The Pentangle Of Sir Gawain And The Green Knight - 1947 Words

The pentangle in Sir Gawain and the Green Knight which is displayed on the front side of Gawain’s shield, represents his knighthood and all that Gawain stands for. â€Å"In particular, Gawain s courtesy is associated with his virtue in the symbolic device of the pentangle in his shield (Morgan, p.770).† One of the points of the pentangle represents courtesy, which means a knight has to be courteous to not only women, but also men, in order to be able to be seen as reaching this pillar. Courtesy is an important virtue to knights because without courtesy knights would be seen as rude and uncaring, so knights provide their service free of charge, while acting as politely as possible, in order to try and achieve this mark of knighthood. Gawain was†¦show more content†¦The pentangle facing up represents reason, and this can be shown by having an image of the pentangle, and seeing that if an image of a person were to be in the middle of the pentangle the head would b e at the top of the point. This means that Gawain thinks first most of the time, before he does anything. Once Gawain arrives at the castle he is given a test that will see if reason out ways passion. The way this is tested is by the lord of the castle making a deal between himself and Gawain in that whatever the person wins or gets for the day they must trade off at the end of the night. Gawain ultimately fails the test when the lady of the castle offers him a gift that will save his life. This failure shows that Gawain values passion over his life more than reason/respect for his deal with the lord of the castle. Since passion won out the pentangle is now flipped upside down with passion taking the lead. Since passion is ultimately winning Gawain has fallen down a level as a knight, because it has now been proven that he is not as pure as everyone made him out to be. The girdle in Sir Gawain and the Green Knight is given by the lady of the castle as a test to see if Arthur’ s court was as noble and honorable as people were lead to believe. â€Å"The girdle which the Lady gives to Gawain, differs to some degree from my first because it is not, like the pentangle, intrinsicallyShow MoreRelatedThe Pentangle in Sir Gawain and The Green Knight Essay3294 Words   |  14 PagesThe Pentangle in Sir Gawain and The Green Knight When writing, never explain your symbols. The author of ``Sir Gawain and the Green Knight dropped this unspoken rule when he picked up his pen. Why? The detailed description and exposition of the pentangle form the key to understanding this poem. By causing the reader to view Gawains quest in terms of the pentangle, the narrator compares the knightly ideals with the reality of Gawains life. The narrator uses the pentangle to promote the knightlyRead MoreExamples Of The Pentangle In Sir Gawain And The Green Knight1233 Words   |  5 PagesIn the poem Sir Gawain and the Green Knight, Gawain brings two very different items to face the Green Knight. The pentangle on Gawain’s shield and the green girdle he ties around himself are both complex symbols with many contrasting meanings. One of the ways the Gawain-poet uses these items is juxtaposing them to develop Sir Gawain’s character. The pentangle represents the ideal human perfection and the green girdle causes Gawain to f ail to teach him about his lack of perfection. At the same timeRead MoreSir Gawain And The Green Knight1482 Words   |  6 PagesIn Sir Gawain and The Green Knight, the protagonist, Sir Gawain, is illustrated as the imperfect hero of the tale. His documented imperfections and various flaws create a sense of irony when put into comparison with the depiction of the pentangle on his shield. The pentangle, designed by King Solomon of old as his own magical seal, symbolizes the virtues that Gawain aspires to uphold: to be faultless in his five senses, that his five fingers were never at fault, being faithful to the five woundsRead MoreChivalry Of Sir Gawain And The Green Knight904 Words   |  4 PagesChivalry in Sir Gawain and the Green Knight There are many great movies, like â€Å"300† or â€Å"Saving Private Ryan,† that are told with the classic chivalry elements that were known to describe the noble knights from hundreds of years ago. Much like the courageous soldiers in these movies, Sir Gawain in Sir Gawain and the Green Knight, faced many conflicts that might have questioned his moral code of nobleness. Sir Gawain was a great knight that was loyal to King Arthur and had the courage to take on theRead MoreSir Gawain and the Green Knight Essay1395 Words   |  6 PagesSir Gawain and the Green Knight In Sir Gawain and the Green Knight the poet depicts an entertaining story of adventure and intrigue. However, the poem is more than a grand adventure. It is an attempt to explore the moral ideals of Sir Gawain. Gawains standards are represented by the pentangle on his shield. The depiction of the pentangle occurs when Sir Gawain is preparing to gear up for his quest for the Green Chapel. Gawains outfit is described in great detail, including its color,Read MoreImportance Of A Pentangle And Their Long Uses And The Past History Associated With It1534 Words   |  7 PagesIn order to understand the importance of a pentangle we must learn about its long uses and the past history associated with it. Beginning around 3500 BC in the vicinity of Mesopotamia is where the oldest known origins of a Pentangle can be found and dated. During this time the pentangle has been used as a religious symbol all around the world from the beginning of recorded history. The most common shape is a five- pointed star that is drawn as one main line that is broken into five line segments whereRead MoreAnalysis Of Sir Gawain And The Green Knight1374 Words   |  6 PagesThe language of symbols plays a major role in medieval poetry â€Å"Sir Gawain and the Green Knight† is no exception. The use of symbolism gives a writer the ability to draw important connections between items in their story and the audience. The poet behind â€Å"Sir Gawain and the Green Knight† gives the reader a detailed description of the pentagram, his most important symbol, in order to form the key understanding of this poem. The narrator compares knightly ideals such as integrity, focus, and strengthRead MoreThe Audience, the Pentagle and the Green Sash in Sir Gawain and the Green Knight1547 Words   |  7 Pagesthe Green Sash in Sir Gawain and the Green Knight Works Cited Missing Although some early manuscripts of the poem Sir Gawain and the Green Knight still exist, nothing, beyond speculation, is known about the poet, which is a pity when considering its rich language and imagery. Believed to have been written between 1375 and 1400, and some 2500 lines long, the unknown poet blent a unique mixture of chivalry, the Beheading Game and the temptation of a knight called Sir GawainRead MoreSir Gawains Shield and the Quest for Perfection Essay1134 Words   |  5 Pages Sir Gawain and the Green Knight is a religious allegory full of Christian symbolism with the central message of sin, forgiveness, and redemption. The poem is a great story of virtues, trust and honor. Its an Arthurian romance in which Sir Gawain carries a shield on his chest in his quest for Green Knight. Gawains shield has two images, a picture of Virgin Mary on the inside and Painted upon his shield is a five-pointed star (pentangle). He is a perfect knight who realizes that it is importantRead MoreSymbolism in Sir Gawain and the Green Knight.1460 Words   |  6 PagesSir Gawain and the Green Knight is a medieval poem by an unknown author, written in Middle English in the 14th century. This poem is uncanny to most poems about heroism and knightly quests as it doesn’t follow the complete circle seen in other heroism tales. This poem is different to all the rest as it shows human weaknesses as well as strengths which disturbs the myth of the perfect knight, or the faultless hero. The author uses symbolism as a literary device in Sir Gawain and the Green Knight to

Canadian Airstrikes During Iraq And Syria - 1601 Words

What these publications and the vast majority of the general population contending that Trudeau ought to proceed with Canadian airstrikes in Iraq and Syria miss are a few motivations to stop the bombarding, some of them coming from a more radical perspective, others immovably even minded. To start with, the even minded. We don t recognize what will come after ISIS Basically everybody who isn t in ISIS concurs that the gathering is awful. In any case, we can t go firearms (or planes, so to speak) bursting after each awful gathering on the planet, and we shouldn t. Iraq and Afghanistan are impeccable samples of this. Ling raised the 2003 attack of Iraq in his section also, and I need to address what he composed: Presently, some are attracting examinations to the 2003 attack of Iraq, in spite of there being for all intents and purposes no sensible association. The West isn t thumping over some worthless tyrant to introduce an inviting majority rule government, it is putting forth air support for an equitably chose government and neighborhood strengths. This is not an attack. It isn t a ground war. It is logistical air support. It s actual that the kind of war being pursued in Iraq and Syria at this moment is distinctive, yet it s not clear that the impacts will be. Both Iraq and Syria are crushed by war, common and something else, and if ISIS is steered from the region there are no solid governments to move in and restore request. The Iraqi government is aShow MoreRelatedThe Future Effect Of The Election Of Prime Minister Justin Trudeau1131 Words   |  5 PagesJustin Trudeau in terms of the Canadian foreign policy in the restructuring of military intervention in foreign affairs and the pro-trade globalization mandates of the Trans-Pacific Partnership (TPP). Trudeau’s election defines the overriding political agenda of the Liberal Party of Canada to stop ineffective bombing missions in Syria and Iraq, yet to maintain special forces troops to better manage the war against ISIS. More so, Trudeau supports the globalization of Canadian trade by promoting the positiveRead MoreThe Islamic State Of Iraq A nd Syria1308 Words   |  6 PagesCanada Should Participate in the Global Coalition to Fight ISIS The Islamic State of Iraq and Syria (ISIS) has made headlines throughout the globe this past year with their atrocities against religious minorities and determination to create an Islamic caliphate. They have expressed, throughout, that their primary objective is to establish a Salafist government over the Levant region of Syria, Lebanon, Israel, Jordan, Cyprus, and Southern Turkey(†¦Ã¢â‚¬ ¦). The group controls hundreds of square miles, whereRead MorePolitical Ideologies Analysis Report : Kenan Ramadan2426 Words   |  10 PagesPolitical Ideologies Analysis Report Kenan Ramadan In this following report, the fascism ideology will be examined and applied to a Canadian political party and to three current political issues. A - Introductions (Background and Definition) Fascism is a form of radical authoritarian nationalism that came to prominence in early 20th century, influenced by national syndicalism. Its movement is based on nationalism and militaries, combining more typically right-wing positions with elements of left-wing

Organizational Behavior for Journal of Psychology- myassignmenthelp

Question: Discuss about theOrganizational Behavior for Journal of Psychology. Answer: Introduction Organizational behavior signifies the way in which the members of an organization interact with each other. It defines the behavioral pattern of the organizational members within an organizational context (Kehoe and Wright 2013). This study will demonstrate the circumstances, where attitude determines the behavior of the organizational members at their workplace. The study will also examine the known factors of job satisfaction and organizational commitment. Apart from that, the study will also assess the extent to which organizational members should care about the organizational commitment level of the employees. Discussion Attitude refers to the way people think or feel about something or someone. Work Attitude refers to the set of evaluation regarding peoples job, which frames their belief about, feelings towards and attachment to their jobs. The attitude of the employees can have both positive as well as negative effect on their behavior at their workplace. Barrick, Mount and Li (2013) pointed out that the employees having positive attitude on their job and their colleagues can have positive influence on their surrounding people. On the other hand, the employees having negative attitude mostly have negative influence on their surrounding people at their workplace. The impact of attitude on the behavior of the employees can be specifically measured through assessing the average behavior of the employees rather than their isolate behavior. According to Bissing?Olson et al. (2013), cognitive dissonance is the feelings of uncomfortable tension in mind due to involvement of two conflicting attitude, behaviors and beliefs. It requires alternation of the one of the attitudes or behaviors for reducing the discomfort in mind. In such situation, alteration of attitude or behavior causes cognitive dissonance. On the other hand, Loi, Chan and Lam (2014) stated that self fulfilling prophecy is the prediction, which directly or indirectly causes itself towards becoming true. In this process, the employees try to convert their attitude in reality. Moreover, such situation leads the attitude of the employees towards determining their behavior in real situation. Attitudes are more likely to share the behavior of the employees, when the attitudes are highly potent. It often indicates the mindless reaction, which can be adaptable in all types of situations. It frees employees mind through indicating specific behavior in some specific w ork situation. Attitude is highly important within a person, which helps that person towards dealing with the highs and lows in his/her life. As per Barrick et al. (2015), living joyful life and getting great accomplishment in life requires positive attitude towards effectively dealing with the difficulties in life. Attitude shapes the employee behavior within the workplace, which actually have huge influence on the organizational culture. Therefore, it can be said that positive attitude assists the employees in building collaborative and warm relationship with their co-workers. Furthermore, Maynard and Parfyonova (2013) stated that positive attitude within the employees facilitates them to be more encouraged towards enhancing their overall productivity. Right and positive attitude of the employees helps in gaining positive personal experience for the employees and they can better interact with other for handling complex business problems effectively. The employees having positive attitude can see things positively and better lead other employees towards extracting best out of them. Right attitude makes the employees able to see the big perspective behind any specific job. Moreover, positive attitude enhances the power of visualization of the employees, which enhances their forecasting power regarding future prospect of the business. The employees having positive attitude love to bring creativity in business, which fosters innovation within the business. Furthermore, Hlsheger et al. (2013) opined that the employees having right attitude are highly capable of developing innovating ideas and coming up with more creative solution for solving complex organizational problems. On the contrary, Rayton and Yalabik (2014) pointed out that negative attitude within the employees restrict their creativity power, as they are not encouraged towards contributing in organizational success. In this way, proper attitude within the persons direct them towards their success in life. Moreover, positive attitude with the employees enhances their determination level, which makes them capable of dealing with complex challenges and gaining better career development in life. Job satisfaction refers to the level of enjoyment or fulfillment, which an employee feels regarding his/her job. Job satisfaction can also define the positive emotional attachment of the employees with their jobs. It actually acts as motivator for the employees towards enhancing their performance. On the contrary, organizational commitment refers to the bonding of the employees, which the employees feel with their organization. Committed employees are more prone to demonstrate greater connection with their organizations. Satisfied employees are generally more loyal and committed towards the success of their organization. However, job satisfaction and organizational commitment of the employees depend on several factors. Ngo et al. (2013) pointed out that payment is the prime factor, which is highly responsible for the satisfaction level of the employees. Adequate and fair amount of payment offered to the employees encourage them towards long term continuation of their job with their organization. Moreover, fair payment actually drives organizational commitment of the employees with their organizations. On the other hand, Bagger and Li (2014) opined that effective working condition enhances the job satisfaction and organizational commitment level of the employees with their organizations. Moreover, the employees should be provided with flexible working condition, where job stress and work overload is less. Such working condition can enhance the satisfaction level of the employees, which also indirectly enhances their organizational commitment level. Furthermore, Jensen, Patel and Messersmith (2013) pointed out that collaborative working relationship and respect from the co-workers meets the social needs of the employees within their workplace. Therefore, collaborative working relationship enhances the job satisfaction and organizational commitment of the employees. Furthermore, effective bonding with the colleagues also enhances the attachment level of the employees with their organizations. According to Maynard and Parfyonova (2013), relationship with the supervisors also plays an important role in enhancing the satisfaction level of the employees. Moreover, the employees are highly prone to show their commitment with their organization, when they avail adequate support from their supervisors. Collaborative relationship with the supervisors enhances their bonding with their organization. Furthermore, the scope of career advancement can also encourage the employees towards serving long term in their organization. Moreover, the scope of career progression actually enhances the satisfaction and commitment level of the employees (Tschopp, Grote and Gerber 2014). Organizational commitment defines the psychological bonding or attachment of the employees, which they feel about their organization. Employees are actually committed with their organizations, when the employers are capable of meeting all their needs and demands. Committed employees feel high level of bonding and connection with their organization. They are more prone to show their determination towards achieving organizational success. Rayton and Yalabik (2014) pointed out that committed employees are extremely serious and feel high level of involvement with the organizational goals and objectives. Therefore, such employees can provide more production than other employees and apply work efficiencies in their job role for ensuring organizational success. Therefore, the managers of an organization should always make sure that their employees are actually committed in their organization. On the other hand, Barrick et al. (2015) stated that committed employees are highly encouraged towards applying their efficiency level in achieving organizational success. Therefore, the managers should obviously assure that the employees are highly committed with their organization. As per Kehoe and Wright (2013), committed employees are extremely loyal with their organizations and they are less likely to leave from their existing organization, even if they are offered with grater job opportunities or salary package. Positive psychological bonding binds the employees with their organization for longer time. In this way, organizational commitment actually reduces employee turnover rate and enhances employee retention level. Therefore, the managers of an organization should make sure about the commitment level of the employees. Loi, Chan and Lam (2014) opined that committed employees are highly prone towards fostering encouraging working environment with their organization. Therefore, the organizational managers should seriously look after the commitment level of the employees. Conclusion While concluding the study, it can be said that positive attitude encourages an employee towards being more enthusiastic on the organizational goals. Positive attitude also encourages the employees in creating positive work environment, which also motivates others in enhancing their overall productivity. Right attitude always enables the employees towards creating innovative ideas, which fosters organizational uniqueness. There are several factors, which foster the job satisfaction and organizational commitment level of the employees. Job satisfaction and organizational commitment of the employees are primarily dependent on fair salary package offered to them. Furthermore, encouraging working condition having less job stress and reduced workloads enhances the satisfaction level of the employees. Apart from that, supportive and collaborative working environment reduced the job stress level of the employees and enhance their satisfaction and commitment level. Furthermore, the employees are highly committed towards demonstrating their commitment to their organization, when they can get any scope for career advancement. Committed employees are less likely to leave their organizations and foster positive working environment. Therefore, the managers of organizations should always make sure that the employees are highly committed with their organization. Reference List Bagger, J. and Li, A., 2014. How does supervisory family support influence employees attitudes and behaviors? A social exchange perspective.Journal of Management,40(4), pp.1123-1150. Barrick, M.R., Mount, M.K. and Li, N., 2013. The theory of purposeful work behavior: The role of personality, higher-order goals, and job characteristics.Academy of management review,38(1), pp.132-153. Barrick, M.R., Thurgood, G.R., Smith, T.A. and Courtright, S.H., 2015. Collective organizational engagement: Linking motivational antecedents, strategic implementation, and firm performance.Academy of Management Journal,58(1), pp.111-135. Bissing?Olson, M.J., Iyer, A., Fielding, K.S. and Zacher, H., 2013. Relationships between daily affect and pro?environmental behavior at work: The moderating role of pro?environmental attitude.Journal of Organizational Behavior,34(2), pp.156-175. Hlsheger, U.R., Alberts, H.J., Feinholdt, A. and Lang, J.W., 2013. Benefits of mindfulness at work: The role of mindfulness in emotion regulation, emotional exhaustion, and job satisfaction.Journal of Applied Psychology,98(2), p.310. Jensen, J.M., Patel, P.C. and Messersmith, J.G., 2013. High-performance work systems and job control: Consequences for anxiety, role overload, and turnover intentions.Journal of Management,39(6), pp.1699-1724. Kehoe, R.R. and Wright, P.M., 2013. The impact of high-performance human resource practices on employees attitudes and behaviors.Journal of management,39(2), pp.366-391. Loi, R., Chan, K.W. and Lam, L.W., 2014. Leadermember exchange, organizational identification, and job satisfaction: A social identity perspective.Journal of Occupational and Organizational psychology,87(1), pp.42-61. Maynard, D.C. and Parfyonova, N.M., 2013. Perceived overqualification and withdrawal behaviours: Examining the roles of job attitudes and work values.Journal of Occupational and Organizational Psychology,86(3), pp.435-455. Ngo, H.Y., Loi, R., Foley, S., Zheng, X. and Zhang, L., 2013. Perceptions of organizational context and job attitudes: The mediating effect of organizational identification.Asia Pacific Journal of Management,30(1), pp.149-168. Rayton, B.A. and Yalabik, Z.Y., 2014. Work engagement, psychological contract breach and job satisfaction. The International Journal of Human Resource Management, 25(17), pp.2382-2400. Tschopp, C., Grote, G. and Gerber, M., 2014. How career orientation shapes the job satisfactionturnover intention link.Journal of Organizational Behavior,35(2), pp.151-171.

Supply Chain Management and Lean Production free essay sample

Abstract The system of interconnected businesses used to push a product from supplier to consumer is defined as a supply chain. Supply chain management focuses on managing the supply chain in an effort to improve the quality and time it requires to manufacture a product. In addition to implementing supply chain management, a helpful lean production practice called Just-in-time can be used to remove any waste present along the supply chain. The marriage of lean production and supply chain management creates lean supply chain management, which provides a much leaner and more economical supply chain for the product to flow through. Supply Chain Management and Lean Production Much uncertainty about what supply chain management entails is present in today’s society. Many people treat supply chain management as being synonymous with logistics, which is the management of the flow of goods from the origin to the consumers However, supply chain management encompasses much more than the purchasing or management of goods to the consumer. We will write a custom essay sample on Supply Chain Management and Lean Production or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Supply chain management (SCM), as defined by Lambert (2008), is the management of relationships across the supply chain, which includes a network of interconnected businesses involved in providing a product or service to the consumer. The management of the relationships between businesses on the supply chain is significant to ensure successful and efficient processes are used in providing products and goods to the customer. Definition of Supply Chain Management (SCM) What is a supply chain? A supply chain is defined as a system of organizations, as well as people and information, which are directly involved with the manufacture and delivery of a product (Phelps, Smith, Hoenes, 2004; â€Å"Supply Chain,† 2008). The supply chain includes the transformation of raw materials at the site of the supplier to finished goods that can be used by the consumer, as shown in Figure 1. The path the product travels is similar to that of a river. A river, when properly banked, is flowing in one direction towards a goal (Tompkins, 2000). Mark Twain stated that â€Å"Without banks the river is just a puddle. † A supply chain, like a river, needs communication and integration as its banks to create a force towards the destination, which is the consumer. Without the presence of the banks, the river would go nowhere and therefore be merely a puddle. Effective communication in business relationships that cross over different departments, as displayed by the arrows in Figure 1, is necessary to provide quality products to the consumer. What is supply chain management? Lambert (2004) defines supply chain management as â€Å"the integration of key business processes from the end user through original suppliers than provides products, services, and information that add value for customers and other stakeholders. † An illustration of supply chain management is displayed in Figure 2. This figure represents a basic supply chain network structure, as well as the flow of information and the product. The eight supply chain management processes, which integrate various tasks within the organization across the supply chain, can also be found in Figure 2 (Lambert, 2008). The implementation of the eight supply chain management processes is necessary to manage the relationships between various departments and tasks across the supply chain. Supply chain management is ultimately about the management of relationships within the network of businesses in the supply chain. Lambert (2008) expresses that the management of a supply chain is managed â€Å"link-by-link, relationship-by-relationship, and the organizations that manage these relationships best will win. † Role of Supply Chain Management (SCM) Overview of the role Supply chain management places attention along the entire supply chain, from raw materials at the supplier to finished goods in the hands of the customer. One role that supply chain management plays within a company is producing more efficient, quality products, which creates a competitive advantage among other companies. Today, management of the supply chain can be completed through the use of supply chain management software, such as E2Open. Supply chain management allows a company to document and track data pertaining to the supply chain. Benefits of the supply chain management Supply chain management places importance on managing the customer relationship, as well as the supplier relationship. By effectively managing these relationships, the company can become more competitive, while increasing the quality of the product to the customer. Placing emphasis on the supplier relationship and the businesses along the supply chain increases product efficiency and quality. The importance placed on the customer relationship focuses on the demands and needs of the customer. Through effective communication within the relationships along the supply chain, a basic balance of supply and demand is established.

Genetic engeneering2 essays

Genetic engeneering2 essays Genetic engineering has some history of good and bad. In 1989as a result of the food supplement Typtophan, 37 people died, 1500 were permanently disabled, and 5000 were very ill as result of high toxin levels in the food. No one knows the future side effects. Such as in August 19994, corn crops grew three inches tall and then suddenly fell over dead, because past crops drained the soil of most nutrients. Genetics have some new applications. They have newer and better-enhanced cells to be bigger and to produce more. For example soybean companies, they try to get a cell of all or mostly protein. It didnt work to well many people had an allergic reactions. Now scientists are looking and trying to make bigger and better plants. Scientists are also looking for a way to make plants grow twice or three times as big and produce more. That will let them get more crops out of one area of land. Scientists are out to educate people about engineering in plants. To let them know what they are eating. So they dont eat something that a major problem, and most of the public agree to be produced. Since scientists dont know about the long-term effects, because no long-term tests have been able to conducted. There are some negatives that come with everything but genetic engineering on plants has some pretty good ones. People have unknown reactions to some foods that have been altered. Our public health agencies are powerless to trace problems of any kind, back to the source, because there are no labels. There are unexpected and unknown side effects yet to be discovered. Genetic engineering also has its good side. We can produce three times as many crops in one field at one time. That will make our plants three times the size. It will also make the food we produce three times as much. This will help people buy making food in good supply year round, and making it c ...

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

Cinema in Egypt Term Paper Example | Topics and Well Written Essays - 750 words

Cinema in Egypt - Term Paper Example First, it is important to consider major milestones in the development of the Egyptian cinematography. It is noteworthy that the first â€Å"purpose-built cinema house† was built in Egypt in 1907 (Gamal 2). It suggests that Egyptians were interested in the new form of art and the industry could easily pave its way. Initially, foreign films were shown. The first national film was produced in 1917 (Danielson 87). However, those were first attempts, though they were quite successful. The industry started developing rapidly in 1925 when Tal’at Harb, a successful banker, started his own film company. Importantly, the banker employed only nationals and he even sent the most promising ones to Europe for the necessary training (Danielson 87). Unshudat al-Fu’ad / Song from the Heart (1932) was one of the first Egyptian sound films (Shafik 45). This musical film was very successful and it inspired many Egyptian filmmakers. Another musical, al-Warda al-Badha / The White Rose produced in 1933, was also the first Egyptian movie â€Å"to be successfully exported to other Arab countries† (Shafik 45). Muhammad Karim, Ahmad Badrakhan, Fatima Rushdi were among those directors who shaped the Egyptian cinematography and created or rather identified its most significant conventions. The middle of the 20th century is regarded as the golden age of the Egyptian cinematography. Numerous brilliant films were created at that period. It is necessary to note that major themes and genres remained the same. Those were often musical films and comedies that promulgated universal values. They will be considered in detail below. However, during the 1970-1980s, the industry was declining and the number of films produced decreased significantly (Russell 344). Their quality was often very low. At present, the Egyptian industry is on its rise and numerous talented filmmakers manage to produce highly successful national films. As has been mentioned above,

The role of innocence in the exoneration process Essay

The role of innocence in the exoneration process - Essay Example However, this is not always to be, and there is always the likelihood that an innocent person is convicted2. This paper attempts to explain ways that people wrongly convicted get proof of their innocence. The causes of wrong convictions are wide ranging and comprise all features of the pre-trial and trial stages of the criminal justice process ranging from false allegations, incompetent police investigation, police misconduct, erroneous forensic science and evidence, and poor representation from criminal defense lawyers. Once an alleged victim of an unjust conviction has lost their appeal, there is a slight opportunity that the courts will be in a position to stop the conviction3. In these cases, victims of wrongful convictions are likely to have exhausted the legal aid unit and it will be up to them, their friends, supporters, families, pro-bono lawyers and voluntary groups to uncover the evidence of innocence and present it to the relevant authorities such as the Criminal Cases Review Commission (CCRC). 2Investigating a suspected wrongful conviction is a long and challenging process. Cases of high profile injustices like the Cardiff Newsagent Three and Sean Hodgson show that it can take several years of investigation before the evidence that leads to the quashing of the conviction is found4. Many projects that attempt to exonerate innocent people out of prison have come up. One such project is the Innocence Network project founded in 1992 whose principle objective is to get as many innocent people out of prison as possible and turn the experience of these people into a learning experience that could help repair the systematic failings in the criminal justic e system5. The project exonerates people by use of post-conviction DNA where the DNA from the crime scene is tested against the DNA of the accused. Often, people wrongly convicted of serious crimes like homicide or abuse has

Oral Presentation on Australian Aboriginal Families Essay Example for Free

Oral Presentation on Australian Aboriginal Families Essay We are doing the Traditional Australian Aboriginal families. The traditional Aboriginals were located in Australia and Tasmania. It is believed that Australian Aboriginals travelled from Africa to Asia around 60 000 years ago and arrived in Australia 50 000 years ago. Today, about 1% of Australian people are Aboriginal. Religion was a very large part of the Aboriginal culture. They do not have a formal religion but they were very spiritual. They believed in The Dreaming, which was when the Ancestral Beings moved across the land and created life and features in the land. Dreamtime stories are told by songs, dance, stories or paintings and pasted through the generations. Aboriginals had a complex family system; it varies from tribe to tribe. But a typical Aboriginal family consisted of grandparents, men and their wives and children. The women played the main role in educating the children but the men and women both shared the roles of healers, law makers, performers and painters. CHANGE PP. The main role of the women was to gather food. They would collect seeds, vegetables, fruits, insects and larvae. It was then their job to cook and prepare the meal. Women took care of the children until they reached the age of six. CHANGE PP. Until around age 6, children would get looked after by their mother. After this age, boys would learn hunting with their fathers and girls would learn food gathering with their mothers. Children would help and care for elders when they needed help physically. The elders of a group were the roles models. Elders would educate and teach the children and children helped them physically. Everyone had a lot of respect for the elders as they had a lot of knowledge and experience. They would decide if the group was to move camp. A typical Aboriginal family used to hunt, craft and tell stories each day. Each day the aboriginal men would go hunting for food using tools they had made themselves. The women and children would spend the day gathering foods. As they did this the women would educate the children on religion and tell them dream stories. At the end of the day the women would cook the meal for the large family around a camp fire. Aboriginal children and families played a lot of games and music together. They would play traditional music that was handed down through generations. Didgeridoos, rattles, clapping sticks and boomerangs were all used as instruments. Ceremonies were a huge part of Aboriginal life. The main ceremonies they conduct are for health of crops and land, initiation of children to adulthood and funerals. These ceremonies can go for days and even months and almost the entire community are involved. They sing songs, decorate themselves and tell stories during ceremonies. The head of a typical clan is usually one of the eldest and talented men and is followed by younger men. The leader position was passed down from father to son. In conclusion, traditional Aboriginal families were very respectful of each other. They each have a specific role in society and each contribute to the life of the community. Thank you for listening. We hope you learnt lots about the traditional Aboriginal families.