwar period. The finance ministry adapts growth first approach. A high proportion of government fund is allocated to accumulation of capital. This policy is accompanied with a low overall government expenditure for the economy. By following this policy the government aims at keeping both the deficit and tax rate as low as possible. In addition, this will make more investible fund available for the economy. Japanese generally put a significant part of their income in saving account. The fiscal policy of Japanese government focuses on formulation of national budget. The national budget is constructed under the the regulation of finance ministry. For each financial year the sector prepares an expenditure budget. In the budget, tax adjustment and net revenue calculation is done by Tax department of the finance ministry. The finance ministry also issues bond, controls borrowing of the government, arranges investment and loan program and other financial responsibility of the government. The fixed investment on loan and infrastructure including both private and public enterprises accounts 15% of gross national product. Approximately 84.7% of the government revenues are collected from different taxes in the nation. A progressive tax rate prevails in Japan (Dore, 2013). In order to improve industrial output Japanese government has adapted complicated set of policies for industrial development. The policies of Japanese government mostly related to labor markets, promotion of trade and providing tax incentives to investors. Labor Market Analysis Types of Unemployment Unemployment is a state when some existing and potential labor in the labor force fail to find job. The labor market of any economy always contains unemployed persons. However, there are different reasons for unemployment in the economy. Following are different types of unemployment that prevails in an economy. Structural unemployment: Structural unemployment resulted from structural factors. Often industry changes their structure to enhance productivity. Labors who are in incompatible in the new structure become unemployed. Cyclical unemployment: This is another common type of unemployment. Economy goes through different phases of business cycle. In the depression phase there is an economy wide depressed demand affecting production and employment opportunities. Unemployment thus resulted from a business cycle fluctuation is known as cyclical unemployment (Harris, 2015). Frictional unemployment: Economic bottleneck causes frictional unemployment. In times of inter industry job switching people remain unemployed for a certain time period. Disguised Unemployment: In certain sectors, there are people who are though employed but do not make any marginal contribution. This is called disguised unemployment. Agriculture is the sector where this type of unemployment mostly prevalent. Unemployment trend in Japan Figure 4: inflation trend in Japan (Source: data.worlodbank.org) In June 2017, unemployment rate in Japan records a 2.8% fall. The unemployment rate in the previous month was 3.1%. The figure stood below 3 percent. This is accounted as reaching below a 23 years low level from the months of February to April in 2017. In addition, the ratio of job creation to its applicants is greater greater than 1. This indicates more jobs have been created in the economy and thus reduces unemployment. The ratio now stands as 1.51 as compared to 1.49% in the previous year. Government measure to achieve full employment In Japan, steady economic growth is viewed as a solution to unemployment problem. Poor economic performance mostly affects the young population. The young population in japan are suffering from lack of training program/. To address this issue Japan government has arranged training program for them. Female employment is very low in Japan. In total employed people the percentage of female employment is only 48.9% (Lockwood, 2015). Full utilization of female labor force will benefit the economy with more creative ideas. Generally, 80% of female employees take leave for their childcare. Among them only 40% continues their job with first child. The female proportion in the managerial post is lower as compared to international standard. In order to improve the situation of female employment new legal framework has been designed by the government that allows 30% female employment in higher post. The government also make arrangement for childcare facilities so that females can continue their participation in the labor market. In times of recession recovery phase government changes its labor market policies to ensure full employment in the economy. The movement towards a flexible labor market has been made in order to reduce frictional unemployment in the economy. This aims at allowing them a smooth switching of their jobs. To resolve the problem of youth unemployment incentives care given to large companies for hiring newly joined members of the labor force. Program has been conducted to extend further support to newly graduates and young people in the society. Comprehensive support program has been arranged by the government. Price Level Analysis The gradual rise in general price level is called inflation. The stability or instability of price level is indicated by the rate of inflation in the economy. Inflation trend Figure 5: inflation trend in Japan (Source: data.worldbank.org) In June 2017, consumer prices rose at a rate of 0.4%. The figure matches with the statistics of two previous month. The price level for food is at a stable level while that of housing and transport fell. In the previous year, food prices rose at a rate of 0.8. the inflation rate for fish and sea good is is maximum. On the other hand, prices for fresh vegetables fall. Corte inflation rate in the economy has gone up 0.4% excluding food prices. In 2015, the figure reached its maximum. When computed on a monthly basis it shows the average consumer prices were flat. Tokyo accounts a 0.1% rise in its consumer prices. Core inflation rate in Tokyo is averaged at 0.2% (Campbell, 2014). Causes of inflation Price increases either due to the forces coming from demand side or from the supply side. When price rises due to components of demand, it is called demand pull inflation while inflation from the supply side factors are called Cost-push inflation (Mankiw, 2014). Demand-Pull inflation A rapid rise in aggregate demand generally forces price up. Rising demand at an unusually high rate creates a positive output gap. The scarcity of output givers upward pressure on price. Cost-Push inflation In the phase of increasing production cost producers increases price of their product to recover cost. Cost-Push inflation resulted increase in direct and indirect cost of the producers. Government measure to achieve Price level stability Price stability is a key policy objective of Bank of Japan (BOJ). Before taking measures of price stability, the term should be well defined. In Japan, Consumer prices are used to measure the stability of price level. Core inflation rate that exclude the basket of fresh food is the primary measure of inflation in Japan. Unlike many other developed countries BOJs inflation does not include energy prices. In price stability front BOJ sets its stable range between 0 and 2. The main policy of BOJ is increase in interest rate (Ishikawa Wall, 2015). BOJ has further stressed that economic situations including movements in prices is respondent to interest rate. The board of monetary policy makes its semi-annual growth rate and the movement in consumer price Index to a moderate level. To handle deflation in the economy central bank in Japan devises ease monetary policy either by increasing the money supply or reducing the interest rate. Conclusion The above discussion gives a brief overview of economic performance in Japan. For analysis purpose GDP, growth of GDP, per capita GDP, inflation and unemployment trend has been taken into consideration. The moderate GDP values indicate well output performance of the economy. Along with this, GDP growth rate and per capita GDP is also improving in the economy. With substantial government measure the country is also achieving its target of full employment. The active measure of bank of japan helps the economy to maintain stability bin the price level. References Angelini, P., Clerc, L., Crdia, V., Gambacorta, L., Gerali, A., Locarno, A., ... Vl?ek, J. (2015). Basel III: Long?term Impact on Economic Performance and Fluctuations.The Manchester School,83(2), 217-251. Campbell, J. C. (2014).How policies change: The Japanese management and the aging society. Princeton University Press. Data.worldbank.org. Retrieved 2 August 2017, from https://data.worldbank.org/country/singapore. Dore, R. (2013).Taking Japan seriously: A Confucian perspective on leading economic issues. AC Black. Harris, J. M. (2015). New macroeconomics teaching for a new era: instability, inequality, and environment.European Journal of Economics and Economic Policies,12(2), 236-242. Ishikawa, T., Wall, R. (2015). Significance of Constructing City Systems in Regional Policy. InFirms Location Selections and Regional Policy in the Global Economy(pp. 281-288). Springer Japan. Lockwood, W. W. (2015). Economic Development of Japan. Princeton University Press. Mankiw, N. G. (2014).Principles of macroeconomics. Cengage Learning. Tachibanaki, T. (Ed.). (2016).Labour market and economic performance: Europe, Japan and the USA. Springer. Tradingeconomics.com. Retrieved 2 August 2017, from https://tradingeconomics.com/singapore/labor-force-participation-rate

The Ecological Effect of the Victorians Desalination Project

The project on Victorian desalination is a scheme that was devised with an aim of realizing the ecological performance necessities. Victorian has been in drought for many years as a result, this lead to a noteworthy diminution in the amount of water available to Victorians. Due to the fact that Victorian experienced adverse water calamities, the government came up with a number of projects to boost Victoria’s water delivery.Advertising We will write a custom report sample on The Ecological Effect of the Victorian’s Desalination Project specifically for you for only $16.05 $11/page Learn More The government also came up with a scheme to grant a long term elucidation to secure water supplies (John, 2009). This was done to; enable a quick and an elastic reply to varying water requirements, advance and expand water provision in the area as well as setting up water resources across the nation via the water framework (Kenneth, 2009). The main goa l of this investigation was to ascertain a sound understanding on the ecological effect on the task. This also includes giving an opinion on the most excellent advance to decrease these effects. In the Victorian’s desalination project the government was to present to the minister for planning with an account on screening tests that are done at the intake of the remains as well as the dregs. Prior to treatment process there are extra steps of amplification on filtration process in the upstream. The clarification engages use of dissolved air floating unit that does away with the massiveness of the hovering solids. Air floats these solids from the faà §ade of the backwash water (Norrie, 2008) Sea water is forced through tiny membranous holes, constituent part that is bigger than the openings of the crust are sieved out. In Victorian membrane filtration is a modern skill that is practiced and can do away with the necessity for the most important coagulant. This allows for the ba ckwash run to be unswervingly mixed with briny concentration that is then released to the sea. The expelled water to the ocean has no toxic effect and hence beneficial for people consumption (Kenneth, 2009). This was one way in which the management was able to restore water resources hence attaining the goal of the project which was to ensure that water was enough water for the various uses. Nevertheless, there is inadequate use of this skill, this could be in a greater way be contributed by the fact that there were other methods like chemical process. This process engrosses chemically consolidating of seawater to flocculate the floating mater for elimination in the pre-treatment sifts as well as for coagulating rationale (Sun, 2008).Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More The management of Victoria’s desalination project ensured that the following factors were enhanced; wa ter security, water quality, flexible water supply, power supply, inlet and outlet tunnels, energy and renewable as well as plant architecture and landscaping. These factors were some of the contributing effects to provision of quality as well as enough water throughout the state (Peter, 2009). The management came up with the choice of conveying the scheme as a public concealed corporation. The decision was motivated by a comprehensive appraisal of the following representation. These models took account of; corporation Victoria privately funded public private partnership, stately funded agreements and nation finance procurement. In conclusion, the Victorian’s desalination project the management was able to attain its goals in realizing the ecological performance necessities since it managed to eradicate drought in the state. References David, Kenneth, 2009, Water policy delivers scary possibilities, the Age Melbourne. Herald,Sun, 2008, Protesters met by police at desal site i n Wonthaggi, Retrieved 2008. Ker,Peter, 2009, True cost of desal plant concealed, The Age. Ross, Norrie, 2008, Opponents of Victorian desalination plant must pay costs, Retrived 2008.Advertising We will write a custom report sample on The Ecological Effect of the Victorian’s Desalination Project specifically for you for only $16.05 $11/page Learn More Satt,John, 2009, Victorian desalination project, Retrieve 2009. This report on The Ecological Effect of the Victorian’s Desalination Project was written and submitted by user Bryant T. to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

To Conquer Fear an Essay on the Short Story First Confession Essay Example

To Conquer Fear an Essay on the Short Story First Confession Paper To Conquer Fear In the short story, â€Å"First Confession,† by Frank O’Connor, a young boy named Jackie finds himself having to conquer his fear of giving his first confession. He realizes by the end that he really had nothing to be afraid of and it was a silly fear. Jackie, scared to death of confession, tries to fake an illness to avoid it, ends up surprising the priest when he does go, and learns that ultimately, perception is scarier than reality. Although it doesn’t seem like it at first, the reader and Jackie learn that in order to conquer fear, one must face it. Jackie, a young seven year old has been told stories by a woman named Mrs. Ryan that really worry him. One story is about a man who gives a bad confession and essentially eternally burns in hell. Mrs. Ryan also tries to give Jackie and the others a sense of what hell is like: â€Å"She lit a candle, took out a new half-crown, and offered it to the first boy who would hold one finger in the flame for five minutes Then she asked were we afraid of holding one finger in a little flame for five minutes and not afraid of burning all over in roasting hot furnaces for all eternity† (O’Connor 26). We will write a custom essay sample on To Conquer Fear an Essay on the Short Story First Confession specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on To Conquer Fear an Essay on the Short Story First Confession specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on To Conquer Fear an Essay on the Short Story First Confession specifically for you FOR ONLY $16.38 $13.9/page Hire Writer When Mrs. Ryan tells stories and plays mind games like this, she’s basically scaring the children into giving a good, complete. However, with Jackie, this is too much, and he is frightened even more that he’ll mess up accidentally and go to hell. Instead of conquering his fear, he runs from it. The day confession comes around doesn’t go. He says, â€Å"I was scared to death of confession. The day the whole class went I let on to have a toothache, hoping my absence wouldn’t be noticed† (27). Mrs. Ryan has done her job well, to the point where Jackie is worried beyond belief. He decides to fake sick so as not to go, but as readers later find, this idea comes back to haunt him. If he had originally gone and faced his fear, the ordeal would already be over. Like many children, Jackie finds it easier to avoid the fears in life rather than confront them. This, however, is not a successful way to live. Since Jackie doesn’t go to confession with his classmates, he receives an order to go alone with his sister. As Jackie enters his church, it’s as if all his worst nightmares are becoming a reality and he’s leaving anything he ever loved: â€Å"The door hut behind me, the sunlight went out and gave place to deep shadow, and the wind whistled outside so that the silence within seemed to crackle like ice under my feet† (28). This imagery shows how even though Jackie is finally beginning to conquer his fear of confession, it’s like a descent into hell. As he walks into the church everything becomes gloomy, creepy, and ominous. This shows how the process of overcoming his trepidation is difficult even though in the long run it will be worthwhile. Once Jackie is in the confessional, he talks too quietly for the priest to hear and everything continues to get worse: â€Å"It was matter between God and me, and He had all the odds† (29). Jackie is facing his fears and so far he’s failing miserably. Of course, if he had not avoided confession in the first place, he would not be struggling. It’s not until the very end of the story that Jackie realizes how beneficial it is to face your fear. Once Jackie and the priest are settled, Jackie slowly begins to open up to the priest and feels more comfortable. The priest makes Jackie feel welcome: â€Å"Feeling I might as well get it over while I had him [priest] in good humour, ‘I had it all arranged to kill my grandmother†¦ I tried to kill Nora too’† (32). Readers finally understand why Jackie is so afraid of confession. Firstly, he didn’t know what would happen if he told and secondly, he was worried if he didn’t tell about his plan to kill his grandmother he’d go to hell. However, the priest only gives Jackie three Hail Mary’s, a small consequence, and it makes him feel like he did the right thing; suddenly it’s all worth it. By the time Jackie leaves he has a complete change of heart. Jackie says, â€Å"He had me there for a full 10 minutes talking†¦ I was genuinely sorry to part with him, because he was the most entertaining character I’d ever met in the religious line. Outside†¦ the sunlight was like the roaring of waves on a beach; it dazzled me† (33). Jackie realizes that there really was nothing to be worried about. The priest knows how to take care of him. When he walks outside again, the imagery changes from gloomy to overjoyed. Jackie is relieved because his burden of the idea of killing his grandma has been lifted and his fears have been subdued. Readers now see that this trepidation that was haunting Jackie has been lifted because he faced it; he didn’t hide from it. In â€Å"First Confession† by Frank O’Connor, readers are shown that facing fears can only help, not hurt. Jackie is excellent proof of this because although he was terrified at first of confession, he ends up finding it enjoyable and relieving. Readers learn that fear itself can be worse than the actual event.

Motivational Reasons for Failure in School Essay Example

Motivational Reasons for Failure in School Essay Example Motivational Reasons for Failure in School Essay Motivational Reasons for Failure in School Essay In August of 2009 two boys began their school year at public schools in Southeastern Idaho. Both boys had been raised in similar settings of a two parent home, average income, and raised in a demographically rural community. These boys have had equal opportunities in the educational system of supportive parents and teachers and after school programs. Intellectually both boys have the ability to succeed in school. This tale of two Southeastern Idaho boys, and of millions of children just like them, raises the question of why some students educationally excel and others do not. If both boys in this scenario have the same opportunities, the same environmental settings, and the same level of intelligence then why will one excel and the other not? Research has shown that motivation reasons, such as fear of failure, incuriosity, and lack of ambition, can cause low classroom achievement. Have you ever been so afraid of failing at something that you decided not to try it at all? Or has fear of failure meant that, subconsciously, you undermined your own efforts to avoid the possibility of a larger failure. Many of us have probably experienced this at one time or another. The fear of failure can immobilize – it can cause us to do nothing, and therefore resist moving forward. But when we allow fear to stop our forward progress in life, we are likely to miss great opportunities along the way. According to the Reiss Motivational Profile, fear of failure in the number one reason for low achievement in school. Students that display this fear of failure often feel that failure hurts less if they don’t try to succeed. Signs that a student may have a fear of failure are a reluctance to try new things or get involved in challenging projects, procrastination, and low self-esteem or self-confidence. We have defined the emotion and identified the symptoms, now how can we help overcome. Students with fear of failure may be at their best when parents and teachers stand behind them and encourage them. Positive encouraging words and actions are observed and taken in. Students will respond if the classroom atmosphere is uplifting and rewarding. Students should be made aware that in everything they do, there’s always a chance that they will fail. Facing that chance, and embracing it, is not only courageous, but it gives them a fuller, more rewarding life. According to Steven Reiss incuriosity scored as the second motivational reason why students have low achievement is school. In the Merriam-Webster dictionary incuriosity is define as lacking a normal or usual curiosity: uninterested. Students in school seem to regulate how much thinking they do. Some need to think a lot, these students need many interests to satisfy their high need for intellect. Others aim to think very little. It is not just one or two topics they hate thinking about, they just dont like to think for any length of time. At least, that is what they say and how they behave. These school children need many practical activities to gratify their need to minimize thinking. They hate school because it makes them do something [think] they dont want to do for longer than a few minutes at a time. Teachers need a general sense of how long each individual student needs to think versus how long he/she needs to rest from thinking. Incurious pupils enjoy thinking for below-average periods of time and need long periods of rest. Teachers should break down the material into small bites and to give emphasis to the practical application of the curriculum. Lack of ambition was rated number three for motivational reason why students have low achievement in school. Lack of ambition is defined in the Merriam-Webster dictionary as absence of the desire to strive toward achievement. For students in school, it manifests as an inability to consistently take action toward goals – or even the inability to create goals in the first place! Without accepting full responsibility for the direction of their life, students will not be able to commit to a plan of action, and will ultimately remain sitting on the fence. These students find it easy to blame people and situations for their failure to move forward in life. Students can be motivated differently for a variety of reasons, from age to culture to special needs. Teachers will need to incorporate various scenarios. Some motivations might work better than another or a combination of the two is a better approach. Individual students respond differently, some may respond to tangible rewards, stickers, and praise. Motivation for others will be a sense of accomplishment, responsibility, and pride. The tale of the two junior high boys in Southeast Idaho illustrates the role that fear of failure, incuriosity, and lack of ambition plays in low achievement at school. Both boys had equal opportunities educationally and environmentally. Their internal self shaped the outcome of their achievement. Teachers can encourage and inspire our children to overcome these setbacks of fear, incuriosity, and lack of ambition. Success can be a

SWOT Analysis on the Internal and External Environments relevant to Essay - 1

SWOT Analysis on the Internal and External Environments relevant to Allergan pertaining to their Botox Product - Essay Example Allergan has been into discovery of innovative products the like of Botox,and marketing them through prescription by doctors in the specialty markets for a long time. It boasts of a research & development wing involved in discovering and producing specialty segment products such as BOTOXÂ ® Cosmetic, which is a prescription medicine that is injected into face muscles for improving the look by reducing or fully eliminating frown lines between the eyebrows in people in the age group of 18 to 65 years temporarily. SWOT Analysis Internal – Strengths Botox not only removes frown lines but is equally effective in other many ailments such as in treating migraine headaches, chronic neck and back pain, sweating overly, and probably spastic disorders also. Allergan internal strengths are many. Its 8000 employees worldwide are its major strength. Allergan has reached to its current customers via its vast network of workforce. R& D investment in the making of the product i.e. Botox has b een the internal strength of the company and the product both. Being a multispecialty healthcare company into discovering, developing and commercializing pharmaceuticals, biologics and medical devices, it is deeply rooted into manufacturing of specialty products such as Botox, which has brought it to the front runners’ line by capturing a niche market worldwide of its customers belonging to all walks of life. Botox being an innovative product, it is comparatively safe from generic erosion, as the medicinal formula of developing the medicine is a well-kept secret, which insulates the medicine from being sold by copying the drug development process. Internal – Weaknesses Botox is not a fully safe drug, as it paralyses facial muscles to the point beyond the earlier natural condition of the muscles where they can no longer react to outside changes emerging from symptoms such as age, use and wear. Forehead muscles can’t express emotions like anger. The community of a ctors and stars, mostly habitual to using Botox can no more show their emotions above the eye through acting. An emotionless face can transform humans into zombies. Botox has a number of side effects like drooping eyelids, drooling mouth, and slurred speech. These side effects are quite serious in nature affecting the personality of a person. Some temporary side effects such as nausea, allergic reactions, headaches, respiratory infections, flu symptoms, and redness and swelling around the injected area could be visible in some or all patients for a short duration. Another weakness of the medicine is that its impact on the related area is not permanent. The treatment remains effective only till six months of taking the Botox injection. It is a very costly treatment and is effective for a short duration compelling consumers to visit the clinics in regular intervals to maintain their visage. External – Opportunities Sales opportunities have increased greatly. Botox can be market ed globally through advertisement to the probable users for cosmetic uses of the product; earlier permission to advertising the product was not granted. Latest fashion trends provide a boost to the sale of Botox, as the product has become very popular in high profile society. Advertisement in the TV and popular magazines has increased the sales of Botox significantly as on an average a person views such ads 10 times a year. Ophthalmic market offers huge business potential for sale of Botox. Dermatology is another area where Allergan has opportunities waiting as use of Botox in dermatology provides possibilities of expanding by acquiring new formulas or by buying licenses from foreign producers, as it is relatively more cost-efficient than developing through R & D. The company can leverage through spending on marketing efforts from the revenue earned in dollar on other products to fight competition. Huge sales opportunities exist in primary segment

Marketing Business Analysis of Costa Coffee Company Term Paper

Marketing Business Analysis of Costa Coffee Company - Term Paper Example Costa is currently the leading coffee chain in the UK in an industry that is highly competitive and rapidly growing. In spite of the current contraction forces within the global and UK economies, Costa has been able to expand sufficiently in the emerging economies as well as in its domestic market in the UK. Costa's brand focus on its various renowned coffee brands has been equaled with portfolio growth and development into new areas of service. Costa operates from the civil parish and market town of Dunstable as its main headquarters, situated in Bedfordshire England. Although leading its major competitors in terms of physical stores, it comes second to Starbucks regarding market share. Costa is completely owned by Whitbread. Among its major competitors, it has cut out its market niche by being the only coffee chain that offers hand-made coffee products to its clients. Costa Coffee has many brands, among them Miscela, Macinatura, Macchina and Manna. Costa specializes with Italian made coffee as their products suggest. All Costa coffee shops have been installed with Italian made Espresso machines. All these machines have been perfectly tuned to a long period to attain wide volumes of flawless coffee. Their special blend of Arabica and Robusta coffee is slowly roasted to perfection, much to the satisfaction of their clients. Towards the end of the year 2010, Costa acquired a market share of 37.7% to become the biggest coffee franchise within the UK. Bruno Costa and Sergio started the company in the year 1971, which later became part of the Whitbread franchise in 1995.

Positive and Negative Aspects of Immigration in the United States Essay

Positive and Negative Aspects of Immigration in the United States - Essay Example However, the earlier immigration at the beginning of the twentieth century had a comparatively greater impact because the United States was less populated at that time (Saiz 14). â€Å"If current immigration rates are sustained, two-thirds of the population growth in the United States could be accounted for by immigration by 2050† (Saiz 14). The arrival of new immigrants is creating severe opposition as well as spirited defense for immigration. Every year, the debate on the benefits and adverse effects caused by immigration grows increasingly heated, and its political discourse is likely to be a major issue in the future (Isbister 1). Philip Martin and Elizabeth Midgley argue that a significant issue is an illegal immigration which began rising in the 1970s. This was the first main immigration issue debated in Congress in the 21st century (Martin and Midgley 3).   The arrival in the United States of large numbers of foreigners from various countries can either be a cause for concern or a trend to be welcomed. â€Å"There is no single answer, which helps to explain why Americans are ambivalent about immigration† (Martin and Midgley 3). The United States has always celebrated its immigrant heritage with mass naturalization ceremonies on July 4; these ceremonies associate immigration with the founding of the United States. American leaders have reiterated the renewal and rebirth caused by the advent of newcomers in America considered as the ‘land of opportunity’. This implies that immigration enables individuals to improve their lives and also strengthen the United States at the same time (Martin and Midgley 11).   

The influential factors behind the growth of globalisation

The influential factors behind the growth of globalisation Current business environment is more volatile and dynamic. There are different reasons behind this transformation in the world. Globalisation is one of the main factors that behind the above change. We can define globalisation as a process by which the world is becoming increasingly interconnected as a result of massively increased trade and cultural exchange. Earlier existed boundaries between countries in the world have been dramatically reduced due to the globalisation. This is seen as more than simply a way of conducting business- it can be considered as a continues process. This is not a new force that emerged few years back, it has been taking place for hundreds of years but it has speeded up enormously over the last half-century. In History, in a similar manner, the techniques of industrial manufacturing lead to create the process of industrialisation, now that process has linked with the globalisation and has created new environment of operating businesses. There are few influential factors behind the growth of globalisation. Increase in communication technology is one of them. TV, telephony and the internet have permitted information and ideas to travel quickly. As an example USA businesses can have a call centre in Philippine or India answering calls from local customers. Another factor is improvements in the transportation sector. It has become more quick and cheap. People can go for holiday all around the world. Workforce can seek for a job opportunity available in another country. Businesses can easily ship their product and raw materials all over the world. Another main influential factor behind the growth is trade liberalisation. This has been excelled due to the Laws restricting for free trade and fo reign investment movements have been relaxed between countries. Some governments even offer grants and tax incentives to attract foreign companies to invest in their country. These actions have lead to create free trade zones in the world. In other words theses are known as trade blocs where groups of nations who form an economic union or customs union. Governments follow friendly rules and regulation within those regions for trading purposes. For example the European Union (EU) aims at not just a customs union but also economic union by way of harmonisation of taxes, establishing a common monetary policy and moves towards a single currency. EU has now expanded over 26 member countries and benefited to combined population of 356 million. Trading blocs generally increase the integration and interdependency of the member economies which is speed up the globalisation process. As a result of trading blocs trade amongst the members has increased, which ultimately increase the world trade capacity. Further it gives the opportunity to businesses better access to effective capital and labour markets which increases the movement of labour within the countries and increase investments. For example Poland workers have been well recognized in the UK and Ireland labour markets. As result of the globalisation process international trade has increased dramatically in the 20th century. Many countries get more chances to participate in the world trade. As a result of increase in Foreign Direct Investment (FDI) many labour oriented countries get access to capital market and vice -versa. Their natural resources value has increased and countries have more capability to use them to manufacture export oriented goods. Increase in international trade brings better standard of living through access to many ways of satisfying their needs and wants. Further it is argued that current development of trading blocs help international trade through making global negotiations easier, in the case of trade negotiations.   For example the EU will negotiate as a single trading block making it easier to push through practises which increase free trade. As per the following graph it is arguable that benefits of international trade have been equally distributed among the world population. Globalisation and increase in international trade is probably helping to create more wealth in developing countries and has affected to the balance of international trade. However globalisation is having a dramatic effect on the organisations for good or ill. Some positive impacts are as follows; Increase greater access to capital market. Inward investment by MNCs helps organisation to start new businesses locally and in foreign countries. This will provide new jobs and skills for local people. Companies can bring wealth and foreign currency to local economies when they buy local resources, products and services. Release of government regulation and establishing better infrastructure in the local economy attract foreign investments. China is well known for cheap labour compared to western countries labour cost. This has become a main reason for many organisations moving their businesses to China. Further investment friendly environment through strong financial support (Tax benefits, financial institutes) for new businesses, attract their cheap resources for other countries. Most of the western countries resources are fully utilised and market have become more matures, but there are emerging economies like China, India, Brazil and Russia which consist many untapped cheap resources. Therefore as a result of pressure built up from the Western markets, businesses now moving for those emerging markets. This process has been made easier and more comfortable due to the globalisation. The extra money created by these investments can be spent on education, health and infrastructure of the countries. (Corporate Social Responsibility activities) Achieve economies of scale. Economies of scale means the increase in  efficiency of production  as the number of goods  being produced increases.  Economies of scale lowers the average cost per unit through increased production since fixed costs are shared over an increased number of goods. Initially Adams Smith identified division of labour and specialization are the main factors that lead to economies of scale. However as Globalisation process increases companies get other opportunities to reduce their production cost and achieve economies of scale. Access to lower inputs and specialized inputs in different countries would bring the economies of scale. Costly inputs such as research and development, advertising, managerial expertise and skilled labor now can be outsourced to specialized countries and it will result in increased efficiency and lead to a decrease in the average cost of production and selling. Therefore economies of scale provides  big companies  access to a larger market with lower cost of production and greater margin for their products.    Globalisation increases awareness of events happening in the world. For example, the USA was quickly made aware of the 2011 tsunami in Japan and sent help rapidly in response. Globalisation may help to make people more aware of global issues such as deforestation and global warming and alert them to the need for sustainable development. The sharing of ideas, experiences and lifestyles of people and cultures. People can experience foods and other products not previously available in their countries. Globalisation has resulted in many businesses starting or buying operations in other countries. Companies that operate in several countries are called multinational corporations (MNCs) or transnational corporations (TNCs). Presence in different countries brings interaction with different cultural and social values. On this case business practices that are successful in local country could be act as negatively or positively under different cultural and social values. Therefore it is advisable to find answer to following questions before starting a new venture with another country. What are the main difference between cultures?, Are they matter of learning a new handshake, or do they go deeper than that?, Can cultural differences really have that much impact on the business deal? Etc. Finding solution for those questions is helpful for organisations to handle cultural differences in business expansions. For example language differences, the way they perceive time, traditional and religious believes etc. play a big role in Asian countries. When US and European base organisations move towards the Asian countries the above cultural factors could act as barriers for entry to those markets. In terms of communication US and Europeans are considered as low context cultures, language is direct and explicit, but when it comes to Asian countries they are known as high context cultures where language is indirect. Further as per certain cultural and social practices men dominate in the business sector than the women but in European organisation everyone gets equal opportunity to participate in the operations. Therefore when companies setup new business in a different culture, that company need to customise their corporate culture as per the local cultural values. As an example the US fast food chain McDonalds, large MNC which has nearly 30,000 restaurants in 119 countries, had a problem of sell ing beef burger in India due to the religious believes. Further they launched Mc Rice in Sri Lanka since rice is the main food in the Sri Lankan culture. Likewise multinational companies tend to customise their strategies to overcome certain social and cultural restrictions as well as implement new thing to take advantageous. In current business environment sometimes it is difficult to follow a global strategy for their operation in throughout the world. Therefore most companies tailor their management strategy and organisational structures to respond to the local factors. In other words local responsiveness is essential when a psychic distance is higher in two different countries. As a result of this new relationships will occur in managing businesses globally. Joint venture agreements, alliances etc. are common relationships that business partners follow to reduce their risk exposure in the current business environment. Designing of organisational structure and management style is important capture the opportunities available in the market. Some companies follow decentralised structure to increase the speed of decision making in the particular market. Some other companies follow a selective approach by some functions are retain in with the parent country and others establish in different markets. As exa mple GAP Inc.s designing function is conducted in centrally and manufacturing function has been outsourced to Asian countries. This mechanism has benefitted them through utilising Asian countries specialised capabilities of manufacturing to convert their design into practical product. Therefore globalisation process brings new organisational designs and management styles to the market. Local markets work force have now increased and well interact with the MNCs. Earlier they were only involved for lower level operations but now management representation also has increased. This is a good advantage for MNCs to take advantage of innovative skills of the local employees since they have more experience in the particular market. Microsoft has given more concentration on Indian market since that workforce well recognised for IT skills. From employees perspective also this will be a good opportunity for them to utilise their skills effectively. Recognition, income level, career opportunities, opportunity to obtain foreign exposures etc. will be increased through working in multinational company. Their innovative concept could bring to the world market through the help of MNCs. So far this report addressed only the good side of the Globalisation and not that mean it doesnt have a dark side. Following are few negative impacts of globalisation Globalisation operates mostly in the interests of the developed countries, which continue to dominate world trade at the expense of developing countries. The role of developing countries market has become to provide the North and West with cheap labour and raw materials at lower cost. There are no guarantees that the proper benefits from inward investment will benefit the local community in developing countries. Often, profits are sent back to the MNCs parent countries. This has become easier for them due the tax relief offered by the local governments. Further these MNCs with their massive economies of scale, possibility to drive local companies out of business. After that If these MNCs realised that it becomes cheaper to operate in another country than the current one then they move for better opportunity by closing down the factory and make local people redundant. This would be a major hit for the local economy. Increase environmental population due to the high industrialisation. Globalisation is viewed by many as it affects to the worlds cultural diversity and it feared that it may westernise the local traditions and languages. After considering the above negative sides of the globalisation we can state that it is not helping to close the gap between the worlds poorest countries and the worlds richest. In the case of trading blocs, it is argued they create conflicting parties fighting for regional interests not for every ones benefits. As per the World Trade Organisations statistics, the worlds poorest countries share of world trade has declined by more than 40 per cent since 1980 to a mere 0.4 per cent and the poorest 49 countries make up 10% of the worlds population, but account for only 0.4% of world trade. (Online, www.gatt.org) This clearly shows benifits of globalisation has not been distributed equally. Further its doubt that MNCs pay fair amount for the developing countries resources. As a result of these negative reasons poor peoples living standards remain same and the gap between poor countries and rich countries wont reduce. Conclusion Globalisation has a major impact on the business environment as well as the people general life pattern. Within the current knowledge economy, knowledge workers have more opportunities due to the globalisation. Their career is not static as compared to the traditional workers. They always seek better opportunities in the market and as a result of globalisation their career path has extended even for different countries. However, as a MNC, they have more responsibilities and accountability for their actions in the different markets. As a good corporate citizen they must give their focus on improving local social and educational life the local people also. Further they must ensure fair consideration for the resources utilised the developing countries. These will ultimately useful to break the bridge between rich and poor countries.

Passive Women in Chaucers Canterbury Tales? Essay examples -- Chaucer

Passive Women in Chaucer's Canterbury Tales? One argument that reigns supreme when considering Chaucer’s The Canterbury Tales is whether or not there is an element of anti-feminism within the text. One thread that goes along with this is whether or not the women of The Canterbury Tales are passive within the tales told. This essay will explore the idea that the women found within the tales told by the pilgrims (The Knight’s Tale, The Miller’s Tale and The Wife of Bath’s Tale to name a few) are not passive at all, but rather influence the turn of events within the stories. It is seen even in the first tale told – The Knight’s Tale – that the women portrayed within it are not passive at all, but, as previously stated, manage to persuade the males in charge to help them or do what they feel should be done. In the tale itself, the weeping of women is seen twice, and both times their weeping influences the men’s actions. The second example of weeping within the tale, as shown here: The queene anon, for verray wommanhede / Gan for to wepe, and so dide Emelye / And all the ladyes in the compaignye. / Greet pitee was it, as it thoughte hem alle / That evere swich a chaunce sholde falle†¦ â€Å"Have mercy, Lord, upon us women alle!† And on hir bare knees adoun they falle / And wolde have kist his feet ther as he stood; / Til at the laste aslaked was his mood / For pitee renneth soon in gentil herte. (Benson p. 49.) influences Theseus to agree to a battle to the death for the knights as opposed to simply beheading them as he was about to do. If these women were truly passive, then they would have not spoken up at all, or Theseus would have ignored them in favor of following through with his own wishes. Instead, he is ... ...of the women presented within Chaucer’s Canterbury Tales are passive and allow anything to happen. Indeed, quite the opposite is true and can be seen in just the few tales presented as well as many others. Though there are obvious signs of anti-feminism within the text, or anti-feminism that can be read within the text, there is also the opposite counterpoint of the activity of women within the text versus the passivity of women within the text. Works Cited Benson, Larry D. ed. The Riverside Chaucer. Huppe, Bernard F. Rape and Woman’s Sovereignty in the Wife of Bath’s Tale. Modern Language Notes. Vol. 63, No. 6. June 1948. pp. 378-381. Mann, Jill. Feminizing Chaucer. Patterson, Lee. â€Å"For the Wyves love of Bathe†: Feminine Rhetoric and Poetic Resolution in the Roman de la Rose and the Canterbury Tales. Speculum. Vol. 58, No. 3. July, 1983. pp 656-695.

Epic poetry Essay

?This article is about the art form. For other uses, see Poetry (disambiguation). Literature Major forms Novel Poem Drama Short story Novella Genres Comedy Drama Epic Erotic Nonsense Lyric Mythopoeia Romance Satire Tragedy Tragicomedy Media Performance (play) Book Techniques Prose Poetry History and lists Outline of literature Glossary of terms History (modern) Books Writers Literary / Poetry awards Discussion Criticism Theory Sociology Magazines Literature portal v t e â€Å"Poem†, â€Å"Poems†, and â€Å"Poetic† redirect here. For other uses, see Poem (disambiguation), Poems (disambiguation), and Poetic (disambiguation). Poetry (from the Greek poiesis — — meaning a â€Å"making†, seen also in such terms as â€Å"hemopoiesis†; more narrowly, the making of poetry) is a form of literary art which uses aesthetic and rhythmic[1][2][3] qualities of language—such asphonaesthetics, sound symbolism, and metre—to evoke meanings in addition to, or in place of, the prosaic ostensible meaning. Poetry has a long history, dating back to the Sumerian Epic of Gilgamesh. Look more:  types of satire essay Early poems evolved from folk songs such as the Chinese Shijing, or from a need to retell oral epics, as with the Sanskrit Vedas, Zoroastrian Gathas, and the Homeric epics, the Iliadand the Odyssey. Ancient attempts to define poetry, such as Aristotle’s Poetics, focused on the uses of speech in rhetoric, drama, song and comedy. Later attempts concentrated on features such as repetition, verse form and rhyme, and emphasized the aesthetics which distinguish poetry from more objectively-informative, prosaic forms of writing. From the mid-20th century, poetry has sometimes been more generally regarded as a fundamental creative act employing language. Poetry uses forms and conventions to suggest differential interpretation to words, or to evoke emotive responses. Devices such as assonance, alliteration, onomatopoeia and rhythm are sometimes used to achieve musical or incantatory effects. The use ofambiguity, symbolism, irony and other stylistic elements of poetic diction often leaves a poem open to multiple interpretations. Similarly, metaphor, simile and metonymy[4] create a resonance between otherwise disparate images—a layering of meanings, forming connections previously not perceived. Kindred forms of resonance may exist, between individual verses, in their patterns of rhyme or rhythm. Some poetry types are specific to particular cultures and genres and respond to characteristics of the language in which the poet writes. Readers accustomed to identifying poetry with Dante, Goethe, Mickiewicz and Rumi may think of it as written in linesbased on rhyme and regular meter; there are, however, traditions, such as Biblical poetry, that use other means to create rhythm and euphony. Much modern poetry reflects a critique of poetic tradition,[5] playing with and testing, among other things, the principle of euphony itself, sometimes altogether forgoing rhyme or set rhythm. [6][7] In today’s increasingly globalized world, poets often adapt forms, styles and techniques from diverse cultures and languages.

Symbolism in Invisible Man by Ralph Ellison

Symbolism in Invisible Man by Ralph Ellison Progress Report #2?Invisible Man? by Ralph Ellison is scattered with symbolism. Especially the first scene, which is widely known as the ?Battle Royal.? This is an important section in the novel, for the reader is introduced to the Invisible Man as someone who is not listened to by most, interrupted by many and instructed to know his place at all times.From the very beginning of the novel the narrator values his education. His education first brings him a calfskin briefcase, when the superintendent rewards him for his success, saying, "Take this prize and keep it well. Consider it a badge of office. Prize it. Keep developing as you are and some day it will be filled with important papers that will help shape the destiny of your people." (Ellison; pg. 32) The Invisible Man treasures the briefcase that included a scholarship to the state Negro college so much but it represents the life that the white authority figures have planned out for the Invisible Man.Invisible Man Living Statue, Thames South Bank, Lo...It was covered in white tissue paper, symbolizing the white control over his planned life.The last few paragraphs of this chapter are embedded with symbolism and foreshadowing. For example when he arrives home after the ?Battle Royal? the Invisible Man believes that he has actually accomplished something by accepting the scholarship. ?When I reached home everyone was excited. Next day the neighbors came to congratulate me. I even felt safe from grandfather, whose deathbed curse usually spoiled my triumphs. I stood beneath his photograph with my brief case in hand and smiled triumphantly into his stolid black peasant?s face. It was a face that fascinated me. The eyes seemed to follow everywhere I went.? (Ellison; pgs. 32-33) The eyes in his picture represent the Invisible Man?s constant feeling that his...

A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting The WritePass Journal

A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting Introduction A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting IntroductionCASE STUDYDISCUSSIONHair AnatomyLifecycle of the hair Factors influencing hair growthGrowth FactorsHormonesMineralsOther factorsTypes Of Non-Scarring AlopeciaDiffuse hair lossFemale Pattern Hair LossAcute telogen EffluviumChronic telogen EffluviumTreatment of FPHLMinoxidilThe Hair ConsultationHistoryExaminationScalpHairPull testNon-scalp hair and skinLab testsCASE DISCUSSION AND CONCLUSIONREFERENCESRelated Introduction CASE STUDY Mrs   KJ, a 29 year old manager at a busy law firm, presented to her GP complaining of recent sudden onset of hair loss over a period of a few weeks. What prompted her visit to the GP, was noticing large amounts of hair on the bathroom floor whilst on honeymoon, and subsequently that her scalp hair was suddenly thinner than usual, especially around the temporal areas. She had wondered whether she should be changed back to Cilest (from the Dianette she was currently taking), her original contraception, the cessation of which had appeared to trigger the same symptoms two years before. On that occasion, after stopping Cilest, she had experienced amenorrhoea with facial hirsutism and similar hair loss, leading to investigations and a diagnosis of polycystic ovarian syndrome (PCOS). She then used Dianette oral contraception and for a short time, oral cyproterone acetate, which improved the hair loss. Mrs KJ, who was also a vegetarian, denied use of hair dye or chemicals on her hair, and on the day of her consultation her hair was not styled in a manner promoting traction. Questions regarding family history revealed that her father had died of a heart attack in his fifties. The GP agreed with Mrs KJ that the hair around the temporal and crown areas appeared less than elsewhere on her scalp. The scalp was found to be otherwise normal, with no evidence of scarring alopecia or alopecia areata. The pull test was negative (however, her hair had been washed that morning), blood results (biochemistry and haematology) were deemed normal by the GP and because of the hair shedding, a diagnosis of telogen effluvium (secondary to stress – work and wedding planning) was made. She was advised to stay on Dianette. Because of the previous history and treatment she was referred to a dermatologist with an interest in alopecia, who described a mixed picture of telogen effluvium secondary to low ferritin, and mild androgenetic alopecia. He also asked for the bloods to be repeated, and these showed a decreased ferritin level, high SHBG, and all the rest normal, including zinc, antibody screen, and thyroid tests. He too advised that Mrs KJ remain on the Dianette, and that she start taking an iron supplement. Of interest is that the initial ferritin level done by the GP was 37ng/l, and this fell to 28ng/l over a period of about a month. Haemoglobin was normal. Both these figures were within the normal range provided by the lab (normal range 13-150ug/l, with optimum ferritin for females advised at 27ug/l)1. A few weeks after starting the iron supplements, Mrs KJ came back to see her GP to discuss work related stress which had spiked. In particular she was concerned that she would not be able to manage a very important presentation to the senior partners at the firm. She was so distressed that she found the only thing that calmed her was drinking alcohol, which she was understandably not keen on using regularly! So after some discussion about stress, the GP suggested that she try low dose propranolol for performance anxiety, for only the few days leading up to the presentation, including the actual day of, then to discontinue. Hair loss was not discussed at this consultation. A month later she was back to see the GP, complaining that there had been an even bigger spike in hair loss, and on contacting the dermatologist she had been advised to continue the iron supplementation. She requested a second dermatology opinion, and was then diagnosed with androgenetic alopecia secondary to PCOS, unmasked by telogen effluvium secondary to low ferritin, and a degree of scalp seborrhoea. She was advised to continue taking Dianette, iron supplementation, Ketoconazole shampoo a few times a week, topical minoxidil and topical cyproterone. She was also put on Metformin by her gynaecologist as part of the treatment for PCOS. A number of months later there was a marked improvement in hair growth. As she was keen on starting a family, she was advised to stop oral contraception and to continue the topical treatments, but to stop both minoxidil and cyproterone once she conceived. DISCUSSION In order to understand abnormalities associated with hair loss, it is important to understand the normal hair physiology and anatomy. Having personally spoken with a group of 12 GP’s, about how they would approach a patient complaining of hair loss, all admitted that they felt underprepared to do so. They also admitted to a poor understanding of hair anatomy and physiology. Hair Anatomy Figure 1.   Structure of a hair follicle2 Types of hair There are three types of hair – terminal hairs are thick hairs found on the scalp, axilla and pubic areas; vellus hairs are finer, shorter hairs on the rest of the body; and lanugo hairs develop in utero and are shed in the first few months of life. Anatomy The hair starts to develop within the hair follicle, which is a stocking-like structure made up of an inner and an outer layer.   The hair is divided into the part that protrudes above the skin, called the shaft, and the root, which is within the follicle. The dermal papilla is a finger-like projection into the base of the follicle. It contains capillaries to allow for a rich blood supply to the hair bulb, forming the base of the hair root, the only living part of the hair, and therefore requires nutrients. The hair bulb is the enlarged lower end of the hair into which the dermal papilla projects. It is made up of living cells with a high potential for division and differentiation which divide every 23-72 hours, the fastest rate of any cells in the body3. These cells are called the hair matrix. They divide and move up the follicle to become either hair cells or cells of the inner sheath of the follicle. Among the matrix cells are melanocytes which produce dark (melanin) or red/blonde (phaeomelanin) hair pigment. Pigment is taken up by the differentiating cells of the matrix by phagocytosis. The matrix gives rise to the layers which form the hair shaft – the medulla is the inner layer(not always present in non-terminal hair), the cortex makes up the main bulk of the hair shaft and contains dead keratinocytes, and the cuticle is the layer of tightly packed overlapping cells surrounding and sealing the shaft. The matrix is fed by the dermal papilla, which plays a significant role in hair growth. The dermal papilla produces a number of substances which have an effect on matrix cell growth and differentiation. The dermal papilla is itself under the influence of hormones and regulating substances, which include growth factors. These can increase proliferation of dermal papilla cells, which release cytokines which can act as inhibitors or stimulators of matrix cell growth. The hair follicle is a component of the pilosebaceous unit – one of the other components being the sebaceous gland (as well as apocrine glands in specific areas such as the groin and axilla). The inner layer of the follicle extends up the shaft and ends below the opening of the gland into the follicle, while the outer sheath extends to the gland itself. The outer sheath has a fibrous membrane to which is attached the erector pili muscle, contraction of which causes the hair to stand upright (giving the effect of ‘goosebumps’ when someone is nervous or cold). The sebaceous gland secretes sebum, an oily substance that helps to moisturise the skin and hair, while the apocrine gland is a sweat and scent gland, and mostly becomes activated at puberty under the influence of hormones. Lifecycle of the hair There are three phases of hair growth. Anagen – is the active phase when the cells of the hair bulb are constantly dividing and causing the hair shaft to elongate. This growth phase can last between 3-4 years. Catagen – is the transitional or involutional phase which follows anagen. The hair stops growing, the follicle shrinks slightly and the root is diminished and breaks away from the dermal papilla. This phase lasts 2-3 weeks. Telogen – is the resting phase when the hair is no longer growing and the dermal papilla is not attached to the follicle. This phase lasts 6-12 weeks. When anagen phase restarts and the follicle and dermal papilla reconnect, a new hair forms and starts growing, and can push the old hair out. About 10-15% of scalp hairs are thought to be in telogen phase at any given time.3,4 There is no synchronicity in the hair cycle and so small amounts, about 100 hairs per day, are lost every day, unnoticeably for the most part.   Very occasionally, cycles can be synchronised, for example toward the latter part of pregnancy, thought to be under the influence of hormones, so that larger amounts at a time are shed a few months postpartum; this hair loss is by and large seen as physiological and not pathological, and normal hair growth pattern is usually soon re-established.5 Factors influencing hair growth Progress has been made toward understanding the processes which influence hair growth, but there is still much work to be done in this regard.3,6 Growth Factors Insulin-like growth factor (IGF) accelerates hair growth depending on its concentration at the dermal papilla. This is regulated by IGF binding protein (IGFBP) which reduces the amount of free IGF available for action, and therefore has an inhibitory effect on hair growth. There are also a number of other growth factors which play in a role in hair growth regulation.3,6,8 Hormones Androgens were proven to play a role in androgenic alopecia by Hamilton who noticed that men who were castrated before puberty never grew beards or developed baldness, unless they were treated with testosterone, and that balding men who were castrated showed no progression of balding.6 Androgens stimulate hair growth in some areas such as the beard and groin. In genetically predisposed individuals the presence of circulating androgens can also cause hair loss in areas such as the temporal and vertex areas of the scalp; the occipital area is usually spared. The reason for this is not well understood, and is thought to be related to specific receptors.6,8 The main androgens are testosterone and its metabolite dihydrotestosterone (DHT), the conversion occurring under the action of the enzyme 5 a-reductase at the site of the end organ, in the case of hair, the skin. DHT is more potent than testosterone in this area as it has a higher affinity for the receptors. Sex hormone binding globul in (SHBG) binds to free testosterone, preventing its breakdown to its more active metabolite DHT. Therefore, SHBG has an inhibitory effect on testosterone function. SHBG is in turn inhibited by IGF and insulin – these therefore help to increase the level of active testosterone and DHT.3 Testosterone reduces the anagen phase of the terminal hair, with the result that the hair is shorter and has a smaller diameter, called miniaturisation of the hair, and conversion of the terminal pigmented hair into a vellus (often) non-pigmented hair.3,6,8 The result is that with time, the areas where this occurs appears to have thinner hair growth or appear balding. In females, androgens are manufactured in the ovaries and the adrenal glands. The ovaries produce both male and female hormones, and under the influence of insulin there is increased conversion to testosterone. 3,9 In women with higher levels of circulating insulin, such as those with polycystic ovarian syndrome (PCOS), metabolic syndrome (MS) and insulin resistance, there can be higher levels of androgens due to increased conversion, and the suppressant effect on SHBG. 9 The net result would be a hyperandrogenic state, which could result in AGA, hirsutism, acne, voice changes, among other signs of virilisation. 7 The role of oestrogens appears to be more complicated. 15 The enzyme aromatase is found in oestrogen producing cells in the adrenals, ovaries, testes, fat cells, as well as a few other organs. Aromatase helps to convert testosterone into oestradiol, thereby decreasing the amount of free testosterone. Women who took aromatase inhibitors as part of treatment for other conditions, were found to develop androgenetic male pattern hair loss, indicating that aromatase has a role to play in the pathogenesis of alopecia. The exact nature of this role is unclear. 10 According to Yip et al. oestrogens are at least of equal importance to androgens in scalp hair growth.15 Minerals While iron deficiency anaemia has been widely accepted to be a cause of hair loss17, it is less clear to what extent ferritin levels without the presence of anaemia, has on hair loss. When comparing women of child-bearing age with diffuse telogen hair loss, to those without, in the presence of no nutritional supplementation or underlying medical conditions, women with the hair loss were found to have a mean ferritin level that was significantly lower than those without hair loss. The odds that someone would have ratio   TE was higher when the ferritin level was at 30ng/ml or lower. The authors concluded that serum levels at 30ng/ml or lower therefore increased the chances of TE. 14 However Olsen et al. compared   iron deficiency in women with female pattern hair loss (FPHL or AGA – difference discussed later), CTE and a control group with no hair loss, and found that while iron deficiency was common in all the women, there was no significant difference in levels between the three groups. This study cited as a limiting factor that the outcome of treating the women, who had been discovered to have iron deficiency, was unknown. 12 Theoretically then, those who had hair loss and iron defiency, could have experienced a degree of hair regrowth after the iron deficiency had been treated. While a number of studies have supported the theory that ferritin levels affect hair loss, such as the study by Kantor et al 11 a number have also. Disputed. 12 Although the effects of ferritin on hair loss is still being studied and debated, Rushton suggests it would be advisable to treat even a low normal ferritin, if it was under the level of about 30-70 ng/ml; Trost et al . also advocate that ferritin above 70ng/ml should be aimed at to optimise treatment for AGA, and that the reason for the presence of anaemia or low iron stores should be sought if appropriate, while iron overload should be avoided. 13,16 Zinc deficiency is known to play a role in alopecia, but the mechanism is unclear. 17,18,19 Lack of essential fatty acids can help cause a diffuse alopecia with some lightening in colour of the remaining hair. Selenium deficiency can cause a hair loss similar to zince deficiency. Biotin deficiency can be genetic or acquired (medications like valproic acid, adult excessive consumption of raw eggs) and is also thought to play a part in causing hair loss, but there have been no clinical trials to support biotin supplementation to improve this. 19 Other factors Hair loss is also a well known side effect of thyroid problems, inflammatory illnesses such as lupus, malnutrition, anorexia nervosa, among other conditions, all of which can be picked up as part of the differential diagnosis when evaluating someone with hair loss. 17,20 Stress has also been known to cause hair loss, such as following major surgery or emotional trauma. 17,20 A long list of medications also affects the hair. Heparin, Warfarin, Ace inhibitors, Beta Blockers, Allopurinol, and levodopa, among many other drugs, have been found to cause hair loss 20 Age is also an important determinant, as balding increases with age 21, as is genetics – baldness appears to run in families. There is a marked difference between races in manifestation of androgenic hair loss, with Caucasians exhibiting this the most. 8,15 Types Of Non-Scarring Alopecia Hair loss can be broadly classified as scarring (or cicatricial) alopecia and non-scarring alopecia. There are some occurrences when there is some overlap between these two. Non-scarring alopecia can be further divided into a diffuse hair loss, or localised/patchy hair loss (alopecia areata, not discussed further). Diffuse hair loss This problem is not an uncommon presenting complaint to a GP. It can be noticed by the patient as either decreased hair density/thickness, or as increased hair shedding. The main causes for this would be acute telogen effluvium (ATE), chronic telogen effluvium (CTE) and female pattern hair loss (FPHL). 17 FPHL, together with male pattern hair loss (MPHL) is also known as androgenetic alopecia (AGA), but more authors are now referring to separate nomenclature for the sexes. 8,15,17,20 Although MPHL and FPHL are histologically identical the age of onset in females is later than in males. Also the patterns of hair loss between the sexes differ. The progression of the problem is not as rapid with women or as severe and there is not as good a response to anti-androgen therapy with women, as there is with men.15, 20 Many authors have therefore suggested that in women there is therefore a very complex, multifactorial aetiology. Female Pattern Hair Loss This is the most common type of hair loss affecting women, with prevalence increasing with age. It affects about 12% of women aged 20-29, to about 50% of women over 40, and over 50% by the age of 80. 20, 28 FPHL is an under-recognised entity.20 Androgenetic alopecia has been defined as progressive hair loss in genetically susceptible people in the presence of circulating androgens. Histologically, there is miniaturisation of the terminal hair follicle with progressive transformation of the terminal hair follicle (with central medulla) into a vellus hair follicle (no medulla). 15,17, 20 The role of androgens and androgen receptors is much more established in MPHL, and therefore finasteride and minoxidil are established treatments for MPHL. Androgens definitely have their role to play in FPHL, but there are other factors which influence the disorder as well, which are not clearly understood, such as oestrogens and iron. Many women with FPHL do not have demonstrable elevated androgen levels or other features of hyperandrogenism. 17 Women with hyperandrogenism respond better to anti-androgen treatment. 20 MPHL commonly follows the pattern described by Hamilton, with temporal recession initially, followed by vertex balding, with eventual fusion of the temporal and vertex balding areas and sparing of the occipital area).23 In women, only a small number present with this pattern of hair loss and the degree of balding is not usually as severe as in men. 20 The pattern in FPHL follows three main distributions: Diffuse central-frontal hair loss with sparing of the frontal hairline. In 1977 Ludwig described this in three scales – mild, moderate and severe (almost completely bald at vertex, this is very rare). 17, 20, 24 Diffuse, mainly frontal hair loss (frontal accentuation) with breach of the frontal hairline. The Olsen scale or Christmas tree pattern – this is demonstrated by parting the hair in the midline and noting the part widening, with the narrowest part at the vertex and the widest part toward the frontal hairline. 17, 20, 24 Fronto-temporal and vertex hair thinning, in other words a male pattern of hair loss or Hamilton-Norwood- type. 17, 20, 24 Hamilton-Norwood  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ludwig  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Olsen  Ã‚  Ã‚  Ã‚   (male pattern)  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  (diffuse central)  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   (frontal accentuation)drawing, courtesy ref.24 More recently the Sinclair 5 point scale has been adapted and introduced, and may become more widely used as it allows more subtle description; this may become more necessary as women start to present more early with their hair loss. 20, 24 Sinclair 5-point scale for FPHL drawing courtesy ref. 24 (drawing by L. Tosti) Because it is a progressive problem, without effective treatment the condition will worsen. However the rate of the progression is variable and unpredictable. Diagnosis is usually clinical, based on history and examination. Correct diagnosis is imperative so that the correct treatment can be commenced to try to at least slow down/halt the progression of hair loss, or at best bring about some degree of hair regrowth.17, 20 Progression tends to be slow, with hair loss quite diffuse. It mainly occurs in the distributions mentioned above. Miniaturised hairs are seen in the affected areas, hair shaft diversity is noted more easily on dermoscopic examination. Very occasionally peripilar halos/atrophy is seen as well.   If shedding is present it is not as significant as in ATE or CTE, and the hair pull test is usually negative. Biopsy shows the abovementioned miniaturisation and a decreased terminal:vellus hair ratio, with a lower anagen:telogen ratio. The biopsy, which is not necessary unless doubt exists as to the diagnosis, should be taken from three sites, as a horizontal section and be about 4mm in diameter.17,20,24 By the time a biopsy is contemplated a patient would probably be seen by a dermatologist. While the diagnosis of FPHL is usually clinical, a biopsy should be performed when the diagnosis is uncertain.17,24The main differential diagnosis is CTE.17,20,23 The main difference is that CTE occurs as a rapid hair loss (FPHL is slower), lots of shedding is noted (as opposed to the presenting complaint being thinning hair). With CTE there is a positive pull test (patient should not shampoo their hair for 24 hours prior to test), when the effluvium is in an active shedding phase. Examination of the scalp in CTE does not show widening of the part, or miniaturisation, and biopsy is normal in CTE (apart from showing an increase in telogen hairs).17, 20 Acute telogen Effluvium ATE is also a diffuse type of hair loss which has an abrupt onset, usually seen 2-3 months after a trigger event, and usually does not last for longer than 6 months. About 15% of adult scalp hairs are in telogen phase – when telogen hairs are shed the bulb or club-shaped tip can usually be seen. Anagen hairs have a more tapered tip – there is no bulb because it is attached to the dermal papilla as the hair is still growing. 25 At the time of the precipitating event or trigger for the effluvium, as many as 75% of anagen hairs can be pushed into telogen. 20 A few months later the new anagen hairs starting to grow in the follicle push the old hairs out, and the hair shedding is noticed by the person as hair loss. In actual fact, this shedding is really a sign that new hair is growing. 25 Shedding reaches a peak and hair thickness gradually returns to normal over months in the majority of cases things are largely back to normal by about 1 year. 17 Sometimes the precipitati ng event causes a corresponding Beau’s line in the nail. 25 Potential causes of ATE would include: (febrile) illness, surgery, trauma/accident, childbirth, emotional trauma. Severe and sudden weight loss can also precipitate this. A number of drugs, including beta blockers, can cause an effluvium. Discontinuing the oral contraceptive can also cause hair to fall out, as can jetlag and excessive sun exposure.25 Chronic telogen Effluvium In CTE, the cause tends not be a single event that acts as a one-off trigger, but something that allows the hair loss to be perpetuated for longer than 6 months. 17 Many cases of CTE are idiopathic, but iron deficiency anaemia, hyper/hypothyroidism, zinc deficiency and malnutrition have been implicated as causative/contributory factors by a number of studies. 17,20 In CTE the hair shedding can fluctuate in severity, for example as an animal might moult. 25 Both acute and chronic telogen effluvium does not cause baldness as there is no miniaturisation or conversion of terminal hairs to vellus hairs, only decreased anagen hair growth. However, it can unmask an individual’s genetic tendency to bald. 20    Treatment of Diffuse hair loss Treatment of telogen Effluvium Treatment of acute and chronic telogen effluvium involves treating the underlying causes, if found. Removing the trigger factor for acute telogen effluvium should allow for an improvement in hair growth in most cases by about one year; most people will see an improvement after a few months already. 17,20 If no cause for CTE is found, a biopsy to rule out FPHL should be considered. 20 The course for CTE is that shedding occurs in phases, but never leads to balding. 20 It is thought to potentially take up to 3-10 years to resolve, but there are insufficient studies that have looked properly at this condition over time. 17 Empiric use of minoxidil 2% has been suggested, in the hope of decreasing telogen and increasing anagen. 20 Treatment of FPHL While a general practitioner may not be expected to able to offer all of the therapies available for the treatment of FPHL, it is very helpful to have a good understanding of the therapeutic processes so that patient questions can be dealt with a knowledgeable manner; this improves the therapeutic relationship. The primary care doctor should be able to initiate medical treatment in an uncomplicated case of FPHL. Minoxidil Minoxidil was first discovered to improve AGA while undergoing development as an oral antihypertensive drug, when it was seen to cause hypertrichosis, and hair growth in balding men. 8, 22, 26 It is now used as a topical treatment for AGA in a 2% and 5% strength. The exact mechanism of action is unclear. It is converted into its active metabolite by an enzyme present in the outer follicle of the hair sheath. In its activated form the drug opens potassium channels to bring about a vasodilatory effect, but studies looking at this effect after topical application of minoxidil, have been inconclusive. 22, 27 Other potential mechanisms of action could include induction of new blood vessel formation by increasing vascular endothelial growth factor gene expression at the site of the dermal papilla. Another theory is that it could stimulate activity of an enzyme (cytoprotective prostaglandin synthase I) which stimulates hair growth. 22, 27 It could also increase expression of the gene for he patocyte growth factor, which stimulates hair growth. Messenger and Rundegren 2004 have proposed that the mechanism of action is to cause premature end to telogen and prolong anagen.20, 27 Ongoing studies are needed into the mechanism of action of minoxidil, as this could help with development of better treatments. Although not enough is known about the mechanism of action to improve alopecia, it has been proven to be efficacious for both men and women. 17, 20, 22, 23, 26, 27 The European Dermatology Forum (EDF) performed an extensive literature review (of specific databases) with the aim of formulating evidence-based treatment guidelines for the treatment of AGA (it differentiates between male and female treatments but calls the conditions AGA). Based on the studies reviewed, it recommends topical application of minoxidil 2% or 5% applied twice daily for mild to moderate AGA, with the 5% strength favoured if greater efficacy required. A foam application (as opposed to the solution) is also available, but further studies comparing efficacy to the solution, are needed. 20 For women, the recommendation is also to use the 2% solution twice daily, but there is no evidence currently available to support the use of 5% strength in females.20, 22, 28 In a study by Lucky et al. female patients were foun d to show psychosocial improvement after using 2% and5% minoxidil respectively, compared with placebo. More pruritis, local irritation and hypertrichosis were reported by women using the 5% solution.28 Patients should always be counselled thoroughly before starting medication. This is vital for compliance, as the progression of the hair loss is only halted/reversed for the duration of compliance. Counselling should include how to apply the medication (1ml in   a dropper, applied to dry scalp morning and night and not washed for at least 4 hours – if hair/scalp get wet within an hour the medication should be reapplied), the importance of compliance for results,   when to expect an improvement, as well as potential side effects. 20 There are three main side effects. One is an apparently paradoxical shedding of hairs – if minoxidil does indeed shorten telogen and stimulate anagen then any new hairs forming would ‘push out’ the old. It is very important that the patient is informed to continue with the treatment, and they could be reassured that this is a sign of the medication working; this effect usually occurs in the first 2-8 weeks of treatment.17, 20 , 22, 23 The other main side effects are related to contact, so it is important to warn the patient to wash their hands immediately after application. Hypertrichosis can occur, mainly because of incorrect application (usually disappears about 4 months after cessation of the treatment). 17, 20, 22, 28 The patient should be advised to apply the medication 2 hours before going to bed at night so that there is less risk of transfer to the pillow, and subsequently to the face. 22Contact dermatitis, either allergic or irritant, has also been reported. 17, 20, 22, 28The main causative agent is the vehicle for the drug, called propyleneglycol, in higher concentration in the 5% solution. 20,22, 28 If contact irritant dermatitis is confirmed then the vehicle should be changed (for example to the foam application – positive results have been produced by Lucky et all with regards to equal efficacy to the solution, and better tolerability from subjects). 20 However if an allergy to minoxi dil is confirmed then the treatment needs to be abandoned/changed completely. 20, 22 The EDF has advised that efficacy should be assessed at 6 months for cessation of shedding and 12 months for regrowth.   22 The treatment should be continued for as long as the therapeutic benefit is required. This is lost with cessation of treatment, with hair loss recommencing about 3 months after cessation. Pregnant and lactating women are advised not use minoxidil, even though no adverse outcomes were noted after a large study.17, 20, 22, 23 5 a-reductase inhibitors These drugs were initially aimed at treating men with prostatic hypertrophy, and both licensed 5 a-reductase inhibitors, finasteride and dutasteride, are currently used to treat this condition. Of the two, finasteride is also registered to treat AGA in men.22 The mechanism of action of finasteride is to act as on 5 a-reductase II, the receptors of which are mainly found in the scalp, skin and liver. Dutasteride acts on both types I (gut and prostate) and II 5 a-reductase. Finasteride reduces serum DHT by about 58-60% 17, 22 while dutasteride reduces serum DHT by about 90% 22 In all the clinical trials assessed by the European Dermatology Forum, 1mg of finasteride taken daily showed a significant improvement by 6 months, compared to placebo, and the same was true at 12 months, and up to a 60 months follow-up. Dutasteride was also looked at by a number of authors and showed an improvement in hair loss but at a much higher dose than that needed to treat benign prostatic hypertrophy. 22 Further studies comparing its efficacy to 1mg finasteride are needed. There are not many studies assessing the efficacy of finasteride in females – in a study of post menopausal women taking finasteride, further hair loss was noted.22, 23 Finasteride is therefore not indicated in women, although one study has shown positive results in women with FPHL and hyperandrogenism. 17, 20 There have also been sporadic reports of finasteride improving hair loss in individual female patients.20, 23More studies into finasteride for use in FPHL, are needed. If finasteride is used off licence in a female of reproductive age, adequate contraception needs to be taken to avoid feminisation of a male foetus. 17, 20, 22, 23   For this reason it is completely contraindicated in pregnancy. Finasteride also lowers PSA levels, so a baseline PSA blood test should be done on men aged 45 years or older, who are starting finasteride.20, 22, 23, 26 Finasteride also has a number of side effects which have potential psychosocial impact – it can cause erectile dysfunction in men and decreased libido. As with minoxidil, counselling is therefore indicated as compliance is important for outcome. For those who do not tolerate the 1mg dosage, a 0.2mg dosage can also be effective. 22 Studies looking at combining the above therapies were done. Khandpur et al showed that 2% minoxidil applied twice daily, and 1mg of oral finasteride daily, taken together, was superior to each therapy used by itself. Taking finasteride with Ketoconazole shampoo was also reported to be superior to the abovementioned monotherapies.20, 29 Combination therapies can therefore be considered if monotherapies are insufficient. Compliance is of course important. Hormone Treatment According to the European Dermatology Forum, evidence for the efficacy of hormonal treatment is limited. Anti-androgens act by blockading androgen receptors (AR) – these are therefore contraindicated in men as they cause feminisation. There is no evidence to support the use of oestrogens in men. (ref. 22) The Forum also decided that, based on their literature review, there was insufficient evidence to support the use of oestrogens, progesterones or anti-androgens in FPHL , although there was a place for anti-androgens in the treatment of some women with hyperandrogenism.22 Use of Spironolactone to treat hirsutism and FPHL is common, especially in the US.20 Spironolactone acts by binding to AR and also acts at the site of the ovary to reduce manufacture of androgens. In a study spironolactone was shown to be as effective as cyproterone acetate in FPHL, but only a small percentage of women showed improvement; the majority of women in the study showed no response. 20 Spironolacto ne   is taken at a dosage of 100mg 200mg per day, with concurrent use of contraception. Cyproterone acetate is taken at a dosage of 25-100mg per day for 10 days of every menstrual cycle, also with concurrent use of contraception.17, 20 Cyproterone inhibits gonadotrophin-releasing hormone (GnRH) and blocks AR; it is also used for treatment of acne, prostate cancer and hirsutism. Vexiau compared minoxidil 2%   and cyproterone – the former was more effective in women who had no hyperandrogenism, and the latter was more effective for those who had, 20, 30 suggesting some role for anti-androgens. Flutamide is another anti-androgen; it compared favourably against finasteride and cyproterone for treatment of FPHL, and also compared favourably against Spironolactone for treatment of acne, seborrhoea, FPHL and hirsutism. 20 However, this drug has a significant side effect profile in that it can potentially cause hepatotoxicity – ongoing monitoring is therefore required and the medication should be stopped or not commenced in the face of significant abnormality.20 Anti-androgen therapy can cause disturbances of the menstrual cycle, breast tenderness, and are contraindicated in pregnancy due to feminisation of male foetus. Spironolactone increases potassium levels, so monitoring of electrolytes is required, as well as hypotension. Adequate counselling prior to commencement of treatment is paramount.20 Surgery There are two types of surgical procedures used to treat alopecia – these are hair transplantation and scalp reduction surgery; they can also be used in conjunction with each other. Because AGA is pattern hair loss, as mentioned earlier, there will be certain areas on the scalp that have a greater tendency to balding than others, for example the occipital area does not have a tendency to bald in pattern hair loss. It makes sense therefore, that for hair transplantation to be effective, the donor site needs to be from an area that is less androgen sensitive or prone to shedding, such as the occipital scalp. The process involves microsurgical techniques of implanting harvested terminal hair follicles under local anaesthetic, into areas of scalp needing more hair. Donor sites must be carefully chosen, the grafts harvested, prepared and implanted without any damage, in order to obtain optimal results. Certain techniques show superiority of efficacy 22.   One study showed a combi nation of hair transplantation surgery with 1mg of oral finasteride had superior results at one year compared with surgery alone. 22 In women the ideal candidate has thick occipital hair and decreased hair density over the frontal scalp. 20 Between one and three sessions are usually required 6 months apart to allow adequate assessment of each surgery. 20 Occasionally there is an effluvium a few weeks after the procedure, but this can often be avoided with concurrent use of 2% minoxidil 20. The best results are achieved in controlled/stabilized AGA and when there is optimal, sufficient donor site. Women with concurrent diffuse effluvium are not good candidates as there is not an optimal donor site. In a good candidate, surgery can result in as good a result as in men. 20 Scalp reduction surgery is not as widely practiced as hair transplant surgery. In scalp reduction surgery the area of scalp with alopecia is surgically removed and two areas of scalp with hair growth are surgically approximated. Scarring and the need for revision surgery, are disadvantages. 20,22 Supplementation A number of trials looking at amino acid supplementation, trace element supplementation (zinc, copper, iron), vitamins like biotin and niacin, antioxidants and millet seed, were assessed by the EDF who found the most of the studies flawed in some way and therefore inconclusive. 22 An improvement in hair growth with use of a herbal treatment containing hibiscus, polygonum, fennel chamomile, thiya and menthe was reported by one author 22Another study also showed some improvement in hair growth after application of a Chinese herbal treatment for six months. 22Retinoids were not proven to show a significant improvement. 22 Saw Palmetto was also looked at by some studies and showed improvements that were significant when compared with placebo.22 Cosmetic Aids While treatments for FPHL are ongoing, or if the patient may for some reason choose not to pursue treatment, or if these were perhaps contraindicated in someone, discussing ways of coping cosmetically may be useful. One study 22 noted that both males and females suffer psychologically when afflicted with hair loss, but for men it was more socially acceptable to be balding than for women, and so the psychological impact can be higher for women who face more pressure to have a ‘normal’ physical appearance. Another study looked at the difference between a woman’s perception of the severity of her hair loss, compared with the clinician’s assessment of this 31.   It found that women consistently rated the severity of their hair loss as higher than the clinician. The study also found that the decrease in quality of life was disproportionate to the degree of hair loss. 31 It is therefore important to consider the patient’s psychological and mental health as well when approaching the issue of hair loss. For this reason it is important to address cosmetic aids and discuss practical issues which may help camouflage the problem in a way that makes the patient feel less conspicuous. Sinclair makes the point that a good hairstylist can be invaluable 20; styling hair in a way to create volume and hide the problem, and learning washing, drying and styling techniques that discourage damage to remaining hair is important. Camouflaging products to create the illusion of thickness include hair building fibres, spray hair thickeners, masking lotion, and topical shading. Fibres can be shaken onto the affected scalp and works in about 30 seconds to create the illusion of thickness. Spray thickeners also create the illusion of increased thickness but can be messy to apply. Tinted lotion and topical shading are less messy and help to create thicker looking hair. Another option, especially if the hair loss is very   advanced or if the application of products is unacceptable for whatever reason, is to use hair extensions, hair weaves/integration pieces or wigs. These depend on choice, and on the quality and amount of remaining hair 20. Hair accessories such as hats, scarves and other fashion accessories can also be useful. The Hair Consultation History After noting gender and age, it is important to determine the nature of the complaint. Has the hair been falling out, breaking off, appearing thinner without noticeable hair loss, or does the quality of the hair appear different.   23 Conditions like monilethrix can result in short fragile hair that breaks easily; in some protein energy malnutritional states such as kwashiorkor hair also breaks easily; with thyroid disorders hair can appear dry and course. Has the problem occurred in the past, or is this the first episode? Has it appeared to improve before? In other words, what is the course of the problem? In CTE, the problem can occur for short periods of time, intermittently for a number of years.   Spontaneous regrowth occurs in TE postpartum. Is there a seasonal variation? Also determine the age at which the problem was first noted. 23,24 Have there been associated symptoms related to the hair problem, such as dandruff, itching of the scalp, burning or painful sensation of the scalp, any rashes occurring simultaneously on the body, any systemic features such as tiredness (anaemia, thyroid problems). Initial signs of AGA can be itching or trichodynia. 24 Any inflammatory condition of the scalp can cause hair loss which can be precluded by itching, scaling or flaking of the scalp. An oily skin can indicate increased activity of the seborrhoeic glands which could indicate increased androgen sensitivity/levels. 24 What is the patient’s past medical history (including any change in health in the year before noticing the hair loss)– severe infections, chronic disease which can cause anaemia of chronic disorder, thyroid problems, medications taken, eczema, any autoimmune disorders, and any chemotherapy or radiation therapy in the past. 23,24 Treatment for breast cancer involving anti-oestrogen therapy can be associated with male pattern hair loss. 10 Gynaecological history for women is also important – menorrhagia, PCOS, amenorrhoea, hormonal contraception, whether post-menopausal and if so has/is hormone replacement therapy used. Discuss past pregnancies – was there difficulty in conceiving, miscarriages, was delivery particularly stressful/complicated. Discuss future family planning. Is there a tendency toward acne, hirsutism, and scalp/skin seborrhoea/oiliness?   23,24 Mental health – issues such as trichillomania, anorexia, and taking antipsycholtic or antidepressant medication. Medications can affect hair growth – beta blockers, anti-epileptics, chemotherapy, thyroid medication, oral contraceptions.   20, 23, 24 Social history is also important – some studies have pointed at smoking exacerbating hair loss. 24 Diet can affect nutritional status, which can affect hair. Sudden weight loss can trigger hair loss. 24Being overweight has been connected with hyperinsulinaemia and metabolic syndrome. The use of anabolic steroids can be significant. 24Enquire about hair products and styling methods – traction can cause problems. Family medical history can indicate an autoimmune problem, family history of male or female pattern balding, skin disorders such as atopy or psoriasis, PCOS, hirsutism. 23,24 It is also important to note from the history how the condition has affected the patient. In the study by Reid et al. mentioned earlier, 31 the clinician’s assessment of severity of hair loss did not predict the patient’s perception of severity of the problem, or their quality of life. While mental health may not always be present as a causative factor, hair loss can cause psychosocial problems such as depression, loss of self esteem and social isolation. 26 It is also important to find out what the patient’s expectations, and hopes, for treatment are. 23 Examination The clinician’s initial impressions are important – is the patient wearing a hairstyle with lots of traction on the scalp, is the person over/underweight, is there obvious hirsutism or acne, is the face looking a bit shiny? Does the person appear emotionally distressed/shy and recalcitrant? It is important to clinically evaluate the whole scalp, including skin and actual hair, facial skin and hair growth (are eyelashes present, is there hirsutism, is there appropriate beard growth), body skin and hair growth, and nails (in alopecia areata the nails can appear pitted). 23,24 Scalp With non-scarring alopecia the scalp should appear normal. Sometimes increased seborrhoea can aggravate AGA. (ref. 26) Scaling, erythema and crusting can indicate inflammation.   With scarring alopecia there is loss of the follicular os. 24 Sun damage in longstanding baldness can be significant. 24 Yellow dots are seen in alopecia areata on dermoscopy, which is thought to represent follicular openings plugged with a keratinous and sebum debris mixture. This can help to distinguish FPHL and TE, from alopecia areata incognita. 32 Hair Note the hairstyle, and whether the hair shafts appear damaged/ dry/ brittle/ broken. 23,24 Part the hair and compare width of the parting at the vertex, frontal, temporal and occipital areas – this is important when describing pattern of hair loss. Use a sheet of white paper for dark hair, and black paper for light/grey hair, over a parting in the hair, to look for miniaturised hair, broken hairs or variations among the hairs. 33 Exclamation hairs (tapering broken hairs) indicate alopecia areata. 32 Miniaturisation indicates AGA. 32 Note the pattern of hair loss – in MPHL, there is thinning and recession bitemporally initially, then in the vertex. In FPHL the pattern can demonstrate the Ludwig, Olsen (Christmas tree pattern) or the Sinclair description, or the Hamilton distribution. 20, 23, 24 Diffuse thinning of the hair can also be caused by diffuse alopecia areata or diffuse telogen effluvium. 20, 26, 24, 32 Pull test This is an important test to help differentiate at the initial consultation between the types of non-scarring alopecia, when not clinically obvious. It is important to determine when hair was washed, as a head washed more recently would be more likely to have lost telogen hairs and have fewer to yield. 17, 20 About 50-60 hairs are pulled between the thumb, forefinger and middle finger. A positive test occurs when more than 10% of the hairs can be pulled out.17, 20, 23, 24 Performing the test on different areas of the scalp is useful in excluding diffuse telogen effluvium; often this can co-exist with a pattern hair loss. 17 The test is usually negative for pattern hair loss, except when performed during a telogen phase in the affected area, when there would be more hairs than usual in the telogen phase. If the pull test is positive, a diagnosis other than pattern hair loss should at least be considered. 24 Non-scalp hair and skin Abnormal distribution of body hair is important to note as can indicate a hormonal problem which may need further investigations. An increased amount of body hair can be hormonal or genetic or related to medication. 24 Absent sexual hair can indicate a hormonal problem, and absent or scanty eyebrows or eyelashes can be associated with alopecia areata or frontal fibrosing alopecia. 24 Acne and seborrhoea can be hormonal. 26 Nails are affected by a number of dermatoses, but of the non-scarring alopecias, only alopecia areata has been known to cause nail changes. 24 Mentioned above is that the trigger causing ATE can sometimes cause Beau’s lines in the nails. 25 Lab tests The history and clinical examination should allow a diagnosis of non-scarring alopecia to be made, and for the problem to be classified as either pattern hair loss, telogen effluvium, or alopecia areata (or a combination). Because confounding factors may also be present which can exacerbate hair loss or prevent treatment, it is reasonable to do some laboratory tests, if suggested by the findings of the history and examination.17, 20, 23, 24 Serum ferritin and thyroid hormone levels should be done. 17, 20, 23, 24 In men it has been advised that after the age of 45, a PSA level should performed prior to treatment with finasteride, as this drug can lower PSA. The patient should be made aware of this side effect.23, 26 If on history and examination there is a suspicion of a virilising tumour, PCOS, or hyperandrogenism in women, then additional tests such as a free androgen index (FAI) (total testosterone x 100 / SHBG) test, and prolactin level as screening tests for hyperandrogenaemia – for example levels of FAI of 5 and above indicate that someone may have PCOS (reference). Depending on findings, FSH, or cortisol levels may also be needed, and the patient referred to either a gynaecologist or endocrinologist (or both if needed). 17, 20, 23, 24 Hormone levels are affected by ingestion of exogenous hormones so should be tested if no hormones taken for 2 months at least, and the time of the menstrual cycle noted for adequate interpretation of hormone results. 23 Oestrogens can increase the level of SHBG, and therefore improve FAI. 23 Other investigative tools available to dermatologists are  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   dermoscopy    in FPHL it shows increased hair diameter diversity and an increased number of vellus hairs. 32 Global photography – helps to evaluate the course of hair changes in clinical studies in an objective fashion – set regions of the scalp are photographed using standardised procedure and equipment 23,24 Trichoscan – for diagnostic and follow-up purposes, it measures hair density and anagen/telogen ratios. For reproducibility tattoos of the sample areas in frontal and occipital regions are needed. 23,24 Trichogram – to be used by a dermatologist experienced in its use. 24 Biopsy – not usually required for diagnosis of non-scarring alopecia, but may be helpful if there is doubt about the diagnosis. Much more relevant for cases of scarring alopecia. 17, 20, 23, 24 CASE DISCUSSION AND CONCLUSION The case of Mrs KJ is interesting because of the complexities involved. Her initial hair loss had occurred on cessation of Cilest. She therefore believed that stopping this had caused the problem, and helped maintain hair thickness, hence her request to be put back on Cilest when she saw her GP. As mentioned above, cessation of the combined oral contraceptive has been noted to cause transitory hair loss. However, at the time of the initial presentation she was put on Dianette and cyproterone as she was found to have PCOS. This is one of the potential causes of hyperandrogenism. Although her blood results did not show any hormonal imbalances, she mentioned that she had had facial hirsutism at the time, so was clinically hyperandrogenous without being biochemically hyperandrogenous. It may be that in the presence of normal hormone levels, she was more responsive to existing hormones, possibly with increased receptor sensitivity. The blood results could also not accurately be relied on as she was not taken off the oral contraception. The fact that there was hair growth with cyproterone suggests that androgens had their role to play in her case. When she presented to the GP for the second time, there were a number of issues to note. She had a very stressful and demanding job. It must be noted that Mrs KJ’s personality was that of a perfectionist, and it could be argued that people like this, who are driven to succeed might be more susceptible to stress. She had also planned her wedding and honey moon in the months leading up to the dramatic hair shedding which occurred whilst on honey moon. Added to this was her vegetarian diet, and although she was not anaemic, her ferritin level was below ‘the optimum’ levels discussed above, even though normal according to the lab reference range. The plot thickens. Based on the above the GP had correctly made the diagnosis of a telogen effluvium. However Mrs KJ had the compounding problem of PCOS. The underlying problem for Mrs KJ was the PCOS, a syndrome affecting about 5-10% of women. 34 PCOS symptoms are related to abnormal levels of sex hormones – high/high-normal Luteinising Hormone (LH) and androgens (including testosterone), and low Follicle Stimulating Hormone (FSH) and progesterone. The cause for PCOS is not known but there is an association with insulin resistance. 35 Insulin resistance causes the body to increase the amount of insulin produced. Higher insulin levels increase ovarian production of androgens, which inhibit ovarian follicular maturation, hence the menstrual abnormalities. 35 Higher androgen production also has an effect on hair growth, specifically, thinning of scalp hair in a pattern of hair loss. Although there was no history of baldness in the family, male or female, she presented with a typical male pattern of baldness with bilateral thinning of the temporal areas (Hamilton I). The second dermatologist noted increased seborrhoea, which can indicate clinical hyperandrogenism, and treated with Ketoconazole. This bitemporal thinning could have been occurring unnoticed as FPHL tends to be slowly progressive. Her hair loss shot to her attention with the abrupt onset of the telogen effluvium. One more interesting point to note is that when she saw her GP to discuss stress, neither considered the impact of the propranolol on her hair loss. She did present a few weeks after the short period of having used the propranolol, with a sudden increase in her hair loss, which may well have contributed to by the beta blocker. Whether a few days at a low dose would have made such an impact, is uncertain. The interesting case of Mrs KJ serves as a perfect example of why primary care physicians need to have a good approach to dealing with the rather complex problem of diffuse hair loss. Once each of the (potential) contributory factors had been treated, Mrs KJ started to grow a thicker, more dense, head of hair. Lastly, there is a small subset of patients in whom non-scarring hair loss serves to uncover more serious medical problems such as thyroid disease, hyperinsulinaemia, PCOS, Metabolic Syndrome and potential for heart disease.   This link has been the subject of numerous studies. Matilainen et al. investigated whether early AGA could serve as a marker for insulin resistance, and concluded that further research was needed, but suggested that people with early AGA could benefit from cardiovascular screening.   36 This was supported by Arias-Santiago et al. who investigated lipid levels in women with AGA, and found that women with AGA were shown to have significantly higher levels than women with no AGA. 37   Abdel Fattah and Darwish found that people with metabolic syndrome, regardless of the presence of AGA, were more likely to be have insulin resistance, compared with people with AGA and normal controls. 38 This serves to highlight the point that while much work is still needed t o clarify the above, the vigilant GP, presented with the problem of FPHL, should also be on the lookout for comorbid disease or potential for these.   Mrs KJ’s father had died of a heart attack in his early fifties, but she maintained a healthy lifestyle, normal lipid and glucose profile, and low-normal blood pressure and so had a low risk for cardiovascular disease. There is much on hair loss that was not discussed in this paper, such as cicatricial or scarring alopecia, localised hair loss (alopecia areata) and hair loss in children and adolescents. If the latter occurs, and appears to be non-scarring, it is best discussed with a paediatric endocrinologist and dermatologist. Dr Yumnah Ras MBChB, June 2011 REFERENCES 1. The Doctors Laboratory reference range for normal ferritin levels,2010. tdlpathology.com 2. Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea Febiger, 1918; Bartleby.com, 2000   www.bartleby.com/107/.June 2011 3. Slobodan M.Jankovic and Snezana V.Jankovic. The control of hair growth. Dermatology Online Journal 4(1):2 http://dermatology.cdlib.org/DOJvol4num1/original/jankovi.html 4. http://emedicine.medscape.com/article/835470 Author Samer Alaiti 5. http://emedicine.medscape.com/article/259724 Author Suzanne R Trupin, 6. Messenger, A. 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