Investigation of Effectiveness of Clozapine

Investigation of Effectiveness of Clozapine Catarina Scott-Beaulieu Abstract: (250) Background: Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. It is effective in treating the positive and negative symptoms of schizophrenia with a reduced chance of extrapyramidal side effects compared with other typical antipsychotics. Clozapine is known to have cardiac side effects including, but not limited to, myocarditis and cardiomyopathy. Approximately 75% of cases, of clozapine-induced myocarditis, occur within the first month of titration, highlighting the need for monitoring. Objectives: To assess the extent to which the monitoring guidelines for myocarditis, at a London mental health trust, are being followed. Method: Patients who were registered with ZTAS from June 2014 to October 2016, at the trust,  Ã‚   were identified. Data was collected based on the audit tool created from the guidelines. Using the patient notes and laboratory data, found using the trusts operating systems, data was collected and stored in the audit tool. Key findings: The monitoring standards were met for full blood count in the week prior to initiation and in week 3. No other standards were met. Conclusion: Introduction: (500-1000) Clozapine is the first atypical antipsychotic created and is used in treatment-resistant schizophrenia, which is defined as a lack of or an inadequate response to at least two antipsychotics.[1] It is a dibenzodiazepine derivative antipsychotic and interferes with dopamine binding with a strong affinity for D4-dopaminergic receptors   and 5-HT2a serotonergic receptor affinity [2], in addition it has an anticholinergic effect and antagonizes histaminergic receptors. [3, 4] Clozapine is useful in treating both the positive and negative symptoms of schizophrenia [4] and is less likely to cause extrapyramidal side effects when compared to first generation typical antipsychotics such as haloperidol[5, 6]. It has also been shown to significantly reduce the suicidal behaviors in schizophrenic patients [1, 7]. However, it is not used as a first line treatment due to its extensive side effect profile, most recognized being agranulocytosis which occurs in approximately 1% of patients in the first year of treatment [8, 9], explaining the need for regular, mandatory hematological tests for the duration of clozapine treatment. Other side effects include fever [4], metabolic effects and seizures.[4, 6, 10] Agranulocytosis, however, is not the only potentially fatal side effect of clozapine use. There is an increasing number of clozapine-related cardiac complaints reported in the literature, resulting in cardiac effects from clozapine treatment having become more recognized over the past few years. [5, 7] Whilst tachycardia is a common side effect it can be indicative of other, potentially more serious, cardiac effects such as cardiomyopathy and myocarditis. [9] Myocarditis is an inflammatory process of the myocardium, which is often of viral aetiology but may also include bacterial, fungal and drug-induced.[11, 12] The condition presents with a wide range of symptoms such as chest discomfort, flu-like symptoms and abnormal vital signs [9] and most are non-specific.[2] Reported cases of clozapine-induced myocarditis range from 0.15% to 1.2%,[5, 8, 13-15] with the highest incidence being reported in Australia, >1%. [16] Time to onset varies, but over 75% of cases occur within the first month of treatment. [12, 16-18] Endomyocardial biopsy was the gold standard for diagnosing myocarditis, but the procedure has only limited sensitivity and specificity. It was by proposed Ronaldson et al.[18] in 2011 that combining C-reactive protein (CRP) and troponin T/I would give a sensitivity for clozapine-induced myocarditis of 100%. This is a less invasive method of diagnosis, with a higher specificity and sensitivity for myocarditis and has led to the current guidelines that are in place for the monitoring of clozapine treatment. Whilst clozapine-induced myocarditis is still rare, the need for consistent monitoring within the first month of treatment is needed to ensure any possible cases are detected early, allowing for prompt treatment, increasing the chances of a better outcome for the patient.[1] This audit aims to assess the extent to which the monitoring guidelines for myocarditis, at a London mental health trust, are being followed. Assessments will explore the extent to which the recommended additional blood tests, CRP and troponin, are being completed and the extent to which the advised echocardiogram (ECG) are being followed. Additionally, it will aim to check to see if a clinician is checking the above objectives and assess the extent to which the nursing staff are asking the patients about signs and symptoms of myocarditis. Method: (500-1000) This audit was designed to investigate the extent to which the monitoring requirements, in regards to clozapine initiation and titration within the first four weeks of treatment, at a London mental health trust had been completed. The monitoring requirements audited were specific to the detection and diagnosis of myocarditis. Data collection occurred between October 2016 and February 2017. It is a baseline, retrospective audit of case notes and laboratory data. As per the Health Research Authority regulations, this audit did not require ethical approval. Audit standards and audit tool The standards used in this audit were taken from the trusts clozapine guideline, which can be found in table 3. The monitoring requirements for the detection of myocarditis involve an ECG, vital sign monitoring (pulse, blood pressure, temperature) and CRP and troponin T blood tests. These had to be completed prior to initiation and weekly for the first four weeks after initiation. It is also necessary for clinicians to verify the results of the CRP and troponin T tests, and for the nurses or clinicians to check if the patient has had any signs or symptoms of myocarditis. For the purpose of this audit, criterion 1 and 3 (table 3) will be met if the results of the investigations were documented. Criterion 2 (table 3) will be met if the clinician has made specific reference to CRP and troponin T tests in the patient notes, criterion 4 (table 3) will be met if there is specific reference to questions being asked about myocarditis symptoms. An audit tool was created using the specified mo nitoring requirements mentioned in the clozapine guideline, a template of the audit tool can be found in table x. Identifying patients to be involved in the audit Clozapine patients require regular and frequent prophylactic blood tests in order to initiate and continue treatment. As such, there is a mandatory need for patients to be registered to a clozapine monitoring service database, which collects and stores the results from the weekly blood tests. Zaponex Treatment Access System (ZTAS) is the monitoring company that was used by the trust. ZTAS provided a list of patients who were registered with them whilst under the care of the trust, from June 2014 to October 2016. This resulted in a total of n=57 patients. The patients were selected to be used in the audit after they adhered to the inclusion criteria, which are shown below. Data Collection Data was collected using various information sources at the hospital. Data on haematological tests were collected systematically from ZTAS, bloodresults.co.uk, and the trust clinical portal. ZTAS and bloodresults.co.uk offered information on the standard full blood count (FBC) monitoring that takes place weekly. The trusts clinical portal was used to collect information on other heamatological tests, CRP and troponin T; this source was also used to check any other available FBC test results. RiO, the trusts operating system, was used to collect information on the other standards being measured in this audit (criterion 2, 3 and 4)(table 3). The data collected was stored in the audit tool. ( table x) Inclusion and exclusion criteria The inclusion of the patients in the audit required them to have been registered with ZTAS at the trust between June 2014 and October 2016. It was also necessary for the patient to have started some (at least two) of the required monitoring standards prior to initiation. Prior monitoring requirements included an ECG within a maximum of 3 months prior to initiation and  Ã‚   FBC, CRP and troponin T within 10 days of the initiation date.   Vital sign monitoring such as pulse, blood pressure and temperature were included if they had been completed a maximum of 7 days before initiation. Patients were excluded from the audit if they had been transferred from another trust and were already on a controlled clozapine treatment regime. Method of data analysis Data analysis and statistical analysis was completed using Microsoft Excel 2013. Overview As stated previously, clozapine is associated with an increased risk of myocarditis, which has been fatal in some cases. Preventative monitoring measures for myocarditis are advised at this trust. Baseline troponin T, CRP and ECG should be done prior to beginning treatment and then weekly for the following first four weeks after initiation. These measures are specific in identifying myocarditis, but should also be done in concordance with standard monitoring during treatment. The standard monitoring procedures include pulse, blood pressure and temperature to be completed every other day and FBC weekly. These monitoring procedures are necessary in helping to diagnose myocarditis; symptoms of myocarditis are non-specific, but tend to indicate the presence of an infection (fever) or simulate myocardial infarction (chest pain). Nurses and practitioners are advised to question patients on the appearance of any side effects similar to myocardial infarction to help ascertain if they could h ave myocarditis. Patient demographics and study data In total, n=57 patients were reviewed. Of those, n=3 patients were excluded based upon the inclusion and exclusion criteria described in the method. Of the remaining n=54 patients, n= 6   (11.11%) patients did not initiate clozapine treatment, but n=5 were included in the audit as they had started the monitoring required prior to initiating treatment. Reasons for not initiating treatment are outlined in table 1. A total of n= 3 patients ceased clozapine treatment in week one (n=2) and during week three (n=1); one patient was persistently tachycardic, one patient refused to continue treatment and one patient was severely hypotensive. The patient group (n=53) was predominantly male 66% (n=35), 34% (n=18) were female. The mean age of patients who initiated treatment (n=48) was 34.42 years old, with the youngest patient age being 16.92 years old and the oldest being 65.21 years old. Length of treatment was calculated as the time between a patient commencing clozapine treatment and either ceasing clozapine or the end of the audit period. A total of n=10 patients were excluded from the calculation, as they either did not start treatment or the end of treatment time was not able to be calculated; reasons for exclusion are explained in table 2. The mean length of treatment was 387 days  ±268, with the shortest length of treatment being 1 day and the longest being 873 days. Of the 53 patients involved at the start of the audit, 65% (n=35) were initiated on an inpatient basis; this means the patients were initiated at the hospital, on a ward. ECG monitoring A baseline ECG had been completed in 96% (n=51)(Figure 1) of patients within 3 months prior to the commencement of clozapine. One patient refused to have an ECG prior to initiation. The percentage of patients who received ECGs decreased to 20% (n=9), 24% (n=11), 17%(n=8) and 9% (n=4) of patients for the following 4 weeks after commencement respectively. A total of 41 out of 45 (Table 4) patients did not receive an ECG in week four of clozapine titration. During week one, a patient complained of flu like symptoms and was given an ECG to rule out myocarditis; likewise, one patient during week three was given an ECG after complaining of centralized chest pain. Temperature monitoring The quantity of patients who had recorded temperatures fluctuated through-out the weeks, being highest in week two of monitoring (n=. Week four had the lowest recorded amount of temperature monitoring of all 5 weeks at patients 69% (n=31) (table 4). In week one, n=2 patients refused to have measurements taken. Pulse and blood pressure monitoring The amount of patients who did not receive BP monitoring was highest in the week prior to initiating clozapine (n=13) and in week four (n=13). The highest proportion of patients who had their blood pressures taken occurred during week one at 96% (n=44 ), with 63% (n=29) of them having their blood pressure taken once and 34% (n=15) having their blood pressure taken twice (one reading measured whilst lying or sitting and one reading measured whilst standing). Week four had the highest proportion of patients who did not have their pulse measured at 29% (n=13) (table 4). One patient was discontinued from clozapine after one day of treatment when the BP check revealed them to be extremely hypotensive, in conjunction with a rapid pulse. Full blood count monitoring FBC monitoring occurred in the highest proportion of patients throughout the monitoring period; 100%, 98%, 93%, 100% and 96% respectively. CRP and Troponin monitoring The majority (>50%) of patients did not receive CRP or troponin T blood tests throughout the duration of the monitoring period. Figure 2 shows a substantial decrease in the number of patients who had CRP tests prior to initiation (n=25) and the following weeks (n=10, n=11,n=11, n=7 respectively). A large propotion of patients (84%, n= 38) did not receive CRP blood tests during their fourth week of clozapine treatement. The number of patients who received troponin T tests were less than those who received CRP tests. Only 36%(n=19) of patients received troponin T tests prior to initiation, reducing to 26%(n=12), 20%(n=9), 15%(n=7) and 9%(n=4) in the following four weeks after initiation respectively. There were n=14 patients who had no CRP or troponin T tests throughout the entirety of the monitoring period. There were no patients who had weekly CRP and troponin T tests throughout the duration of the mointoring period. Other monitoring parameters In total, the number of patients who had their CRP and troponin checked by clinicians was less than 100% in all cases (69% (n=9), 75% (n=9), 56% (n=6) and 63% (n=5) for weeks one through four respectively).   Due to the lack of data regarding criterion 4 (table 3), there are no results available to be discussed. Summary of main findings FBC monitoring requirements were met in the week prior to monitoring and in week three. All other standards were not met in any of the five weeks. Over all, there was a better outcome seen in the week prior to initiation for most of the standards. CRP and troponin T tests were completed in less than 50% of patients throughout the five weeks measured. Likewise, excluding the week prior to initiation, less than 50% of patients received an ECG for weeks one to four. Limitations Study data was collected using patient notes and the trusts clinical portal, data was therefore reliant on the relevant health care professional entering the information onto the systems. Consequently, the lack of data could be attributed to the lack of documentation of the monitoring, as opposed to the lack of monitoring all together, especially in regards to criterion 4 (table 3). No useful results could be drawn for criterion 4 and criterion 2 may have also been significantly affected by a lack of documentation. The sample size of this audit was small (n=53), any conclusions drawn from this data may not be relevant to a larger sample size. However, in future studies, a larger sample size could be used, if this is not possible the audit could be expanded to include other trusts. Results could also be affected if the patient refused to have the relevant monitoring required, as advised in the trusts clozapine guidelines.    This audit is the first one to be completed at this trust, therefore it cannot be compared to any previous data. However, the results are being measured against set standards (table x) and can be used to compare to future audits. Results in context      Ã‚   Clozapine is highly effective in the management of treatment-resistant schizophrenia; it reduces the risk of suicidal behaviours[5, 6]and it is effective in the treatment of both the positive and negative symptoms of schizophrenia.[1] It is not widely used due to its extensive side effect profile [8], most recognised being haematological disorders, such as agranulocytosis and neutropenia which have strict monitoring protocols in place.   However, cardiac side effects of clozapine treatment have become more widely recognised over the past few years.[5] Myocarditis is an inflammatory condition of the myocardium, which is normally attributed to viral aetiology. Clozapine-induced myocarditis is a rare, but potentially fatal result of treatment. Over 75% of cases occur within the first month of treatment, making it important to monitor for myocarditis during the first four weeks of treatment.[2, 14-16] A study by Ronaldson et al.[18] developed an evidence-based monitoring tool, based on 75 cases and 94 controls for routine monitoring up to 28 days. It suggested that an ECG, CRP and troponin I/T should be completed at baseline, with routine vitals every other day. CRP and troponin I/T tests should also be repeated on days 7, 14, 21 and 28. This study proposes that combining CRP and troponin tests provides a 100% sensitivity for myocarditis. The trusts clozapine guidelines also suggest the same monitoring protocol, with the addition of an ECG every week, for the first four weeks. Individuals with schizophrenia have a 20% shorter life expectancy than that of the general population and a greater vulnerability to several illnesses (diabetes, coronary heart disease).[19] Due to the nature of the illness and the heightened health risks associated with schizophrenia and the antipsychotic medications used in its treatment, it is important to adhere to the relevant monitoring protocols. It is evident, from the results, that the proposed guidelines for the monitoring of clozapine-induced myocarditis are not being met. Likewise, a number of studies have shown a poor adherence to standards in the monitoring of antipsychotic medications.[20] Physicians may have doubts about the relevance of monitoring, or feel that it is not necessary as the incidence of myocarditis is very low; rate of incidence occur in approximately 0.15-1.2%[1, 13, 21] of patients. If we consider other medications with stringent monitoring protocols, such as insulin, due to health care professionals awareness of this medication and the implications if the standards are not met, there is often a higher standard of monitoring. There may also be an implication of cost; extensive monitoring is often expensive, making it appear to be an unnecessary expense, particularly when the chances of myocarditis occurring are very low. Health care professionals may have a lack of awareness of the need for the monitoring of myocarditis, and the implications if these are not met. The incidence of fatality due to clozapine-induced myocarditis can be as high as 50%[1], making it important to abide by the set guidelines. The monitoring guidelines are made to reduce the harm caused to patients and reduce the possibility of fatalities. However, a delayed diagnosis could result in poorer outcomes for the patients.[1] The standards allow for earlier detection and diagnosis of myocarditis, reducing the chance of poorer outcomes. The results of this audit indicate a need for an increased awareness of clozapine-induced myocarditis among health care professionals. This would improve the clinicians awareness of the need for the monitoring of myocarditis and highlight the implications if the standards are not met. A standardised questionnaire could be created to monitor the signs and symptoms of myocarditis and be used by nurses to document the results, this could be incorporated into the clinical notes. This baseline audit emphasises the need for future re-audits, to evaluate whether the standards have improved. Table 1: Reasons for not initiating treatment Number of patients (n) Consistent amber results 1 Patient changed mind/ refused 2 Previous health conditions made the patient unsuitable to start clozapine 2 Unknown 1 Total 6 Table 2: Reasons for not being included it length of treatment calculation Number of patients (n) Never initaited clozapine 6 Patient transferred to another trust 2 Patient returned to country of origin (unknown if they continued treatment) 2 Total 10 Table 3: Policy Title Clozapine Guide Trust-Wide Medication Policy Date July 2016 Local/National Local Standard Setting Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion Full blood count, including troponin T, CRP, neutrophil and white blood cell count should be done prior to initiating clozapine and then weekly for the first four weeks. A clinician verifies the blood test results every week before treatment can be approved. An ECG is to be performed prior to clozapine commencement and every week for the first four weeks after initiation of clozapine. A nurse or physician enquires about the signs and symptoms of myocarditis weekly for the first 4 weeks of titration. Target 100% 100% 100% 100% Exceptions None None None None Table 4: Monitoring Prior to initiating (Total number of patients n=53) Week 1 (Total number of patients n=46) Week 2 (Total number of patients n=46) Week 3 (Total number of patients n=46) Week 4   (Total number of patients n=45) ECG Yes 51 (96%) 9 (20%) 11 (24%) 8 (17%) 4 (9%) No 2 (4%) 37 (80%) 35 (76%) 38 (83%) 41 (91%) Blood pressure Taken once 36 (68%) 29 (63%) 26 (56%) 25 (54%) 21 (47%) Taken twice 4 (7.5%) 15 (33%) 15 (33%) 12 (26%) 11 (24%) Not taken 13 (24.5%) 2 (4%) 5 (11%) 9 (20%) 13 (29%) Temperature Yes 39 (74%) 38 (83%) 40 (87%) 37 (80%) 31 (69%) No 14 (26%) 8 (17%) 6 (13%) 9 (20%) 13 (31%) Pulse Yes 42 (79%) 43 (93%) 41 (89%) 37 (80%) 32 (71%) No 11 (21%) 3 (7%) 5 (11%) 9 (20%) 13 (29%) FBC Yes 53 (100%) 45 (98%) 43 (93%) 46 (100%) 43 (96%) No 0 (0%) 1 (2%) 3 (7%) 0 (0%) 2 (4%) CRP Yes 25 (47%) 10 (22%) 11 (24%) 11 (24%) 7 (16%) No 28 (53%) 36 (78%) 35 (76%) 35 (76%) 38 (84%) Troponin Yes 19 (36%) 12 (26%) 9 (20%) 7 (15%) 4 (9%) No 34 (64%) 34 (74%) 37 (80%) 39 (85%) 41 (81%) References 1.Munshi, T.A., et al., Clozapine-induced myocarditis: is mandatory monitoring warranted for its early recognition? Case Rep Psychiatry, 2014. 2014: p. 513108. 2.Aboueid, L. and N. Toteja, Clozapine-Induced Myocarditis: A Case Report of an Adolescent Boy with Intellectual Disability. Case Rep Psychiatry, 2015. 2015: p. 482375. 3.Fineschi, V., et al., Sudden cardiac death due to hypersensitivity myocarditis during clozapine treatment. Int J Legal Med, 2004. 118(5): p. 307-9. 4.Bruno, V., A. Valiente-Gà ³mez, and O. Alcoverro, Clozapine and Fever: A Case of Continued Therapy With Clozapine. Clin Neuropharmacol, 2015. 38(4): p. 151-3. 5.Swart, L.E., et al., Clozapine-induced myocarditis. Schizophr Res, 2016. 174(1-3): p. 161-4. 6.Castle, D., et al., A clinical monitoring system for clozapine. Australas Psychiatry, 2006. 14(2): p. 156-68. 7.Annamraju, S., et al., Early recognition of clozapine-induced myocarditis. J Clin Psychopharmacol, 2007. 27(5): p. 479-83. 8.Murch, S., et al., Echocardiographic monitoring for clozapine cardiac toxicity: lessons from real-world experience. Australas Psychiatry, 2013. 21(3): p. 258-61. 9.Wooltorton, E., Antipsychotic clozapine (Clozaril): myocarditis and cardiovascular toxicity. CMAJ, 2002. 166(9): p. 1185-6. 10.Kar, N., S. Barreto, and R. Chandavarkar, Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clin Psychopharmacol Neurosci, 2016. 14(4): p. 323-329. 11.Cohen, R., et al., A Case of Clozapine-Induced Myocarditis in a Young Patient with Bipolar Disorder. Case Rep Cardiol, 2015. 2015: p. 283156. 12.Merrill, D.B., G.W. Dec, and D.C. Goff, Adverse cardiac effects associated with clozapine. J Clin Psychopharmacol, 2005. 25(1): p. 32-41. 13.Ronaldson, K.J., et al., Clinical course and analysis of ten fatal cases of clozapine-induced myocarditis and comparison with 66 surviving cases. Schizophrenia Research, 2011. 128(1-3): p. 161-165. 14.Haas, S.J., et al., Clozapine-Associated Myocarditis. Drug Safety, 2007. 30(1): p. 47-57. 15.Barry, A.R., J.D. Windram, and M.M. Graham, Clozapine-Associated Myocarditis: Case Report and Literature Review. Can J Hosp Pharm, 2015. 68(5): p. 427-9. 16.Ronaldson, K.J., P.B. Fitzgerald, and J.J. McNeil, Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand, 2015. 132(4): p. 231-40.

Business Requirements Document for Baderman Island Resorts Essay

Table of Contents Revision History3 1.Assumptions, Constraints, and Dependencies3 1.1Related Projects and Dependencies3 1.2Assumptions and Constraints3 2.Business and Customer Requirements3 2.1Strategic Business and Customer Requirements3 3.References3 Revision History NameDateChanges and Reason for ChangesVersion Annamae Goodrick04/05/2014Baderman Island resort wants a reservation system to support the three hotels on the island. 1.0 1.Assumptions, Constraints, and Dependencies 1.1Related Projects and Dependencies The resort has three hotels. The hotels cater to different market segments and have slightly different needs in an online reservation system. Client needs and expectations are set forth in a set of business rules outlined below. 1.2Assumptions and Constraints IDAssumption or Constraint 1.2.1The new reservation system will be proficient in achieving the requirements. 1.2.2Design constraints for the new reservation system are based on budget limitations and migration issues since the resort has three different locations using different systems. 2.Business and Customer Requirements Enter any summary requirement information here. 2.1Strategic Business and Customer Requirements The goal is to implement a reservation system to cover all three of Baderman Island Resorts and assist in meeting business requirements. †¢Priority Legend: MH (Must Have) or WH (Want to Have) †¢Status Legend: (A: Approved, C: Cancelled, D: Delayed). Req IDDateRequirementPriorityStatus 2.2.104/06/2014The system would require that future guests make a reservation for a span of dates. MHA 2.2.204/06/2014Guests may reserve a type of room, but not a specific room. The specific room will be assigned to each guest at check-in. WHA 2.2.304/06/2014The room descriptor will include the type and number of beds available and other amenitiesMHA 2.2.404/06/2014Event or conference rooms may also be reserved.MH 2.2.504/06/2014Overbooking – Because there are many no-show reservations at the hotels, each hotel will allow a certain percentage of overbooking. This overbooking percentage must be available for each hotel and must be modified dynamically. MHA 2.2.604/06/2014The reservation system will collect customer and payment information. Future guests will use a credit card to secure their reservation. MH A 3.References Enter any references here. #Req ID RelatedReference DescriptionLocationOwner 3.1.1SR-bi-004Virtual Organization PortalBaderman Island ResortAnnamae Goodrick 3.1.2Oracle Websitehttp://docs.oracle.com/cd/E19636-01/819-2326/aavby/index.htmlOracle

My cousin vinny & criminal law in california

In 1992, the Jonathan Lynn directed movie My Cousin Vinny, made a perfect blend of courtroom drama with commercial comedy. Though the elements of criminal law and courtroom procedures distinctly deviated from reality, the movie stirred constructive debate for years to come. Joe Pesci played the role of funny New York lawyer Vincent Gambini or Vinny, Marisa Tomei played his girlfriend Monalisa or Lisa. Vinnys’s cousin Bill, along with his friend Stan, gets implicated in a murder case for which the trial takes place in an Alabama court. Vinny comes from New York to defend his cousin as a favor towards family. The case is about a utility store clerk’s murder and incidentally most of the clues point to Bill and Stan. Right after their visit to the store, the actual assailants, who drove an almost identical car, executed the crime. Ironically, Vinny had taken more than six years to clear his bar exam and had to win at least one case to get an approval for marrying Lisa. Completely devoid of judicial procedures and naà ¯ve about professional etiquette, Vinny finds it hard to plead the case. His incompetence makes an instant impression on the Judge who struggles to control his temper during the proceedings. The courtroom drama gets alive with witty remarks of struggling-to-be-lawyer. Judge Chamberlain Haller, played by Fred Gwynne, has tough time to instill discipline in the case proceedings. There is also an evident clash of cultures between a New Yorkers visiting Alabama. With the start of the case, the movie seemingly portrays many aspects of the US legal system including the courtroom procedures, rights of defendants, judicial arraignment and errors that can be construed as contempt of court. Vinny, a complete novice, finds it hard to understand the basics of pleading the case. After hearing the charges the judge expects him to plead guilty or not guilty. Vinny repeatedly labels the charges to be â€Å"bullshit†, earning him the ire of Judge Haller. In reality such impudence might have resulted in stripping of his bar license. Astonishingly, he did not even have the license to practice law. Another fictional turn is that the judge does not make any significant effort to check Vinny’s license as a member of the bar apart from a phone call. While doing so, Vinny violated the California Rules of Professional Conduct Rule 1-300: Unauthorized Practice of Law, under sub-part (B) which states â€Å"A member shall not practice law in a jurisdiction where to do so would be in violation of regulations of the profession in that jurisdiction.† However, Vinny is obviously a street-smart New Yorker and arranges his acquaintance to prove his eligibility. In real life such a lax of interest in checking a lawyer’s credentials may result in criminals defending other criminals in courts. Obviously, he had to lie about his identity to the Judge and lying to the Judge is violation of California Business and Professions Code sections 6076 and 6077 under Rules of Professional Conduct. The formal procedures of the court seemed superficial in the light of hard reality. The first moral dilemma that is encountered by the law bodies in such cases is the ability of the defendants to select a paid lawyer for them. Under California law, the defendant has the right to choose the lawyer of his choice but the guarantee of such a lawyer’s competence is not measured till the case hearing begins. If the defendant ends up hiring a cousin as incompetent as Vinny and loses the case, should the law authority intervene? Thorough incompetence in practice has also been dealt by those who framed the law for California. Vinny personified the efficacy of the Rule 3-110; â€Å"Failing to Act Competently†. The subsection (A) states that, â€Å"A member shall not intentionally, recklessly, or repeatedly fail to perform legal services with competence.† As for Vinny, two innocents could get punished because he added his stupidity to Bill’s bad luck. Bill and Stan get quite apprehensive about Vinnys ability and rightly so, as murder is a serious charge to be handled by a rookie. Even when Bill tries to express his doubt, Vinny snubs him by making a simple point that its Bill’s life that is at stake. At least twice in the case, Vinny is charged with contempt of court and sent to lock-up. In reality, either such situation doesn’t arise in the first place or the judge takes a disciplinary action against the erring Lawyer. (California Business and Professions Code sections 6076 and 6077) As the case proceeds, Bill realizes that Vinny is his best chance to get saved. The state recommended lawyer got so nervous, when he was tried, that couldn’t even make a single statement without stuttering. The well polished prosecution team reveals brilliant witness testimonies which further scare Bill and his friend. Quite often the state prosecution teams do a good homework in homicide cases. Law of the land owes a moral responsibility to the public in dealing with such heinous crimes, though the defendant was innocent in this case. Vinny and Lisa are and genuinely do look, out of the place in the rural background of Alabama. The ensuing conflicts with locals and constant bickering with the conditions took a toll on poor Vinny. But as the case proceeds he is able to demonstrate his prowess in using simple logic while cross-questioning the witnesses. He exhibits incredible intuitiveness to prove that even an eye witness account cannot be taken as unchallengeable. With the mud on the window pane and power of glasses that needed a recheck, the eyewitness’s testimony on recognizing Bill and Stan, was ripped apart by Vinny. His girlfriend Lisa that looked a beautiful but dumb proves to be a genuine expert on automobiles. Ironically, she felt helpless in helping out Vinny in the case, her expert observation on the skid marks made by the assailants’ car, simply turned the case on its head. She proved her efficacy of being an expert when the prosecution tried to hogwash her with a flawed question on ignition temperature about a particular engine. The engine described by the prosecution did not even exist in the year that he asked. Vinny and Lisa end up in a heated argument while he tries to question her as a witness, though expert witness’s opinion should already to be known to the lawyer who calls the witness. Adding to Vinny’s errors, a lawyer should already have the information of the answer that he wants the witness to render. This rule is widely accepted in legal circles as the â€Å"Eleventh Commandment† of Trial Advocacy by Professor Mark Dobson. Through hook and crook and going through hoops as well, Vinny manages to win the case, rescuing his cousin from a likely indictment. As a reward for winning, he also won the right to marry his sweetheart, Lisa. In real life however, Vinny might have been booked for fraud and impersonation. References and Citations â€Å"Rules of professional Conduct of the State Bar of California.†: The Rules of Professional Conduct are rules of the Supreme Court of California regulating attorney conduct in this state. See In re Attorney Discipline System (1998) 19 Cal. 4th 582, 593-597 [79 Cal Rptr.2d 836]; Howard v. Babcock (1993) 6 Cal. 4th 409, 418 [25 Cal Rptr.3d 80]. The rules have been adopted by the Board of Governors of the State Bar of California and approved by the Supreme Court pursuant to California Business and Professions Code sections 6076 and 6077. Mark Dobson, Professor of Trial Advocacy, Nova Southeastern University (Feb. 2, 1999).   See also BERGMAN & ASIMOW, supra note 5, at 105–06.      

`` Araby `` By James Joyce - 1885 Words

Jacelyn Donevant March 4th 2015 ENG 102 Professor Abbott As we age into adult life we are faced with decisions and situations where we are forced to think for ourselves and suffer through the consequences of those decisions. Through those bad decisions and terrible ideas we shape ourselves into the adult we are creating ourselves to be. â€Å"AP† by John Updike and â€Å"Araby† by James Joyce both introduce two young protagonist who both share in blinded adoration for young women. Both young men attempts to woo the young woman by proving their nobility. Both efforts go completely unnoticed by both girls and both young men are left alone dealing the aftermath of their failed nobility, which changes the way they view themselves. James Joyce’s â€Å"Araby† is a medieval romance set in Dublin, Ireland. As we are introduced to the story, Joyce describes the setting that takes place through the eyes of the young protagonist who remains nameless throughout the entire story. The young boy who begins by describes his ho me on North Richmond Street, and we get a feel of how it was growing up in Dublin during this time in which their culture was oppressed by Catholicism. The age of the young boy can be widely debated, we are provided with subtle hints throughout his introduction. We assume the boy is between twelve and fifteen due to him playing childish games â€Å"The career of our play brought us through the dark muddy lanes behind the houses, where we ran the gauntlet of the rough tribes from theShow MoreRelatedAraby and James Joyce1207 Words   |  5 PagesThe short story â€Å"Araby† is clearly identifiable as the work of James Joyce. His vocalized ambition of acquainting fellow Irish natives with the true temperament of his homeland is apparent throughout the story. Joyce’s painstakingly precise writing style can be observed throughout â€Å"Araby† as well. Roman Catholicism, which played a heavy role in Joyce’s life, also does so in the story which is another asp ect which makes Joyce’s authorship of the story unmistakable. As a result of Irish heritage displayedRead MoreAraby, By James Joyce1013 Words   |  5 Pages James Joyce’s short fiction, â€Å"Araby†, speaks of the loss of innocence when one enters adulthood. The narrator of â€Å"Araby† reflects back to his childhood and the defining moment when he reached clarity on the world he stood before. The young boy, living in a world lifeless and religious influence, becomes consumed with the lust of a neighbouring girl. The girl, Mangan, is symbolically the narrator’s childhood obsession with growing up. As she resembles the desire to become an adult, the Araby is theRead MoreAraby, By James Joyce917 Words   |  4 PagesAraby is a short story by James Joyce about a young boy who is infatuated a young woman who is the older sister of one of his friends. He watches her from afar and believes that his feelings are true love. He lacks the confidence to sp eak to her or confide in anyone else. The narrator speaks of her as if she were the most beautiful and wondrous human on earth, however, he does not realize that he is in love with the thought of her and not necessarily her. The narrator lives in Ireland as James JoyceRead More`` Araby `` By James Joyce1315 Words   |  6 PagesThe short story â€Å"Araby† by James Joyce is a young boy who has such an infatuation for his friend Mangan sister, he begins to idolize her as if she was a saint. This is when the idea of love and desire come into play. He simply can’t stop thinking about her and sees her in a godly like way. As the story begins to unfold the realization that the young boy doesn t quite understand the concept of the illusion and the reality of what Mangan’s sister really means to him. The young boy realizes that hisRead MoreAraby, By James Joyce956 Words   |  4 PagesIn the short story â€Å"Araby,† James Joyce uses religion to give a the story deeper meaning. The narrator of the story finds himself in a confusing love that is unrealistic and distorted. In â€Å"Araby,† Joyce uses an underlying theme of religion to portray a confusing admiration that is bro ught to a twisted end. Throughout â€Å"Araby† there is an underlying theme of religion. The boy himself lives with his uncle who is feared by the other kids on the street. If he is seen the kids â€Å"hid in the shadows† untilRead MoreAraby, By James Joyce869 Words   |  4 Pages Araby In the short novel, Araby by James joyce which was one of the most influential writers in the modernist era of the early 20th century. In Araby, Joyce highlights a young boy who describes the North Dublin Street where he lives in a house with his aunt and uncle. The narrator recalls when he and his friends used to run through the dark muddy lanes of the house to avoid his uncle or when Mangan’s sister came out on the doorstep to call her brother in to his tea. He is obsessed with the youngRead More`` Araby `` By James Joyce843 Words   |  4 PagesIn â€Å"Araby†, James Joyce uses the young unnamed boy as her main character. Representing himself in this first person view, the main character takes us on a journey that suggests the verge of adolescence. The events that take place in this story create a very clear image for us, reflecting the difficulties a young boy may undergo during the last years of his juvenile life. The awakening is sometimes unknowingly refreshing. He would watch the girl he most desires at times throughout the day as if mesmerizedRead More`` Araby `` By James Joyce1451 Words   |  6 PagesJames Joyce, an Irish novelist, wrote fifteen short stories that depict Irish middle class life in Dublin, Ireland during the early years of the twentieth century. He entitled the compilation of these short stories Dubliners. The protagonist in each of these stories, shares a desire for change. This common interest motivates the protagonist and helps them to move forward in their lives. Additionally, the protagonist has an epiphany, or moment of realization or transformation. In â€Å"Araby†, the narratorRead MoreAraby, By James Joyce Essay1888 Words   |  8 PagesJames Joyce’s, Araby, is an emotional short story that centers around a nameless boy living in Dublin, with his aunt and uncle, who has a consuming crush on his friend’s sister. His love for her leads him to the Araby bazaar, and there he comes to a realizat ion about his immature actions. This event is the basis for the entire story, but the ideas Joyce promotes with this story revolve around the boy’s reactions to his feelings about his crush. Joyce spends much of the story describing the boy’sRead More Araby by James Joyce Essay620 Words   |  3 Pagesâ€Å"Araby† by James Joyce   Ã‚  Ã‚  Ã‚  Ã‚  There seems to be a great deal of controversy surrounding the short story, â€Å"Araby† by James Joyce. This isn’t controversy dealing with various political issues or controversy involving issues of free speech or anything related to these things. It is of a more simple matter: whether the young boy in this story is capable of having a deep emotional realization at the conclusion of the story. It is obvious to me via the final sentence, (Araby, 398), that he does not make