Design, Instrumentation And Analytical Tools Essay

The previous chapter focused on the identification and discussion of the theoretical framework, related theories and the theoretical assertions of previous studies. This chapter identifies the methods, design, instrumentation and analytical tools. The content of the chapter aims at the identification of appropriate and suitable methods and the adoption of such within the confines of a systematic design which clearly stipulates population and sampling procedures; data collection instruments with regards to variable measurement and operational definitions, instrument reliability and validity as well as descriptive and inferential statistical tools (Sekaran, 2003; Sarantakos, 2005). 3.2 Research Design The research design is primarily concerned with the structure and framework of plans within which empirical activities concerned with research are to be undertaken. It encapsulates concepts such as population and sample of the study, methodology and characteristic of the study as well as instrument for generation of data and defines the layout for the entire field work (Sullivan, 2001; Sarantakos, 2005). Similarly, Baridam (2008) describe research design as the basic question of how the focus of the research will be brought into and how they will be employed within the research setting to obtain the required information. It is a framework for collecting valid and reliable data to test the hypotheses and answer the research questions. There are two main types of researchShow MoreRelatedDevelopment Of Instruments With Applications953 Words   |  4 Pagesresearches and applications of various machines, tools, etc. When I entered grade XII, I decided that I too would pursue their footsteps and enrolled for an undergraduate program in instrumentation engineering. The 4 year program introduced me to subjects such as Transducers and Instrumentation Components, Electrical and Electronic measurements, Electronic Equipment design, Analytical Instrumentation, Process Control Instrumentation, Power plant Instrumentation, Digital and optimal Control Systems amongRead MoreEvaluating The Usability And Effect Of A Problem Focused Clinical Decision Support Essay1590 Words   |  7 Pagesthis study is to develop and assess the usability and effect of a problem focused clinical decision support tool designed to improve medical decision-making. The overall goal is to design an effective dashboard that will support both rapid pattern recognition and slower, more deliberative reasoning and analysis of information, when managing the care of complex patients. The dashboard design may support cognition by simplifying and grouping information to enhance pattern recognition and prompt situationalRead MoreElectrical Engineering And The Field Of Engineering1476 W ords   |  6 Pagesthese include telecommunications, energy and power distribution, transportation, manufacturing and consumer electronics. In this report we will go over the education and coursework requirements, fields of the industry, the work environment, salary, tools of the trade, and professional organizations of electrical engineers. According to Frederick Terman; Electrical Engineering as a discipline first appeared in the United States during the early 1880’s as classes in physics and energy flows intendedRead MoreKirkham Instruments Case Analysis Essay1355 Words   |  6 Pagesit was too vague to help select which New Product Development to fund/cancel. The Harvard professors presented tools to help structure these decisions, but division leaders did not want to see their projects cut, so they criticized the list and delayed action, resulting in no development or implementation of a strategy. Kirkham Instruments was a manufacturer of laboratory analytical equipment with turnover of  £450M in 1995. The company was organized into four divisions: the Mass SpectrometerRead MoreAnalysis Of Bitner s Servicecape ( Fig ) Essay928 Words   |  4 Pagesframework to use as foundation for this study. For example, academics must analyse relevant literature, theories and analytical models that are relevant to the framework, and are related to the area of study. And the selected theory must also depend on the applicability, ease of execution and justifications. Figure 1: Servicecape Model – by Mary J Bitner â€Å"Bitner’s framework can be a useful tool in enhancing a ‘food and beverage’ experience while certain servicescape components are emphasized† (Bitner,Read MoreResearch Methodology On Staff Turnover, Retention And Productivity1795 Words   |  8 Pageschapter (3) is attempts to describe the design, methods and empirical means in which the objectives of the study are to be carried out within the specified time-frame and upon the identified population. The chapter is therefore structured as follows – (1) The research design (2) population of the study (3) Data collection methods (4) Instrumentation (5) Reliability and validity, and finally (7) Method of data analysis 3.3 Research Design: The research design is concerned with the steps, methods orRead MoreAssumptions in Quantitative Research2346 Words   |  10 Pageshas been defined. Hall (1976) has used etic, Kaplan (1964) calls it logic-in-use, Smith (1983) defines it as realist and rationalist, and Habermas (1988) calls it empirical-analytical (Habermas, Nicholsen, amp; Stark, 1988; Hall, 1977; Kaplan, 1998; Smith, 1983b). For the purposes of this paper the empirical-analytical is used to describe the paradigm structuring quantitative research. Most commonly, the empirical-analytic has been associated with positivism which also has many varieties (PhillipsRead MoreNuclear Magnetic Resonance Spectroscopy1841 Words   |  7 Pages1) THEORY OF NMR Nuclear magnetic resonance spectroscopy is an analytical tools that use in quality control to analyze the microscopic physical and chemical structures of molecules. Many nuclei may be studied by NMR technique, but hydrogen and carbon are most available. NMR gives information about the number of magnetically distinct atoms of the type of nuclei being studied. When an electromagnetic radiation applied with specific frequency, and atomic nuclei are immersed in an external magneticRead MoreThe Importance of Developing Renewable Energy in Europe1887 Words   |  8 Pageshave not been conducted in detail, in order to provide significant indications that the benefits of SHM systems outweigh their cost. In this respect, one should mind that stakeholders, managers and infrastructure operators need simple and reliable tools in the form of â€Å"yes/no actions†, or â€Å"green/red buttons†. Unavoidably, this implies that SHM systems should be transformed from complex research-o riented measurement campaigns into robust, integrated solutions that accompany the structure throughoutRead MoreMy Job Evaluation Matrix : Obstetrics And Gynecology, Database Administration And A Computer System Analyst Essay1932 Words   |  8 Pageslittle income, fewer current opportunities and not much passion for this particular career. The third career I chose is a computer systems analyst. A computer systems analyst studies the computer systems of an organization and its procedures and then designs solutions for information systems in order for the organization to operate more efficiently and effectively. They also bring business and information technology together by understanding their needs and limitations. This career was rated based on

Did the Ancient Greek Gods Exist - 1234 Words

Did the Ancient Greek Gods exist? The Ancient Greeks regarded their religion and mythology with much respect and loyalty. Although the Ancient Greek Gods are now seen as an explanation created by man, for natural forces and the world around us, there has been much evidence both for and against the debate that these Gods were real. The Greeks believed that the Earth was created with the birth of Gaia, or Mother Earth, from the dark void known as Chaos. It was believed that Gods were all-powerful giants and heroes, who were responsible for our creation. The Olympians were a younger race of Gods led by Zeus, who eventually overthrew the formidable Titans, led by Zeus’ tyrannical father Cronus. Once in power, the Olympians, named after their†¦show more content†¦However many argue that it was from the bull sensation that came the origins and inspiration for the tale of the Minotaur. The creature eventually grew for a horrific taste for blood, forcing Minos to imprison it in a twisting labyrinth under his palace, Knossos. Several years ago, Oxford university geographer Nicholas Howarth uncovered an underground cave complex consisting of a dark,Show MoreRelatedCreation Of Society : Ancient Myths Essay1419 Words   |  6 PagesVictor Cime English 10 Period 1 Ms. Cha 3/23/15 Creation of Society: Ancient Myths The telling of tales is a tradition old as time. Ancient culture from all over the world have folktales and grand stories of their land. Although many of these cultures are divided by language barriers and thousands of miles, they all all share one thing in common: Myths. Myths were told to answer questions that these ancient societies pondered. Although there were many types of myths, creation myths were told toRead MoreThe Incompleteness of Platos Euthyphro Essay848 Words   |  4 Pagesincompleteness. On account of the dialogues dual effect -- the presentation of Socrates spirit as well as the Greeks inability to define piety -- explanations for its incompleteness often place too much emphasis on Socrates and, as a result, fail to unearth its true genesis. Some students argue, for example, that the failure to define piety is induced by the non-existence of the Gods, which they declare Socrates implied through out his life. Hence arises the purpose of this interpretation: to Read More Exploring The Four Ancient Civilizations- Mesopotamia, Egypt, Greece and Israel1009 Words   |  5 Pagesleader elected by the citizens. He established an army and led it into battle. Kingship was hereditary. Commoners were free citizens. In ancient Egypt, both women and men could act on their own and were responsible for their own actions. In contrast, Mesopotamia didn’t even give the amount of rights that Egypt has given to their female population, where women did not have their own legal identity, were not allowed to participate in the legal system without a male present usually a closest male relativeRead MoreExamples Of Archetypes In The Odyssey1291 Words   |  6 Pagesof writing, contains many archetypes. The Odyssey is a 3,000 year-old epic written by Homer in Ancient Greece. It describes the adventures of Odysseus. As well as being found in The Odyssey, archetypes are evident throughout Greek culture. These archetypes depict the ideals and beliefs of the Ancient Greeks. Through Homer’s use of archetypes in The Odyssey, the reader gains insights about Ancient Greek culture. Three major archetypes shown in The Odyssey include the archetypal characters the heroRead MoreExamples Of Archetypes In Homers Odyssey1292 Words   |  6 Pagesof writing, contains many archetypes. The Odyssey is a 3,000-year-old epic written by Homer in Ancient Greece. It describes the adventures of Odysseus. As well as being found in The Odyssey, archetypes are evident throughout Greek culture. These archetypes depict the ideals and beliefs of the Ancient Greeks. Through Homer’s use of archetypes in The Odyssey, the reader gains insights into Ancient Greek culture. Three major archetypes shown in The Odyssey include the archetypal characters the heroRead MoreOrder From Chaos : Analyzing And Evaluating The Hellenic Creation Myth Through The Lens Of Biblical Tradition1384 Words   |  6 Pagesthe Hellenic Creation Myth through the Lens of Biblical Tradition Greek mythology is often understood through the lens of analyzing a dead religion; it is assumed that the influence of such myths is passive and fixed, only effecting the lives of those already long gone, whereas the very nature of such myths is to be active, dynamic, and illuminative. I, like many others with Greek heritage, rarely engage actively with the ancient Hellenic myths. Despite this, it is valuable to understand their placeRead MoreAncient Greek Empire : A Of Culture1583 Words   |  7 PagesEssay Exam One The ancient Greek empire was full of culture. In those times, the empire was considered large. With that being said it was very surprising that most aspects of Greek culture were unanimous throughout the empire. The most consistent similarity is found in Greek religion. Greek religion included many gods, practices, and ways of worship. While religion was generally unanimous throughout the empire, the opposite can be said about politics and government. Many different ways of governingRead MoreAncient Greek Influences Essay886 Words   |  4 Pageshave long considered Ancient Greece to be one of the most influential societies on modern day life. Ancient Greece has inspired the modern world in five main areas: theatre, government, philosophy, art, and architecture. Theatre flourished in Greece, particularly in Athens, between c. 550 BC and c. 220 BC. During its beginnings theatrical performances were part of Dionysia, a festival held in honour of the god Dionysus. The plot of the plays was always inspired by Greek mythology, a theme thatRead MoreHuman Sacrifice And The Gods Essay1360 Words   |  6 Pagesthe sacrificial table as the priest cuts out the man’s heart to offer it to the gods.â€Å" The occurrence of human sacrifice can usually be related to the recognition of human blood as the sacred life force†(â€Å"Human Sacrificing†). The thought of human sacrificing may seem inhuman or uncivilized; however, in the ancient times, it was considered a prayer for better times. Human sacrificing was not only a ritual act to earn a god s favor, but also for a greater cause. Usually people would benefit luck, fertilityRead MoreAncient History And Biography : A Week On The Concord And Merrimack Rivers1215 Words   |  5 Page sâ€Å"To some extent, mythology is only the most ancient history and biography. So far from being false or fabulous in the common sense, it contains only enduring and essential truth, the I and you, the here and there, the now and then, being omitted. Either time or rare wisdom writes it. Said Henry David Thoreau in A Week on the Concord and Merrimack Rivers published in January 18, 1849. All over the world, during the ancient times, many cultures had developed their own mythological systems to help

Memory Boy Essay Free Essays

Memory Boy The book that I choose to read this 9 week period is called Memory by Will Weaver. The book is based on the lives of a family of 4 people; Miles, Sarah, and their two parents. Memory Boy starts out in the Mid West after a mountain range in Washington erupts and spews ash what seems billions of feet up, and over the entire United Sates like a blanket. We will write a custom essay sample on Memory Boy Essay or any similar topic only for you Order Now The ash is so thick that people have to wear dust masks outside to avoid the risk of breathing it in. Miles and his family finally decide to leave the town that they live in to head northwest. Since the ash is so heavy they can’t drive a car because those are restricted, and people can only use them on certain days to avoid the problem of pollution. So Miles assembles a new vehicle that he calls the Princess. It is a mix between a bicycle and a boat that they must pilot by either peddling, or when there is enough wind they have a sail from a boat to put up. They decide to leave under the curtain of night to avoid being detected by other people who would want to take their vehicle from them. As they make their way North they must face encounters with many obstacles such as road blocks, bandits, hunger, the government, nature, each other, and other hazards. In between telling us about they’re adventure north, Miles, who is the main character tells us the events leading up to their departure, starting with the day that the eruption happened. The novel starts out a peaceful journey by the family but they soon learn that their trip will not be easy and they must work together to survive. Miles is our main character and we watch all the events happen through his point of view. He would be a junior in high school if they still actually went to school. Miles is a smart individual who enjoys doing the job of a mechanic. He built the Princess by himself and is the only one who is about to fix and maintain it throughout the book. He takes a strong leadership role; even his parents look to him to solve the solutions. When the volcano erupted he was only in the 9th grade. So every other chapter he will flashback to his 9th grade year to tell us a story about after the volcano erupted. He often compares his life now to that of his 9th grade year, and how he would have done things different. He used to be disrespectful and would often act out in school to seek attention. He will explain to us how some of the events he tells us about have changed him. Miles sister Sarah is a few years younger than he is. She is a dark and morbid girl; the type that is into vampire, dark music, and dark literature. But even though she seems tough on the outside, but she is actually just hiding how scared she has been throughout this entire ordeal. She secretly looks up to miles even though she would never say so to him. She doesn’t like her father very much because he was always away when she was a child. Miles’s father was a jazz musician in a band before the eruption. He was always on the road with his band, so he wasn’t around much when Miles and Sarah were growing up. Although he seems quite docile at the beginning of the book we soon learn that he is actually quite the leader, and when Miles gets overwhelmed his father is always there to take the lead for awhile. Miles’s mother was the main caretaker of the children so she was always around. At the beginning of the book she kept the family together as a unit, they referred to her as being. The children see their mother as being helpless most of the time. It isn’t until later in the book that she really blooms as a character, and becomes a very useful asset to the group. How to cite Memory Boy Essay, Essay examples

Comparative Issues in International Management

Question: Discuss how the various economic, international trade, legal and technological factors assist or hinder Multi-National Corporations in entering new global or regional markets you should seek to provide specific Multi-National Corporations examples to support your answer. Answer: Introduction Globalization is shaping our lives and is leading us into a new territory. New technologies help in reducing the cost of global communication and travel where the people are exposed to the international cultures by travelling. The Countries these days have taken major decisions where they have reduced their rules and policies in terms of travel and in terms of allowing new business firms to grow (Milmo 2008). These moves in terms of globalisation have transformed the ways in which the business organizations respond to the growing competencies and they have also helped the organizations grow more effectively. The multi - national corporations are looking out for newer opportunities to grow and to emerge in the newer markets with their own customers by intensifying the competition on an international scale (Milmo 2008). The Companies face a lot of issues in terms of economic factors, the international trade barriers, legal barriers and technological factors depending on the political and economic situation of that specific international market which they choose to enter. All the new strategies of the organizations have started to motivate the Managements alter their management strategies and policies in terms of implementing their projects. International Business involves different issues at some junctures where there could be sure possibilities of exchange of views and systems in terms of various economic, international trade, legal and technological factors which can cause some type of hindrance in promoting the Multi National corporations to a greater level (Branigan 2008). The dynamic nature of the International Business Organizations has been changing a lot where if we consider the examples of the alarm clock with which we wake up on a daily basis has a major link with the international country China and these clocks are being exported to almost all the Countries in the world. This shows that the business is being outsourced a lot to the international locations for a lot of advantages like emerging markets in those countries, the competitive advantage in those countries which the Multi National corporations are being able to realise (Branigan 2008). These Multi National corporations are also being proposed as stronger business firms in the market where they have proven to exhibit a greater sustainability and corporate social responsibility. There are a lot of international companies or the Multi National corporations which have made their ways to almost all the Countries in terms of their products like the Adidas shoes, Nike stores and their large variety of clothes, the Mobile Phones with Companies like Samsung and Xiaomi, electrical products from General Electric, Computers, Laptops and Accessories from companies like Dell, Chocolate brand which almost all the people in the world are familiar with like Nestle and the phone companies like Vodafone who are a major mobile service providers in the world (Mercado, Welford and Prescott 2001). 2) Factors assisting or hindering Multi National Corporations in entering new markets Overview of new market entry The Organizations see the local determinants in terms of their interaction which would be ownership specific and based on the internalisation advantages in terms of a larger situation in designing the corporate strategies. The Organizational strategies aim and spread their objectives in terms entering new markets, reducing risks, entering markets like oligopolistic and competitive environments. What makes MNCs enter into new market The new market seeking objectives could be majorly focussed on entering new markets in order to enhance the scope of acquiring new businesses, starting up newer branches in the international locations, attaining the market power and aiming at diversifying the markets in terms of spreading the risk strategy (Mercado, Welford and Prescott 2001). Brief discussion of factors economic, international trade, legal and technological There are various factors which can assist or cause hindrance to MNCs to enter new markets which include Economic factors like Free market capitalisation and various economic enhancements which they can achieve The average market profits which they can make Governments rules and policies which might affect the market decisions Market factors like economic situation of the Country, market borrowings and fluctuations Levels of Education and labour market laws Availability of skilled labour Levels of infrastructure which is maintained International Trade FDI policies and interventions levels of protectionism Levels of Government interference in business activities Economic and Trade pacts with the other Countries Participation in international and regional trade agreements Legal Levels of Government interference and Governments rules and policies which might affect the market decisions Legal policies and codes of conduct which are formed Rules of law Issues of jurisdiction in terms of policies to be adapted and implemented Technological Types of technological development like infrastructure of the buildings to open the new ventures Types of technological qualification which people should have Technological products which would be introduced in terms of technical qualifications and skills to acquire Technological skill assessment to contribute towards the economic development which is required in that specific country 2.1 Economic Factors a) The general economic factors which are to be considered before entering the new global and regional market depend on various situations. All the business organizations face some competition in terms of setting their business in the international markets with respect to the internal and the external factors (Bhalla and Shiva Ramu 2003). The external environmental factors which have to be considered include economic factors, socio cultural factors, Government factors and policies inclusive of the legal factors, demographic factors and the internal local economic factors. b) The economic situations can turn out to be viable and non viable in some cases depending on the situations of the country and the type of business and the situation of their local economic and political factors (Helmore 2004). The environmental factors are beyond the control of any Organization and the success will depend on the adaptability to the environment which would in turn control the opportunities which the Organizations would get and the threats which they might face in order to sustain in that specific local market. c) For example the changing economic situations in the Countries have set low standards in terms of growth rates especially for the Companies in the Consumer Business like NESTLE in the UK. The brands have to come up with newer strategies in order to come up with newer products and offers to sustain the competition in the local market. The same is the case with Companies like Vodafone, Dell and General Electric where the changing economic situations can hamper the development of the products and can also impact the market decisions to a great extent (Ewing and Edmondson 2005). The changing economic factors can cause a great deal of discomfort in the markets by causing changes like increased unemployment because of the non-performance of the Companies and their products in the markets. These situations also arise because of the change in interest and exchange rates in the international global environment when the Companies try to enter newer international markets like EU and UAE. The rise of the other international economies like China and India can also hamper the economic growth of their local market (Bulkley 2008). All these factors happen when there is a large transformation of a specific brand or a company into a consumable product like for example DELL and VODAFONE. When the market for such products grow there is a large competition which develops due to the emerging newer brands in the international market. For example in the case of DELL they have faced a large competition with COMPAQ (Bulkley 2008). 2.2 International Trade a) International Trade International Trade is the exchange model of various types of products and services across various international locations. The International trade processes consist of different initiatives taken by the Government and the Companies in most of the international markets. The international trade share is represented by the GDP Gross Domestic Product. b) What type of International Trade is preferred by MNCs and why The International trade preferred by the MNCs is similar to that of the trade which is conducted between the Countries where they expect something from each other in terms of exchange of products and services. The trade is an essential activity which involves exchange however it might not always focus on the Government policies which are involved. c) Examples to support arguments For example in case of DELL and VODAFONE the trade happens between the products, accessories and peripherals related to the production and sales of the products. The MNCs prefer to specialise in types of products and services which are unique to their brand and they trade in those specific products. This figure shows us the product possibility curve and the constant opportunity costs which it might create. 2.3 Legal a) What are the legal issues In terms of business firms there could be a possibility of various legal issues in terms of handling consumers, partnership companies, Government and Suppliers and Vendors. Legal issues can be related to any litigations because of the Companies, the internal employees, suppliers and the Management. Litigations could also arise due to the patent issues of their products and the issues related to their dissatisfied Consumers. b) How could it help or hinder MNCs to enter global market. What causes Legal environment to change The external or the environmental factors like the economic and socio cultural factors, government and the legal factors are all called as uncontrollable factors where the environmental factors are far beyond the control of a firm and the success of the Organization depends on its adaptability to change and adjust to the new environment. There could be a lot of legal factors like macro environment and micro environment factors which could involve external environment factors like suppliers, market vendors, competitors and partnership companies. All these factors could change the macro environment by causing some changes in the legal environment of the company. Apart from these parameters factors like exchange markets, foreign legal systems, cultural differences, rates of inflation and fluctuation in the markets cause the legal environment of a company to change. There are a distinct set of strategies which have a major control on the responses of any specific issue where the firms c an restructure themselves based on various legal strategies in order to work towards the organizational growth (Bartram 2004). c) Examples to support arguments If we consider the case of DELL the company has grown to a major extent and the computers have become more of a commodity and the companies in competition like Compaq have become rivals to DELL. The factor here is the market competition. In this category Compaq has continued to maintain its processes with great systematic procedures and the competition shifted to the value for money (Chindnovsky 1999). In the case of NESTLE and Vodafone the companies have to consider the legal laws and policies of that specific country and have to implement their sales strategies. The laws include various aspects like health and safety, consumer laws, employee laws and discrimination laws which can protect the interests of the employees on a legal front on the Governments front (Jones and Mackintosh 2005). The laws are safeguarded for all purposes where the Employees are treated with great care and equally. 2.4 Technology a) Role of Technology Technology can have a significant impact on the people in terms of the companys future and fortune. There have been a lot of technological achievements which have made a lot of contribution in terms of introducing newer tools and apps to make some processes function and in innovating new products like mobile phones, computers, accessories, apps, internet related products and scanners. There has been a heavy investment in new technology which has paid a lot of higher returns for the Companies. If we consider the mobile technologies the companies have invested in a greater technology which can support newer platforms and make the global company stand out as a global leader in the international market. b) Advantages and Disadvantages The critical factor to technological investment and implementation is market understanding of the products and the technological sophistication. A higher investment in the technological companies can majorly change the fortune of the companies in a positive way. If we consider the GEs products we would see that the implemented technology has changed the quality of the products which has allowed to exhibit their talent in a great way. Vodafone with its technology has changed the quality of the speakers and the microphones with which the listening ability has been enhanced. These technological investments have contributed to high end market potential where the companies have identified the required technological changes which had to be brought in order to enhance the quality of their products and services. These technological changes can also contribute to provide newer opportunities for new products to be introduced and they can also reduce the risks in the markets. c) Examples to support your arguments Having the products of General Electric are for sure a great hit in terms of a product brand as they are known to be the pioneers in the product categories of electric stoves, cleaners, dishwashers and electrical products. In cases of products like computers and electronics there has been a large competition in terms of introducing newer product category by revolutionising their mobile technology and devices (Bhalla and ShivaRamu 2003). DELL is known for its higher reputation in terms of quality, specifications, reliability and innovation. Conclusion We have analysed various economic, international trade, legal and technological factors assist or hinder Multi-National Corporations in entering new global or regional markets. The Management of the companies should identify various dimensions in order to handle all the issues related to identifying new markets and analysing them. This type of an analysis will recommend newer styles and dimensions where the companies can deal with any of the extremities which they might face (Engardio 2005). The Companies can also adapt and implement any of the contingency models which can ensure a better approach for successful implementations of their products and services. References Milmo, D 2008, Former BA Bosses Face Price-Fixing Charges, Guardian, 7 August, 26 Mercado, S., R. Welford and K. Prescott 2001, European Business: An Issue-Based Approach, Harlow: FT Pearson. 5 Helmore, E 2004, Do Not Pass Go Says EC, Observer, 28 March, 3. Jones, A. and J. Mackintosh 2005, Taking the Hit: European Exporters Find the Dollars Weakness is Hard to Counter, Financial Times, 3 May, 17. 13 Watts, N 2006, Migrant Workers from East Helping to Boost EU Fortunes, says Report, Guardian, 9 February, 22. 14 Ewing, J. and G. Edmondson 2005, Rise of a Powerhouse, Business Week, 12/9 December, 4260. 15. Ewing and Edmondson (2005) op. cit. 16 Bartram, P 2004, Targeting the New Ten, Marketeer, May, 225. 17 Engardio, P 2005, A New World Economy, Business Week, 22/29 August, 328. 18 Bulkley, K 2008, Partnerships Are Key, Media Guardian, 29 September, 1; Anonymous (2008) Alternative Reality, Economist, 2 February, 69. 19 Branigan, T 2008, Rush for Yorkshire Pud and Cotton Socks, Guardian, 3 October, 21. Bhalla. V.K. and ShivaRamu. S., 2003, International Business, Anmol Publications, New Delhi Chindnovsky, Danial. B., 1999, The Globalization of Multinational Enterprise Activity and Economic Development, Macmillan, London Branigan, T 2008, Rush for Yorkshire Pud and Cotton Socks, Guardian, 3 October, 21.

How desirable is censorship Essay Example

How desirable is censorship? Essay Most people think that censoring materials is going against peoples right to information and press but in some cases censorship is unavoidable. Censorship is the suppression or deletion of material which may be considered objectionable, harmful or sensitive, as determined by a censor. But it is an arguable topic on who gets to censor materials and the criteria for a material not to be censored. Mainly censorship is done on three bases: materials regarding national security, liable materials which can damage an individuals or a firms dignity and reputation and finally material that is obscene materials such as pornography. When it comes down to the security of a nation from attacks by terrorist and other countries, it is obvious that the material which put it in jeopardy is bound to be censored. Materials like maps of secret location like the Whitehouse and other government areas of most of the countries are censored on Google earth and out of reach of the local population because it provides an easy access for the terrorists as they will be able to view those places and plan their attacks. Other official papers also like of those of research done by a country and military tactics is censored because the linkage of the information may turn out to be a huge problem for a country. So these types of censoring are justified and are reasonable. But when the government holds back secret information which they think will start a revolution and the people will rebel against the government isnt the correct use of censorship as the citizens of the country have the right to know what is happening and show their feeling and thoughts towards what the government of doing with the country. We will write a custom essay sample on How desirable is censorship? specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on How desirable is censorship? specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on How desirable is censorship? specifically for you FOR ONLY $16.38 $13.9/page Hire Writer This type of censorship is usually seen in Middle Eastern countries like Iran and Saudi Arabia. Another material which is usually censored is obscene or vulgar materials like pornography, or usage of foul languages. In most of the countries pornography is legal for adults and is only banned for children under the age of 18. So this type of censoring is expectable as exposure to such material can affect the growth of the child and put negative images in their minds. Censoring foul languages from songs is also a good thing as the songs are played on radio and the child may learn the language trying to imitate their idols and singers which isnt a good thing. A song of a famous hip-hop artist Akon had to be re-sung to have a permission to be broadcasted on radio and television as it contained swearing words. On the other hand, another song which was banned was of the black eyed peas. The song lets get retarded had to be changed on to lets get it started to be broadcasted as the censor thought that it would offend the physically challenged people. I dont think this type of censoring in music is justified as the whole concept of the song and the meaning behind it has to be changed. There are many other songs which offend a lot of people but they arent banned like those of Slim shady. Why is it so? So the criteria for a song to be banned should be made clear and shouldnt be bias. There is a lot of censoring done by certain schools, colleges, universities and other educational institutions itself because they dont want some things to be known by the students or it goes against the morals of the school. As an example of a just banned book, David Gutersons acclaimed book Snow Falling on Cedars has been banned by the South Kitsap School District in Washington State as an inappropriate and obscene book. Why it was banned is much deeper, as the book is written about the racism and anti-Japanese persecution during and after World War II on the Kitsap Peninsula. The book was banned because Kitsap is still a right wing, racist stronghold and they wish to block any recognition of their bigoted past and present. This is known as white washing where they try to hide their past which they are ashamed of. Many books in the past have been banned for reasons varying from offending religious beliefs to portraying women as liberated because of this reason many Canadian childrens books are censored as well, not at the government level, but at the level of local schools and libraries. Restricting childrens literature puts a severe limitation on a childs right to read. This type of censorship shouldnt be done as it goes against many of the rights of the people like the freedom of expression and press. The people have the right to read such books and know about the truth and get these types of ideas. Censoring is done in every field these days. There are many other types of censoring done: like corporate censoring where they hide the materials of a project or tender from their adversary; commercial censoring where certain advertisements cannot be played during a certain period of time; parental locking where the parents are able to lock channels and web pages which they dont want their children looking at; political censoring which keeps certain information from the public for certain reasons; personal censoring where an individual decides not to say anything about a subject matter even after knowing the truth for money or some other reason. Censorship is a controversial issue as we know and there will always be two sides of the story to tell. But some materials even though people dont want it to be censor have to be cause if there is no censoring done than a big problem would arise socially, economically as well as politically. So drawing the line between censoring materials and non censoring materials should be the highlight of the agenda rather than try to completely censor materials or completely removing censorship.

Comparing Araby and Going to the Moon

Comparing Araby and Going to the Moon Free Online Research Papers When one talks about the allure of the other, many different meanings can rise up into the conversation. Allure is defined as an attractive or tempting quality possessed by somebody or something, often glamorous and sometimes risky. In both short stories, Araby and Going to the Moon, the allure of the other, love or acceptance, shared a similar yet different pattern as it happens throughout the two stories. For the stories, the protagonists were attracted to a female character because both of them seemed capable of providing an imaginary satisfaction, either for love or recognition that would fill up the void of loneliness and isolation. Due to the appeal of the unknown, both of the protagonists were allured to a location that they believed to be secure and harmonious. Then at the end, both protagonists realized that what they desired, love or acceptance, can not be fulfilled because their deep emotions and feelings blindly misled them. The main similarity between the two stories is that both protagonists were drawn towards a female character because they portrayed the superficial appeal of love and acceptance. In Araby, the boy was attracted to the girl because he is a senior teenager who as all other teenagers is interested in the matter of sexuality. The author illustrated that boy has no way of escaping the allure of the female character in the story, Mangan’s sister, because she composed of an attractive appearance and body figure. As a result, her body figure and movements became the main focus on his mind. â€Å"Her dress swung as she moved her body and the soft rope of her hair tossed from side to side† (288, James Joyce). Instead of realizing that he was really interested in sexuality, he blindly led himself to believe this is a high ordered romance. Due to the appeal revealed from Mangan’s sister, the boy was blindly infatuated with her. Evidence supporting this is that the author use d a metaphor to imply that the narrator felt like a harp controlled by Mangan’s sister. In the other story, Going to the Moon, the young protagonist was drawn to a female character who he believes can connect him with the outside world and provides him with protection and acceptance. She is so exceptionally different from the others that she â€Å"stood out from the stiff formality of the priests and nuns like a burst of colour in a grey landscape† (213, Nino Ricci). The reasons for her difference are her striking beauty, rich and colourful apparel, and unique ways of teaching. Therefore, including the protagonist, all the kids admire her to a great extend. The moon in the unique moon game started by her symbolizes an ideal world where the boy believes he can be accepted and welcomed. Since the game was organized by her, she then became the connection to his hopes of acceptances. So in both stories, the young and innocence of the story led them to succumb to the superf icial appeal of love and acceptance because they seemed so interesting and comforting. Due to the appeal of love and acceptance, both protagonists had a location in mind that reflects their hopes and dreams. In the story Araby, the magical place in the mind of the boy was the bazaar Araby. This place is implied with significance and heavenly decoration because it is where the protagonist can start his plan of consummating his love. Since the boy promised the girl that he will retrieve something back for her from the bazaar, the mission to the bazaar then represents a mission of winning the girl’s love. The bazaar then was constantly on his mind, â€Å"†¦the word Araby were called to me through the silence in which my soul luxuriated and cast an Eastern enchantment over me† (Joyce 289). In the story, Going to the Moon, the desirable location the protagonist dreams of was U.S.A. His family and he were originally planning to go to U.S.A, and they see it with a greater importance and significance in comparison to Canada. This was illustrated at the begi nning where Windsor, Canada, was like a purgatory. An allusion was also used to show the protagonist’s desire to go to U.S.A by comparing their family to Dorothy which â€Å"falling asleep on the road to Emerald city†, or U.S.A. Not only so, the protagonist view the building structure in U.S.A with high respect and admiration, â€Å"†¦that skylines tall buildings stood unnaturally still and crisp in the cold air†¦they had a strange, unreal quality†¦.my eyes could not believe their own power to hold so much in a glance† (Ricci 210). So for both of the stories, the appeal of the unknown caused the allure to a location, changing from feeling or emotion to a materialized desire for a place. High expectations usually conclude with a note that disappoints the person with the hope. Just as in the story, Araby, where the protagonist came into a realization that the girl does not love him as she treated him out of duty, and in some way, she seemed to be using him to buy things for her. The author prelude the realization by showing a flat, meaningless conversation between the protagonist and a saleswoman in comparison to the flirtation shared between the same women and two other men. Mangan’s sister is just like the saleswoman, treat the boy out of duty rather than the passion he desired. At the end, the reality was learnt by the boy in the harshest way possible, as he saw himself â€Å"as a creature driven and derided by vanity; and my eyes burned with anguish and anger† (292, James Joyce). The realization in the story Going to the Moon is that U.S.A was not a utopia as imagined. Due to the death of the astronauts and riots in Detroit, the boy can no longer mislead himself to believe that U.S.A is a safe and secure country. Not only that, the death of the astronauts had changed Miss Johnson, as she changed and acted in the same way as all other teachers in the school. The change in her, the termination of the moon game had completed destroyed the boy’s hope and faith of the easy acceptance into a welcoming world. However, though, the boy had began to accept his life, his position in Canada, because it seems Windsor can be a peaceful place to be in comparison to U.S.A, because at the end he called Windsor â€Å"home†. Overall, the tough realizations caused pains and sufferings to both protagonists as they cannot be satisfied with their hopes and desire. However, the same time they learn from these harsh lessons, they advance in life significantly. The allure of the other plays a major role in both Araby and Going to the Moon. In both short stories, the main characters were attracted to a certain character for a variation of reasons. It could be to fill a void in their life, or to fulfill an imagination or dream they have had in the past. Either way, the allure controlled them to the point where they discovered that is wasn’t safe or pleasant like the main characters thought it would be. The disappointment of the allure not being what was expected hit the protagonists hard and in a deep manner. The results changed their way of life and way of thinking, which made them see the world in a different way. In conclusion, one cannot always go with the allure of the other and expect perfect results, but one can always try and accept the results regardless. Research Papers on Comparing "Araby" and "Going to the Moon"Mind TravelHonest Iagos Truth through DeceptionWhere Wild and West MeetTrailblazing by Eric AndersonThe Masque of the Red Death Room meaningsAnalysis Of A Cosmetics AdvertisementBook Review on The Autobiography of Malcolm XComparison: Letter from Birmingham and CritoEffects of Television Violence on ChildrenHip-Hop is Art

World War II Essay Example | Topics and Well Written Essays - 500 words

World War II - Essay Example 6, 600 million towards damages that were caused by the war, Germany would not build their army and the Rhineland area was to be de-militarized, and finally some parts of Germany was to be allocated to other countries. Despite the harsh conditions imposed by the treaty, Germany went ahead and signed the treaty which resulted in acute poverty in the 1920s as the country suffered serious setbacks and could not pay the money. It was at this juncture that the German people voted Adolf Hitler to power as he promised them that he would put an end to all their sufferings. Once in power, Hitler began to build the German army and also stationed troops in the Rhineland area. Though France and Britain kept track of Hitler’s moves they were unwilling to begin another war and instead believed that a stronger Germany would prevent the spread of Communism to the west. Hitler also entered into an alliance with Italy and Japan in 1936. Hitler wanted to expand his territory by acquiring Austria and with about 99% of the Austrian people favoring a union with Germany; Hitler acquired Austria but promised that this would be the end of his expansion plans.

Spring awakening Essay Example | Topics and Well Written Essays - 500 words

Spring awakening - Essay Example This writing compares modern America and the issues faced by the teenagers in Spring Awakening. In Spring awakening the parents and the society at large are not ready to inform their children about the sexual exploration. Parents consider it unethical to discuss issues of sexual relationship with their children. This is really unfortunate since most of the children in the play are starting to experience changes in their bodies. No one is out there to explain to them about these changes. Even the very parents with the responsibility of caring are not giving their children any explanation to the biological changes they experience. The big issue of the play was the challenges the teenagers had due to the societal suppression and fear of discussing sexuality and reproduction. For instance, Wendla who is a teenage school girl is in a big trouble because her mother Bergmann is not comfortable with her daughter’s quick growth. Wendla’s mother is not ready to discuss with Wendla the facts about reproduction and sexuality despite her daughter’s growing curiosity. Martha is also emotionally disturbed by her parents’ continual physical abuse. It is surprising to note that 17-year old Lammermeier does not even have sexual thoughts and even the expulsion of Melchior from school simply because he has knowledge about sex and he is able to express himself in writing. Failure by the society and the parents to discuss sexuality and reproduction in the play makes Wendla conceive Melchior’s child unknowingly and finally dies after unsafe abortion. It is quite sarcastic to find that the same parents who do not want to talk about sex decide to send Melchior to a reformatory because they discover that he got Wendla pregnant. I feel that modern America has actually changed especially the perception of the topic of sexuality and reproduction. By the time I was an adolescent, I had known a lot about this topic. I got the knowledge from the school, media and very many

Bipolar Disorder as a Mental Illness Research Paper

Bipolar Disorder as a Mental Illness - Research Paper Example There are specific medical events that take place that chemically represent the nature of the disease. Despite the fact that there are some people who believe that bipolar disorder is not a physical manifestation, the truth is that it is a disease that can be treated with pharmaceutical methods of treatment. The nature of bipolar disorder is that it is a mental disease with specific treatments that can assist a person who is suffering from its affects to have a vital and meaningful life. Mood Swings The nature of bipolar disorder is that it is defined by mood swings. This type of definition lends itself to interpretations that suggest that perhaps it should be more easily controlled by the individual and is a matter of choice over a matter of disease. As well, there are times when the disease is attributed to normal hormonal mood swings and is discounted as the unreasonable nature of the individual, rather than being understood as outside of their control. There are those who do not have an understanding, nor wish to believe, that a mental disorder can be accountable for the actions of a person, rather than the mental issues that are based upon a biological factor. Mood swings have been attributed to an unreasonable mind, rather than to the chemical state of an illness that can be treated. ... ves in a position where instead of their loved ones recognizing that they are experiencing a disorder, they are blamed for their symptoms without there being an understanding of how they can possibly not be in control of themselves. Women with bipolar disorder are more susceptible to larger mood swings in association with their periods, their symptoms of PMS lasting for weeks rather than days and their anger and irritability being beyond their ability to conduct themselves as they normally would (Burgess, 2006, p. 186). The problem that comes with this is that a blame is set up that creates stress, shame, and guilt, as the actions and behaviors manifest outside of the control or the actual responses that a person would have to any given situation. In this situation, the problem will begat the problem, perpetuating a cycle of episodes from the stress that is created from not addressing the problem sufficiently and from blaming a person for not having control, when they suffer from a d isease that takes control from them. Bipolar Illness Sartorius (2005) describes bipolar disorder as â€Å"a chronic remitting and relapsing illness that causes significant burden to patients, families and society† (p. 69). Hudson and Rapee (2005) through saying â€Å"Although patients with bipolar disorder may also experience many †¦psychotic symptoms, their major problem is mood instability. Periods of abnormally elevated mood, increased energy and decreased need for sleep, alternate with episodes of depressed mood, decreased interest, and low energyâ€Å" (p. 205). â€Å"It exists within the patience as an active illness for about 1% of the lifetime. Per year, 9-15 per 100,000 men contract the illness and 7-30 per 100,000 women. Most people who have the illnesses will seek some sort of help for

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study 1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests showed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique since day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple therapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 She was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and control of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs and avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic cou nselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthmati c patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ÃŽ ²2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ÃŽ ²2 agonists act on ÃŽ ²2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ÃŽ ²2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ÃŽ ²2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-ÃŽ ³) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ÃŽ ²2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ÃŽ ²2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ÃŽ ²2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of ipratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-blind randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ≠¤40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan Acute Exacerbation of Bronchial Asthma (AEBA) Case Study Acute Exacerbation of Bronchial Asthma (AEBA) Case Study 1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests showed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique since day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple therapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 She was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and control of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs and avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic cou nselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthmati c patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ÃŽ ²2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ÃŽ ²2 agonists act on ÃŽ ²2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ÃŽ ²2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ÃŽ ²2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-ÃŽ ³) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ÃŽ ²2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ÃŽ ²2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ÃŽ ²2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of ipratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-blind randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ≠¤40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan