The Concepts And Effectiveness Of The Supply Chain Management Essay

The Concepts And Effectiveness Of The Supply Chain Management - Essay Example M as a form of management that covers all transportation and storage of raw material, refined goods, and inventory in the process from points of departure or origin up to the points of need (consumption). The track of transported goods from the point of origin up to the point of consumption constitutes what has been termed as the supply chain in business management and logistics science. Further perspectives on SCM stem from the view of the discipline as pertaining to the entirety of the aspects planning and overseeing of all activities entailed in procuring, conversion and management of all the logistical activity. Also crucial to this view is the inclusion of aspects coordination and alliance within the network players which may be the suppliers, the middlemen, and even third-party services render as well as clients. Contemporary SCM is undergoing significant transformation and modification under the influence of various sweeping phenomena in the forms of globalization and technological leaps. Scholars around the discipline are factoring in the importance of various dynamics that have been largely less considered in the earlier conceptualization of SCM. The SCM discipline has had remarkable contributions from the works of Coyle, Langley, and Gibson among others. Although the scholars s have brought the supply chain element to t fore of the contemporary concepts on SCM, the scholars have underscored the role the information is playing and will continue to play in contemporary and future SCM networks. Coyle, Langley, Gibson, Novack, Bardi (2008), contend that, â€Å"A supply chain perspective germane for appropriate deciphering and application of the feasible SCM tenets will tap in the essence and merits of information technology as well as the rate of change and a closer recognition of logistics with all its associative dimensions† The Supply chain industry is one of the thriving industries in Australia.

Accreditation and Private Prisons Essay Example for Free

Accreditation and Private Prisons Essay According to the American Correctional Association website, accreditation can be define as â€Å"a system of verification that correctional agencies/facilities comply with national standards promulgated by the American Correctional Association† (â€Å"Standards Accreditation†, n. d.). In order to achieve accreditation, it must go through reviews, appraisals, analysis, and hearings first. For a correctional agency to be accepted for accreditation, they at least must have one of the following: â€Å"pretrial or presented adult or juveniles; convicted adults or juveniles adjudicated delinquent; and/or adult or juvenile offenders sentenced to community supervision† (â€Å"Standards Accreditation†, n.d.). There are many advantages and benefits of accreditation. The benefits have shown assessments of facilities’ strength and weaknesses, shown goals obtained, implantation of policies and procedures, established specific guidelines for everyday procedure, â€Å"aid in the defense of frivolous lawsuits, and increase of community support and a higher level of staff professionalism and morale† (â€Å"Standards Accreditation†, n.d.). See more: Strategic Management Process Essay At ACA, they believe accreditation can enhance staff and development training. While though accreditation, there will be transcribe policies and agendas to help designate a training and staff development. The program will be for all levels of personnel. Employees’ experiences will automatically grow throughout all the training related to their job-related positions. They will receive current job-related training in relation to position requirements, new theories, current correctional issues, techniques and technologies. With the professional trainings, correctional officers will work toward compliance with standards which represent a professional practice. After all their hard work through the training, they will take pride in their professionalism. Through the ACA and the accreditation process, corrections has become more respected as a profession. They apply evidence-based practices which provide safe, secure, and humane conditions of confinement for over the millions of prisoners confined in this country. There are many valuable insights the Association provides about criminal justice and correctional policies to legislatures and government officials (Hamden, 2006-2013). Privatization are private sector prison used to hold prisoners. It is one of the solution used to solve the overcrowding of prisoners. With private prisons, it can help reduce the cost of incarcerating prisoners in an overcrowding prison (Joel, 2013). During the past couple of decades, prison population has increase. To solve this problem, it would require higher taxes on the people to build more prisons. The people responded by refusing to pay higher taxes to the government to build more prisons. Unable to solve the overcrowding of prison, a solution occurred to build private prisons to decrease overcrowding prisons. During the mid-1980s, private business interests saw the overcrowding prison as a profit and a way to expand their businesses. Corrections Corporation of America, the first modern private business was the first to emerge and established itself in 1984. The contract for the facility in Hamilton County, Tennessee was awarded to Corrections Corporation of America (CCA). It was the first time any government in the country to ever contract the entire jail operation to a private operator (Smith, 1996-2013). Privatization of prisons is thought to be more cost-effective and more efficient than public prisons (Smith, 1996-2013). Through some research to doubt on these claims, evidence show private prisons did not live up to its expectations. Research showed private prisons were no different from public prisons. In private prisons, lower staff and training may likely increase incidents of violence and escapes. With a nationwide study conducted, assaults on prison guards by inmates occur more frequently than in government-run prisons (Smith, 1996-2013). The study also show inmates assaulting other inmates occurred more often in private prisons. Concerning private vs. public prisons, there is no comparison between the two. Private prisons does not exactly help reduce the cost in public prisons. With few staffing and increase of proper training, it is likely to have more problems in private prisons than public prisons.

Independant Amateur Filipino Film Makers Film Studies Essay

Independant Amateur Filipino Film Makers Film Studies Essay In the spirit of independent expression, the Cinemalaya Awards seeks to discover, encourage and honor the cinematic works of Filipino filmmakers that boldly articulate and freely interpret the Filipino experience with fresh insight and artistic integrity. Cultural Center of the Philippines As of today, we filipinos are very fond of Hollywood films. Cinemas in the Philippines are currently full of different Hollywood films. There are very few films that are recognized throughout the country. This is one of the reasons why the Cultural Center of the Philippines arranged Cinemalaya, an awards show giving Filipino independent films credit. We wonder, though, is it enough? We think that it is absolutely not. Most of the Philippines creative young minds are not recognized by as much people as that of Hollywood films. We also believe that independent films carry more true-to-life stories, and that it actually has more values instilled in it. We find it very disappointing that cinemas today show less of these, and show more of Hollywood films that make us fantasize more than make us realize the harsh realities of life, and how to deal with them in a realistic way. Also, Filipinos nowadays are supporting the movies of other countries more than their own. This is why we are forw arding our proposal that cinemas in the Philippines should showcase more Filipino independent films than Hollywood films. In this paper, we define independent films as films made by amateur Filipino film makers, films that are low-budget, or home-made. We define Hollywood films as films made in Hollywood, films that have high-budget productions, films that have professionals working on it and the like. We will be limiting our statistics to only Philippine Independent films. We will make surveys regarding the awareness of students of independent films, their stand (against it, for it, neutral) on independent films, their views toward independent films. We will also research more about independent films. First of all, we believe that independent films are needed more than Hollywood films when it comes to education, especially for the children. From our observations, weve noticed that independent films capture a more realistic view on life. One example of these independent films is Idol: Pag-asa ng Bayan (2007) which is about an honor student ending up cheating for the sake of his friends, portraying a reality of peer pressure, selfless actions, and of course cheating. Another example is Ang Pagdadalaga ni Maximo Oliveros which focuses on the emotional damage a boy can undergo, as if he was a female. Lastly, the most dramatic and realistic example is Magnifico which shows us how hard life is especially when youre poor. A young mind, Magnifico attempts to help out his family earn by working at such an early age. It shows the effects of poverty, the beauty of simple living or contentment, and the love for family. Whether it focuses on social issues such as cheating (Idol: Pag-asa ng Bayan,2007) or homosexuality (Ang Pagdadalaga ni Maximo Oliveros,2005) or economic issues such as poverty (Magnifico, 2003) , independent films successfully presented actual happenings in our world today. Most Hollywood films, on the other hand, a re fiction, a literary work, history, and the like. Some Hollywood films also depicted realistic stories such as World Trade Center (2006) which focused on the 9-11 bombing, Kramer vs Kramer (1979) which focused on the realities of marriage and family problems, and John Q (2002) which focused economic problems, but these films dont have much of a filipino sense. It is important to be reminded of our values not only as people but as Filipino people, so we should be seeing these realities set on the Philippine situation, the Philippine customs, the Filipino attitude. Another point is that sure, some Hollywood films like Troy (2004), 300 (2007), and Beowulf (2008), are very helpful in our studies, but then we arent planning on removing films like that from cinemas. We just need to have more Filipino independent films because we need more education about the realities of the present situation, as weve established earlier. We also noticed the difference between the objectives and focuses of Philippine independent films and Hollywood films. Weve noticed that Philippine independent films seem to aim to open the minds of children rather than adults. Hollywood films seem to aim to open the minds of adults- parents, teachers etc. Weve also noticed that Philippine independent films seem to aim to remind people of the mistake in actions, mistake in character, and mistake in society. It seems like these films focus on the problems present. Hollywood films on the other hand, seem to aim to make people see possible problems, though these problems are less likely to occur in the Philippines. Like racism, for example, there are fewer races here so the chances of racism are minimal. In terms of focus in target, through research, we were able to find out that independent film, as said by the online Wikipedia focuses on niche audience (Wikipedia, no page), meaning a portion of people, not the general public. Hollywoo d focuses on the general public. We researched more about art films in contrast with Hollywood films. David Bordwell, as Wikipedia said, wrote about the difference of the two kinds of films. According to an article in Wikipedia, Bordwell wrote in his article, The Art Cinema as a Mode of Film Practice(Wikipedia, no page) , that those of Hollywood films use stereotype characters, familiar settings, and wherein the protagonists actions lead to only one end point, sort of like a cause and effect. He also stated that independent films often deal with an inner drama that takes place in a characters psyche. (Bordwell. no page). He also said that its more realistic, and it breaks away from the stereotype, mainstream structures. Looking at these facts, we saw that independent films have more value in content. This is one more reason why there should be more independent films in our cinemas. In terms of appeal, of course the majority will go to Hollywood films. Hollywood films have a greater budget; so of course, they will have trailers that could capture an audiences attention. Since Independent films are low-budget films, they can not advertise their works, or even if they could, they wouldnt bother because as Bordwell said, independent films are focused only on a portion of the public. Hollywood films also have better effects and cinematography than that of independent films. But we dont take this as a liability, mainly because if there is less quality of effects and cinematography, the audience is forced to focus on the main story, the lessons, and more importantly, the problems presented. If youre thinking how are cinemas going to earn money if you put more independent films, which are less appealing to the public? theres answers for that. First of all, there have been films that were made a hit, especially Magnifico (2003), and Ang Pagdadalaga ni Maximo Oliveros (2 005), though not in box office. Independent movies are also beautiful, and we believe that people would like to watch these films if they were aware of this. Also, in Malls, we see a lot of advertisements of films, and if independent films were to be put on big screen, with matching advertisement, people would be encouraged to watch. Lastly, since most people can relate to these films better, theyd be encouraged by people whove seen the film. Therefore, putting these films in theaters wouldnt really affect the cinemas in terms of economy. How many people are actually aware about independent films? Based on our surveys, the average ratios we got were the following: six out of ten people are aware of these independent films, one out of six is for independent films, four out of six are against independent films, and one out of six are neutral about it. This is another problem. The answers we got indicated that many people arent even aware of these films. So, all the more we have to show these independent films. As you can see with the statistics, more filipinos are against it, showing lack of nationalism. If you are wondering What benefits would cinemas gain with this proposal? our proposal has a lot. First of all, it encourages nationalism. By watching an independent filipino film, you support a group of filipino citizens. By supporting these people, you support the country. Second of all, more talent would be recognized. We are used to recognizing the same people as producers, directors, and especially actors. In indep endent films, since you have low budget, you get people who are either unprofessional, or people who have low talent fees, but of course, have talent. So, when the movie hits the theaters, the people who contributed there would be recognized. Also, was we said said in our introduction, there is something called the Cinemalaya awards which is an awarding ceremony for all independent films. If these films are shown in theaters, more people can vote/nominate independent films, plus this awarding ceremony will be given more attention by the public. Furthermore, showing these films in theaters help us showcase the talents of young filipino artist to foreigners. That is something to be proud about. Lastly, as weve said earlier, independent films have more value in content, and are aiming to enlighten or remind us about the realities or problems in life, therefore showing these films in the cinemas are also a way of spreading education to the youth, and even to the adults, especially filip inos. As the world evolves into a more modern world, our values and nationalism goes down. Our talents, its hidden in one corner of the world, while stardom, its just across the theater doors. This is the problem we want to solve. That is why we exposed our views and points about our preposition: The cinemas in the Philippines should showcase more Filipino independent movies than Hollywood Movies. We need to raise our Filipino flag. We have to show them what we have. We have to educate the future of the country. We have to restore the values that were gone. If this proposition is approved, then maybe its another victory for me and you.

How should states who are all facing the same security dilemma interact

Within a society, the populace are compelled to follow rules due to being prompted by a higher authority. When these laws fail, rectifying this deficiency becomes a priority of the state; murderers are arrested, riots are suppressed, new regulations and safe checks are imposed to deter future renegades from harassing the system. These actions by the state’s sovereign power ensure that the community remains harmonious and balanced. Within the international community an individual state is unable to defer to a higher authority to demand that justice be enforced, since there is no authority higher than the state itself. The consequence of this is that independent nations are forced to rely on themselves for security within international society. These facts lead to a question that has been at the core of just war theory debates; how should states who are all facing the same security dilemma interact with one another? The various theoretical answers to this question form to t wo fundamentally opposed conclusions; nations will either seek to expand their individual power to facilitate their own security, or will construct an international union to ensure mutual defense. While the latter promotes an international community based upon cooperation, the former predicts perpetual conflict. In order to perform an analysis of these conflicting predictions we will turn to Thucydides, who provides a historical example of this debate within his recount of the Melian Dialogue. Within this dialogue, the powerful Athenians assert that strength alone justifies their demand for the submission of the weaker island of Melos. The Melians counter with their own plea to justice, claiming that the advancement of Athenian power and Melian autonomy a... ...rve life and avoid death proves that the law of nature is more suited to cooperation than conflict. Using power to maintain power ensures the necessity of the continual use of force to quell those who a state’s power is used to oppress. As the Athenians looked to history to prove that â€Å"Nature always compels men to rule over anyone they can control,† it fails to recognize that nature also compels men to be free, and the violence of the oppressor will be pitted against the violence oppressed. Even if the more powerful state is successful in its conquest, it will always be at war with those whose liberty it infringes upon. The strength that a nation utilizes to allow them to conquer today will be the same strength that forces them to fight tomorrow, and the next day. For these reasons the arguments of the Athenian’s must be rejected for those of the Melian’s.

Heart of Darkness – Decay Within a Society

The environments surrounding has a huge effect on the culture of the greater number of inhabitants. The indigenous scenery, which is holds an abundant amount of natural resources, is in a state of transition and the way the landscape is treated, directly relates to greed, narcism within the society, violence in a highly numbers populated area, particularly from developed countries. In Joseph Conrad’s book Heart of Darkness , Conrad represents the decay of the indigenous scenery as a metaphor to the decay within developed countries, specifically in England.This decay is a direct result of the actions taken by the society within this indigenous scenery. Within the book Heart of Darkness greed is a immense description toward the English and the scenery that they inhabit. The English show a excessive rapacious desire for wealth and possessions . There greed and rapacious desire for health and possessions take them to the heart of the congo, where elephants are slaughtered for ther e tusks that are ivory. The ivory is considered a high commodity in England.The ivory symbolizes greed and destructive nature of man and agents of the company are so opposed with obtaining ivory that they forget there morals , so called civilized ways. This representations of the greed over the ivory on the landscape can be seen in this quote found in the book Heart of Darkness â€Å" to tear treasure out of the bowls of the landscape was there desire† (Conrad 110). The desire or greed over the land, and all the wealth, and possessions found in it, the effects that it brings upon the landscape can be proven from this statement found in the bible â€Å" The greedy bring ruin to there households† (Psalms 10:3, NIV).This decay in this indigenous scenery resulted though greed is a direct reason why its decaying The decay of the indigenous scenery within the book Heart of Darkness is a result of violence shown through developed countries specifically England in the book. Th e violence and cruelty depicted in Heart of Darkness escalate from acts of inhumanity committed against the natives of the Congo to unspeakable and undescribed horrors.Kurtz who is representing European imperialists has systematically engaged in human plunder. The natives are seen chained by iron collars abut their necks, starved, beaten, subsisting on rotten hippo meat, forced into soul crushing and meaningless labor, and finally ruthlessly murdered. Beyond this, it is implied that Kurtz has had human sacrifices performed for him, and the reader is presented with the sight of a row of severed human heads impaled on posts leading to Kurtz's cabin.Conrad suggests that violence result when law is absent and man allows himself to be ruled by whatever brutal passions lie within him. Under such circumstances, anything is possible, and what Conrad sees emerging from the situation is the profound violence that lies at the heart of the human soul and results in the decay of the indigenous s cenery â€Å"It was just robbery with violence, aggravated murder on a great scale, and men going at it blind—as is very proper for those who tackle a darkness†(Conrad 5).This limitless violence that Krutz has witnessed forced upon the indigenous scenery within the society of the natives is a direct of the decay within the indigenous scenery of developed countries. Throughout the book Heart of Darkness narcism has a major effect on the indigenous scenery. The English have a narcissistic attitude in the Heart of Darkness. A narcissistic attitude is a person who is overly self-involved, and often vain and selfish. This narcissistic attitude has a prominent effect on the indigenous scenery.While the English have become so utterly confident in there civilizations powers. In the book Heart of Darkness, the English enter the Congo thinking that they are civilized, because of there overly self involved, and vain and selfishness, they travel into the Congo taking ever consider able valuable natural resource such and destroying the indigenous scenery. In Congo, however, obsessed with ivory that renders him money, status, and power, the original, Kurtz transforms into a mercenary, evil madman, who â€Å"takes a high seat amongst the devils of the land†.Krutz narcissistic attitude being overly self involved, and vain and selfishness takes a immense amount of ivory, killing large amounts of elephants, and killing all the people that got in his way â€Å"They would have been even more impressive, those heads on the stakes, if their faces had not been turned to the house†(Conrad 40) showing that a narcissistic attitude is a direct result of why the indigenous scenery is decayed.This decay is a direct result of the actions taken by the society within this indigenous scenery. The indigenous scenery, which is a direct result of the natural resources before us on the earth , that is in a state of transition and the way the landscape is treated, direct ly relates to greed and over exceeding numbers of human beings, particularly from developed countries. Conrad represents the decay of the indigenous scenery as a absolute metaphor to the decay within developed countries, specifically in England.These actions such as greed, violence, and narcissism taken by the developed countries causes the indigenous scenery to decay. Heart of Darkness – Result of decay on society Work Cited: â€Å"Heart of Darkness. † SparkNotes. Ed. Joesph Conrad. SparkNotes, 1 Jan. 2012. Web. 24 Oct. 2012. . Conrad, Joesph. â€Å"Heart of Darkness. † By Joseph Conrad. Search EText, Read Online, Study, Discuss. N. p. , July-Aug. 2012. Web. 24 Oct. 2012. . Conrad, Joseph. Heart of Darkness. New York: Knopf, 1993. Print.

How to effectively communicate with your boss

How to effectively communicate with your boss Anyone who’s ever been employed and has had to answer to a boss- whether you have one destined for the great boss hall of fame or one who’s the devil incarnate- has come to learn that the key to having an effective working relationship is communication. Developing and maintaining an appropriate flow of thoughts, ideas, and work updates with the person you report to on a daily basis does the following:It empowers you to perform the varied tasks and responsibilities associated with your job while minimizing confusion or miscommunication.It helps you stay connected to the flow of essential information across teams and departments.It allows you to build a relationship of mutual respect and trust with your superiors and colleagues- all allowing you to do your best at work every day.Ideally, this communication flow goes two ways- and your boss will be just as eager to maintain a helpful sharing of information with you as you are with them, all of which serves to benefit your team’s productivity and effectiveness. However, we don’t always get to live in the perfect world of our dreams, and most of us don’t get to control every aspect of our work lives.Although some of us are lucky enough to work with great bosses who are naturally gifted communicators, some of us aren’t so lucky and must work harder to ensure that key information gets communicated effectively. The flip-side of the coin is also true- some of us are great communicators with minimal effort while others among us have to work harder at it.If you’re in a position where you need to figure out how to communicate effectively with your boss- whether the issue lies with you, your boss, or somewhere in the middle- there are ways to improve the situation. Like learning any new skill, effective communication requires extensive practice and effort until you get good at it.Use the following strategies to enhance communication with your boss.Cut to the chaseIn todayâ₠¬â„¢s insanely hectic work world, most of us are doing multiple jobs and juggling a small universe of responsibilities at any given time. With limited hours in the day to get things done, your work time is extremely valuable- and so is your boss’s. Therefore, it’s essential that you make the most of the limited time you have to communicate with your boss. Avoid meandering stories, long speeches, and lengthy preambles when talking to your boss- if you get a rep for being too unnecessarily verbose or too much of a time drain, they may start trying to avoid you at all costs and your relationship might suffer. Whenever possible, just cut to the chase with the precise information you need to share, which hopefully will inspire your boss to do the same. Then, your lives can move on with minimal disruption.Also, be sure to strategically choose your moments for communication. Is your boss about to go into an important meeting or is heading out for the day? Perhaps those arenâ €™t the best times to drop an important work bombshell. Choose wisely.Look aheadWhen communicating with your boss, try to anticipate their reaction to the information you’re about to share. Do you foresee specific questions? If so, then try to have answers prepared for them. Can you envision them asking for additional data or stats to back up something you’re going to share? Have it at the ready. Not only will you save time and effort every time you speak with your boss, you’ll also come across as more prepared and effective every time you interact with them- a real win-win for you.Choose your communication approachOf course, the substance of your communication matters a great deal, but what also matters is how you deliver the message. Make sure your body language and tone are appropriate and professional. It might be helpful if you took a second to make sure you look polished and put together when interacting with your boss. Figure out how and when your bos s likes to communicate with others, and do your best to adapt to their preferred style and approach- it will benefit your relationship in the long run.Don’t waitIf you have important information to share with your boss- even if it’s not great news- don’t wait. If you put off providing them with actionable information until it’s too late to act, then your news will never be well received, whether it’s good or bad. In almost every conceivable scenario, it’s to your advantage to communicate as quickly as possible, allowing everyone involved to understand and digest the information, formulate an appropriate reaction, and respond accordingly. If it is bad news, your early warning just might allow for sufficient planning to minimize the damage.Above all, remain professional, polite, direct, and clear- all traits that will move your communication in the right direction during your time at your current place of work.

Using the Spanish Verb Dejar

Using the Spanish Verb Dejar Like many other verbs, dejar has a basic meaning - in this case, to leave something somewhere - that has broadened over the centuries to be used under a wide variety of circumstances. Most of its meanings, however, pertain at least in a broad sense to the idea of leaving something (or someone) somewhere, placing something somewhere, or abandoning something. Dejar Meaning To Leave While to leave is one of the most common translations of dejar, it should not be confused with to leave in the sense of to leave a place, where salir is used. Thus, shes leaving tomorrow is sale maà ±ana, but I left my keys at home is dejà © las llaves en casa. Examples of dejar with its basic meaning: Dà ©jalo aquà ­. (Leave it here.) ¿Dà ³nde dejà © el coche aparcado? (Where did I park the car?)Dejarà © el libro en la mesa. (I will leave the book on the table.)Dejà © a Pablo en Chicago. (I dropped Pablo off in Chicago.) When the object of dejar is an activity or person, dejar can mean to leave, abandon or give up: Deja su carrera para irse a la polà ­tica. (He is leaving his career to go into politics.)Han fallado en sus tentativas de dejar el fumar. (They have failed in their attempts to quit smoking.)Dejà ³ a su esposa por la mujer que deseaba. (He abandoned his wife for the woman he wanted.) Dejar Meaning To Lend When an object is left with a person, dejar often means to lend. (The verb prestar can also be used with the same meaning.): Como era un buen jefe me dejaba su coche. (Since he was a good boss he would lend me his car.)Me dejà ³ su casa de vacaciones. (He let me use his vacation home.) ¿Me dejas tu telà ©fono?  (Could I borrow your phone?) Dejar Meaning To Pass On In many contexts, dejar can mean to give or to pass on: Mi madre me dejà ³ su capacidad de esperanza. (My mother passed on to me her capacity to hope.)Me dejà ³ su direccià ³n postal para escribirle. (He gave me his mailing address so I could write to him.)Cuando murià ³ me dejà ³ su panaderà ­a en su testamento. (When he died he left me his bakery in his will.)Siempre mi pap le dejaba la tarea mas difà ­cil a mi mama. (My father always passed the most difficult tasks to my mother.) Dejar Meaning To Leave Alone Sometimes, when the object of dejar is a person, it can mean to leave alone or to not bother:  ¡Dà ©jame! Tengo que estudiar. (Leave me alone! I have to study.)No nos dejaba en paz. (He did not leave us in peace.) Dejar Meaning To Allow Another common meaning of dejar is to allow or to let: No me dejaban comprar nada que no fuese reciclable. (They didnt let me buy anything that wasnt recyclable.)El faraà ³n se asustà ³ y dejà ³ salir al pueblo de Israel. (The pharaoh got scared and let the people of Israel go.) Using Dejar With an Adjective When followed by an adjective, dejar can mean to put or leave someone or something in a certain state or condition: La ley no dejà ³ satisfecho a nadie. (The law didnt satisfy anybody.)Me dejà ³ feliz, como ver un oasis. (It made me happy, like seeing an oasis.)El partido me dejà ³ rota la rodilla. (My knee got broken during the game.) Dejar Meaning To Delay or To Stop Sometimes, dejar means to postpone or delay:  ¿Por quà © no deja el viaje para maà ±ana? (Why not put off your trip until tomorrow?) The phrase dejar de usually means to stop or to give up: Hoy dejo de fumar. (Today I give up smoking.)La hepatitis A dejà ³ de ser una cosa de nià ±os. (Hepatitis A is no longer a childrens disease.)Nunca dejarà © de amarte. (Ill never stop loving you.) Using Dejar With Que Finally, dejar que usually means to wait until a certain time: Dejo que las cosas se sucedan naturalmente. (Im waiting until things happen naturally.)La madre no dejaba que los socorristas atendieran a su hija. (The mother didnt wait for the rescuers to help her daughter.)

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. The control of Hair Growth: An overview.Journal of Investigative Dermatology Vol.101 No.1supplement,July 1993 7. http://emedicine.medscape.com/article/273153   Author Mohamed Yahya Abdel-Rahman, 8. Trueb, R. Molecular mechanisms of androgenic Alopecia. Experimental Gerontology 37 (2002) 981-990 9. Apridonidze et al.Prevalence and Characteristics of the Metabolic Syndrome in Women with Polycystic Ovary Syndrome. The Journal of Clinical   Endocrinology Metabolism April 1, 2005 vol. 90 no. 4 1929-1935 10. Carlini, et al. Alopecia in a premenopausal breast cancer woman treated with letrozole and triptorelin. Ann Oncol (2003) 14 (11): 1689-1690. doi: 10.1093/annonc/mdg444 11. Kantor et al. Decreased Serum Ferritin is Associated with Alopecia in Women. Journal of Investigative Dermatology (2003) 121, 985–988; oi:10.1046/j.1523-1747.2003.12540.x 12. Olsen et al. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. Journal Am. Acad. Derm 2010 Dec 63 (6):991-9 Epub 2010 Oct 13. Rushton, D. Decreased Serum ferritin and Alopecia in Women. Journal of Investigative Dermatology (2003) 121, xvii–xviii; doi:10.1046/j.1523-1747.2003.12581.x 14. Moeinvaziri et al.   Iron status in diffuse telogen hair loss among women. Acta Dermatovenerol Croat. 2009;17 (4):279-84. 15. Yip et al. Role of genetics and sex steroid hormones in male androgenetic alopecia and female pattern hair loss: An update of what we now know. Australian Journ derm (2011) 52, 81-88 16. Trost et al. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. Journ. Am. Acad. Dermatol. Vol (54) No.5 824-844 17. Shrivastava et al. Diffuse Hair loss in an adult Female: Approach to diagnosis and management. 18. Prasad, A. Clinical, endocrinological and biochemical effects of zinc deficiency. Clinics in Endocrinology and Metabolism Volume 14, Issue 3, August 1985, Pages 567-589 19. Goldberg et al. Nutrition and Hair. Clinics in Dermatology, Volume 28, Issue 4, July-August 2010, Pages 412-419 20. Dinh, Q and Sinclair, R. Female pattern hair loss: current treatment concepts. Clin Interv Aging. 2007 June; 2(2): 189-199. Published online 2007 June. 21. Gan, D and Sinclair, R. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005 Dec;10(3):184-9. 22.European Dermatology Forum, S3-Guideline on Androgenetic Alopecia. euroderm.org/edf/images/stories/guidelines/S3_guideline_androgenetic_alopecia.pdf 23. Blume-Peytavi, U and Vogt, A. Current Standards in the diagnostics and therapy of hair diseases. JDDG; 2011 9:394-412 24. Blume-Peytavi et al. S1 guideline for diagnosic evaluation in androgeentic alopecia in men, women and adolescents. Br J Dermatol. 2011 Jan;164(1):5-15. doi: 10.1111/j.1365-2133.2010.10011.x. Epub 2010 Dec 8. 25. http://dermnetnz.org/hair-nails-sweat/telogen-effluvium.html June 2011 26. Hordinsky, M. Medical Treatment of Noncicatricial Alopecia. Seminars in Cutaneous Medicine and Surgery Volume 25, Issue 1, March 2006, Pages 51-55 27. Messenger, A and Rundegren, J. Minoxidil: Mechanisms of Action on Hair Growth. British Journal of Dermatology Vol 150 (2):186–194, Feb 2004 28. Lucky et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol Vol 50 (4) p 541-553 29. Khandpur et al. Comparative efficacy of various treatment regimens for androgenetic alopecia in men.J Dermatol. 2002 Aug;29(8):489-98. 30. Vixiau et al. Effects of minoxidil 2% vs. cyproterone acetate treatment on female androgenetic alopecia: a controlled, 12-month randomized trial. British Journal of Dermatology Volume 146, Issue 6, pages 992–999, June 2002 31. Reid et al. Clinical Severity does not reliably predict quality of life in women with alopecia areatam telogen effluvium, or androgenenic alopecia. Journal of the American Academy of Dermatology, In Press, Corrected Proof, Available online 24 May 2011. 32. Tosti, A and Duque-Estrada, B. Dermoscopy in Hair Disorders. J Egypt Women Dermatol Soc. Vol. 7, No. 1, 2010 33. Course Notes on Hair, QMUL post.grad. Dip.Derm 2010/2011. 34. verity-pcos.org.uk/guidetopcos/whatispcos 35. Kovacs,P. Metabolic Syndrome amd PCOS. Medscape Ob/Gyn 2003; 8(2) medscape.com/viewarticle/456221 36. Matileinen et al. Early Androgenetic Alopecia as a marker of Insulin Resistance. The Lancet Vol(356) p1165-1166 Sept 30, 2000. 37. Arias-Santiago et al. Lipid levels in women with angrogenetic alopecia. International Journal of Dermatology 2010, 49, 1340-1342 38. Abdel Fattah, N and Darwish Y. Androgenetic alopecia and insulin reistance: are they truly associated? International Journal of Dermatology 2011, 50, 417-421

Economics of Singapore and Hong Kong Essay Example | Topics and Well Written Essays - 2500 words

Economics of Singapore and Hong Kong - Essay Example The Asian countries of India, China Korea, Taiwan, Hong Kong, Singapore, Indonesia, and Malaysia are notable examples NICs and their dramatic successes in economic growth have often been referred to as the East Asian Miracle. Other Asian countries like China and India have also achieved successes in economic growth. The 'economic miracle' of these East Asian countries is however not exclusive to Asia as countries in the Americas like Chile, Brazil and Mexico have also achieved appreciably high growth rates in their economies and could thus be referred to as NICs as well. It must be said though the growth rates vary amongst all the NICs and as such some growths may be relatively higher compared to others in other NICs. Countries like China, India Singapore and Hong Kong however standout of the rest due to the rapid nature of their growth within a space of about 30 years. Also, the use of NICs is a matter of definition and as such a country like South Africa that was largely secluded f rom the international economy due to its apartheid policies may now be categorised as an NIC by some, while others may classify it as a developed country. This essay will first conduct a generalised or panoramic view of the features that underlie the development experiences of NICs before undertaking a closer look at the experiences of selected NICs. It must be said that though the development experiences may be very varied, some common cardinal features can be seen in the experiences of all NICs. Most NICs were able to achieve high growth rates by instituting market reforms that favoured exports. (Hamilton 1987) There was also a strong emphasis on value added manufacturing that changed their economies from predominantly agrarian economies into industrial and manufacturing based economies. Increased capital investments from foreign and domestic sources played a key role in the development experiences of NICs and so did the development of domestic corporations that could compete with other foreign corporations both on the domestic market and on the regional or international markets as well. (Bhagwati, 1996) Typical examples are the automotive, steel and ship building companies of Korea. Political leadership also contributed significantly to the high growths in the economies of NICs. As stated earlier, though the 'authoritarian' thesis is a disputed one, the fact that relative political stability pertained in the countries that recorded significant growths in their economies goe s to show that political leadership played a crucial role in the development experience of NICs (Combie, 2000). The next segment of this essay will undertake a closer look at economies of Hong Kong and Singapore."Singapore, a leading trading power and financial centre, is one of the quintets of trillion dollar economies of Asia. Over the past two decades, the government has been kept minimum. Still the Government bodies such as sovereign wealth fund Temasek control corporations responsible for 60% of GDP. The distinguishing characteristic of Singapore's Economy is the low level of corruption, stable prices one of the highest per capita gross domestic products (GDP) in the world. The country has open business environment and one of the