Cause and Effect Essay Essay

As a child my mom always taught me to be proud of who I am; to disregard all the negativity that was sure to come my way. As a constant reminder she bought books like Black Beautiful Me and Strong and Black to keep up my self-esteem. It was a good reminder, but because of all the negativity that surrounded me I started to feel bad about who I am. I never thought that I would have been a victim of discrimination moving to such an isolated place, but it comes to show that you will never be rid of the negativity in the world. Moving to a small town where African Americans are hard to find; a lot of racism was always targeted towards my sisters and I. Attending School was the hardest part; I always saw myself as being beautiful, but walking down the hall being called â€Å"that ugly black girl† started to take its toll on my self-esteem. Everywhere I went I ran into discrimination and stereotypes; I was constantly asked if I wanted fried chicken or watermelon, I would have guys tell me â€Å"I would date you if you had lighter skin,† or walking in the store and have the word â€Å"nigger† shouted and not know where it originated from. I didn’t understand why I wasn’t liked or given the chance to prove myself, but I felt unwanted, like I didn’t belong. When I had read â€Å"The Myth of a Latin Woman† I found it quite relatable to my situation when I had first moved to Cortez. Cofer talks about how she was stereotyped when she moved to America; how she wanted to fit in, but found it difficult because of her traditions and culture. She stresses the fact that nobody really understood her, that movies about Latin and Puerto Ricans were the closest understanding people got to her culture. Cofer then states that all the hard times that she had growing up made her stronger, and more successful. She tells the reader to take all the negative experiences and turned them positive so that nothing is stopping one from being successful. The negativity was a struggle for me, I wanted to quit public school and start homeschooling. But, I began to learn how to ignore people and not care how or what anybody thought of me. With that idea I became more at peace with myself. I started to look up when walking down the hallways, I learned  to just smile and at the negativity. Instead of the hurtful words putting me down I used it as fuel to my flame, motivation in other words, to do better and be successful.

Bag of Bones CHAPTER ONE

On a very hot day in August of 1994, my wife told me she was going down to the Derry Rite Aid to pick up a refill on her sinus medicine prescription this is stuff you can buy over the counter these days, I believe. I'd finished my writing for the day and offered to pick it up for her. She said thanks, but she wanted to get a piece of fish at the supermarket next door anyway; two birds with one stone and all of that. She blew a kiss at me off the palm of her hand and went out. The next time I saw her, she was on TV. That's how you identify the dead here in Derry no walking down a subterranean corridor with green tiles on the walls and long fluorescent bars overhead, no naked body rolling out of a chilly drawer on casters; you just go into an office marked PRIVATE and look at a TV screen and say yep or nope. The Rite Aid and the Shopwell are less than a mile from our house, in a little neighborhood strip mall which also supports a video store, a used-book store named Spread It Around (they do a very brisk business in my old paperbacks), a Radio Shack, and a Fast Foto. It's on Up-Mile Hill, at the intersection of Witcham and Jackson. She parked in front of Blockbuster Video, went into the drugstore, and did business with Mr. Joe Wyzer, who was the druggist in those days; he has since moved on to the Rite Aid in Bangor. At the checkout she picked up one of those little chocolates with marshmallow inside, this one in the shape of a mouse. I found it later, in her purse. I unwrapped it and ate it myself, sitting at the kitchen table with the contents of her red handbag spread out in front of me, and it was like taking Communion. When it was gone except for the taste of chocolate on my tongue and in my throat, I burst into tears. I sat there in the litter of her Kleenex and makeup and keys and half-finished rolls of Certs and cried with my hands over my eyes, the way a kid cries. The sinus inhaler was in a Rite Aid bag. It had cost twelve dollars and eighteen cents. There was something else in the bag, too an item which had cost twenty-two-fifty. I looked at this other item for a long time, seeing it but not understanding it. I was surprised, maybe even stunned, but the idea that Johanna Arlen Noonan might have been leading another life, one I knew nothing about, never crossed my mind. Not then. Jo left the register, walked out into the bright, hammering sun again, swapping her regular glasses for her prescription sunglasses as she did, and just as she stepped from beneath the drugstore's slight overhang (I am imagining a little here, I suppose, crossing over into the country of the novelist a little, but not by much; only by inches, and you can trust me on that), there was that shrewish howl of locked tires on pavement that means there's going to be either an accident or a very close call. This time it happened the sort of accident which happened at that stupid X-shaped intersection at least once a week, it seemed. A 1989 Toyota was pulling out of the shopping-center parking lot and turning left onto Jackson Street. Behind the wheel was Mrs. Esther Easterling of Barrett's Orchards. She was accompanied by her friend Mrs Irene Deorsey, also of Barrett's Orchards, who had shopped the video store without finding anything she wanted to rent. Too much violence, Irene said. Both women were cigarette widows. Esther could hardly have missed the orange Public Works dump truck coming down the hill; although she denied this to the police, to the newspaper, and to me when I talked to her some two months later, I think it likely that she just forgot to look. As my own mother (another cigarette widow) used to say, ‘The two most common ailments of the elderly are arthritis and forgetfulness. They can't be held responsible for neither.' Driving the Public Works truck was William Fraker, of Old Cape. Mr. Fraker was thirty-eight years old on the day of my wife's death, driving with his shirt off and thinking how badly he wanted a cool shower and a cold beer, not necessarily in that order. He and three other men had spent eight hours putting down asphalt patch out on the Harris Avenue Extension near the airport, a hot job on a hot day, and Bill Fraker said yeah, he might have been going a little too fast maybe forty in a thirty-mile-an-hour zone. He was eager to get back to the garage, sign off on the truck, and get behind the wheel of his own F-150, which had air conditioning. Also, the dump truck's brakes, while good enough to pass inspection, were a long way from tip-top condition. Fraker hit them as soon as he saw the Toyota pull out in front of him (he hit his horn, as well), but it was too late. He heard screaming tires his own, and Esther's as she belatedly realized her danger and saw her face for just a mome nt. ‘That was the worst part, somehow,' he told me as we sat on his porch, drinking beers it was October by then, and although the sun was warm on our faces, we were both wearing sweaters. ‘You know how high up you sit in one of those dump trucks? ‘ I nodded. ‘Well, she was looking up to see me craning up, you'd say and the sun was full in her face. I could see how old she was. I remember thinking, ‘Holy shit, she's gonna break like glass if I can't stop.' But old people are tough, more often than not. They can surprise you. I mean, look at how it turned out, both those old biddies still alive, and your wife . . . ‘ He stopped then, bright red color dashing into his cheeks, making him look like a boy who has been laughed at in the schoolyard by girls who have noticed his fly is unzipped. It was comical, but if I'd smiled, it only would have confused him. ‘Mr. Noonan, I'm sorry. My mouth just sort of ran away with me.' ‘It's all right,' I told him. ‘I'm over the worst of it, anyway.' That was a lie, but it put us back on track. ‘Anyway,' he said, ‘we hit. There was a loud bang, and a crumping sound when the driver's side of the car caved in. Breaking glass, too. I was thrown against the wheel hard enough so I couldn't draw a breath without it hurting for a week or more, and I had a big bruise right here.' He drew an arc on his chest just below the collarbones. ‘I banged my head on the windshield hard enough to crack the glass, but all I got up there was a little purple knob . . . no bleeding, not even a headache. My wife says I've just got a naturally thick skull. I saw the woman driving the Toyota, Mrs. Easterling, thrown across the console between the front bucket seats. Then we were finally stopped, all tangled together in the middle of the street, and I got out to see how bad they were. I tell you, I expected to find them both dead.' Neither of them was dead, neither of them was even unconscious, although Mrs. Easterling had three broken ribs and a dislocated hip. Mrs. Deorsey, who had been a seat away from the impact, suffered a concussion when she rapped her head on her window. That was all; she was ‘treated and released at Home Hospital,' as the Derry News always puts it in such cases. My wife, the former Johanna Arlen of Malden, Massachusetts, saw it all from where she stood outside the drugstore, with her purse slung over her shoulder and her prescription bag in one hand. Like Bill Fraker, she must have thought the occupants of the Toyota were either dead or seriously hurt. The sound of the collision had been a hollow, authoritative bang which rolled through the hot afternoon air like a bowling ball down an alley. The sound of breaking glass edged it like jagged lace. The two vehicles were tangled violently together in the middle of Jackson Street, the dirty orange truck looming over the pale-blue import like a bullying parent over a cowering child. Johanna began to sprint across the parking lot toward the street. Others were doing the same all around her. One of them, Miss Jill Dunbarry, had been window-shopping at Radio Shack when the accident occurred. She said she thought she remembered running past Johanna at least she was pretty sure she remembered someone in yellow slacks but she couldn't be sure. By then, Mrs. Easterling was screaming that she was hurt, they were both hurt, wouldn't somebody help her and her friend Irene. Halfway across the parking lot, near a little cluster of newspaper dispensers, my wife fell down. Her purse-strap stayed over her shoulder, but her prescription bag slipped from her hand, and the sinus inhaler slid halfway out. The other item stayed put. No one noticed her lying there by the newspaper dispensers; everyone was focused on the tangled vehicles, the screaming women, the spreading puddle of water and antifreeze from the Public Works truck's ruptured radiator. (‘That's gas!' the clerk from Fast Foto shouted to anyone who would listen. ‘That's gas, watch out she don't blow, fellas!') I suppose one or two of the would-be rescuers might have jumped right over her, perhaps thinking she had fainted. To assume such a thing on a day when the temperature was pushing ninety-five degrees would not have been unreasonable. Roughly two dozen people from the shopping center clustered around the accident; another four dozen or so came running over from Strawford Park, where a baseball game had been going on. I imagine that all the things you would expect to hear in such situations were said, many of them more than once. Milling around. Someone reaching through the misshapen hole which had been the driver's-side window to pat Esther's trembling old hand. People immediately giving way for Joe Wyzer; at such moments anyone in a white coat automatically becomes the belle of the ball. In the distance, the warble of an ambulance siren rising like shaky air over an incinerator. All during this, lying unnoticed in the parking lot, was my wife with her purse still over her shoulder (inside, still wrapped in foil, her uneaten chocolate-marshmallow mouse) and her white prescription bag near one outstretched hand. It was Joe Wyzer, hurrying back to the pharmacy to get a compression bandage for Irene Deorsey's head, who spotted her. He recognized her even though she was lying face-down. He recognized her by her red hair, white blouse, and yellow slacks. He recognized her because he had waited on her not fifteen minutes before. ‘Mrs. Noonan?' he asked, forgetting all about the compression bandage for the dazed but apparently not too badly hurt Irene Deorsey. ‘Mrs. Noonan, are you all right?' Knowing already (or so I suspect; perhaps I am wrong) that she was not. He turned her over. It took both hands to do it, and even then he had to work hard, kneeling and pushing and lifting there in the parking lot with the heat baking down from above and then bouncing back up from the asphalt. Dead people put on weight, it seems to me; both in their flesh and in our minds, they put on weight. There were red marks on her face. When I identified her I could see them clearly even on the video monitor. I started to ask the assistant medical examiner what they were, but then I knew. Late August, hot pavement, elementary, my dear Watson. My wife died getting a sunburn. Wyzer got up, saw that the ambulance had arrived, and ran toward it. He pushed his way through the crowd and grabbed one of the attendants as he got out from behind the wheel. ‘There's a woman over there,' Wyzer said, pointing toward the parking lot. ‘Guy, we've got two women right here, and a man as well,' the attendant said. He tried to pull away, but Wyzer held on. ‘Never mind them right now,' he said. ‘They're basically okay. The woman over there isn't.' The woman over there was dead, and I'm pretty sure Joe Wyzer knew it . . . but he had his priorities straight. Give him that. And he was convincing enough to get both paramedics moving away from the tangle of truck and Toyota, in spite of Esther Easterling's cries of pain and the rumbles of protest from the Greek chorus. When they got to my wife, one of the paramedics was quick to confirm what Joe Wyzer had already suspected. ‘Holy shit,' the other one said. ‘What happened to her?' ‘Heart, most likely,' the first one said. ‘She got excited and it just blew out on her.' But it wasn't her heart. The autopsy revealed a brain aneurysm which she might have been living with, all unknown, for as long as five years. As she sprinted across the parking lot toward the accident, that weak vessel in her cerebral cortex had blown like a tire, drowning her control-centers in blood and killing her. Death had probably not been instantaneous, the assistant medical examiner told me, but it had still come swiftly enough . . . and she wouldn't have suffered. Just one big black nova, all sensation and thought gone even before she hit the pavement. ‘Can I help you in any way, Mr. Noonan?' the assistant ME asked, turning me gently away from the still face and closed eyes on the video monitor. ‘Do you have questions? I'll answer them if I can.' ‘Just one,' I said. I told him what she'd purchased in the drugstore just before she died. Then I asked my question. The days leading up to the funeral and the funeral itself are dreamlike in my memory the clearest memory I have is of eating Jo's chocolate mouse and crying . . . crying mostly, I think, because I knew how soon the taste of it would be gone. I had one other crying fit a few days after we buried her, and I will tell you about that one shortly. I was glad for the arrival of Jo's family, and particularly for the arrival of her oldest brother, Frank. It was Frank Arlen fifty, red-cheeked, portly, and with a head of lush dark hair who organized the arrangements . . . who wound up actually dickering with the funeral director. ‘I can't believe you did that,' I said later, as we sat in a booth at Jack's Pub, drinking beers. ‘He was trying to stick it to you, Mikey,' he said. ‘I hate guys like that.' He reached into his back pocket, brought out a handkerchief, and wiped absently at his cheeks with it. He hadn't broken down none of the Arlens broke down, at least not when I was with them but Frank had leaked steadily all day; he looked like a man suffering from severe conjunctivitis. There had been six Arlen sibs in all, Jo the youngest and the only girl. She had been the pet of her big brothers. I suspect that if I'd had anything to do with her death, the five of them would have torn me apart with their bare hands. As it was, they formed a protective shield around me instead, and that was good. I suppose I might have muddled through without them, but I don't know how. I was thirty-six, remember. You don't expect to have to bury your wife when you're thirty-six and she herself is two years younger. Death was the last thing on our minds. ‘If a guy gets caught taking your stereo out of your car, they call it theft and put him in jail,' Frank said. The Arlens had come from Massachusetts, and I could still hear Malden in Frank's voice caught was coowat, car was cah, call was caul. ‘If the same guy is trying to sell a grieving husband a three-thousand-dollar casket for forty-five hundred dollars, they call it business and ask him to speak at the Rotary Club luncheon. Greedy asshole, I fed him his lunch, didn't I?' ‘Yes. You did.' ‘You okay, Mikey?' ‘I'm okay.' ‘Sincerely okay?' ‘How the fuck should I know?' I asked him, loud enough to turn some heads in a nearby booth. And then: ‘She was pregnant.' His face grew very still. ‘What?' I struggled to keep my voice down. ‘Pregnant. Six or seven weeks, according to the . . . you know, the autopsy. Did you know? Did she tell you?' ‘No! Christ, no!' But there was a funny look on his face, as if she had told him something. ‘I knew you were trying, of course . . . she said you had a low sperm count and it might take a little while, but the doctor thought you guys'd probably . . . sooner or later you'd probably . . . ‘ He trailed off, looking down at his hands. ‘They can tell that, huh? They check for that?' ‘They can tell. As for checking, I don't know if they do it automatically or not. I asked.' ‘Why?' ‘She didn't just buy sinus medicine before she died. She also bought one of those home pregnancy-testing kits.' ‘You had no idea? No clue?' I shook my head. He reached across the table and squeezed my shoulder. ‘She wanted to be sure, that's all. You know that, don't you?' A refill on my sinus medicine and a piece of fish, she'd said. Looking like always. A woman off to run a couple of errands. We had been trying to have a kid for eight years, but she had looked just like always. ‘Sure,' I said, patting Frank's hand. ‘Sure, big guy. I know.' It was the Arlens led by Frank who handled Johanna's send off. As the writer of the family, I was assigned the obituary. My brother came up from Virginia with my mom and my aunt and was allowed to tend the guest-book at the viewings. My mother almost completely ga-ga at the age of sixty-six, although the doctors refused to call it Alzheimer's lived in Memphis with her sister, two years younger and only slightly less wonky. They were in charge of cutting the cake and the pies at the funeral reception. Everything else was arranged by the Arlens, from the viewing hours to the components of the funeral ceremony. Frank and Victor, the second-youngest brother, spoke brief tributes. Jo's dad offered a prayer for his daughter's soul. And at the end, Pete Breedlove, the boy who cut our grass in the summer and raked our yard in the fall, brought everyone to tears by singing ‘Blessed Assurance,' which Frank said had been Jo's favorite hymn as a girl. How Frank found Pete and persuaded him to sing at the funeral is something I never found out. We got through it the afternoon and evening viewings on Tuesday, the funeral service on Wednesday morning, then the little pray-over at Fairlawn Cemetery. What I remember most was thinking how hot it was, how lost I felt without having Jo to talk to, and that I wished I had bought a new pair of shoes. Jo would have pestered me to death about the ones I was wearing, if she had been there. Later on I talked to my brother, Sid, told him we had to do something about our mother and Aunt Francine before the two of them disappeared completely into the Twilight Zone. They were too young for a nursing home; what did Sid advise? He advised something, but I'll be damned if I know what it was. I agreed to it, I remember that, but not what it was. Later that day, Siddy, our mom, and our aunt climbed back into Siddy's rental car for the drive to Boston, where they would spend the night and then grab the Southern Crescent the following day. My brother is happy enough to chaperone the old folks, but he doesn't fly, even if the tickets are on me. He claims there are no breakdown lanes in the sky if the engine quits. Most of the Arlens left the next day. Once more it was dog-hot, the sun glaring out of a white-haze sky and lying on everything like melted brass. They stood in front of our house which had become solely my house' by then with three taxis lined up at the curb behind them, big galoots hugging one another amid the litter of tote-bags and saying their goodbyes in those foggy Massachusetts accents. Frank stayed another day. We picked a big bunch of flowers behind the house not those ghastly-smelling hothouse things whose aroma I always associate with death and organ-music but real flowers, the kind Jo liked best and stuck them in a couple of coffee cans I found in the back pantry. We went out to Fairlawn and put them on the new grave. Then we just sat there for awhile under the beating sun. ‘She was always just the sweetest thing in my life,' Frank said at last in a strange, muffled voice. ‘We took care of Jo when we were kids. Us guys. No one messed with Jo, I'll tell you. Anyone tried, we'd feed em their lunch.' ‘She told me a lot of stories.' ‘Good ones?' ‘Yeah, real good.' ‘I'm going to miss her so much.' ‘Me, too,' I said. ‘Frank . . . listen . . . I know you were her favorite brother. She never called you, maybe just to say that she missed a period or was feeling whoopsy in the morning? You can tell me. I won't be pissed.' ‘But she didn't. Honest to God. Was she whoopsy in the morning?' ‘Not that I saw.' And that was just it. I hadn't seen anything. Of course I'd been writing, and when I write I pretty much trance out. But she knew where I went in those trances. She could have found me and shaken me fully awake. Why hadn't she? Why would she hide good news? Not wanting to tell me until she was sure was plausible . . . but it somehow wasn't Jo. ‘Was it a boy or a girl?' he asked. ‘A girl.' We'd had names picked out and waiting for most of our marriage. A boy would have been Andrew. Our daughter would have been Kia. Kia Jane Noonan. Frank, divorced six years and on his own, had been staying with me. On our way back to the house he said, ‘I worry about you, Mikey. You haven't got much family to fall back on at a time like this, and what you do have is far away.' ‘I'll be all right,' I said. He nodded. ‘That's what we say, anyway, isn't it?' ‘We?' ‘Guys. I'll be all right.' And if we're not, we try to make sure no one knows it.' He looked at me, eyes still leaking, handkerchief in one big sunburned hand. ‘If you're not all right, Mikey, and you don't want to call your brother I saw the way you looked at him let me be your brother. For Jo's sake if not your own.' ‘Okay,' I said, respecting and appreciating the offer, also knowing I would do no such thing. I don't call people for help. It's not because of the way I was raised, at least I don't think so; it's the way I was made. Johanna once said that if I was drowning at Dark Score Lake, where we have a summer home, I would die silently fifty feet out from the public beach rather than yell for help. It's not a question of love or affection. I can give those and I can take them. I feel pain like anyone else. I need to touch and be touched. But if someone asks me, ‘Are you all right?' I can't answer no. I can't say help me. A couple of hours later Frank left for the southern end of the state. When he opened the car door, I was touched to see that the taped book he was listening to was one of mine. He hugged me, then surprised me with a kiss on the mouth, a good hard smack. ‘If you need to talk, call,' he said. ‘And if you need to be with someone, just come.' I nodded. ‘And be careful.' That startled me. The combination of heat and grief had made me feel as if I had been living in a dream for the last few days, but that got through. ‘Careful of what?' ‘I don't know,' he said. ‘I don't know, Mikey.' Then he got into his car he was so big and it was so little that he looked as if he were wearing it and drove away. The sun was going down by then. Do you know how the sun looks at the end of a hot day in August, all orange and somehow squashed, as if an invisible hand were pushing down on the top of it and at any moment it might just pop like an overfilled mosquito and splatter all over the horizon? It was like that. In the east, where it was already dark, thunder was rumbling. But there was no rain that night, only a dark that came down as thick and stifling as a blanket. All the same, I slipped in front of the word processor and wrote for an hour or so. It went pretty well, as I remember. And you know, even when it doesn't, it passes the time. My second crying fit came three or four days after the funeral. That sense of being in a dream persisted I walked, I talked, I answered the phone, I worked on my book, which had been about eighty percent complete when Jo died but all the time there was this clear sense of disconnection, a feeling that everything was going on at a distance from the real me, that I was more or less phoning it in. Denise Breedlove, Pete's mother, called and asked if I wouldn't like her to bring a couple of her friends over one day the following week and give the big old Edwardian pile I now lived in alone rolling around in it like the last pea in a restaurant-sized can a good stem-to-stern cleaning. They would do it, she said, for a hundred dollars split even among the three of them, and mostly because it wasn't good for me to go on without it. There had to be a scrubbing after a death, she said, even if the death didn't happen in the house itself. I told her it was a fine idea, but I would pay her and the women she brought a hundred dollars each for six hours' work. At the end of the six hours, I wanted the job done. And if it wasn't, I told her, it would be done, anyway. ‘Mr. Noonan, that's far too much,' she said. ‘Maybe and maybe not, but it's what I'm paying,' I said. ‘Will you do it?' She said she would, of course she would. Perhaps predictably, I found myself going through the house on the evening before they came, doing a pre-cleaning inspection. I guess I didn't want the women (two of whom would be complete strangers to me) finding anything that would embarrass them or me: a pair of Johanna's silk panties stuffed down behind the sofa cushions, perhaps (‘We are often overcome on the sofa, Michael,' she said to me once, ‘have you noticed?'), or beer cans under the loveseat on the sunporch, maybe even an unflushed toilet. In truth, I can't tell you any one thing I was looking for; that sense of operating in a dream still held firm control over my mind. The clearest thoughts I had during those days were either about the end of the novel I was writing (the psychotic killer had lured my heroine to a high-rise building and meant to push her off the roof) or about the Norco Home Pregnancy Test Jo had bought on the day she died. Sinus prescription, she had said. Piece of fish for supper, she had sa id. And her eyes had shown me nothing else I needed to look at twice. Near the end of my ‘pre-cleaning,' I looked under our bed and saw an open paperback on Jo's side. She hadn't been dead long, but few household lands are so dusty as the Kingdom of Underbed, and the light-gray coating I saw on the book when I brought it out made me think of Johanna's face and hands in her coffin Jo in the Kingdom of Underground. Did it get dusty inside a coffin? Surely not, but I pushed the thought away. It pretended to go, but all day long it kept creeping back, like Tolstoy's white bear. Johanna and I had both been English majors at the University of Maine, and like many others, I reckon, we fell in love to the sound of Shakespeare and the Tilbury Town cynicism of Edwin Arlington Robinson. Yet the writer who had bound us closest together was no college-friendly poet or essayist but W. Somerset Maugham, that elderly globetrotting novelist-playwright with the reptile's face (always obscured by cigarette smoke in his photographs, it seems) and the romantic's heart. So it did not surprise me much to find that the book under the bed was The Moon and Sixpence. I had read it myself as a late teenager, not once but twice, identifying passionately with the character of Charles Strickland. (It was writing I wanted to do in the South Seas, of course, not painting.) She had been using a playing card from some defunct deck as her place-marker, and as I opened the book, I thought of something she had said when I was first getting to know her. In Twentieth-Century British Lit, this had been, probably in 1980. Johanna Arlen had been a fiery little sophomore. I was a senior, picking up the Twentieth-Century Brits simply because I had time on my hands that last semester. ‘A hundred years from now,' she had said, ‘the shame of the mid-twentieth-century literary critics will be that they embraced Lawrence and ignored Maugham.' This was greeted with contemptuously good-natured laughter (they all knew Women in Love was one of the greatest damn books ever written), but I didn't laugh. I fell in love. The playing card marked pages 102 and 103 Dirk Stroeve has just discovered that his wife has left him for Strickland, Maugham's version of Paul Gauguin. The narrator tries to buck Stroeve up. My dear fellow, don't be unhappy. She'll come back . . . ‘Easy for you to say,' I murmured to the room which now belonged just to me. I turned the page and read this: Strickland's injurious calm robbed Stroeve of his self-control Blind rage seized him, and without knowing what he was doing he flung himself on Strickland. Strickland was taken by surprise and he staggered, but he was very strong, even after his illness, and in a moment, he did not exactly know how, Stroeve found himself on the floor. ‘You funny little man,' said Strickland. It occurred to me that Jo was never going to turn the page and hear Strickland call the pathetic Stroeve a funny little man. In a moment of brilliant epiphany I have never forgotten how could I? it was one of the worst moments of my life I understood it wasn't a mistake that would be rectified, or a dream from which I would awaken. Johanna was dead. My strength was robbed by grief. If the bed hadn't been there, I would have fallen to the floor. We weep from our eyes, it's all we can do, but on that evening I felt as if every pore of my body were weeping, every crack and cranny. I sat there on her side of the bed, with her dusty paperback copy of The Moon and Sixpence in my hand, and I wailed. I think it was surprise as much as pain; in spite of the corpse I had seen and identified on a high-resolution video monitor, in spite of the funeral and Pete Breedlove singing ‘Blessed Assurance' in his high, sweet tenor voice, in spite of the graveside service with its ashes to ashes and dust to dust, I hadn't really believed it. The Penguin paperback did for me what the big gray coffin had not: it insisted she was dead. You funny little man, said Strickland. I lay back on our bed, crossed my forearms over my face, and cried myself to sleep that way as children do when they're unhappy. I had an awful dream. In it I woke up, saw the paperback of The Moon and Sixpence still lying on the coverlet beside me, and decided to put it back under the bed where I had found it. You know how confused dreams are logic like Dal clocks gone so soft they lie over the branches of trees like throw-rugs. I put the playing-card bookmark back between pages 102 and 103 a turn of the index finger away from You funny little man, said Strickland now and forever and rolled onto my side, hanging my head over the edge of the bed, meaning to put the book back exactly where I had found it. Jo was lying there amid the dust-kitties. A strand of cobweb hung down from the bottom of the box spring and caressed her cheek like a feather. Her red hair looked dull, but her eyes were dark and alert and baleful in her white face. And when she spoke, I knew that death had driven her insane. ‘Give me that,' she hissed. ‘It's my dust-catcher.' She snatched it out of my hand before I could offer it to her. For a moment our fingers touched, and hers were as cold as twigs after a frost. She opened the book to her place, the playing card fluttering out, and placed Somerset Maugham over her face a shroud of words. As she crossed her hands on her bosom and lay still, I realized she was wearing the blue dress I had buried her in. She had come out of her grave to hide under our bed. I awoke with a muffled cry and a painful jerk that almost tumbled me off the side of the bed. I hadn't been asleep long the tears were still damp on my cheeks, and my eyelids had that funny stretched feel they get after a bout of weeping. The dream had been so vivid that I had to roll on my side, hang my head down, and peer under the bed, sure she would be there with the book over her face, that she would reach out with her cold fingers to touch me. There was nothing there, of course dreams are just dreams. Nevertheless, I spent the rest of the night on the couch in my study. It was the right choice, I guess, because there were no more dreams that night. Only the nothingness of good sleep.

Methodology chapter in my dissertation Essay Example | Topics and Well Written Essays - 500 words

Methodology chapter in my dissertation - Essay Example Interpretivism denotes a research method that lays importance on deductive reasoning and is thus in contrast to positivism. For the deductive reasoning process, the researcher interprets data keeping in mind the context and meaning of the observed phenomenon, and hence is a qualitative process (Carson et al., 2001; Denzin & Lincoln, 2003). Pragmatism denotes an attitude that reflects efficiency and utility (Thayer, 2011). The researcher interprets the data in a manner that serves his purpose best. In this sense, it can be said that pragmatism combines both qualitative and quantitative aspects of data collection and interpretation. Investment decision in the selected chemical companies is to be based on a analysis of the data of each firm at micro-level, in the macro-context of the chemical industry. It entails both quantitative and qualitative analysis. Hence, the Researcher is choosing the pragmatism methodology for this

MIMO implementation Case Study Example | Topics and Well Written Essays - 750 words

MIMO implementation - Case Study Example Some of the reasons are because it is facilitating easy transactions and enhancing a lot of convenience in their lives as compared to before. Currently, billions of people own a mobile phone around the world. The need for other industries to embrace mobile technology advancements and make heavy investments in it has resulted in the need for high speed, and reliable communication channels. Thus, the industry has witnessed an increasing need for enhancing users’ demands for throughput, and superior service and coverage. The research utilizes GNU Radio platform for implementation, and this is extended by the use of SFBC cipher. A demodulation block is part of the receiver component for data demodulation. The GNU Radio toolkit offers the platform for development. Multiple Input Multiple Output (MIMO) is increasingly being recognized as the most superior data transmission technology with the capacity to realize these arising requirements. Wide level of research by a number of scholars have validated the fact that, MIMO promises to offer a number of precise system solutions. In comparison to SISO, the technology has specific capabilities that would enable it to enhance radio channel capacity as well as the service eminence. According to Ryu (2008), â€Å"this can be done by exploiting the spatial diversity and overcoming the effects of multipath fading†. GNU Radio is a platform comprising of core runtime library. It is an open-source software development toolkit that is quite powerful and useful especially, in developing components of real-time signal processing applications. Programs developed under this platform are often written using C++ and Python programming languages. Users can reuse codes from earlier developed signal processing components, carrying out modifications, or creating their own original blocks. The objective of this paper is to objectively look at how MIMO applicable systems can be

Develop customer service plan Coursework Example | Topics and Well Written Essays - 500 words - 1

Develop customer service plan - Coursework Example Customer services team will contact on regular basis to understand their experiences after using the product and requirements. Customer satisfaction is the first priority of the company. Survey will be conducted to identify the needs of the customer. Our main aim is to achieve customer satisfaction by providing quality product and meeting the needs of the customers. The company is planning to consider formal and informal feedback technique to get feedback from the customers. Customers will be contacted over email and telephone to get a view about their experiences. It also tends to develop proper client relationship with the existing client base to make them feel comfortable to start after sales services anytime within the service period. The company will use RATER survey procedure (Reliability, Assurance, Tangibles, Empathy and Responsiveness) and it will focus on these five different areas to obtain full satisfaction of the customers. It will ensure that the customer can fully relay on the quality of the product that has been delivered to him/her. Assurance states that the company assures of proving service at any point of time within the service period. Tangibility of the product will be updated and delivered as shown in the product description. The company will always be empathetic towards any issues faced by the customers starting from the ordering period till the duration of service period. Any issues and problems will be quickly resolved by our customer service team members. Customers will always get quick response and the issue will be solved as fast as possible. McKinsey&Company., 2014. The three Cs of customer satisfaction: Consistency, consistency, consistency. [Online]. Available at: http://www.mckinsey.com/insights/consumer_and_retail/the_three_cs_of_customer_satisfaction_consistency_consistency_consistency. [Accessed on September 17, 2014]. Anderson. E., et al. Customer Satisfaction, Productivity and

Exploitation in the Social Structure of Civilizations Assignment

Exploitation in the Social Structure of Civilizations - Assignment Example Discussion Let us first take the recordings of Diego Duran regarding the Aztec civilization, its social structures and beliefs. Though these recordings were made from interviews taken from voyagers or their descendants at least fifty years after the Spaniards had encountered the Aztec empire, yet we find a compelling story that shows the interest that Duran must have had in recording them for posterity. They do not aspire to compare one civilization to another in terms of superiority or greatness; rather they are a faithful representation of the Aztec civilization as seen through Spanish eyes. Quite likely the Spaniards were taken aback at the elaborate social structure that existed in the Americas so far away from home, even though they felt revulsion at the human sacrifices that were made to the sun god Quetzalcoatl and other demigods. Contrarily speaking, the Spanish treatment of the Aztecs at the hands of Hernando Cortes was no less barbaric and demeaning, and leaves one with a b itter taste in the mouth. As Mel Gibson has so eloquently shown in Apocalypto, neither could aspire to be on the higher moral ground. What is clear is that religion and economics had a key role in separating society into classes. The upper class consisting of the king and nobles led an existence quite different from that of the lower social classes. There were three ways in which a man could aspire to move upwards in society, through distinguishing himself in battle, through entering the priesthood or through being a good trader and marketer (Stryker, 604). Quite consciously, hundreds of families would have aspired to rise in the annals of society but only a few would have achieved this feat. Imagine a normal Aztec not even being able to wear sandals on his feet, while this was a privilege given only to the nobles and leaders in society. The average Aztec would have led a life of subsistence and want. Indeed, circumstances could become so dire that a man could sell his wife and vice versa in times of economic distress. Or they could decide to sell the child that troubled them the most, claiming that he or she was a misfit and a troublemaker. The Aztecs treated their prisoners of war in brutal fashion, seeking no doubt upward social mobility by sacrificing their victims to the gods and after having torn their hearts out, would even take home the carcasses to feast upon like cannibals (Stryker, 603). Moving on to the account given by King Kangxi of the Qing Dynasty, he regards the supreme power of the King was to be able to pardon or condemn a subject, thereby ending his life or sparing it. It was of course necessary to make an example of dishonest men like Hu Chien-Ching, a corrupt official who terrorized his neighborhood and usurped their lands, for which the King recommended he be executed along with his family in his native place. At other times he made a careful review of appeals and spared people their lives. The King appears to be a practical man, and is disdainful of the practices that men use to gain favor with him. Quite often these men talk of principles and teaching that they themselves do not follow, but seek to impress by their knowledge. This kind of knowledge is empty and useless, much in the manner of

GLOBAL IMPACT Essay Example | Topics and Well Written Essays - 1250 words

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Mass Spectrospcopy Essay Example | Topics and Well Written Essays - 1250 words

Mass Spectrospcopy - Essay Example Consequently, the ratio of mass to charge abbreviated as m/e becomes the equivalence of the molecular weight of the component. In this technique, the analysis of the data generated involves the re-assembling of the components and then moving backwards to find the original sample molecule (Klein 673). The fundamental guidelines of mass spectroscopy date back to as early as the 1890s when J.J Thomson was able to ascertain the mass to charge ratio of the electron. Additionally, Wien who illustrated that the magnetic deflection of anode (negatively charged terminal) rays were positively charged is a founding figure in mass spectroscopy. These men were honored with Nobel Prizes for their experiments in this technique. In later years, probably in 1912, J.J. Thomson again was in the limelight yet with another study on Neon atom. In his study, he subjected the Neon-20 atom to mass spectrometry and found a variant atom, Neon-22. This suggested that neon in fact was an isotopic element. The ea rliest form of a mass spectrometry machine was built in 1918 by A.J. Dempster. It was until the mid 1960s that the method of mass spectrometry came into proper and common use because the machines were reliable and affordable (Pavia 443). With the advancement in ionization techniques of high molecular weight substances between 1980s and 1990s, this analytic procedure has grown immensely. Introduction of affordable instruments that provide high resolution has enabled researchers in all fields to conduct in depth analysis of various molecules ranging from oligonucleotides, and other biological compounds. Mass spectrometry traverses all fields and has been of significant value in drug development, and drug discovery. Within the health sector, this technique has been vital in the testing of blood and urine samples for detection of compounds termed as markers in specific conditions. Environmentally, this technique has been relied on for monitoring water and air quality as well as testing of energy reserves (Pavia 449). The procedural breakdown of mass spectroscopy begins when a very low concentration of sample molecule is allowed to pass through an ionization chamber. The chamber is usually maintained at very high levels of vacuum. Within this chamber, the sample substance is subjected to a high energy electron beam that essentially produces negatively charged ions. As a result of this bombardment, the constituent molecules in the sample substance fragment. The positively charged ions that are produced are the passed on to an analyzing tube. The path which these cations flow within the tube is curved as result of a magnetic field. Positively charged particles, cations which have the lowest rates of motion implying a low mass, are deflected most by the strong magnetic field. These molecules subsequently collide with the walls of the analyzer. On the other hand, high molecular weight components which tend to have high momentum are not deflected by the magnetic forces and as such do not undergo collision. Of importance are the ions which possess proper mass to charge proportion (Klein 687). Notably, these ions flow through the path of the analyzer, leave the path through an outlet and run into the collector. This collision with the collector produces an electric current which is stepped up

Imaginative Staffing as New Yorks Temporary Services Firm Essay

Imaginative Staffing as New Yorks Temporary Services Firm - Essay Example Team selling can be defined as utilizing the full resources of a company to sell an account through all their relevant decision makers (Waterhouse Group, 2007). Imaginative Staffing should incorporate a team selling system. This system will bring more flexibility to the sales force. Employees will benefit from the feedback they can provide to each other. A sales representative assigned to a major account will be able to provide the client with more customer support and the lines of communication will open up. Such an environment will be enhanced the relationship and increase in sales should follow. The sales team in Imaginative Staffing should include all the employees. Direct involvement from the CEO, the CFO, and the sales director during the presentation are necessary, especially if the potential client is big. In order to successfully implement the new team sales system, the company needs to provide training for its employees. The appropriate training modality for this company is a combination of initial and recurrent training. Initial training should be provided to the CFO, the administrative assistants and to the receptionist. These employees probably have limited exposure and experience working in sales. A standardized training program is the most suitable solution for them. The sales director should provide the training. Some of the methods the sales director can utilize are lectures, discussion, and web-based training. The sales representatives, account managers, the sales director, and the CEO need a recurrent training program. The most appropriate way to provide recurrent training is through decentralized training. Decentralized training includes activities such as: It is essential to establish clear objectives when designing a training program. Three important elements to take into consideration when designing a training program are: reinforcing skills learned, assessing training needs, considering buyers preferences.

The Influence That Criminology Has Had on the Criminal Justice System Since 1750 Essay Example for Free

The Influence That Criminology Has Had on the Criminal Justice System Since 1750 Essay The question is what is criminology and what effect has it had on the criminal justice system? The study of criminology has had a significant effect on the criminal justice system since the 1700’s. There are three main schools of thought within criminology, they are -Classicist -Positivist -Chicago/Subculture theory Discussion Criminology is the study of causation, correction and the prevention of crime. Criminology was brought about during the late 18th century when people sought the reform of the criminal justice and penal systems. This was because they saw the system at the time as cruel and inhuman, because the systems were applied unequally and were subject to large amounts of corruption. They were seen as inhuman as they often used death or torture as forms of punishment no matter what the crime committed was (Farlex, n. d). During the early 18th century there is an obvious decrease in the amount of power held by the church and an increase in poverty. Also at this time there is a marked increase in crimes being committed. There was a great need to establish a better criminal justice system (Dawkin, J, 2011). This brought about the classicist school of thought, the leading writer within classicist theory is Cesare Banesano Beccaria (1738-1794) he wanted the law to apply equally to everyone, instead of some people being able to buy their way out of punishments others who held positions within society which allowed them to be exempt. Baccaria also wanted crimes to hold specific punishments and that these punishments should be standardised by legislatures, he believed this would avoid abuses of power within both the criminal justice system and also the penal system to some extent (Farlex, n. ). Jeremy Benthem, was also a leading writer of classicist theory, both he and Baccaria wrote that all people are rational and have free will, so therefore commit crime by choice. Benthem also believed that people made the choices they did because they are seeking pleasure and that people will avoid causing themselves pain. Baccaria and Benthem concluded that the punishment received for committing a crime could be seen as a form of pain and so should be one greater than the pleasure gain from committing that crime (Farlex, n. d) The beliefs: -That all people are rational People commit crime by choice -The punishment of a crime should be equal to the pleasure gained create the foundation of what is seen as classicist theory today, classicists believe that preventing crime is as important as punishing crime but also that it is important restrict people as little as possible. (Farlex, n. d) During the 19th century it was noticed that even though there had been changes made to the criminal justice system, in line with classicist theory, there did not appear to be any changes to the crime rates (Dawkins, J, 2011). At this time positivist theory were becoming apparent, they give a more scientific approach to criminology, Cesare Lombroso was the most well know of the positivist writers. Lombroso was mainly influenced by Dawins theory of evolution, he believed that a persons physical features could determine whether they were likely to display criminal behaviour. Lombroso believed that a persons cranial, skeletal and neurological malformations could give a clue to whether a person would commit a crime or not, he believed that biology created aa criminal class. However since lambroso wrote about this theory, he has been disagreed with harshly (Farlex, n. d) Lombroso did have a much bigger effect on criminology, when he emphasized the difference causes of crime, those included environmental causes that have no biological basis (Farlex, n. d) he also believed that somebody could be born a criminal and that criminality was not a choice but in you genes, this is known as â€Å"Atauism† (Akeis, R. L and Sellor, C. S, 2004) The Chicago school is the scientific study of social problems, if there is an understanding of how social, physical and environmental factors affect people then by studying them it may be possible to find a solution to them. This school of thought believes that the community plays a big factor in how and why people behave the way that they do (umsl, n. d. ). Albert Cohen was the first sociologist to develop a Chicago/subculture theory. The main idea within the Chicago theory is that the area people live in has a direct effect on the way in which those people act. In particular the study looks at younger boys who have underachieved in education, living in inner city areas. Cohen found that mainstream values of success created problems for young working class males -They did badly at school -They failed to gain the skills needed to succeed in society Cohen coined the term â€Å"Status Frustration† to describe the way in which young working clss males became easily frustrated with their low status in society as a result of their lack of income and they underachievement. Due to status frustration and all the elements that cause status frustration they are often labelled by their peers and elders which results in them getting little respect, this often leaves young working class males to believe that there is no other alternative than committing crime, specifically stealing the things that they want in order to stop being labelled as a â€Å"loser† and gain the respect that they crave from the peers and elders (Smith . D, n. d). The subculture that these young working class males often belong to actually support the idea that school in a â€Å"waste of time† and â€Å"not and important part of their future†, which leads to them believe that they do not need to succeed within education (Smith . D, n. d) â€Å"Members of such subcultures take the norms and values of mainstream society and turn them â€Å"upside down†, where as anti-social and criminal behaviour is looked down upon by wider society, it is highly valued by the delinquent subculture† The consequences of turning mainstream norms and values on their head, provides a release from subculture frustration. By succeeding the norms and values they created the young working class males gain respect from their peers, which in turn encourages this criminal behaviour. Among certain peer groups the committing of some types of crime such as joy riding and vandalism helps to gain respect and to increase their status within their social group (Smith . D, n. d) The current criminal justice system is based almost completely on the posivitist and classicist theories, these make little or no allowance for why women commit crime. If there is no understanding of this, how can there be an accurate solution? People should look at a gender specific approach to the criminal justice system (Sentencing project, n. d). Feminist criminology is mostly concerned with the victimisation of women, along with victimisation; feminists also look at female delinquency, and inequality between genders within both the law and the criminal justice system (hermida. J, n. d) Feminist’s theory is split into four main areas: -Liberal Feminism -Marxist Feminism Radical Feminism -Socialist Feminism Liberal feminism came about in the 1960’s; there main issue is that women are discriminated against because of their sex. The two most well-known of liberal feminist theorists are Freda Alder and Rita Simon (hermida. J, n. d) Both Alder and Simon challenge the â€Å"sexist† assertions made by Lombrosian criminologists. They believe that it is sociological factors and not physiological factors that are the best way to explain why women commit crime in today’s society. They also believe that the more women become involved in and have full time jobs the more likely they are to commit crime that are seen to be male orientated, but this lack support as most crimes committed by women are not related to labour market opportunities (hermida. J, n. d). Marxist feminist theory generally agrees with liberal feminists is that women are often dominated by men which prevent them from fully participating in society. They believe that rape is made more common in our society because of how women are dominated by men, they believe that society has made it more acceptable in our society (hermida. J, n. d). Radical feminism focus mainly on the abuse of women, the see male power as the cause of all problems in society including crime (hermida. J, n. d). Socialist feminists’ most well-known theorists are Piers Beirre and James Masserschmidt. It comes from both Marxist and radical feminism; they see crime as a product of our capitalism society (hermida. J, n. d) Conclusion Since the 1700’s when people began to want change within the criminal justice system and the penal system, criminology has had a big effect on the changes made within the criminal justice system. Initially the new criminal justice system was just based on the classicist point of view and when there was no change in the crime rates, it was changed again to include both the classicist, positivist and subculture theories. There are still changes that need to be made as there is no consideration made for feminism and why women are committing more crime in today’s society than ever before.

Case Study Of A Patient With Diabetes Mellitus Nursing Essay

Case Study Of A Patient With Diabetes Mellitus Nursing Essay Patient Mr. NCS is a 53 year old Chinese man with the height of 1.72m, and weighs 82kg where his BMI is 27.7kg/m2 (overweight). Patient runs his own business and is currently staying with his wife and 3 children. He claims that he does not smoke and does not drink at all. According to the patient, the paternal side of his family has family history of hypertension and kidney failure where else for the maternal side, hypertension was known to be the family history. Patient has no known drug or food allergy. Patient was known to have had hypertension 15 years ago and also a history of pulmonary tuberculosis 35 years ago. Patient denied of being diagnosed with diabetes mellitus in the past. As for drug history, patient was only on 10mg of lovastatin (tablet) once at night and according to the patient, he was compliant to the medication. 1.2 Clinical Progress Patient was admitted into Accident and Emergency department and complained of shortness of breath (SOB) and mild giddiness. He also complained of having chest pain and a first episode of shortness of breath earlier before he was admitted into the hospital. On examination, he was found to be alert and conscious. Venous blood gas sampling was done and pH was found to be 7.306 (low), pCO2 was 44.2mmHg, pO2 was 45.8mmHg and HCO3 was 24.7mmol/L. Blood pressure was found to be 157/95mmHg, pulse rate was 72bpm, SPO2 was 97%, body temperature was 35.4 °C and respiratory rate was 21 breaths per minute. Reflo value was also obtained and it was found to be 17.1mmol/L and blood ketone was 0.9. Lungs were clear and abdominal was soft and non tender. Cardiovascular testing was done and it showed dual rhythm no murmur. The initial impression of this patient by the general practitioner in the hospital was impending diabetes ketoacidosis. Patient was immediately given 6 units Actrapid subcutaneousl y and the GP also planned to give O2 3L/min and to prescribe GTN 1/1 subcutaneously and Aspirin 1/1. Later on day 1 of admission, patient complained of increased in sweating, shortness of breath, body weakness and vomiting for 3 times in the morning. Patients blood pressure was 123/76, pulse rate was 82bpm, SPO2 was 99% and respiratory rate was 20 breaths per minute. When patient was asked, he mentioned that he has not done body check up and blood pressure measurement for at least 5 years now. Later in the afternoon, patient complained of excessive sweating and lack of appetite for the past 3 days. Patient then denied of having any chest discomfort or shortness of breath, headache and abdominal pain. Besides that, patient also complained of having polyuria and needed to wake up more than 3 times at night for micturation. He also complained of having polydypsia, lethargic and vomiting for 2 times in the morning. Patient was examined and he was found to be alert and conscious where he responded fully to Glasgow Coma Scale (GCS). Patient was also found to have good hydration and his ca pillary refill time (CRT) was less than 2 seconds. Vital signs were obtained and temperature was back to normal, 37 °C, blood pressure was 151/69, SPO2 was 97%, pulse rate was 88bpm and reflo value was 14.6. The management plan by the local GP was to continue monitoring the reflo value, prescribe 10mg lovastatin (tablet) once at night and 10mg amlodipine (tablet) once daily and have the patient to rest in bed. As patient was able to tolerate orally, IV drip was off and patient was allowed to take fluid orally. On day 2, patient was found to be comfortable. However, patient complained of having poor oral intake and that he was sweating profusely. He was still feeling mild giddiness and lethargic but no more chest or abdominal pain. Vital signs were observed and temperature was 37 °C, blood pressure was 128/84, pulse rate was 96bpm and reflo was 14.9mmol/L. Fundoscopy was also done and patient was found to not have any signs of retinopathy and chest X-ray was found to be clear. The management plan for day 2 was to continue 10mg amlodipine once daily, allow fluid intake orally, continue reflo monitoring 4 hourly and to trace and review the fasting blood sugar (FBS). On examination, patient was found to be alert and responded well to the GCS with the score of 15/15. Blood pressure was taken and it was 145/100 when patient was lying down and 130/90 when patient was standing. Renal profile was normal except for low potassium level of 3.0mmol/L. Impression for this patient was newly diagnosed d iabetes mellitus. Further management plan for this patient was to conduct a stress test on patient after discussing with the specialists and to monitor patients blood pressure for both lying down and standing up position 4 hourly for a day. Further plan was to start 500mg metformin (tablet) twice daily, 150mg aspirin (tablet) once daily, 20mg lovastatin (tablet) once at night, trace urine full examination microscopic examination and to refer the patient for diabetic counseling. Besides that, local GP also decided to off amlodipine and to change it to 4mg perindopril (tablet) once daily. Table 1 : Patients laboratory findings on Day 2. Sodium 129 mmol/L à ¢Ã¢â‚¬  Ã¢â‚¬Å" [135 145mmol/L] Potassium 3.0 mmol/L [ 3.5 5.0mmol/L] Creatinine 83  µmol/L [27 62  µmol/L] Glucose fasting 14.1 mmol/L [3.9-5.0mmol/L] Total Cholesterol 5.7 HDL 0.82 Triglycerides 6.7 AST 24 IU/I [10-37IU/I] ALT 45 IU/I [10-65IU/I] Bilirubin 11  µmol/L [2-24  µmol/L] INR 1.03 Trop I 0.02 CKMB 0.5 Disease Overview and Pharmacological Basis of Drug Therapy. Disease Background The prevalence of diabetes mellitus (DM) varies vastly from population to population and throughout the whole wide world. In United Kingdom (UK) itself, diabetes prevalence increased from 2.8% in the year of 1996 to 4.3% in the year of 2005. The incidence of type 2 DM showed an increase from 2.60/1000 person-years in 1996 to 4.31/1000 person-years in 20059. As much as the incidence of DM is increasing, it was estimated that up to half a million more have not had their condition diagnosed and treated10. Diabetes mellitus (DM) is a disorder in which blood glucose level is persistently above the normal range. This hyperglycaemia is thought to be due to either deficiency of insulin secretion or resistance to the action of insulin, or it could also be a combination of these6,7. DM is classified into four different types which include Type 1 DM, Type 2 DM, DM due to specific mechanisms and diseases and lastly, gestational DM8. Only type 2 DM will be discussed further here. Type 2 DM is normally caused by a combination of insulin resistance and decreased insulin secretion to overcome the resistance. It is the more common form of DM and it comprises of approximately 90-95% of the total DM cases8. The common risk factors associated with type 2 DM include increasing age, high caloric intake, overweight, central adiposity and sedentary lifestyle8. In type 2 DM patients, insulin secretory peaks every 5-10 minutes seen in normal subjects are hardly or absolutely not seen. In normal cases, when intravenous glucose is administered into a humans body, this will stimulate normal insulin secretion and is illustrated by a biphasic pattern, with an initial peak rising immediately 3-5 minutes after the administration, and lasted for 10 minutes, then followed by a deliberat e and more progressive phase, which lasts throughout the glucose infusion period. In type 2 DM, initial phase insulin secretion is not seen and the late phase occurs later and to a lesser extent11. For the diagnosis of DM, hyperglycaemia must be established before confirming that the patient has DM. Persistent hyperglycaemia needs to be confirmed and in order to do so, at least two plasma glucose measurements must be taken on separate days. There are three different types of plasma glucose test that can be used which include casual plasma glucose, fasting plasma glucose and oral glucose tolerance test (OGTT). According to WHO, there are three main criteria to be met to confirm diabetes in patients. The first would be symptoms of diabetes which include thirst, polydipsia, loss of weight and polyuria are seen in patients and their casual plasma glucose à ¢Ã¢â‚¬ °Ã‚ ¥ 11mmol/L. The other two would be if patients fasting plasma glucose à ¢Ã¢â‚¬ °Ã‚ ¥ 7.0mmol/L and patients 2-hours plasma glucose à ¢Ã¢â‚¬ °Ã‚ ¥ 11.1mmol/L during OGTT being conducted by giving the patient 75g of glucose load6. OGTT is the most effective test to detect glucose metabolism disorder where it assesses the rate of glucose excretion after administration of glucose. OGTT is strongly recommended when fasting blood glucose is within 7.0-7.8 mmol/L in the diabetic range where OGTT is practical to clarify the diagnosis6,8. Summary of Drugs Pharmacology Aspirin Aspirin with the dose of 150mg is used as an anti-platelet agent or as prophylaxis to cardiovascular events. The mechanism of action of aspirin as an anti-platelet agent is strongly associated with the permanent inactivation of prostaglandin synthase and cyclooxygenase12. It also inhibits the formation of thromboxane in the platelet concurrently. The common side effects of aspirin include bronchospasm, gastrointestinal haemorrhage and also other forms of haemorrhage13. Lovastatin Statin reduces the risk of cardiovascular disease events without taking into account of the serum cholesterol concentration and is often used as the drug of first choice in the primary and secondary prevention of cardiovascular disease. The mechanism of action of statins involves competitive inhibition of 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, which is the enzyme involved in the synthesis of cholesterol13. As liver is the major site of cholesterol biosynthesis, it appears to be the main target organ for the statins14. Statins can cause several muscular adverse effects which include myositis and other side effects include gastrointestinal disturbances, sleep disturbances, dizziness, paraesthesia, fatigue, sexual dysfunction and alopecia13. Metformin Metformin is so far the only biguanide available in the market now. It is an antihyperglycemic agent that improves glucose tolerance in patients with type 2 DM by decreasing both the intestinal absorption of glucose and the hepatic glucose production, and improves insulin sensitivity in the tissues. Metformin was also found to have potentially favourable effects on decreasing serum lipid levels and fibrinolytic activity15. Gastrointestinal side effects such as nausea, abdominal pain and diarrhoea are common with metformin and may persist in some patients13. Lactic acidosis due to metformin is rare, and the risk of this complication is higher in patients with renal impairment13,15. Amlodipine Amlodipine falls in the calcium channel blockers group which act by interfering with the inward entrance of calcium ions via slow channels present in the active cell membranes. They act mainly on the myocardial cells and the vascular smooth muscle cells which then lead to reduction of myocardial contractility. It affects both the electrical impulses and vascular tone within the heart where they may be depressed or diminished13. 2.2.5 Perindopril Perindopril is an angiotensin converting enzyme (ACE) inhibitor where it acts by inhibiting the conversion of angiotensin I to angiotensin II. ACE inhibitors are the preferred initial drug to be used for hypertension13. ACE is the enzyme that converts angiotensin I to angiotensin II where angiotensin II causes increase blood pressure, systemic vasoconstriction, Na2+ and fluid retention and etc16. Thus, ACE inhibitors act by directly blocking the formation of angiotensin II and also increase the bradykinin level at the same time. This results in reduced vasoconstriction and increased vasodilation through the release of bradykinin. The common side effects of perindopril include profound hypotension, dry cough, angioedema, rash and gastrointestinal disturbances13. Actrapid (Soluble Insulin) Insulin plays an important role in the regulation of carbohydrate, protein and fat metabolism where it helps to increase the glucose utilization in human body. Actrapid, soluble insulin, is a short acting form of insulin where it is normally injected into patients 15 to 30 minutes pre-meal. Actrapid is normally given in emergency cases especially in patients suspected with diabetic ketoacidosis4. It is normally administered subcutaneously as it gives a rapid onset of action (30 to 60 minutes) and a longer duration of action of up to 8 hours. One of the potential problems of insulin is hypoglycaemia where patients can be advised on how to avoid it13. 2.2.7 Glyceryl Trinitrate (GTN) Nitrate plays a key role in the prophylaxis and treatment of angina. It causes direct relaxation on vascular smooth muscles and also dilation of the coronary vessels which improves oxygen supply to the heart. Dilation of the blood vessels results in reduction of preload and afterload and thus, myocardial oxygen consumption is reduced17. Sublingual form of GTN is one of the most effective drugs to provide a fast symptomatic relief of chest pain but it is of short duration of action. Dose of 300mcg is appropriate as the starting dose for patients who have not used GTN before previously. Side effects of nitrates include postural hypotension, tachycardia, dizziness, throbbing headache and possible nausea, vomiting, flushing and heartburn13. 2.2.8 Oxygen Oxygen is normally prescribed for patients experiencing hypoxia to raise the alveolar oxygen tension and to lessen the workload of breathing in patients. There are generally four types of oxygen therapy which include long term oxygen therapy, short burst oxygen therapy, emergency oxygen and ambulatory oxygen. It is commonly given in emergency cases to achieve oxygen saturation within the normal range, just like in this case. The administration of the correct oxygen concentration is important as inappropriate concentration of oxygen may result in serious or fatal outcomes13. Evidence for Treatment of The Condition. Metformin Metformin is one of the main therapeutic drugs used in managing Type 2 DM and many clinical studies have been conducted to support the clinical use of metformin in the management of type 2 DM. In one of the Cochrane Review, it confirms that metformin as a single agent is one of the key therapeutic options for type 2 DM in patients with overweight or obesity problems, as it may prevent some cardiovascular complications events and mortality as well. Just as mentioned in this patient, he is a newly diagnosed diabetes patient who is overweight and he was given metformin 500 mg twice daily. In the study, 29 trials with 5259 participants were included in the analysis, comparing metformin (2007 participants) with sulphonylureas (1167), placebo (702), diet (493), thiazolidinediones (132), insulin (439), meglitinides (208), and glucosidase inhibitors (111). Obese patients who are given metformin as blood glucose control agent showed a superior benefit than glibenclamide, chlorpropamide, or insulin for any diabetes-related consequences (P = 0.009), and for mortality (P = 0.03). Besides that, patients assigned to metformin as a single therapy showed a significant greater benefit for blood glucose control, weight, dyslipidaemia, and blood pressure18. Besides that, the Comparative Outcomes Study of Metformin Intervention versus Conventional (COSMIC) study was done to compare the incidence of serious adverse effects, mortality and hospitalization in patients receiving metformin and also those who are on other usual care treatments. Among the patients, 7,227 of them received metformin and another 1,505 of the patients received usual care. To the end of the study, there were only 89.7% of the metformin group and 76.9% of the usual care group remained receiving their initial intended treatment. Serious adverse events were reported in 10.3% of the metformin group and in 11.0% of the usual care group, where both the groups reported similar adverse events. Cardiovascular events were found to be the most ordinary cause of death in DM patients where 0.7% occurred in metformin group while 0.9% in usual care group19. A population-based cohort study was also done to study on the mortality rates with the use of sulphonylureas compared to metformin. The mean age of the patients was 66.3 ±13.4 years old where 43.4% were female and their mean length of follow-up was 4.6 ±2.1 years. A greater risk of mortality was observed with higher daily doses of the first-generation sulfonylureas and glyburide but not metformin20. 3.2 Insulin secretagogues (Sulphonylureas and Meglitinides) Sulphonylureas is another group of antidiabetic treatment used after metformin in Type 2 DM. Patients blood glucose level remained high on day 2 and thus should be monitored closely after administering metformin. If blood glucose level has not been brought down, addition of sulphonylureas or meglitinides should be considered. The sulphonylureas act by enhancing insulin secretion. The sulphonylureas act at the pancreatic ÃŽÂ ²-cell membrane by causing closing of ATP-sensitive potassium (K+) channels. Closure of the channels occurred when sulphonylurea binds to the sulphonylurea receptor (SUR) subunit of the K+ channel. Meglitinides, which is not a sulphonylurea, act through the same mechanism where it also binds at the sulphonylurea binding site. Examples of sulphonylureas include tolbutamide, gliclazide, glibenclamide and glimepiride. Meglitinides is referred as an alternative to sulphonylureas as it does not cause additional stimulation of insulin excretion when patient failed to respond to maximal dosage of sulphonylureas. Examples of meglitinides include repaglinide and nateglinide21. Adding on a sulphonylurea or meglitinide to metformin as a therapy to type 2 DM was found to have a better control of blood glucose level. 318 patients (61 from metformin group, 126 from glimepiride group and 131 from glimepiride + metformin group) completed the study to compare the effectiveness of metformin monotherapy, glimepiride monotherapy and the combination treatment in controlling blood glucose level. It was found that the greater efficacy of combination treatment in reducing HbA1c levels than either glimepiride alone (p Comparison was conducted in a study where 124 patients were randomly given either repaglinide 1 mg daily or glimepiride 1 mg daily. The dose of study drug was given over an 8 week titration duration, which then followed by a 12 months treatment length. FPG levels, HbAlc values and PPG levels significantly fall from baseline in both groups after 6 and 12 months of treatment. However, after 12 months, fasting plasma insulin (FPI) levels on the other hand were significantly increased in the repaglinide group (p So far, the most commonly reported adverse event in sulphonylureas was hypoglycaemia. 605 people over 34,052 person-years were diagnosed with hypoglycemia during sulphonylurea therapy, which equals to an annual risk of 1.8%24. There is also high risk of hypoglycaemia in diabetic patients who are taking ACE inhibitors at the same time. Therefore, the use of sulphonylureas in this patient should be used in caution as he is currently taking perindopril as his anti-hypertensive drug. Several studies suggested that there is an increase in mortality due to cardiac events in patients treated with sulphonylureas. In one of the studies, 120, 4138 and 1537 patients were given a first-generation sulfonylurea, glyburide monotherapy and metformin monotherapy respectively. 24.8% of the total deaths were found to be due to an acute ischaemic event. Those given first-generation sulfonylurea monotherapy had the highest mortality (67.6 deaths per 1000 person-years), compared with metformin monotherapy users (39.6 deaths per 1000 person-years). As higher doses are used, higher rates of death are observed as compared to those who are on lower doses20. Other less common side effects of sulphonylureas include weight gain, nausea, diarrhoea, gastrointestinal pain and cutaneous reactions such as rashes, urticaria and pruritus21. Further Management Thiazolidinediones, gliptins (GLP-1) mimetic, also known as exenatide and insulin administrations are the further management in type 2 DM if the above oral anti-diabetic agents are not able to control the high blood glucose level. Pioglitazone and rosiglitazone are examples of thiazolidinediones where they are the newer oral anti-diabetic agents which are more expensive but present better adverse effects profiles. A thiazolidinedione can be added on instead of a sulfonylurea as second-line therapy if sulphonylurea is contraindicated or not well tolerated or it can be added on to the sulphonylurea therapy if metformin is contraindicated. Another recommendation is to add on a thiazolidinedione to metformin plus sulphonylurea when the blood glucose is not well controlled and the use of insulin therapy is not suitable25. Two randomised trials were conducted and in the first study, 317 patients who are already on metformin received an add-on therapy of pioglitazone at the dose 15-45 mg/day and another 313 patients received gliclazide at the dose 80-320 mg/day instead. In the second study, 319 patients who are already on sulphonylurea therapy were randomly assigned to receive add-on therapy of pioglitazone at the do se 15-45 mg/day and another 320 with metformin at the dose of 850-2,550 mg/day. After 2 years, the mean reduction in HbA1c from baseline was found to be 0.89% for pioglitazone and 0.77% for gliclazide addition to metformin. The reduction in mean FBG after 2 years was statistically significant between the two add-on therapies where a decrease of 1.8 mmol/L for pioglitazone and a decrease of 1.1 mmol/L for gliclazide was seen (p Another option is adding on a GLP-1 mimetic agent as third-line therapy to first-line metformin and a second-line sulfonylurea25. Effectiveness of exenatides in bringing down the blood glucose level in type 2 DM patients was extensively studied. One of the studies includes patients at the age of 22-76 years old and had type 2 DM treated with at least the maximally effective dose of a sulfonylurea as monotherapy for at least 3 months. After a 4 weeks single-blind, placebo period, 377 patients were randomized (60% men, age 55 ±11 years, BMI 33 ±6 kg/m2, HbA1c 8.6 ±1.2%) and began either at 5  µg subcutaneous exenatide twice daily(before breakfast and dinner; arms A and B) or placebo for 4 weeks. Patients in arm B were then increased to 10  µg bd of exenatide. At week 30, HbA1c changes from baseline were -0.86 ±0.11, -0.46 ±0.12, and 0.12 ±0.09% ( ±SE) in the 10- µg, 5- µg, and placebo arms respectively (p à ¢Ã¢â‚¬ °Ã‚ ¤ 0.001). FPG values also showed a significan t reduction in the 10- µg arm compared to the placebo arm (P à ¢Ã¢â‚¬ °Ã‚ ¤ 0.05) 28. If all else fails to control blood glucose, insulin therapy should be introduced in patients with poorly controlled type 2 DM. It was believed that there is possibility that the oral anti-diabetic agents mentioned above might be useful in combination with insulin therapy in enhancing better blood glucose control, reducing insulin dose requirement, or minimizing side effects of insulin therapy. A study was conducted to compare the efficacy of adding once-daily basal insulin with switching to twice-daily premixed insulin in type 2 DM patients uncontrolled by oral anti-diabetic agents (OADs). It was a 24 weeks period clinical trial where 371 patients with poor glycaemic control (FBG à ¢Ã¢â‚¬ °Ã‚ ¥120 mg/dl, HbA1c 7.5-10.5%) were randomized to once-daily morning insulin glargine plus glimepiride and metformin or to only 30% regular/70% human NPH insulin (70/30) twice daily without any OADs. It was found that mean HbA1c decrease from baseline was significantly better in the presence of O ADs than the one without OADs (p = 0.0003). More patients reached HbA1c à ¢Ã¢â‚¬ °Ã‚ ¤7.0% without confirmed nocturnal hypoglycemia (45.5 vs. 28.6%, p = 0.0013) with glargine plus OAD than with only 70/30 NPH insulin. In addition, decrease in FPG was greater with glargine plus OAD (p Conclusion In this patient, he was newly diagnosed with type 2 DM and was given metformin 500mg twice daily initially to control his high blood glucose level, which was appropriate according to the guideline. If blood glucose is still not well controlled, changing of medication or further management as above should be considered. As hypertension and overweight are risk factors of DM, hypertension should be well managed in this patient and the patient should be advised on complying with his medication. Besides that, patient should also be advised on healthy diet and lifestyle to control his weight.