Symbolism of the Island

The Island Major Joe Ridge View High School English 1 Mrs. Walker December 17, 2012 There are many different symbols in the book Lord of the Flies. Some of the symbols represent peace and some represent war. Some of the characters themselves represent different symbols. The item of symbolism that stood out the most was the island itself. The island itself is an excellent item of symbolism because it uses the boys themselves to convey what it stands for thus almost making itself seem alive. The island represents peace, atavism, the struggle to hang on to civilization, life, and the struggle to hang on to humanity.The island itself stands for peace. It shows this through Simon. The special place in the jungle where Simon went shows the peaceful part of the island. There is not much of it but it is there hidden by all of the confusion other factors at work. â€Å"He came to a last place where more sunshine fell. Since they had not so far to go for light the creepers had woven a great m at that hung at the side of an open space in the jungle; for here a patch of rock came close to the surface and would not allow more than little plants and ferns to grow. The whole space was walled with dark aromatic bushes, and was a bowl of heat and light.A great Tree, fallen across one corner, leaned against the trees that still stood and rapid climber flaunted red and yellow sprays right to the top† (Golding 56). Simon found that place peaceful and beautiful. He goes there in the middle of the night just to escape the atavistic character of the island itself which is portrayed through the forest and Jack. The island also shows atavism through the forest and through Jack. Throughout the story the boys continued referring back to creepers â€Å"I can’t hardly move with all these creeper things† (Golding 7).Creepers are like vines that climb up tree trunks and grow across open patches of ground. They cover up the trees and ground and make it hard for the tree or the ground to get sunlight or water. The vines take the water from the trees so that they can survive in the conditions of the island. Jack and his hunters do similarly the same thing with the pigs. The boys engulf the pig with their presence and beat it to death making it nearly impossible for them to escape the rancorous attacks and also making it nearly impossible for the pigs to breed and fill the island with wildlife and swine.The island also portrays life. For this it uses the open space that Simon found and the fire. When Simon found his special part of the island, he noticed that the creepers did not grow there allowing the fruit trees and the flowers to grow there abundantly. The fire also symbolizes the life of not only the island but the life of the boys’ morale and hope of going home again. â€Å"The fire was dead. They saw the straightaway; saw what they had really known down on the beach when the smoke of home had beckoned. The fire was out, smokeless and dead ; the watchers were gone.A pile of unused fuel lay ready,† (Golding 67-68). The boys saw a ship passing by in the distance when they found out that the fire was dead. At that moment Ralph called an assembly. Jack and his hunters came from the forest with a pig. Ralph told Jack about the fire and the ship but the only thing the Jack was concentrated on was how he and his hunters managed to capture the pig. The Island also represents the struggle to hang on to civilization. The Island shows this through the scar that the plane left when it crashed.The entire island is in order with creepers and trees making an attempt to grow everywhere. The beach is sandy and the lagoon is not too far from the beach everything on the island was neat and in order. The plane crashed it left a scar that left a path of burned creepers fallen trees and overturned dirt and debris. The rocks on the island also had a role in breaking the rope of civilization. When Piggy’s glasses broke they fell on a rock after Jack smacked them off of Piggy’s face. â€Å"Ralph made a step forward and Jack smacked Piggy’s head. Piggy’s glasses flew off and tinkled on the rocks.Piggy cried out in terror: ‘My specs! ’†¦ ‘One side’s broken† (Golding 71). At that moment in the book the normal world’s idea of civilization went out of the window and Jack’s idea took over. Ralph and piggy both wanted to keep the island as civilized as possible. Piggy gave ralph the idea to blow the conch and try to call all the boys to one central location. While resting on the mountain he realized the conditions of himself and the other boys on the island: With the memory of his sometime clean self as a standard, Ralph looked them over.They were dirty, not with the spectacular dirt of boys who have fallen into mud or been brought down hard on a rainy day. Not one of them was an obvious subject for a shower, and yet—hair much too long , tangled here and there, knotted round a dead leaf or a twig; faces cleaned fairly well by the process of eating and sweating but marked in the less accessible angles with a kind of shadow; clothes, worn away, stiff like his own with sweat, put on, not for decorum or comfort but out of custom; the skin of the body, scurfy with brine—He discovered with a little fall of heart that these were to conditions he took as normal now and that he did not mind, (Golding 110). This realization from Ralph shows that he misses the rest of the world and that being shut off from the rest of the world gave him and even stronger need to try to restore civilization on the island. The island also symbolizes the struggle to hang on to the humanity of the island. Before the boys came to island the pigs had no real enemy that was known. The boys were the same way.When the boys were luckily landed on the island the pig’s predator became Jack and his hunters. It was easy for Jack to find his first pig but not as easy for him to kill it. The second time he carried out his task. As the story continues Jack has to go through different procedures and tricks in order to find a pig. He painted his face, he crawled around on the ground following a pig slide and pig droppings. He ends up killing pigs almost every day for the group. The pigs adapt to Jack’s ways and try to avoid him.When Jack killed the mother sow, the amount of humanity left on the island was in question. â€Å"Rodger found a lodgment for his point and began to push till he was leaning with his whole weight. The spear moved forward inch by inch†¦ ‘Right up her ass! ’† (Golding 135). The island was the most important symbol in the book. Without the island and the natural features of it then one may not think that the island could stand for anything other than an uninhabited graveyard for an assortment of young boys.In order to really see the significance of the island one needs to look closely at the events that happen and where they happen in the book. The island talked to the reader through the characters of the story. Each character represented a different trait of the island. Jack was the fear of the island, Piggy was the gentle side, Ralph was the firm part of the island, and Simon was the peace on the island. There are many other situations like this in many other stories, one just has to pay attention and open their eyes. References Golding, W. (1954). Lord of the Flies. Salisbury, England: Faber and Faber.

Cari Story Essay

How can an infection in Cari nasal passages and pharyns spread into her sinuses? The infection in Cari’s nasal passages and pharynx was able to spread into her sinuses due to the sinuses being a drainage area for the nasal passages. What is the cough reflex? Describe the process that Cari’s respiratory system is using to clear her lungs by coughing. The cough reflex is used to clear sputum and irritants that are in the nasal passages and pharynx. There are cilia in her trachea that is moving mucus up from the lungs. When the mucus becomes or abundant it triggers the cough reflex. Which structures found in the terminal bronchioles and alveoli normally would protect Cari’s lungs from infectious pathogens and particulate matter? Macrophages found in the terminal bronchioles and alveoli that normally would protect Cari’s lungs from infectious pathogens and particulate matter. How would the resistance of Cari’s airways be affected by excess mucus and flu id in her lung? Excess mucus and fluid in the lungs would raise the resistance of Cari’s airways because of the small diameter the buildup would cause. The fluid would have some of alveoli under water where they could not function properly and there would also be more friction from the buildup. How would Cari’s lung compliance (the effort required to expand the lungs) be altered as her alveoli fill with fluid due to pneumonia? Lung compliance would increase from trying to force gases into and out of the alveoli. Those are filled with fluid due to the pneumonia. How would fluid in Cari’s lung affect her total lung capacity? Fluid in Cari’s lungs would lower her total lung capacity by not allowing the space that is taken up by the fluid to be filled with air. How does the elevation of Cari’s respiratory rate alter her minute ventilation? Elevation in her respiratory rate would alter her minute ventilation by raising it. Minute ventilation is determined by times ing respiratory rate by total volume. Normal blood oxygen saturation levels are greater than 94 percent; Caris blood oxygen saturation level was 90 percent at the time of her exam and an initial arterial blood gas analysis done when she was admitted to the hospital revealed her arterial Po2 was 54mmhg. How do these clinical finding relate to the internal respiration in cari body?

Write About the Ways Love Is Explored in Two Soliloquies. One from Romeo and Juliet, and One from Othello.

Write about the ways love is explored in two soliloquies. One from Romeo and Juliet, and one from Othello. Write about the ways love is explored in two soliloquies. One from Romeo and Juliet, and one from Othello. A Soliloquy is an dramatic technique used in plays to convey to the audience, a character’s true most inner thoughts, feelings and emotions. Shakespeare is famous for using soliloquies to place the audience in an omniscient position, allowing them to develop an intimate relationship with the characters, often creating dramatic irony and tension.Shakespeare expresses the theme of death throughout Romeos soliloquy to enable the audience to empathise and feel pathos toward Juliet â€Å"Death that hath suck the honey of thy breath†. The word â€Å"breath† is ironic and is symbolic of how Romeo cannot bare to be without Juliet, so much so that he feels the sensation of suffocation. Dramatic irony is also apparent as the audience knows that Juliet is still al ive; this sentiment provokes emotion as the audience is willing for Romeo to notice that she is not dead.Also the fact that love is blind plays an ironic almost humorous part here as Romeo is failing to see Juliet is still alive. The theme of death continues as Shakespeare personifies death throughout the soliloquy to present it as a more sinister force and rival for Juliet’s love: â€Å"shall I believe that unsubstantial death is amorous? And that the lean abhorred monster keeps thee here in the dark to be his paramour? † The negative language negative language used to personify death, â€Å"lean abhorred monster†, illustrates Romeos sense of disgust but more importantly, the fear that death has taken Juliet from him.Romeo’s fear is clearly expressed when Shakespeare writes: â€Å"For fear of that I still will stay here with thee/here i will remain†. The repetition of â€Å"here† conveys Romeos determination to stay with Juliet to the exten t that he will take his own life. Therefore, the audience get the impression that Romeo feels he must kill himself to preserve their love, a trait which links with his hamatia. Furthermore, Shakespeare employs the ongoing lexical field of death to create a sense of foreboding and heighten the dramatic irony.The main protagonist Romeo personifies death using a metaphor to express its severity. He explains how death has not â€Å"conquered† Juliet’s beauty â€Å"yet†. The word yet implies that death is inevitable which links to the phrase â€Å"star crossed lovers† that is delivered in the prologue. Elizabethan people were highly superstitious and believed heavily in fate which would have contributed to the many attributes that make Romeo a tragic hero. â€Å"And deaths pale flag is not advanced there. Shakespeare‘s use of nautical language is used to infer how Romeo has almost been â€Å"shipwrecked† (as he says later in the soliloquy) which highlights his solitude and his incomplete sensation he feels without Juliet present. In Addition, the audience so observes that Romeo’s obsessive and unconditional love for Juliet contributes to his fall from grace and greatly adheres to his hamartia. â€Å"Thee here in dark to be his paramour/here’s to my love†. Dramatic irony and a paradox of light is used her to show Romeo’s possessiveness and impetuousness.The fact that he says â€Å"my† shows his obsessive naivety, as he almost loves Juliet too much so to speak. It is clear for the audience to see that Romeo is ruled by fate, doomed from the start. A contemporary audience would have profoundly disagreed to this ethos as in a modern way we believe that we choose or make our own â€Å"fate†. Contrastingly Shakespeare uses powerful repetition to emphasise the importance and severity of Othello’s opening line. The use of monosyllabic words creates tension, highlighting Othelloâ€⠄¢s chilling tone. It is the cause, it is the cause my soul â€Å". Here Othello is addressing his soul and conscience, trying to justify the terrible act which he is about to commit; but in his mind he already has established the inevitability of his actions. The fact that Othello uses the word â€Å"It â€Å"shows he cannot bring himself to name the act that Desdemona has supposedly committed. Even this early in the soliloquy, the reader can clearly distinguish Othello’s hamartia (the traits that make a tragic hero).We see his serious errors in judgment (believing Iago without proof) which later leads him to committing the dead (Taking Desdemona’s) that leads to his downfall. Additionally, Othello changes the address of his soliloquy from his inner self, to the â€Å"Chaste stars â€Å". It is a commonly known fact that the Elizabethan era were very superstitious; so it is very understandable that they could empathise with Othello’s â€Å"cause â€Å" a nd understand his alliance with the stars. â€Å"Let me not name it to you, chaste stars â€Å".This is reminiscent of the prologue in Romeo and Juliet, where it refers to â€Å"star crossed lovers â€Å", the audience can now see a clear correlation between obsessive love and death, which is sad as in both plays the deceased lovers are â€Å" innocent â€Å". Here Othello is further trying to reassure himself that he is doing the just thing; that his actions are almost written in â€Å"alabaster â€Å"inevitable. Referring to the â€Å"chaste stars â€Å" is also part of Othello’s hamartia; the idea of being doomed from the beginning .Also his obsessive, overpowering love for Desdemona, distorts his perception of reality, which is why he failed to detect the lies being fed to him by Iago. Shakespeare uses dramatic irony to highlight Desdemona’s innocence, the fact that Othello says â€Å"chaste â€Å"is almost humorous as the audience knows that Desdemona is completely innocent, never committing adultery in her extremely short life. Just as Romeo speaks of Juliet’s beauty, even in death, to emphasise his love for her, so too does Othello in acknowledging Desdemona’s outward perfection and beauty. â€Å"†¦.. hiter skin than snow/And smooth as monumental alabaster†¦.. † Here Shakespeare uses and extended metaphor, which is ironic as Othello is comparing Desdemona to white snow, white being symbolic of innocence and purity which paradoxes the vile dead which he is about to commit. Shakespeare use of figurative language here powerfully reflects Othello’s intense love and adoration for Desdemona. The fact that Othello elevates Desdemona to a position of â€Å"Monumental† perfection shows that he is savouring her beauty before confirming his resolve that â€Å"she must die†.Furthermore, Shakespeare’s clever use of dramatic irony and ability to control the audiences’ emotions through powerful imperative verbs is shown in this part of the soliloquy. â€Å"Yet she must die, else she’ll betray more men†. Othello’s resolve is highlighted by a break in the flow of the verse, emphasised by a colon. This break represents his sorrow, regret and anguish. The fact that Othello is a â€Å"Moore† means he suffered both outwardly (isolation and alienation attacks) and inwardly (tortured conscience). Unfortunately the finality of this statement conveys to the audience the harsh reality that Othello is going carry out this injustice.Also this particular line said by Othello links with what Brabantio (desdamona’s father) says in the beginning of the play â€Å"Look to her, Moor, if thou hast eyes to see: She has deceived her father, and may thee†. This here is very ironic, as Othello is going to murder Desdemona for the exact thing her father warned him about, except she has not committed the act. We the audience feel pathos to ward Desdemona as even her father had a false predicament and made an extreme error in judging his own daughters character.Unsurprisingly this links with Romeo and Juliet’s struggle to be together as a result of the â€Å"family feud†. Love is portrayed to be a hardship in both plays, which may be one of the reasons the love is so obsessive and unhealthy. To conclude, I believe that the theme of love is convayed very effectively in both Romeos and Othello’s soliloquy. Both invoked a variety of emotions and allow the audience to really connect with the characters. A great amount of dramatic irony and tension is delivered at pivotal points in both plays where obsessive leads to the suicide of Juliet and contrastingly the murder of Desdemona.

Is inclusion in main stream school ideal for children with sen Dissertation

Is inclusion in main stream school ideal for children with sen - Dissertation Example .......................................................... Literature Review...................................................................................................... Inclusive Education of Children with SEN: A Look Back. Does inclusion help children to fit it to society? Does inclusion work for all children, can schools be changed so that all children are included if not which children can be included and which cannot? How far should a school change to meet the needs of individuals? Do they like coming to school? Do they have lots of friends also what do they like about school? Is there any improvement in their lessons such as numeracy and literacy, being in the main stream school? How is the inclusion helpful in promoting overall health and well being? How the denial of inclusion is an outright violation of their rights? Results and Data Presentation.................................................................................. Discussion and Analysis................ ............................................................................. Conclusion................................................................................................................... Recommendations....................................................................................................... Bibliography................................................................................................................ ... Therefore, one is sure of the elite role of nations in assuring the growth of physically and mentally healthy younger generation. Consequently, the care and attention of the governments, parents, teachers and peer groups in assuring the well being of the children with special educational needs (SEN) seeks special attention. The issue on inclusion or integration of SEN to mainstream education has been a subject of debate among authorities and experts for many decades now. Questions on the ability of the SEN pupils to face the pressures of a mainstream school and the capacity of these schools to cater the special needs of these children are only few of the identified points that can hinder the possibility of achieving the highest potentials of these children while attaining education in mainstream schools. Despite these concerns, several local, national, and even international organizations worldwide have always advocated that segregation—that is, the act of separating these chi ldren from the general population—is an outright violation of their rights since it is believed that integration to mainstream education is a key to promoting their overall health and well being. In connection, this paper will seek for evidences to these claims by reviewing related literatures that tackle the issues surrounding the situation. This will also present the execution and process of a mini case study involving two children with SEN. The study is conducted on the grounds that the authorities have the responsibility to safeguard the interests of children by providing them better education available and protect the rights of SEN in accessing to specialist teaching and other resources which enable them to rise up to the level of other students

Child of the Dark The diary of Carolina Maria de Jesus Essay

Child of the Dark The diary of Carolina Maria de Jesus - Essay Example Another deterrent of having faith in democracy is the lying that politicians do. Carolina wrote a poem, "Politicians on their platform, Promise they will give you raises, And the people find out soon enough, That its their suffering that was raised" (Maria, 123). Through Carolinas views, one can see that support of democracy weakens with the distrust of politicians. The problems within Brazil also deter Carolina from having sympathy to democracy. She says, "The cost of living makes the worker lose his sympathy for democracy" (Maria, 103). She also makes the promise that, "If the cost of living keeps on rising until 1960, were going to have a revolution" (Maria, 119). The key word, revolution, supports the claim that democracy and poverty cannot coexist, at least not for long. If the cost of living does not change, the democratic state will be challenged. Another challenge of democracy is corruption. Carolina talks of how the collector for electricity money is allowed to charge those living in the favelados whatever he wants (Maria, 147). When the poor realize that they are being stolen from, they are not willing to accept a flawed form of government. On the other hand, Carolina also negates the argument that democracy cannot coexist with poverty. She does this through her political actions. On July 7th, 1958 Carolina went to register to vote. She said, "When I got to Semanario Street, I needed a photo for registration papers. I had a picture taken in Foto Lara. It cost me 60 cruzeiros" (Maria, 76) This may not jump out as an action to support democracy, but when one takes into account how much 60 cruzeiros is worth to her, one can see how much she sacrificed to register to vote. 60 cruzeiros was the equivalent to about 1 kilo of beans in Brazil in the 50s. She could have fed her family for days, but yet she still made it a priority to take part in the political process. Another example of her participation occurs while addressing

Major Corporation Assignment Example | Topics and Well Written Essays - 500 words

Major Corporation - Assignment Example Wal-mart Corporation has managed to maintain corporate responsibility as a form of philanthropic effort by enhancing close relationship among all its stakeholders. Moreover, the corporation has managed to maintain social responsibility as a way of developing its success. The corporation has managed to enact its business practices according to the set legal and ethical values. For example, Wal-mart has always been able to maintain a clean name all over the years that it has been operation. The corporation has also been able to engage in corporate social responsibility (Kneer, 2009). This means that Wal-mart appreciates its customers and the community by engaging in various development activities for the well-being of the society. In order to achieve the best within the competitive business sector in America, Wal-mart has also managed to enact a number of core values. One of the core values include offering respect for all individuals associated with the company daily operations (Kneer, 2009). This means that the corporation offers respect to all its employees through employing the appropriate leadership. The other core value that the corporation has managed to employ in its business operations is offering the best service to customers (Kneer, 2009). Each customer in Wal-mart is plays a significance role in enabling the corporation to meet its profit goals. Therefore, the corporation maintains a strong relationship with all its customers by treating them well and equally. The other core value that Wal-mart has been employing in its operations is striving for excellence (Kneer, 2009). This means that the corporation’s goal has always been being the best in the competitive market through providing better services to all its potential customers (Kneer, 2009). Wal-mart Corporation has also played a significant to enhance core competence through

Lexicography Dictionary Criticism Essay Example | Topics and Well Written Essays - 1500 words

Lexicography Dictionary Criticism - Essay Example approach to define a word and hence it appeals a broader English speaking audience. The division of this polysemous lexeme into geographical usage is particularly helpful for a speaker to make a clear distinction, which is important when either engaged in writing or conversation about a particular context. Both editions provide such a sense division around various English speaking contexts. The COED10 also provides a "characterization of the meaning of the lexeme; it does not give an exhaustive explanation of all possible referents" (Jackson, 2002, p.93). Following random example taken from COED10 elaborates this aspect. offside adj. & adv (in games such as football) occupying a position on the field where playing the ball not allowed, generally through being between the and the opponents goal. n 1 the fact of bring offside (usu. the off side) chiefly Brit. the side of a vehicle furthered from the kerb. Compare with NEARSIDE > the right of a horse. In the above definition, as was the case with other random samples, the definiendum is related to its super ordinate concept (for either sport or vehicle, a position). Another common tactic relied upon in COED9 and COED10 was to add a typifying definition to a synonym one-basically describing what is 'typical' of the referent. An important distinction between COED9 and COED10 is that contrary to COED9, COED10 has employed the concept of fourth definition which explains the use 'of which a word or send of word is put, usually in the grammar of the language' (Jackson. 2002. p. 95). Following random sample taken from COED10 signifies this feature. widow n 1. A woman who has lost her husband bydeath and has not married again. > Humorous a woman whose..."Anyone who has ever read or written a review of a particular dictionary will know that generally agreed criteria and standards for the assessment of quality and performance are still rare, if they can be said to exist at all" (Jackson, 2002, p.173), and same supposedly simple act applies here too.

Tax Reform Essay Example | Topics and Well Written Essays - 1500 words

Tax Reform - Essay Example The Bush tax cuts have not proven to be good for our economy. Although, we had a budget surplus our government jumped the gun with the tax cuts. These tax cuts will decrease the surplus extremely quickly and this money should be going towards most of the governmental run programs that usually are geared toward the moderate to low income people. Bush did not anticipate any future events that could lead us right back into a budget deficit and this has become the biggest problem our economy is facing today. Taxes are necessary for the administration and funding of governmental organizations, as well as construction and universal infrastructure services. Taxation presents positive and negative characteristics within an economic system. As history presents, most taxes have been geared toward the middle to lower classes with the upper classes receiving many tax breaks. With tax cuts for corporations, estates and the top one percent of high incomes all the little people will be left out in the cold. By demolishing the entire budget surplus, government programs, such as social security, will be neglected once the baby boomers begin retiring (Friedman, et al May, 2001, p 1). As Mark Breslow states, "The corporate income tax, which is relatively progressive, has been replaced by taxes that are a particular burden on people with moderate and low incomes. The cut of the alternative minimum tax has done nothing to help put money where it is needed, in the moderate to low income pockets. These people would definitely help stimulate the economy to help get us out of the recession we are falling into. John Miller points out, "that only two percent of estates are actually taxed and even the well off have little to worry about (Miller 2001 p 59.)." This still does not help the situation with the moderate to low income taxpayers. This group is being over taxed because they can never make enough money to meet the upper one percent of income that would be a benefit to them. This group also does not participate in the decision which does not help their situation. Robert S. McIntyre argues that, "The individual tax changes, which includes a ten percent decrease in capital gains taxes, are sharply tilted towards the wealthy (McIntyre, 2001 p. 1)." According to Joel Friedman, "some fifty-five percent of the stimulus package benefits are going to the wealthiest one percent of taxpayers (Friedman, et al November 2001 p. 1). This is very discouraging but it seems that if the people really cared about or was fully informed of the results of these tax cuts there would be severe rallying in the streets. Bush's tax cut, or stimulus package, has only been geared toward the upper class and this class has a very low marginal

Journal Entry 14 Coursework Example | Topics and Well Written Essays - 250 words

Journal Entry 14 - Coursework Example The second stage involves discussion between the instructor and the student whereby the importance of effort and motivation in writing is encouraged. Thereafter, the instructor comes up with a model on how to employ self-regulation strategies to reflect the needs of the student and match their personal writing style. The student is encouraged to memorize the strategy steps and the teacher in turn supports the writing strategy of the student to ensure that they achieve their goals. Independent performance is the last stage whereby students can now use the strategy they developed effectively and independently. In this last stage of independent performance, there are several procedures for endorsing preservation and simplification throughout the model. Some of the procedures include prompts to use the strategies, recognizing opportunities in employing self-regulation strategies, studying how the procedure can be adapted in certain situations, allocating assignments to the students in using the recognized situations and assessing the triumph of such undertakings (Graham & Harris,

Connections Les Murray Essay Example for Free

Connections Les Murray Essay A connection is an avenue of interaction that establishes and develops a relationship between people, places, and culture. Connections as social constructs may be positive or negative, impacted by internal beliefs, values and ideas that underlie the external determinants of environment, attitudes and culture within society. Poet Les Murray and educator Jane Elliott critically explore in their texts the cultural disconnection in the Australian and Canadian communities in response to the interaction of these factors and their effect on the avenues of interaction between people. Les Murray’s Sydney and the Bush embodies the poet’s personal connection and attachment to the ‘farmer lifestyle’ as he blames the disconnection of urban and rural Australia entirely on the city’s infatuation with materialistic pleasure. This consequently emphasises his value of the nature of rural society. Murray perceives the infatuation as an external attitude of the modernised and corrupted urban society, factored by the city individual’s internal values of luxury, wealth and power being the unmistakable cause of the cultural divide. He reinforces this notion through the technique of repetition, using the phrase ‘When Sydney’ in order to periodically mark the progression of cultural disconnection and accentuate the attributing internal and external factors. â€Å"When Sydney ordered lavish books, and warmed her feet with coal† reiterates the internal necessity for comfort and sophistication as few of limited sources of satisfaction. Les Murray further develops the concept of disconnection in the poem when â€Å"then bushman sank and factories rose, and warders set the tone†, contextualising this to reveal a loss of cultural identity for the rural community through industrialisation. â€Å"Then convicts bled and warders bred, the bush went back and back† whereby the poet suggests that nature is the central value of the farmer lifestyle, governing the internal and external factors of their connections, which in this poem is a disconnection to the urban society. Thus, Murray demonstrates that our connections are negatively impacted by internal and external factors, expressing a critical perspective that reflects his own value of and connection to nature and its simplicity as a source of contentment. creates another social critique of the urban social hierarchy contrast he begins the poem with â€Å"When Sydney and the Bush first met, there was no open ground† and ends with a juxtaposing â€Å"When Sydney and the Bush meet now, There is no common ground† enabling readers to identify the divided Australia in its urban and rural communities.

COPD Case Study Assignment

COPD Case Study Assignment 1) CASE SUMMARY Mr TLT is a 58 year old taxi driver who was admitted to Hospital Batu Pahat due to newly diagnosed chronic obstructive pulmonary disease. He has had hypertension for the past one year and is taking T Amlodipine 5mg od. He is also a chronic smoker for the past 40 years who smokes about 20 sticks of cigarettes a day. Mr TLT presented with shortness of breath which progressively increased in severity for the past 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory tract infection. Mr TLT has been having intermittent chronic cough associtaed with mucoid sputum for the past 3 years. He has also been having persistent breathlessness for the past 1 year especially on exertion. He has not sought treatment prior to this admission. On physical examination, Mr TLT was tacypnoiec with a respiratory rate of 28 breaths per minute. There was no cyanosis. Repiratory system examination showed use of accesory muscles as well as increased anterior posterior diameter of the chest and reduced cricosternal distance. On auscultation, vesicular breathing was heard with generalised rhonchi and coarse early inspiratory crepitations at the lower zone of both lungs. The cardiovascular system examination was normal. There were no other abnormalities on physical examination. Investigations done include chest plain radiograph which showed a hyperinflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No P pulmonale indicative of right atiral hypertrophy seen. A working diagnosis of acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection was made. Mr TLT was given nebulization of ipratropium bromide, salbutamol and normal saline for 2 times. His symptoms improved after being given the nebulization. He was discharged after three days when the dyspnoea had resolved. He was given metered dose inhaler of Ipratropium Bromide 40microgrammes tds and MDI salbutamol 200microgrammes PRN. He was given an appointment to assess his symptoms at the outpatient department in one month time. STUDENT NAME: Tan Hai Liang ID NO : M0409146 NAME OF SUPERVISOR : Prof Khin ROTATION: Internal Medicine PATIENTS DETAILS I/C NUMBER : 510912-01-6343 AGE : 58 SEX : Male DATE OF ADMISSION : 2 June 2009 R/N NUMBER : 1143451 2) CLINICAL HISTORY Chief complaint: Mr TLT is a 58 year old taxi driver who presented with shortness of breath for the past four days. History of present illness: Mr TLT is a chronic smoker for the past 40 years who has been smoking about twenty sticks of cigarettes a day. He had been diagnosed with hypertension for the past one year and is currently on T Amlodipine 5 mg od. Mr TLT has been having intermittent chronic cough for the past 3 years. The cough is productive at times. The sputum produced is mucoid in nature and about one tablespoonful in amount. There is no blood in the sputum. It is also not foul-smelling. Mr TLT then proceeded to have shortness of breath for the past one year. The dyspnoea is persistently present and described as requiring increased effort to breathe. It is worse on exertion and Mr TLT experinces reduced effort tolerance. He is now able to climb one and a half flights of stairs before becoming breathless. He has not consulted any doctors for these symptoms prior to admission. Mr TLT then developed symptoms of upper respiratory tract infection such as rhinorrhea and sore throat one week prior to admission. He had fever of 38 degress celcius at that time which resolved with paracetamol. He also had a productive cough with mucoid sputum at this time. Mr TLT then developed increasing shortness of breath 4 days prior to admission. The shortness of breath worsened over the 4 days and was associated with noisy breathing. He was breathless even at rest but was still able to speak in sentences. There was also an increase in cough as well as production of sputum. The sputum was mucoid and non purulent. He also did not notice any blueness around his lips or at his fingers. Systemic review: There was no loss of appetite or loss of weight. He had mild ankle oedema but no other signs of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea. Past medical history Mr TLT has not had any hospital admissions prior to this. He was diagnosed with hypertension last year as an incidental finding during a visit to the kilinik kesihatan for an upper respiratory tract infection. He is currently taking tablet Amlodipine 5 mg once daily. Family history Mr TLT is the eldest of 5 siblings. There is a strong family history of hypertension in that his mother as well as two other siblings are also hypertensive. There is no family history of asthma, diabetes or ischaemic heart disease. Social history Mr TLT used to work as a taxi driver but has stopped working full time 2 years ago. He still occasionally drives his taxi but spends more time at home with his family. He is a chronic smoker for the past 40 years and smokes about 20 sticks of cigarrettes a day. He drinks alcohol with his friends on weekends. He drinks one to two bottles of beer each time. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine ____________________________________________________________________________ 3) FINDINGS ON CLINICAL EXAMINATION On general examination, Mr TLT was well nourished and alert but was tachypnoiec. He was able to speak in sentences but there was use of his accessory muscles. There was no clubbing or cyanosis seen. There was also no peripheral oedema, pallor or jaundice. Vital signs: Pulse rate: 72 beats per minute, regular with good volume. No bounding pulse. Respiratory rate: 28 breaths per minute Blood pressure: 129/73 Temperature: 37 degrees Celsius SpO2: 95% under nasal prong oxygen 3 litres per minute Examination of the respiratory system: On inspection of the hands, there was no peripheral cyanosis or flapping tremors seen. There was also no clubbing, muscle wasting or palmar erythema seen. There was presence of nicotine stains. The jugular venous pressure is mildly elevated at 3.5 cm above the sternal angle. On palpation of the trachea, the trachea is central but the cricosternal distance is 2 fingers which is reduced. The apex beat could not be palpated. On inspection of the chest, there is an increased anterior posterior diameter giving rise to a barrel shaped chest. The chest moves equally with respiration and there is use of accessory mucles with intercostal, subcostal and suprasternal retraction. There are no chest wall deformities. On palpation, chest expansion is reduced on both sides. Tactile fremitus is equal on both sides. On percussion, there is hyperresonance over both lungs with loss of liver and cardiac dullness. On auscultation vesicular breathing is heard. There is generalised expiratory rhonchi. There is also fine early inspiratory crepitations heard at the lower zones of both lungs. Examination of the cardiovascular system: The apex beat could not be palpated. There were no parasternal heaves or thrills palpable. On auscultation, normal first and second heart sounds were heard. There was mild bilateral pitting oedema. Examination of the abdomen: On inspection, the abdomen is flat and moves with respiration. There was no guarding or tenderness. The liver and spleen were not palpable. There was no organomegaly. Examination of the neurological system was normal. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional diagnosis: Acute exacerbation of newly diagnosed chronic obstructive airway disease due to upper respiratory tract infection. Evidence for: Patients with chronic obstructive airway disease (COPD) usually present with a persistent dyspnoea and reduced effort tolerance which was present in the history given by Mr TLT. He is also at increased risk of developing COPD due to exposure to associated risk factors such as tobacco smoke. He has been a chronic smoker for the past 40 years. There is also the presence of chronic cough occasionally associated with mucoid sputum which further suggests COPD. Physical findings of a hyperinflated chest and vesicular breathing with generalised expiratory rhonchi also point to an obstructive airway disease. During this admission Mr TLT had increasing severity of shortness of breath even at rest. This was associated with a wheeze that was described as noisy breathing. Sudden worsening of symptoms suggest an episode of acute exacerbation. The history of upper respiratory tract infection symptoms suggest that it was the trigger for this episode of exacerbation. Differential diagnosis: 1) Congestive cardiac failure. Mr TLT may have developed congestive cardiac failure as a primary event or as a complication of chronic lung disease. There is history of reduced effort tolerance. Patients with congestive cardiac failure may also present with a wheeze and sudden increase in dyspnoea. Physical examination of fine crepitations at both bases of the lungs may also indicate congestive cardiac failure. There is also evidence of mildly raised JVP as well as mild pittint ankle oedema. Evidence against: There is no history of any cause of heart failure such as ischaemic heart disease or cardiac valve defect. Mr TLTs previous records during follow-up show well controlled blood pressure. Additional investigations need to be carried out in order to rule out this condition. A chest plain radiograph may be done in order to look for evidence of heart failure such as cardiomegaly. An ECG may be done to look for right atrial hypertrophy. An echocardiogram should also be performed in order to assess the function of the ventricles. 2) Bronchiectasis Patients with bronchiectasis have a history of chronic cough as well as production of copious amounts of sputum. They may also have persistent shortness of breath, reduced effort tolerance and wheeze. Evidence against: The sputum produced by Mr TLT is mucoid in nature and not purulent which is typical in bronchiectasis. It is also not copious and foul smelling in nature. On physical examination, coarse crepitations would be heard in bronchiectasis as opposed to the fine crepitations heard in Mr TLT. There is also no evidence of clubbing. Chest plain radiograph should be done in order to look for thickened bronchial walls or cystic shadows. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Shortness of breath and reduced effort tolerance Mr TLTs chief complaint is shortness of breath. This may be attributed to the increase in number of goblet cells and later on fibrosis of the bronchial walls causing airway obstruction seen in chronic obstructive airway disease. The shortness of breath may be partially relieved with the use of nebulization of ipratropium bromide, salbutamol and normal saline or with the use of metered dose inhalers. Chest physiotherapy may also be useful. Mr TLT also has had reduced effort tolerance and persistent dyspnoea for the past a year. As such he may require the use of ipratropium bromide in a metered dose inhaler upon discharge in order to feel less breathless due to the bronchodilator effect of the ipratropium bromide. 2. Upper respiratory tract infection Mr TLT may require antibiotics as he still has symptoms of upper respiratory tract infection such as sore throat. Furthermore patients who present with an acute exacerbation are at greater risk of having a bacterial infection. This is because of the depressed immune state that the patient is in as a result of the acute illness as well as due to any steroids that would be given as part of the management plan. The appropriateness of usage of antibiotics in chronic obstructive airway disease will be further discussed below. 3. Adequate inhaler technique Mr TLT would need to be taught about the correct technique to be used when using metered dose inhalers. He would probably require daily use of ipratropium bromide metered dose inhalers to reduce his breathlessness. In the event that he is unable to learn proper technique, he may be encouraged to buy an aerochamber. 4. Smoking cessation Mr TLT should be counseled on smoking cessation as it has been proven that smoking cessation would alter the course of progression in COPD and is associated with lower all-cause mortality. He should be counseled on the various options of smoking cessation which will be discussed further below. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1) Full Blood Count Justification: In order to view the total white count as well as the differential count to see if there is an infection which has caused this episode of exacerbation. There may also be secondary polycythemia if the patient has chronic pulmonary hypertension. Results: White cell count : 7.91 X 109/L Red blood cell : 4.48 X 1012/L Haemoglobin : 133.00 g/dl Haematocrit : 42.00 ratio Mean cell volume : 93.80 fL Mean cell haemoglobin : 29.70 pg Mean cell haemoglobin conc. : 317.00 g/l Platelets : 141.00 X 109/L Differential count Neutrophils : 60.10% 4.76 X 109/L Lymphocytes : 25.30% 2.00 X 109/L Monocytes : 13.80% 1.09 X 109/L Eosinophils : 0.50% 0.04 X 109/L Basophils : 0.30% 0.02 X 109/L Interpretation: This is a normal full blood count result with normal total white count as well as normal haemoglobin levels. 2) Plain chest radiograph Justification: Done in order to look for evidence of chronic obstructive airway disease such as hyperinflated chest or evidence of congestive cardiac failure such as cardiomegaly and prominent upper lobe vessels. Results: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No other abnormalities seen. Interpretation: Hyperinflation of the lung fields is consistent with the provisional diagnosis of chronic obstructive airway disease. 3) Sputum FEME, culture and sensitivity (not done) Justification: In order to look for any bacteria which may have been the cause of the exacerbation . If there any organism cultured, proper antibiotics can be given based on the sensitivity test. 4) Arterial blood gas (not done) Justification: May be necessary in severe cases of breathlessness to look for respiratory failure and associated changes in blood pH. 5) Blood urea serum electrolytes and creatinine Justification: To look for renal impairment which may be present due to Mr TLT having hypertension. Renal impairment may also affect the dosage and type of antibiotics used. Results: Urea : 3.7mmol/L Sodium : 135 mmol/L Potassium : 3.7 mmol/L Creatinine : 65 umol/L Interpretation: Normal result. There is no renal impairment 6) Electrocardiogram Justification: To look for evidence of right ventricular hypertrophy or right atrial hypertrophy which may be seen in chronic lung disease. Results: ECG with sinus rhythm. There is no P pulmonale seen. There is low voltage seen. No ischaemic changes seen. No left ventricular hypertrophy. Interpretation: Normal ECG with low voltage is seen in a hyperinflated chest such as in patients with COPD STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working diagnosis: Acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection My proposed plan of management is as follows: Acute management 1. Provide supplemental oxygen via nasal prong 3L/min and maintain SpO2 above 90%. Arterial blood gas should be done in order to ensure adequate oxygenation without carbon dioxide retention of acidosis. 2. Close monitoring of vital signs and SpO2 hourly until the patients breathlessness improves. Nursing staff to inform if patient deteriorates such as increased respiratory rate or drop in oxygen saturation below 92%. 3. Give nebulization of Ipratropium Bromide:Salbutamol:Normal Saline in ratio of 2:2:1 every four hours until breathlessness decreases. 4. Oral prednisolone 40mg once daily for 10 days 5. Postural drainage and chest physiotherapy may be performed. 6. Oral antibiotics such as T. Cefuroxime may be given. This was not given in this patient with further discussion below. Long term management 1. MDI ipratropium bromide 40 microgrammes tds 2. MDI salbutamol 200 microgrammes PRN 3. Counseling on proper inhaler technique. 4. Couseling on smoking cessation. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES) Mr TLT was warded for a total of 3 days. His breathlessness improved after nebulization with ipratropium bromide, salbutamol and normal saline for one day. He no longer required nebulization after one day. Mr TLT was also able to ambulate without feeling breathless. He was able to eat and to sleep well without being bothered by the dyspnoea. His vital signs were also normal and his respiratory rate improved to about 20 breaths per minute. There was still some ronchi heard on auscultation but it was much reduced. He was afebrile during his stay. Mr TLT was discharged after 3 days of admission and educated on chronic obstructive airway disease. He was also counseled on the importance of smoking cessation. He was given an appointment with the medical outpatient department in one month time in order to review his symptoms after being given MDI ipratropium bromide. He was told to return to the hospital if he had similar episodes. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge Plan 1. Medications: i. MDI Salbutamol 200 µg PRN ii. MDI Ipratropium Bromide 40 µg TDS iii. T. Amlodipine 5mg once daily iv. T. Prednisolone 20mg od for 7 days. 2. Counseling on COPD and use of metered dose inhaler Mr TLT should be taught about the correct technique in using a metered dose inhaler. The technique should then be assessed before discharge. In the event that Mr TLT is unable to coordinate well, he may be advised to purchase an aerochamber. 3. Counseling on smoking cessation The approach to counseling a patient on smoking cessation as well as various options will be further discussed below. 4. Education on the symptoms of an acute exacerbation and advise to return to the hospital if there is development of those symptoms. 5. For follow-up at the medical outpatient department for review of symptoms while on MDI ipratropium bromide. He should also be taught about pulmonary rehabilitation. A spirometry appointment may also be made. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 10) REFERRAL LETTER (MANDATORY) Dr Tan Hai Liang Medical Department, Hospital Batu Pahat Family physician, Klinik Kesihatan Batu Pahat, 83000 Batu Pahat, 10 June 2009 Dear esteemed colleague, Patients name: Teo Lai Thing Patients I/c number: 510912-01-6343 Problem: Chronic Obstructive Airway disease Thank you for seeing this 58 year old gentleman who is hypertensive for the past 1 year currently on T. Amlodipine 5mg once daily. He presented to Hospital Batu Pahat with shortness of breath for 4 days that was increasing in severity. A diagnosis of chronic obstructive airway disease was made. He was discharged uneventfully on the third day of admission with the following medication: MDI Salbutamol 200 µg PRN, MDI Ipratropium Bromide 40 µg TDS and T. Amlodipine 5mg once daily. Mr Teo has been a chronic smoker for the past 40 years and smokes up to 20 sticks of cigarettes a day. We have counselled him about the benefits of smoking cessation while in the ward. He is currently considering it and would like to learn more about the various options of smoking cessation. Kindly assess the patients keenness for smoking cessation as well as provide him with additional information on the options available to quit smoking. Thank you. Sincerely ____________ (Tan Hai Liang) Medical Department Hospital Batu Pahat STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 11) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1) Communication skills What are the benefits of smoking cessation in COPD patients and how should counseling be done? Counseling for smoking cessation should play a significant role in the holistic management of a patient with chronic obstructive airway disease. This is because studies have shown that smoking cessation changes the clinical course of COPD by preserving lung function. One study of patients reviewed at 14.5 years after stopping smoking showed that smoking cessation intervention showed 18% reduction in all-cause mortality compared with usual care without smoking cessation intervention. Patients who had stopped smoking had lower rates of death due of coronary heart disease , cerebrovascular disease, lung cancer, and other respiratory disease as compared with those assigned to usual care who continue to smoke. [1] Fig. 4. Effect of smoking cessation on mortality cause at 14.5 years in the Lung Health Study. (A) Comparison of smoking cessation intervention with usual care. (B) Comparison according to smoking status. I therefore looked up for counseling methods for smoking cessation. The American College of Chest Physicians recommend that physicians should be the first line in introducing smoking cessation. [2] There are 5 As that a doctor should perform for a patient who is a smoker: †¢ Ask about tobacco use at every visit †¢ Advise tobacco users to quit †¢ Assess the willingness to attempt quitting †¢ Assist the patient with methods for quitting †¢ Arrange for follow-up contact via phone or face to face If the patient is not yet willing to quit, there are 5 Rs which should be identified together by the patient and the doctor: †¢ Relevance of quitting for the patient †¢ Risks of illness related to continued tobacco use †¢ Rewerds/benefits of smoking cessation †¢ Roadblocks for quitting, internal and external †¢ Repetition of the motivation intervention at each encounter There are two means of intervention in smoking cessation namely pharmacological and behavioural. The pharmacological means include nicotine replacement therapy or buproprion. Behavioural interventions include counseling programs that teach problem-solving skills and support groups. [3] In conclusion, I learned that doctors have an important role in actively encouraging patients who smoke to stop as there are many proven benefits of smoking cessation. The steps discussed above on techniques in the counseling of patients would be helpful to me in the future. 2) Professionalism, ethics and personal development Should antibiotics be given for episodes of exacerbation of chronic obstructive airway disease? Mr TLT was not given antibiotics during this episode of exacerbation. Certain quarters support the use of prophylactic antibiotics in all exacerbations due to the knowledge that most exacerbations are caused by the common organisms of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), Pseudomonas aeruginosa (P. aeruginosa) and Moraxella catarrhalis (M. catarrhalis). Sputum culture may not be useful as even in the clinical stable state, some patients have sputum positive for bacteria. As such a broad spectrum antibiotic is usually used to cover different bacteria. However, is this use of antibiotics justified in that do patients benefit from it or is the overjudicious use of antibiotics merely promoting antibiotic resistant bacteria? Current Global initiative for chronic Lung Disease guidelines [4] recommend that antibiotics should be given in: i) patients with exacerbations of COPD and the three cardinal symptoms of increased dyspnoea, increased sputum volume and increased sputum purulence. ii) patients with exacerbation of COPD with two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms iii) patients with severe exacerbations of COPD that requires mechanical ventilation A meta-analysis by Ram et al [5] of 11 placebo controlled RCTs with 917 patients attempted to analyse the value of antibiotics in the management of acute COPD exacerbations. The results show that there is a decrease in short-term mortality, treatment failure and sputum purulence with antibiotic therapy compared to placebo. The authors concluded that antibiotics therapy is appropriate in exacerbations of COPD associated with increased cough and sputum purulence. They further found that antibiotics have the greatest effect for patients with severe exacerbations who are admitted to the hospital. They were unable to comment on exacerbations with non-purulent sputum, what antibiotics were the best to be used and also the duration of therapy due to the lack of RCTs done on these aspects. In conclusion, it was appropriate that Mr TLT was not given antibiotics as he did not have the cardinal signs as mentioned by the GOLD guidelines and further supported by the systemic review. 3) Self directed life long learning What are extrapulmonary manifestations of COPD and what are its therapeutic implications? Chronic obstructive lung disease has long been known as a localized pulmonary disorder. However new evidence have shown that COPD may be a systemic disease that involves pathology in several extra-pulmonary systems. An article by Remels et al [6] summarized the extrapulmonary manifestations as well as its implications on the holistic management of chronic obstructive airway disease. The article showed that there is skeletal muscle dysfunction as well as systemic inflammation in chronic obstructive airway disease. There is loss of muscle mass associated with impaired protein metabolism. The loss of muscle mass which is called sarcopenia may progress to cachexia. Studies have also shown that there is increased apoptosis of muscle cells at the cellular level. Independent of the loss of muscle mass is the reduced muscle endurance. This finding has been attributed to abnormalities in mitochondria or to hypoxia. These findings have significant implications on management of a COPD patient which will be discussed below. Systemic inflammation is also seen in patients with COPD. This is evidenced by elevated levels of the proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-a), interleukin-6, interleukin-8, and TNF-a receptors. The origin of the systemic inflammation is thought to be independent of the pulmonary manifestation of COPD. One postulation is the increase systemic inflammatory mediators such as neutrophils and lymphocytes in the circulation of patients with COPD. Another proposed mechanism is increased cytokine production due to chronic hypoxia. The therapeutic implications of these findings is that muscle atrophy should be prevented by resistance exercise as well as combined strength and endurance exercise. Current Malaysian guidelines on the management of COPD [7] recommend pulmonary resistance including lower and upper limb exercises as well as inspiratory muscle training. This concurs with a Cochrane metaanalysis by Lacasse et al [8] which strongly support respiratory at least four weeks of exercise training as part of the of management for patients with COPD. The authors found that there was clinically and statistically significant improvements in quality of life as measured by dyspnea, fatigue and emotional function. 4. Critical thinking and research What is the efficacy of systemic corticosteroids for acute exacerbations of chronic obstructive airway disese? The use of systemic oral or intravenous corticosteroids is recommended by GOLD guidelines in the management of acute exacerbations of chronic obstructive airway disease. However the patient, Mr TLT was not given any systemic corticosteroids. This could be because he merely had a mild exacerbation. I therefore looked up a Cochrane metaanalysis on the use of systemic corticosteroids for acute exacerbations of chronic obstructive airway disease [9]. The authors reviewed randomized controlled trials comparing parenteral or oral corticosteroids with placebo for the treatment of exacerbation of COPD. The primary outcomes measured were treatment failure (hospital readmission, return to emergency department), relapse and mortality. The authors reviewed 11 studies involving 1081 participants. The results show a statistically significant difference between placebo and use of corticosteoids. There was less treatment failure in patients given corticosteroids. Relapse within 30 days were also reduced. However there was no statistically significant reduction in mortality. As such the authors concluded that administration of oral or parenteral corticosteroids in the treatment of acute exacerbations of COPD reduces the likelihood of treatment failure. This is associated with early and continuing improvement during treatment with corticosteroids in lung function, breathlessness and blood gases and with a shorter hospital stay. This in turn has a positve impact on the economic cost of treating exacerbations, with fewer follow-up visits and hospital admissions. The authors also found that although there is an increased incidence of corticosteroid side effects such as fluid retention, hypertension and adrenal suppression, the effects are unlikely to persist after treatment ceases. EVIDENCE BASED MEDICINE WORKSHEET FOR REVIEW OF THERAPY STUDIES ASKING QUESTION Patient (P): Patients who present with stable COPD Intervention (I): Oral corticosteroids Comparison (C): Placebo Outcome (O): Effects on health status ACCESSING EVIDENCE THE SEARCH PATH How was the article identified: The Cochrane Library Search keywords : corticosteroids, stable COPD Citation: Walters JAE,Walters EH,Wood-Baker R.Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 3. 1. Is