Free

Freedom Short Story from Tkam After Tom Robinsons Trial Essay As I sat outside watching the other inmates, a gentle breeze caressed my face, providing relief from the sun’s hot rays. I was used to the heat, but maybe it was the circumstances that I was in that made it unbearable. I could see that my fellow inmates felt the same as they lazed about, their skin glistening with sweat, their shirts clinging to their backs. ‘Guilty until proven innocent’ rang angrily in my mind when I saw the number of Negroes compared to white people incarcerated. The amount of court cases, as well as families, jobs and lives, lost due to our colour was innumerable. Half of us didn’t even commit a crime worth being sent to jail for, but here we are! I wiped my forehead with an already sticky hand and surveyed my surroundings in an effort to shake off the contemptuous thought. The dirt oval consisted of some simple worn out exercising equipment, their hinges squeaking in protest with very movement; a few withering trees dying in the midday heat, two lookouts sitting on the inside of the perimeter where the prison guards patrolled the prisoners and a barbed wire fence which enclosed the space in an ominous hug. I thought pensively about my situation as I kicked the dusty ground vehemently, scuffing my already torn prison boots in the process. The rising hopelessness that I had kept bottled up throughout the court case, believing that with Mr Finch on my side I would definitely be acquitted, quickly vanished, much like the specks of dirt that I had kicked up had disappeared, carried away with the breeze of reality. I observed the bluejays on the nearby trees, warbling their little hearts out with not a care in the world, unaware of the injustice that had occurred. I was being punished for a crime that I had not committed, accused by a woman whom I have assisted for nigh a year! The court case didn’t just affect me it affected my family as well and I don’t want them to suffer because of it. What will they do? How will Helen watch the chillun’ and work? They don’t deserve this! My family needs me. It was already a struggle to bring food to the table everyday, and now with most of our income ripped away, I can’t bring myself to fantasise what my family would have to suffer. Would Helen have to starve to keep the chillun’ physically satisfied? I’ve prayed for them every night confined in the dungeon, praying that God would help them through this adversity. Ms Mayella obviously doesn’t realise that her decision to accuse me affects my family just as much as it affects me. She used the only ticket that would guarantee her victory over the court case, which would prove her innocent from the despicable crime that she had committed – her race. The inequity displayed towards Negroes always perplexed me. We came from the same ancestors, Adam and Eve, but somehow, white people were born having more rights than others, perceived as superior to others, more moral than others. I should’ve conceded that I was a black man living in a white man’s world, and no matter what I did to prove myself innocent, there would be no justice for me. I hate how all white people acrimoniously conclude that all Negroes lie, all Negroes are basically immoral beings and all Negroes aren’t to be trusted around women, as Mr Finch mentioned. How can people be so shallow, so malevolent and so blind? They’re living a lie! How dare America call themselves a democracy when they can’t even treat their own people equally, lowering our rights, our standards and our lives! The act of incarcerating all black people for almost everything that we do is a paradox to their self-proclaimed government. It is overdue to set things straight, but there is no better time than now to change the way Negroes are treated. I am not going to wait for someone else to take justice, as God knows when that is going to come. Justice is in my hands. The only possible way that I can achieve this is to run. They’re going to kill me nonetheless so I’m already a dead man walking, but I’m not dying knowing that I just sat there letting them persecute me while knowing that I did nothing to prevent this precedent from occurring again to other Negro families. I must run. I quickly rose from the bench which I was seated on and began jogging the perimeter of the oval, keen to find an escape route to freedom. I took a quick glance at the patrollers- they were watching us inattentively, their faces impassive and eyes glazed over, contenting themselves in their current daydreams. I scrutinized the fence for any weakness. There were several places where the fence sagged, but all seemed intact. I searched for other possible escape routes, my eyes slowly taking in every detail of the oval, but when failing to find any, I approached an oak tree to ponder over my next move, when flashbacks of my family and previous life overwhelmed me. There were many oak trees in my life – in my backyard, on the sidewalk, at work but I never knew until now that they were so prominent in my life. There were oak trees that my children loved to climb on, loved to hide in, loved to have mini adventures in. There were oak trees that I watched from my kitchen window as their branches were softly tickled by the wind, which Helen used to sit under and pensively think about life’s uncertainties, which grew and thrived with my family. There were oak trees which provided me a job, which I spent countless hours climbing up and down laboriously picking acorns, which earned me money to support my family. My heart ached with sadness when I thought back to those wonderful memories, making me miss my family even more than I originally did. Helen would probably be working strenuously to support the children now without my help. What this event has put my family through is unthinkable. I can’t prevent what I am currently putting them through, but they must understand that if I do no try to get free I will be killed nonetheless. Everyone deserves to have equal rights, and I am going to be the person bringing justice. I am not going home after my jail sentence knowing that I did nothing to prevent further injustice from occurring to thousands of other Negroes. I want to be able to tell my chillun’ that I didn’t just sit there being persecuted, allowing other Negroes to be persecuted as well, as the pain that discrimination puts us through throughout our lives is unbearable. I want to be a role model for them; to be an example for fighting for what is right. Even though doing so may be dangerous and may lead to death, bringing justice to every race is worth losing a life for. In a sudden burst of adrenaline and surprising confidence I sprinted as fast as my legs could carry me to the barbed wire fence and began climbing. I almost leaped backwards in surprise as my bare skin came into contact with the burning metal that had been basking in the sun all day, but my mind was set on my goal, and so I ignored the acrid pain and scaled the fence. Consecutively, shouts of surprise and disbelief spread through the prisoners, and, as if my actions brought them back to life, the angry voices of the prison guards soon followed. Hollering warnings and portentous threats, the patrollers showed no evidence that a few seconds ago they were practically lifeless, but their efforts were wasted as it proved completely futile. With my prior experience climbing trees for Mr Deas, I quickly adapted to my situation and climbed, my hand and feet working simultaneously to make up for my deprivation. My eyes darted to elusive spaces between the barbs and my hand quickly followed suit, with my legs climbing after them. The barbs clung and sliced at my arms and clothes as the patrollers’ threats became more ominous, their cries climbing to a climatic forte, ineffective at impeding my pilgrimage. The word justice was repeated over and over in my mind, instilling a new hope in me, encouraging me to continue climbing. This failed when a gunshot shattered my tranquillity. A bolt of pure panic shot through me, causing my heart to thrash against my ribs as I realised the severity of my situation. I lost my footing, dangling in mid-air for a second, but immediately found another foothold and scaled the fence even faster than before. Seeing that the gunshot failed to stop me, several more shots were fired into the air, counterproductive as it only made me move twice as fast. ‘Quicker! Quicker! ’ my body seemed to holler at me, dissatisfied with the speed that I was travelling. My stomach started to twist with despair, my newfound hope abandoning me, slowly overtaken by doubt then a bullet whistled past my ear inches from my face. My hand began shaking uncontrollably from pure fear. My lungs were screaming for air, the spikes were screaming for blood, but my scream for justice overpowered them all. More deathly bullets whistled past, when one successfully tore through my leg. An explosion of pain raked my leg, and immediately I felt warm blood gush out of my pulsing wound. I was almost over the fence though! Clenching my teeth, I reached between the razor wire. The screams and hollering of the prisoners were vociferous, but nothing mattered as the second bullet hit my crippled shoulder. It immediately burst into flames as I started sweating uncontrollably, the back of my shirt soaked with blood, clinging to me. In a last ditch effort, I hauled myself between the razor wire to the other side of the fence leading to freedom. A third bullet tore through my thigh, sending me rolling to the ground in a bloodied heap while other bullets whizzed past and wounded me. The shrill roar in my ears gradually ceased to a dull hum, and dizzying black splotches began crowding my vision. The last thought that left my mind was: Freedom.

Advanced breast cancer

Advanced breast cancer Background Cancer accounts for 13% of all deaths in 2007, making it the largest cause of mortality worldwide and is the leading cause of premature death in Scotland. 2,22 Out of the staggering figure of 27,500 new cases that were diagnosed on that same year in Scotland, 4044 of them are breast cancer cases, making breast cancer the most commonly diagnosed cancer among Scottish women.3 In the UK, 16-20% of women have advanced breast cancer and approximately 40-50% of those diagnosed with early or localised breast cancer may eventually develop metastatic disease. Breast cancer is usually defined using a staging system known as the Tumour, Node and Metastasis Staging System (TNM) and stage III and IV are known as advanced stages of the disease with stage III being locally advanced and or has spread to regional lymph nodes and stage IV describing the presence of metastases at distant sites such as the bone, brain, or lung.23 In the elderly group of female cancer patients, the prevalence of breast cancer is highest at 4% and these post-menopausal women make up 80% of all breast cancer patients, hence proving that the risk increases with age.1 Apart from age, other factors like family history, uninterrupted oestrogen exposure, early menarche, late menopause, late first pregnancy, hormone replacement therapy, obesity, not breast feeding, taking oral contraceptives and past breast cancer may all attribute to a higher risk of developing breast cancer.9 Over the last decade, mortality rates from breast cancer have dropped by almost 14%, despite having more women diagnosed with the disease. In 2000-2004, the survival rate for breast cancer patients has also bumped up to 84% compared to a mere 64% 20 years earlier.4Improvement in prognosis, screening techniques such as mammography, ultrasound and Magnetic Resonance Imaging(MRI), earlier diagnosis of cancers in women participating in the Scottish Breast Screening Programme, a myriad of new hormonal and chemotherapy treatments, and better organisation and patient care plans has attributed to the substantial increase in incidence and survival rate of breast cancer patients. Women today are also encouraged to perform self breast examinations, hence are familiar with the shape and feel of their breasts, as well as to look out for abnormities like a new discrete lump, nipple discharge, unilateral persistent pain especially in post-menopausal women or pain associated with a lump and skin changes comprising of skin tethering, ulceration, abscess or inflammation.However, there is still a disparity between women from different social classes in terms of combating this disease. Women from more affluent backgrounds are more likely to have their breast cancer diagnosed earlier, have slower disease progression from the time of diagnoses and higher survival rates compared to women from poorer socioeconomic backgrounds. Women from more deprived communities are more likely to be diagnosed with the advanced stage of the disease. Pathogenesis Cancer or malignant neoplasm which literally means new growth is a disease manifested in the form of uncontrolled cell proliferations, dedifferentiation and loss of function, invasiveness and metastasis.6 Breast cancer usually forms from the inner lining of milk ducts or the lobules that supply the ducts with milk. In patients with Breast Cancer, women who inherit a single defective copy of tumour suppressor genes BRCA1 or BRCA 2 have a marked higher risk of developing breast cancer in their lifetime. The presence of a defective BRCA1 or BRCA 2 gene can invoke changes in several cellular systems including the signaling pathways and receptors of growth factors and cell cycle tranducers, the apoptotic machinery which responsible for programmed cell death that normally disposes of abnormal cells, the secretion of telomerase, and local blood vessels which results in tumour-directed angiogenesis to supply nutrients to these tumours both aids the proliferation of cancer cells.7,8 Breast cancer cells are able to invade other tissues like the lymph nodes as they no longer exercise the same restraints as the normal cells and they also secrete enzymes like metalloproteainase to break down the extracellular matrix, conferring them mobility. Metastases are secondary tumours normally found in the advanced stage of breast cancer formed by cells released from the primary tumour and have reached and have established themselves at other sites like the lung brain or the bones which are common sites for metastatic cancers of breast origin through blood vessels and lymphatics. The tissues of lung, brain and bone origin express high levels of CXR4 chemokine receptors produced by the breast cancer cells, facilitating the selective accumulation of the cells at these sites.6 Treatment Options There are three main approaches to treating breast cancer, namely surgical excision, irradiation and a host of systemic disease-modifying therapies or a combination and is chosen based on the stage of breast cancer. However, when caring for patients with advanced breast cancer, the goal of treatment of advanced breast cancer is to palliate symptoms, improve survival and quality of life. There are notably three types of systemic disease-modifying therapies to treat advance breast cancer namely endocrine therapy, chemotherapy and biological therapy. Endocrine Therapy Oestrogen exposure has been instrumental in inducing mutations that can lead to breast cancer as they can stimulate cell growth in most of human breast cancer cell lines expressing Oestrogen Receptor (ER) ÃŽÂ ± .8 Clinical studies have proven that more than half of breast carcinomas are ER ÃŽÂ ± positive and respond fairly well to endocrine therapy. Drugs are aimed either to change the ER signaling pathways or prevent estrogen synthesis.7 Tamoxifen and 3rd generation Aromatase Inhibitors (AI) have been used for advance breast cancer with the former being effective in premenopausal, perimenopausal and post menopausal women. Pre-menopausal and perimenopausal cancer patients with ER positive tumours should be offered Tamoxifen tablets 20 mg daily, an oestrogen -receptor antagonist and ovarian ablation or the administration of LHRH agonists such as Buserelin or Goserelin as first-line treatment.5,12 Both options are just as effective in terms of tumour response and overall surviva l rates. The latter group of drugs, AI, are the preferred choice for post-menopausal women only with no prior history of endocrine therapy or have been previously been treated with Tamoxifen. AI work predominantly by suppressing oestrogen levels in post-menopausal women by blocking the conversion of androgens to oestrogens in the peripheral tissues. However, they do not inhibit ovarian oestrogen synthesis, hence can cause an elevation in oestradiol levels in pre-menopausal women. Anastrozole and Letrozole are non-steroidal AIs are known to be as efficacious as Tamoxifen as first -line treatment of metastatic breast cancer. 14Exemestane is a steroidal AI used as second-line treatment in advanced breast cancer in post-menopausal women in whom anti-oestrogen therapy has failed. Fulvestrant, an oestrogen receptor antagonist also confers short term benefits in the clinical setting for post-menopausal women who was previously prescribed a non-steroidal AI, delaying the need for chemotherapy. 13AI h ave been associated with an increased progression-free survival and 13% decrease risk of mortality and lower incidence of vaginal bleeds and blood clots. However, patients given AI are more prone to hot flushes and gastro-intestinal symptoms. 5 Other endocrine therapies available include older and less popular therapies such as progestogen and androgen for pre-menopausal women and stilboesterol and trilostane for post-menopausal women. 5 Chemotherapy Both ER positive and negative patients with advanced breast cancer would benefit from either a choice of two or three regiments of chemotherapy and classes of drugs commonly prescribed includes antharacyclines, taxanes, capecitabine, vinorelbine, gemcitabine, alkylating agents like cyclophosphamide and platinum based drugs like carboplatin.5 Anthracyclines such as Epirubicin, Mitoxantrone and Doxorubicin are prescribed as first line chemotherapy as they boost modest survival advantage in patients with advanced breast cancer and are superior to non-anthracycline regimens.1,5Doxorubicin is commonly given via injection into a fast running infusion at 21 day intervals as extravastation can cause severe tissue damage. It exerts a cytotoxic effect by interfering with DNA and RNA synthesis by inhibiting DNA toposiomerase II action. The metabolites are excreted through the bile, hence elevated bilirubin levels are indicative of a need to reduce the dosage. 6,12 Higher accumulation of doses may result in cardiopathy precipitating to heart failure, hence cardiac monitoring is deemed important in managing cancer patients taking it and a limit of total cumulative doses is set at 450 mg/m2.Other symptoms of toxicity includes myelodysplasia and neutropenic sepsis. Doxorubicin is also available in liposomal formulations which are safer in terms of reduced incidents of cardiotoxicity and local necrosis but is not recommended by the Scottish Medicines Consortium for treatment of metastatic breast cancer.1,12 Both Epirubicin,an anthracycline derivative, and Mitoxantrone ,an anthracenedione derivative,are structurally related to Doxorubicin, hence similar drug activity could be predicted for all three drugs.12 Mitoxantrone given intravenously is licenced to treat metastatic breast cancer and has been well tolerated by patients.However, side effects like myelosuppression and cardiotoxicity are evident and cardiac examinations are recommended after a cumulative dose of 160 mg/m2.12When both drugs are compared in a clinical trial, Epirubicin boosts higher response rates despite demonstrating a higher percentage of toxicity related side effects.20Clinical trials suggest the efficacy of Epirubicin in treating advanced breast cancer is comparable to Doxorubicin as similar response rates were recorded when equal doses were given. These trials also indicated that patients taking Epirubicin had fewer episodes of congestive heart failure and other complications resulting from cardiotoxicity. Therefo re, it could be surmised that Epirubicin is the drug of choice in this regimen .However,a limit of 0.9-1 g/m2 was still imposed when Epirubicin is given to avoid cardiotoxicity. 1,12 Due to the ineffectiveness of single-agent anthracycline therapies in impeding disease progression, combination therapies are often considered for the treatment of advanced breast cancer after failure of with anthracycline monotherapy, provided that the patient is able to tolerate additional toxicity and have a higher chance of response.5 There are clinical evidence suggesting that a combination of anthracycline and taxanes like Doxorubicin and Docetaxel have resulted in better tumour response, delayed progression time compared and reduce risk of mortality to anthracycline monotherapy. The benefits of this synergistic combination, however, did not include improved survival and side effects experienced were more numerous such as thrombocytopenia, alopecia in 75% of these patients,a 10% increase in peripheral neuropathy and neutropenia in 40 to 68% of these patients.1,5 A combination of Epirubicin and Docetaxel would be a better choice as it is just as potent as the Doxycycline and Pac litaxel combination but deemed free of side effects like cardiotoxicity and fluid retention whereas neutropenia was the dose-limiting toxicity .21 Systemic chemotherapy should be offered to patients whom antrhracyclines are contraindicated in cases of cardiac disease hypertension,the elderly, those who have received myocardial irradiation ,those receiving radiotherapy for breast cancer or had receive prior adjuvant treatment with anthracycline. Docetaxel monotherapy is prescribed as the first-line drug followed by single-agent Vinorelbine or Capecitabine as the second-line treatment. Third-line treatment encompasses the use of either Vinorelbine or Capecitabine of which was not offered previously.5 Docetaxel, a member of the taxane group derived from a naturally occurring compound from the bark of yew trees, is licensed to treat locally advanced or metastatic breast cancer. It acts by stabilizing microtubules in the polymerized state, preventing cell division. Side effects associated with Docetaxel are myelosupression, peripheral neuropathy, cardiac conduction defects with arrhythmias, alopecia, muscle pain, nausea and vomiting . Patients currently on Docetaxel are also susceptible to leg oedema and hypersensitivity reactions, which can be ameliorated by taking Dexamethasone orally.1,6,12 Antimetabolites like Capecitabine is a rationally designed tumour-activated and tumour-selective fluoropyrimidine carbamate thatis metabolized to generate 5-fluorouracil at the tumour site which would then be converted to fluorodeoxyuridine monophosphate (FDUMP), a fraudulent nucleotide and interact and inhibit thymidilate synthetase,preventing the synthesis of 2-deoxythymidilate (DTMP),which is vital for DNA synthesis.17Capecitabine has a role in second-line or third-line treatment of chemotherapy for patients of locally advanced or metastatic breast cancer either in combination with Docetaxel or given orally alone at a dose of 1250 mg/m2 twice daily for a forthnight and subsequent courses are repeated after a 7-day interval. Vinorelbine is a semi-synthetic analogue of vinblastine, a vinca alkaloid derived from Madagascar periwinkle. Unlike taxanes, it is targeted at tubulin of mitotic microtubules to form tubulin dimers which prevents spindle formation in dividing cells leading to mitotic arrest at metaphase resulting in cell death. 6 Besides inhibiting mitosis, its effects are also significant in inhibiting leucocyte phagocytosis, chemotaxis and axonal transport in neurons. Hence, side effects includes neutropenia which was found to be the dose-limiting, peripheral or autonomic neuropathy which manifests as peripheral paraestesia, loss of deep tendon reflexes and motor weakness,constipation and abdominal pain. Neurotoxicity caused by Vinorelbine is considered relatively mild compared to other vinca alkaloids even at maximum tolerated dose as it preferentially binds to mitotic over axonal microtubules. 6,12 Vinorelbine is an option to anthracycline or taxane pre-treated patients with advanced breast canc er as second-line or third-line chemotherapy given via intravenous administration at a dose of 30mg/m2 in 250 ml of normal saline over 1 hour. Alternatively, Vinorelbine can be given orally at a dose of 60 mg/m2 for 3 weeks and can be increased if the patient shows good tolerance to the regime to maximum dose of 160 mg once weekly. A clinical response rates of 16-60% was seen with Vinorelbine as a single agent, 28-77% in combination chemotherapy.5, 16 A study comparing Vinorelbine in intravenous(i.v.) form used in combination with Capecitabine given orally and a combination therapy of Vinorelbine and Capecitabine both in oral formulations was done to observe the efficacy of both combinations in anthracycline and taxane pretreated patients with metastatic breast cancer. Despite showing a marginally higher percentage in control of the disease in the oral group,improved survival rates and lower incidence of neutropenia and thrombocytopenia were associated with the i.v. group.17 This study has also shown that a combination of Vinorelbine with Capecitabine therapy may confer advantages as both have unique mechanisms of action, different proposed mechanism of drug resistance and relatively non-overlapping toxicity profiles. However, this combination has yet to be recommended by the NICE or SIGN guidelines as it has yet to be proven to be cost-effective. The recommendation for systemic chemotherapy by NICE is done following a cost-utility analysis which compares chemotherapy regiments in terms of survival, quality of life and associated costs of 17 different strategies drawn up. From the table below, strategies that gives the best survival rates and quality of life are combinations 3,4,13 and 15.However,combinations 3 and 4 that offer Gemcitabine and Docetaxel as the first line are somewhat more costly by approximately  £ 10 000 in total costs compared to combinations 13 and 15.It is also proven here that offering Docetaxel as a first-line drug is also superior to Paclitaxel as survival rates and quality of life are slightly poorer in combinations 8 and 10. 5 Biological Therapy New agents to specifically target molecular processes have been developed over the last decade like Tratuzumab, Bevacizumab and Lapatinib which are all used to treat advanced breast cancer. Tratuzumab, the sole drug of its kind recommended by NICE for use in the UK, is a recombinant humanized monoclonal antibody which binds to Human Epidermal Growth Factor (HER2) on the cancer cells with HER2 over expression and impedes the growth. Hence, HER2 status should be assessed before commencing this therapy as only a quarter of patients with advanced breast cancer have HER2 positive tumours. Tratuzumab is given intravenously in combination with Paclitaxel, Docetaxel or Vinorelbin has been well tolerated. 5,11However, once disease progression occur outside the central nervous system, Tratuzumab should be discontinued. Bevacizumab is another monoclonal antibody aimed at affecting the growth of tumour blood vessels and Lapatinib affects the metabolic pathways of the HER2 and Epidemal Growth Fac tor Receptor (EGFR). 5,23. Surgery Surgical intervention comprises of conservation surgery which involves the removal of the tumour with a rim of surrounding breast tissue with retention of the breast followed by radiation therapy and mastectomy which is usually followed by breast reconstruction. However, these surgical procedures are limited to patients diagnosed with primary operable breast cancer or as palliative surgery for locally advanced breast cancer as they may not confer much benefits to patients diagnosed with later stages of breast cancer.1,11,19 Some patients may have already underwent surgery which was not very successful in eliminating the disease.1 Treatment Recommendation Hormonal therapies are the recommended first-line therapy for patients with an ER positive tumour, are widely used and are said to be appropriate for 70 % of patients who have hormone receptor -positive advance breast cancer. However, in circumstances whereby the disease is life-threatening or the patient has an ER negative tumour, the hormonal therapy would be of no benefit to these patients. At the time of initial diagnosis, the oestrogen receptor (ER) was accessed and the results came out positive before considering commencing on endocrine therapy. Several factors like previous endocrine therapy including adjuvant therapy, the extent and period of response to the therapy and menopausal status have to be taken into account before prescribing hormonal therapy. 5The patient is 62 years of age and is considered to be post-menopausal, hence would benefit tremendously when given aromatase inhibitors(AI),regardless of whether she is tamoxifen naÃÆ' ¯ve. A choice of non-steroidal AIs o f either Anastrozole 1 mg daily or Letrozole 2.5 daily could be given orally. However, if she has a prior history of non-steroidal AIs and she failed to respond well to it, she should be given either Exemestane 25 mg orally or Fulvestrant 250 mg via intramuscular injection into the gluteal muscle every 4 weeks.5,12 Chemotherapy would be the second choice of treatment following failure to respond to hormonal therapy. If anthracyclines are not contraindicated for this patient, Epirubicin would be a good choice. Initial doses of 75 mg/m 2 of Epirubicin could be given intravenously every three weeks.20The addition of Docetaxel 75 mg/m2in combination with Epirubicin 90 mg/m2 both by intravenous infusions could be given should Epirubicin monotherapy fails. Docetaxel monotherapy could also be given as an intravenous infusion at a dose of100 mg/m2 as a 1-hour intravenous infusion every 3 weeks should anthracyclines be contraindicatedas first-line chemotherapy. Vinorelbine monotherapy could be given intravenously at a dose of 30 mg/m2 for days 1 and 8 of a cycle or whereares Capecitabine monotherapy could be given orally at a dose 1250 mg/m2 twice daily for two weeks. If the patient fails to respond to the entire treatment, the last resort would be to offer support and palliative care to this patient. Pain Management Pain is usually associated with progression of cancer with three quarters of patients with advanced cancer reporting pain during treatment. The principles for treating pain in cancer patients are outlined by the World Health Organisation (WHO) analgesic ladder: Patients are the prime assessor of pain and should have treatment outcomes monitored regularly using visual analogue scales, numerical rating scales. Patients usually start with non-opioids and then progress stepwise to step 2 and step 3. However, critics have debated that the progression to step 2 analgesics was obsolete as inadequate pain control was an issue despite having to endure similar adverse effects when given step 3 analgesics and recommended a immediate step up to step 3. Most patients with advanced breast cancer will be on step 3 for pain control. Oral morphine with an initial dose of 5-20 mg every four hourly, adjusted according to patients response, would be the first-line therapy to treat severe pain in cancer before switching to a modified release preparation once the patient is stabilized on it. Breakthrough pain should be managed while on a modified release preparation by prescribing oral morphine at 1/6th of the total daily dose to be taken when necessary. The use of adjuvants such as antidepressants like Venlafaxine and anticonvulsants like Gaba-pentin are recommended for neuropathic pain. 18 Managing Complications Complications that may arise from treating patients with advance breast cancer includes lymphoedema,cancer-related fatigue,uncontrolled local disease,bone metastases and brain metastases. Lymphoedema may occur due to damage to lymph nodes and vessels following surgery and radiotherapy or as a sign of loco-regional disease progression. This condition can be managed through manual lymphatic drainage, multi-layer lymphoedema bandaging,goos skin care and remedial exercise. Cancer-related fatigue may be well managed by identifying the factors causing lethargy which may be a host of psychological, nutritional and cognitive factors apart from the cancer itself and them treating them accordingly. Patients may also develop local disease characterized by ulceration on the chest wall and axilla, fungating tumours that may bleed and exude discharge, causing pain and giving off repulsive odours. Hence, good wound management should be adopted in relation to preventing dire consequences when wounds are left unattended. Out of the three categories, cancer with distant metastases is the hardest to treat and is considered an incurable disease with palliative care being the sole priority in treatment plans. A diagnosis of metastatic disease could be confirmed with the use of positron emission tomography fused with computed tomography (PET-CT) and bone scintilography.1As bone metastases may be a long-term condition, management involves prevention of skeletal events, pain control with Biphosphonates,radiotherapy and cementoplasty and treating complications such as fractures,immobility and spinal cord compression.5,18 Brain metastases may develop in multiple sites in these patients as most drugs used in chemotherapy cannot penetrate the blood brain barrier, especially in women with HER2-overexpressing tumours. Diagnosis of brain tumours ultimately mean a loss of independence, physical deterioration, communication difficulties,psychological distress and issues regarding body image.Treatment regimens includ es surgery for patients who have solitary metastasis, corticosteroids for symptomatic relief of inflammation and radiotherapy.

Defoe, Richardson, Fielding and the English Novel :: Literature Essays Literary Criticism

Defoe, Richardson, Fielding and the English Novel      Ã‚  Ã‚  Ã‚   The roots of the novel extend as far back as the beginning of communication and language because the novel is a compilation of various elements that have evolved over the centuries.   The birth of the English novel, however, can be centered on the work of three writers of the 18th century: Daniel Defoe (1660-1731), Samuel Richardson (1689-1761) and Henry Fielding (1707-1754).   Various critics have deemed both Defoe and Richardson the father of the English novel, and Fielding is never discussed without comparison to Richardson.   The choice of these three authors is not arbitrary; it is based on central elements of the novel that these authors contributed which brought the novel itself into place.   Of course, Defoe, Richardson and Fielding added onto styles of the past and writing styles of the period, including moralistic instruction and picaresque stories.   Using writing of the time and the literary tradition of the past, Defoe first crafted the English novel while Richardson and Fielding completed its inception.      Ã‚  Ã‚   Critics disagree on a strict definition of the novel; D.H. Lawrence has remarked, "You can put anything you like in a novel" (Stevenson 2), and Wagenknecht in his Cavalcade of the English Novel has claimed the "...'novel' has never been satisfactorily defined" (xvii).   Henry James had a unique perception of the novel:    "A novel is a living thing, all one and continuous, like any other organism, and in proportion as it lives will it be found, I think, that in each of the parts there is something of the other parts."  Ã‚  Ã‚  Ã‚  Ã‚   (Kettle 12)    "Novel" comes from the Italian "novelle," which was used for sensational news stories.   One collection, Giovanni Boccaccio's The Decameron, was popularized in the 14th century (Phelps 11).   The term carried over into English to form the basis of the English novels.      Ã‚  Ã‚   There are certain components that a novel should contain.   George Phelps has come up with a six-part basis for identifying novels: the writing must be fictitious, or in other words "not pretend to tell the truth," have a certain length, attain a unity of "plot, theme, tone, atmosphere, or vision," create an illusion of reality, be concerned with character, and be prose (Phelps 7-8).   Kettle, in his An Introduction to the English Novel, argues a novel must have two elements -- a quality of life and a significant pattern (13).

Who I would take to dinner :: essays research papers

Given the opportunity to invite five people to a dinner party, I thought about what I should serve, who would be my server, and which five people I will invite. To start off this infamous dinner party I chose to have it at the Santa Barbara Hotel in California. I picked out the largest banquet room, and had it stocked with art supplies, music equipment, and various other items. I chose to serve anything and everything, sushi, watermelon, pasta, meat, liquor, etc. I chose to invite five very different people, Andy Warhol, Ross Pero, Victoria Taylor, Cheech and Chong, Ja Rule, and of course myself.   Ã‚  Ã‚  Ã‚  Ã‚  One of my all time favorite artists is Andy Warhol. I wanted him to be at my party to ask what inspired his whole idea of pop art and if he would do a portrait of myself and the dinner party. Warhol seems like a very emotional and mixed up person and I would just like to meet him one time to experience Warhol.   Ã‚  Ã‚  Ã‚  Ã‚  The media gives Ross Pero a bad image. An image that gives the public visualizations of his appearance. I have always wanted to see Pero in person. I want to see if his ears are really that big. I don’t want to put down his intelligence so he will also inform us of world news and anything else his mind holds.   Ã‚  Ã‚  Ã‚  Ã‚  There is a series of movies that these two star in, and their names are Cheech and Chong. They will liven up the atmosphere and try to get everyone to smoke marijuana. I made them something special for them to eat while they were at my party, pot leaf soup and hash brownies. I have wondered what it would be like to be Cheech and Chong to see how much of there brains were really left and marijuana they could smoke.   Ã‚  Ã‚  Ã‚  Ã‚  Victoria Taylor is my God Mother, she is my living day role model. She owns a high fashion clothing store in Portland, Oregon. I wanted her to come because she really knows how to get people going and how to have great parties. She respects different people which makes her a prime choice to come because she would not be â€Å"weirded† out by my guests.   Ã‚  Ã‚  Ã‚  Ã‚  My last guest is music artist Ja Rule. He is a rap/ hip hop artist, but his voice and appearance is really nice. I wanted him to come to my party to not only be a guest but to perform, that is what the music equipment is for.

Culutual Anthropology :: essays papers

Culutual Anthropology As an amateur anthropologist, I was to participate in my observation, which I did to the best of my ability. Choosing my topic was the most difficult for me. Coming to America there are so many options that I could choose to research. So what was I to do? Well, being in the state of Kentucky, Lexington at that, I decided to research a sporting event in which Americans call basketball. As soon as I stepped of the big metal bird, I saw a picture of a wild cat holding a round orange ball. I remember thinking, "I could never hunt these animals, they are too smart, they are nothing similar to the ones in the Outback of Australia. So I stopped the person that rode next to me on the metal bird, "What is that animal doing with that ball?" He remarked, "We are in Lexington, home of the Kentucky Wildcats." With that he walked away. How could Kentucky be considered the home of the wildcat? We have many in the Outback. So, I continued down the nest where the birds drink and rest. Then it finall y hit me, the name of the basketball team were the Wildcats. I was well on my way to find these "Kentucky Wildcats." I arrived where they house the wildcats that play ball. The name of the cage was Rupp Arena. Apparently, I was not the only one interested in watching these trained animals play the sport of basketball. The price to watch these animals were extremely expensive; thirty dollars in American currency which would translate into 300 of my own currency. Once inside the cage I found that it was not at all what I thought it to be. There was an enormous amount of people present. In my observation this event is the biggest that people in this culture attend. In this cage you could smell a variety of things. Some smells were all too familiar from home; the urine smell as you walked into the place where people went to relieve themselves reminded me of the "Hole." They had many different foods that smelled nothing like anything that I have ever smelled before. They had a brown thing that was twisted into a weird design; they had something that was in the form of a triangle that looked like a piece of bread with cheese on top and round meat.

Major Appliance Business Group

The technique of segment markets and targets of particular groups are a technique aimed to choose a certain class of customers, and It focus on study and find the dimensions of the products that could be played by Increasing marketing. It's important for the company to segmenting the market demands. This means that they need to focus on categorizing certain categories, so that it is possible for each category product to be similar to another one.By doing this technique, the company s selling the same product to match all the needs of the customers. The other goal is to reach and get the largest possible area of the customers by identifying the category or market sector, which has a purchasing power that leads to increase the value of marketing. That market segmentation helps in proper planning to pack the right marketing of the product. It also makes us extend our product at the same time to meet the needs of consumers, which Is very Important In the creation of the product.For examp le if the target category is for the people who are older than 70 years or younger than 20 years old, then we have to take into consideration that there is a limited income of the teenage and the elderly. Market segmentation helps to reduce the risk in determining where, when, how, and who will be marketing the product, service, or brand. It also increases the efficiency of direct marketing through special efforts towards a particular sector in a manner insistent with the characteristics of that part.Segmenting markets Is the simplest and the most Important technique for matching supply and demand. Steven Major Appliance Business Group By gerrymander aimed to choose a certain class of customers, and it focus on study and find the dimensions of the products that could be played by increasing marketing. Of consumers, which is very important in the creation of the product. Segmenting markets is the simplest and the most important technique for matching

How is happiness conveyed in Jane Austen’s Emma and Charlotte Bronte’s Villette?

The nineteenth century was an era of great discovery, invention and social change as a result of political unrest in the previous years. The American Revolution which culminated in the United States Declaration of Independence, lead to a change in political thought, bringing ideas of ‘Life, Liberty and the Pursuit of Happiness' (1776: line4), though how much this extended to women is debateable. Published thirty-seven years apart, Emma and Villette tell the stories of two girls trying to find happiness in difficult societies. The two lead characters are very different; Emma is a respected, wealthy and attractive young woman yet rather spoilt, whereas Lucy Snowe is passive and secretive, with no significant amount of money or family connections. Living in the same century, therefore, it would seem safe to assume that the girls would find happiness in the same things; good company, money and a happy marriage. As Philip Davis argues, Victorian novels (though Emma predates Victoria's reign by approximately twenty years) were concerned only with ‘Humanity, Duty, Vocation, Work, Marriage [and] Family' (2002:2). However, this is not the case for either of the girls. Lucy finds comfort in solitude and some of the passages in Bronte's novel where she is most at ease are those in which she is alone. If not alone, Lucy prefers the company of just one or two trusted friends, but even this is problematical, as she often hides her feelings from the reader. Emma on the other hand, appears to take pleasure in helping others to be happy; often to their detriment! What can be said, nonetheless, is that both novels convey moral journeys towards a greater understanding of self and society. By looking at a few specific incidents in each novel, the methods with which the authors explore the feeling of happiness can be uncovered. Emma Woodhouse, handsome, clever, and rich, with a comfortable home and happy disposition, seemed to unite some of the best blessings of existence; and had lived nearly twenty-one years in the world with very little to distress or vex her (Emma p. 5). The opening sentence of Jane Austen's novel manages to summarise Emma's situation and history in a few simple words. The reader is already informed by the omniscient narrator that this central character is content and privileged in every aspect that a young lady could wish for. In comparison, Villette has a very different approach. For example, it is not until the second chapter that we find out the name of the protagonist and narrator, Lucy Snowe. Interesting to note also that the first two chapters are names of characters, ‘Bretton' and ‘Paulina', as if the narrator is happy to talk about them, but reluctant to talk about herself. We hear about the people surrounding the narrator, events in the past but very little physical or characteristic detail. We are given few clues as to how Lucy feels or thinks about these events; ‘well I liked the visit' (Villette p. 1) is the only indication of preference or opinion. Even by the end of the novel we do not know where her ‘home' was, and Lucy is constantly evasive about places and locations. The reader is left to speculate why this is; because of unhappiness there and desire to forget it? Or perhaps she is ashamed? It is almost as if she does not trust the reader and as a result becomes difficult to like. Most readers will assume that this past, of which Lucy is so vague, holds bad memories or experiences which set the tone of her character from the start. As a narrator, Lucy is unreliable and the revelation that Dr. John and Graham Bretton are, in fact, the same people, is the prime example of this. ‘I first recognized him on that occasion, noted several chapters back, when my unguardedly-fixed attention had drawn me on the mortification of an implied rebuke' (Villette p. 70-1). Only when the reader will find out for themselves, does Lucy tell us that she knew all along. ‘I had preferred to keep the matter to myself' she reasons, ‘I liked entering his presence covered with a cloud he had not seen through' (Villette p. 171). This motif of hiding, or being screened, recurs throughout the novel. Lucy is often seen observing or people watching, preferring to be out of the limelig ht. However, this changes when she is recruited to be in M. Paul's play after one of the lead characters falls ill. Nevertheless, she puts on a performance, a mask, and is not herself. The clothes she wears are men's and by speaking another person's lines, Lucy distances herself from that which makes her feel so uncomfortable, her own feelings. It seems as if she is afraid to admit to herself how she feels. By suppressing her emotions and living an almost muted life, Lucy denies herself happiness. This alienation is heightened by her being in Belgium, where she does not speak French initially, by being a Protestant in a Catholic society and through the atmosphere of the Mme. Beck's school. Despite working very closely with the headmistress, Lucy still finds her searching through her belongings one evening, showing a lack of trust between the characters. Lucy's narrative style shows a lot about her unhappiness as a character and surprisingly Emma shares some of these traits. Emma is told through a third-person omniscient narrator, whereas Lucy tells us the story through her own, if somewhat limited perspective. Austen's narrator gives us a wider outlook on the events at Highbury, although the free-indirect style means that the narrator's opinions are sometimes blurred with those of the characters and there is some mimicry of Emma's thoughts and tone. She is a more open character, whom the narrator can easily display to the reader, and her feelings are more easily accessible, on first impression. As Emma is already ‘handsome, clever and rich' (Emma p. 1), her happiness is taken for granted, but looking a little deeper it is evident that she is not fully content. The novel is based around a series of shocks for Emma; Miss Taylor's marriage, Mr. Elton's proposal, Frank and Jane's engagement, and she seems in a constant struggle to maintain a certain decorum and propriety. It is ironic that Jane Austen's novels are so often seen as portrayals of a stagnant society, when Highbury is full of entrances and exits; Mrs. Elton, Frank Churchill, Jane Fairfax and Harriet. The proximity to London, peculiarly, does not seem to have an effect on the community. Emma's constant need to help others could be interpreted as dissatisfaction within herself. Instead of realising her feelings for Mr. Knightly at the beginning of the novel, as so easily could have occurred, Emma goes through systematic pairing up of her acquaintances, to try and arrange as many couples as possible. It is only when Harriet confides in her regarding her own feelings for Knightly that Emma is forced to identify and realise her attachment to him. Because she demands a kind of variety and excitement life cannot supply, Emma allows her fancy and imagination to shape and distort her perception of reality [†¦. What Emma constantly desires and frequently demands is not simply that her world admire her; it must also be as rich and vital and beautiful as she feels herself potentially to be [†¦. ] The crux of the matter, then, is the peculiar way in which Emma's life depends upon and is dedicated to richness and beauty in human experience. (Minter 1966 : 51) Minter argues that Emma relies on this constant application of herself to try and adapt her surroundings to suit her. In doing this, Emma is attempting to create an environment in which she is truly comfortable; not a trait one would associate with a young lady of ‘happy disposition' (Emma p. ), but more with slightly nervous and compulsive behaviour. It is as if Emma must have control of the events around her to feel content. This shows a certain extent of self-consciousness and dissatisfaction, reflected most clearly in her thoughts of Jane Fairfax: Why she did not like Jane Fairfax might be a difficult question to answer; Mr Knightly had once told her it was because she saw in her the really accomplished young woman, which she wanted to be thought herself. (Emma p. 125) View in this manner, Emma becomes, in essence, a structured action in which Jane Austen renders both the nobility and the dangers, the significance and the consequences of Emma's endeavour to force an aesthetic ideal upon her world' (Minter 1966 : 51). As a character, Lucy Snowe is built up in a different way by Charlotte Bronte than Emma is by Jane Austen. By looking at their happiest and lowest points in each text, the reader has an insight into their extremes of emotion, and how these are created by the authors. Lucy characterises her weakest moments by images of storms and tempests. This occurs several times throughout the novel and blurs the situations which Lucy does not want the reader to know or understand fully, perhaps because she does not understand herself. This is first seen upon Lucy's departure from Bretton; ‘I must have somehow fallen overboard, or that there must have been wreck at last' (Villette p. 30). It is not certain whether Lucy actually embarks on a boat journey or whether she just uses this as an extended metaphor. Bronte adds the scream of the Banshee to symbolise the coming of bad news; Miss Marchmont dies and leaves Lucy with little money. However, the worst for Lucy personally is arguably the fall ‘headlong down an abyss' (Villette p. 160) after her visit to the church. She has been ill for a long while and her soul leaves her body ‘hoping to leave for rest (Villette p. 160). The reunion of the two is a particularly painful image, ‘a sort of racking struggle', ‘with pain, with reluctance' (Villette p. 161). Villette's final chapter is the most ambiguous sequence of the whole text, in which Lucy almost leaves the conclusion of the novel down to the reader. ‘Reader, they were the three happiest years of my life. Do you scout the paradox? Listen' (Villette p. 488), she appeals to us. Whether M. Paul is killed in a tempest on his return is not overtly stated, though the image of the storm again would imply that he does. If the past three years ‘were' the happiest, then it follows that these are now unhappy times. As with the beginning of the novel, Lucy finishes by telling us what happened to other characters, but not herself; ‘Madame Beck prospered all the days of her life; so did Pire Silas; Madame Walravens fulfilled her ninetieth year before she died. Farewell' (Villette p. 491). With a similar style of description and attitude, it is as if Lucy Snowe has come full circle; she is just as happy at the end of the novel, as at the start, or there seems no noticeable difference. Victor Hugo wrote in Les Miserables that ‘life's greatest happiness is to be convinced we are loved' (1862) and it is this sentiment that gives Lucy the highest moment in Villette. She says that her love for M. Paul ‘gave me such pleasure as, certainly, I had ever felt' (Villette p. 403). Emma's happiest moment comes with similar thoughts on Mr. Knightley, but also a revelation about herself and her own actions; ‘How long had Mr. Knightley been so dear to her, as every feeling now declared him now to be? When had his influence, such influence begun? ‘ (Emma p. 312). This sequence comes with a long set of rhetorical questions in which Emma begins to see her flaws; perhaps this is the ultimate happiness for her? Mahatma Ghandi is often famously quoted as saying, ‘Happiness is when what you think, what you say and what you do are in harmony'1 and this can be seen clearly in the closing chapters of Emma. Finally Emma is settled in herself; knows how she feels, is able to talk openly and does, of course, eventually marry Mr. Knightley. What totally different feelings did Emma take back into the house from what she had brought out! – she had then been only daring to hope for a little respite of suffering; – now in an exquisite flutter of happiness – and such happiness, moreover, as she believed must still be greater when the flutter should have passed away. (Emma p. 328) Emma's reaction is markedly different from Lucy's. Her language is more descriptive and appears fast, almost as if she cannot keep up with what her mind is thinking. The narrator here sounds just like the character of Emma, speaking rapidly with the use of many exclamation marks. Lucy falters, questions M. Paul's affections and seems unsure of the situation. ‘I was content', she states (Villette p. 403) compared to Emma's ‘state of spirits' (Emma p. 328). Emma's unfeeling comments to Miss Bates at the picnic however, paint her in a very different light; ‘†Ah! Ma'am, but there may be a difficulty. Pardon me – but you will be limited as to a number – only three at once†Ã¢â‚¬Ëœ (Emma p. 280). This can be seen as Emma's most unkind and lowest moment in the text, ‘she had never been so depressed' (Emma p. 284) it is a necessary addition that makes her realise how badly she has behaved, although requiring a little help from Mr. Knightley. Throughout Emma and Villette, Austen and Bronte shape their main characters with the use of these dramatic highs and lows, which alter their perceptions and also the reader's perceptions of them. By using specifically chosen language, the feelings and emotions of Lucy Snowe and Emma Woodhouse are made apparent and so the reader can share in their delight and depression. Jane Austen's novel appears overall a happier text, despite the continual failings of Emma's matchmaking, and ends positively with both Emma and Harriet getting married, and Harriet discovering her parentage. Although their marriages are well paired, with men who will complete them, the reader cannot help questioning whether marriage and money will always create ‘perfect happiness' (Emma p. 367). Villette on the other hand, ends just as mournfully as it begins, with very little defined ending. It could be argued that Lucy Snowe finds an inner peace with herself, after enjoying three happy years, despite not having M. Paul with her. Perhaps knowing she is loved is enough, and so with this and the solitary life which has given her comfort throughout the novel, Lucy can be settled. With her flourishing school as financial security, Lucy does not require anything more; she has stability and security, that which she has lacked from a young age. Though the storm imagery, if consistent with the rest of Bronte's novel, indicates further change, we are not given any clues as to how this will transpire. With so many novels of this era, both Emma and Villette look at the difficulty of a woman finding true happiness in such a patriarchal society. Kate Millett argued that Villette was ‘too subversive to be popular' (1977:140), accurate considering the conformity of many novels of the time. Emma, for example, still allows a happy ending and a marriage, despite the main character's actions throughout. In creating this alternative style, Charlotte Bronte shows happiness through a perhaps more realistic perspective, rather than Austen's romanticised, ‘happily-ever-after' story.