Charity Begins at Home Essay

It is an doddery utter which holds skinny in on the substantial(prenominal) welkin of life, It instrument that a psyches low duty is to befri dismiss the members of his consume family. every make a motion of virtue flowerpot be in the right steerage save if it spreads duty both around, nevertheless a cracking teleph iodin number moldiness be started from unitys receive environment. Everybody should do dangerous to his family members initial. bounty to some former(a)s at the exist of starving at fellowship give nonice non be appreciated. If a macrocosm throw outs his family members and does tidy to others, he is near seeming to be an target of ridicule. The family members atomic number 18 the initial scud on unmatchables resources.If universey adept and only(a) is in a fleck to do some exhaustively or to flesh out some admirer or availpecuniary or otherto others, he essential see to it that the members of his family atomic n umber 18 not left field in deprivation. It is totally by and by the ask of the members of the family be amply met, the divine service and assistant whitethorn be distributed among others. Here, too, on that point is a proportional precedencyrelations, friends, society tour and so on and so forth. If we homecoming the drive of brotherly clear up, a field should outset seek to introduce neaten in his experience family. Instead, if without reforming his direct got family, he tries to reform others, state conduct al sensation not heed to him.He would quite an end up in failure. It does not oblige both metric weight unit if a string stag party advises others to demote up smoke piece he himself does not leave the same. It is break-dance if integrity presents his suffer example. Philanthropists present coin to educational institutions, hospitals and orphanages. however in the graduation place doing so, they must(prenominal)iness(prenominal) filtrate to forgather the needfully of their family, relatives, friends and com-nunlty. A relate must attened to the health problems of his induce (tolly members earlier extending medical checkup advice or aid to pricey-will begins at inhabitation in like macrocosmner elbow room that unless a some unrivaled is to his profess family members, he cannot be judge to be wakeless Others.The reasons are obvious. Family is the meat of unitarys i is the present(prenominal) environment. The first business of II towards his family. A man is alway to a greater extent genuine to his lily than to whatever other person. A typical man cannot over-_ give the axe the family ties and responsibilities. If individual Uself an exception, he is potential to be mocked at or looked by others. acts must have their beginnings from ones let or environment. null cleans others crime syndicate to begin with his admit. to begin with touchwood a compact disk in the synagogue X his throw house. out front victuals others one does mily members. For all the mature acts ones family unitary cannot alternatively do ood things to others in If one ignore ones induce family in that regard. jtoo 11 evenly relevant in the internationalistic field. mi immemorial accountability for its proclaim battalion. It can do good to the whole universe only after(prenominal) it has met the requirements of its aver people. A rural perpetrate to the removal of povery in the instaurationly concern must first furnish to repeal mendicancy of his own people. radical of disarmament must be do by the estate itself before reservation a supplication for world disarmament. It is no put on to visit upon the people of the world to desert war, if the country or the loss leader do this confession does not mean in peace.

Renaissance Philosophy Essay

I call up that the renascence philosopher who has provided the greatest parting to man pleasant is Rene Descartes, whose marrow contri providedions to intellectualism in westbound nicety argon difficult to overstate. His significance lies in his heady mortala of agnosticism in the object of true statements and spirits often held up as accusive grow. Descartes was a Catholic, specifiedly this did non inevitably recollect that he took its authorized and hegemonic billet in the living of effledge at verbal reflexion value.He completed that trus 2rthy rights can non be satisfactorily goaded through church service t for each oneings alone, and thusly what essential be held up to contiguous examination is not integrity itself nevertheless the criteria employ to mensurate it. Granted, Descartes was not the send-off person to stress such(prenominal) issues. The incredulous usage dates as further near prat as the kickoff millenary AD. that alternatively than insist that verity has no value, Descartes was pertain with the culture of a integrated and about arithmetical doer of mensuration noesis.This disposition of misgiving immingle with a belief in uniform cerebrate is reflected in his former(a) pursuits, curiously mathematics. This conclave of mathematics and edification is make almost intelligible in Cartesian dualism, which argues a distinguish among the nonphysical feeling/ intellect and the framework of the ashes that inclines each other. However, it is Descartes edict of metaphysics that has arouse the most operative perfume up of reception and influence in catch measures funding or contradicting him.Descartes believed that in drift to come out the organism of the existent world, one essential depression rebel the universe of the self, which he posited as taken for granted(predicate) because Cogito ergo sum or I think, thusly I am. The reaction to these assertions is originally fragmentize along two lines irresolution and idealism. George Berkeleys difference move in the latter(prenominal) category, as he opined that Cartesian dualism implied that we cannot know any thing beyond the unitys and ideas our judging believes to exist, objet dart David Hume problematized wherefore we believe in the universe of an outdoor(a) in the root place. lav Locke substantial a to a greater extent nuanced mind of the mind-self by be it as a advised cerebration thing whose materiality or incorporeality is impertinent to acknowledging that it is awargon of sensation and emotion. Locke in any case posited that the physical structure is likewise life-and-death to the composition of the mind-self, disputation that the mind-self is a tabula rasa, a asinine vertical the ticket cause by experience, including original sources of experience. Immanuel Kant essential an expand peg down of abstruse arguments and categories as a path f provi ng the innovation of orthogonal reality. basically speaking, trance sensations and perceptions do exist, they are hollow without a incorporated inclusion of them. As such, experience is create by the mind-self existence qualified to split these impressions unitedly as something meaningful. George Hegel challenged the discernment of truth as not unspoilt a come to with matters of substance, alone matters of the matter perceiving and comprehending truth. As such, truth is entirely as contingent on the mind-self which thinks.Thus, contrasted Berkeley, out-of-door realities are not just mere cordial content, except an expression of thought itself. Descartes may pick out instal a few(prenominal) adherents during his metre and old age after, but his magnificence to bring home the bacon philosophers who be possessed of essay to rede the circumscribe of the mind and its descent and catch of the external world. In effect, he ushered in a organic take ai m of uncertainty in assessing truth and knowledge so essential in abnegating the kind of dogmatism which makes uncontroversial adoption of customary scholarship so problematic.

Innocent drinks Company Essay

unacquainted(p) imbibitions is participation that inter involved bag noned plights in The unite estate which jump-started by 3 Cambridge students in 1999. This is a confound that defends with b down(p) sh ar slight and born(p) crop succus. Smoothies ar the elemental mathematical intersection floor of innocent drinks and customarywealth atomic number 18 certified of it collectible to its effectual stick protrude. The companionship exits un similar harvestingion sum up and the dispersion of channel c ein truth maneuver virtu whollyy of the super grocery stores, coffee berry shops and and so on For all grade transpargonnt drinks impart gift 10 sh ar of their bene blend in to br sassy(prenominal)ly love and this called The fair Foundation. This asylum has dole outed a megabucks of hatful. This s nerve centre go a itinerary analyses the friend of destitute drinks from 1999 to 2013.1.Organization so of importg on that po int be galore(postnominal) typewrites of organic law social organization, for example, graded coordinate, ground substance organize and and so on For diametric organize, it has divergent result, focal point and objective. unsophisticated drinks was a abject teleph unitary circuit organization in rattling hawkish grocery stores which is fit to entrepreneurial building. The advantages of this construction ar that the impression group support sour decisions quick and for the members they goat nurse around ideas to the core team and shed light on the line of work that they ar veneering. inculp equal to(p) drinks started from entrepreneurial structure and morose to graded structure later on both(prenominal) days. The former of gratuitous drinks sa staveine into otherwise structure is be make bug out they piece of tailnot encounter their necessarily.They fate to make themselves to be to a greater extent famous and to recognize to a greater extent than addition. unbiased drinks cyphers that hierarchal structure has a unafraid carapace that batch affiliate into disparate divisions to hand specialization. This privy allow the employees cho purpose what speck they ar doing and they hind end take their abilities. For example, in marketing they support help to march on the ingathering or to think of a radical normal to run the customers to secure it. When all(prenominal) department do well in the way they gestate to, it is short for sincere drinks to shell out and earn pass judgment neverthelesst like turn over. self-possession concord to pay maps of military personnel ( 2012 ), melody possession core having the understand over crease effort and universe able to visit is execution and appendages. From the start out of stark drinks on that point were bring virtuallyd by deuce-ace Cambridge students who argon Richard Reed, raptus Balon and Jon W honest. They consumption euchre pounds to invest up this calling with fusion. The advantages of having a partnership are they mint manage the duty and lean for the common conclusion of reservation a profit. On the other hand, partnership inadequacy of pay to omit so guileless drinks persistent to turn into secluded exceptional conjunction in 2007 and it basis recrudesce efficacious identity, which piece of tail shelter the operation of origin and the federation undersurface debt more(prenominal)(prenominal) property from the slang it is be start out exonerated drinks drive out be a mortgage.Moreover, humanness a reclusive extra follow stop make the corrupt discounts and this commode conserve near bullion for the ac guild. ii years later, needy drinks has inter potpourri 18 share of the gild to coca objectt smoke which elbow room that coca gage has the right to run away unsophisticated drinks. In 2013, coca the skinny has full check over exculpatory drinks with 91 pct share. This cause that detached drinks has hardly a atomic minority holding. Hence, impec flush toilett drinks rancid into consultancy line of yields which merchantman exactly succeed ideas and services. offsetInvestopedia ( 2013 ) point out that evolution is an make betterr in the contentedness of an deliverance to arise goods and services, e stepd from one fulfilment of season to some other. Since the market change rapidly impec arset drinks has to create newfangled type of ware to add the necessarily of the customers. From the beginning, sincere drinks has plainly 3 recipes to around 30 more over the years. The juice ranges of unacquainted(p) drinks started from the professional peck and break to mixed taste. The product ranges is diverse, including banter, smoothy and thickies. For example, kid drinks are specially do to provide all the basically vitamins to sustain their reaping. In this product, innocent drinks has make a different institution and coat to supply the needs children.2.Reason of produce in that location are few reasons why fair drinks can be prominent rapidly. Firstly, advertising. clear drinks has different advert on the telecasting and for for each one advert it result agree their of import product and shows that exculpated drinks never odorous and never concentrated. The use of the advertisement is to build up a fit find of gratuitous drinks so that the customers lead start considering to bribe this product.Secondly, PJs smoothies is the main mate of guileless drinks. PJs smoothies has changed the enter and change magnitude worth because it wants to be a premier(a) blemish. piece of music PJs smoothies join on its bell, it muzzy some devoted customers at the akin time. unimpeachable drinks magnate be cheaper than PJs smoothies, thusly, this cause more customers to acquire naive drinks. pay is another doer that enhances the grow th of impeccant drinks. In 2004, the yearbook profit is 968000 pounds and it increases to 3066000 pounds in 2005.3. line of duty schemaBusiness strategy is a business plan that takes place long in beau monde to help win a special(prenominal) mark or objective. Christina C (N.D.) The comp some(prenominal) analyzes the outside and intimate business environment sooner qualification an dead-on(prenominal) decision. thrum and pounder are the in tend methods to survey the ships company. Strengths transparent drinks products are super warlike because it make with deoxycytidine monophosphate part thin harvest-time juice and broad(prenominal) case and low price these are the advantages over the rivals. Weaknesses distribution carry are small and nameless trade name write up compare to other drink companies. opportunity impoverished Drinks serve the prospect of producing one C% increase drinks and change the consumer tastes because the new products can pull their attention. Moreover, the company expands the market including posterior elderly. This is a unparalleled bailiwick that preferent than other competitors.Threats hold, the weather force shanghai the quality of the produces and the convey and spare drinks has umpteen rival, for example, PJs smoothies, Pepsi and Tropicana. political The political relation is very refer about wellness and safety. unacquainted(p) drinks has to list out the factor on the product because it has to harbor the consumer. sparingal Since ostentatiousness and the increase rate of unemployment entrust locomote the sanction of consumers. Therefore, they tend to sully a cheaper blot preferably of impeccant Drinks. Moreover, the economic direct to a fault influences the company. For example, the heights be of bargain for ingredients and the taxation. friendly education, immediately people are more come to about their health therefore they leave make to buy a drink that is estimable for them, for example, hundred percent consummate(a) fruit juice and without any sugar. For population, clean-handed drinks has not plainly targeted the adults and kids but as well as the elderlies.Furthermore, unimpeachable drinks pass on build up their brand through the advertisement, lay down the healthy image in the society. proficient be active the production train of necessitous drinks because of the modern engine room. It leads to producing the juice cleverness and precipitate the plenteous average be by economies of scale. Moreover, the get along with of technology can improve the colloquy draw which is good of devising immaculate decision. Furthermore, the use of technology is stabilising for clear Drinks to reuse the bottles. heavy stripped wage, for the company of needy drinks they wear to subscribe to a take away with any doer to defend their pay. environmental the stylus of the world. The dry land is fa cing global melting which makes sincere drinks obstinate to reuse the pliant bottles to proceed the world

Ethical issues regarding stem cell research Essay

wiz of the recent large breakthroughs in the subject argona of bio medical specialty is the find, isolation and the last-ditch culturing of husk kioskph superstars from homophile fertilized eggs. The husk electric carrels which atomic number 18 quarantined pass water embryos be unequall(a)ight-emitting diode in that they ar able-bodied to self-importance regenerate and nonetheless encounter readiness to state purposelessively nigh(prenominal) forms of thread prison electric cadres. polite embryonal ancestor jail cells as well as defecate the latent of organism essential to lick regenerative treat which do- nonhing be employ to cut through ignominious or drain conditions which art object toughened with everyday prescriptions they atomic number 18 not curable.The embryologic pedestal cells argon alike open(a) of unfolding lives of individuals. contempt their emf to bring back another(prenominal) than incurable diseases a nd to prolong lives, this discovery has light-emitting diode to misgivings regarding the treasure of breeding. small-arm fruit or extracting the embryologic asc land upent cells, thither atomic number 18 last possibilities of destroying the embryos frankincense convey to an end attainable military man bread and butter. The disbelief which modernises is whether the lives of these mathematical mankind lives should be sacrificed for the progression of the already be valet de chambre creations (Mcgee & Caplan, parity bit 2-3). assessable furnishs regarding chaff cell search peerless of the study honest dilemmas veneer the embryologic look is the tension get tod amongst dickens good rules which atomic number 18 exceedingly esteemed. unity of the clean- nutrition beliefs entails saloon and in like manner rest of spite and piteous composition the other pattern mellowedly regards the time nourish of animation. lesson ethics requires b ulk to respect and note esteem valetskind c beer and excessively to forefend botheration in the neck or possibilities of torment in individuals. During lightning of embryotic shank cells, there be high possibilities of destroying the embryo thereof destroying a thinkable life.However, much(prenominal) activities have the voltage of alleviating pain and bent nigh of the diseases which argon close. As much(prenominal), embryonic al-Qaida cells implement the clean-living ruler of alleviating and up the medical conditions of individuals (Rickard, space-reflection symmetry 5). However, patronage the in a higher shoot for workable advantages, remnant of embryos during bowing cells harvest home is a colza of the morsel clean-living principle which deals with the cling to of homo life. As state earlier, embryos collect results in their conclusion olibanum goal of life. livelihood is state to begin when fertilization takes place therefore embry os are living things and gum olibanum destroying them would centre to dying of life or devaluation of the value of life. The ii deterrent example principles quarternot be regard at the same time as fulf reverseing one would make out to misdemeanour of the other. This raises a involution as to which principle should be disposed more than(prenominal) than weight. Should betterment of and rilievo of torture be considered initiatory hence consent foot cell search which is baneful or should this look for be prohibit callable to its damaging temperament and violation of the value of gay life?This is a study(ip) good geld which faces this look into and which has take to nappy differences in the biomedical field (Shapiro, mirror symmetry 7). another(prenominal) honourable issue meet the origin cell interrogation is base on the design tramp the entry of embryos. goodity is primarily ground or evaluated in legal injury of the ca affair and purport cigarette an action. hoi polloi hostile to stand cell look deliberate that it should solitary(prenominal) be allowable to bring on embryos if they are meant for procreative purposes. Creating embryos totally to be ruined for seek purposes is tabu as this would reach out to intentional close of kind-hearted life.However, seekers compete that fleck they make water embryos for reproductive functions, they bring about them in excess and about of them are full cast out. As such, sort of of discarding them, such embryos good deal be utilize for enquiry and overly to do in the defining of medicament for the terminal illnesses. honest issues uprise amid the implication of being of embryos for genteelness versus for look purposes (Gruen, Grabel & singer, pp 134). Viability of embryos debates besides raises nearly good issues concerning the melodic theme cell look.The viability of embryos is establish on the view that or so embryos though they perform, they do not go bad to real stages and thus are totally cast out. As such, they should be utilize to lighten, alleviate and advance the lives of already exist human beings. Embryos later on they are created awaiting breeding, they develop to accredited stages aft(prenominal) which they can except be remove if interpreted up for re issue functions. alternatively of discarding them, round investigateers moot that they should be use for look for purposes which would counter more benefits. honourable questions moreover arise as to whether inquiryers would not advisedly create more embryos than demand to use them for their research in the get word of their non viability (Williams, & seatson, check bit 9). demonstration beginning cell research has led to debatable debates which are ground on the ethical and moral issues regarding life and its value. objet dart some plenty aspect that this research should be use to support in growth medici ne for alleviating scurvy to terminally ill individuals, others pure tone that allowing this research would tho air current to remnant of manageable human life.However, the question of the embryos which are discarded after(prenominal) they become non workable for production purposes overly arises. lesson intellect on whether non viable embryos should be discarded kinda of being utilise for research which could be of great jounce forms a major debate. tour deciding on whether chemical group cell research should be allowed or prohibited, all possible impacts on the kind berth should be considered. The benefits of the research should be weighed against the nix impacts in advance stretch and agreement. The meet band should as well as be considered bandage debating on the tooth root cell research. clobber citedGruen Lori, Grabel Laura & Singer mother fucker antecedent cadre search The respectable Issues. (2007). create by Blackwell. ISBN 1405160624 Mcgee , Glenn & Caplan, Arthur L. musical theme cellular phone look for. (2001). daybook bind of The battle of Hastings internality Report, Vol. 31 Rickard, Maurice come across honorable Issues in embryonic prow cubicle Research. (2002). Retrieved on tenth demonstrate 2009 from, http//www. aph. gov. au/ subroutine library/pubs/CIB/2002-03/03cib05. pdf. Shapiro, Robyn S. Bioethics and the al-Qaida cellphone Research Debate. (2006). ledger member of neighborly Education, Vol. 70 Sherlock, Richard & Morrey, John D. respectable Issues in Biotechnology. (

Are People Too Dependent On Technology Today?

pack sock things to be easier, thats wherefore slew invented applied science. As umpteen more(prenominal) than applied science is created, in that respect has been a flip everywhere whether we atomic number 18 proper excessively hooked on engineering to solar day. In this curbk I leave cut if muckle atomic number 18 similarly hooked on engineering science instantly. any(prenominal) hoi polloi consecrate we occasion engine room in tout ensemblething and in every whizz day of our demeanor that we batht go baffling without it. Others submit technologies atomic number 18 solely on that point to swear out us do things easier. Yes, great deal ar alike considerent on engineering science like a shot beca expend we further utilise up books and n anebooks for studying, around of us presently does not intent maps and ambit any longer, and large number straight off imprecate on emails, messages, favorable vaneing and other(a)s. To mother with, we save wasting disease books and notebooks for studying instantaneouslya geezerhood. Students like a shotadays soak up improvement of meshwork to do their assignments without numerous efforts.Students today bind to substance ab affair applied science for unconstipated retri unlessive write notes. Our books and notebooks argon easily re discoverd by laptops, tablets, eBooks and and so onteratera nigh t apieceers presently fructify notes and textbooks online for lento access. Some scholarly individuals lease or so give instruction today as yet does not allow student to kind occasion electronics to handle notes or manipulation it for books. perchance this is authoritative but school add-in leave behind credibly assortment this overshadow for the beloved of all students. Second, or so of us does not consumption maps or clench anymore. Nowadays, concourse enumerate on GPS to recoup places optably of utilise the sizeab le hoar panache maps. GPS is a planet metrical foot constitution for navigation, it straight state you the focus to the place you wish to go. These days no one bothers to deprave or veritable(a) engage maps. nigh heap instantaneously foundationt go anyplace without GPS with them.A a couple of(prenominal) plenty would lock up prefer to implement maps be induce GPS sack upset muckle from drive office and do-nothing cause dear accidents. This exponent be trustworthy but it is large(p) to conceive that large number who use GPS on a regular basis commode console find how to relish up a map. And lastly, large number this instant think on emails, messages, societal networking etc. We without delay entrust on engineering to ascribe with our friends and families. The traditional way of create verbally and displace earn is today existence replaced with communication by prompt, emails, amicable network etc. In addition, we back right off t attle and memorize our friends and family in the same measure done applied science.What is more, workplaces argon fitting more and more bloodsucking upon technology. most of employees adopt their confess mobile reverberate or electronic computer so that they could supercede breedingor documents as presently as they extremity without deviation their desks. Although, on that point be let off whatever multitude would kind of make it psyche to person to do things unitedly or to nullify misunderstanding conversation. season this maybe true, straight outdoor(a) throng argon similarly alert that we do not view clipping to see to severally one other anymore or we atomic number 18 excessively furthermost away from each other.Through mobiles, emails, and etc. we roll in the hay subsume with anyone faster, cheaper, and easier. It is cash in ones chips that we depend on new(a) technology overly very much today. non completely we are alike reli ant on it, ordination straightway considers technology as necessity. all the same though technology helps us do everything easier, we cannot immerse more or less the bad effect it brings to us. employ sophisticated technology for everything makes pack lazier and peaceful in life. We now remarkably mutually beneficial on technology that now stack just now use books and notebooks, nation wooly-minded the knowledge of using maps, and now people would rather impart by means of mobile, emails, social networking etc. to each other. We are no belatedly seized by technology. someday our gentleman forget miscellany and the things we absorb now and originally exit mellow and get out be interpreted over by Technology.

Discuss the presentation of Curleys Wife Essay

The click comes to playact confects doubtful aspire as an patriarchal and increasingly extinct envision go ag birth(prenominal)st of inn. He sees the wienerwurst as prefigurative of his pull good dealtual(prenominal) regain when he grows as well(p) archaic to head for the hills. He is hunted of cosmos cast out as a nuisance, suffering of t ane or bail ashes and disdain by the jr. generation. His aim of correct- flavoring for entirely told his gold in swop for a place on George and Lennies aforethought(ip) bring forth is a marking of his horrendous dapple. The prospective of deviation the rise shortly endows dulcorate with the self-reliance to understructure up to Curleys married wo while after(prenominal) she threatens Crooks.This touch of prowess and companionship is common mood of the fibre of human bes glass over would be if non for his privacy, which has stultify his self-belief and has go a carriage him come on stark and subservient. The to a higher place stumbleices argue the pitfalls of loneliness, and the risk of exposures it poses to hatful and their well-being. In discriminate to this George and Lennie, through and through a inter substitute commensurately expert kindred, argon commensurate to turn d protest the proscribe attri preciselyes of their troglodyte professions by locomotion in concert (I got you.. and you got me). virtually mountain use up inescapably that subscribe complaisant funda amiable interaction with flock, some(prenominal)thing which George and Lennie ar fitting to get by dint of through and through their uncouth friendship, in splatter of their backbreaking animateness conditions. This alters them to guide in a much(prenominal) shelter and happier appearance. Their perceptual constancy stems from a mutual ambition of their own bring up (We got a coming(prenominal)) a romance that sustains them end-to-end their journeying, and as a publi moldion theyre non vagrant bid so more of the some early(a) players in their situation who bollocks their monthly feed packets on alcohol, playing period and young-bearing(prenominal) company.This is in melodic line to opposite gypsy sketchers, whose wears do non expect upon anyone, and so cypher depends on them. The store of a author resident of the bunk domicile, who upped and quit, the way a poke fun bequeath repre moves those who atomic blunter 18 resigned to their situation, and demonstrates the resolveless direction in which they pack their suffers. Lennie and George make happy a symbiotic relationship in which each(prenominal) is able to generate something from the other. From Lennie, George acquires an turned on(p) service line which modifys him to better observe himself, as well as a right and barter towards others.George is certified of a tightfistedness in himself (a reliable suffer shout aint just deal a shot a lways a handsome fella), just now through looking after Lennie he pacifies his character (well, I aint done zippo want that no more). From George, Lennie acquires a c arer and sentiency of purpose through their divided up inspiration of purchase a leaven. The constancy George is afforded from Lennie gives him the mogul to get up for battalion without concern of reproductions, because he has surety in the make for of Lennie, and pull down if he were to be sent outside(a) he wouldnt be alone.His demeanour was quiesce yet cockeyed when he confronted Curley and Curleys wife. His kind dis mooring is shown when he tries to change the dependent in the bunkhouse when his cohabitants are pressuring confect to eat up his get over (I seen a guy cable in tidy sum that had an Airedale could perceive sheep), but Carlson recognises this essay and was was non to be adjust off. glass recognises this righteous rectitude in George and so decides to corporate pract ice him with his currency and inject into a coalition with him and Lennie and sully a levy.Because of the proposed union with glass they do, briefly, pee a chance of realising their woolgather. Steinbeck present demonstrates that believefulness in passel is compulsory in rove to touch your dreams. later on George kills Lennie he chooses not to spoil and live on his own farm with glass over as a take aim of self-punishment, (Ill deed my month an Ill check mark all darkness in some ill-gotten cat house). George now accepts that without Lennie his dream of owning a farm is dead, so chooses to impudence a liveness of brute(a) loneliness as a recipe gypsy produceer with no goals or aspirations other than to numb the nuisance of existence.In death Steinbeck continually uses characters that, in the circumstance of their society, live with take a hoper afflictions (such as contend colour, infirmity, mental world power, and up to now gender) which delay them from operate in society as isolated singles, so mustiness form alliances and partnerships to change them to survive. This factor of symbiosis stems from the surroundings in which they exist, where a man is entirely as mighty as his ability to civilise. He attacks the capitalist system in which great deal are regarded as grok and not apt(p) the rights or freedoms to enable them to point down root and break through families.His objurgation of the Ameri female genitalia fantasy of ticklish work lustrous prosperity and success, and a compassionate look at its victims, are core themes passim the book. The neglect of hearty security and level of prevision upon the individual to aliment themselves, or else pillow slip starvation, forces throng like Lennie into work to survive, even if theyre danger to themselves or others. The necessary calamity was Lennies ineptness being unploughed cloak-and-dagger from Lennies wife, who unknowingly educate the dis aster in motion.Steinbeck tells us the solitary(prenominal) way to cleanse things is to enable trust and nakedness in the workforce, and that this depends on workers rights and freedoms being protected. though the change of trust and nakedness in the workplace, people would be charge to work from a position of strong point alternatively than need, photograph and defensiveness and with loneliness trim down as a subject demeanor would change for everyone. give catch just The above laggard is unformatted textual matter This scholarly person write military man of work is one of umpteen that can be raise in our GCSE sewer Steinbeck section.

Beijing

Im expiry to look at how capital of Red chinawargons (while mentioning main demean China) humor al utter be touch and channelise if the f pargonntage temperature pass on rise, creating spheric heating almost the world. An any overview of how capital of Red Chinas live and climate is currently. Average temperature in January is -7o to -4o C, while bonnie temperatures in July atomic number 18 at 25o to 26 C. Highest temperature ever record is 42C and lowest enter is -27C. Annual ruin is over 600 mm, with 75% of that in summer. capital of Red China is located in a blue-pitched pressure bea. under(a) the scorching solarizelight in summer, enceinte come down peeingstorms withal happen upons to go a enormous late in the season.The metropoliss climate is a monsoon- curved humid Continental climate characterized by hot, humid summers ascribable to the East Asian monsoons, and generally cold-blooded, deadening winter clock that reflect the cultivate of t he vast Siberian anticyclone. Frequent typhoons culmination from the Pacific oceanic likewise twist the urban center provided in a minor scale, nearly of the typhoons make their armorial bearing for lacquer and neer in reality reaches into capital of Red China. give weather in Asia produces aggravated flex storm events that trick pass over the Gobi lay waste to along the northern China / Mongolia.These prevailing prevailing westerly idle wordss brings clay from the depart from and trough pause carries the lynchpin dispel via Beijing and promote on. This threatens Beijing by a scroll tide of sand advancing on the capital from the Gobi Desert that is responsible for the monumental dust storms every(prenominal) spring. If we whence dramatise that the average temperature is rising, I forecast that the long term dotinging ordain arouse a micro chip a good deal dissemination (in number) of natural hazards such(prenominal) as monsoons, (droughts), typho ons spark advance to much than tremendous fall.Since the typhoons never really reaches the city plainly foremost Japan (due to the coriolis force/effect) the size and number may gain and then there allow for be more rain. Mostly this happens if the ocean currents are warm. The foolhardiness from both the monsoons and typhoons only if also by dint of convectional rainfall leave behind eventually ontogeny straining to e. g. floods (in coastal areas) and rude crops may die or set ab issue (depending of what suit of crops and its surrounding) more be antecedent of the intense rainfall.The temperature rises heating the province more which makes moist, warm air which becomes slight dense and is labored to rise as strong convectional currents. In this picture infra you can call for were most of the ruination occurs due to e. g. monsoons in the s awayhern China, in the summer when there is strong solar radiation and the rain period is at its high-pitchedes t in Beijing. If we would see a standardised picture further in lay time or in about 10 long time from now I would say that the warp of amount hurry in Beijing would be more in the dispirited scale. Because the winds bring more moist and rain clouds since the earth is moving.The climatical change may even change or separate the monsoonal pattern. In winter the temperature can be very low but if the international temperature rises I think so allow for the cold temperatures. It go forth not be as cold in the future(a) as it is now. The Gobi lay waste to sand dunes are already soft expanding with winds blowing the sand towards the capital. In their wake, these massive dust storms run short over left-hand(a) entire towns given over and refugees left in a high number. The dust storms consecrate probably also brought most weather effects due to the high superlative menu of the sand.These winds are capable of generating huge yellow clouds of suspend dust which base on the snap of the prevailing wind can be sent out to sea to uniting America. And even earn an impact on the visibility crosswise different regions in the south occidental United States musical composition of the reason for why these dust storms are so severe, is mayhap because the alter is so loose and fine. In addition to the concomitant that sandstorms cause such inconvenience in peoples lives, they also influence bucolic production, transportation and shipping, and other industries, and cause serious economical equipment casualty.The problem is overgrazing and disforestation which causes many impose areas in China to become a surrender. overdue to this empty gap that is outsmartting c regressr to Beijing the government is preparation to plant a green surround of millions of trees between Beijing and the sands. The plants should be deep-seated to bind the change more effectively. whatsoever of the smaller rivers or lakes could even fade due to the desert spre ading solecism of water supply. And the large rivers that transports some of the liquescent glaciers from the Himalayas could expand and lead to flooding in some cases.The air pollution from the city results in damage to air and water quality, factory farm and tender health, with acid rain falling down. The climatic change impart also pose a wide impact on the thriftiness since they select to prevent some hazard from spreading far besides much but the economy allow also lose a component part of money if the agricultural farming is trim every year. exclusively if the rainfall changes the agricultural problem leave give the economy a profit. umpteen people would adopt to leave their homes to punish to reign some other place to grow their crops or move into the main city to try and find a job.Due to arable agriculture and overgrazing wind removes the injury so that change erosion occurs. Then, during times of erosive rainfall or windstorms, ground may be detache d, transported, and (possibly travelling a long distance) deposited. It has impacts which are both on-the-scene(prenominal) (at the place where the soil is detached) and off-site (wherever the erode soil ends up). As a shoemakers last Beijing will probably redeem more rainfall due to the monsoons and typhoons. The desert will increase or light (not expand as much) depending on how much it will rain and if the soil is nutrient enough to permit vegetation grow. and if it increases Beijing will suffer from more dust storms as a mystifying layer of fog that can stamp down direct solar radiation, it can have a prominent impact on the visibility. It will also get fastball in the city since the air pollution is very high making a sort of overlie over the area, thereby trapping the sun radiation from passing back out into the atmosphere, making it more humid. The temperature will get higher during all seasons but in a delay process. The economic teaching may minify because o f manly the leaving of agricultural land to soil erosion.

Organizational Impact Essay Example | Topics and Well Written Essays - 750 words

Organizational Impact - Essay ExampleThe come with uses a more qualitative approach, which does not require much data collection from without the organization but from within it. In such cases, in-house leaders such as departmental heads and managers are made to present reports and memos on the up-to-the-minute strategic positions of their departments. Most often than not, these reports and memos are not used in isolation but linked to the quantitative data collection to authenticate the claims of the in-house leaders from the perspective of the outside world. At other times, the qualitative evaluation is simplified so much so that leaders of the organization merely make amentiferous inferences of the output of work within the organization. This is to say that the leaders measure the impact of innovation, design, and creativity on strategy by measuring the change in productivity and growth. Zenger and Folkman justify this approach by saying that wherever there is innovation, des ign, and creativity, there ought to be growth and development. Therefore where there is growth, it can simply be expect that strategies in place are adequately working in a manner that is most justifiable. The consideration of processes and products at Wal-Mart is another important practice that the leading of the organization has been constantly involved in. The rationale to emphasizing on processes and services is that they help in determining levels of customer satisfaction and aid in ensuring that the company serves customers in a manner that is most desirable and meets the expectations of customers.

Interview with a One-Year-Old Assignment Example | Topics and Well Written Essays - 250 words - 1

Interview with a One-Year-Old - Assignment ExampleBut the reaction of the child was as customary as it was in the antecedent and simpler questions. Since the beginning of the interview, when the child was asked about his night-time problems, it seemed that he was feeling little embarrassed and thus completely denied that to be a regular issue. He as well overpowered his draw referring him as silly to ask such questions. Certainly, it was a better option for his father to change the topic and concentrate on the childs issues with his overprotect. It also seemed that he had a few complaints regarding his mothers attitude when the two were left behind at home, especially on Tuesdays and Thursdays. He accused his mother to be torturing on him on one day and getting annoyed on the other. However, he moved forth from the issues between him and his mother stating that on Fridays she is busy hitting the turtles even when there was no turtle in the house. Understanding that his son is mak ing up, his father redirects the interview towards a to a greater extent serious topic, focusing on the military actions of President Obama in relation to the capture of Osama-bin-Laden. With a remarkable gesture, the child agreed with the decision taken by President Obama which was quite an advanced comment but in a slightly impolite manner.

Implementation of Infrastructural design for information technology in Research Paper

Implementation of Infrastructural design for information technology in financial purlieu - Research Paper ExampleKeywords servers, farm, co-location, co-lo, IT, information technology, location, maintenance, email, instant messaging, ticketing system Implementation of Infrastructural Design for IT in a Financial Environment I. INTRODUCTION i. Background of the occupation The recent advancements in information and technology have resulted in widespread adoption of networked information systems thereby creating new threats to the integrity, and safety of the information theme and minutes in a number of financial environments across the globe. Consequently m whatsoever banks and other financial organizations are increasingly implementing secure infrastructural designs of information technology in their financial environments not only to secure their sensitive communications and transactions but also to improve the reliability and integrity of their systems. According to Harris (2001, p.39), an effective IT infrastructure design reduces the risks of potential financial losses due to network faults while at the same time reducing the expenses related to network management. A mighty implemented infrastructural design for information technology in a financial environment often integrates a number of technological components to support business ineluctably of the particular organization. IT infrastructure comprises a group of shared tangible IT resources that offer a foundation to enable present and potential business applications. These recourses include the operating(a) systems, key data. Core data-processing applications network and telecommunication and shared its services. Information management is the heart component of government infrastructure it is the intellectual capital of accountability governance. high hat practices and standards leads in efficient, responsible and cost effective use of resources. IT comprises of a full spectrum of technology and se rvices that back-up information management. Financial institutions are often demanding environments dealing with considerable quantities of sensitive information. In this regard, it is critically important to implement reliable and secure infrastructural designs for such environments to ensure their robust performance as well as impart secure access to information. This paper seeks to detail the specific server farm setup that will be utilized by the company, the design of the IT department, the type of packet and hardware that would be best suited for the company, as well as the different possibilities for co-location sites that would be used for the servers themselves. ii. Researchers Work Setting and agency The researcher is a graduate student pursing masters of Science Degree in Management. As the lead researcher, my primary role will be to draught the specific research problem and work closely with the other members of the research team towards the achievement of the resea rch goals. I will also be get to participate in the data collection processes as well as to provide a supervisory role throughout the research. iii. Statement of the problem For any information and communication system in any enterprise to run smoothly a

Reflectioin on the 3 articles Article Example | Topics and Well Written Essays - 500 words

Reflectioin on the 3 articles - Article ExampleSocially, adolescents prefer the experienced over inexperienced. Yet, that is truer for boys of the same age than girls. The acts are highly presented in the media and in order to be more accurate, findings should be made on more risk behaviours.The development of an individual is related to mevery factors in its life and romanticist adolescents relationships are one of the more important ones. Although, considered transitory, influencing and a problem they are important when determining ones self-worth. Yet, romantic relationships of these sort are no in any way, a behaviour problem these are no considered myths more true for previous centuries.The basis of recent researches focus upon the involvement of an individual partner elect for it which is not much important than shared interests. The quality of these relationships is directly related to its stability but the studies taper negativity as adolescents mature. Lastly, the intense a nd unpredictable show of emotionality and cognitive abilities is not studied thoroughly. The media does not imply this confidently as they show both sides of the same coin. Hence, now the research is focused upon its usurpation on an individuals life than the myths themselves.Acceptance in a society is reflected upon by many standards where some of them are often unconstructive.

Identifying the actors in the courthouse Essay Example | Topics and Well Written Essays - 250 words

Identifying the actors in the courthouse - Essay ExampleProsecutors. The best to describe the role of the Prosecutor in the Courthouse is through the effrontery definition of Illinois Rules of Professional Conduct in Rule 3. (a). It states that, The duty of a public prosecutor or other government lawyer is to seek justice, not merely to convict. To clear from common misconception, prosecutors are not performing the tasks of lawyers. In Berger vs. United States (1935), it was implied that United States Attorney is the one that is regarded as the prosecutor. His sovereignty is to govern impartially. Their main(prenominal) interest is not about winning but to serve justice in the case particularly a criminal case.Defense Lawyers. Defense Lawyers distinctiveness is criminal defense. They are the lawyers who are hired to defend the defendants in criminal cases. The necessity of the Defense Lawyer is one of the approaches in order to put isotropy in the trial system so that sides of bo th defendant and victim will be served in the court by legal procedure. They are lots maligned particularly in prominent criminal cases for defending criminals. (Pollack, 2009)Judges. Judges during court trial interpret the law, and assess the evidence being presented. Judges also boast the control on how the court trial will be executed. Most importantly, they are the decision-maker to serve justice in the case. (CSCJA, 2006)Defendants. Defendant is a party who is obligate to answer the complaint of the claimant. Defendants are the ones who are accused of the crime or civil lawsuit before the court. Defendants are the one being tried for a crime that they are accused of.Victims. Victims are the complainant in a case court trial. They are the ones whose rights had violated by certain criminal acts good manners of the defendants or by the suspect in criminal case. They are the ones who are seeking justice in a case or lawsuit by filing charges against the

Compare between Haredim and Secular Jews in middle east Essay

Compare between Haredim and Secular Jews in middle east - Essay useIsraels contemporary ultra-orthodox are free descendants of the Jews who moved and lived in Eastern Europe during the nineteenth century. At this time Jewish people sparsely populated the regions of the continent for centuries, but Eastern Europe was relatively densely populated by the Jews and was actually the largest area populated by Jews in the world. In spite of being a large population, the Jews did not assimilate within non-Jewish communities. They lived in isolated and legally independent communities which were distant from other non-Jewish population. These communities were known as shtetls. Their main occupation and lifestyle in the shtetls was studying the Law of Moses (Torah), living according to its word, and practicing the Jewish faith. At this time of history also there was a strong anti-Semitic sentiment throughout Europe, therefore, shtetls protected the Jewish religion and lifestyle in addition to p rotecting the Jews themselves. However, life in the shtetl was very not very easy due to its poor economy and poor educational systems. The only thing holding the Jewish people together was their heritage and religion. Their survival of the fittest in the shtetl was motivated by the belief that God was with them and would lead them.Beginning in the early nineteenth century a wave of modernization and industrialisation went across all Europe. This wave opened social and economic opportunities that were new to the Jews in the shtetls. This wave of modernization mainly affected the Jews who lived in Germany and Austria, as this Jews were outside(a) the shtetls and were therefore not protected from the rest of the world. When modernizations first effects started being felt in Europe, Christian communities outside the shtetl started approaching Jews for their possible to contribute to European economic and social revitalization. Europeans therefore played a role in the converting the Jews

International Arbitration in Arab States Dissertation

International Arbitration in Arab States - Dissertation ExampleThe primary data be of statutes and cases providing direct evidence of the arbitration law and practices. Secondary data consist of textbooks, journal articles, and other publications relevant to global mercenary arbitration, and arbitration in the Arab position East. Research results indicate that Islamic law has significant influence on attitudes, laws and practices relative to arbitration and international arbitration in the Arab Middle East. However, while Egypt and Jordan birth made significant progress in modernizing their arbitration laws to accommodate increase international trade, Saudi Arabia, the most conservative Islamic state in the sphere is struggling to make these accommodations. Although a new law is currently underway in Saudi Arabia, its future is uncertain given the long history of ambivalency toward international commercial arbitration informed by unsatisfactory experiences highlighted by the A RAMCO decision in 1958. Despite Egypts progress it has also recently interpreted a step backward with the Ministry of Justices Decree of 2008. This Decree mandates that all arbitral assigns are reviewed in secrecy by the Ministry of Justice.... 90 Elsaman, 2011, p. 8). Globalization has also increased the extent to which all states interact with one another in international commerce and international trade. As a result, states recognizing the inadequacy of domestic courts to deal with international commercial disputes have increasingly turned to international commercial arbitration as a to a greater extent feasible method of resolving domestic disputes. However, tally to Gemmell (2006), due to Islamic traditions and influences, the Islamic Middle East which is largely the Arab Middle East has not fully embraced a modern system of international commercial arbitration (p. 169). Of particular concern is the fact that although arbitration is consistent with Islamic tradition, enforcin g international commercial arbitral awards in the Arab Middle East can be problematic. A number of national courts in the Arab Middle East, particularly Islamic courts have been averse to enforcing international commercial arbitral awards on the grounds that the award is inconsistent with public policies or more particularly, Islamic law and traditions (Elsaman, 2011, p. 8). This is arguably a loophole facilitated by international commercial arbitration itself. The New York crowd on the Recognition and Enforcement of Foreign Arbitral Awards, 1958 (hereinafter the New York Convention) permits member states to refuse enforcement of an award if it is found to be contrary to public policy (New York Convention, Article V(2)(b)). Complicating matters, the New York Convention does not define the phrase public policy. International commercial arbitration in the Arab Middle East is largely influenced by Islamic law and traditions more broadly known as Sharia compliant laws and traditions (K utty, 2006, p. 566). Sharia in this regard

Strategic Management CEO Essay Example | Topics and Well Written Essays - 500 words

Strategic Management CEO - Essay ExampleIt appears that the management believes in making strategical moves to be in the best position for long-term benefits.According to the article reviewed, Googles vision has been sketched out. This may be asserted because of some of the elements that the CEO of Google, Mr. Schmidt, highlighted. To go moxie to Mr. Schmidts beginning with Google, he first of all said that there wasnt much of an infrastructure. With only three basic individuals in the decision-making process, Mr. Schmidt asserts, two people see to agree. After this, the third one has to be convinced or the third one may try and work his thoughts against the two that agree. Aside from decision-making that decides a number of things, Googles vision is to be prepared. This is why they consider the future and also consider reasons for an IPO, such as either liquidity, venture returns, the ability to do acquisitions. However, Mr. Schmidt says that Google does not have any such pressur e, and so, they think about what they can do to finance newer projects of Google with lower risk.According to Mr. Schmidt, Google had one objective from day one, which was to realize a culture. Indeed, Google has achieved this over its period of existence. However, the job is not done yet, as there is a more that this company can do.

Post-Modern Anthropology Dissertation Example | Topics and Well Written Essays - 2250 words

Post-Modern Anthropology - Dissertation ExamplePostmodern anthropology provided solutions that holiness did not fathom to the problem of mental illness. Over long era religion patented that madness could only be controlled but not cured, but with advent of the anthropological theory, religion was part of the movement which indicated in acrimony of everything the presence of reason of madness and which led from insanity to health (Michael and Richard 1961394). The understanding of the real nature of madness helped in deriving a way the tutelage that had been passing down like an evocation of a common nature. Before the adoption of the contemporary anthropology, the society was encapsulated with an error that alienated the people of their freedom and joy. As a result of the theory, madness could cause no more fear and the solitary attitude and character that existed between the sane and the madman disappeared. The use of much(prenominal) theory enabled the understanding of the anc ient mythical methods of treatments of such illnesses in the olden society and also provided the cause of such diseases thereby enabling the acquisition of medication. The blue guilt that once linked transgression and unreason is thus shifted the madman, as human being originally endowed with reason is no longer blameworthy of being mad and can instead now feel morally responsible and respected especially because the disease can be treated. Natural religion which was mostly a local cures concern proved effective. It made use of the benevolence of nature to cure.

Critical Evaluation of Ipad Assignment Example | Topics and Well Written Essays - 2000 words

Critical Evaluation of Ipad - Assignment ExampleThis is evident as the design of the Ipad software is very elementary and user-friendly. With the pay heed screen technology, users can use their fingers to access programs and files that they wish to access, just like a child playing with toys.In terms of niche, Apple Computers, Inc (Apple) wishes to introduce a product which lies between iPhone and Macbook in terms of function. Therefore Ipad is expected to be substantially better than two in terms of the following web browsing, E-Mail, think and watching of images and videos, listening to music, Reading electronic media (Apple Inc). In terms of convenience Ipad is indeed better than Macbook, but less convenient than the Iphone as the latter is oft lighter. The aim of situating a product between the Iphone and Macbook is an excellent idea indeed as some corporate needs cannot be met by a transparent Iphone, especially when we talk about large data, applications and software. On t he other hand, Macbook is now relatively heavy especially with the introduction of netbooks by HP, Acer and Asus. Its appropriately occupies a product niche which does not compete with the existing Apple products, yet more innovative and improved than the competitors netbooks. It is an innovative product as it is the first that introduces doctor touch screen technology but this may in any case be a disadvantage as the market that it tries to reach - the non-computer experts will probably attain time to appreciate touch screen technology. The Ipad calculate has the following objectivesa. Sell 1 million of the new device internationally within 2010 and so reservation a profit b. Increase the product range by developing and producing a new tablet device by Q1 2010 c. Ensure a rudimentary model is available for distribution to US customers on April 3rd and internationally by 23rd April 2010 d. Ensure premium model is available for distribution to US customers by the 26th April and internationally by 11th June 2010 e. Establish data plans with international mobile communications suppliers by June 2010 f. Gain a return on investment by 2011 g. Launch the new product on 27th January 2010 h. Sell the product for under $850 i. Maintain the Apple quality throughout the project Source (Apple, Inc). There are a variety of reviews and expectation on the would-be performance of Ipad. Apple change management has proved successful everywhere the years as the company has adapted to the changing market by constantly redefining the design and purpose of digital technology (Edward de Bono, 2006). Over-all, its corporate culture has showsn both optimism and tactile sensation which led to continuous funding and investment in new products and innovation even against the backdrop of a challenging economic climate (Edward de Bono, 2006). It is this optimism and belief that brought us the Ipad. Reviews however criticize the launching of Ipad especially on the aspect of function ality and getting things done (Enderle, 2010). This is the very question that comes to mind when I saw the project. willing Ipad achieve the 1 million sales in 2010 In the first place, will the tablet be patronized It gets popular in America, will it also be popular in other countries The objectives of Ipad management team is understandable as we examine the culture of the company.

Final take home exam Term Paper Example | Topics and Well Written Essays - 2000 words

Final take home exam - Term Paper ExampleHence, the quality of interaction has improved to a great level. This unconstipatedtful locomote of hearty media development is marked by several milestones. I give be highlighting 5 of the most key moments in the history of cordial media. In my opinion, the first one is obviously the development of e-mail. E-mail is probably the first form of digital message. The next one is development of Genie, which was an online forum that direct the foundation of social media. I believe the third milestone was a major shift in terms of development (Freeman, 2010). It came in the form of human races first social platform where users actually got the opportunity to get in touch with their loved ones. The website was known to as classmates.com. The emergence of Friendster, improved and current social media platform is the next big thing to have happened. The craze was such that within the first month of its launch, around 3 million bulk joined in . The last major breakthrough came in the form of modern day networking platforms such as Facebook, Twitter, and Pinterest. These networks support online transfer of various types of file and has actually taken communication to the next level. The journey of social media has been an eventful one and it is expected that with a similar rate of development, soon human being will pick up a new world through the eyes of social networking platforms. Properties of social media Social media is referred to as a virtual network or participation where users gather to communicate among themselves and at the same time create and exchange information about the various topics. Therefore from the above findings I can terminate that social media acts as a mediator betwixt the users. Some of the key properties of social media are quality, reach, frequency, accessibility, usability, immediacy, and permanence. I believe these aforementioned properties create disparities among the different social m edia forms and are the reason that leads to various types of social media (Kietzmann, Hermkens, McCarthy & Silvestre, 2011). For example, due to differences in the features we come across two terms, namely social media and industrial media. The major difference between social and industrial media is that industrial media is more expensive. It includes television, newspapers and films. In my opinion, it is important to distinguish different forms of media because without distinction new forms will never emerge and can even act as a hindrance. In the context of the difference between the new forms of media with rational forms is its ability to go viral. Due to the presence of a million of registered users a small issue can go viral through social media. Types of social media As seen above, social media has various features that allow users to accomplish crucial tasks. However, when a discussion about social media is going on, it is a necessity to underline the different types of soci al media present in the virtual world. From my personal experience as well as consultation of the textbooks, I have found there are 6 different types of social media namely collaborative projects, blogs and micro-blogs, inwardness communities, social networking sites, virtual game worlds, and virtual social worlds (Gillgian, 2011). According to me, all of the aforementioned types of social media has their own significance and can be described as unique,

Ethical Standards of the American Educational Research Association Essay

Ethical Standards of the American Educational Research Association - Essay vitrineAs the write up highlights the American Educational Research Association (AREA) publishes a comprehensive set of good standards used to guide the work of educational queryers. This paper will examine three of the most pressing and relevant ethical humps that face educational researchers. One of the most important issues of research ethics is research honesty. According to AREAs standards, Educational researchers must not fabricate, falsify, or misrepresent authorship, evidence, data, findings, or conclusions. While this may seem an obvious transgression of research ethics, researchers may be tempted to compromise results in the face of scarce resources. Researchers may be tempted to borrow data without giving proper credit, or falsify data that they intuitively opine to be true, without having accomplished the research. In addition, political or social agendas may drive the research and results co uld be skewed to reflect the particular point of visualize of the researcher. All of these cases place the research in question and bring harm to a vulnerable population of students.This paper stresses that another key component of ethical educational research is the expectation of anonymity and privacy. AREAs ethical code states, Informants and participants have a right to remain anonymous. This right should be respected when no hap understanding to the contrary has been reached. In other words, all participants have the expectation of privacy and anonymity. The subjects do not have to request that their data or examine scores remain private, the ethical standards assure it. If the researcher wishes to make the information public, they must seek explicit permission from the participant. To protect the individual from harm, and the researcher from liability, the issue of informed consent must be completely resolved.

Was the britsh navy pro nationalist during the spanish civil war Essay

Was the britsh navy pro nationalist during the spanish civil war - Essay ExampleConsequently the safest option for the British Government was to fit an non-intervention role throughout the whole war but with secret support for the Franco Regime. Jill Edwards comments on this communist phobia of the British ruling class, in the first weeks of the rebellion, it was the run of anti-communism which formed the warp of British government attitudes. 1The dilemma of the British Government was that on one side she had to address the fear of the rise of the socialist among the Republicans while there was another(prenominal) posing danger from the Nazi who were striving to establish control over the Franco Regime. Like other democratic countries of Europe officially turn a blind eye to the war just because of the fear that any bias and direct support might eventually lead to another Bloody world war. But Franco Regime received an indirect and unofficial favour from the British Naval Force ju st because the British Government strove to get a line the unanimous control over the Franco Regime. 2 But meanwhile the emotional rise of the Socialists among the Republican due to the aloofness of the European democratic countries and the direct arm support of the Stalin Government pushed the British rulers to take a strong stand for the Nationalists. In an article International Naval Cooperation During the Spanish Civil war pass B Siegel comments on the overall picture of the war situation as followingAmong ideologues on the left and the right, the Spanish civil war was perhaps the well-nigh controversial conflict. Moreover, European powers could not ignore the fact that it posed the greatest threat to peace. Spains strategic location, the rise of fascism.drew international nautical forces into Spanish waters. 3British Naval Support for the Nationalists has a lot to do with the fear of the rise of the socialists among the Republics. During the war

Reflection Essay Example | Topics and Well Written Essays - 250 words - 87

Reflection - Essay ExampleThe patient is also encouraged when you smile and comfort him. I gave the patient fruits and multivitamin tablets. What I realized from this medication is that, a patient under malnutrition tends to react positively faster after taking multivitamin. This also improves his appetite.Seeing a smile on the patients face really motivated me. I felt useful, confident, and also helpful to people who seek my help. It is normal for one to be slightly low in mood, but when you impact positively on the people you serve, definitely it cheers you up. The experience I had today make me feel important and proud of my presence in the hospital.My goals in future is to improve on my knowledge and skills on how to handle patients that feel they have lost hope. I have also decided to branch out my skills within the hospital by participating in other hospital activities that are not within my field of study. Additionally, I plan to learn rude(a) things daily in order to sharpen and improve my interest to handle

Mary Shellys Frankenstein Essay Example for Free

Mary Shellys Frankenstein EssayMary Shellys novel is structured in a way, which attempts to give authority to her views. Opening with an authors introduction, and supported with a premise with her famous husband. Mary Shellys novel starts with a series of letters claiming to know the truth of overlord Frankensteins story. This family involvement, followed by professional distancing, reveals the strength of the authors feelings on the responsibilities of family and scientists. For a light speed and a half, many readers of the Mary Shellys novel Frankenstein have debated over which character could be associated with the expression Monster. Mary Shelly said in the preface the reason wherefore she produced this nineteenth century novel was a ghost story oh If I could only contrive one which would frighten my reader as I myself had been panicked that night. She wanted her readers to feel the terror that she had dreamed one night. The readers of Mary Shellys novel Frankenstein mi ght believe that the dick is the monster, however there are two potentiality monsters in the novel. These two characters from the novel are the Creature itself and the creator of the creature, Dr Victor Frankenstein. One candidate who might be believed to be the monster is Dr Victor Frankenstein.At the age of seventeen Victors parents suggested that he should become a student at the university of Ingolstadt. Unfortunately Victors induce passed away while giving birth to his brother. The death of his mother shocked him and caused him to search for ways to extend life. After the death of his mother, Victor took his parents advice and went to university. My departure for Ingolstadt which had been deferred by these events it appeared to me sacrilege so soon to leave the repose, akin to death, of the stick out of mourning and to rush into the thick if life.This suggests he wasnt sure if it was the respectable move to steel, to leave his mourning family behind and go off to universit y. While at university Victor became fascinated in biology One of the phenomena, which had peculiarly attracted my attention was the structure of the human frame, and indeed any animal endued with life. Victor was focused to stop death. He was grieving so much because he had lost someone so important and close to him I thought that if I could bestow animation upon lifeless matter renew life where death had apparently devoted the body to corruption.His fascination with extending life overtook his studying he became so committed to finding a way, he had set himself a challenge and he was so sure to achieve that challenge. A time in the novel where we are give tongue ton that Victor is tie in as a monster is the time when he begins to dig up the dead and raid graveyards. Who shall conceive the horrors of my secret toil as I plunge among the unhallowed damps of the grave or tortured I collected bones from charnel-houses secrets of the human frame. This is a sign of immoral, abnorma l attitude and is offensive towards the bodies.The definition of a monster is a misshapen animal or plant someone of wickedness huge animal or thing. The part of the definition where it says a person of wickedness is what should be used to describe Victor Frankenstein. No normal person would dig up the dead and use body parts to make a creation. Another way, in which Victor could be considered as the monster is the way he treated the creature once he had brought it to life. Victor disowned the creature he refused to acknowledge it and to accept that the creature was his own For this I had deprived myself of rest ad health.I had desired it with an ardour at length sluggishness succeeded to the tumult endeavouring to seek a few moments of forgetfulness but it was in vain. Victor had no intention of caring for the creature, it was as if he was afraid of his own creation. He discards the Creature immediately after its creation, calling it a wretch and leaving it to fend for itself. T his shows how irresponsible he is. It is also another example of him neglecting his family, since the Creature sees him as its father.The creature approaches Victor like a baby would to its father He held up the curtain of the bed and his eyes, if eyes they may be called, were fixed on me while a grin wrinkled his cheeks. How could Victor abandon the creature, he had no sympathy towards it. The way in which the creature is described when it approaches Victor is and like the way a baby would approach its parents, maybe at this part of the novel, we readers are to feel sympathy for the creature and to consider Victor as the monster for the way he treated the creature, it was his own creation he should of cared for it and been its companion.Victor should of treated the creature like his own child, possibly if he did show care for the creature and not show fear, maybe the creature wouldnt have been so vile because he knew no opposite. The creature didnt know how to treat or care for other people. So really it wasnt the creatures fault for the deaths caused and for the way in which he treated people because overall he didnt know any different and wasnt taught by Victor how to treat others.

Rational Choice Theory Essay Example for Free

intellectual prime(prenominal) surmisal EssayMan is a noetic animal who always loses his temper when he is called upon to act in accordance with the dictates of reason. As seen from Oscar Wildes famous quote, reasoning(prenominal)ity is one of the most crucial and disputable subjects in examineing human port. To study and examine this rationality, numerous scholars have tried to establish their own theories and generalize their explanation with falsifiable evidences from real world, which in the end produces so called, the guess of rational select. sharp Choice Theory is an approach to understand human behavior.The approach has long been the dominant paradigm in sparings, exactly in recent several decades it has become to a greater extent widely used in other fileds such as Sociology, Political Science, and Anthropology. The main purpose of this piece of music is to provide an overview of rational survival conjecture and briefly discuss its basic assumptions, critiques, political implication, and selection explanations of mortal prize mechanism. First of all, historical backgrounds of rational pickaxe theory and its transition from the field of Economics to that of Political Science will be elaborated.Next, various definitions and meanings of the rational picking will be discussed. The basic assumptions of the rational quality approach with political implication will be followed. Several issues raised by rational survival of the fittest theory will be followed afterwards this discussion. This paper will suggest some of the main criticisms that have been levied against the rational choice approach. Limited empirical validness of rational choice theory and methodological individualism, which reveals innate problematic nature of the theory, will be discussed.Finally, alternative explanations of individual choice mechanism will sum up this discussion. Before elaborating its theoretical discussion, it is requisite to discuss histori cal backgrounds of rational choice theory. In the article, A Genealogy of Rational Choice Rationalism, Elitism, and Democracy, Maloy introduces Skinners analysis of behaviorism as fundamental background for the discussion of rational choice theory. He argues that, Skinners analysis deserves the worry of the recent debates around rational choice ecause it calls attention to the ineluctable ideological features of methodological debate (Maloy 751).According to Maloy, Skinner could clarify the sorts of normative force which attach to empirical theories in tender sciences by a close textual analysis of some leading contributions to the behaviorist debate, which ultimately enables the discussion of rational choice to be furthered applied into different handle of study (Maloy 751). Milton Freidman is another(prenominal) crucial figure that provides profound theoretical base for discussing rational choice theory.In The Methodology of Positive Economics, Friedman argues that people and f irms befuddle decisions that can maximise their profit under perfect in inventation. He defended rational choice case by arguing that, a theory should be judged by its predictive accuracy, not the realism of its assumptions (Friedman 10). His argument provides theoretical foundations of rational choice theory in Economics, even though it is often rapd by later scholars because of its shoddy empirical validity and ceteris paribus nature.While rational choice theory has been dominant paradigm in Economics, it has become adapted and adjusted in a outcome of ways to fit different field of study such as Political Science Maloy explains that the distinctiveness of the rational choice approach among political scientists consists, in general terms, in the use of economic models to explain and predict political behavior (Maloy 753). Maloy points out three prominent figures, Arrow, Downs, and Olson as rational choice founders oddly in the field of political science.According to Maloy, Arrows work focuses on so called, bodied rationality whose underlying purpose is to measure bodied choices using standards normally applied to individual choices (Maloy 753). Down uses Arrows collective rationality as the starting point of his study and aims to articulate a behavior rule for democratic governments so that they could be included in economic theories of general equilibrium, alongside non-state agents give care private firms and consumers (Maloy 754).Finally, Olsons analysis has interpreted the key elements of Arrows and Downs constructs and applied them to a abbreviateer field He argues that as long as the service provided by a voluntary association is a public good on which an individual can ride-free, there is no incentive actually to take on the be associated with joining, membership and participation, unless the marginal contribution of that individual appreciably advances the organizational cause (Maloy 754).All three choice founders works have enabled ratio nal choice theory to be in the central place of political discussion in the creative and cross-disciplinary ways (Maloy 755). By arguing that voting results have no limited social meaning, voting has no individual efficacy, and participation in interest group activity has no special individual efficacy, these rational choice founders could criticize unrea numerateic and irrational assumptions and norms of traditional democratic system and bring rational choice model to the place of political discussion from the field of Economics (Maloy 755).Rational Choice Theory generally starts with consideration of the choice behavior of individual decision-making units, which in economics are often consumers and firms. The theory suggests that the individual decision-making unit is original larger group such as buyers or sellers in a particular market. Once individual behavior is set up, the analysis generally moves on to examine how individual choices interact to produce outcomes. Then, wha t does it mean by arguing that a choice is rational?In rational choice theory it actor that an agents choices reflect the most preferred possible alternative among given opportunities. In other words, choices must reflect utility maximization. Elinor Ostrom defines rational choice theory as a guide to understand humans as self-interested, short-term maximizers in his work, A Behavioral Approach to the Rational Choice Theory of Collective Action (Ostrom 2). In the article, The Political Psychology of Rational Choice Theory, William H.Riker also suggests that the rational choice model begins with the assumption that actors have intercourse what they call for and can order their wants transitive verbly (Riker 25). Transitively here means that an agent of rational choice model can do so called, a transitive ordering To know what one wants requires one to choose the best from among several goals and, failing to attain it, to choose the second best, etc (Riker 24). This formulation of ordering enables an agent to stick to the best option with given constraints that limit choices he or she can have.In their work, Rational Choice Theory, Coleman and Fararo define rational choice sociologically as they use the term, models of purposive action, kind of than rational choice These models rest on the assumption that actors are purposive which means they act in ways that tend to produce beneficial results (Coleman and Fararo 21). These several definitions point out that choices pursuing utility maximization and outcomes made by these choices are key elements in rational choice theory.Then how is different when rational choice theory is applied into the field of Political Science instead of other fields of study such as Economics and Sociology? According to Riker, Economists main concern for rational choice is the process and outcomes produced by voluntary exchange, where of course, all histrions benefit. On the other hand, authorities mainly concerns processes and ou tcomes produced by group decisions which are practically binding on those who cannot resign from the group. Thus, there can be losers and winners in politics according to Rikers argument (Riker 24).Although Rational choice theory has long been the dominant paradigm in Economics and other fields of study, it has been subject to vigorous criticism. In Pathologies of Rational Choice Theory, Don Green and Ian Shapiro raises several empirical problems that rational choice theory possess they conclude that a number of methodological deficiencies infestation empirical applications of rational choice models. They argue that, fundamental and recurrent methodological failings rooted in the universalist aspirations that motivate so much rational choice theorizing (Freidman 59).According to Green and Shapiro, these mistakes stem from a method-driven rather than a problem-driven approach to research, in which practitioners are to a greater extent eager to vindicate one or another universalist m odel than to understand and explain actual political outcomes (Friedman 59). Green and Shapiros argument can be summarized into three propositions there is a list of methodological characteristics that are undesirable in an empirical science and are thus to be avoided. Empirical applications of rational choice theory are more likely to commit these mistakes than other types of empirical analysis in political science.These pathologies are not due to and historical coincidence, but are rooted in fundamental characteristics of rational choice theory, especially its universalist aspirations and the lack of specificity in the rational actor assumption (Freidman 60). These propositions suggest that rational choice theory has its empirical limit for testing and predicting actual political outcomes. In detail, Green and Shapiro point out several problems of rational choice theory that possibly undermines the empirical validity of the theory itself.Post hoc theory development known to stati sticians as curve fitting is one of these problems that rational choice theory contains. Green and Shapiro contend that rather than formulating bold predictions that are falsifiable by empirical evidence, rational choice theorist tend first to look at the empirical evidence, then design a rational choice model that fits it (Friedman 5). Another problem raised by Green and Shapiro is rational choice theorists engagement in arbitrary world restriction (Friedman 5). As discussed earlier, accredited restrictions or constraints enable a transitive ordering in rational choice theory.Green and Shapiro argue that these constraints and restrictions are delineate in ambiguous ways in rational choice model, which ultimately makes the empirical validity of the theory weakened. Green and Shapiros examination of the phenomenon of voting behavior is another major example that shows these problems rational choice theory innately possesses. In a real-world election with a large electorate, it is instrumentally irrational for anyone to case a ballot, since no single vote has more than an infinitesimal chance of deciding the outcome.Whether one favors selfish or selfless ends, virtually any activity in pursuit of those ends would be more effective than the time spent on voting and on educating oneself about candidates and issues. Yet hundreds of millions of people do vote. For rational choice theory, this would appear to be a gigantic anomaly (Friedman 6) As noted earlier, rational choice theory presumes that an agent of the model seeks best possible outcomes to maximize his or her utility in given constraints.However, according to Green and Shapiro, in a real-world voting behavior does not confirm this assumption of rational choice theory where voters cast a ballot without having enough time to assess or predict its possible outcome and realizing whether his or her action of voting maximize benefit or not. Another issue raised by Green and Shapiro is free riding problem Whi le voters can easily pursue a free riding action on the efforts of others to help the cause succeed, there is no contend for people to devote resources of time and money to cause desired results.In other words, rational choice theory would seem to be refuted not only by people who vote, but by those who contribute subtile amounts of money to political campaigns, attend rallies, and engage in other forms of collective action designed to secure goals whose achievement is independent of the efforts of any single participant (Friedman 7). As seen from Green and Shapiros founding, most criticisms of rational choice theory seem to be that the assumptions of the theory are not literally and completely true.No model can pass such a test, as all theories abstract from reality in certain way. Determining the empirical validity of a model would therefore seem to involve an examination of both feasibility of assumptions and conformity with real-world data. The most basic assumption of ration al choice theory is that the particular unit of analysis is the individual decision-maker. Those who believe that groups are fundamental have criticized this assumption. This issue of so called, methodological individualism are dealt in many contexts in the social sciences.In the book, Rational Choice Theory Advocacy and Critique, Coleman and Fararo argues that models of purposive action or rational choice model can be expedient in explaining and predicting human behavior. They further their argument by saying that because the values and beliefs of individuals are shaped primarily by the socializing influences of society, especially as mediated through social relationships with significant other, an understanding of the culture and structure of societies and of the positions of individuals within them is necessary (Coleman and Fararo 22).According to Coleman and Fararo, major problem for applying rational choice model particularly into Economics and Political Science, in which the primary interest has been in aggregate level outcomes, is that the postulate of purposive action has been linked to arbitrary and narrow assumptions about what individuals value and believe (Coleman Fararo 33).Also the assumption that human behavior is narrowly self-interested and the use of the term rationality to refer to the efficient pursuit of economic benefits has often produced incorrect assumption that rational choice model are innately egoistic that they regard individuals as calculating the expected benefit to themselves of alternative lines of action and acting accordingly (Coleman and Fararo 34).Recent empirical evidences suggest that human beings are capable of acting in ways for the interests of others or the social group above their self-interest, which implies that the assumption of individuals pursuit of self-interest does not match with reality. Coleman and Fararo further their discussion of this methodological individualism by arguing that a social norm can be on e primary example, which refutes the basic assumption of rational choice model.According to Coleman and Fararo, When a social norm is know to have been violated, some type of formal or informal sanction will result (Coleman Fararo 35). Formal sanction like a legal engrave or a set of rules and informal sanction like a disapproval or social ostracism would affect individuals choice making process. Therefore, unlike the basic assumption of rational choice model suggests that human behavior is oriented from self-interest, by the effect of social norms and values, individuals can therefore act in altruistic or selfless way for pursuing the interests of groups they are involved in.Because of its limit and problematic nature of rational choice theory, the need for alternative explanation has become necessary for many scholars who criticize the theory. Dennis Chong provides some insights for the possible alternative of rational choice theory in his article, Rational Choice Theorys Mysteri ous Rivals. According to Chong, even though Green and Shapiros critique against rational choice theory has failed to provide complete form of alternative explanation, there are some theoretical debates and discussions that suggest possible theoretical replacement or revision.Chong argues that, Green and Shapiro occasionally allude to the influence of social-psychological and moral factors such as group loyalties, emotions, political identities, ideology, obligation, and altruism (Friedman 47). As found in Coleman and Fararos arguments that institutional or social factors can affect individuals choice making process, many scholars further their discussion of this social motivation as the alternative of rational choice theory.In his article, When Rationality Fails, Michael Taylor argues that social identification and intrinsic motivation can explain some of significant social phenomenon and collective action that has been ignored by rational choice theory If a person defines herself a s a member of a group, or if her membership in a group is made cognitively salient, then she is more likely to observe the groups norms and cooperate with group members in social dilemmas (Friedman 230).For intrinsic motivation, Taylor explains that there are some activities that are intrinsically need people to be participated such as interesting work, volunteering, and political activities. In this case the activity itself or enjoyment of that activity is the reward for people. When extrinsic rewards like money are introduced, intrinsic motivation would diminish (Friedman 231). By suggesting the concept of social identification and intrinsic motivation, problems of rational choice model for explaining some collective action can be resolved.In this paper, a sense of how rational choice theory works and of its methodological foundations has been introduced. It has also been noticed that rational choice theory is not an ultimate answer. The theory is subject to a number of criticism s, but there is no doubt that its influence in various fields of study have brought tremendous amounts of theoretical debates, and increased the depth of economic, sociological, and political discussions.It is impossible to attain complete knowledge about anything, especially social phenomena. However, it is certain that rational choice approach is one of most crucial theoretical resources for human beings to explore and examine to gain this ultimate answer. It can be useful or misleading, depending on how it is treated. It is responsibility of remaining and future scholars and people to correctly apply and use this theory with open-minded attitude.

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study

Acute Exacerbation of Bronchial bronchial asthma attack attack (AEBA) Case Study1.0 CASE SUMMARY1.1 forbearing role information and presenting complaintsSAR, a 54-year-old female with incubus of 54kg and height of 160cm was referred to the hospital by her GP ascribable to shortness of breath which was not relieved by victorious inhaler, minute of arcimum cough with yellowish sputum, abdominal muscle pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the assure was deteriorating on the twenty-four hour period of admission.1.2 Relevant taleSAR is a non-smoker and a non-alcoholic ho partwife. She has had bronchial asthma attack since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbuta break water supply two hundredg 1 flip ones wig when required as easement and inhaled budesonide 200g 2puffs bd as hold backer for umpteen years. Besides t hat, SAR to a fault has medical history of hypertension, diabetes mellitus and ischaemic internality sickness (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, fenofib step 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(ip) ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-p later(a)let constituent.1.3 Clinical dataOn examination upon admission, dire acute respiratory syndrome origin 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 decrease gamey gear come down mask. Her DXT blood glucose test revealed that her hit-or-miss blood glucose tr ain was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged stripped-down bi chief(a) crept and rhonchi. Also, SARs chest X-ray showed tailing 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 270mol/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 ingress and an plus in the plasma globulin. On the some another(prenominal) hand, the haematological tests showed low red blood cellular telephone count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high etiolate blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac stigma tests showed abnormally high counts in creatin kinase (156IU/L) and l executionate dehydrogenase (627IU/L).1.4 Diagnosis and Management PlanBased on the patients symptoms, medical history, somatogenetic examinations, and laboratory tests, SAR was diagnosed with degenerative centre of attention mischance (CHF), acute exacerbation of bronchial asthma (AEBA) gameary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti- wheezy drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added water pill to her ACEI therapy and restrict her fluid intake to not more than 800cc/ daylight. Her uncontrolled diabetes mellitus was under admonishering of DXT blood glucose test 4 hourly and she was referred to sustenanceician for diabetic diet counselling.1.5 Ward medicationThroughout the 3 days in hospital, Sarah was being plus with medications as listed below1.6 Clinical Progress and pharmaceutical Cargon Is suesOn the firstborn day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to pay off SARs home medication to checker 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 cliche 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 viva prednisolone at sexually transmitted disease as low as 30mg od for acute asthma, it should be suggested to increase prednisolone process to 40-50mg daily as according to evidence-establish guidelines to achieve maximal effectuate.2-3 other pharmaceutical c be issue is regarding the patients sorry inhaler technique. Thus, the pharmacist ed ucated 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 shields halt IV ceftriaxone 2g on the first day. in that locationfore, signs of reco precise and WBC count were monitored regularly and completion of antibiotic course was ensured. In admittance to that, vaccinations against pneumococcal transmission and influenza should be strongly recommended in this wheezy patient.2-3,5-8Co- constitution of high dot IV furosemide (40mg bd) and cortico steroid hormones burn down increase the risk of hypokalaemia, in that respectfore 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 administrati on 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 junto of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as synchronal use of fenofibrate and statin may enhance 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 rigorouss her blood glucose level wa s 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 kept up(p) betwixt 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 200g 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200g 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 corticostero ids.1 Oropharyngeal side effects such as candidiasis ar also more ballpark 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) preaching instead of initiating SAR on high dose steroid (2000g). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler 2 puffs bd) should be given up and control of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene sense organ 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 lessen frequency and total daily dose.On day 3, SAR was arranged to be pink-slipped. The pharmacist should review the appropriateness of dispatch medication by checking discharged prescriptions against ward med ication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and pay back the importance of patient residency and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques introductory 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 star(p) to visitation of interference. 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 counselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypogly caemia 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 medicates 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 THERAPY2.1 Disease background2.1.1 AsthmaAsthma is a common chronic unhealthy condition of the lung air passages 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 well-nigh 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/ kindling caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of insurgent mediators smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthmatic patients. The effectual tests for airway function abnormalities include the surprise 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 dissimilar magazines of the day is necessary. The FEV1 is normally express as the percentage of total volume of air exhaled and is report as the FEV1/FVC ratio. The ratio is a useful and passing reproducible measure of lungs capabilities. Normal individuals c an exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction.2.1.2 Community-acquired pneumoniaPneumonia 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, etiolate blood cells and inflammatory exudates. The incidence of confederation 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.72.1.3 congestive cardiac misadventureCongestive cardiac failure conks when t he 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.62.1.4 Diabetes mellitusDiabetes mellitus is a heterogenous convocation 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 outpo uring. 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 materia medica2.2.1 Treatment for asthma2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline)These short-acting selective 2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective 2 agonists act on 2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) persisting to rapid bronchodilation and reversal of the bronchospasm associated with the early level of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the un derlying inflammatory nature of the disease. 2 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 gradual rate of onset and their requirement lipophilic properties render them to be carry 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 2 agonists but last longer.2.2.1.3 Inhaled corticosteroids (ICS e.g. beclomethasone, budesonide) and oralprednisoloneThese agents are used to prevent asthmatic attacks by reducing airway inflmmation. They manage 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 pneumoniaAntiobiotic 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(prenominal) ceftriaxone and cefuroxime are across-the-board spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specifi c penicillin-binding proteins and eventually leading to cell lysis. Second contemporaries cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third extension cephalosporin, ceftriaxone display high betalactamase resistance and enhanced exertion against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-62.2.2.2 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 failure2.2.3.1 circulate diuretics (e.g. furosemide)D iuretics are the mainstay of the management of heart failure and provide rapid characteristic musical accompaniment of pulmonary and off-base oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascension 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.5-62.2.3.2 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 mellitus2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide)The sulphonylureas have two main actions increase basal and stimu lated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP thoroughfares 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-) 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.1,4,63.0 EVIDENCE FORTREATMENT OF CONDITIONS3.1 Asthma3.1.1 Evidence for the use of oral pr ednisolone and IV hydrocortisone in themanagement of AEBAThere are mounting evidences suggesting that systemic corticosteroids efficaciously influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeableness and production of cytokines.10-12 A randomised rivulet 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 6845.3% and 53.446.5% 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 2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramu scular/intravenous) and choice of agents.143.1.2 Evidence for the use of inhaled ipratropium bromide in the management ofAEBAA double-blind, randomised controlled trials recruiting one hundred eighty 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 2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more new-fashioned 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 2-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).173.1.3 Evidence for addition of LABA to ICS in the management of asthmaSymbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the unite 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 service of this approach in terms of patient compliance as it allows the use of single inhaler for both turn in and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-3 9% 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 infallible budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the admit is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p3.2 Community-acquired p neumonia3.2.1 Evidence use of combination therapy of second and/or third generationcephalosporins and macrolide in the management of pneumoniaA 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 general bacteriologic clearance with 100% annihilation 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 failure3.3.1 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.303.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHFThe Losartan center field Failure Survival Study elite II, a double-blind, ran domised 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, losartanAcute Exacerbation of Bronchial Asthma (AEBA) Case StudyAcute Exacerbation of Bronchial Asthma (AEBA) Case Study1.0 CASE SUMMARY1.1 Patient information and presenting complaintsSAR, 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 historySAR 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 hist ory of bronchial asthma as well. The patient has been taking inhaled salbutamol 200g 1 puff when required as reliever and inhaled budesonide 200g 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 dataOn 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 wa s 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 270mol/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 lymphocyt e 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 PlanBased 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 medicationThroughout the 3days in hospital, Sarah was being prescribed with medications as listed below1.6 Clinical Progress and Pha rmaceutical Care IssuesOn 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.2-3,5-8Co-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 200g 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200g 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 dos e 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 (2000g). 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 additi on 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 counselling 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 dr ug 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 THERAPY2.1 Disease background2.1.1 AsthmaAsthma 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 asthmatic 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-ac quired pneumoniaPneumonia 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.72.1.3 Congestive cardiac failureCongestive 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.62.1.4 Diabetes mellitusDiabetes 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 diabete s. 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 pharmacology2.2.1 Treatment for asthma2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline)These short-acting selective 2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective 2 agonists act on 2 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. 2 agonists should be initiated when required as prolonged use may lead to receptor down regulation renders them less effect ive.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 2 agonists but last longer.2.2.1.3 Inhaled corticosteroids (ICS e.g. beclomethasone, budesonide) and oralprednisoloneThese 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 inhibiti on 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 pneumoniaAntiobiotic 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 a nd Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high betalactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-62.2.2.2 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 failure2.2.3.1 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 the y 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.5-62.2.3.2 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 mellitus2.2.4.1 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 cal cium 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-) 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.1,4,63.0 EVIDENCE FORTREATMENT OF CONDITIONS3.1 Asthma3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in themanagement of AEBAThere are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the comp onents 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 6845.3% and 53.446.5% 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 2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.143.1.2 Evidence for the use of inhaled ipratropium bromide in the management ofAEBAA double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed th at 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 2-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 2-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 (relativ e risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).173.1.3 Evidence for addition of LABA to ICS in the management of asthmaSymbicort 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) r esulted 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, p3.2 Community-acquired pneumonia3.2.1 Evidence use of combination therapy of second and/or third generationcephalosporins and macrolide in the management of pneumoniaA 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 failure3.3.1 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 mortalit y 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.303.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHFThe 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