Friday, March 6, 2020
A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting The WritePass Journal
A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting Introduction A case study diffuse non-scarring alopecia in an adult female patient and an approach to diagonossis and management female-pattern hair loss in primary care setting IntroductionCASE STUDYDISCUSSIONHair AnatomyLifecycle of the hair Factors influencing hair growthGrowth FactorsHormonesMineralsOther factorsTypes Of Non-Scarring AlopeciaDiffuse hair lossFemale Pattern Hair LossAcute telogen EffluviumChronic telogen EffluviumTreatment of FPHLMinoxidilThe Hair ConsultationHistoryExaminationScalpHairPull testNon-scalp hair and skinLab testsCASE DISCUSSION AND CONCLUSIONREFERENCESRelated Introduction CASE STUDY Mrs KJ, a 29 year old manager at a busy law firm, presented to her GP complaining of recent sudden onset of hair loss over a period of a few weeks. What prompted her visit to the GP, was noticing large amounts of hair on the bathroom floor whilst on honeymoon, and subsequently that her scalp hair was suddenly thinner than usual, especially around the temporal areas. She had wondered whether she should be changed back to Cilest (from the Dianette she was currently taking), her original contraception, the cessation of which had appeared to trigger the same symptoms two years before. On that occasion, after stopping Cilest, she had experienced amenorrhoea with facial hirsutism and similar hair loss, leading to investigations and a diagnosis of polycystic ovarian syndrome (PCOS). She then used Dianette oral contraception and for a short time, oral cyproterone acetate, which improved the hair loss. Mrs KJ, who was also a vegetarian, denied use of hair dye or chemicals on her hair, and on the day of her consultation her hair was not styled in a manner promoting traction. Questions regarding family history revealed that her father had died of a heart attack in his fifties. The GP agreed with Mrs KJ that the hair around the temporal and crown areas appeared less than elsewhere on her scalp. The scalp was found to be otherwise normal, with no evidence of scarring alopecia or alopecia areata. The pull test was negative (however, her hair had been washed that morning), blood results (biochemistry and haematology) were deemed normal by the GP and because of the hair shedding, a diagnosis of telogen effluvium (secondary to stress – work and wedding planning) was made. She was advised to stay on Dianette. Because of the previous history and treatment she was referred to a dermatologist with an interest in alopecia, who described a mixed picture of telogen effluvium secondary to low ferritin, and mild androgenetic alopecia. He also asked for the bloods to be repeated, and these showed a decreased ferritin level, high SHBG, and all the rest normal, including zinc, antibody screen, and thyroid tests. He too advised that Mrs KJ remain on the Dianette, and that she start taking an iron supplement. Of interest is that the initial ferritin level done by the GP was 37ng/l, and this fell to 28ng/l over a period of about a month. Haemoglobin was normal. Both these figures were within the normal range provided by the lab (normal range 13-150ug/l, with optimum ferritin for females advised at 27ug/l)1. A few weeks after starting the iron supplements, Mrs KJ came back to see her GP to discuss work related stress which had spiked. In particular she was concerned that she would not be able to manage a very important presentation to the senior partners at the firm. She was so distressed that she found the only thing that calmed her was drinking alcohol, which she was understandably not keen on using regularly! So after some discussion about stress, the GP suggested that she try low dose propranolol for performance anxiety, for only the few days leading up to the presentation, including the actual day of, then to discontinue. Hair loss was not discussed at this consultation. A month later she was back to see the GP, complaining that there had been an even bigger spike in hair loss, and on contacting the dermatologist she had been advised to continue the iron supplementation. She requested a second dermatology opinion, and was then diagnosed with androgenetic alopecia secondary to PCOS, unmasked by telogen effluvium secondary to low ferritin, and a degree of scalp seborrhoea. She was advised to continue taking Dianette, iron supplementation, Ketoconazole shampoo a few times a week, topical minoxidil and topical cyproterone. She was also put on Metformin by her gynaecologist as part of the treatment for PCOS. A number of months later there was a marked improvement in hair growth. As she was keen on starting a family, she was advised to stop oral contraception and to continue the topical treatments, but to stop both minoxidil and cyproterone once she conceived. DISCUSSION In order to understand abnormalities associated with hair loss, it is important to understand the normal hair physiology and anatomy. Having personally spoken with a group of 12 GP’s, about how they would approach a patient complaining of hair loss, all admitted that they felt underprepared to do so. They also admitted to a poor understanding of hair anatomy and physiology. Hair Anatomy Figure 1. Structure of a hair follicle2 Types of hair There are three types of hair – terminal hairs are thick hairs found on the scalp, axilla and pubic areas; vellus hairs are finer, shorter hairs on the rest of the body; and lanugo hairs develop in utero and are shed in the first few months of life. Anatomy The hair starts to develop within the hair follicle, which is a stocking-like structure made up of an inner and an outer layer. The hair is divided into the part that protrudes above the skin, called the shaft, and the root, which is within the follicle. The dermal papilla is a finger-like projection into the base of the follicle. It contains capillaries to allow for a rich blood supply to the hair bulb, forming the base of the hair root, the only living part of the hair, and therefore requires nutrients. The hair bulb is the enlarged lower end of the hair into which the dermal papilla projects. It is made up of living cells with a high potential for division and differentiation which divide every 23-72 hours, the fastest rate of any cells in the body3. These cells are called the hair matrix. They divide and move up the follicle to become either hair cells or cells of the inner sheath of the follicle. Among the matrix cells are melanocytes which produce dark (melanin) or red/blonde (phaeomelanin) hair pigment. Pigment is taken up by the differentiating cells of the matrix by phagocytosis. The matrix gives rise to the layers which form the hair shaft – the medulla is the inner layer(not always present in non-terminal hair), the cortex makes up the main bulk of the hair shaft and contains dead keratinocytes, and the cuticle is the layer of tightly packed overlapping cells surrounding and sealing the shaft. The matrix is fed by the dermal papilla, which plays a significant role in hair growth. The dermal papilla produces a number of substances which have an effect on matrix cell growth and differentiation. The dermal papilla is itself under the influence of hormones and regulating substances, which include growth factors. These can increase proliferation of dermal papilla cells, which release cytokines which can act as inhibitors or stimulators of matrix cell growth. The hair follicle is a component of the pilosebaceous unit – one of the other components being the sebaceous gland (as well as apocrine glands in specific areas such as the groin and axilla). The inner layer of the follicle extends up the shaft and ends below the opening of the gland into the follicle, while the outer sheath extends to the gland itself. The outer sheath has a fibrous membrane to which is attached the erector pili muscle, contraction of which causes the hair to stand upright (giving the effect of ‘goosebumps’ when someone is nervous or cold). The sebaceous gland secretes sebum, an oily substance that helps to moisturise the skin and hair, while the apocrine gland is a sweat and scent gland, and mostly becomes activated at puberty under the influence of hormones. Lifecycle of the hair There are three phases of hair growth. Anagen – is the active phase when the cells of the hair bulb are constantly dividing and causing the hair shaft to elongate. This growth phase can last between 3-4 years. Catagen – is the transitional or involutional phase which follows anagen. The hair stops growing, the follicle shrinks slightly and the root is diminished and breaks away from the dermal papilla. This phase lasts 2-3 weeks. Telogen – is the resting phase when the hair is no longer growing and the dermal papilla is not attached to the follicle. This phase lasts 6-12 weeks. When anagen phase restarts and the follicle and dermal papilla reconnect, a new hair forms and starts growing, and can push the old hair out. About 10-15% of scalp hairs are thought to be in telogen phase at any given time.3,4 There is no synchronicity in the hair cycle and so small amounts, about 100 hairs per day, are lost every day, unnoticeably for the most part. Very occasionally, cycles can be synchronised, for example toward the latter part of pregnancy, thought to be under the influence of hormones, so that larger amounts at a time are shed a few months postpartum; this hair loss is by and large seen as physiological and not pathological, and normal hair growth pattern is usually soon re-established.5 Factors influencing hair growth Progress has been made toward understanding the processes which influence hair growth, but there is still much work to be done in this regard.3,6 Growth Factors Insulin-like growth factor (IGF) accelerates hair growth depending on its concentration at the dermal papilla. This is regulated by IGF binding protein (IGFBP) which reduces the amount of free IGF available for action, and therefore has an inhibitory effect on hair growth. There are also a number of other growth factors which play in a role in hair growth regulation.3,6,8 Hormones Androgens were proven to play a role in androgenic alopecia by Hamilton who noticed that men who were castrated before puberty never grew beards or developed baldness, unless they were treated with testosterone, and that balding men who were castrated showed no progression of balding.6 Androgens stimulate hair growth in some areas such as the beard and groin. In genetically predisposed individuals the presence of circulating androgens can also cause hair loss in areas such as the temporal and vertex areas of the scalp; the occipital area is usually spared. The reason for this is not well understood, and is thought to be related to specific receptors.6,8 The main androgens are testosterone and its metabolite dihydrotestosterone (DHT), the conversion occurring under the action of the enzyme 5 a-reductase at the site of the end organ, in the case of hair, the skin. DHT is more potent than testosterone in this area as it has a higher affinity for the receptors. Sex hormone binding globul in (SHBG) binds to free testosterone, preventing its breakdown to its more active metabolite DHT. Therefore, SHBG has an inhibitory effect on testosterone function. SHBG is in turn inhibited by IGF and insulin – these therefore help to increase the level of active testosterone and DHT.3 Testosterone reduces the anagen phase of the terminal hair, with the result that the hair is shorter and has a smaller diameter, called miniaturisation of the hair, and conversion of the terminal pigmented hair into a vellus (often) non-pigmented hair.3,6,8 The result is that with time, the areas where this occurs appears to have thinner hair growth or appear balding. In females, androgens are manufactured in the ovaries and the adrenal glands. The ovaries produce both male and female hormones, and under the influence of insulin there is increased conversion to testosterone. 3,9 In women with higher levels of circulating insulin, such as those with polycystic ovarian syndrome (PCOS), metabolic syndrome (MS) and insulin resistance, there can be higher levels of androgens due to increased conversion, and the suppressant effect on SHBG. 9 The net result would be a hyperandrogenic state, which could result in AGA, hirsutism, acne, voice changes, among other signs of virilisation. 7 The role of oestrogens appears to be more complicated. 15 The enzyme aromatase is found in oestrogen producing cells in the adrenals, ovaries, testes, fat cells, as well as a few other organs. Aromatase helps to convert testosterone into oestradiol, thereby decreasing the amount of free testosterone. Women who took aromatase inhibitors as part of treatment for other conditions, were found to develop androgenetic male pattern hair loss, indicating that aromatase has a role to play in the pathogenesis of alopecia. The exact nature of this role is unclear. 10 According to Yip et al. oestrogens are at least of equal importance to androgens in scalp hair growth.15 Minerals While iron deficiency anaemia has been widely accepted to be a cause of hair loss17, it is less clear to what extent ferritin levels without the presence of anaemia, has on hair loss. When comparing women of child-bearing age with diffuse telogen hair loss, to those without, in the presence of no nutritional supplementation or underlying medical conditions, women with the hair loss were found to have a mean ferritin level that was significantly lower than those without hair loss. The odds that someone would have ratio TE was higher when the ferritin level was at 30ng/ml or lower. The authors concluded that serum levels at 30ng/ml or lower therefore increased the chances of TE. 14 However Olsen et al. compared  iron deficiency in women with female pattern hair loss (FPHL or AGA – difference discussed later), CTE and a control group with no hair loss, and found that while iron deficiency was common in all the women, there was no significant difference in levels between the three groups. This study cited as a limiting factor that the outcome of treating the women, who had been discovered to have iron deficiency, was unknown. 12 Theoretically then, those who had hair loss and iron defiency, could have experienced a degree of hair regrowth after the iron deficiency had been treated. While a number of studies have supported the theory that ferritin levels affect hair loss, such as the study by Kantor et al 11 a number have also. Disputed. 12 Although the effects of ferritin on hair loss is still being studied and debated, Rushton suggests it would be advisable to treat even a low normal ferritin, if it was under the level of about 30-70 ng/ml; Trost et al . also advocate that ferritin above 70ng/ml should be aimed at to optimise treatment for AGA, and that the reason for the presence of anaemia or low iron stores should be sought if appropriate, while iron overload should be avoided. 13,16 Zinc deficiency is known to play a role in alopecia, but the mechanism is unclear. 17,18,19 Lack of essential fatty acids can help cause a diffuse alopecia with some lightening in colour of the remaining hair. Selenium deficiency can cause a hair loss similar to zince deficiency. Biotin deficiency can be genetic or acquired (medications like valproic acid, adult excessive consumption of raw eggs) and is also thought to play a part in causing hair loss, but there have been no clinical trials to support biotin supplementation to improve this. 19 Other factors Hair loss is also a well known side effect of thyroid problems, inflammatory illnesses such as lupus, malnutrition, anorexia nervosa, among other conditions, all of which can be picked up as part of the differential diagnosis when evaluating someone with hair loss. 17,20 Stress has also been known to cause hair loss, such as following major surgery or emotional trauma. 17,20 A long list of medications also affects the hair. Heparin, Warfarin, Ace inhibitors, Beta Blockers, Allopurinol, and levodopa, among many other drugs, have been found to cause hair loss 20 Age is also an important determinant, as balding increases with age 21, as is genetics – baldness appears to run in families. There is a marked difference between races in manifestation of androgenic hair loss, with Caucasians exhibiting this the most. 8,15 Types Of Non-Scarring Alopecia Hair loss can be broadly classified as scarring (or cicatricial) alopecia and non-scarring alopecia. There are some occurrences when there is some overlap between these two. Non-scarring alopecia can be further divided into a diffuse hair loss, or localised/patchy hair loss (alopecia areata, not discussed further). Diffuse hair loss This problem is not an uncommon presenting complaint to a GP. It can be noticed by the patient as either decreased hair density/thickness, or as increased hair shedding. The main causes for this would be acute telogen effluvium (ATE), chronic telogen effluvium (CTE) and female pattern hair loss (FPHL). 17 FPHL, together with male pattern hair loss (MPHL) is also known as androgenetic alopecia (AGA), but more authors are now referring to separate nomenclature for the sexes. 8,15,17,20 Although MPHL and FPHL are histologically identical the age of onset in females is later than in males. Also the patterns of hair loss between the sexes differ. The progression of the problem is not as rapid with women or as severe and there is not as good a response to anti-androgen therapy with women, as there is with men.15, 20 Many authors have therefore suggested that in women there is therefore a very complex, multifactorial aetiology. Female Pattern Hair Loss This is the most common type of hair loss affecting women, with prevalence increasing with age. It affects about 12% of women aged 20-29, to about 50% of women over 40, and over 50% by the age of 80. 20, 28 FPHL is an under-recognised entity.20 Androgenetic alopecia has been defined as progressive hair loss in genetically susceptible people in the presence of circulating androgens. Histologically, there is miniaturisation of the terminal hair follicle with progressive transformation of the terminal hair follicle (with central medulla) into a vellus hair follicle (no medulla). 15,17, 20 The role of androgens and androgen receptors is much more established in MPHL, and therefore finasteride and minoxidil are established treatments for MPHL. Androgens definitely have their role to play in FPHL, but there are other factors which influence the disorder as well, which are not clearly understood, such as oestrogens and iron. Many women with FPHL do not have demonstrable elevated androgen levels or other features of hyperandrogenism. 17 Women with hyperandrogenism respond better to anti-androgen treatment. 20 MPHL commonly follows the pattern described by Hamilton, with temporal recession initially, followed by vertex balding, with eventual fusion of the temporal and vertex balding areas and sparing of the occipital area).23 In women, only a small number present with this pattern of hair loss and the degree of balding is not usually as severe as in men. 20 The pattern in FPHL follows three main distributions: Diffuse central-frontal hair loss with sparing of the frontal hairline. In 1977 Ludwig described this in three scales – mild, moderate and severe (almost completely bald at vertex, this is very rare). 17, 20, 24 Diffuse, mainly frontal hair loss (frontal accentuation) with breach of the frontal hairline. The Olsen scale or Christmas tree pattern – this is demonstrated by parting the hair in the midline and noting the part widening, with the narrowest part at the vertex and the widest part toward the frontal hairline. 17, 20, 24 Fronto-temporal and vertex hair thinning, in other words a male pattern of hair loss or Hamilton-Norwood- type. 17, 20, 24 Hamilton-Norwood                             Ludwig                                                 Olsen    (male pattern)                                 (diffuse central)                      (frontal accentuation)drawing, courtesy ref.24 More recently the Sinclair 5 point scale has been adapted and introduced, and may become more widely used as it allows more subtle description; this may become more necessary as women start to present more early with their hair loss. 20, 24 Sinclair 5-point scale for FPHL drawing courtesy ref. 24 (drawing by L. Tosti) Because it is a progressive problem, without effective treatment the condition will worsen. However the rate of the progression is variable and unpredictable. Diagnosis is usually clinical, based on history and examination. Correct diagnosis is imperative so that the correct treatment can be commenced to try to at least slow down/halt the progression of hair loss, or at best bring about some degree of hair regrowth.17, 20 Progression tends to be slow, with hair loss quite diffuse. It mainly occurs in the distributions mentioned above. Miniaturised hairs are seen in the affected areas, hair shaft diversity is noted more easily on dermoscopic examination. Very occasionally peripilar halos/atrophy is seen as well. If shedding is present it is not as significant as in ATE or CTE, and the hair pull test is usually negative. Biopsy shows the abovementioned miniaturisation and a decreased terminal:vellus hair ratio, with a lower anagen:telogen ratio. The biopsy, which is not necessary unless doubt exists as to the diagnosis, should be taken from three sites, as a horizontal section and be about 4mm in diameter.17,20,24 By the time a biopsy is contemplated a patient would probably be seen by a dermatologist. While the diagnosis of FPHL is usually clinical, a biopsy should be performed when the diagnosis is uncertain.17,24The main differential diagnosis is CTE.17,20,23 The main difference is that CTE occurs as a rapid hair loss (FPHL is slower), lots of shedding is noted (as opposed to the presenting complaint being thinning hair). With CTE there is a positive pull test (patient should not shampoo their hair for 24 hours prior to test), when the effluvium is in an active shedding phase. Examination of the scalp in CTE does not show widening of the part, or miniaturisation, and biopsy is normal in CTE (apart from showing an increase in telogen hairs).17, 20 Acute telogen Effluvium ATE is also a diffuse type of hair loss which has an abrupt onset, usually seen 2-3 months after a trigger event, and usually does not last for longer than 6 months. About 15% of adult scalp hairs are in telogen phase – when telogen hairs are shed the bulb or club-shaped tip can usually be seen. Anagen hairs have a more tapered tip – there is no bulb because it is attached to the dermal papilla as the hair is still growing. 25 At the time of the precipitating event or trigger for the effluvium, as many as 75% of anagen hairs can be pushed into telogen. 20 A few months later the new anagen hairs starting to grow in the follicle push the old hairs out, and the hair shedding is noticed by the person as hair loss. In actual fact, this shedding is really a sign that new hair is growing. 25 Shedding reaches a peak and hair thickness gradually returns to normal over months in the majority of cases things are largely back to normal by about 1 year. 17 Sometimes the precipitati ng event causes a corresponding Beau’s line in the nail. 25 Potential causes of ATE would include: (febrile) illness, surgery, trauma/accident, childbirth, emotional trauma. Severe and sudden weight loss can also precipitate this. A number of drugs, including beta blockers, can cause an effluvium. Discontinuing the oral contraceptive can also cause hair to fall out, as can jetlag and excessive sun exposure.25 Chronic telogen Effluvium In CTE, the cause tends not be a single event that acts as a one-off trigger, but something that allows the hair loss to be perpetuated for longer than 6 months. 17 Many cases of CTE are idiopathic, but iron deficiency anaemia, hyper/hypothyroidism, zinc deficiency and malnutrition have been implicated as causative/contributory factors by a number of studies. 17,20 In CTE the hair shedding can fluctuate in severity, for example as an animal might moult. 25 Both acute and chronic telogen effluvium does not cause baldness as there is no miniaturisation or conversion of terminal hairs to vellus hairs, only decreased anagen hair growth. However, it can unmask an individual’s genetic tendency to bald. 20  Treatment of Diffuse hair loss Treatment of telogen Effluvium Treatment of acute and chronic telogen effluvium involves treating the underlying causes, if found. Removing the trigger factor for acute telogen effluvium should allow for an improvement in hair growth in most cases by about one year; most people will see an improvement after a few months already. 17,20 If no cause for CTE is found, a biopsy to rule out FPHL should be considered. 20 The course for CTE is that shedding occurs in phases, but never leads to balding. 20 It is thought to potentially take up to 3-10 years to resolve, but there are insufficient studies that have looked properly at this condition over time. 17 Empiric use of minoxidil 2% has been suggested, in the hope of decreasing telogen and increasing anagen. 20 Treatment of FPHL While a general practitioner may not be expected to able to offer all of the therapies available for the treatment of FPHL, it is very helpful to have a good understanding of the therapeutic processes so that patient questions can be dealt with a knowledgeable manner; this improves the therapeutic relationship. The primary care doctor should be able to initiate medical treatment in an uncomplicated case of FPHL. Minoxidil Minoxidil was first discovered to improve AGA while undergoing development as an oral antihypertensive drug, when it was seen to cause hypertrichosis, and hair growth in balding men. 8, 22, 26 It is now used as a topical treatment for AGA in a 2% and 5% strength. The exact mechanism of action is unclear. It is converted into its active metabolite by an enzyme present in the outer follicle of the hair sheath. In its activated form the drug opens potassium channels to bring about a vasodilatory effect, but studies looking at this effect after topical application of minoxidil, have been inconclusive. 22, 27 Other potential mechanisms of action could include induction of new blood vessel formation by increasing vascular endothelial growth factor gene expression at the site of the dermal papilla. Another theory is that it could stimulate activity of an enzyme (cytoprotective prostaglandin synthase I) which stimulates hair growth. 22, 27 It could also increase expression of the gene for he patocyte growth factor, which stimulates hair growth. Messenger and Rundegren 2004 have proposed that the mechanism of action is to cause premature end to telogen and prolong anagen.20, 27 Ongoing studies are needed into the mechanism of action of minoxidil, as this could help with development of better treatments. Although not enough is known about the mechanism of action to improve alopecia, it has been proven to be efficacious for both men and women. 17, 20, 22, 23, 26, 27 The European Dermatology Forum (EDF) performed an extensive literature review (of specific databases) with the aim of formulating evidence-based treatment guidelines for the treatment of AGA (it differentiates between male and female treatments but calls the conditions AGA). Based on the studies reviewed, it recommends topical application of minoxidil 2% or 5% applied twice daily for mild to moderate AGA, with the 5% strength favoured if greater efficacy required. A foam application (as opposed to the solution) is also available, but further studies comparing efficacy to the solution, are needed. 20 For women, the recommendation is also to use the 2% solution twice daily, but there is no evidence currently available to support the use of 5% strength in females.20, 22, 28 In a study by Lucky et al. female patients were foun d to show psychosocial improvement after using 2% and5% minoxidil respectively, compared with placebo. More pruritis, local irritation and hypertrichosis were reported by women using the 5% solution.28 Patients should always be counselled thoroughly before starting medication. This is vital for compliance, as the progression of the hair loss is only halted/reversed for the duration of compliance. Counselling should include how to apply the medication (1ml in a dropper, applied to dry scalp morning and night and not washed for at least 4 hours – if hair/scalp get wet within an hour the medication should be reapplied), the importance of compliance for results,  when to expect an improvement, as well as potential side effects. 20 There are three main side effects. One is an apparently paradoxical shedding of hairs – if minoxidil does indeed shorten telogen and stimulate anagen then any new hairs forming would ‘push out’ the old. It is very important that the patient is informed to continue with the treatment, and they could be reassured that this is a sign of the medication working; this effect usually occurs in the first 2-8 weeks of treatment.17, 20 , 22, 23 The other main side effects are related to contact, so it is important to warn the patient to wash their hands immediately after application. Hypertrichosis can occur, mainly because of incorrect application (usually disappears about 4 months after cessation of the treatment). 17, 20, 22, 28 The patient should be advised to apply the medication 2 hours before going to bed at night so that there is less risk of transfer to the pillow, and subsequently to the face. 22Contact dermatitis, either allergic or irritant, has also been reported. 17, 20, 22, 28The main causative agent is the vehicle for the drug, called propyleneglycol, in higher concentration in the 5% solution. 20,22, 28 If contact irritant dermatitis is confirmed then the vehicle should be changed (for example to the foam application – positive results have been produced by Lucky et all with regards to equal efficacy to the solution, and better tolerability from subjects). 20 However if an allergy to minoxi dil is confirmed then the treatment needs to be abandoned/changed completely. 20, 22 The EDF has advised that efficacy should be assessed at 6 months for cessation of shedding and 12 months for regrowth.  22 The treatment should be continued for as long as the therapeutic benefit is required. This is lost with cessation of treatment, with hair loss recommencing about 3 months after cessation. Pregnant and lactating women are advised not use minoxidil, even though no adverse outcomes were noted after a large study.17, 20, 22, 23 5 a-reductase inhibitors These drugs were initially aimed at treating men with prostatic hypertrophy, and both licensed 5 a-reductase inhibitors, finasteride and dutasteride, are currently used to treat this condition. Of the two, finasteride is also registered to treat AGA in men.22 The mechanism of action of finasteride is to act as on 5 a-reductase II, the receptors of which are mainly found in the scalp, skin and liver. Dutasteride acts on both types I (gut and prostate) and II 5 a-reductase. Finasteride reduces serum DHT by about 58-60% 17, 22 while dutasteride reduces serum DHT by about 90% 22 In all the clinical trials assessed by the European Dermatology Forum, 1mg of finasteride taken daily showed a significant improvement by 6 months, compared to placebo, and the same was true at 12 months, and up to a 60 months follow-up. Dutasteride was also looked at by a number of authors and showed an improvement in hair loss but at a much higher dose than that needed to treat benign prostatic hypertrophy. 22 Further studies comparing its efficacy to 1mg finasteride are needed. There are not many studies assessing the efficacy of finasteride in females – in a study of post menopausal women taking finasteride, further hair loss was noted.22, 23 Finasteride is therefore not indicated in women, although one study has shown positive results in women with FPHL and hyperandrogenism. 17, 20 There have also been sporadic reports of finasteride improving hair loss in individual female patients.20, 23More studies into finasteride for use in FPHL, are needed. If finasteride is used off licence in a female of reproductive age, adequate contraception needs to be taken to avoid feminisation of a male foetus. 17, 20, 22, 23  For this reason it is completely contraindicated in pregnancy. Finasteride also lowers PSA levels, so a baseline PSA blood test should be done on men aged 45 years or older, who are starting finasteride.20, 22, 23, 26 Finasteride also has a number of side effects which have potential psychosocial impact – it can cause erectile dysfunction in men and decreased libido. As with minoxidil, counselling is therefore indicated as compliance is important for outcome. For those who do not tolerate the 1mg dosage, a 0.2mg dosage can also be effective. 22 Studies looking at combining the above therapies were done. Khandpur et al showed that 2% minoxidil applied twice daily, and 1mg of oral finasteride daily, taken together, was superior to each therapy used by itself. Taking finasteride with Ketoconazole shampoo was also reported to be superior to the abovementioned monotherapies.20, 29 Combination therapies can therefore be considered if monotherapies are insufficient. Compliance is of course important. Hormone Treatment According to the European Dermatology Forum, evidence for the efficacy of hormonal treatment is limited. Anti-androgens act by blockading androgen receptors (AR) – these are therefore contraindicated in men as they cause feminisation. There is no evidence to support the use of oestrogens in men. (ref. 22) The Forum also decided that, based on their literature review, there was insufficient evidence to support the use of oestrogens, progesterones or anti-androgens in FPHL , although there was a place for anti-androgens in the treatment of some women with hyperandrogenism.22 Use of Spironolactone to treat hirsutism and FPHL is common, especially in the US.20 Spironolactone acts by binding to AR and also acts at the site of the ovary to reduce manufacture of androgens. In a study spironolactone was shown to be as effective as cyproterone acetate in FPHL, but only a small percentage of women showed improvement; the majority of women in the study showed no response. 20 Spironolacto ne is taken at a dosage of 100mg 200mg per day, with concurrent use of contraception. Cyproterone acetate is taken at a dosage of 25-100mg per day for 10 days of every menstrual cycle, also with concurrent use of contraception.17, 20 Cyproterone inhibits gonadotrophin-releasing hormone (GnRH) and blocks AR; it is also used for treatment of acne, prostate cancer and hirsutism. Vexiau compared minoxidil 2% and cyproterone – the former was more effective in women who had no hyperandrogenism, and the latter was more effective for those who had, 20, 30 suggesting some role for anti-androgens. Flutamide is another anti-androgen; it compared favourably against finasteride and cyproterone for treatment of FPHL, and also compared favourably against Spironolactone for treatment of acne, seborrhoea, FPHL and hirsutism. 20 However, this drug has a significant side effect profile in that it can potentially cause hepatotoxicity – ongoing monitoring is therefore required and the medication should be stopped or not commenced in the face of significant abnormality.20 Anti-androgen therapy can cause disturbances of the menstrual cycle, breast tenderness, and are contraindicated in pregnancy due to feminisation of male foetus. Spironolactone increases potassium levels, so monitoring of electrolytes is required, as well as hypotension. Adequate counselling prior to commencement of treatment is paramount.20 Surgery There are two types of surgical procedures used to treat alopecia – these are hair transplantation and scalp reduction surgery; they can also be used in conjunction with each other. Because AGA is pattern hair loss, as mentioned earlier, there will be certain areas on the scalp that have a greater tendency to balding than others, for example the occipital area does not have a tendency to bald in pattern hair loss. It makes sense therefore, that for hair transplantation to be effective, the donor site needs to be from an area that is less androgen sensitive or prone to shedding, such as the occipital scalp. The process involves microsurgical techniques of implanting harvested terminal hair follicles under local anaesthetic, into areas of scalp needing more hair. Donor sites must be carefully chosen, the grafts harvested, prepared and implanted without any damage, in order to obtain optimal results. Certain techniques show superiority of efficacy 22.  One study showed a combi nation of hair transplantation surgery with 1mg of oral finasteride had superior results at one year compared with surgery alone. 22 In women the ideal candidate has thick occipital hair and decreased hair density over the frontal scalp. 20 Between one and three sessions are usually required 6 months apart to allow adequate assessment of each surgery. 20 Occasionally there is an effluvium a few weeks after the procedure, but this can often be avoided with concurrent use of 2% minoxidil 20. The best results are achieved in controlled/stabilized AGA and when there is optimal, sufficient donor site. Women with concurrent diffuse effluvium are not good candidates as there is not an optimal donor site. In a good candidate, surgery can result in as good a result as in men. 20 Scalp reduction surgery is not as widely practiced as hair transplant surgery. In scalp reduction surgery the area of scalp with alopecia is surgically removed and two areas of scalp with hair growth are surgically approximated. Scarring and the need for revision surgery, are disadvantages. 20,22 Supplementation A number of trials looking at amino acid supplementation, trace element supplementation (zinc, copper, iron), vitamins like biotin and niacin, antioxidants and millet seed, were assessed by the EDF who found the most of the studies flawed in some way and therefore inconclusive. 22 An improvement in hair growth with use of a herbal treatment containing hibiscus, polygonum, fennel chamomile, thiya and menthe was reported by one author 22Another study also showed some improvement in hair growth after application of a Chinese herbal treatment for six months. 22Retinoids were not proven to show a significant improvement. 22 Saw Palmetto was also looked at by some studies and showed improvements that were significant when compared with placebo.22 Cosmetic Aids While treatments for FPHL are ongoing, or if the patient may for some reason choose not to pursue treatment, or if these were perhaps contraindicated in someone, discussing ways of coping cosmetically may be useful. One study 22 noted that both males and females suffer psychologically when afflicted with hair loss, but for men it was more socially acceptable to be balding than for women, and so the psychological impact can be higher for women who face more pressure to have a ‘normal’ physical appearance. Another study looked at the difference between a woman’s perception of the severity of her hair loss, compared with the clinician’s assessment of this 31. It found that women consistently rated the severity of their hair loss as higher than the clinician. The study also found that the decrease in quality of life was disproportionate to the degree of hair loss. 31 It is therefore important to consider the patient’s psychological and mental health as well when approaching the issue of hair loss. For this reason it is important to address cosmetic aids and discuss practical issues which may help camouflage the problem in a way that makes the patient feel less conspicuous. Sinclair makes the point that a good hairstylist can be invaluable 20; styling hair in a way to create volume and hide the problem, and learning washing, drying and styling techniques that discourage damage to remaining hair is important. Camouflaging products to create the illusion of thickness include hair building fibres, spray hair thickeners, masking lotion, and topical shading. Fibres can be shaken onto the affected scalp and works in about 30 seconds to create the illusion of thickness. Spray thickeners also create the illusion of increased thickness but can be messy to apply. Tinted lotion and topical shading are less messy and help to create thicker looking hair. Another option, especially if the hair loss is very  advanced or if the application of products is unacceptable for whatever reason, is to use hair extensions, hair weaves/integration pieces or wigs. These depend on choice, and on the quality and amount of remaining hair 20. Hair accessories such as hats, scarves and other fashion accessories can also be useful. The Hair Consultation History After noting gender and age, it is important to determine the nature of the complaint. Has the hair been falling out, breaking off, appearing thinner without noticeable hair loss, or does the quality of the hair appear different.  23 Conditions like monilethrix can result in short fragile hair that breaks easily; in some protein energy malnutritional states such as kwashiorkor hair also breaks easily; with thyroid disorders hair can appear dry and course. Has the problem occurred in the past, or is this the first episode? Has it appeared to improve before? In other words, what is the course of the problem? In CTE, the problem can occur for short periods of time, intermittently for a number of years. Spontaneous regrowth occurs in TE postpartum. Is there a seasonal variation? Also determine the age at which the problem was first noted. 23,24 Have there been associated symptoms related to the hair problem, such as dandruff, itching of the scalp, burning or painful sensation of the scalp, any rashes occurring simultaneously on the body, any systemic features such as tiredness (anaemia, thyroid problems). Initial signs of AGA can be itching or trichodynia. 24 Any inflammatory condition of the scalp can cause hair loss which can be precluded by itching, scaling or flaking of the scalp. An oily skin can indicate increased activity of the seborrhoeic glands which could indicate increased androgen sensitivity/levels. 24 What is the patient’s past medical history (including any change in health in the year before noticing the hair loss)– severe infections, chronic disease which can cause anaemia of chronic disorder, thyroid problems, medications taken, eczema, any autoimmune disorders, and any chemotherapy or radiation therapy in the past. 23,24 Treatment for breast cancer involving anti-oestrogen therapy can be associated with male pattern hair loss. 10 Gynaecological history for women is also important – menorrhagia, PCOS, amenorrhoea, hormonal contraception, whether post-menopausal and if so has/is hormone replacement therapy used. Discuss past pregnancies – was there difficulty in conceiving, miscarriages, was delivery particularly stressful/complicated. Discuss future family planning. Is there a tendency toward acne, hirsutism, and scalp/skin seborrhoea/oiliness? 23,24 Mental health – issues such as trichillomania, anorexia, and taking antipsycholtic or antidepressant medication. Medications can affect hair growth – beta blockers, anti-epileptics, chemotherapy, thyroid medication, oral contraceptions.  20, 23, 24 Social history is also important – some studies have pointed at smoking exacerbating hair loss. 24 Diet can affect nutritional status, which can affect hair. Sudden weight loss can trigger hair loss. 24Being overweight has been connected with hyperinsulinaemia and metabolic syndrome. The use of anabolic steroids can be significant. 24Enquire about hair products and styling methods – traction can cause problems. Family medical history can indicate an autoimmune problem, family history of male or female pattern balding, skin disorders such as atopy or psoriasis, PCOS, hirsutism. 23,24 It is also important to note from the history how the condition has affected the patient. In the study by Reid et al. mentioned earlier, 31 the clinician’s assessment of severity of hair loss did not predict the patient’s perception of severity of the problem, or their quality of life. While mental health may not always be present as a causative factor, hair loss can cause psychosocial problems such as depression, loss of self esteem and social isolation. 26 It is also important to find out what the patient’s expectations, and hopes, for treatment are. 23 Examination The clinician’s initial impressions are important – is the patient wearing a hairstyle with lots of traction on the scalp, is the person over/underweight, is there obvious hirsutism or acne, is the face looking a bit shiny? Does the person appear emotionally distressed/shy and recalcitrant? It is important to clinically evaluate the whole scalp, including skin and actual hair, facial skin and hair growth (are eyelashes present, is there hirsutism, is there appropriate beard growth), body skin and hair growth, and nails (in alopecia areata the nails can appear pitted). 23,24 Scalp With non-scarring alopecia the scalp should appear normal. Sometimes increased seborrhoea can aggravate AGA. (ref. 26) Scaling, erythema and crusting can indicate inflammation.  With scarring alopecia there is loss of the follicular os. 24 Sun damage in longstanding baldness can be significant. 24 Yellow dots are seen in alopecia areata on dermoscopy, which is thought to represent follicular openings plugged with a keratinous and sebum debris mixture. This can help to distinguish FPHL and TE, from alopecia areata incognita. 32 Hair Note the hairstyle, and whether the hair shafts appear damaged/ dry/ brittle/ broken. 23,24 Part the hair and compare width of the parting at the vertex, frontal, temporal and occipital areas – this is important when describing pattern of hair loss. Use a sheet of white paper for dark hair, and black paper for light/grey hair, over a parting in the hair, to look for miniaturised hair, broken hairs or variations among the hairs. 33 Exclamation hairs (tapering broken hairs) indicate alopecia areata. 32 Miniaturisation indicates AGA. 32 Note the pattern of hair loss – in MPHL, there is thinning and recession bitemporally initially, then in the vertex. In FPHL the pattern can demonstrate the Ludwig, Olsen (Christmas tree pattern) or the Sinclair description, or the Hamilton distribution. 20, 23, 24 Diffuse thinning of the hair can also be caused by diffuse alopecia areata or diffuse telogen effluvium. 20, 26, 24, 32 Pull test This is an important test to help differentiate at the initial consultation between the types of non-scarring alopecia, when not clinically obvious. It is important to determine when hair was washed, as a head washed more recently would be more likely to have lost telogen hairs and have fewer to yield. 17, 20 About 50-60 hairs are pulled between the thumb, forefinger and middle finger. A positive test occurs when more than 10% of the hairs can be pulled out.17, 20, 23, 24 Performing the test on different areas of the scalp is useful in excluding diffuse telogen effluvium; often this can co-exist with a pattern hair loss. 17 The test is usually negative for pattern hair loss, except when performed during a telogen phase in the affected area, when there would be more hairs than usual in the telogen phase. If the pull test is positive, a diagnosis other than pattern hair loss should at least be considered. 24 Non-scalp hair and skin Abnormal distribution of body hair is important to note as can indicate a hormonal problem which may need further investigations. An increased amount of body hair can be hormonal or genetic or related to medication. 24 Absent sexual hair can indicate a hormonal problem, and absent or scanty eyebrows or eyelashes can be associated with alopecia areata or frontal fibrosing alopecia. 24 Acne and seborrhoea can be hormonal. 26 Nails are affected by a number of dermatoses, but of the non-scarring alopecias, only alopecia areata has been known to cause nail changes. 24 Mentioned above is that the trigger causing ATE can sometimes cause Beau’s lines in the nails. 25 Lab tests The history and clinical examination should allow a diagnosis of non-scarring alopecia to be made, and for the problem to be classified as either pattern hair loss, telogen effluvium, or alopecia areata (or a combination). Because confounding factors may also be present which can exacerbate hair loss or prevent treatment, it is reasonable to do some laboratory tests, if suggested by the findings of the history and examination.17, 20, 23, 24 Serum ferritin and thyroid hormone levels should be done. 17, 20, 23, 24 In men it has been advised that after the age of 45, a PSA level should performed prior to treatment with finasteride, as this drug can lower PSA. The patient should be made aware of this side effect.23, 26 If on history and examination there is a suspicion of a virilising tumour, PCOS, or hyperandrogenism in women, then additional tests such as a free androgen index (FAI) (total testosterone x 100 / SHBG) test, and prolactin level as screening tests for hyperandrogenaemia – for example levels of FAI of 5 and above indicate that someone may have PCOS (reference). Depending on findings, FSH, or cortisol levels may also be needed, and the patient referred to either a gynaecologist or endocrinologist (or both if needed). 17, 20, 23, 24 Hormone levels are affected by ingestion of exogenous hormones so should be tested if no hormones taken for 2 months at least, and the time of the menstrual cycle noted for adequate interpretation of hormone results. 23 Oestrogens can increase the level of SHBG, and therefore improve FAI. 23 Other investigative tools available to dermatologists are  ·Ã‚       dermoscopy  in FPHL it shows increased hair diameter diversity and an increased number of vellus hairs. 32 Global photography – helps to evaluate the course of hair changes in clinical studies in an objective fashion – set regions of the scalp are photographed using standardised procedure and equipment 23,24 Trichoscan – for diagnostic and follow-up purposes, it measures hair density and anagen/telogen ratios. For reproducibility tattoos of the sample areas in frontal and occipital regions are needed. 23,24 Trichogram – to be used by a dermatologist experienced in its use. 24 Biopsy – not usually required for diagnosis of non-scarring alopecia, but may be helpful if there is doubt about the diagnosis. Much more relevant for cases of scarring alopecia. 17, 20, 23, 24 CASE DISCUSSION AND CONCLUSION The case of Mrs KJ is interesting because of the complexities involved. Her initial hair loss had occurred on cessation of Cilest. She therefore believed that stopping this had caused the problem, and helped maintain hair thickness, hence her request to be put back on Cilest when she saw her GP. As mentioned above, cessation of the combined oral contraceptive has been noted to cause transitory hair loss. However, at the time of the initial presentation she was put on Dianette and cyproterone as she was found to have PCOS. This is one of the potential causes of hyperandrogenism. Although her blood results did not show any hormonal imbalances, she mentioned that she had had facial hirsutism at the time, so was clinically hyperandrogenous without being biochemically hyperandrogenous. It may be that in the presence of normal hormone levels, she was more responsive to existing hormones, possibly with increased receptor sensitivity. The blood results could also not accurately be relied on as she was not taken off the oral contraception. The fact that there was hair growth with cyproterone suggests that androgens had their role to play in her case. When she presented to the GP for the second time, there were a number of issues to note. She had a very stressful and demanding job. It must be noted that Mrs KJ’s personality was that of a perfectionist, and it could be argued that people like this, who are driven to succeed might be more susceptible to stress. She had also planned her wedding and honey moon in the months leading up to the dramatic hair shedding which occurred whilst on honey moon. Added to this was her vegetarian diet, and although she was not anaemic, her ferritin level was below ‘the optimum’ levels discussed above, even though normal according to the lab reference range. The plot thickens. Based on the above the GP had correctly made the diagnosis of a telogen effluvium. However Mrs KJ had the compounding problem of PCOS. The underlying problem for Mrs KJ was the PCOS, a syndrome affecting about 5-10% of women. 34 PCOS symptoms are related to abnormal levels of sex hormones – high/high-normal Luteinising Hormone (LH) and androgens (including testosterone), and low Follicle Stimulating Hormone (FSH) and progesterone. The cause for PCOS is not known but there is an association with insulin resistance. 35 Insulin resistance causes the body to increase the amount of insulin produced. Higher insulin levels increase ovarian production of androgens, which inhibit ovarian follicular maturation, hence the menstrual abnormalities. 35 Higher androgen production also has an effect on hair growth, specifically, thinning of scalp hair in a pattern of hair loss. Although there was no history of baldness in the family, male or female, she presented with a typical male pattern of baldness with bilateral thinning of the temporal areas (Hamilton I). The second dermatologist noted increased seborrhoea, which can indicate clinical hyperandrogenism, and treated with Ketoconazole. This bitemporal thinning could have been occurring unnoticed as FPHL tends to be slowly progressive. Her hair loss shot to her attention with the abrupt onset of the telogen effluvium. One more interesting point to note is that when she saw her GP to discuss stress, neither considered the impact of the propranolol on her hair loss. She did present a few weeks after the short period of having used the propranolol, with a sudden increase in her hair loss, which may well have contributed to by the beta blocker. Whether a few days at a low dose would have made such an impact, is uncertain. The interesting case of Mrs KJ serves as a perfect example of why primary care physicians need to have a good approach to dealing with the rather complex problem of diffuse hair loss. Once each of the (potential) contributory factors had been treated, Mrs KJ started to grow a thicker, more dense, head of hair. Lastly, there is a small subset of patients in whom non-scarring hair loss serves to uncover more serious medical problems such as thyroid disease, hyperinsulinaemia, PCOS, Metabolic Syndrome and potential for heart disease. This link has been the subject of numerous studies. Matilainen et al. investigated whether early AGA could serve as a marker for insulin resistance, and concluded that further research was needed, but suggested that people with early AGA could benefit from cardiovascular screening. 36 This was supported by Arias-Santiago et al. who investigated lipid levels in women with AGA, and found that women with AGA were shown to have significantly higher levels than women with no AGA. 37  Abdel Fattah and Darwish found that people with metabolic syndrome, regardless of the presence of AGA, were more likely to be have insulin resistance, compared with people with AGA and normal controls. 38 This serves to highlight the point that while much work is still needed t o clarify the above, the vigilant GP, presented with the problem of FPHL, should also be on the lookout for comorbid disease or potential for these. Mrs KJ’s father had died of a heart attack in his early fifties, but she maintained a healthy lifestyle, normal lipid and glucose profile, and low-normal blood pressure and so had a low risk for cardiovascular disease. There is much on hair loss that was not discussed in this paper, such as cicatricial or scarring alopecia, localised hair loss (alopecia areata) and hair loss in children and adolescents. If the latter occurs, and appears to be non-scarring, it is best discussed with a paediatric endocrinologist and dermatologist. Dr Yumnah Ras MBChB, June 2011 REFERENCES 1. The Doctors Laboratory reference range for normal ferritin levels,2010. tdlpathology.com 2. Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea Febiger, 1918; Bartleby.com, 2000 www.bartleby.com/107/.June 2011 3. Slobodan M.Jankovic and Snezana V.Jankovic. The control of hair growth. Dermatology Online Journal 4(1):2 http://dermatology.cdlib.org/DOJvol4num1/original/jankovi.html 4. http://emedicine.medscape.com/article/835470 Author Samer Alaiti 5. http://emedicine.medscape.com/article/259724 Author Suzanne R Trupin, 6. Messenger, A. The control of Hair Growth: An overview.Journal of Investigative Dermatology Vol.101 No.1supplement,July 1993 7. http://emedicine.medscape.com/article/273153 Author Mohamed Yahya Abdel-Rahman, 8. Trueb, R. Molecular mechanisms of androgenic Alopecia. Experimental Gerontology 37 (2002) 981-990 9. Apridonidze et al.Prevalence and Characteristics of the Metabolic Syndrome in Women with Polycystic Ovary Syndrome. The Journal of Clinical Endocrinology Metabolism April 1, 2005 vol. 90 no. 4 1929-1935 10. Carlini, et al. Alopecia in a premenopausal breast cancer woman treated with letrozole and triptorelin. Ann Oncol (2003) 14 (11): 1689-1690. doi: 10.1093/annonc/mdg444 11. Kantor et al. Decreased Serum Ferritin is Associated with Alopecia in Women. Journal of Investigative Dermatology (2003) 121, 985–988; oi:10.1046/j.1523-1747.2003.12540.x 12. Olsen et al. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. Journal Am. Acad. Derm 2010 Dec 63 (6):991-9 Epub 2010 Oct 13. Rushton, D. Decreased Serum ferritin and Alopecia in Women. Journal of Investigative Dermatology (2003) 121, xvii–xviii; doi:10.1046/j.1523-1747.2003.12581.x 14. Moeinvaziri et al. Iron status in diffuse telogen hair loss among women. Acta Dermatovenerol Croat. 2009;17 (4):279-84. 15. Yip et al. Role of genetics and sex steroid hormones in male androgenetic alopecia and female pattern hair loss: An update of what we now know. Australian Journ derm (2011) 52, 81-88 16. Trost et al. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. Journ. Am. Acad. Dermatol. Vol (54) No.5 824-844 17. Shrivastava et al. Diffuse Hair loss in an adult Female: Approach to diagnosis and management. 18. Prasad, A. Clinical, endocrinological and biochemical effects of zinc deficiency. Clinics in Endocrinology and Metabolism Volume 14, Issue 3, August 1985, Pages 567-589 19. Goldberg et al. Nutrition and Hair. Clinics in Dermatology, Volume 28, Issue 4, July-August 2010, Pages 412-419 20. Dinh, Q and Sinclair, R. Female pattern hair loss: current treatment concepts. Clin Interv Aging. 2007 June; 2(2): 189-199. Published online 2007 June. 21. Gan, D and Sinclair, R. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005 Dec;10(3):184-9. 22.European Dermatology Forum, S3-Guideline on Androgenetic Alopecia. euroderm.org/edf/images/stories/guidelines/S3_guideline_androgenetic_alopecia.pdf 23. Blume-Peytavi, U and Vogt, A. Current Standards in the diagnostics and therapy of hair diseases. JDDG; 2011 9:394-412 24. Blume-Peytavi et al. S1 guideline for diagnosic evaluation in androgeentic alopecia in men, women and adolescents. Br J Dermatol. 2011 Jan;164(1):5-15. doi: 10.1111/j.1365-2133.2010.10011.x. Epub 2010 Dec 8. 25. http://dermnetnz.org/hair-nails-sweat/telogen-effluvium.html June 2011 26. Hordinsky, M. Medical Treatment of Noncicatricial Alopecia. Seminars in Cutaneous Medicine and Surgery Volume 25, Issue 1, March 2006, Pages 51-55 27. Messenger, A and Rundegren, J. Minoxidil: Mechanisms of Action on Hair Growth. British Journal of Dermatology Vol 150 (2):186–194, Feb 2004 28. Lucky et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol Vol 50 (4) p 541-553 29. Khandpur et al. Comparative efficacy of various treatment regimens for androgenetic alopecia in men.J Dermatol. 2002 Aug;29(8):489-98. 30. Vixiau et al. Effects of minoxidil 2% vs. cyproterone acetate treatment on female androgenetic alopecia: a controlled, 12-month randomized trial. British Journal of Dermatology Volume 146, Issue 6, pages 992–999, June 2002 31. Reid et al. Clinical Severity does not reliably predict quality of life in women with alopecia areatam telogen effluvium, or androgenenic alopecia. Journal of the American Academy of Dermatology, In Press, Corrected Proof, Available online 24 May 2011. 32. Tosti, A and Duque-Estrada, B. Dermoscopy in Hair Disorders. J Egypt Women Dermatol Soc. Vol. 7, No. 1, 2010 33. Course Notes on Hair, QMUL post.grad. Dip.Derm 2010/2011. 34. verity-pcos.org.uk/guidetopcos/whatispcos 35. Kovacs,P. Metabolic Syndrome amd PCOS. Medscape Ob/Gyn 2003; 8(2) medscape.com/viewarticle/456221 36. Matileinen et al. Early Androgenetic Alopecia as a marker of Insulin Resistance. The Lancet Vol(356) p1165-1166 Sept 30, 2000. 37. Arias-Santiago et al. Lipid levels in women with angrogenetic alopecia. International Journal of Dermatology 2010, 49, 1340-1342 38. Abdel Fattah, N and Darwish Y. Androgenetic alopecia and insulin reistance: are they truly associated? International Journal of Dermatology 2011, 50, 417-421
Wednesday, February 19, 2020
Customer Relationship Management Essay Example | Topics and Well Written Essays - 1500 words - 1
Customer Relationship Management - Essay Example According to the research findings learning relations should mature for positive results to be achieved; the use of IDIC enables customization of customer relationship. According to Peppers & Rodgers, IDIC involves several tasks, which can assist an organization to build learning relationship. Identifying customers is very important for a company, since it is easier to know the preferences of that specific customer. Differentiating customers involves identify customers of different levels, and their different needs; indeed, interacting with customers is vital. Therefore, organizations must improve their interaction, which enables the company to identify the needs of customers. Customizing customer treatment involves engaging the customer in a learning relationship, which includes adjusting the company’s behavior to meet the needs of a customer. In addition, use of ICTs enables an organization to research on effective CRM tools, which can foster learning relationships, and as a result, attracting and retaining customers. An organizational chart clearly shows the structure of an organization. As a result, these charts aid in organizing the place of work, by providing managers with departmental information. Therefore, a well-organized structure will definitely boost the customer relationship management through prioritizing on customer needs and fostering healthy interaction with such customers. Below is the Imperial Limited’s organizational chart; this organization interacts with customers daily, as it provides decoration services for weddings and other events. Figure 1: imperial decoration company, organizational chart How should that chart be changed in order to facilitate customer management and to make sure people are evaluated, measured, and compensated for building the value of the customer base? Currently, the company comprises of the chief executive officer, a vice president, and managers in all the respective departments. Generally, managers ’ responsibility involves co-coordinating activities in their respective departments and reporting to the vice president, who reports to the chief executive officer. However, in order for the organization to foster customer value through managing relationships, it must be ready to identify, differentiate, and interact with customers. According to Day (N.d, p.2), organization structures include coordinating mechanisms; however, they should be more customer-focused. Imperial Decoration Company is a service rendering company, where the human resources department deals with employees’ welfare, which includes training, salaries, and annual leaves among others. The marketing department markets the company through advertising, good customer services, and promotion. The accounts department handles all the returns of the company. Competition is increasing and the company needs to
Tuesday, February 4, 2020
Macro Economics Assignment Example | Topics and Well Written Essays - 500 words - 5
Macro Economics - Assignment Example It also provides individuals to act based on their self-interest regarding the decisions in the economy. This thought ensures that the economic resources are allocated based on the desires of businesses and individuals. The classical economists uses the value of money in determining the prices in the market. On the other hand, the Keynesian school of thought depends on the aggregate demand and spending in defining the economic marketplace. The Keynesian economists believe that the private and public decisions influences the aggregate demand. Public decisions entails the municipalities and government agencies. Private decisions entails the businesses and the individuals found in the economic marketplace. Government spending is not one of the major forces in classical economic literature. Business investments and consumer spending represent the most important section of the country. Too much government expenses takes away the resources needed by businesses and individuals. On the contrary, the Keynesian economics relies on the government spending to jumpstart the nation (Nikaido, 546). The classical school of thought focuses to create long term mitigation for economic problems. The issues on inflation, government taxes, and government regulations are the main agenda for the classical school of thought. The Keynesian school of thought focuses on the immediate outcome in the economic theories. The policies set by the Keynesians were short term and required instant corrections to the nation. This is the reason why government spending is the main cog in this school of thought. From the classical model graph, the aggregate supply curve is illustrated by the vertical line. From the Keynesian model, the aggregate supply curve slopes upwards based on the Keynesian school of thought. The two school of thought represents the aggregate supply and aggregate demand and they
Sunday, January 26, 2020
Analysis Of Cultural Imperialism With Hollywood Films Media Essay
Analysis Of Cultural Imperialism With Hollywood Films Media Essay With the rising of electronic media, in the 1960s scholar Marshall Mcluhan raised the notion of global village, which provides a common platform of random communication without physical and geography distance for worldwide people. In this perspective, this kind of information circumstance will enforce everyone globally to be the participant of, and struggle for a same strategy, because we are inevitably connected with each other (Mcluhan and Quentin, 1967). In the rest years of twentieth century, with the assistant of advanced technology and high-developing economy ¼Ã…’the whole world seems to increasingly move forwards to the global village in nature. The concept of globalization, to some extent, already gradually rooted in peoples mind. In the process of globalization, in generally, two primary constituent parts cannot be neglected. One is the distance between time, space and place has shrunk (Giddens, 1990; Harvey, 1990; Rantanen, 2005), which is owing to the technological adv ances, such as electronic media, instantaneous communication that enable people to realize interaction over the boundaries of country and time, which is also the precondition of the realization of globalization. In this sense, the global communication systems prompt the instant currency of capital and offer possibility for the expansion of production and marketing strategies. The other one concerns the content of the communication. With the help of telecommunication technology, the diffusion of media products have surpassed the country border. By the way of music, press issues, films and broadcast channels, the images, thoughts, and sounds of different cultures are mutually flowing among a vast network of people in the worldwide sphere. For this, the project of globalization refers to the communication and incorporation of culture from different areas. In addition, the globalization of mass media, especially, aims to the content of cultural products can be obtained globally (Croteau and Hoynes, 2003). In this sense, confronting the problem of the promise and reality of media globalization, researchers respectively hold different viewpoints. Among these debates, an important discourse called cultural imperialism, which is resulted from the worry of the inequality of global media ownership, control consumption and content, should be highlighted. A number of scholars, because of the superiority of Western media products on the consumption marketing, claim that media globalization equals cultural imperialism, and convey deep concerns with globally cultural homogenization and standardization. Especially, accompanied by the globally prevailing consumerism, traditionally national cultures of each country all have the possibility of being unified into a common global commercial culture system. The most typical evidence is the export of American cultural goods in the range of whole world. As we can see, Coca-Cola, IBM, Levis, and Hollywood films, these global brands ar e all produced by the U.S.. However, there are still a part of socialists understandably suspect the discourse of cultural imperialism on the concept of culture and the confusion of cultural goods and ideological effects (Tomplinson, 1999). On the Basis of the controversy over the discourse of cultural imperialism, in this essay, I intend to through the analysis of concrete and weighted American media product-Hollywood films, research whether so-called cultural imperialism can work under the condition of consumerist culture, which appeared as the key representation of cultural homogenization. The focus of part 1 is the literature review of the details of cultural imperialism, which involving its original definition, critique and impacts. Based on the theoretical analysis of cultural imperialism in part1, the next section will associate with specific data and text analysis, to examine the relative statement of cultural imperialism. In the last part, I will point out my own discussion over the cultural imperialism, and conclude the limitation. The Discourse of Cultural Imperialism Before moving to the main argument of this paper, it is necessary to define the notion of cultural imperialism. As early as the first decade of the nineteenth century, Lenin suggested the concept of imperialism. In his perspective, the term of imperialism was closely linked with economy, and we can regard it as the highest form of capitalism. ( Lenin, 1939). He pointed that at this level of capitalism, imperialism appeared as a process that big conglomerates incorporate smaller enterprises for the further profits, and moreover, this kind of operation could surpass the national boundaries. In addition, this sort of economic conduction is between the major capitalist nations, and it will result in specific imperialist patterns of domination. In this sense, Maybe cultural imperialism is one consequence of the specific imperialist patterns of domination Lenin said. Williams (1983) also has more further viewpoint towards the concept of imperialism. As for Williams, he concludes imperialis m as: Like any word which refers to fundamental social and political conflicts, cannot be reduced, semantically, to a single proper meaning. Its important historical and contemporary variations of meanings point to real processes which have to be studied in their owen terms (p. 160). Additionally, he even particularly generalized the development of imperialism into two categories, politically and economically. Relating with this paper, the economic category is worth being mentioned. As Williams argued, this process originated from Marxist analysis of the development of modern capitalism, which is similar as Lenins argument. As a result, combining current modern capitalism statement with the characteristic of imperialism, Williams claimed, imperialism in contemporary context is applied to the practices of US and Soviet Union. However, American imperialism refers to a primarily economic denomination associated with the global reach of capitalism but not having the political form of colonialism (John, 1991). As a result, with the post-war non-colonial process since the 1960s and the development of contemporary capitalism, the analysis of new imperialism has emerged among academic circle, which considered that, in the new international settings, the imperialist expan sion strategy has moved primarily from military aggression and directly colonial domination to economic and cultural penetration, in which, the discourse of cultural imperialism is a significant and critical theory of cultural globalization. About the concept of cultural imperialism, there are existing different versions. The earliest systematic one was given by Herbert Schiller. Furthermore, Tunstall(1977) crystalized the definition of cultural imperialism as: The cultural imperialism thesis claims that authentic, traditional and local culture in many arts of the world is being battered out of existence by the indiscriminate dumping of large quantities of slick commercial and media products mainly from the United States. In this sense, it is clear that the process of cultural imperialism is operated by the products import of majority capitalist countries (mainly the U.S.A.), primarily media products. In this sense, non-Marxists prefer to see cultural imperialism as media imperialism. If that, the discourse of cultural imperialism can be approached on the sphere of media, which turns to the empirical territory instead of theoretical assumptions (Chin-Chuan Lee, 1979). Similar as Lees account of media imperialism, Oliver Boyd Barrett (1977) defines media imperialism as: The process whereby the ownership, structure distribution or content of the media in any one country is subject to substantial external pressures from the media interests of any other country or countries- without proportional reciprocation of influence by the country so affected (p. 116). He also suggests four modes of media imperialism: 1) the shape of the communication vehicle 2) a set of industrial arrangements 3) a body of values 4) media content, which could exert the cultural dominance instead of direct economic relationship. David Croteau and Wiliam Hoynes (2003) proposed more detailed connection and explanation of Boyd-Barretts statement. First of all, they claims that the linkage between cultural imperialism and media imperialism is because of the media products, which from Western side, especially America, intensely impact other regions culture, almost have reached the level of cultural domination. Here, it refers to the relation of media ownership and media content. According to the theory of media imperialism, both values and ideology of Western society are embedded in the media products sold on the interests of Western corporations. Next, Croteau and Hoynes (2003) in their book Media/Society also cite Antonio Gramscis theory of hegemony to explain the con cept and significance of cultural hegemony, and sociologist Stuart Halls analysis of how mass media institutions mix with this conception of hegemony. The conception of Gramscis (1971) hegemony is connecting all culture, power, and ideology together. In his perspective, besides military force, power can be obtained by the way of cultural and ideological domination as well. For this direction, the key strategy is to create consent, which can be realized through a kind of cultural hegemony. Croteau and Hoynes said that consent is something that is won ¼Ã¢â‚¬ ºruling groups in a society actively seek to have their worldview accepted by all members of society as the universal way of thinking (p.166). In this sense, schools, religion, and media naturally become the sites where help the dominant class approach this kind of hegemony, due to these institutions are the places where we form the ways of thinking. On this basis, Hall(1982) suggested that mass media is the main site where the cultural hegemony is exercised, because media images are not merely reflecting the world, but represent ing the world, and could actively make things have meanings. And then, associating with media ownership and commercial profits, many scholars argue that media is principally on the behalf of the dominant assumptions, and applying the universal views of the world that most people know. With the development of the globalization of mass media, this conception is more convincing. For example, because of the motive of media globalization is commercial interests, plus the economic distance among different countries, the inequality of media globalization is inevitable and obvious. The growth of centralized media conglomerates will result in a concentrated global media industry. And additionally, the ownership of these global media firms are still in the hands of a few advanced developed countries, which also dominate the production of global media products. As a result, from this respect, major researchers are likely to connect the elite status of Western media products with cultural imperialism. The most typical one should be the impact of American media items globally. Coca-Cola, the products of Disney series, McDonald, Hollywood movies, and so forth American products are all prevailing across the world because of the propaganda of American mass media. The supporters of cultural imperialism claims that these foreign imports will threaten and even dominate the local culture. (Coteau and Hoynes, 2003). For instance, according to the data of Ministry of Culture and Communication in 2001, American films occupy 54% to 92% of the performing movie in theaters in countries of the European Union, in contrast, European films make up only 3% of films shown in the United States (Ministry of culture and Communication, 2001). Schiller (1992) also from the television program export to describe the high level of American media domination globally. He indicated that commercial television has become an important and flourishing national export (p.129). He also quoted the former official of United States Information Agency Woilson P. Dizards (1964) words to prove this point, who said that today, overseas sales account for 60 percent of all U.S. telefilm syndication activities and represent the difference between profit and loss for the entire industry (p. 58). Besides, in 1967, Dizard reported that the amount of [TV commercial] exports, now approaching $100 million a year, is such that the television screen is becoming the main source of the American image for increasing millions of people abroad (1967, p. 59). From all these data, it is clear that American media industry, to a large extent, is relying on foreign markets, and its impact of media products is intensifying. Associating with Halls analysis of mass media and culture, through media products to diffuse Western values and ideology seems sensible. The discourse of cultural imperialism looks like could be used to describe one phenomenon of cultural globalization, which through exporting media products to diffuse own countrys values and ideology, in order to the last culture domination. However, there are partial scholars who dont agree with this discourse of cultural imperialism or media imperialism. The main critic of the discourse of cultural imperialism-John Tomlinson, provided a comprehensive critique pinpointing each part of cultural imperialism. Schillers theory of cultural imperialism focuses on the media, and from economic and political perspective to view the unequal structure of global cultural production and distribution. For this, Tomlinson (1991) argues that there are two mistakes underlying in this theory. First, though media is an important component of culture, it can not substitute all aspects of culture, and its impact on indigenous culture is closely connected with local audiences understanding and individual experience of media products. Secondly, Tomlinson argues that it is a kind of exaggeration to attribute the overwhelming significance of cultural imperialism to the media. It is problematic to equate cultural imperialism with media imperiali sm. All these studies are very helpful in the depiction of the discourse of cultural imperialism, either proponent or sceptic. In next part, I will combine the specific media text-American Hollywood films, to analyze the expression of cultural imperialism on the basis of American primarily cultural values. Hollywood Films Like I mentioned in last section, media products are an effective way to diffuse certain values and ideology, consequently, realizing the purpose of cultural domination. In this respect, in order to analyze the discourse of cultural imperialism through the dissection of one concrete media text, it is inevitable to mention what kind of values or ideological theory is implied in that media text, and these ideas is serving for whose benefits. Undoubtedly, in recent decades, the United States of America through its powerful economic and technological strength, its cultural perpetrator to the less advanced countries is apparent, either material products or spiritually cultural products and social political values. For example, the standard American icons-Mickey Mouse, Coca-Cola, McDonalds, Hollywood are typical evidences. Then, what American values have been propagated through these popular issues? In general, white peoples traditional culture is the leading culture in America, what is al so called WASP culture (White Angle-Saxon Protestant Culture) (Kennedy, 2001. p. 913). American main stream culture actually is the special mixture of Christianity, Capitalism and democracy (translated from: Majie Zhu, 2003). Contemporary Hollywood films can, to some extent, through this specially cultural value, gain the market and extraordinary box office receipts, and subsequently, become the key approach for the expansion and penetration of culture imperialism. Individualism as the cultural value originated from the thinking of European burgeoning bourgeoise, which was used to oppose the autocracy feudal aristocracy during the renaissance. The early North American Puritan as same as the reason for getting rid of the European religion oppression migrated to America. And then, in American The Declaration of Independence, some self-evident truth is included, all men are created equal, that they are endowed by their creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness (Tefferson and Fink, 2002, p. 21-23). In American peoples thought, individual liberty is the final purpose, and society just the channel to reach this aim. In addition, Americans advocate surpass others by own effort, against any kind of inference to personal liberty from country or society. In short, individualism, is I will take responsibility of every thing by myself. In 1998, when American president Clinton visited China, he has said that the rights of life, liberty and the pursuit of happiness, free from government interference to express different views and the right of free faith, are the central idea of the founding of the United states. And this is also the thought that leaded Americans from one side of continent to another side, and finally stand on the top of the world , and so far, American people still value it as a precious thinking (translated from: Zheng Yuan, 1998). In this respect, individualism is the main motive stimulating not only American constant innovation, but also the reckless expansion with the indifference of other countries interests. On the basis of above introduction of several American mainstream values, it is timing to associate it with the analysis of concrete Hollywood films to research the discourse of cultural imperialism in American way. The classic film-Forrest Gump in 1995, ever gained the Best Film Reward of Oscar Award. Through the picture of the life of retarded Gump, we can get in touch with many aspects of American social life. This film was adapted from the same named novel of Winston Groom. The original book is fantastic fiction filling with ironic senses, however, the film has decorated and beautified the whole story. The original fantastic and ironic meaning have been removed, and the rebellious fighting spirit was sacrificed as well. Gump in the film has been shaped as an idealized American civilian hero, who has noble morality, and his way of earning life and pursuing happiness is on the effort to glorify America. The role of Gump in film, can be seen as the representative figure of American individualism, and this image is advocated by American society, which can be testified from the scene that Gump is endowed of congress badge. Another instance is the extremely costing Hollywood war film- Saving Priva te Ryan, which is an propaganda of American individualism. The whole story is processing along with the group rescue of individual life. This theme matches the Jewish traditional principle in the film Schindlers list- he who saves one life saves the world entire. Additionally, Hollywood films always put the mission of saving all the world on the shoulder of an individual. In the film Air Force One, the image of American President Tim Marshall is a good example. For protecting own countrys people and reputation, he insists on not compromising over the terrorists. In the condition of utter helplessness, by the familiar with each precise device of Air Force One, Marshall struggled with those terrorists by himself, and finally, realized the promise of zero-tolerance and save the world (lines in the film Air Force One, 1997). Within this film, American President is eager to expand the liberal-democracy, the Christian faith and the concept of American family to global people. However, in realistic life, this kind of omnipotent heroism is merely a myth. What anti-terrorism really need is the cooperation of all the nations, which has been proved through the fact of Somali Piracy event in April, 2009. Another film Bable in 2006 provides another angle to view cultural imperialism in Hollywood film. An accidental gun shooting event leads to the whole plots in the next story. Western people in this film enact rare indecision when they are encountering accident, which seems to lose the traditional image of the leadership globally. However, it cannot say that Hollywood films give up to play the role as an assistant of undertaking American cultural imperialism. One made-up clip story in the film that American tourists get innocent attacked, is bringing the color of cultural imperialism seemingly, because we can see the scene in the way that it tells the immense audiences that terrorism is prevailing in East as well, and Americans in this turn are becoming innocent victims. Although the director of this film attempts to utilize a large number of Eastern images to cover the hegemony of American cultural imperialism, the propagated American universalism and human right have been performed obviously. Furthermore, another kind of Hollywood films should be paid attention in particularly-Hollywood cartoon, some of which are coated by Chinese traditional culture. The film Mulan presented by Disney corporation was adapted from Chinese folktale. The protagonist Mulan made her promise to resist outside invasion, and protect family reputation, which looks as if expressed Chinese traditional loyalty and filiality. But, the role of Mulan enacted in the film is independent and pursuing the confirmation of self-value and the sexual equality, which is against the original Chinese convention. Additionally, her intensive desire of individual happiness and freedom are all representing the individualism of America. And as same as the elements of KungFu Panda presented by Dreamwork, which are not real Chinese culture. As the first cartoon that has over hundreds million tickets sale in Chinese market, KungFu Panda benefited from the outfit of Chinese culture and the inside substantive c ontents of Western culture. On the surface, there are plenty of Chinese culture facts in the films, such as the architecture music, martial arts, firecrackers, and Chinese food. Even many story details have precisely conformed to the relative characteristics of Chinese culture. In spite of all these work, the protagonist Po, it still a hero in the context of American culture values. The process of how he turns to legendary warrior just from a cooker is a typical instance of Americanized value. Originally, Po is a normal people, although because of an accidental opportunity he becomes the candidate of legendary warriors, he is indeed attending the selection ceremony. In another words, although his hero role is destined officially, he also follows the contest policy. This is a classic paradox logic in American culture: advocating everyone possesssing equal right to be a hero, although frequently, the hero is destined. Pos success is through defeating the bad guy-Tai Lung, to gain the final hero coronation ceremony. This kind of fight between justice and evil, and the procedural of how the justice side defeats the bad side are the essence of American heroism. Pos success, simultaneously, is bringing the peace to the whole village, which as same as the line in Spiderman- great power comes with great responsibility (cited from the lines of the film Spiderman, 2002). In American individualism, the standard of being a hero is to defeat the evil power and have the sense of bearing huge responsibility, which consequently, might be improved into the thinking that only the supremacy of strength is equivalent with the duty of guarding the world peace. In this sense, we can see the color of cultural imperialism is embedded in KungFu Panda. Thus maybe we can think in this way like that the set of films such as Mulan and KungFu Panda are packed with Chinese culture, but actually, are the means of distributing American ideology through adaption. Further Discussion of Culture Imperialism In contemporary global market, Hollywood movie is merely one of the popular import media products of America, but from the analysis of its underlying elements of culture imperialism, maybe we can consider the media products, television programs, advertisements, and music in the similar way. However, in this respect, I dont mean that the discourse of cultural imperialism does make sense, or even could be totally equaled with media imperialism, because after all, it is just a researching theme raised in the background of globalization and consumerism, and the debate about it is still taking place, therefore I cannot arbitrarily suggest its character here. What I want to do here is to use already existing facts to demonstrate that the discourse of cultural imperialism to some extent in particular time and condition may be could have an effect, but with the moving of age and society, in certain environment, another possibility maybe emerge. Among several suspicions of the possibility of cultural imperialism or media imperialism, an important one is to oppose to mix the material media products with complicated ideology together. In other words, the sceptic claims that the way of thinking that media products could diffuse Western values or ideology is ridiculous and doubtful, all of those analysis, such as the one above about Hollywood movie, are just assumption. In this perspective, if by some way I can prove the causal relationship between media productions and ideology or mind, the discourse of cultural imperialism at least will be more convincing. I will still utilize films as the evidence. During the 1980s there were two popular film genres-action adventure and military/war films deserving research, such as the films Raiders of the Lost Ark, Romancing the Stone and the series of Rombo were all effective and classic in that age. The most historical and typical one, I think should be Rombo. From the presentation time, we can know that it was after the Vietnam War and during the period of the Cold War, which represented by the United States and Soviet Union. The protagonist Rombo is a Vietnam Veteran, his mission is to return to Vietnam for rescuing American prisoners who have been abandoned by the U.S. government. And the common ending of this series of films was that the protagonist won the final victory and he become the hero in audiences mind. Following the story of these films, American people as if return to the battle of Vietnam War, but in this battle there are no vanquish and shame any more, American soldier will always be the victor. A part of scholars analyzed that these films could be seen as one political approach of Regans presidency, which was helpful to re-shape national image and regain national conviction. And actually, in the late 1980s, American people indeed overcame the so-called Vietnam syndrome, which was the subsequence of American failure of Vietnam War (Croteau and Hoyne s. 2003). From this example, we can see that there actually exists some relation between media texts and peoples way of thinking. So in this sense, the discourse of cultural imperialism maybe really can have an effect. However, the analysis of media texts is a plural item, which should be connected with special time and conditions, because of media texts are made under special historic background and people. We also cannot use one example to explain all the other terms. Additionally, the discourse of cultural imperialism was raised under the context of global culture, which maybe impact on global people, who have different religion, education, national culture and ideology, the possibility of their reactions over a media text are so hard to define. As a result, the relation between media texts and ideology maybe exist, but it is hard to say when put it in the global environment, then, dont even say the realization of cultural imperialism. Tunstall (1977) also claims that there are a t least two problems on the discourse of cultural imperialism of America. Firstly, the precondition of cultural imperialism is the superiority of Western countries on the aspect of media product market share , especially the United States of America, but the researchers thinks that with the economic and technologic development globally, other countries will rapidly create local media products, which would substitute the dependance on exporting American media products. Secondly, Tunstall said that the range of media is fairly wild, we cannot only concentrate on the popular American media products to analysis its impact of global culture. And in the aspect of some media forms, such as music, the tendency of globally incorporation is ongoing. If another media texts develop in the same way, the possibility of cultural imperialism will reduce. In addition, the debate of central status of media of cultural imperialism, like what Tomlinson said above, it is incorrect to make media equal cu lture. The term of culture is a complex to be clearly explain, and add the different way of understanding in different places, Western countries intention of conducting culture penetration or invasion is not a simple progress. Conclusion Combining all the supporting points and scepticism of the discourse of cultural imperialism together, maybe we can conclude this debate in this way, firstly, we should consider the wholly global society condition and the detailed situation of relative areas. As what Tunstall (1977) suggested, the arise of the media products is just an assumption so far, it still needs the time to testify. According to the current condition of global media distribution market, the diffusion range and impact of Western media products is considerable, so if in this respect to argue the discourse of cultural imperialism, it indeed exists the possibility. Secondly, confronting a number of differences between culture and nations, for the pursuit of commercial benefit, the big media corporations has start making relevant policy to remove the obstacles. For example, some media producers will invite global superstar to propagate their products, and another way is to apply the resources within local culture, a nd decorate the products to coherent to the local character, in fact, the global expansion of American advertising agency is a good example. Actually, to a large extent, the popularity of American products is the direct consequence of American transnational advertising. The central office in the U.S.A firstly send the advertisement mode to the relevant branch agencies around the world sphere. And then on the basic of remaining the essence of original advertisement, the local agency will blend the indigenous elements into it for satisfying the regional taste and culture. By this way, the impact on some places is this country is occupied, and there is no consciousness of that (Escobar and Anne. 1995). From this example, the threat of the discourse of cultural imperialism does deserve cautions, although maybe as Tomlinsons suggestion, there is no necessity to view media as the central reference of the argument towards cultural imperialism, the power of it cannot be ignored, because in current consumption society, for the economic interest, the media consortiums are rolling to make any policy to break down the obstacles on the way to maximize global market share. What I suggest here is when we are facing the discourse of cultural imperialism, first of all, we should have a correct attitude, excessive reception and neglect are both incorrect. Especially when we are surrounded with the numerous foreign media texts, the primary thing is to recognize the innate character embedded in them, and distinguish which part of it is useful for us, and which is useless. The discourse of cultural imperialism is more like a kind of trepidation in the context of globalization, researchers just around the necessity of this anxiety offer their different viewpoints, which are having different standpoints, angles, and conditions. So for the masses, what they can do is to have the cautious consciousness towards foreign media products, and depend on own values to make correct judgement.
Saturday, January 18, 2020
Lakshminarayan case (partnership act) Essay
Case Note: Direct Taxation assessment of income – Section 4 of Partnership Act appellant a registered company entered into an agreement with Mill company appointing its agent for thirty years – amount received by appellant from Mill company were assessed under income tax – appellant contended remuneration received from the Mills company was not taxable as it was not profit or gains from business – following question referred to High Court – whether under the terms of the agreement the petitioner is an employee of the Mills Company or is carrying on business – whether the remuneration received from the Mills is on account of service or is the remuneration for business – matter decided against appellant – appellant moved to the Supreme Court – Court observed the objects of the appellants in this case inter alia were to act as agents for Government – appellants were therefore rightly assessed for excess profits tax. JUDGMENT Bhagwati, J. 1. These are two appeals from the judgment and decision of the High Court of Judicature at Hyderabad answering certain questions referred at the instance of the appellants by the Commissioner of Excess Profits Tax, Hyderabad, and adjudging the liability of the appellants for excess profits tax in regard to the amounts received by them as remuneration from the Dewan Bahadur Ramgopal Mills Company Ltd. as its Agents. 2. The Mills Company was registered on the 14th February, 1920, at Hyderabad in the then territories of His Exalted Highness the Nizam. The appellants were registered as a private limited company at Bombay on the 1st March, 1920. On the 20th April, 1920, an Agency agreement was entered into between the Mills Company and the appellants appointing the appellants its Agents for a period of 30 years on certain terms and conditions therein recorded. The appellants throughout worked only as the Agents of the Mills Company and for the Fasli years 1351 and 1352 they received their remuneration under the terms of the Agency agreement. A notice was issued under section 13 of the Hyderabad Excess Profits Tax Regulation by the Excess Profits Tax Officer calling upon the appellants to pay the amount of tax appertaining to these chargeable accounting periods. The appellants submitted their accounts and contended that the remuneration received by them from the Mills Company was not taxable on the ground that it is was not income, profits or gains from business and was outside the pale of the Excess Profits Tax Regulation. This contention of the appellants was negatived and on the 24th April, 1944, the Excess Profits Tax Officer made an order assessing the income of the appellants for the accounting periods 1351 and 1352 Fasli at Rs. 8,957 and Rs. 83,768 respectively and assessed the tax accordingly. An appeal was taken by the appellants to the Deputy Commissioner of Excess Profits Tax who disallowed the same. An application made by the appellants under section 48(2) for statement of the case to the High Court was rejected by the Commissioner and the appellants filed a petition to the High Court under section 48(3) to compel the Commissioner to state the case to the High Court. An order was made by the High Court on this petition directing the Commissioner to state the case and the statement of the case was submitted by the Commissioner on the 26th February, 1946. Four questions were referred by the Commissioner to the High Courts as under :- (1) Whether the Petitioner Company is a partnership firm or a registered firm ? (2) Whether under the terms of the agreement the petitioner is an employee of the Mills Company or is carrying on business ? (3) Whether the remuneration received from the Mills is on account of service or is the remuneration for business ? (4) Whether the principle of personal qualification referred to in section 2, clause (4), of the Excess Profits Regulation is applicable to the Petitioner Company ? 3. These questions were of considerable importance and were referred for decision to the Full Bench of the High Court. The Full Bench of the High Court delivered their judgment the majority deciding the questions (2) and (3) which were the only questions considered determinative of the reference against the appellants. The appellants appealed to the Judicial Committee. But before the Judicial Committee heard the appeals there was a merger of the territories of Hyderabad with India. The appeals finally came for hearing before the Supreme Court Bench at Hyderabad on the 12th December, 1950, when an order was passed transferring the appeals to this Court at Delhi. These appeals have now come for hearing and final disposal before us. 4. The questions (1) and (4) which were referred by the Commissioner to the High Court at Hyderabad have not been seriously pressed before us. Whether the appellants are a partnership firm or a registered company the principle of exclusion of the income from the category of business income by reason of its depending wholly or mainly on the personal qualifications of the assessee would not apply because the income could not be said to be income from profession and neither a partnership firm not a registered company as such could be said to be possessed of any personal qualification in the matter of the acquisition of that income. 5. The principal questions which were therefore argued before the High Court at Hyderabad and before us were the questions (2) and (3) which involved the determination of the position of the appellants whether they were servantsv or agents of the Mills Company and the determination of the character of their remuneration whether it was wages or salary or income, profits or gains from business. 6. The appellants were registered as a private limited company having their registered office in Bombay and the objects for which they were incorporated were the following : (1) To act as agents for Governments or Authorities or for any bankers, manufactures, merchants, shippers, Joint Stock Companies and others and carry on all kinds of agency business. (2) To carry on in India and elsewhere the trade or business of merchants, importers exporters in all their branches etc. etc†¦Ã¢â‚¬ ¦. 7. Under Article 115 of the Articles of Association of the Mills Company the appellants and their assigns were appointed the agents of the Company upon the terms, provisions and conditions set out in the Agreement referred to in clause 6 of the Company’s Memorandum of Association. Article 116 provided that the general management of the business of the Company subject to the control and supervision of the Directors, was to be in the hands of the Agents of the Company, who were to have the power and authority on behalf of the Company, subject to such control and supervision, to enter into all contracts and to do all other things usual, necessary and desirable in the management of the affairs of the Company or in carrying out its objects and were to have power to appoint and employ in or for the purposes of the transaction and management of the affairs and business of the Company, or otherwise for the purposes thereof, and from time to time to remove or suspend such managers, agents, clerks and other employees as they though proper with such powers and duties and upon such terms as to duration of employment, remuneration or otherwise as they thought fit and were also to have powers to exercise all rights and liberties reserved and granted to them by the said agre ement referred to in clause 6 of the Company’s Memorandum of Association including the rights and liberties contained in clause 4 of the agreement. Article 118 authorised the agents to sub-delegate all or any of the powers, authorities and discretions for the time being vested in them, and in particular from time to time to provide by the appointment of an attorney or attorneys, for the management and transaction of the affairs of the Company in any specified locality, in such manner as they thought fit. 8. The Agency agreement which was executed in pursuance of the appointment under Article 115 provided that the appellants and their assign were to be the Agents of the Company for a period of 30 years from the date of registration of the Company and they were to continue to act as such agents until they of their own will resigned. The remuneration of the appellants as such Agents was to be a commission of 2 1/2 per cent. on the amount of sale proceeds of all yarn cloth and other produce of the Company (including cotton grown) which commission was to be exclusive of any remuneration or wages payable to the bankers, solicitors, engineers, etc., who may be employed by the appellants for or on behalf of the Company or for carrying on and conducting the business of the Company. The appellants were to be paid in addition all expenses and charges actually incurred by them in connection with the business of the Company and supervision and management thereof and the appellants were entitled to appoint any person or persons in Bombay to act as their Agents in Bombay and any other places in connection with the business of the Company. 9. Clause 3 and 4 of the agency agreement are important and may be set out in extenso :- 3. Subject to the control and supervision of the Directors, the said Lachminarayan Ramgopal and Son Limited shall have the general conduct and management of the business and affairs of the company and shall have on behalf of the company to acquire by purchase lease or otherwise lands tenements and other buildings and to erect maintain alter and extend factories, ware-houses, engine house and other buildings in Hyderabad and elsewhere in the territories of His Exalted Highness the Nizam and in India and to purchase, pay for, sell, resell and repurchase machinery, engines, plant, raw cotton, waste, jute, wool and other fibres and produce, stores and other materials and to manufacture yarn cloth and other fabrics and to sell the same either in the said territories as well as elsewhere in India and either on credit or for cash, or for present or future delivery, and to execute become parties to and where necessary to cause to be registered all deeds, agreements, contracts, receipts and other documents and to insure the property of the Company for such purposes and to such extent and in such manner as they may think proper; and to institute, conduct, defend, compromise, refer to arbitration and abandon legal and other proceedings, claims and disputes in which the Company is concerned and to appoint and employ discharge, re-employ or replace engineers, managers, retain commission dealers, muccadums, brokers, clerks, mechanics, workmen and other officers and servants with such powers and duties and upon such terms as to duration of office remuneration or otherwise as they may think fit; and to draw, accept endorse, negotiate and sell Bills of Exchange and Hundies with or without security and to receive and give receipts for all moneys payable to or to be received by the company and to draw cheques against the moneys of the company and generally to make all such arrangements and do all such acts and things on behalf of the Company, its successors and assigns as may be necessary or expedient and as are not specially reserved to be done by the Directors. 4. The said Lachminarayan Ramgopal & Son Ltd., shall be at liberty to deal with the Company by way of sale of the Company of cotton all raw materials and articles required for the purpose of the Company and the purchase from the Company of yarn cloth and all other articles manufactured by the Company and otherwise, and to deal with any firm in which any of the shareholders of the said Lachminarayan Ramgopal & Son Ltd., may be directly or indirectly concerned provided always such dealings are sanctioned passed or ratified by the Board of Directors either before or after such dealings. Clause 8 provided that two of the members for the time being of the appellants were at the option of the appellants to be the ex-officio Directors of the Company and clause 9 empowered the appellants to assign the agreement and the rights of the appellants thereunder subject to the approval and sanction of the Board to any person, firm or Company having authority by its constitution to become bound by the obligations undertaken by the appellants. 10. No materials other than these were placed by the appellants either before the Income-tax Authorities or the High Court and the question that arise before us have to be determined only on these materials. If on the construction of these documents we arrive at the conclusions that the position of the appellants was not that of servants but the agents of the Company the further question would have to be determined whether the activities of the appellants amounted to the carrying on of business. If they were not the servants of the Company, the remuneration which they received would certainly not be wages or salary but if they were agents of the Company the question would still survive whether their activities amounted to the carrying on of business in which case only the remuneration which they received from the Company would be income, profits or gains from business. 11. The distinction between a servant and an agent is thus indicated in Powell’s Law of Agency, at page 16 :- (a) Generally a master can tell his servant what to do and how to do it. (b) Generally a principal cannot tell his agent how to carry out his instructions. (c) A servant is under more complete control than an agent, and also at page 20 :- (a) Generally, a servant is a person who not only receives instructions from his master but is subject to his master’s right to control the manner in which he carries out those instructions. An agent receives his principal’s instructions but is generally free to carry out those instructions according to his own discretion, (b) Generally, a servant, qua servant, has no authority to make contracts on behalf of his master. Generally, the purpose of employing an agent is to authorise him to make contracts on behalf of his principal. (c) Generally, an agent is paid by commission upon effecting the result which he has been instructed by his principal to achieve. Generally, a servant is paid by wages or salary. 12. The statement of the law contained in Halsbury’s Laws of England – Hailsham Edition – Volume 22, page 113, paragraph 192 may be referred to in this connection :- â€Å"The difference between the relations of master and servant and of principal and agent may be said to be this : a principal has the right to direct what work the agent agent has to do : but a master has the further right to direct how the work is to be done.†13. The position is further clarified in Halsbury’s Laws of England – Hailsham Edition – Volume 1, at page 193, article 345 where the positions of an agent, a servant and independent contractor are thus distinguished :- â€Å"An agent is to be distinguished on the one hand from a servant, and on the other from an independent contractor. A servant acts under the direct control and supervision of his master, and is bound to conform to all reasonable orders given him in the course of his work; an independent contractor, on the other hand, is entirely independent of any control or interference and merely undertakes to produce a specified result, employing his own means to produce that result. An agent, though bound to exercise his authority in accordance with all lawful instructions which may be given to him from time to time by his principal, is not subject in its exercise to the direct control or supervision of the principal. An agent, as such is not a servant, but a servant is generally for some purposes his master’s implied agent, the extent of the agency depending upon the duties or position of the servant.†14. Considering the position of the appellants in the light of the above principles it is no doubt true that the appellants were to act as the agents of the Company and carry on the general management of the business of the Company subject to the control and supervision of the Directors. That does not however mean that they acted under the direct control and supervision of the Directors in regard to the manner or method of their work. The Directors were entitled to lay down the general policy and also to give such directions in regard to the management as may be considered necessary. But the day to day management of the business of the Company as detailed in Article 116 of the Articles of Association and clause 3 of the Agency Agreement above set out was within the discretion of the appellants and apart from directing what work the appellants had to do as the agents of the Company the Directors had not conferred upon them the further right to direct how that work of the general management was to be done. The control and supervision of the directors was a general control and supervision and within the limits of their authority the appellants as the agents of the Company had perfect discretion as to how that work of general management was to be done both in regard to the method and the manner of such work. The appellants for instance had perfect latitude to enter into agreements and contracts for such purpose and to such extent and in such manner as they thought proper. They had the power to appoint, employ, discharge, re-employ or replace the officers and servants of the Company with such powers and duties and upon such terms as to duration of office remuneration or otherwise as they thought fit. They had also the power generally to make all such arrangements and to do all such things and acts on behalf of the Company, as might be necessary or expedient and as were not specifically reserved to be done by the Directors. These powers did not spell a direct control and supervision of the Directors as of a master over his servant but constituted the appellants the agents of the Company who were to exercise their authority subject to the control and supervision of the Directors but were not subject in such exercise to the direct control or supervision of the principals. The liberty given to the appellants under clause 4 of the Agency Agreement to deal with the Company by way of sale and purchase of commodities therein mentioned also did not spell a relation as between master and servant but empowered the appellants to deal with the Company as Principals in spite of the fact that under clause 8 of the Agreement two of their members for the time being were to be the ex-officio Directors of the Company. The power to assign the agreement and the rights of the appellants thereunder reserved to them under clause 9 of the Agency Agreement though subject to the approval and sanction of the Board was hardly a power which could be vested in a servant. There was further the right to continue in employment as the agents of the Company for a period of 30 years from the date of the registration thereof and thereafter until the appellants of their own will resigned, which also would be hardly consistent with the employment of the appellants as mere servants of the Company. The remuneration by way of commission of 2 1/2 per cent. of the amount of sale proceeds of the produce of the Company savoured more of the remuneration given by a principal to his agent in the carrying out of the general management of the business of the principals than of wages or salary which would not normally be on such a basis. All these circumstances together with the power of sub-delegation reserved under Article 118 in our opinion go to establish that the appellants were the agents of the Company and not merely the servants of the Company remunerated by wages or salary. 15. Even though the position of the appellants qua the Company was that of agents and not servants as stated above it remains to be determined whether the work which they did under the Agency Agreement amounted to carrying on business so as to constitute the remuneration which they received thereunder income, profits or gains from business. The contention which was urged before us that the appellants only worked as the agents of the Mills Company and no others and therefore what they did did not constitute a business does not avail the appellants. The activities in order to constitute a business need not necessarily be concerned with several individuals or concerns. They would constitute business in spite of their being restricted to only one individual or concern. What is relevant to consider is what is the nature and scope of these activities though either by chance or design these might be restricted to only one individual or concern. It is the nature and scope of these activities and not the extent of the operations which are relevant for this purpose. 16. The activities of the appellants certainly did not come within the inclusive definition of business which is given in section 2 clause 4 of the Excess Profits Tax Regulation, Hyderabad. Business is there defined to include any trade, commerce or manufacture or any adventure in the nature of a trade, commerce or manufacture or any profession or vocation but not to include a profession carried on by an individual or by individuals in partnership if the profits of the profession depend wholly or mainly on his or their personal qualifications unless such profession consists wholly or mainly in the making of contracts on behalf of other persons or giving to other persons of advice of commercial nature in connection with the making of contracts. The work which the appellants did under the terms of the Agency Agreement constituted neither trade, commerce or manufacture or any adventure in the nature of trade, commerce or manufacture nor was it a profession or vocation. 17. The activities which constitute carrying on business need not necessarily consist of activities by way of trade, commerce or manufacture or activities in the exercise of a profession or vocation. They may even consist of rendering services to other which services may be of a variegated character. The consideration which apply in the case of individuals in the matter of determining whether the activities constitute a business within the meaning of the inclusive definition thereof set out above may not apply in the case of incorporated companies. Even though the activities if carried on by individuals might constitute business in that sense they might not constitute such business when carried on by incorporated companies and resort must be had to the general position in law in order to determine whether the incorporated company was carrying on business so as to constitute the income earned by it income, profits or gains from business. Reference may be made in this context to William Esplen, Son and Swainston, Limited v. Commissioners of Inland Revenue [1919] 2 K.B. 731. In that case a private limited company was incorporated for carrying on business as naval architects and consulting engineers. Before the formation of the company, a partnership had existed for many years between three persons who, on incorporation, became the sole shareholders and directors of the company. The partnership had carried on the profession of naval architects and consulting engineers and the work done by the company was identical in character with that formerly done by the partnership which is succeeded. The work done by the company was identical in all respects with the work of a professional naval architect and consulting engineer, and was performed by the said three shareholders and directors of the company personally. A question arose whether the company was carrying on a profession within the meaning of section 39 paragraphs C of the Finance (No. 2) Act, 1915. It was contended that it carried on a profession of naval architects and consulting engineers because the members composing it were three naval architects. That contention was however negatived and it was held that even though what was to be looked at was the character of the work done by the company, it was not carrying on the profession of the naval architects within the meaning of the section, because for that purpose it was of the essence of a profession that the profits should be dependent mainly upon the personal qualifications of the person by whom it was carried on and that could only be an individual. A company such as that could only do a naval architect’s work by sending a naval architect to its customers to do what they wanted to be done and it was held that the company was not carrying on a profession but was carrying on a trade or business in the ordinary sense of the term. 18. When a partnership firm comes into existence it can be predicated of it that it carries on a business, because partnership according to section 4 of the Indian Partnership Act is the relation between persons who have agree to share the profits of a business carried only by all or any of them acting for all. (See Inderchand Hari Ram v. Commissioner of Income-tax U.P. & C.P. [1952] I.T.R. 108) But when a company is incorporated it may not necessarily come into existence for the purpose of carrying on a business. According to section 5 of the Indian Companies Act any seven or more persons (or, where the company to be formed will be a private company, any two or more persons) associated for any lawful purpose may by subscribing their names to a memorandum of association †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. form an incorporated company, and the lawful purpose for which the persons become associated might not necessarily be the carrying on of business. When a company is incorporated for carrying out certain activities it would be relevant to enquire what are the objects for which it has been incorporated. As was observed by Lord Sterndale. M.R., in Commissioners of Inland Revenue v. The Korean Syndicate Limited (1921) 12 Tax Cas. 181 : If you once get the individual and the company spending exactly on the same basis, then there would be no difference between them at all. But the fact that the limited company comes into existence in a different way is a matter to be considered. An individual comes into existence for many purposes, or perhaps sometimes for none, whereas a limited company comes into existence for some particular purpose, and if it comes into existence for the particular purpose of carrying out a transaction by getting possession of concessions and turning them to account, then that is a matter to be considered when you come to decide whether doing that is carrying on a business or not.†19. Justice Rowlatt followed the above view of Lord Sterndale, M.R., in Commissioner of Inland Revenue v. Birmingham Theatre Royal Estate Co., Limited (1923) 12 Tax Cas. 580 , and held that â€Å"when you are considering whether a certain form of enterprise is carrying on business or not, it is material to look and see whether it is a company that is doing it.†The objects of an incorporated company as laid down in the Memorandum of Association are certainly not conclusive of the question whether the activities of the company amount to carrying on of business (See Indian Law Reports 55 Calcutta 1059 andMANU/WB/0002/1952 : [1951]19ITR571(Cal) ). But they are relevant for the purpose of determining the nature and scope of such activities. 20. The objects of the appellants in this case inter alia were to act as agents for Governments or Authorities or for any bankers, manufacturers, merchants, shippers, Joint Stock Companies and others and carry on all kinds of agency business. This object standing by itself would comprise within its ambit the activities of the appellants as the agents of the Company and constitute the work which they did by way of general management of the business of the company an agency business. The words â€Å"carry on all kinds of agency business†occurring at the end of the object as therein set out were capable of including within their general description the work which the appellants would do as agents for Governments or Authorities or for any bankers, manufacturers, merchants, shippers and others when they acted as agents of the Company which were manufacturers inter alia of cotton piece goods they would be carrying on agency business within the meaning of this object. Apart however from this there is the further fact that there was a continuity of operations which constituted the activities of the appellants in the general management of the Company a business. The whole work of management which the appellants did for the Company within the powers conferred upon them under Article 116 of the Articles of Association and clause 3 of the Agency Agreement consisted of numerous and continuous operations and comprised of various services which were rendered by the appellants as the agents of the Company. The appellants were also entitled though with the sanction or ratification by the Board of Directors either before or after the dealings to enter into dealings with the Company by way of sales and purchases of various commodities. There was nothing in the Agency Agreement to prevent the appellants from acting as the agents of other manufacturers, Joint Stock Companies etc., and the appellants could have as well acted as the agents of other concerns besides the Company. All these factors taken into consideration along with the fixity of tenure, the nature of remuneration and the assignability of their rights, are sufficient to enable us to come to the conclusion that the activities of the appellants as the agents of the Company constituted a business and the remuneration which the appellants received from the Company under the terms of the Agency Agreement was income, profits or gain from business. 21. The appellants were therefore rightly assessed for excess profits tax and these appeals must stand dismissed with costs. 22. Appeal dismissed.  © Manupatra Information Solutions Pvt. Ltd.
Friday, January 10, 2020
Attributes of the ideal leader in higher or K-12 education Essay
Introduction The educational institution exists and cooperates in a network of dedicated, goal-oriented peers, in an environment of high expectations and immense collaboration. Communicating daily with adult education professionals and with students, a substantial background and specific competencies must be gained in this kind of practice. Faculty members are confronted with a fresh generation of students that live and study in a digital environment. They are challenged to convey persuasive learning milieus that are both instructionally evocative and thoroughly appealing to these digital students. Their job involves directing, guiding, or teaching adults. The online curriculum the knowledge and skills you need for working more effectively with adult learners and is designed for busy, working professionals. As the select few of these days’ higher educational institutions create and enhance their vision to meet the needs of the changing student population into the twenty-first century, the skills and attributes required are also changing. This paper attempts to provide an overview of the skills and attributes perceived as important in this changing environment. It is essential that the leaders and managers of our higher educational institutions welcome all their roles, contribute to the responsibility with the environment, and be acquainted with and incorporate change (Kincheloe, 1991). What makes a leader ideal? What specific qualities make an individual suited to handling responsibilities, various roles and demands that are expected in an institutional setting catered to adults and the like? What training development model should be used to train those seeking such positions in institutions of higher learning? Every now and then a decision maker in an establishment pre-determines a need for training but savoir-faire trainers constantly evaluate the analysis data before jumping on to settle on the training objectives. Why? This is because intuition-based training interventions frequently detect symptoms rather than root sources. On top of that training is never the key to all performance problems. Around 80% of performance obstacles are environment-connected. Developing occupation aptitudes will not advance these institutional issues (Yukl, 2002). Considerations should also include the personality type of the individual, the hopes and aspirations the person have within him/herself; and the type of institution that the individual is placed into-the subculture prevalent that influences the decision-making processes of all the people or constituents involve. All of which and more, are indispensable factors for consideration. Training, as most people assume about it, is concerned about developing particular skills. The function and relationship of preparation to the place of work is implied. Training dubbed as performance improvement has been the focus in instructional professional which includes solving performance problems to attain business results. Performance improvement covers skills training and considers other issues as well, such as does the organizational structure (decision making, supervision, feedback) sustain the workflow and are the environmental working situations (equipment, light, interruptions) suitable. The notion of â€Å"performance improvement†is frequently an easier sell to management and trainees than â€Å"training†for the reason that the emphasis moves from the person to overall performance of the organization. The ISD model, occasionally alternatively called Instructional Systems Development Model, consists of five phases, usually illustrated as analysis, objectives, design, delivery and evaluation. This training model is a methodical approach to managing human resources. Those who study and make use of that data in exclusive contexts are rightly described as professionals; in them lies the heart and soul of the profession. Abstract professional learning, on the other hand, can be infuriatingly difficult to classify. It expands past distinct responsibilities to embrace the combination of practice and insight. It requires rudiments of art as well as science. Transmitting abstract learning by means of instruction has parallel distinctiveness. Teaching in the professional education organization entails more than delivering subject matter. Good instruction is an art form in its own right. A first-class teacher can prevail over a poor curriculum, while a great curriculum will not replace with for a poor instructor. Industrial-age institutions look for routine and habit accomplished through standardized measures. Complex responsibilities are split into simple steps that are assigned to organizational positions to guarantee that employees are both interchangeable and effortlessly replaced. Bureaucratic hierarchies are likely to esteem proven evaluation of specific aspects of complex managerial tasks. In view of this, the picture of leadership is in reality changing as the image of organizations changes. Analysis ascertains those who require training and what skills or performance improvements are designated. Aims and goals set the restriction for the instructional outline and help attain the appropriate learning outcomes (Kincheloe, 1991). At the heart of any profession is a body of expertise and abstract knowledge that its members are expected to apply within its granted jurisdiction. Those who discover and utilize that knowledge in unique contexts are rightly described as professionals; in them lies the heart and soul of the profession. A good teacher can overcome a poor curriculum, while a great curriculum will not substitute for a poor teacher. In the industrial-age organizations seek routine and habit achieved through standardized procedures. Complex tasks are broken into simple steps that are assigned to organizational positions to ensure that employees are both interchangeable and easily replaced. Here are aspects of the systems analysis approach to education that are useful. There is nothing inherently harmful in developing competency lists, provided they are kept general in nature and viewed with the appropriate level of circumspection. Competency maps take on a wide variety of forms. The competencies might be called knowledge areas, skills, attributes, attitudes, components, tasks, traits, or simply competencies. Once identified, numbered, and listed, they are usually broken down into sub-components, which are also numbered, so they might be associated with the broader competency area or cluster of competencies. The mapping aspect comes into play when the competency areas are charted to training and educational objectives and events, and then ultimately to desired leadership behaviors. Competency mapping is chiefly appealing to analytically oriented decision makers. Advocates for aptitude and competency mapping stress that one can utilize a metric to determine the relative accomplishment of an individual competency that will predict success in associated leadership behaviors. Advocates refer to competency mapping as adaptive because the list and the educational experiences that match the competencies can continually be revised. Advocacy of competency mapping seems to be spreading. Its aim is to advance a blueprint, map, or matrix of desired skills, knowledge, attributes, and attitudes at various levels of the organization. The map is then used to direct recruiting, hiring, and training assessment. Competency mapping has gained a following in the human resources community and fashioned a cottage industry of business consultants and sellers who profess expertise in its application At the heart of list-based methods like competency mapping is a supposition that specific qualities such as motives, values, and skills can be acknowledged and reproduced through training and education, resulting in effectively led organizations. The roots of this approach lies in trait theories of leadership that correspond with Taylorism. Education scholars Joe F. Donaldson and Paul Jay Edelson have noted that â€Å"trait theory was developed in the first part of the twentieth century and took a psychological approach to specifying the personality traits of effective leaders. Although research has shown no relationship between individual traits and effectiveness, this approach still finds modern expression†(Donaldson & Edelson, 2000). The trait approach has largely been supplanted by more sophisticated frameworks, yet leader competency mapping is proof positive that despite its dubious foundation the approach endures. Noted leadership author and scholar Gary Yukl has observed: â€Å"Early leadership theories attributed managerial success to extraordinary abilities such as tireless energy, penetrating intuition, uncanny foresight, and irresistible persuasive powers. Hundreds of studies were conducted during the 1930s and 1940s to discover these elusive qualities, but this massive research effort failed to find any traits that would guarantee leadership success. One reason for the failure was a lack of attention to intervening variables in the causal chain that could explain how traits could affect a delayed outcome such as group performance or leader advancement†(Yukl, 2004). Peter Northouse, author of Leadership: Theory and Practice observed the revival of an all-encompassing skills-based model of leadership distinguished by a map for how to reach efficient leadership in organizations (Porthouse, 2004). He recommended that the classification of specific skills which can be improved by training has an intuitive appeal: â€Å"When leadership is framed as a set of skills, it becomes a process that people can study and practice to become better at their jobs†(Northouse, 2004). He also suggests that although the skills-based approach claims not to be a trait model, it includes individual attributes that look a great deal like traits. The act of leadership is also an exercise of moral reasoning. In their book Unmasking Administrative Evil, Guy Adams and Danny Balfour caution against elevating the scientific-analytical mindset higher than all other forms of rationality. Even as the rise of â€Å"technical rationality led inevitably to specialized, expert knowledge, the very life blood of the professional,†it also â€Å"spawned unintended consequences in the areas of morals and ethics as the science-based technical rationality undermined normative judgments and relegated ethical considerations to afterthoughts†(Balfour, 2004). Distinguished scholar Ronald Heifetz on the other hand, developed a definition of leadership that takes values into account. He maintains that we should look at leadership as more than a means to organizational effectiveness. Efficiency means getting achievable decisions that execute the goals of the organization. â€Å"This definition has the benefit of being generally applicable, but it provides no real guide to determine the nature or formation of those goals. †(Heifetz, 1994). Heifetz went on to say that values such as â€Å"liberty, equality, human welfare, justice, and community†are inculcated with first-rate leaders (Heifetz, 1994). It is a necessity then, the infusion of these principles into the leader and from the leader into the organization. Reference: 1. Joe L. Kincheloe, Teachers as Researchers: Qualitative Inquiry as a Path to Empowerment (New York: Falmer Press, 1991), p. 77. 2. Draft US Army HR System Project Plan, Fort Leavenworth, Kans. , 21 January 2004. 3. Joe F.Donaldson and Paul Jay Edelson, â€Å"From Functionalism to Postmodernism in Adult Education Leadership,†in Handbook of Adult and Continuing Education, ed. Arthur L. Wilson and Elisabeth R. Hayes (San Francisco: Jossey-Bass, 2000), p. 193. 4. Gary Yukl, Leadership in Organization (5th ed. ; Upper Saddle River, N. J. : Prentice Hall, 2002). 5. Peter G. Northouse, Leadership Theory and Practice (Thousand Oaks, Calif. : Sage, 2004), pp. 35-52. 8. Guy B. Adams and Danny L. Balfour, Unmasking Administrative Evil (Armonk, N.Y. : M. E. Sharpe, 2004), pp. 31-36. 9. Ronald A. Heifetz, Leadership Without Easy Answers (Cambridge, Mass. : Harvard Univ. Press, 1994), pp. 21-22. 10. R. L. Shaw and Dennis N. T. Perkins, in Tara J. Fenwick, â€Å"Putting Meaning into Workplace Learning,†in Handbook of Adult and Continuing Education, ed. Arthur L. Wilson and Elisabeth R. Hayes (San Francisco: Jossey-Bass, 2000), p. 296. 11. James G. March, A Primer on Decision Making, How Decisions Happen (New York: The Free Press, 1994), pp. 96-97.
Thursday, January 2, 2020
Overview of the Peoples Crusade
A popular movement of crusaders, mostly commoners but also including individuals from all levels of society, who did not wait for the official leaders of the expedition but took off for the Holy Land early, unprepared and inexperienced. The Peoples Crusade was also known as: The Peasants Crusade, The Popular Crusade, or The Crusade of the Poor People. The Peoples Crusade has also been termed the first wave of crusaders by noted Crusades scholar Jonathan Riley-Smith, who has pointed out the difficulty of distinguishing separate crusade expeditions among the almost ceaseless stream of pilgrims from Europe to Jerusalem. How the Peoples Crusade got started: In November 1095, Pope Urban II made a speech at the Council of Clermont calling for Christian warriors to go to Jerusalem and free it from the rule of Muslim Turks. Urban no doubt envisioned an organized military campaign led by those whose entire social class had been built around military prowess: the nobility. He set the official date of departure for mid-August of the following year, knowing the time it would take for funds to be raised, supplies to be procured and armies to be organized. Shortly after the speech, a monk known as Peter the Hermit also began to preach Crusade. Charismatic and passionate, Peter (and probably several others like him, whose names are lost to us) appealed not just to a select portion of travel-ready combatants but to all Christians -- men, women, children, the elderly, nobles, commoners -- even serfs. His enthralling sermons fired the religious zeal in his listeners, and many people not only resolved to go on Crusade but to go right then and there, some even following Peter himself. The fact that they had little food, less money, and no military experience did not deter them in the least; they believed they were on a holy mission, and that God would provide. Armies of the Peoples Crusade: For some time, the participants in the Peoples Crusade were regarded as nothing more than peasants. While it is true many of them were commoners of one variety or another, there were also noblemen among their ranks, and the individual bands that formed were usually led by trained, experienced knights. For the most part, to call these bands armies would be a gross overstatement; in many cases, the groups were simply a collection of pilgrims traveling together. Most were on foot and armed with crude weapons, and discipline was almost nonexistent. However, some of the leaders were able to exercise more control over their followers, and a crude weapon can still inflict serious damage; so scholars continue to refer to some of these groups as armies. The Peoples Crusade moves through Europe: In March 1096, bands of pilgrims began to journey eastward through France and Germany on their way to the Holy Land. Most of them followed an ancient road of pilgrimage that ran along the Danube and into Hungary, then south into the Byzantine Empire and its capital, Constantinople. There they expected to cross the Bosphorus to territory controlled by the Turks in Asia Minor. The first to leave France was Walter Sans Avoir, who commanded a retinue of eight knights and a large company of infantry. They proceeded with surprisingly little incident along the old pilgrim route, only encountering any real trouble in Belgrade when their foraging got out of hand. Their early arrival at Constantinople in July took the Byzantine leaders by surprise; they had not had time to prepare proper lodging and supplies for their western visitors. More bands of crusaders coalesced around Peter the Hermit, who followed not far behind Walter and his men. Greater in number and less disciplined, Peters followers encountered more trouble in the Balkans. At Zemun, the last town in Hungary before reaching the Byzantine border, a riot broke out and many Hungarians were killed. The crusaders wanted to escape punishment by crossing the Sava River into Byzantium, and when Byzantine forces tried to stop them, violence ensued. When Peters followers got to Belgrade they found it deserted, and they probably sacked it in their ongoing quest for food. At nearby Nish, the governor allowed them to exchange hostages for supplies, and the town almost escaped without damage until some Germans set fire to mills as the company was leaving. The governor sent troops to attack the retreating crusaders, and although Peter ordered them not to, many of his followers turned to face the attackers and were cut down. Eventually, they reached Constantinople without further incident, but the Peoples Crusade had lost many participants and funds, and they had inflicted serious damage on the lands between their homes and Byzantium. Many other bands of pilgrims followed after Peter, but none made it to the Holy Land. Some of them faltered and turned back; others were sidetracked in some of the most horrific pogroms in medieval European history. The Peoples Crusade and the First Holocaust: The speeches of Pope Urban, Peter the Hermit, and others of his ilk had stirred up more than a pious yearning to see the Holy Land. Urbans appeal to the warrior elite had painted Muslims as enemies of Christ, subhuman, loathsome, and in need of vanquishing. Peters speeches were even more incendiary. From this malevolent viewpoint, it was a small step to see Jews in the same light. It was, sadly, an all-too-common belief that Jews had not only killed Jesus but that they continued to pose a threat to good Christians. Added to this was the fact that some Jews were notably prosperous, and they made the perfect target for greedy lords, who used their followers to massacre entire Jewish communities and plunder them for their wealth. The violence that was perpetrated against European Jews in the spring of 1096 is a significant turning point in Christian and Jewish relations. The horrific events, which resulted in the deaths of thousands of Jews, have even been called the First Holocaust. From May to July, pogroms occurred at Speyer, Worms, Mainz, and Cologne. In some cases, the bishop of the town or local Christians, or both, sheltered their neighbors. This was successful at Speyer but proved futile in other Rhineland towns. The attackers sometimes demanded that the Jews convert to Christianity on the spot or lose their lives; not only did they refuse to convert, but some even killed their children and themselves rather than die at the hands of their tormentors. The most notorious of the anti-Jewish crusaders was Count Emicho of Leiningen, who was definitely responsible for the attacks on Mainz and Cologne and may have had a hand in the earlier massacres. After the bloodshed along the Rhine was over, Emicho led his forces onward to Hungary. His reputation preceded him, and the Hungarians would not let him pass. After a three-week siege, Emichos forces were crushed, and he went home in disgrace. The pogroms were decried by many Christians of the day. Some even pointed to these crimes as the reason God forsook their fellow crusaders at Nicaea and Civetot. The end of the Peoples Crusade: By the time Peter the Hermit arrived in Constantinople, Walter Sans Avoirs army had been restlessly waiting there for weeks. Emperor Alexius convinced Peter and Walter that they should wait in Constantinople until the main body of Crusaders, who were massing in Europe under powerful noble commanders, arrived. But their followers were not happy with the decision. Theyd undergone a long journey and many trials to get there, and they were eager for action and glory. Furthermore, there still wasnt enough food and supplies for everyone, and foraging and theft were rampant. So, less than a week after Peters arrival, Alexius ferried the Peoples Crusade across the Bosporus and into Asia Minor. Now the crusaders were in a truly hostile territory where there was little food or water to be found anywhere, and they had no plan for how to proceed. They quickly began squabbling amongst themselves. Eventually, Peter returned to Constantinople to elicit help from Alexius, and the Peoples Crusade broke into two groups: one primarily made up of Germans with a few Italians, the other of Frenchmen. Toward the end of September, the French crusaders managed to loot a suburb of Nicaea. The Germans decided to do the same. Unfortunately, Turkish forces expected another attack and surrounded the German crusaders, who managed to take refuge in the fortress at Xerigordon. After eight days, the Crusaders surrendered. Those who did not convert to Islam were killed on the spot; those who did convert were enslaved and sent eastward, never to be heard from again. The Turks then sent a forged message to the French crusaders, telling of great riches the Germans had acquired. In spite of warnings from wiser men, the Frenchmen took the bait. They rushed onward, only to be ambushed at Civetot, where every last crusader was slaughtered. The Peoples Crusade was over. Peter considered returning home but instead remained in Constantinople until the main body of the more organized crusading forces arrived. The text of this document is copyright  ©2011-2015 Melissa Snell. You may download or print this document for personal or school use, as long as the URL below is included. Permission is not granted to reproduce this document on another website.
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