Case Study Of Unstable Angina

Case Study Of Unstable Angina The patient in context is a 61 year old male, Mr. X, admitted to hospital in the late evening for a case of unstable angina. Presenting complaints include left-sided chest pain which was less severe than that of his previous admission and localized pain during rest. Absent symptoms are profuse sweating as well as nausea and vomiting, orthopnea and paroxysmal nocturnal dypsnoea, cough and fever. Patients past medical history includes diabetes mellitus and hypertension diagnosed 6 years ago, ischaemic heart disease (IHD) since 3 years ago, for which the last hospital admission was 11 months ago. In the previous admission for IHD, Mr. X also suffered from pneumonia and ventricular failure, his electrocardiogram (ECG) indicated right bundle branch block, his serum troponin I levels were 0.3 ng/mL (normal levels 0-0.1 ng/mL), and his creatinine levels were 5.0 mg/dL (normal for males 0.2-0.6 mg/dL). Mr. X is also afflicted with chronic kidney disease, for which his baseline creatinine dur ing his last admission was 208 ÃŽÂ ¼mol//L. Mr. X has retired from the military and is living with his wife, who monitors his medications and compliance. He used to be a chronic smoker but has stopped smoking 15 years ago. His previous medication history is as below: Drug and Form Strength Frequency Furosemide tabs 40 mg BD Omeprazole tabs 20 mg PRN Amlodipine tabs 10 mg OD Simvastatin tabs 20 mg ON Perindopril tabs 4 mg OD Table 1: Table showing past medications of Mr. X. Mr. X takes no non-prescription medications and has no known drug allergies. On examination he appears to be alert and comfortable on his nasal cannula for delivery of oxygen 3L/min. His blood pressure is 134/81 mmHg, pulse rate is 76 bpm, body temperature 37oC, SpO2 of 99%, abdomen feels soft and non-tender, and no pedal oedema was observed. A blood glucose strip test reveals that Mr. Xs glucose levels were 10.3 mmol/L. Emergency ECG shows right bundle branch block and no ischaemic changes. The tentative diagnosis was unstable angina and further tests were scheduled, including a full blood count (FBC), renal profile (RP), liver function test (LFT), troponin and creatinine (CKMB) investigations, as well as a urine full examination and microscopy (UFEME). The immediate plan was to give Mr. X subcutaneous enoxaparin 60 mg stat and twice daily thereafter, aspirin 75 mg tablets once daily, lovastatin 20 mg tablets once daily, sublingual glyceryl trinitrate when required, and to continue the 3L/min oxygen cannula. Clinical Progress Day 1 Morning Patient was well, free from chest pain, tolerating orally and suffering from no nausea or vomiting. He had minimal shortness of breath (SOB). Troponin I levels were at 0.15 ng/mL and ECG showed no acute or evolving changes. Fasting plasma glucose was at 4.8 mmol/L (within normal range). Secondary dehydration was observed using the skin pinch test, so patient was started on intravenous normal saline drip (3 x 500 mL bag per 24 hours). Patient was found to be anaemic due to pre-existing chronic renal failure. Evening Patient reported mild chest pain and SOB. His troponin I levels were 0.15 ng/mL and other vitals were normal. His creatinine levels were 423 ÃŽÂ ¼mol/L. Day 2 Patient felt comfortable and his vitals were normal. His creatinine levels decreased to 345 ÃŽÂ ¼mol/L. Day 3 Patients condition was well, no chest pain was reported but he was still experiencing some SOB in the morning, which subsided in the afternoon. Patient was put on continuous peritoneal dialysis in the late morning. Patients vitals were normal, and he was taken off enoxaparin in the evening. Day 4 Patient complained of chest pain in the morning, with minimal SOB. His vitals were normal. Subcutaneous enoxaparin 60 mg was given and the IV saline was continued. Lab Findings Urine Biochemical Analysis (Day 1) Investigation values Normal values Protein ++100 mg/dL Glucose negative negative Blood negative Leucocytes +-10 WBC/ÃŽÂ ¼L Ketone negative negative Bile negative negative Urobillinogen normal Specific gravity 1.025 1.003 1.040 pH 5.5 4.6 8.0 Nitrite negative negative Table 2: Results of urine biochemical analysis on Day 1 Lipid Panel Fasting Serum Lipid Plasma total cholesterol / mmol/L 4.5 Desirable Borderline 5.17-6.19 High risk >6.20 Plasma triglyceride / mmol/L 1.27 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 1.7-5.64 High risk >5.65 Plasma LDL-cholesterol / mmol/L 2.91 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 3.36-4.12 High risk >4.13 Plasma HDL-cholesterol / mmol/L 1.01 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable >1.03 High risk Total cholesterol / HDL-cholesterol 4.5 Desirable Borderline 3.8-5.8 High risk >5.9 Table 3: Results of lipid panel (fasting serum lipid levels). Renal Profile Electrolytes Measured levels on Day 1-1.14am Measured levels on Day 1-12.54am Measured levels on Day 2-10.47am Normal range Urea / mmol/L 22.8 22.4 21.1 2.8-7.2 Sodium / mmol/L 129 128 129 136-146 Potassium / mmol/L 5.3 4.8 4.7 3.5-5.1 Chloride / mmol/L 98 94 101 98-107 Creatinine / ÃŽÂ ¼mol/L 423 398 345 58-96 Table 4: Renal profile of Mr. X showing levels of electrolytes and creatinine. Plasma troponin I 0.15 ng/mL Liver Function Test Measured level Normal range Plasma total protein 81 g/L 66-83 g/L Plasma albumin 34 g/L 35-52 g/L Plasma globulin 47g/L 25-44 g/L A/G ratio 0.7 0.9-1.8 Plasma alkaline phosphatase 119 u/L 30-120 u/L Plasma aspartate transaminase 19 u/L Plasma alanine transaminase 43 u/L à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Plasma total bilirubin 6 ÃŽÂ ¼mol/L 5-21 ÃŽÂ ¼mol/L ESR 47mm/hour à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ 0-20 mm/hour Table 5: Results of liver function test showing protein and liver enzyme levels in plasma. Full Blood Count (FBC) (Beckman Coulter) Cell type Measured level Normal range WBC 9.9109/L 4-10109/L RBC 3.341012/L 3.8-4.81012/L Haemoglobin 95g/L 120-150g/L Haematocrit 0.273L/L 0.36-0.46L/L Mean cell volume 81.8fl. 83-101fl. Mean cell haemoglobin 28.4pg. 27-32pg MCH concentration 347g/L 315-345g/L Platelets 353109/L 150-400109/L RDW 19.4% Neutrophils 3.3 2-7 x109/L Lymphocytes 1.74 1-3 x109/L Monocytes 0.55 0.2-1.0 x109/L Eosinophils 0.21 0.02-0.5 x109/L Basophils 0.03 0.02-0.1 x109/L Table 6: Full blood count of Mr. X. Vital Stats Chart Date Time Blood Pressure/ mmHg Temperature / oC Pulse Rate/ bpm SpO2/ % Blood Glucose levels/ mmol/L Day 0 11.05 pm 140/80 37 91 100 13.9 11.30 pm 137/84 37 80 100 Day 1 8.30 am 130/80 37 70 4.8 (fasting) 3.55 pm 130/70 37 90 10.30 pm 108/64 37 81 Day 2 8.20 am 119/69 37 78 4.50 pm 130/90 37 82 9.6 9.45 pm 140/90 37 80 6.7 Day 3 8.50 am 114/77 37 72 98 6.6 Table 7: Records of vital stats of Mr. X from Day 0 3. Disease Overview Pharmacological Basis of Drug Therapy Acute coronary syndrome (ACS) is a broad term used to classify a continuum of symptoms and events stemming from acute ischaemic episodes affecting the cardiac muscle.1 This includes unstable angina, non-ST segment elevation myocardial infarction (NTEMI), and ST segment elevation infarction. It is usually characterised by chest pain which increases in its severity at rest or with physical exertion. The ischaemic events usually arise from the development of unstable atheromatous plaques,2 which explains the fact that stable angina (due to a stable coronary atheromatous plaque) is not included under this umbrella term. Rupture, ulceration or fissures of the atherosclerotic plaque often leads to formation of a thrombus, causing occlusion of coronary arteries and inadequate blood flow and, subsequently, inadequate supply of oxygen and nutrients to the cardiac muscle. This can be precipitated by acute stress factors on the sclerotic cap usually consisting of fibrous material, which is caus ed by local blood flow disturbances or vasospasms3. Unstable angina usually occurs without cardiac muscle damage while myocardial infarction (MI) may occur with or without myocardium damage. The thrombus formed in unstable angina is labile and obstruction is transient, and not a full-on occlusion as would occur in MI.4 Unstable angina occurs at rest and is almost indistinguishable from a non-ST segment elevated myocardial infarction except in the severity of cardiac muscle ischaemia. Theoretical definitions of unstable angina would include changes in usual patterns of stable angina after a stable pain-free period, or severe acute anginal pain causing almost total incapacity5, though it is difficult to define it exactly as the term is often used by medical professionals to describe a range of different conditions intermediate between stable angina and MI. The primary clinical symptoms of unstable angina are: sudden occurrence of chest pain that persists for more than 20 minutes which may be felt in other areas such as the jaw, arm, shoulder, neck or back; without cause (as opposed to stable angina which stems from physical exercise); shortness of breath, rapid pulse rate, and sometimes a rapid drop in blood pressure. Patients suffering from an ACS have a high risk of MI and possible even death; immediate hospitalization is often required1 and treatment is of a more urgent nature compared to that of stable angina. It has been suggested by the National Health Service (NHS) Hospital Episode Statistics in 1998 that 1000 out of every million per population is affected with unstable angina, or 10 acute hospital admissions per week.6 On a more recent note, NHS has reported in 2009 that angina affects between 10-15% of women and 10-20% of men aged 65 and above in England.7 Due to the close relationship between unstable angina and coronary events, it is worth noting that the highest averaged rates of cardiovascular events were observed in Glasgow and Belfast (UK), North Karelia and Kuopio (Finland), Newcastle (Australia), and Warsaw (Poland).8 Diagnosis of an unstable angina episode, or any ACS in that matter, is based on several aspects9. Physical symptoms include anginal pain at rest that lasts for 20 minutes or more; new onset angina severely limiting ability of physical activity; or changes in existing angina intensity, frequency or length of attack. One or more of these symptoms are an urgent indication that the patient is suffering from an ACS attack. Upon admission to hospital, ECG and blood tests should be performed to confirm the type of ACS in order to initiate treatment. In unstable angina, the ST segment is not elevated and levels of cardiac enzymes are normal (especially troponin T and I). If the onset of symptoms is unclear as to indicate ACS, a measurement of serum troponin concentration should be carried out 12 hours from presentation to establish the diagnosis.10 Treatment of unstable angina and NSTEMI are similar in terms of pharmacological management; indeed they are at presentation indistinguishable exc ept in terms of the severity and extent of cardiac muscle ischaemia, in which the ischaemia is less severe in unstable angina and less troponin T and I are released into the bloodstream. Antiplatelet agents. Aspirin and clopidogrel are the immediate emergency drugs used in the ambulance, both being antiplatelet drugs. Aspirin is an irreversible inhibitor of arachidonate cyclooxygenase (COX) enzyme, in which covalent acetylation of the serine moiety in a hydrophobic channel in the enzyme11 reduces synthesis of thromboxane A2 in platelets and prostaglandins in the endothelium. This prevents platelet aggregation and further enlargement of the thrombus formed in the coronary artery. Clopidogrel is an inhibitor of the ADP-dependent activation of the GPIIb/IIIa receptor and prevents the formation of fibrinogen bridges between glycoprotein IIb/IIIa receptors on the surfaces of platelets11, subsequently preventing platelet activation. Glycoprotein IIB/IIIA receptor antagonists, eg, abxicimab, have the advantage of inhibiting all pathways in the platelet activation process by inhibiting the glycoprotein IIB/IIIA receptor. Anticoagulants. Unfractionated heparin is an activator of antithrombin III, which inhibits the action of thrombin and serine proteases. The heparin also binds to thrombin; the combined effect of this and the heparin-antithrombin complex formed inhibits thrombin, which decreases the conversion of fibrinogen to fibrin and reduces platelet aggregation. In contrast, low molecular weight heparins (LMWH) have molecular sizes that are too small to bind to thrombin but still bind to antithrombin III, which inactivates all serine proteases including Factors XIIa, IXa, and Xa11, preventing the coagulation process. Direct thrombin inhibitors such as hirudin and bivalirudin inhibit thrombin reversibly. These agents can bind to free and bound thrombin, thus have the ability to prevent and dissolve preformed clots. Synthetic pentasaccharides (fondaparinux) is a selective indirect inhibitor of Factor Xa. It binds to antithrombin III reversibly, catalyzing the inactivation of Factor Xa12 and inhibit ing the coagulation cascade. Beta blockers. All beta blockers bind to beta-adrenoceptors, competitively antagonizing the action of catecholamines. These drugs block the beta-1 adrenoceptors at the heart, achieving a decreased heart rate and force of cardiac contractions, as well as lowering blood pressure. Atenolol is relatively specific for cardiac beta-1 adrenoceptors and exerts fewer side effects associated with beta-2 adrenoceptor blockade, for example bronchospasm in asthmatics. Nitrates. Organic nitrates mimic the actions of endogenous nitric oxide to relax vascular smooth muscle by increasing the synthesis of cGMP, leading to the dephosphorylation of myosin light chains.11 Vasodilatation of coronary arteries causes increased coronary blood flow and coupled with its effects of decreasing arterial pressure and also cardiac output, the myocardial oxygen consumption is largely reduced. Statins. Also termed HMG-CoA reductase inhibitors, these medicines inhibit the rate-limiting enzyme in the synthesis of cholesterol, in which this enzyme converts HMG-CoA to mevalonic acid. ACE inhibitors are diuretics acting on the rennin-angiotensin system which inhibit the angiotensin-converting enzyme (ACE) and block the production of angiotensin II from angiotensin I. This reduces vascular resistance, increases tissue perfusion, and reduces cardiac afterload. Angiotensin II receptor inhibitors also act on the same system as the ACE inhibitors, except that they block the angiotensin II receptors directly instead of inhibiting their formation. The outcome is the same as above. Evidence for Treatment of the Condition Antiplatelet Agents The SIGN guidelines advocate that aspirin and clopidogrel be given to patients with ECG ischaemic changes or increased levels of cardiac markers; and aspirin is advocated for all patients suffering from ACS. A meta-analysis of 287 randomised trials proves the protective effect of aspirin on patients with unstable angina, halving the rate of cardiovascular events, including death, non-fatal MI and strokes, or also termed the first primary outcome; while in those with an acute MI, it reduces the rate of coronary events by almost a third13. Long-term use of aspirin for these patients was also shown to be a beneficial antiplatelet therapy. According to the same study, reduction of serious vascular events by clopidogrel was 10% compared to aspirin. The combined use of clopidogrel and aspirin as compared with a placebo and aspirin showed significantly higher success rates in reducing occurrences of first primary outcomes (9.3% compared to 11.4%, P On the flipside, although short term studies have shown that antiplatelet medications are effective for patients with renal failure in the prevention of serious vascular events13, the risks of bleeding is increased by renal disease15, posing a possible contraindication for antiplatelets to Mr. X. A clinical study found that treatment for NSTEMI ACS in patients with chronic renal disease (mild to moderate stages) was less aggressive than those with normal renal function, despite the risk that these patients with renal disease would experience greater adverse outcomes from insufficient treatment for ACS compared to the other patient group16. However the available information on adverse effects of antiplatelets on patients with varying degrees of renal disease is limited and it would appear that this would result in the reluctance of medical professionals in using this class of drugs for patients with chronic renal disease as well as ACS. It can be inferred that Mr. X would gain the maximum benefits if his medications were changed to aspirin 300 mg and clopidogrel 300 mg stat and aspirin 75 mg and clopidogrel 75 mg thereafter, in which the patient should be closely monitored for signs of bleeding. Heparins LMWHs A 2003 review of 7 studies involving 11,092 patients with non-ST elevation ACS found that low molecular weight heparins (LMWH) were more effective than unfractionated heparins in reducing MI events, requirement for revascularization procedures, and thrombocytopenia17. No difference in the mortality, recurrent angina, major and minor bleeds were observed in the two types of drugs. A meta-analysis of 12 randomised trials with 17,157 patients involved found that patients who have had a non-ST elevation ACS who were put on aspirin experienced no significant difference in benefits in efficacy (preventing MI or death) or safety (major and minor bleeding complications) when they were put on unfractionated heparin or LMWH17, implicating no difference in the thrombolytic effect in both classes of drugs. These results are partially similar to those of the first review. Another meta-analysis of 2 phase-3 trials comparing enoxaparin and unfractionated heparin, on the other hand, showed a signifi cant (20%) difference in reducing death or severe cardiac ischaemic events18. From an economic point of view, authors of yet another meta-analysis on the subject stated that the cost of LMWH is 3-5 times higher than unfractionated heparin19. From these data it can be concluded that LMWHs does indeed have additional positive treatment outcomes compared to unfractionated heparins22; it does not show significantly decreased side effects (bleeding). Enoxaparin has, though, an increased bleeding effect on patients with renal disease as reported by an investigation of 106 patients, in which total bleeding complications occurred in 22% of normal patients and 51% of patients with impaired renal function (p It is still the drug of choice for patients present with non-ST elevated ACS, and this is applicable to Mr. X with unstable angina. Beta-Blockers Beta-blockers were not prescribed for Mr. X. The SIGN guidelines states that beta-blockers should be the drug of choice for first line treatment of anginal pain in patients with non-ST elevated ACS. A meta-analysis of 5 trials consisting of 4700 patients in all showed a 13% reduction in anginal pain with the use of beta blockers (initially IV then oral for a week) in patients with non-ST elevated, MI-characterised chest pain23. It was stated in the clinical progress Mr. X had chest pain on Day 1 and 4, thus the addition of a beta blocker to his medications would be useful in alleviating his pain. Despite the popular belief that beta-blockers are contraindicated in patients with diabetes mellitus, it is possible to treat these patients using beta-blockers as long as good glycaemic control is achieved and the patient is monitored regularly24. This would further support its use in Mr. X; furthermore, several studies have shown that diabetic patients derive a significant benefit from the use of beta-blockers after an MI, in which diabetic patients had a significantly lower mortality 1 year post-discharge25, total mortality after 3 years, and deaths from cardiac events26. A multicentre randomized trial, the HINT trial, on patients with unstable angina found that metoprolol, a relatively cardioselective beta blocker, reduced occurrence of myocardial ischaemia or progress to MI within 48 hours, indicating that metoprolol has a short term beneficial effect on patients not already taking beta blockers prior to the unstable angina episode27. It has been suggested that beta-blockers be the first line treatment for unstable angina and if patients remain unstable, a calcium channel blocker should be added28. Statins The beneficial effects of statins in reducing mortality and cardiovascular events have been proven by a meta-analysis of large, randomized controlled trials (n=90,056) where coronary artery disease was present or absent29. The positive results were also proven spanning a large range of serum cholesterol levels. Investigations comparing the use of intensive versus moderate doses of statins in the early stages and post-ACS showed positive results: a meta-analysis of 4 large trials (n=27,548) shows a 16% reduction in cardiovascular deaths or MI, as well as a 16% reduction in cardiovascular deaths or coronary events30. This view is shared by another meta-analysis of the same subject of 13 randomised controlled trials which found a decrease in mortality and coronary events after 4 months of treatment31. These data support the use of statins by Mr. X. Nitrates Nitrates have been widely used in relieving pain from unstable angina, despite its lack of clinical evidence in supporting its role in improving survival and reducing the rate of MI and cardiovascular events32. ISIS-433 and GISSI-334 reports no significant difference of the use of glyceryl trinitrate post-MI in reducing the overall mortality; however this may be explained by the fact that more than 50% of patients in the controlled group are also on other forms of nitrate therapy, such as intravenous glyceryl trinitrate. Despite this, nitrates will still be of use for reducing the pain in post-MI patients and those with unstable angina. The BNF advises against the use of nitrates in patients with serious anaemia (Hb Glycaemic control Mr. Xs plasma glucose levels were elevated on the day he was admitted to hospital (13.9 mmol/L). Diabetes mellitus has been proven to be a strong independent risk marker for coronary heart disease: patients with poorly controlled diabetes at hospital admission have a worse outlook on prognosis and future development of cardiovascular events35. The DIGAMI investigation reports that the use of intensive insulin therapy increased long-term prognosis (P=0.011) of patients presenting with hyperglycemia (>11mmol/L) at admission compared with those on standard antidiabetic therapy36. These data support the use of insulin to control the blood glucose levels of Mr. X which were highly increased upon admission. This is also supported by the SIGN guidelines which advocate immediate control of blood glucose is carried out for MI patients with glucose levels of more than 11.0 mmol/L for at least 24 hours. ACE Inhibitors The SIGN guidelines recommend that patients with unstable angina should be given ACE inhibitors as long-term therapy. In patients at high risk of cardiovascular events, ACE inhibitors (ramipril was investigated in a report37) have been proven to reduce overall mortality, MI, and stroke, particularly in patients with diabetes mellitus. Perindopril was found to reduce cardiovascular risk (relative risk reduction =20%, P=0.0003) in a population with stable coronary heart disease in absence of heart failure38 in a double-blinded, randomized multicentre trial involving 13,655 patients. A meta-analysis of the 2 above trials and a third one (PEACE) showed a reduction in overall mortality, cardiovascular death, non-fatal myocardial infarction, stroke, heart failure, and coronary artery bypass surgery by ACE inhibitors39. This demonstrates the benefits of ACE inhibitors in patients with atherosclerosis: as patients who had an ACS event would have a higher rate of cardiovascular events, the po sitive outcomes of ACE inhibitors can perhaps be extrapolated to this population in order to decrease coronary events and improve prognosis. However, the BNF advises caution and close clinical monitoring if ACE inhibitors are to be used in patients with hyponatremia ( Oxygen therapy On admission, Mr. Xs SpO2 was 99% and remained high throughout his stay in the hospital. The use of oxygen therapy is significantly beneficial only in hypoxic patients (with SpO2 Anaemia and Unstable Angina Anaemia can disturb the balance between myocardial oxygen supply and demand: a decrease in the number of red blood cells can lead to a reduction in the supply of oxygen to the myocardium. Thus correction of the causative factor would be sensible in the treatment of unstable angina for the patient in context. Mr. X was given a combination of ferrous fumarate, vitamin B complex, and folic acid for treatment of his anaemia. From the data in Table 6, it can be seen that Mr. X has low haemoglobin concentrations (95 g/L) and a low mean cell volume (81.8 fl.). To confirm that Mr. X is indeed suffering from iron-deficiency anaemia (as suggested by his treatment medication), three parameters must be established namely the plasma iron, the plasma ferritin, and total iron binding capacity. However, as very few conditions can cause abnormalities in the mean cell volume, and a decreased value is due to iron-deficiency anaemia or thalassemia42, it is safe to assume that Mr. Xs anaemic condition is due to an insufficiency of iron. Iron supplements are given to correct the iron status of the patient, in which the ferrous form given orally is found to be cheap, safe and effective in the majority of patients with iron-deficiency anaemia2. Vitamin B complex and folic acid are only indicated in patients with the respective deficiencies2; there is little evidence that they would be of any significant benefit in patients with iron-deficiency anaemia. Summary Based on the evidence given, Mr. Xs aspirin dose should be changed to 300 mg stat and 75 mg thereafter, and clopidogrel should be added into his medication profile in the same doses. These changes ensure that Mr. X is obtaining sufficient antiplatelet effects from his medications to prevent another attack of unstable angina or even a myocardial infarction. Present drugs that were given for his condition that are suitable and supported by evidences include enoxaparin, lovastatin, insulin, and GTN: these can be safely continued without problems. A beta-blocker (metoprolol tablets) may be given additionally in doses of 50-100 mg as evidences described above have shown that they can be safely used in diabetic patients contrary to popular belief; an ACE inhibitor (perindopril as previously used by Mr. X) may be initiated coupled with regular electrolyte

The Harlem Drag Culture :: History Culture Cultural Essays

The Harlem Drag Culture Foucault, Moraga, Fuss, hooks, Butler. These authors, along with many more, have concerned themselves with the defining of categories. In reading these authors our class has, upon every occasion of meeting, discussed the formation of categories. What we have discovered, in part, is that things are not defined by what they are, but by what they are not. Diana Fuss, in her article "Inside/Out," states "any identity is founded relationally, constituted in reference to an exterior or outside that defines the subject's own interior boundaries and corporeal surfaces" (Fuss, "Inside/Out," 234). A common example of this, derived from Freud, is that males are defined by their having a penis, while females are defined by their lack of one. Defining identity is not necessarily so binary. As Cherrà ­e Moraga puts it "Call me something meant to set me apart from you and I will know who I am" (Moraga, "The Breakdown of the Bicultural Mind," 237). The subcultures of American society, cultures that are not part of the white patriarchy, are defined by how they differ from this white patriarchy. Our class was privileged to be introduced to one subculture found in Harlem during the late 1980s through the documentary Paris is Burning by Jennie Livingston (1992). This documentary captured the lives of men who lived outside the dominant culture. They had several strikes against them: they were Latino and African American, they were homosexual, and many of them were poor, sometimes even homeless. These men came together to form a kinship network, in the form of houses, to protect and support one another. Out of this milieu developed drag balls, balls in which the men dressed up and competed in different categories, such as "executive," "realness," and "voguing." The object of most of these categories was to mimic dominant society by looking like the heterogeneous members of the white patriarchy. After watching Paris is Burning, reading critiques of it, listening to class discussions, and processing through my own thoughts about the film that I have come to struggle with an extremely large tension I am confronted with in thinking about the drag ball subculture of Harlem. Is the mimicking of dominant society by this culture a way of subverting it or is it supporting and perpetuating the white patriarchal ideal? Do these men redefine dominant society in their own terms and take control of it?

Irish Dancing: A Celtic Family Passion Essay

Every family has some wonderful tradition that they share with each other and the rest of their kindred spirits. Our family holds Irish dancing as our most beloved musical tradition, and we share it amongst ourselves along with those in the world around us. Individuals who have viewed Michael Flatley’s, Riverdance or The Lord of the Dance, have heard the beautifully entrancing music and the almost hypnotic percussion nimbly played by the tapping of dancer’s feet. The swift and graceful movements, colorful costumes and mystic aura that this Irish dancing traditions hold can only be told best by those who have partaken in the event, danced the dance and been allured by the magic of the sounds. The following writing will explore some of the experiences of our family’s Irish step dancing tradition, as well as how we share it with the public world. Irish dancing means a great deal to us because it serves as an expression of our ethnicity and of who we are as a family. The females of our kin begin their dance training early, at about the age of three to four years. Almost as soon as they can fit into the shimmering brocaded dresses and tiny tapping shoes, the young ladies eagerly take to their lessons. Each dance that they master acts almost like a rite of passage and many of the girls soon find themselves performing at pubic fairs, parades and even dancing competitions. We pride ourselves in our little dancer’s endeavors since as stated by Wulff, â€Å"When it comes to Irish competitive dancing, the attempt to build character goes back to childhood and circles around the idea of national identity†(Wulff 2003, 186). Through this media we can express our particular ethnic heritage in the ever diverse United States. Younger and older generations practice together at family gatherings and put on a show for everyone. Males of our family also receive encouragement to pursue the activity, but the accomplishment of the women usually outshines them. In relation, the accomplishments of our Irish dancing heritage come with time, difficulty and dedication, in which our family takes pride. Irish dancing consists of rules of movement that do not make for an easy learning experience. To watch Irish dancers in competitions is to see how they must move in â€Å"jumps† with their backs straight, their arms tight to their sides and make it only appear that their legs do the work. Now imagine trying to do all of that and make a distinct rhythm with nimbly tapping feet. One of the proposed theories for why such strict rules of movement in Irish dancing exist states, â€Å"Irish bodies have long been subjected to particularly stringent forms of control by church and state, and within this context dancing has been deemed especially problematic†(Dyck and Archetti 2003,5). Others believe that the Irish values of, â€Å"proper manners† plays a vital role in the dancing posture (Wulff 2003, 182). Either way, the skill comes with hours of practice and dedication. Winning a public award for Irish dancing plays an important role in our family affairs. Those who have competed often travel around the nation at various times of the year, and many of us will travel with them to encourage and support their efforts. Award winners also usually have a lead part in producing the dances for our family gatherings, as well as act as teachers to our younger dancers. Consequently, the type of dancing that has been spoken of thus far constitutes a type of Irish dancing called â€Å"step dancing†. There are also jigs, polkas and other genres of Irish dancing that we partake in. These less formal types of dance usually occur solely at family gatherings. None of our family members have pursued a professional learning experience or participated in competition in any of these other genres that we know of to date. However, just because we do not pursue them as vigorously as step dancing does not mean that they are not enjoyable. Family events and competitions do not make up the entirety of our Irish dancer’s experiences. As mentioned previously, parades and community events also don the list. Sometimes our family dancers put on shows for charitable causes, church functions and Irish festivals. All of the opportunities that avail themselves help us express ourselves and our unique cultural heritage to our community. Also, as with the charitable causes, we have the opportunities us to use our talents help those in need. Performing for these community gatherings helps to inspire us as, and encourages our dancers to continue on with their grueling practice. Concerning Irish step dancing, it has probably by far the most dynamic of the music structures of Irish dance genres. This is due to the fact that the tapping of the dancers feet give more intricate percussion to the established musical rhythm. For example, â€Å"Riverdance is usually associated with the crescendos of the signature section and the long Chorus Line of Irish dancers pounding out their unison steps†(Wulff 2003, 187). The aim of such percussion centers on eliciting a powerful emotional reaction from audiences, aside from just impressing them with complicated dance steps. Irish dancers want their audiences to feel every note, every tap and every emotion that the music and dance combined can convey. As dancers, the goal revolves around letting others experience the heart and soul they put into their activity with every pounding beat on the stage. Joining with several dancers on stage not only urges those feelings deeper into the hearts of the audience members; it also gives them the sense of how the power of several individuals acting in unison can create a breathtaking experience. Acting together to create such a response in the audience helps dancers to recognize and appreciate the bonds of their ethnic heritage as well as their achievement in performance skills. Correspondingly, immense evolution of Irish step dancing has taken place since Michael Flatley entered the spotlight. In his performances Irish step dancing takes on more fluid movements, rather than the rigid, hands-at-sides traditional postures. This addition of the greater emotional expression using body movement caught on and made Irish step dancing quite popular. The outcome: The response was extraordinary; after the performance calls poured in from all over Europe for the video. A CD was recorded; it sold out and the show was transformed into a full-length evening of dance and music, which swept London, New York City, and the world. Today in towns and cities around U. S. boys and girls are taking up step-dancing in record numbers (Finnegan, and McCarron 2000, 394). Flatley’s work has brought Irish step dancing to the forefront, romanticized it and possibly changed its course in history as the popularity continues to grow. By and large as it can be seen, the magic and honor of our experiences in Irish dancing comes through to our family from many sources. We gain a sense of nationality and cultural heritage from dancing with our fellow family members and other Irish step dancers. We take pride in our ethnic heritage as we perform for both charitable causes and competition, which inspires our public audiences. Not to mention that our family’s field of musical tradition in turn has taken inspiring turns as Michael Flatley’s performances have drawn immense amounts of attention and popularity. Overall, the intricate steps and emotional combination of music and movement in Irish step dancing has created for us a unique way for our family to continually appreciate our ethnic background and take pride in our heritage. Works Cited Carmichael, Jennifer. â€Å"Re: Interview questions. † Email to Irish dancer. 9 July 2006. Dyck, Noel, and Eduardo P. Archetti, eds. Sport, Dance, and Embodied Identities /. New York: Berg, 2003. Questia. 10 July 2006 . Finnegan, Richard B. , and Edward T. McCarron. Ireland: Historical Echoes, Contemporary Politics. Boulder, CO: Westview Press, 2000. Questia. 10 July 2006

Filling the Void Karl Marx, John Stuart Mill and Others...

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The Ku Klux Kl A Brief History - 1096 Words

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Risk Management Plan Proposal - 986 Words

Risk Management Plan Proposal FIN/415 Background of organization Pepsi Co is a global food and beverage leader with net revenues of more than $65 billion (Pepsico.com, 2012). Pepsi Co began its life in the summer of 1893. In 1893 Caleb Bradham invented â€Å"Brad’s Drink† or Pepsi Cola as it is called today (Pepsistore.com, 2012). By 1898 Caleb Bradham bought a trade name of â€Å"Pep Cola† from a competitor who had gone out of business. On December 24, 1902 the Pepsi Cola Company was incorporated (Pepsistore.com, 2012). The following June the Pepsi Cola Syrup was registered with the US Patent Office for use in the fountain machines in the drug stores Caleb Bradham operated. After opening a second drug store†¦show more content†¦Financial reporting, forward financial reporting and audits are the key techniques that PepsiCo’s Board of Directors use in order to protect the associates, shareholders and stockholders from any substantial risk. Every market that PepsiCo is part of operates very uniquely, it is the responsibility of the Board of Directors and designated teams to ensure the operations, and transactions are compliant. Risk management techniques PepsiCo risk management techniques â€Å"ensure that risks are taken knowingly and purposefully† (PepsiCo, Inc. 2011 Annual Report, p 34). â€Å"At its most fundamental level, risk management involves identifying risks, predicting how probable they are and how serious they might become, deciding what to do about them and implementing these decisions† (Merna AL-Thani, 2008). The technique used by PepsiCo is a structured framework that eliminates risk when possible, reduces risk exposure, and transfers or retains risk when either is identified as the best option. â€Å"PepsiCo leverages an integrated risk management framework to identify, assess, prioritize, address, manage, monitor and communicate risks across the Company†(PepsiCo, Inc. 2011 Annual Report, p 34). 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Resistance to Change and Its Implications in an Organization

Question: Discuss about theResistance to Change and Its Implications in an Organization. Answer: The occurrence of the change, especially in an organization, could be brought out by various factors either external or internal. A natural response to change is resistance especially in organizations (Burke, 2009) Resistance to change is sometimes unavoidable especially in situations where the proposed change does not fit well with the employees. Resistance to change Resistance to change is quite frequent in organizations. Employees can resist the proposed change due to various factors. For instance, change brings about anxiety and uncertainty. In most cases, the change affects every employee in the organization and it is for this reason that they may offer resistance so as to maintain their status quo rather than embracing the unknown brought about by the change. Oreg (2008) believes that factors such as an employees short-thinking of the immediate discomfort rather than long-term benefit, the cognitive rigidity of an employee as well as the desire to have a stable routine can facilitate their resistance to change. However, not all employees provide resistance to change. Among those who may resist change are; those who are likely to receive an increase in their workload, those who advocate for a different kind of change, those who are successful and received awards in their current way of working and employees who have invested highly in the cur rent way of working as well as those who developed the current way of working (Bratton, 2010) Managers often view resistance to change as a drug to the development of the organization that has to be managed. For instance, managers in an editorial firm can decide to introduce new editorial tools that editors have to use in addition to the existing ones when editing. This move, in the long run, will improve the efficiency and reliability of the firms work. However, the editor is likely to resist to this change as this means more work for him. The manager is more likely to see this as a problem as their goal of providing high-quality work will not be attained easily. Thus there is need to manage this resistance. There is a link between power and resistance to change when it comes to organizational change (Erkama, 2013) to understand the resistance to change, it is important for one to understand the notion of power as the two are intertwined. There are four faces of power in an organization that influences resistant in organizations(Fleming, 2010). These include coercion, manipulation, subjection, and domination. Resistance is viewed as a source of power that the employees use to avert change. In coercion, a person in a position of power can coerce the employees to accept or follow orders. The employees can use resistance to refuse what they are coerced to do. Manipulation is the control that one imposes on another to get something done. As it is mainly through non-participation, then resistance, in this case, can be used to gain access to gain a voice through either trade unions or social movements. Domination is the power that shapes the preferences and general outlook of the employees. To avert this, one can use resistance as a means of escape to disengage from this domination. The fourth power, subjectification, is one where the organization molds the employees into a certain way. Resistance, in this case, can be as a result of the employees creating something that contradicts what the management intended. Thomas and Hardy (2011) provide that there are those who shape the decisions while there are those whores are resistant to the decisions. Resistance is conceptualized in various ways including as pathology, psychological and sociological. As a pathology, managers have the best and crucial knowledge to develop a rational approach towards change. This can be through using empirical data that will lead to a predictable change. As employees resist the change, employers and managers view this as a problem that has to be dealt with thus causing them to use secrecy, coercion, sanctions and other forms of power to overcome this resistance. Additionally, resistance can be conceptualized as the outcome of ones psychological state including emotions and attitudes. A persons feelings such as selfishness, cognition, and powerlessness can make them resist change. This necessitates for the managers to first fix the individual through communication so as to inform and enlighten them on the new ideas and what it means to the organization as well as encourage them to accept the proposed changes. Additionally, managers and change agents can incorporate some of the employees ideas as well as encouraging their participation so as to ensure they attain effective change management. However, the interests, power, and assumptions of the agents and managers are to remain the most dominant. Resistant to change can be viewed on the sociological aspect (Johns, 2013). Resistance is itself a form of resistance as a response to power which is employed by employees. Change is a vital decision that managers and change agents formulate for better service delivery. However, as the change is likely to face resistance, managers tend to demonize the action stating that the resistance affects service delivery(Burke, 2009). For one, resistance to change lowers the work morale of employees especially in cases where they lack detailed information on the implemented change. Additionally, resistance to change can result to the negative conceptualization of the organization as employees are likely to have a negative attitude of the change as well as the proposed change. To manage the resistance, managers and change agents in, most cases use their power to influence the employees to accept and adopt the change. On the other hand, the employees tend to use resistance to avert or express resistance. An implication of this, move by the employees can be poor service delivery or satisfaction and low job turnover. For instance, a delivery firm can change the modes of delivery from a pickup point to offering door-to-door delivery services. The managers might impose this change with an aim of improving their customer relations. However, employees view this move as an addition to their workload thus resists the move. This will affect the service delivery and can tarnish the companys name. It is in this light that the managers demonize resistance and derive ways to manage the resistance (Jabri, 2017) Ethical issues associated with power and resistance Ethics refers to the decent guidelines that drive a persons behavior when piloting or articulating an activity. When dealing with issues that require ethical considerations, it is important for one to develop an ethical framework that is to be followed to arriving at a solution(Dolan, 2012). An appropriate ethical framework relevant to the organizational management of change is the use of the basic right approach. According to this approach, the managers have a duty in consulting the employees on matters affecting them at work as well as giving employees a right to see and understand how decisions involving employment are taken. This framework is associated with the clear and open relationship between the managers and the employees meaning that the decisions undertaken by any of the parties have to be informed to the other party first. Power and resistance to change raise a number of issues. For instance, when managers coerce their employees to partake or do something that they are unwilling to do, they violate the persons freedom of choice. Coercion can be in form of threats or use of force. A manager in can make a decision requiring all employees to report to work on Saturday which is against their jurisdiction and to respond to this change, the employees can boycott work. In the same way, a manager can provide laws that require employees to pay for certain services that were previously attained with no costs, with an excuse of raising extra funds for a certain project. This can be through manipulation or even subjection. Once employees realize that they have been manipulated and subjected to paying for these services, they are more likely to resist the change by failing to pay or even through sanctions. The use of power to implement changes that one wants causes raised various ethical issues that affect the orga nization at large. On the other hand, the move to resist a change has its ethical issues. In addition to resistance to organizational change, other factors likely to cause dissent include performance evaluation, tactics for decision making and how employees are treated (Thompson, 2009)Dissent can be presented in various ways. Articulate dissent involves presenting the disagreement directly to the superiors. This method provides that the employees are concerned with the issue at hand for the benefit of the whole organization rather than for personal gain. Latent dissent is where one presents the opposition to the coworkers especially in situations which they are unable to have a clear audience with the supervisors or managers. This is a method that is useful in situations where one feels the superiors are not receptive. Displaced dissent involves expressing disagreement to the external audiences such as friends and family. This dissent, however, limits the employees feedback on the o rganization thus presenting the picture that the proposed organizational change has been accepted by all employees. The use of ethical frameworks to respond to these ethical issues raised by resistance and power is a key consideration for any organization. The framework is to provide a possible solution or method in which a proposed change can be articulated and accepted by all without the use of powers or resistance. Even as change is inevitable, change agents and managers should always consider the ethical issues likely to arise and use the ethical frameworks as a guide to implementing a particular organizational change. The basic right framework provides a ground in which the managers have to consult or inform the employees of a change likely to happen so as to receive their feedback as they are the ones likely to be affected by the implementation of the particular change. Other additional frameworks that are useful or relevant to issues arising from organizational change according to Woodhall, Winstanley, and Heery (1996) include; the universalism approach which deals with the principle of Do as you would be done by, and respect for the individual; the community of purpose approach which holds a stakeholder view that accept that change can affect different groups differently and therefore there should not be extreme disparities of benefits in these groups and the organizational justice approach which advocates for fair treatment of the employees through provision of equal opportunities as well as in decisions on performance and rewarding (Bratton, 2010).To achieve an effective change management, it is advisable for the change agents to clearly outline the details of the change and what it involves. The employees should also provide their thoughts on the proposed change to the managers including what they propose to be done. This will reduce the collision that arises as a result of the use of power and resistance mechanisms. Conclusion Resistance to change is a natural response that is provided by employees in an organization in situations where the change is likely to affect their work. Factors such as ambiguity in the details of the change, the feeling of powerlessness and anxiety as well as cognition of the proposed change are among those that make them resist the change. However, managers and change agents may feel the need to manage this action as it affects the job satisfaction as well as service delivery. Additionally, resistant to change and power are interlinked as managers can use powers to advocate for change while employees use resistance power as a response to the same. Ethical considerations are important especially when managers are implementing a particular organizational change. References Bratton, J. S. (2010). Work and Organizational Behaviour 2nd Ed. UK: Palgrave Macmillan, Burke, W. W. (2009). Organizational change: A comprehensive reader. San Francisco: .: Jossey-Bass. Cummings, T. G., Worley, C. G. (2009). Organizational development change (9th ed.).Mason: South-Western Cengage Learning. Dolan, S. L. (2012). Sharing the culture: Embedding storytelling and ethics in the culture change management process.. Journal of Management and Change, 29 Pp. 10-23. Douglas, F. (2011). Between a rock and a hard place: Resistance and the formation of professional identity. International Journal of Education and Vocational Guidance. 11 (3) pp. 163-173 Erkama, N. (2013). Power and resistance in a multinational organization. Scandinavian Journal of Management., 26. Pp. 151-165. Fleming, P. a. (2010). The Faces of Power in Organizations. In Contesting the Corporation: Struggle, Power, and Resistance in Organizations. Cambridge University Press. Jabri, M. (2017). Managing Organizational Change: Process, Social Construction and Dialogue. 2nd Ed. . london: Palgrave Macmillan. Johns, E. A. (2013). The Sociology of Organizational Change. Pergamon Publications. Oreg, S. (2008). Resistance to Change: Developing an individual differences measure. Journal ofApplied Psychology Thomas, R. Hardy, C. (2011). Reframing resistance to organizational change. ScandinavianJournal of Management. 27 pp. 322-333. Thompson, P. . (2009). Work Organization: A Critical Approach. , London. : Palgrave Macmillan.