Case Study On A Patient With Pulmonary Tuberculosis

Case Study On A Patient With Pulmonary Tuberculosis The case that is about to be discussed here revolves around a patient diagnosed with pulmonary tuberculosis. The patient that was clerked, Mrs A, was a 61 year old woman. She was a Malay housewife. Her Body Mass Index value of 26.0 kg/m2 based on her height of 1.58 m and weight of 65 kg indicated that she fell into the overweight range. The patient was admitted to the Accident Emergency mode transferred in from another hospital via an ambulance. She presented symptoms such as shortness of breath(SOB) and her respiratory rate was 20 breaths per minute. She appeared pale and weak and her blood glucose levels were low (2.1 mmol/l) and her blood pressure values indicated she was hypertensive with a value of 152/93 mmHg. Upon physical examination, mild leg swelling was observed. Based on her past medical history, patient was diagnosed with pulmonary tuberculosis for the past 3 months, hypertension for the past 5 years, diabetes for the past 5 years and advanced renal failure for the past 6 months. Upon enquiry, she was seen to be a non-smoker and a non alcoholic. Patient lived with her daughter. Several investigations were performed to evaluate the patients condition. A positive sputum smear test indicated that the patients tuberculosis was still active. Upon renal function assessment, creatinine clearance was calculated and a value of 5.5 ml/min indicated Stage 5 renal failure. Her potassium and urea levels were also above range based on Table 1. Upon haematology assessment, her low blood sugar levels indicated hypoglycaemia and patients haemoglobin count was also low signifying anemia. Chest X ray was conducted on this patient and minor lesions at the apical segments of the upper lobe were seen. This is a typical radiographic representation of patients with tuberculosis. Table 1: Results of the investigations performed Laboratory Test Readings Normal range Sputum Smear Test Positive Renal Function Creatinine, Cr Urea Potassium, K+ 912 ÃŽÂ ¼mol/l 37.8 mmol/l 5.5 mmol/l 44-80 ÃŽÂ ¼mol/l 1.7 8.5 mmol/l 3.5 5.0 mmol/l Haematology Assessment Blood Sugar Level Haemoglobin 2.1 mmol/l 9.8 g/dl 4.5 6.0 mmol/l 13.5 18 g/dl Table 2 provides details about patients drug history giving information about patients drugs and their respective doses. Upon interview, patient informed that she had not been purchasing any over the counter medications. She also has no known drug allergy. Table 2 : Drug History and their respective doses and their indication Drug Dose Duration Indication Rifampicin 300 mg OD 2 months Anti TB Isoniazid 200 mg OD 2 months Anti TB Pyrazinamide 750 mg OD 2 months Anti TB Ethambutol 600 mg OD 2 months Anti TB Pyridoxine 20 mg OD 2 months Treatment of neuropathy Gliclazide 40 mg OD 5 years Anti diabetic Prazosin 2 mg TDS 5 years Anti Hypertensive Furosemide 80 mg OD 5 years Anti Hypertensive Nifedipine 20 mg TDS 5 years Anti Hypertensive Based on the investigations performed, the patient was diagnosed to be suffering from pulmonary tuberculosis and diabetes mellitus. Patients daily condition was monitored and appropriate management was undertaken to control the patients condition. Patients overall progress is tabulated in the table 3 and the observation is recorded. Table 3 : Patients clinical progress and management Day Clinical Progress Management 1 Hypoglycemia = 2.1 mmol/L AFB test positive Chest X ray performed SOB Hyperkalaemia ( 5.5 mol/L) Anemic ( 9.8 g/dL) BP : 152/93 mmHg Strict fluid intake IV Dextrose 10%/24 hours Refer to chest physician Lesions at upper lobes NPO2 to resolve SOB Start on Calcium polystyrene Start Ferrous (IV) sulphate Start antihypertensives Monitor input output 2 AFB test +ve Blood Sugar Level = 3.0 mmol/L BP : 140/90 mmHg Start TB regimen (EHRZ) Continue IV Dextrose 10% Monitor Blood Glucose Continue antihypertensives 3 Blood Sugar level = 3.2 mmol/L Severe renal impairment ( CrCl =5.6 ml/min ) Chest X ray done time to time BP : 130/70 mmHg Continue dextrose infusion Send patient for dialysis Lesions still present Continue antihypertensives 4 No SOB Hypoglycaemia resolved = 5.5 mmol/L AFB +ve BP : 130/75 mmHg Remove nasal prongs Stop Dextrose. Monitor blood glucose Continue TB regimen 6 K+ level in normal range ( 4.5 mmol/L) Blood Sugar level = 6.0 mmol/L CrCl = 7.7 ml/min BP : 130/65 mmHg Stop Calcium polystyrene. Monitor blood glucose Send patient for dialysis 8 Hyperglycemia = 11.1 mmol/L BP : 125/75 mmHg Start on Insulin DM counselling 13 AFB -ve DXT = 10.2 mmol/L BP : 120/70 mmHg Transfer out of isolation Continue insulin. Monitor blood glucose Based on patients presentation and results from investigations performed on day 1, patient was started on dextrose and her blood glucose levels were regularly monitored. Based on patients previous history, a sputum smear test was ordered and two consecutive positive results resulted in the patient being referred to the chest physician. A chest X ray was performed and lesions in the apical segment were present. To resolve patients SOB, patient was started on Nasal Prongs at 3L/min. To control her hyperkalemia, patient was given calcium polystyrene sulphonate powder. Patient was also started on ferrous sulphate infusion to help her cope with her anaemia. A strict fluid intake was imposed on patient to resolve her leg swelling and this was monitored through an input output chart. Her blood pressure (BP) levels were also elevated and patient was given antihypertensives such as nifedipine, prazosin and furosemide to control her BP. On day 2, her sputum smear remained positive and patient was commenced on the intial phase therapy for tuberculosis which consists of isoniazid, rifampicin, pyrazinamide and ethambutol. There was not much improvement in her blood glucose levels and patient was remained on the dextrose infusion. Moving on to day 3, not much improvement was observed and due to patients deteriorating renal function, patient was sent for peritoneal dialysis. By day 4, patient could breath normally and no shortness of breath was seen. Nasal prongs were removed. When her blood glucose levels were monitored, the results indicated patient was within the normal range and dextrose was withheld. Blood glucose levels were still monitored to prevent sudden drops and increase in blood glucose. Her potassium levels were within range by day 6 and calcium polystyrene sulphonate was stopped and potassium levels were monitored as well. Patient suffered from a hyperglycemia episode on day 8 and the patient was given biphasic insulin to treat this condition. By this day, her BP was also in the normal range but the antihypertensives were still continued. On day 13, patient was transferred out of the isolation ward as her sputum smear test produced negative results. Patients condition for tuberculosis was still being monitored. Her blood glucose levels were still in the high range and patient was to be continued on insulin. To summarize this case, patients active tuberculosis state should be managed well to ensure patient does not suffer from further complications that might arise in the future. Patients history was well noted and this helped in treating the patient in early stages. Adequate investigations were performed to assist the healthcare professional team to diagnose the patient and also to manage the patient. Patient was admitted for a long period but the appropriate management that was undertaken resulted in improvement in patients condition. Further care for the patient would improve the patients quality of life in the future Pathophysiology and Incidence Tuberculosis (TB) is an infectious disease that has plagued many nations across the world. Based on the report by World Health Organization (WHO), almost 9.4 million cases of TB were reported 3. It is highly common of those with TB to contract the Human Immunodeficiency Virus (HIV) and a prevalence of almost 1.7 million deaths from TB among HIV-negative people was recorded around the globe 3. In the United Kingdom, an increasing trend in TB incidence has been reported and this is shown in Figure 1. In 2008, a rate of 14 per 100 000 population in the UK were reported to be suffering from TB 4. Malaysia on the other hand has a higher record of TB cases with 103 per 100 000 population being reported in 2007. Table 1 summarizes some of the data obtained from World Health Organization 3. Figure 1: Number of TB cases reported in the UK from 2000 to 2008 4 Table 1: Statistics displaying number of TB cases in Malaysia in 2007 3 All In HIV + people Incidence All forms of TB (per 100 000 population) 103 17 Mortality All forms of TB (per 100 000 population) 121 8.3 Multi-drug Resistant TB (MDR-TB) MDR-TB among new cases (%) 0.1 Notified relapse cases (per 100 000 pop/yr) 61 The bacteria that is responsible for this disease is the acid fast bacilli aerobic bacterium Mycobacterium tuberculosis 1. A key feature that enables this bacterium to survive would be its unique cell wall. Mycolic acids are linked covalently to arabinogalactan that provides a barrier to host defense mechanism. Antigens such as lipoarabinomannan present on the exterior of the cell wall facilitate the survival of the organism within macrophages 1. Tuberculosis is spread usually spread within droplets containing the microorganism that are produced when an infected person coughs, sneezes or even talks 1,2. Figure 1 gives a schematic impression of the progression of the disease. The inhaled droplets are initially trapped by dendritic cells that act to expel any foreign particles out. Most mycobacteria are able to surpass this defense mechanism and travels further to the alveoli where it gets ingested by macrophages 1. It then undergoes intracellular replication that might take duration o f 4 to 6 weeks. Cytokines are further released during this period and this attracts T lymphocytes that are involved in mediating a cell immune response. The next natural defense system step would be the formation of granuloma that contains the activated T lymphocytes and macrophages. These nodular lesions disable further spread of the disease as the environment within restricts the growth of the bacilli and a latent period occurs 1. For less immunocompetent individuals, the granuloma will not be able to contain the bacilli and the active disease takes form 1. Figure 1: Image depicting the progress of tuberculosis 2 The diagnostic tests available are summarized in Table 2. TB can be divided to latent and active and to diagnose each different test has been recommended. For latent TB, Mantoux test can be carried out and those with positive results can be considered for QuantiFERON TB test 5. To diagnose active pulmonary TB, a chest X-ray would be taken followed by multiple sputum samples that are sent for smear test 5. Table 2: Diagnostic tests available for tuberculosis 1 Variable Purpose Time required for results Sputum smear Detect acid fast bacilli Sputum culture Identify M tuberculosis 3-6 weeks with solid media, 4-14 days with high-pressure liquid chromatography Tuberculin skin test/ Mantoux Detect exposure to mycobacteria 48 72 hours QuantiFERON TB-test Measure immune reactivity to M tuberculosis 12 24 hours Chest radiography Visualize lobar infiltrates with cavitation Minutes The drugs that are commonly used in tuberculosis are isoniazid, rifampicin, pyrazinamide and ethambutol. Rifampicin is a bactericidal agent that inhibits RNA synthesis by binding to the ß subunit of RNA polymerase. It can be given via oral administration and can even be distributed to the central nervous system due to its lipophilicity. Metabolism of this drug occurs in the liver and it is usually excreted in the urine. Isoniazid is a bactericidal pro-drug that inhibits ketoenoylreductase enzyme, InhA, that is responsible in synthesizing mycolic acids. Isoniazid can be administered orally, intramuscularly or intravenously and is acetylated in the liver and subsequently excreted in the urine. Pyridoxine 10 mg is given concurrently to minimize this risk. Pyrazinamide is another prodrug that is activated by nicotinamidase to pyrazinoic acid. This component at low pH carries proton into the cell and collapses the proton motive force present in the mycobacterium which results in cell d eath. It is only bactericidal against non growing bacilli forms.. Ethambutol works by binding to arabinosyl transferase enzyme and inhibits the polymerization of the cell wall arabinan component. Table 3 gives the details of the dose and side effects reported with the administration of the tuberculosis drugs. Table 3: Tuberculosis drugs with their respective doses and side effects 6,7 Drug Dose Side effects Isoniazid 5 -8 mg/kg (max 300 mg) Peripheral neuropathy, hepatotoxicty Rifampicin 10 15 mg/kg (max 600 mg) Nausea, vomiting, thrombocytopenia, orange discolouration of urine Pyrazinamide 20 40 mg/kg ( max 1.5 g 50 kg) Nausea , vomitting, hyperuricemia Ethambutol 15 25 mg/kg Neuropathy, red green color blindness Evidence based medication review Treatment for Tuberculosis In the past three decades, no new drugs have been discovered in fighting TB. The 4 drugs have been the gold standard in treating TB The chemotherapy regimen available for tuberculosis therapy can be divided to the initial phase and the continuation phase. In the initial phase, drugs such as rifampicin, isoniazid, pyrazinamide and ethambutol are used 6. These drugs act to decrease the amount of bacteria present and also prevent resistance from emerging from the strains. This regimen is usually for 2 months. The continuation phase would consist of drugs such as isoniazid and rifampicin. Isoniazid was the first drug to be introduced into combating tuberculosis back in the 1950s. Rifampicin , an antibiotic, was later added to the market and was added to the isoniazid regimen in 1967. This resulted in shortening the duration of treatment from 12 months to a 6 to 9 month treatment 9. Addition of pyrazinamide to the regimen decreased the chemotherapy duration further. Clinical studies have indicated that a pyrazinamide containing short course regimen had a sputum negative conversion rate of 70-95% in the first two months compared to the treatment without pyrazinamide 11. The relapse rates recorded from these studies also were only 4%. A clinical study conducted in East Africa compared the four 6-month daily regimens that comprised of Streptomycin, Isoniazid and Rifampicin (SHR), Streptomycin, Isoniazid and Pyrazinamide (SHZ); Streptomycin, Isoniazid and thiacetazone (SHZ) and Streptomycin and Isoniazid (SH) 10. The SHZ regimen that was the most effective amongst all the regimens and the SHR regimen had the lowest relapse rate of 2% 30 months post treatment 10. No significant difference results were obtained from the treatment regimen that was carried out for 18 months 10. This study gives an impression of the efficacy of the isoniazid, rifampicin and pyrazinamide regimen when used together In a Poland study, the efficacy of the 4 different drug regimens containing rifampicin, isoniazid and ethambutol were assessed. During the initial phase, patients were given isoniazid 300 mg, rifampicin 600 mg and ethambutol 25 mg/kg 8. In the continuation phase the regimens given to patients comprised of rifampicin 600 mg, isoniazid 15mg/kg(Regimen A), isoniazid 15 mg/kg rifampicin 600 mg twice a week (Regimen B), Isoniazid 15kg/mg, rifampicin 600 mg ethambutol 50mg/kg once a week (Regimen C) and Isoniazid 15mg/kg, rifampicin 600 mg, ethambutol 50mg/kg twice a week (Regimen D) 8. The result of this study demonstrated that Regimen D had 47% of its patients displaying a significant change in their sputum result to a negative result compared to the other regimens. There were no significant differences in rates between all regimens by the end of the fifth month as all patients had their sputum converted to negative. This study had the limitation of not including pyrazinamide in its regi men but it can be seen that to achieve a quicker rate of sputum negative cultures a regimen containing ethambutol could be used in the continuation phase. A trial conducted by Jindani et al. assessed the effectiveness of daily dosing of the intial phase drugs compared to the intermittent thrice weekly dosing. The drugs that were assessed were isoniazid, rifampicin, pyrazinamide and ethambutol. The doses that were given to the patients were based on WHO recommendations. The outcome measured after 2 months had 77% of the patients with negative sputum cultures after their 2 month stint (p=0.001) 13. A similar study was conducted in Hong Kong with the difference being a 12 month follow up period. By the end of the second month, 94% of patient receiving the daily regimen had improved. 90% of those under the intermittent regimen also had improved by the second month. Over the long term follow up, more relapse cases were recorded but the values were not significant 14. Hypoglycemia Treatment Patient was hypoglycemic upon arrival and dextrose infusion was provided to restore the patients normal blood glucose range. Two forms of treatment are usually available for hypoglycemic attacks namely glucagon and dextrose infusion. A study compared the efficacy between both the options and it was observed that both were capable of treating hypoglycemia effectively. The only disparity observed was the recovery. Patients on dextrose infusion are capable of regaining consciousness by 4 minutes compared to 6 minutes for patients that were on glucagon ( p Table 4 : Results of 51 hypoglycemic patients treated with dextrose 10% and dextrose 50% 27 Dextrose 10% Dextrose 50% Median time needed to attain recovery (minutes) 8 8 Median total dose administered 10g ( p 25g (p Median post treatment blood sugar levels 6.2 mmol/l (p=0.003) 9.4 mmol/l (p=0.003) Diabetes Treatment Oral antidiabetic agents such as gliclazide in the patients drug history would not be sufficient for her to have proper control over her glycemic levels. It was reported that tuberculosis affects the hormonal secretion by interfering with endocrinal organs such as pancreas 15. Rifampicin reduces the concentration of gliclazide by inducing liver microsomal enzymes CYP 2C9 that rapidly eliminates gliclazide from circulating in the system 15,16,17. In a study by Park et al., patients given with 80 mg gliclazide had the concentration of the drug present in the body reduced by 70% on day 7. The elimination half life of the drug also increased 3 fold 17. All these contribute to the inability of the sulfonyluea to reduce the glucose levels in this patient. According to the stepwise approach in NICE guidelines, the next step to manage this patient would be to start the insulin regimen18. The type of insulin that was given was biphasic Mixtard insulin analogue that consists of a short acting analogue and also a long acting analogue. P.V. Rao reported that, due to the insulin resistance present in patients started on anti Tb therapy, the doses of insulin needed to manage these patients increase 15. It is well proven that insulin can achieve better HbA1c levels as a clinical trial by United Kingdom Prospective Diabetes Study (UKPDS) revealed that after 9 years monotherapy with insulin, 28% of patients achieved HbA1c levels below 7% and 42% patients achieved fasting plasma glucose levels below 7.8 mmol/l 19. Hypertension Treatment Patient was suffering from Stage 5 renal disease and the target for blood pressure in this patient would be 125/75 mm Hg 20. First line treatment for this patient would be loop diuretic, furosemide 20. They act by inhibiting the Na+/K+/2Cl- transporter on the ascending limb of loop of Henle which results in natriuresis and hence a fall in blood volume 21. This loop diuretic also performs its vasodilator actions via prostaglandin (PGE2 and prostacyclin) formation. This results in an increased blood flow in the medulla 21. In accordance to SIGN guidelines as well, long acting dihyrdopyridines such as nifedipine and ÃŽÂ ± blockers can be added as supplementary therapy 20. Nifedipine, a calcium antagonist acts by causing vasodilatation due to reduction in peripheral resistance. ÃŽÂ ± blockers such as prazosin block ÃŽÂ ±1 receptors and this results in vasodilation. A study by Vadasz displayed that Furosemide doses at 40 mg did not display any significant changes in systolic blood pressure. However, when the dose was increased to 60 mg, there was a significant reduction in blood pressure 21,22. A combined dose of 40 mg and 60 mg were effective in reducing the diastolic blood pressure. Based on this evidence, it is clear that furosemide on its own is not capable of decreasing blood pressure. When nifedipine was combined with diuretics it was observed that a statistically significant lower risk of cardiovascular events was observed compared to the non-statistically significant difference that was noted with nifedipine monotherapy 22. In another study by Psaty et al, nifedipine did not demonstrate an increase of risk in myocardial infarction compared to the other calcium channel blockers 25. Prazosins efficacy in lowering blood pressure was studied and the lowest effective dose that is capable of reducing blood pressure was noted to be 10mg 26. Doses below 10 mg per day did not significantly reduce the blood pressure compared to the placebo arm. Treatment of Anaemia Patient had very low haemoglobin levels and this was indicative of anaemia. NICE guidelines have recommended that in order to manage anemia, patients are usually given eryhtropoetin stimulating agents and also iron supplements to help produce haemoglobin 23. There has been no evidence in the use of iron supplements in patients with chronic kidney disease prior to treatment with erythropoietin. But it is recommended that the erythropoietin therapy should not be commenced in conditions of complete iron absence 23. In some conditions, where patients were in Stage 5 renal failure also diagnosed with other co-morbidities, treatment with erythropoietin stimulating agents is decided based on clinical judgment by the professional team if the patient were to benefit from the treatment 23. Treatment of Hyperkalaemia Patient was suffering from mild hyperkalemia and it was necessary that this was be treated before it progresses to severe hyperkalemia that might lead to adverse events such as cardiac arrest. A study compared the effectiveness between sodium polystyrene sulfonate and calcium polysterene sulfonate and it is noted that treatement with sodium increases sodium concentration in the body and this escalates the risk of hypertension 24. Treatment with calcium polystyrene sulfonate resulted in 50% decrease in potassium content and an additional advantage of increase in calcium concentration was observed as well 24. Conclusion Based on all the evidence provided for the patients condition, it is clear that the guidelines were adhered in treating the patients individual disease with some minor differences. Tuberculosis treatment for the initial phase was extended for more than 2 months due to the positive result obtained from sputum smear. Patient eventually achieved negative sputum smear and the patient was to be monitored before the patient was commenced on the continuous phase drugs. Effective treatment was undertaken to treat patients hypoglycemia condition, and based on the evidence gathered, dextrose 10% is the suitable treatment option for the patient. The antihypertensive regimen that was chosen was due to the patients renal failure. Nifedipine, prazosin and furosemide collectively controlled the blood pressure of the patient. Ferrous sulphate was chosen as her treatment compared to erythropoietin and this was based on the doctors clinical judgement. Her hyperkalemia which was treated with calcium su lfonate did benefit the patient as her potassium levels were within the normal range at the end of the treatment. PATIENT MEDICATION PROFILE PATIENT DETAILS Name Mrs A Consultant General Practitioner Address Kuala Lumpur Gender Female Weight 65 Height 158 Community Pharmacist Date of Birth (Age) 61 Known Sensitivities None Social History Non smoker Non Alcoholic PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date April Low Sugar Level : 2.1 mmol/L Discharge Date Discharged to Not Known Shortness of breath RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments Feb Pulmonary Tuberculosis Feb Rifampicin 6 months Advanced Renal Failure Feb Isoniazid 5 years Hypertension Feb Pyrazinamide 5 years Diabetes Mellitus Feb Ethambutol Feb Pyridoxine 6 months Prazosin 6 months Nifedipine 6 months Furosemide Gliclazide RELEVANT NON DRUG TREATMENT Peritoneal Dialysis Prescribed Medication Start Stop Clinical/Laboratory Tests Date Result 1 Rifampicin Day 1 Sputum Smear Test Day 1 Positive 2 Isoniazid Day 1 Creatinine Day 1 912 Â µmol 3 Pyrazinamide Day 1 Urea Day 1 37.8 mmol/l 4 Ethambutol Day 1 Potassium Day 1 5.5 mmol/l 5 Pyridoxine Day 1 Blood Glucose Day 1 2.1 mmol/l 6 Prazosin Day 1 Blood Pressure Day 1 152/93 7 Nifedipine Day 1 Haemoglobin Day 1 9.8 g/dl 8 Furosemide Day 1 Chest Xray Day 1 Lesions in the apical segment 9 Dextrose Solution Day 1 Day 4 Blood Glucose Day 8 11.1 mmol/l 10 Ferrous sulphate Day 1 Sputum Smear Day 13 Negative 11 Calcium polystyrene sulphate powder Day 1 Day 6 12 Insulin Mixtard Day 8 CLINCIAL MANAGEMENT Diagnosis Pharmaceutical Need Pulmonary Tuberculosis Continue patient on intial phase drugs Hypoglycemia Start patient on dextrose Hypertension Continue antihypertensive treatment Hyperkalaemia Start calcium polystyrene sulphonate powder Anaemia Start ferrous sulphate Advanced Renal Failure Send patient for peritoneal dialysis PHARMACEUTICAL CARE PLAN Date Care Issue/Desired Output Action Output Sub therapeutic doses For Anti TB drugs Discussed with the pharmacist and patients diabetic condition was the reason for the dose regimen Doses were not changed Drug sensitivity testing was not performed Patient is diabetic and is more susceptible for MDR-TB No test was performed Management of patients compliance towards anti tuberculosis drugs -Patient might be hospitalised for a long period of time due to renal failure -DOTS scheme to be implemented upon discharge -Adequate patient education on the importance of completing the regimen is important Hospitalisation or DOTS scheme Renal failure Ethambutol excreted by kidney. Suggest change of medication to 2 Isoniazid + Rifampicin + Pyrazinamide -If treatment continued, monitoring essential Continue treatment as before and patient being monitored AFB test Another 2 samples should be taken for AFB tests before switching to the continuous phase Action yet to be taken Monitor drug toxicity Lab investigations on full blood count, liver function, serum uric acid, serum bilirubin, should be done to ensure no toxicity Eye examination for ethambutol side effects Scheduled appointments for patient Education on side effects of drugs To inform patient about anti Tb drugs side effect and advise patient not to stop the drug and side effects can be controlled ( PZA and arthralgia ) Counseling by pharm

Consider how Emily Bront introduces the reader to the themes of enclosure and the supernatural

Wuthering Heights is a novel which criticisers the idea of enclosure in pre 19th century books and life. It was published in December 1847, but only 250 copies were published. It centres on pivotal characters, which Emily Brontà ¯Ã‚ ¿Ã‚ ½ heavily describes. People who read the book from the contemporary audience would have been shocked from the language and all the swearing, they thought it was a depressing and morose novel. Emily Brontà ¯Ã‚ ¿Ã‚ ½ was born in Thornton, Yorkshire, in the north of England; similarly the book is set in the north of Yorkshire, in the moors. This amplifies the idea enclosure already as it is a hard to reach place, and the place where it is set, is remote to every where else! Emily had a rough life because she lived in a small stone cottage on the 2nd floor with three bedrooms, no bigger than a small closet. She died of Tuberculosis in late 1848. She caught a cold at her brother, Branwell's, funeral in September. Her novel â€Å"Wuthering Heights† reflects on her life, as she lived a rough life living in a small house with two sisters in the moors. Moving on the opening of this prestigious novel opens with a specific date, 1801. This specific date â€Å"1801† is a similar to a diary so it would make the reader feel more intimately enclosed with Emily Brontà ¯Ã‚ ¿Ã‚ ½; plus the use of her heavy vocabulary and description makes me feel quite involved with the book and it's characters, yet it cleverly ties you into her grasp so you feel you have to carry on reading. But as this is a diary type opening the person, in this case the narrator: Lockwood, will inevitably express his feelings, which is indeed what he does so there is a sense of biased in his views and opinions. Lockwood seems to be a pleasant man who thinks himself to be in the same league as Heathcliff, yet he is much more polite and affectionate and can show his emotions more freely than Heathcliff. Yet as we enter this heavily described book he is the narrator and is quite provoked by Heathcliff, in the sense that he is a role model towards him. The opening of the book is set in a remote place with a garish house, quite distressed and characterised, especially with gothic creatures. Lock mentions â€Å"1500† this was over the door of the house with the name â€Å"Hareton Earnshaw†, so the story the is written in a 1st person narration. Also the fact that Heathcliff expresses the words â€Å"go to the Deuce† is quite atrocious and not appealing. This would immediately astonish the contemporary audience as witchcraft and mentioning the Devil was quite blasphemous and profound; this may have triggered a slight distaste towards the dreadful keeper of this dreadful house. Lockwood also asks himself questions like â€Å"Why did I think of Linton?† on page 17, this leads on to impression of enclosure like â€Å"Situation so completely removed from the stir of society† and â€Å"Misanthropists heaven†, this means someone who hates society and everyone else. This is ideal for an misanthropist because no one else is around and the nearest house is about 2 miles away. Another sense of a misanthropist is when Heathcliff says â€Å"Walk in† and when the dogs attack Lockwood because they are not use to anyone else. Nobody helps Lockwood when he shouts accept for Zillah, this is because women were cheap labour and disrespected back then. This leads to a description of Wuthering Heights it shows an influence of a gothic novel because of the different features like â€Å"quantity of grotesque carving lavished over the front†, this is on page 2 and he says there is â€Å"Crumberling griffins and shameless little boys† over the door, so the book reinforces the idea of supernatural. When it says â€Å"dark skinned gypsy† people thought they were into aroused suspicion. Another part of the supernatural is when Lockwood says â€Å"The storm subsided magically†. The language reinforces the supernatural. By this time the reader feels that Lockwood has made an effort to be polite but all his efforts were thrown back in his face by Heathcliffs rudeness. â€Å"The walk in was littered with closed teeth, and expressed in the sentiment.† This novel shows that the life she led she was very, powerfully influenced by enclosure and that she was very enclosed being a women, as men were more dominant and allowed to vote, whereas women were still treated as the lower powered sex! Also in those times women weren't allowed to write and publish books, so with this in mind, how did Emily Bronte's book become so famous? If women weren't allowed to write books, how did Emily Bronte's book, and her sisters' for that matter, get published in what used to be a powerfully, male dominated world? It seems to me that Emily Bronte was very influenced by enclosure in her life and that she is tired of the way women are exploited in the world. This is where the ideas of women, and supernatural mix â€Å"a lusty dame, with tucked-up gown, bare arms and fire-flushed cheeks, rushed into the midst of us flourishing a frying-pan: and used that weapon, and her tongue, to such a purpose, that the storm subsided magically.† In addition there are further, reinforced ideas of the supernatural in the mind of the reader as; there is an incident, after Lockwood has entered the house, and is waiting to talk to Heathcliff. He is seated anxiously waiting with Heathcliff's dogs, which are â€Å"haunting the recesses†. This shows that the dogs are more powerful or seem to be more powerfully personified, and it gives the idea that the dogs are ghosts and dark spirited, especially the use of the word â€Å"haunted†, as it implies bringing displeasure to someone or something, and maybe not welcoming anything. At the end of the chapter, the reader would feel different towards Lockwood as they would have done at the beginning. At the beginning Lockwood seems more provoked as he thinks himself to be in the same league as Heathcliff, towards the end he is shown to be quite different from Heathcliff; further more we would feel sympathetic towards him as he was callously attacked by Heathcliffs' dogs. Having been annoyed by this racket, Heathcliff is angry and unsympathetic towards him. Moving on, Emily Brontà ¯Ã‚ ¿Ã‚ ½ builds up the idea of the supernatural and enclosure, through a number of ways. Firstly we see Lockwood, anonymously, returning to Wuthering Heights, to have, yet another meeting with Heathcliff. â€Å"Yesterday afternoon set in misty and cold. I had half a mind to spend by my study fire, instead if wading through heath and mud to Wuthering Heights.† This shows that Lockwood is optimistic to still show Heathcliff he can be a nicer person than normal. Furthermore, after re entering Wuthering Heights, Lockwood is bombarded by displeasure and hints of hatred, towards him, as Heathcliff does not want a repeat of what happened before, â€Å"You should not have come out.† This would make the audience feel slight sympathy towards Lockwood, but as he unconventionally turned up, it was not wrong for Heathcliff and the others to feel this way.

Fundamentals of Leadership Mindmap

Semiotics Symbols are a means of communication – can include authority and process. A symbol is something which signifies something else. The purpose of symbols is to convey meaning. Semiotics Symbols are a means of communication – can include authority and process. A symbol is something which signifies something else. The purpose of symbols is to convey meaning. Ideology Coherent set of ideas and their underpinning logic, which inform action, preferences. It is the framework we use to make sense of the world.It is only visible to those who can look beyond the message, it lures people into forgetting that meaning is always socially constructed. Ideology Coherent set of ideas and their underpinning logic, which inform action, preferences. It is the framework we use to make sense of the world. It is only visible to those who can look beyond the message, it lures people into forgetting that meaning is always socially constructed. Hegemony The rule or influence of one count ry over others. The dominance or leadership of one social group over others.Gramsci developed this 20th century Marxism – where hegemony tries to explain the control of the dominance class in capitalism. Hegemony The rule or influence of one country over others. The dominance or leadership of one social group over others. Gramsci developed this 20th century Marxism – where hegemony tries to explain the control of the dominance class in capitalism. Managerialism Organisations have more similarities than differences so the performance of all organisations can be optimised by the application of generic management skills and theory.Managerialism Organisations have more similarities than differences so the performance of all organisations can be optimised by the application of generic management skills and theory. Key points 1)Co-founder of Marxism. 2)critique against capitalism 3)communist manifesto (1848) capital (1867-94) 4)focus on alienation and exploitation of the wor king class Key points 1)Co-founder of Marxism. 2)critique against capitalism 3)communist manifesto (1848) capital (1867-94) 4)focus on alienation and exploitation of the working class Habermas’ contributionsHis major contribution is his development of a theory of rationality. He criticises industrial democracies in the west for equating humanity with economic efficiency. A possibility for community through communicative action that strives for agreement between others. The importance of ‘ideal speech’ where you are able to raise moral and political concern and defend them by rationality only. Habermas’ contributions His major contribution is his development of a theory of rationality. He criticises industrial democracies in the west for equating humanity with economic efficiency.A possibility for community through communicative action that strives for agreement between others. The importance of ‘ideal speech’ where you are able to raise moral and political concern and defend them by rationality only. Karl Marx 1818-1883 Karl Marx 1818-1883 Critique of Capitalism As a mode of production with 2 key features: goods and services produced as commodities. Individuals labour power is also a commodity and can be bought and sold in the labour market. Wage slaves – Capitalism involves free exchange rather than pressure, but must sell their labour power to a capitalist to survive.Value added – machines, tools and innovations are used to help in production, this helps to gain abnormal profits or reduce turnover times etc. however these practices are adopted by competitors and workers productivity and wages become crucial thus only labour power can add value. Fundamental basis of economical class struggle in capitalism by increasing productivity by longer working day, intensifying effort during working hours, boosting output by cost effective and labour cutting techniques. Critique of CapitalismAs a mode of production w ith 2 key features: goods and services produced as commodities. Individuals labour power is also a commodity and can be bought and sold in the labour market. Wage slaves – Capitalism involves free exchange rather than pressure, but must sell their labour power to a capitalist to survive. Value added – machines, tools and innovations are used to help in production, this helps to gain abnormal profits or reduce turnover times etc. however these practices are adopted by competitors and workers productivity and wages become crucial thus only labour power can add value.Fundamental basis of economical class struggle in capitalism by increasing productivity by longer working day, intensifying effort during working hours, boosting output by cost effective and labour cutting techniques. Modernism Modernism Max Weber 1864-1920 Max Weber 1864-1920 Jurgen Habermas 1929 – Jurgen Habermas 1929 – Key points 1)major work – rationalisation and disenchantment associ ated with capitalism and modernity. 2)strong relationship between protestant morality and successful western capitalism. 3)3 different types of authority: traditional, charismatic and legal rational. )defined rationalisation 5)developed a theory of bureaucracy. Key points 1)major work – rationalisation and disenchantment associated with capitalism and modernity. 2)strong relationship between protestant morality and successful western capitalism. 3)3 different types of authority: traditional, charismatic and legal rational. 4)defined rationalisation 5)developed a theory of bureaucracy. Critical Management studies Is a movement that questions the authority and relevance if mainstream thinking and practice. Its focus is management as a pervasive institution that is entrenched within capitalist economic formations.Critical Management studies Is a movement that questions the authority and relevance if mainstream thinking and practice. Its focus is management as a pervasive institu tion that is entrenched within capitalist economic formations. Habermas on communication A model of communicative rationality that takes into account the effect power has on the situation and opposes the traditional idea of an objective and functionalist reason. He wanted to construct a non-oppressive, inclusive and universalist moral framework for discourse – where all speech acts are for mutual understanding. Habermas on communicationA model of communicative rationality that takes into account the effect power has on the situation and opposes the traditional idea of an objective and functionalist reason. He wanted to construct a non-oppressive, inclusive and universalist moral framework for discourse – where all speech acts are for mutual understanding. Post Modernism Post Modernism Michel Foucault 1926-1984 Michel Foucault 1926-1984 Critical Theory To develop a more rational, enlightened society through a process of critical reflection. To mobilise the potentials of critical reasoning in order to question and transform oppressive features of the modern world.Critical Theory To develop a more rational, enlightened society through a process of critical reflection. To mobilise the potentials of critical reasoning in order to question and transform oppressive features of the modern world. 1979 Discipline and punish: The birth of the prison. The privatisation of property activated the privatisation of power. Compares 18th century torture and execution to 19th century prison and disciplinary prisons used- showing power. 1979 Discipline and punish: The birth of the prison. The privatisation of property activated the privatisation of power.Compares 18th century torture and execution to 19th century prison and disciplinary prisons used- showing power. Weber and Bureaucracy The iron cage – the high reliance on machine production determines our lives that threatens to confine us within an ‘iron cage’ Clear division of labour. Standard s of impersonality govern interpersonal relations. People do not act as people but as a role of an office. Rules are carried out without any regard for people. Weber and Bureaucracy The iron cage – the high reliance on machine production determines our lives that threatens to confine us within an ‘iron cage’ Clear division of labour.Standards of impersonality govern interpersonal relations. People do not act as people but as a role of an office. Rules are carried out without any regard for people. Habermas and ideal speech When communication and dialogue are free of distortions an ‘ideal speech’ situation can be said to exist. To attain this lies in a specific form of knowledge, based on self- reflection. Habermas on communicative action Meaningful interaction between persons. Action that is couched in ordinary language and saying something. A way of doing something by conveying a message, establish social relationships.Express opinions and feelings and expressing self-identity. Habermas and ideal speech When communication and dialogue are free of distortions an ‘ideal speech’ situation can be said to exist. To attain this lies in a specific form of knowledge, based on self- reflection. Habermas on communicative action Meaningful interaction between persons. Action that is couched in ordinary language and saying something. A way of doing something by conveying a message, establish social relationships. Express opinions and feelings and expressing self-identity.Foucault : power and control Classical and system theory: organisations as logical, functional, impersonal passionless entities – neutral rules of efficiency and economy. Brought to life and maintained through: language, conversation and experience. Talking and arguing, reinforce structures of membership, acceptance and decision making. Political forces. Organisations as social constructions: legal and emotional ownership, membership and control. Skill , ability and learning capacity. Human frailty, willingness, passion and self-centredness. Foucault : power and controlClassical and system theory: organisations as logical, functional, impersonal passionless entities – neutral rules of efficiency and economy. Brought to life and maintained through: language, conversation and experience. Talking and arguing, reinforce structures of membership, acceptance and decision making. Political forces. Organisations as social constructions: legal and emotional ownership, membership and control. Skill, ability and learning capacity. Human frailty, willingness, passion and self-centredness. Foucault and Discipline Discipline is a series of techniques of observation, training and the direction of individuals.Where one is subjected to the will of another. Foucault wanted to understand the disciplinary power that is diffused throughout society. Our reliance and acceptance of certain norms circulates through our language and politics. Foucau lt and Discipline Discipline is a series of techniques of observation, training and the direction of individuals. Where one is subjected to the will of another. Foucault wanted to understand the disciplinary power that is diffused throughout society. Our reliance and acceptance of certain norms circulates through our language and politics.Organisational control Organizational structures hierarchy, influence tactics such as: compliance, surveillance, technology, pay and rewards, power to set the agenda and power to execute. Organisational control Organizational structures hierarchy, influence tactics such as: compliance, surveillance, technology, pay and rewards, power to set the agenda and power to execute. Weber and Rationalisation The process by which nature, society and individual action are mastered to orientation to planning, technical procedure and rational action Weber and RationalisationThe process by which nature, society and individual action are mastered to orientation to planning, technical procedure and rational action Weber’s thoughts Spread of bureaucracy to all areas of life would imprison us in an ‘iron cage’ with no escape. It could crush the human spirit by regulating all spheres of social life. Bureaucracy has potential to suffocate and dehumanise people. Bureaucracy excludes public from decision making and participation in the production of consensus, which leads to loss of democracy. Weber’s thoughtsSpread of bureaucracy to all areas of life would imprison us in an ‘iron cage’ with no escape. It could crush the human spirit by regulating all spheres of social life. Bureaucracy has potential to suffocate and dehumanise people. Bureaucracy excludes public from decision making and participation in the production of consensus, which leads to loss of democracy. The Frankfurt school (Institute of social research) ( The Frankfurt school (Institute of social research) ( Founded to interpret critique and ref rame the relevance of Marxist thought for contemporary industrial society.Founded to interpret critique and reframe the relevance of Marxist thought for contemporary industrial society. They gathered together dissident Marxists – severe criticisms of capitalism who opposed Marx’s thought of economic determinism and special role of communist party. They selected parts of Marxist thought that they fitted in with the modern world – influenced especially by the failure of working class revolutions and advanced German nation. Looked at Max Weber and Sigmund Freud to fill Marx’s perceived omissions – attempt to overcome the limits of positivism, crude materialism and phenomenology.They gathered together dissident Marxists – severe criticisms of capitalism who opposed Marx’s thought of economic determinism and special role of communist party. They selected parts of Marxist thought that they fitted in with the modern world – influenced especially by the failure of working class revolutions and advanced German nation. Looked at Max Weber and Sigmund Freud to fill Marx’s perceived omissions – attempt to overcome the limits of positivism, crude materialism and phenomenology. Marx and ExploitationThe exchange value of a product is determined by the quantity of labour necessary to produce it. Marx’s position is that while it is labour that determines the exchange value of commodities, the exchange of labour for wages is not reciprocally balanced. What is exchanged is labour power: the capacity to work. Marx and Exploitation The exchange value of a product is determined by the quantity of labour necessary to produce it. Marx’s position is that while it is labour that determines the exchange value of commodities, the exchange of labour for wages is not reciprocally balanced.What is exchanged is labour power: the capacity to work. Marx and alienation Marx identifies 4 types of worker alienatio n under capitalism: 1) self-estrangement 2) estrangement from the product of their labour. 3) Estrangement from their species being 4) estrangement from others. 1)Alienation of the worker from the work he produces, from the product of his labour – the absence of control by the producer over the product. The product reduces, rather than expresses the producer’s humanity, and sustains alienation by buttressing capitalism. )Alienation of the worker from working, from the act of producing itself – increasing division of labour. This fragments the productive process into meaningless, and ostensibly unrelated tasks such that the general orientation of labour to work is not one of the creative liberation but instrumental and forced labour. 3)Alienation of the worker from other workers or producers – turn every productive group into competitors, setting individual against individual and reducing the social relations between people to economic exchanges or commodi ties. ) Alienation of the worker from himself as a producer, from his or her species being – objects designed for use by humans are transformed via the capitalist mode of production into commodities that dominate humans. Marx and alienation Marx identifies 4 types of worker alienation under capitalism: 1) self-estrangement 2) estrangement from the product of their labour. 3) Estrangement from their species being 4) estrangement from others. )Alienation of the worker from the work he produces, from the product of his labour – the absence of control by the producer over the product. The product reduces, rather than expresses the producer’s humanity, and sustains alienation by buttressing capitalism. 2)Alienation of the worker from working, from the act of producing itself – increasing division of labour. This fragments the productive process into meaningless, and ostensibly unrelated tasks such that the general orientation of labour to work is not one of th e creative liberation but instrumental and forced labour. )Alienation of the worker from other workers or producers – turn every productive group into competitors, setting individual against individual and reducing the social relations between people to economic exchanges or commodities. 4) Alienation of the worker from himself as a producer, from his or her species being – objects designed for use by humans are transformed via the capitalist mode of production into commodities that dominate humans.

Nomination Process for Supreme Court Justices

The nomination process for Supreme Court justices begins with the departure of a sitting member of the high court, whether by retirement or death. It is then up to the president of the United States to nominate a replacement to the court, and the U.S. Senate to vet and confirm his choice.  The nomination process for Supreme Court justices is among the most important obligations on presidents and members of the Senate, in part because members of the court are appointed for life. They dont get second chances to make the right choice. The U.S. Constitution gives the president and the Senate this vital role. Article II, Section 2, clause 2 states that the President â€Å"shall nominate, and by and with the Advice and Consent of the Senate, shall appoint ... Judges of the Supreme Court.† Not all Presidents have the opportunity to name someone to the court. There are nine Justices, including the chief justice, and one is replaced only when he or she retires or dies. Forty-two presidents have made nominations to the Supreme Court. The president with the most nominations was George Washington, who had 13, with 10 of those being confirmed. The President’s Selection As the president considers who to nominate, investigations of possible nominees begin. The investigations include a probe into a person’s private background by the Federal Bureau of Investigation, as well as an examination of the person’s public record and writings. The list of possible nominees is narrowed, with the goal being to ensure that a nominee has nothing in his or her background that would prove embarrassing and to guarantee that the president selects someone likely to be confirmed. The president and his staff also study which nominees agree with the president’s own political views and which ones would make the president’s supporters happy. Often a president confers with Senate leaders and members of the Senate Judiciary Committee before selecting a nominee. This way the president receives a heads-up on any potential problems a nominee may face during confirmation. The names of possible nominees may be leaked to the press to gauge the support and opposition to different possible nominees. At some point, the president announces the selection, often with great fanfare and the nominee present. The nomination then is sent to the Senate. The Senate Judiciary Committee Since the end of the Civil War, almost every Supreme Court nomination received by the Senate has been referred to the Senate Judiciary Committee. The committee does its own investigation. A nominee is asked to fill out a questionnaire that includes questions about his or her background and to fill out financial disclosure documents. The nominee also will make courtesy calls to various senators, including party leaders and members of the Judiciary Committee. At the same time, the American Bar Association’s Standing Committee on the Federal Judiciary begins evaluating the nominee based on his or her professional qualifications. Ultimately, the committee votes on whether a nominee is â€Å"well-qualified,† â€Å"qualified,† or â€Å"not qualified.† The Judiciary Committee then holds hearings during which the nominee and supporters and opponents testify. Since 1946 almost all hearings have been public, with most lasting more than four days. The president’s administration often trains a nominee before these hearings to ensure that the nominee does not embarrass himself or herself. Judiciary Committee members may ask nominees about their political views and backgrounds. Since these hearings receive a great deal of publicity, senators may attempt to score their own political points during the hearings Following the hearings, the Judiciary Committee meets and votes on a recommendation to the Senate. The nominee may receive a favorable recommendation, a negative recommendation or the nomination may be reported to the entire Senate with no recommendation. The Senate The Senate majority party controls the Senate agenda, so it is up to the majority leader to determine when a nomination is brought to the floor. There is no time limit on debate, so if a senator wants to conduct a filibuster to hold up a nomination indefinitely, he or she may do so. At some point, the minority leader and majority leader may reach a time agreement on how long a debate will last. If not, the nominee’s supporters in the Senate may attempt to end debate on the nomination. That vote requires 60 Senators to agree to end debate. Often there is no filibuster of a Supreme Court nomination. In those cases, a debate is held on the nomination and then a vote is taken by the Senate. A majority of voting senators must approve the presidents choice for the nominee to be confirmed. Once confirmed, a nominee is sworn into the position of justice of the Supreme Court. A justice actually takes two oaths: the constitutional oath that is taken by members of Congress and other federal officials, and a judicial oath. Key Takeaways Step 1: A sitting justice retires or dies, leaving a vacancy on the bench.Step 2: The president nominates a candidate to replace the departing justice.Step 3: The nominee is vetted by the Federal Bureau of Investigation.Step 4: The Senate Judiciary Committee conducts its own investigation and hearings with the nominee. It will then take a vote on whether to send the nomination to the full Senate for confirmation. If the committee does not approve of the nominee, the candidate is dropped from consideration.Step 5: If the Senate Judiciary Committee approves, the full Senate votes on the nomination. If a majority of the 100-member Senate approves, the nominee ascends to the U.S. Supreme Court.