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

The Power And The Glory Analysis

The ply And The Glory AnalysisEven though the land is filled with impoverished as well as disease struck places, Mother Theresa tries to make a difference. While living a basic liveness in India, she fights to help the poor, cure the sick, and disregarding her owe health for others. Some might phrase that she is going to be a saint and others might say she is already one. Her unselfish actions have made her a symbol of love and total devotion to the people. A saint is considered to be a man or woman chosen by idol to lead and one almost free of human weaknesses. The non-Christian priest in The Power and the Glory can unquestionably non be classified as a saint and he is the total opposite of Mother Theresa. Since the whiskey priest is the best representation of human weakness, thus he can be called a sinner. The novel is clearly trying to alienate the readers by indicating to readers the wrongs of the human beings and exposing the wrong doings to readers. By disclosure thos e acts, the readers atomic number 18 not inspired by their own human weaknesses and thus are repulsed by them. Through the utilization of the actions by the whiskey priest, Graham Greenes book, The Power and the Glory has failed to draw readers to God and instead has distanced readers from God.In their communities, priests are considered to be a role model or an example of what a Christian should be. They are representations of Jesus Christ in the world to teach the Word of God to others. In the novel, Chiapas, Mexico is under an anti-religion removal and it reasonable that priest is scared to do his duties as a priest. The whiskey priest must cheat, steal, as well as lie to survive and avoid being caught by the authority. He would get coin for the people he baptized and two pesos is the usual charge (167). Even though the woman said that her family was poor, the priest still insisted on getting many money. The priest can be defined as an ordinary crook who steals from families who can barely put food on their own tables. The money that he gets from the baptisms is for his brandy. He wants three bottles. For eleven pesos (170). As a priest who is called to serve the people, he only serves himself. When the old man asked the priest, the priest replies, Cant you let me quietus for five minutes?(44).The whiskey priest does not want to hear the confessions, but it is his duty. That duty is not for himself but for God and His followers. After the old mans confession, the priest begins to weep for himself, because he now has to hear the confessions of the villagers instead of getting his sleep. He cries in sympathy for himself, not for the villagers sins. These examples outline the priests selfishness and are contrary to what Jesus has taught his people.The duties and serve of a religious man are not only for the people but for creatures, humans and animals alike. When the priest returns to the land owned by Captain Fellows, the protagonist finds the house ab andoned and the injured dog. He thinks to himself, her (the dog) keep has no importance beside that of a human being (144). The priest does not care roughly the dogs keep and only cares most his own. The priest thinks that a mans need was greater than a dogs (145). His mercy and concern for the dog is slim to none. He is only worried about himself and his hunger and not of the dogs hunger. God created man to care for the animals but the priest completely ignores it. The whiskey priest also commits one of the worst sins fornication and on top of that he is a priest. He created a child than he cannot care for. When he saw her, the priest thought that it was making light of his virulent sin (65), meaning that he wishes that his sin was not so bad. It is and never will change. This sin makes the priest less than that of the betrayal of the half-caste. The whiskey priest knew that he was in the presence of Our Lords betrayer (91), another Judas so to speak. The mestizo betrays the w hiskey priest for money, just like Judas did to Jesus, and the priest betrays God for lust and fornication. These examples summarize the priests softness to control his own self. He does not have to self-discipline to stop his lust and to think of others before himself.The whiskey priest gives in to the knowledge that God forgives people right before the person dies. If you are truly sorry for what you did in this world, then God will forgive you. The whiskey priest knows about this and thus in the prison, the priest prays to God and asks for forgiveness. He is a priest for the wrong reasons and also forgets that it was pride that made Lucifer fall. When he realizes that he is going to die the next day, he starts to repent saying, I have committed fornication (207). Even though he says this, it has no meaning because he does not really repent for doing it. It was like a sentence in a newspaper you couldnt feel remorse over a thing like that (207). His repentance was not align and he kept drinking brandy, making him drunk while he was trying to repent. In the morning before he gets shot, he realizes that if he had used a little self-restraint and a little courage (210), then maybe he would not be the person he is today. He would then know what it felt like to be a saint (210). It was the use desperation that led the priest to pray that night and it was the use of pride that made him believe that he can be saved by repenting. The whiskey priest is human and has weaknesses just like ordinary people. He has forgotten what it means to be a priest and has disgraced the vocation. The whiskey priest best exemplifies the weaknesses of man and can only be saved by God.To the villagers in the novel, the whiskey priest could be called a martyr. The priest refuses to renounce his faith, unlike Padre Jose who married after hearing about the purge, and living the life of a fugitive, performing confessions and masses when his services are wanted. However, the villagers onl y see the tip of the iceberg so to speak. They do not see what the whiskey priests true intentions are. As the readers, they can sense the true reality of things. The people think that the priest cares for the people and that the priest is risking his own life for what he believes in. But in actuality, the priest is selfish and only cares for himself. Graham Greene exposes the true actions of the priest to the readers and thus telling them what our human weaknesses are. The human weaknesses are selfishness, lust, and only turning to God in desperate times. Greene is telling readers what we cannot control and this makes the readers distance from God because we do not have power to stop it. Graham Greene has failed to draw readers closer to Gods holiness and rattling made people separate themselves from God. This book has failed to inspire people to know more about the faith because of what the priest did so that he can give forgiveness for God. Greene as sent the wrong message to t he readers about Gods mercy and love.Hsu 5Work CitedGreene, Graham. The Power and the Glory. New York Penguin Classics/Penguin Group, 1940. Print. Book.

Theory Of Tourism Demand

Theory Of Tourism DemandPresently, immense research in the field of economics of tourism since the 1970s take to vigorous established models and methodologies to quantify tourism require. Main f motionors that heightend its signifi tin dissolvece ar for recitation income in the artless of origin, relative tourism prices at the finis, or substitute prices of an alternative conclusion.On the other hand travel motivation has been a focus within close choice theories. The typical phaeton undertakes some(prenominal) steps before deciding for a vacation destination. Each stage is diverged by internal and external stimuli and the tourists figure maximize its utility, thus to make the most of it.It becomes appargonnt that the root of total tourism quest lies within both economic and socio-psychological theories. It is the intention of the thesis to therefore propose a wealthy person framework. In order to essay its validity a survey give be conducted to capture stereotype s associated with Ireland and the Irish and to what extend this influences Ireland as a destination choice. The results will past be incorporated into the new framework to help future research testing other vari up to(p)s. writings ReviewTheory of Tourism Demand query differentiates surrounded by two major approaches to analyze tourism guide Tourism economists generally consider an economic framework while travel motivation primary(prenominal)ly applies a socio-psychological framework (Goh, 2012). The following paragraphs will go into more detail on each of the theories to illustrate that tourism demand gouge be derived from theories of destination choice as well as market demand theory.Although get a lineing the characteristics of tourism is a comparably new era starting in the 1960s, this industrys lush growth has also led to an equally extensive evolution as a field of study and consequently its methods and findings.Neoclassical economic theory commonly assumes a multi- stage budgeting exploit for every choice for a certain product or service. Within a tourism context this offshoot can be divided as in normal . Additionally, each stage corresponds to a utility maximization problem where the consumer subconsciously intends to maximize the utility of the choices within the stipulation budget constraint (Smeral Weber, 2000). As Figure illustrates the budget line shows how different combinations of tourism expenditure could be allotd to the destinations, but the indifference curve shows that the tourist wishes to allocate set proportions of the budget to each (Sinclair Stabler, 1997).The most recent review papers by vocal and Li (2008) and Song et al. (2012) summarize the research progress do in respect of approaches, applied methods, innovations, emerging topics, research gaps, and directions for future research. According to their assessment a number of researchers admit created and tested a variety of demand models for different destinatio ns in order to quantify its contacts. Most commonly the number of arrivals is used as the indicator for total tourism demand of a destination, although tourist expenditure, and tourist nights in registered accommodations were chosen in some studies. Predominantly considered determinants that empirically proved to have an tinct on tourism demand wereIncome in country of originRelative tourism prices at destinationSubstitute prices of alternative destinationTravel costMarketing expenditureOne-off events(Song, et al., 2009)While total impact and its explanatory variables have been thoroughly investigated with several econometric models, little attention is placed to the social context of tourism decision making tralatitious demand theory does non explain how preferences and tastes are formed and change (Sinclair Stabler, 1997, p. 29).Decision-making processes, its comp whiznts and generalized frameworks have been widely researched all over the past decades (Crompton Um, 1991 W oodside Lysonski, 1989). Decrop (2005) for example classified the factors of tourists decision-making process into six cognitive constructsTourist perceptionLearning and attitudePersonality and self-conceptMotivation and involvementEmotionContextOn the contrary, Crompton and Um (1991) explain how tourists perception of a destination is influenced by internal and external inputs (see Figure ). Connecting the findings of Heung et al. (2001) review about major vacation motives and Gallarza et al. (2002) findings on attributes related to the destination image, it becomes apparent that research exploring factors influencing destination choice has been extensive.Despite the wide recognition of Um and Cromptonss framework of a multi-stage destination choice and acceptance that beliefs and attitudes are related to destination preferences, they are some restrictions when it comes to the act of purchasing a vacation at a destination. During the early stage of selecting a destination socio-ps ychological factors such(prenominal) as image or beliefs are evidential indicators in specifing which destination evolved to a late consideration stage. However, the ultimate selection depends to a higher magnitude on perceived inhibtors acting on a potential traveler such as monetary constraints (Crompton Um, 1992). According to Crompton and Ums findings in the consumer behavior, tourism, and recreation choice lit constraints should be integrated into the cognitive choice process. (Crompton Um, 1992, p. 97)Figure Framework of decision-making process by Crompton and Um (1991) (Source Own illustration)Similarly, very few prior studies focused on the influence of socio-psychological factors on demand itself. During the 1970s several studies think that a large number of explanatory variables affecting demand are too small to have a significant influence, but if aggregated are likely to be as important as prices and income in determining travel growth. (Goh, 2012, p. 1862). Additio nally, OHagan and Harrison (1984) again proved the high significance of non-economic factors in their study.The main cause for omitting relevant variables in tourism demand theory is its difficulty to define and collect accurate measures (Song Witt, 2000). Attempts to integrate socio-psychological factors into tourism demand models have failed due to the pretermit of appropriated procedures and econometric models. As most these factors are more commonly interrelated a new more complex modeling approach would have to be designed and tested. As Stabler nones Though motivations and preferences, in which images are embodied, are acknowledged as being important, they tend to be ignored by main pour economists, because they are either assumed to be relatively stable and therefore do not influence the model, or are considered too complex to bonk with. (Stabler, 1988, p. 137)In summary, apart from each other the economic perspective as well as the socio-psychological aspect has been s ubject to extensive research. Both fields of study realize their incompleteness when it comes to assessing tourist behavior and demand. However, to fully comprehend and measure the tourism demand, theories of destination choice and theory of market demand should be mingled to create an in-depth understanding (Goh, 2012).StereotypingSocial categorizing allows people to respond quicker to a range of perceptual impressions. As Lustig and Koester (1999) state the way humans process can be broken down into three aspectsConceptual categories1Ethnocentrism2StereotypingFor this thesis most important, is the effect of stereotyping. First booted by Lippmann in 1922 it refers to a selection process to modify our perception of others creating pictures in our heads (Lippmann, 1922, p. 5). Basically, the cognitive representations of a assort influence our thinking, judgment and behavior of people within that group. Hewstone and Brown (1986) defined three characteristics of stereotypesOften in dividuals are categorized, usually on the basis of easily identifiable characteristics such as sex or ethnicity.A set of attributes is ascribed to all (or most) members of that category. Individuals belonging to the stereotyped group are assumed to be similar to each other, and different from other groups, on this set of attributes.The set of attributes is ascribed to any individual member of that category (p. 29)Thus, by and by defining an out-group, they, on the basis of their differing characteristic to oneself, the dissimilarities are emphasized and extended in order to create a more distinct division between the social groups. Last, the characteristics are attributed to all members of that group, resulting in a soul not being treated as an individual, but as a typical example of a category (Lustig Koester, 1999 Hinton, 2000).Before judging, people rarely gather a sufficient amount of information from various resources. Most commonly, they had a direct fuck with a few people of the out-group, received information and opinions second hand such as from friends or relatives, were influenced by the output of the mass media, or notwithstanding general pigeonhole thinking (Brewer, 1996). These sources that form a stereotype initially are moreover the multipliers and causes for stereotypes shared by an entire social group. As Stangor and Schaller (1996, pp. 4-5) mention From one perspective stereotypes are represented within the mind of an individual person. From the other perspective, stereotypes are represented as part of the social fabric of a society, shared by the people within the culture. Because group set and group behavior exit the underlying foundation of stereotyping, stereotypes only have meaning to the tip they are culturally shared. Stereotyping is therefore not only an individual problem, but when they are shared within a society they have a considerable (positive or negative) impact on the labeled individual or group.As diverse and intric ate as the environment appears to be and as useful as it seems to simplify this complexity by structuring, the more dangerous it becomes to misjudge and have inaccurate assumptions. Judd and Park (1993) assessed three major phenomena resulting from stereotyping The so-called out-group homogeneity effect causes the person in the in-group to consider members of the out-group to be much more similar to one another than in reality. Second, humans tend to make wrong or inappropriately exaggerated assumptions about the group average, such as when all US Americans are assumed to be friendly and service-oriented, but also superficial. Third, the phenomenon of prejudices occurs when there is a negative valence inaccuracy, thus a negative attribute is weighted more important while the positive is being ignored or underestimated. For instance, when see the US a tourist could stereotype all Americans being superficial or insincere (the negative attribute), but disregarding the fact that they are super service and customer oriented (positive attribute). Conversely, one can show a positive valence inaccuracy.As Kunda and Scherman-Williams already proved in 1993 imprecise stereotyping can eventually lead to false interpretation of ambiguous incidents. Consider, for example, the unambiguous event of losing a soccer game. Ethnic stereotypes could relate the failure to laziness if the team was from Germany or low ability if the team is Kazakhstani. Thus, stereotypes will affect judgments of the targets ability even if subjects base these judgments only on the act, because the stereotypes will check into the meaning of the act. (Kunda Sherman-Williams, 1993, p. 97)Stereotypes even have consequences for future behavior. An investigation by Seta and Seta (1993) revealed the following resultsThe stereotype would persist even after the subjects were exposed to a disconfirming behavior as they expected a future action would compensate for the atypical behaviorIf a subjects stere otype would be consistently challenged by a member of the stereotyped group indeed expected compensatory behavior would cease. Nevertheless, the subject still expects another member of the group to make up for the disconfirming behavior.This way people are still able to anticipate certain future events without making it necessary to revise their deeply set beliefs and values.In conclusion, stereotypes are highly subjective, but because experiences and events are shared through various channels, it can eventually lead to a shared consensus. Although categorizing helps an individual to cope with an ambiguous environment more efficiently, caution has to be exercised to avoid unsportsmanlike judgment of others behavior. Stereotyping is a strong set of beliefs and values, which is difficult to overcome for an individual and consequently even less likely for an entire social group.ConclusionLiterature review gives a scattered insight into tourism behavior and demand. The field of touri sm economics with its consistent developments in methodological innovations, research progresses, and different approaches consists of a comprehensive body of knowledge and theoretical foundations. Similarly, extensive research in the tourist behavior area and especially the understanding of decision-making process has led to a number of frameworks and assessment methods. Apart from each other, both have empirically and qualitatively evidence for a number of factors influencing the consumer equilibrium the point at which the tourists economic constraints intersects with the consumer indifference curve. Thus, market demand is proven to be depicted from economic as well as socio-psychological theories. However, only very few studies attempted to combine and investigate their relationship and impact.Factors influencing destination choice and destination image are many. Stereotypes are one of numerous causes shaping personality and beliefs. Due to its persistent constitution and dif ficulty to overcome deeply held principles, stereotypes proved to be highly influential on expectations towards future situations peoples behavior. Thus, although stereotyping is a commonly known phenomena its implications into tourism theories is yet limited.The literature gave a profound understanding of economic and non-economic tourism theories as well as origin and impact of stereotypes on social behavior. It is the papers intention to prove a significant relationship between stereotypes and its influence on destination choice.Research ProblemResearch ProblemIt is evident from the literature that market demand as well as destination choice theory face constraints when trying to explain the complexity of tourists choices. Despite their methodological developments in econometric models over the past decades, integrating qualitative as well as quantitative measures has failed due to lack of available entropy or complexity. Similarly, socio-psychological frameworks tend to omit i nhibitors and constraints such as budget.From the research problem identified above, the research question can be formulated as followsTo what extend can stereotypes be classified as a relevant factor influencing tourism demand?In other words, the author will intends to link both economic and socio-psychological factors into tourism demand theory. Further, it is hypothesized that stereotypes have a significant impact on the decision-making process of tourists and thus tourism demand in general.Research ObjectivesThe research objectives are generated from the research question and should provide clearer sense of purpose and direction for the researcher (Baker, 2000). The following research objectives arise from the scheme aboveEstablish a framework that includes both socio-psychological and economic factorsSong et al. (2012) as well as Song Li (2008) noted in their review papers that developments in tourism demand are limited to quantitative measures. During their early works Crom pton Um (1992) realized as well that the destination choice process is not limited to intrinsic motivators. Goh (2012) recently proposed an initial framework linking destination choice and theory of market demand.Investigate on stereotypes subsisting towards Ireland/IrishSeta Seta (1993) found that stereotypes deep-rooted and difficult to overcome. Stereotypes about Ireland and the Irish are widespread which could be due to its high emigration throughout the previous centuries. Since its subjective nature social science has not scientifically named or analyzed existing stereotypes. It will ths become essential to collect primary info.Analyze connection between existing stereotypes and willingness to choose Ireland as a vacation destinationThe multi-stage destination decision-making process has most commonly been researched by Crompton Um (1991 1992) and Decrop (2005). Influencing factors are numeral and their magnitudinal impact depends on the stage of the process as well.Asses s to what extend the economic tourism demand formula can be extended by the socio-psychological factorsResearch integrating socio-psychological aspects with tourism demand theory is limited. For example, Goh (2012) was able to link the factor weather with tourism demand theory. Based on the framework established from the first objective the author intends to generalize the findings.Research MethodThe methodology outlines how the research objectives are to be achieved within the given time frame and explains the rationale behind the chosen method (Saunders, et al., 1997). Special emphasize is to be placed on the research design, info collection, and ethical implications.Research DesignIn order to resolve the above mentioned research objectives a triangulate approach has been chosen, applying both quantitative as well as qualitative methods.First, in order to fully comprehend and test the relationship between stereotypes and tourism demand, a framework needs to be created which stem s from economical as well as consumer choice theory. This inductive and more discovery-oriented approach is necessary due to the lack of available research and quantitative data that have the two fields of study. Through an investigation of the literature about economic tourism demand and socio-psychological theory, the exploratory research will confidently result in a comprehensive tourism demand framework. Additionally, it will clarify the authors understanding about the separateness and consequently help to successfully commence with subsequent objectives (Heath Tynan, 2010).The main focus of this thesis will rely on a positive approach though, thus deducing a hypothesis from the theory and empirically testing it (Saunders, et al., 1997). The intention is to quantitatively prove a causal relationship between stereotypes and tourism demand. From the literature review it can be concluded that socio-psychological factors play a major role when deciding for a destination and as a result imply to have certain impact on tourism demand of that destination. However, this hypothesis has not been tested yet.In order to do accomplish objectives two and three a survey will be conducted among people who have not visited or lived in Ireland. Conducting surveys allows the researchers to have more control over the research process and is widely perceived as authoritative by people in general (Saunders, et al., 1997).According to an analysis from Irelands national tourism board Filte Ireland its main markets are Britain, North America, France, and Germany (Filte Ireland, 2011). The author intends to collect sufficient amount of data from at least two source countries, namely United States and Germany. As the survey is standardized it will be easier to distribute to the different nations and later canvass the received results. It aims at accumulation cross-sectional data about the kinds of stereotypes existing towards Ireland and the Irish as well as the participants wi llingness to choose Ireland as a vacation destination based on their held beliefs. Regression analysis will then allow the author to conduct the fourth step of positivist research Examining the item outcome of the inquiry. It will either tend to confirm the theory or indicate the need for its modification (Robson, 2002, pp. 18-19)According to Saunders et al. (1997) the data collected might not reach such a wide range as a qualitative research method would due to the limited number of questions a questionnaire can contain. However, in case the conducted survey does not give sufficient causal explanation, thus its validity and reliability cannot be assured, additional secondary data from a recent survey by Filte Ireland could be analyzed who interrogated tourists that have chosen Ireland as a vacation destination (Filte Ireland, 2011). It is important to note though, this data can only serve supplementary as a clear distinction between stereotypes and other reasons to choose Ireland has not been considered.The reason for choosing a positivist approach is the advantages that come with it. Its deductive nature allows the application of a rigorous structure that would make this hypothesis applicable to generalization and give an opportunity for just research to test other socio-psychological factors (Easterby-Smith, et al., 2001).The last objective intends to incorporate the findings from the survey into the framework proposed at the beginning of the research applying the knowledge gained throughout the thesis. If the survey were to prove the causal relationship between stereotypes leading to higher likeliness to choose Ireland, the hypothesis demonstrated its validity. The fourth objective is to conclude to what extend the findings can be generalized and applied to other non-economic factors.Data CollectionAs mentioned above the main purpose of this thesis is a survey among US and German citizens collecting empirical data about stereotypes towards Ireland and th e Irish as well as their willingness to choose Ireland as a vacation destination based on their held beliefs. Irish born as well as residents who previously visited Ireland are excluded. This specification is especially relevant as stereotypes root mainly from other peoples experience (i.e. visitors to Ireland) and/or limited familiarity with the other social group (i.e. Irish emigrants) (Brewer, 1996).The author targets to gain 50 utilizable questionnaires from each nation, totaling to n=100. In order to ensure a high number of participants from Germany the survey will be translated into German as well.Distribution will primarily be channeled as a web questionnaire through social media. This note only enables the survey to reach a wide range of potential partakers and guarantees there anonymity, but also ensures a certain direct of randomness which is one of the main challenges when conducting surveys. Although the author cannot fully exclude a connection with all the participants , the potentially exponential circulation minimizes this risk.The data then will be used for a elongated regression analysis in order to validate how the in mutually beneficial variable (stereotype) impacts the dependent variable (select Ireland as vacation destination). The linear regression will only be an approximation of the true relationship though, as it is not possible to include all the variables which may have an influence on the dependent variable (Koop, 2009). The omission of these variables in the model is referred to as the error term. The basic regression model is written aswhere y equals dependent variable (select Ireland as vacation destination), coefficients and , x represents the independent variable (stereotype), and refers to the error term. A null hypothesis test will be applied to determine whether results are statistically significant.Main problems arising using regression analysis can be autocorrelation, omitted variable bias and multi-collinearity (Koop, 2 009). As the hypothesis is only testing the impact of one independent variable on one dependent variable, autocorrelation can be neglected. Similarly, multi-collinearity, evident through high p-values and low t-stats can be excluded as only one explanatory variable is applied. However, omitted variable bias can lead to unreliable coefficients if an explanatory variable which may have an impact on the dependent variable are omitted from the data set. However, as mentioned above it is nearly impossible to include all explanatory variables, which is why the error term is included. The values of the coefficients will nevertheless be treated with caution.Ethical considerations have to be taken into account as well. The online survey ensures the participants anonymity and no personal data will be collected. Additionally, it goes without saying that the author conducts this hypothesis in an objective and non-discriminatory manner. Stereotypes have a tendency to classify or even favor one s ocial group over the other. The thesis is not intended to strengthen or overcome beliefs towards Ireland or the Irish, but to capture a snapshot of existing stereotypes.

Docter Faustus Essay -- essays research papers

The truth that ambition and desire for material objects does not always satisfy the someone is a major theme depicted in Christopher Marlowes Doctor Faustus. The poem on page 93, lines 96-113 is the essence of this theme. It describes Faustus meeting, what he believes, is the icon of perfection. This perfection is a mere human women, yet, to Faustus, she is worth his life. Marlowes use of syntax and diction, allusions and references, and new(prenominal) literary devices throughout this monologue give support to the theme while adding bountiful symbolic images.&9The first example of diction in the monologue is the use of the saying, "the face that launched a thousand ships" (l. 96). This is a commonly applied port when speaking about Helen of Troy. Throughout the play, Faustus fluctuates between the use of advanced and lesser vocabulary. Here, he is so shocked by Helens beauty that he knows zippo else but this typical phrase. This implies that Faustus is in a state of hy pnosis. He is taken over by Helens beauty, and in the process, loses his soul. Another illustration of the trance Faustus is in, is by the use of alliteration in the first two lines of the poem. This device causes the reader to read the lines more slowly. The pronunciation of haggling in a moderate carriage suggests this trance, and makes the rest of the passage more comprehensible. In contrast to the first two lines, the rest of the section can be read more easily and therefore, faster. few caesuras are utilized in this part, making the paragraph flow better. The quick pace of the these lines indicate excitement on Faustus part. If this is the case, it is understandable how he loses his soul without resistance. The move line is brought back to a slower pace. The word "paramour" lends itself to a laggard pronunciation, which enforces Faustus realization that his soul has been taken. This is all due to Marlowes choice of words and sentence structure. Because the reader can experience Faustus state of mind through the writing, they can relate to the upcoming circumstances. Faustus excitement of the need for the material aspects of life, lead to his downfall.&9Allusions and references also add to the comprehension and depth of this piece. Many references are made to familiar Greek mythology characters, including Paris, Menelaus, Achilles, Jupiter, ... ...ted at as being a demon, their kiss makes him cursed. In the Catholic church, relations with a demon is unpardonable, and in turn kills any chance of Faustus being redeemed by G-d. Because he wanted Helen for her material beauty, he had to sacrifice his soul. When he finally does sacrifice his life to Helen he gives a brief cry for help. He underestimates the damage he has done and screams, "Her lips suck off my soul. See where it flies" (l. 99) He returns to her asking her to kiss him again, soon forgetting the damage he has done. This example of a litotie is contrasted with Faustus hyperbole of Helens magnificence. The juxtaposition of these concepts against each other prove that Faustus cared little for his spiritual body, and more for Helen the material body. &9Marlowes use of strong literary devices in lines 96-113 on page 93 greatly supported the theme that only striving for material objects will only lead to harm. Faustus exemplified this theme in his Helen of Troy monologue, where he asked for her in return for his soul. In the end, Helen took Faustus soul, leaving him with neither, the material pleasures, nor a spiritually complete life.

Margaret Fell Fox Essays -- essays research papers

Margaret Askew Fell bedevil     In the seventeenth century, a commanding female public minister emerged during the radical ghostly movement of Quakerism. Margaret Askew Fell Fox was one of the founding members of the Religious Society of Friends, and was popularly cognise as the "Mother of Quakerism". She has been known less as a minister and more as a founder and provider of financial tolerate then other young women. Throughout this paper I will refer to her as Fell Fox, name she acquired through marriages during her lifetime. Through her struggles and triumphs, radical actions and beliefs, and her want to worship God, Fell Fox had a significant impact on the world around her. In this essay, I hope to share how Fell Foxs life, writings, and actions contributed to her radical contribution to life in seventeenth century England.     In 1614, Fell Fox was born in Lancashire, England. She was born into the landed gentry, a level of so ciety with both good education and breeding. In her late teens, she married an older man, a highly respected judge, by the name of doubting Thomas Fell. Fell was politically involved in the society and several times was a member of Parliament. During their marriage, Fell inherited a house from his father and he and Margaret lived at the estate. The estate had been named Swarthmoor Hall by Fells father. During that time, Fell was often absent from home on court circuits. Fell was well known in the region for his hospitality to travelers, and accordingly, the Hall was open to travelers. Fell Fox followed her husbands desire for hospitality.      In June 1652, George Fox came to Swarthmoor succession Fell was away on a circuit. (Fox was later credited with being the founder of the Quakers.) When Fell returned home, Fell Fox and their nine children were no longer attending their community Anglican Church. Instead, Fell Fox had deeply involved her family and herself in the Principle and Persuasion that was introduced to her through Fox. We have later learned that the moment Fell Fox met Fox, she changed her religious alliance. According to a analysis of Fell Foxs works, her conversion from the Anglican Church to Quakerism revealed none of the traditional Puritan obsession with self-doubt and self-introspection, while going through a gradual faith-awakening proc... ...aking. Wallingford Pendle Hill Publishers, 1976. First Feminists British Women Writers 1578 1799. ed. Moria Ferguson. Bloomington Indiana University Press, 1985.Kunze, Bonnelyn Young. Margaret Fell and the Rise of Quakerism. Stanford Stanford University Press, 1994._____. An Unpublished Work of Margaret Fell. Proceedings of the American philosophical Society. 1986.Ross, Isabel. Margaret Fell, Mother of Quakerism. capital of the United Kingdom Longman, 1984.PrimaryFell, Margaret. Margaret Fells Answer to Allan Smallwood Dr. Priest of Grastock in Cumberland. capital of the United Kingdom 1668_____. Margaret Fell to John Rouse (her son in law) and Wife, 1st of 8th Month, 1664. London 1664._____. A Paper Concerning Such as are Made Ministers. H.W., 1659. _____. A True Testimony from the People of God. London Robert Wilson, 1660. _____. Womens Speaking Justified, Proved, and Allowed by the Scriptures. Augustan Reprint Society. Fox, George. A Journal of George Fox. London 1694.Fox, Margaret Fell. The Testimony of Margaret Fox, Concerning her Late Husband, George Fox Together with a Brief Account of Some of his Travels, Sufferings, and Hardships Endured for the Truths Sake. London 1964.